general surgery fellowships - lifestyle rankings

I'd like to say that neurosurg should fall under worst.. and that no one should (at least for the next 3 years) apply to neurosurg.

footcramp said:

best:
plastics, surg onc, minimally invasive?, colorectal

average:
vascular?, pancreas/liver, endocrine

worst:
ct, transplant, pediatric, trauma/critical care

your input appreciated

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I think endocrine probably can be put up there with "best", but otherwise it looks pretty good to me. Vascular is a bit variable too. It depends on where you practice, I think.

In selecting a fellowship, you must consider many things beyond the lifestyle of the fellow. I think the lifestyle of the career that follows is much more helpful to you. I would like to use my favorite example. Pulmonary-Critical Care Medicine was an easy lifestyle to many people that I trained with. The private practice, however, is perhaps the worst job in my medical community. They are badly overworked, oversued, and underpaid.

There are a variety of great fellowships out there for you to choose from. Look in to each one carefully. I know of one example where someone was planning to make a long commute to a nearby large city for a "laparoscopy" fellowship. To their dismay, they were old after starting the fellowship that one of their duties was to be staff and take call for the trauma service several nights a week!

My personal experience is limited. The least life consuming seem to be private, non-accredited, non-acgme type programs that offer good practical experience such as laparoscopy fellowships.

Best of luck to you.

This varies so much on where you practice and the your type of practice. People in private work tend to have much better hours. If you’re working in an academic hospital in a major city then expect to be busy. I come under this category and all the general surgeons I work with work pretty damn hard. Breast, endocrine, colorectal, hepatobiliary, ect. all take a gen surg/trauma on-call. Their normal days include ward rounds, OR lists, and clinics, ect. The vascular surgeons, peads, and CT do on-call for their own specialty because they are busy enough, however, I do know of some vascular surgeons that also do general on-call.

Blade28 said:

But neurosurg isn't a G Surg fellowship.

I take it from your post that you're interesting in NSGY?

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Depending on my grades and board scores I am.

footcramp said:

best:
plastics, surg onc, minimally invasive?, colorectal

average:
vascular?, pancreas/liver, endocrine

worst:
ct, transplant, pediatric, trauma/critical care

your input appreciated

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I'm wondering about trauma/CC though - in talking to a couple of attendings boarded in that it sounded like a pretty lifestyle friendly specialty in some circumstances. I heard parkland attendings for example only had about 6 24 hour calls a month. and then did a week of critical care on top of that, and the rest of the time was for "research". don't know if this is totally accurate, but it does seem like since it's shift work that it would be more lifestyle friendly, ala Emergency medicine.

footcramp said:

people have told me that vascular is not very lifestyle friendly. from what i've seen it doesn't seem so bad, so i'm not sure where the disconnect is from. i haven't seen very many emergent cases except for trauma. are most vascular emergencies from trauma?

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Part of me thinks you must be joking, but I'll assume you're sincere.

Vascular emergencies
1) ruptured AAA
2) actuely ischemic limb
3) graft thrombosis after a case requiring immediate reoperation
4) mesenteric ischemia (covered by GS in some cases)
5) vascular problems encountered by other surgeons requiring intraop consultation (i.e. urology rips the cava during a nephrectomy)

Blade28 said:

Vascular call can be rough because the vasculopaths are some of the sickest patients in the hospital.

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yeah, lets add
1) septic patient with dead foot requiring guillotine amp
2) patient coding on floor (pre and post amp patients are code magnets)
3) post op patient having MI
4) post op patient having stroke
5) patient in unit going south

The pre and post op care of vasculopaths is particularly fraught with emergent complications!

Let's add another MD poking the carotid during a central line.

mysophobe said:

Let's add another MD poking the carotid during a central line.

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And cardiac cath vascular access complications (bleeding, ischemia, etc.)

A lot of general surg. subspecialties are very demanding. Vascular surgery is unique in that it can be very stressful as most vascular emergencies need intervention asap. Arterial reconstructions can be unforgiving of mistakes and sometimes haemorrhages can be very difficult to control... even during routine operations.

Cardiac surgery is very high-risk too… there have been several occasions when I have shat myself in the OR (not literally)

Good point about difficulty during routine procedures. Mistakes during even routine av grafts can add tons of work to the case, as you're dealing with small vessels that you're putting a lot of work into making fit for use. It takes a while to sew the anastamosis you had planned--imagine now having to sew up a hole you put in a vessel accidentally (had that happen today during a fem-pop).

where does orthopedic fall in this grand scheme of things?

how hard is it to obtain surg onc fellowship? is it up there with plastics?

zbruinz said:

where does orthopedic fall in this grand scheme of things?

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Ortho varies quite a bit. If you go into areas like upper extremity surg. or sports medicine (mostly knee and shoulder arthroscopy) your lifestyle is fairly relaxed. However, there are the few die hard orthopods that go fully into trauma or maintain a subspecialty interest in it, which can be quite demanding especially if your working in a level 1 trauma centre in a large city.

mysophobe said:

Good point about difficulty during routine procedures. Mistakes during even routine av grafts can add tons of work to the case, as you're dealing with small vessels that you're putting a lot of work into making fit for use. It takes a while to sew the anastamosis you had planned--imagine now having to sew up a hole you put in a vessel accidentally (had that happen today during a fem-pop).

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depends on the size of the hole...

GuP said:

how hard is it to obtain surg onc fellowship? is it up there with plastics?

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Not as difficult as Plastics, but still quite competitive.

avgjoe said:

I'm wondering about trauma/CC though - in talking to a couple of attendings boarded in that it sounded like a pretty lifestyle friendly specialty in some circumstances. I heard parkland attendings for example only had about 6 24 hour calls a month. and then did a week of critical care on top of that, and the rest of the time was for "research". don't know if this is totally accurate, but it does seem like since it's shift work that it would be more lifestyle friendly, ala Emergency medicine.

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6 24 hour calls does not seem lifestyle friendly to me.. thats 72 times a year you are sleeping in the hospital.. Not my idea of fun.. Your lifestyle specialty will be is there a lot of post op care...... If youare doing big bowel cases... those patients will be going to the icu and WILL have issues post op that need to be managed.. and guess who is responsible.. YOU ARE.. so all the major surgery like hepato biliary transplant CT vascular.. trauma... ****ing nightmare lifestyle. Plastics is the best.. patients are young and go home.. and they pay you cash... nobody is gonna touch the plastic surgeons.. just look at dr rey.. on dr 90210... do you see him doing anything he doesnt wanna do? absolutely not...

you can judge lifestyle.. by who do you see in the hospital at off hours.. nights and weekends.. you see the anesthesiologist, obstetrician/gynecologists, vascular surgeons, general surgeon, neurosurgeons, very rarely will you see. ent surgeons, breast surgeons, endocrine surgeons.. but you have to be at like a university to do breast and endocrine.. **** a plastic surgeon doesnt even have priveleges at a hospital if he doesnt want to..

footcramp said:

best:
plastics, surg onc, minimally invasive?, colorectal

average:
vascular?, pancreas/liver, endocrine

worst:
ct, transplant, pediatric, trauma/critical care

your input appreciated

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'lifestyle' in surgery is largely based on what one's call schedule is like. any specialty with potential exposure to emergency general surgery cases is gonna be impacted by this. most MIS specialist I know take ER call for gen surg, as do a few colorectal and surg onc guys. plastics does not, but have other ER problems to content with, if they choose to take ER call at all.

the problem is this (if you view it as a problem): if you have admitting privlidges at a local hospital, you'll likely have to take some ER call for your discipline (gen surg, or neurosurg or whatever) Its part of the deal.

thenavysurgeon said:

if you have admitting privlidges at a local hospital, you'll likely have to take some ER call for your discipline (gen surg, or neurosurg or whatever) Its part of the deal.

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no its not part of the deal.... its part of the deal if you want it to be part of the deal

Perhaps you could explain to all of us how you managed to circumvent taking ER call in whatever surgical specialty you do, while maintaining admitting privlidges at your local hospital.

xTNS

Blade28 said:

Usually requires research too, no?

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Yes, generally expected.

stephend7799 said:

no its not part of the deal.... its part of the deal if you want it to be part of the deal

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I am as confused as thenavysurgeon is. Perhaps your experience has been different but I have yet to see a surgical faculty member have the ability to refuse to take call except in the most senior cases (ie, close to death/retirement/etc). Its "part of the deal" and if you don't like it, you can find a job elsewhere tends to be the mantra.

Plastic surgery at a university hospital (which tends to do much less aesthetic work and lots more trauma) is hardly lifestyle friendly. The call may be from home, but these guys are coming in all the time for Hand and Face trauma. They aren't paid in cash except for the few cases they may do at the outpatient surgical centers. Lets not confuse private practice Plastics (like Dr. 90210) with academic PRS.

thenavysurgeon said:

how you managed to circumvent taking ER call

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Perhaps a small hospital desperate for any surgical coverage would not require ER call -- but I can't imagine there would be many.

thenavysurgeon said:

Perhaps you could explain to all of us how you managed to circumvent taking ER call in whatever surgical specialty you do, while maintaining admitting privlidges at your local hospital.

xTNS

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if you are a breast surgeon adn only have priveleges for breast related work..which is what most of them have.. you wont be taking er call. If you are a plastic surgeon, and have a cosmetic practice.. you think they will see patients in the ER. I think not.. When you are making 2 million dollars doing outpatients breasts facelifts tummy tucks and the like.. You will not be going to the hospital ever. and if you do its rare.. when they start out they make take er call so people can know their name. You think dr rey gets consulted for sacral decubitus ulcers.. absolutely not.

rainking said:

if you are a breast surgeon adn only have priveleges for breast related work..which is what most of them have.. you wont be taking er call. If you are a plastic surgeon, and have a cosmetic practice.. you think they will see patients in the ER. I think not.. When you are making 2 million dollars doing outpatients breasts facelifts tummy tucks and the like.. You will not be going to the hospital ever. and if you do its rare.. when they start out they make take er call so people can know their name. You think dr rey gets consulted for sacral decubitus ulcers.. absolutely not.

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If you do not have admitting privileges to a hospital and practice solely at an outpatient surgery center, you don't have to take ER call - no one can make you. If you want/need admitting privileges - even if you admit rarely - the hospital can make you take ER call. Same with breast surgery - a hospital can very easily require any boarded general surgeon to take ER call as a condition of admitting privileges. If they are overstaffed with general surgeons or really want a fellowship trained breast surgeon, you might not have to take call. All depends on what the hospital wants.

rainking said:

if you are a breast surgeon adn only have priveleges for breast related work..which is what most of them have.. you wont be taking er call. If you are a plastic surgeon, and have a cosmetic practice.. you think they will see patients in the ER. I think not.. When you are making 2 million dollars doing outpatients breasts facelifts tummy tucks and the like.. You will not be going to the hospital ever. and if you do its rare.. when they start out they make take er call so people can know their name. You think dr rey gets consulted for sacral decubitus ulcers.. absolutely not.

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I would strongly disagree with the statement that most breast surgeons do not take ER gen surg call. In speaking with current breast surgery fellows and those out in practice, actually finding a job in an academic setting which doe NOT require you to take gen surg call as a Breast surgeon is difficult. It does happen, but it is not the norm by any means, especially in the academic/university hospital setting.

Same for the Plastic surgeon. I think the problem is that rainking is focusing on the private practice setting, where Plastic surgeons may not take Emergency call, and we are focusing on the academic/university setting, where they do (and a lot). Very few Academic Plastic surgeons focus on outpatient aesthetic surgery. Dr. Rey is by no means the typical plastic surgeon and should not be used as an example of what PRS gets consulted for.

So, lets not split hairs. You can make your career what you want, within reason. An academic practice is very different from private practice.

Pilot Doc said:

the hospital can make you take ER call. .

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the hospital cant make you do anything.. ( you guys are thinking like residents).

rainking said:

the hospital cant make you do anything.. ( you guys are thinking like residents).

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Yes they can.

They can say, "this is what we are looking for in a physician/surgeon/etc". Of course, as an attending you have more room to negotiate the contract but in the end if they are looking for someone to take ER call, they probably won't offer you the job if you refuse to do so. Why should they when they can hire someone who will (unless you are some Internationally known Superstar that they would kill their own mother to have on staff, which most of us are not).

Kimberli Cox said:

......unless you are some Internationally known Superstar that they would kill their own mother to have on staff, which most of us are.

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Like Dr. Rey?

Sorry Dr. Cox, I know how much you hate him! (Just Kidding)

rainking said:

the hospital cant make you do anything.. ( you guys are thinking like residents).

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The hospital can make you jump around in a tutu singing Dixie if they want.

Admitting privileges are just that - they are not a right and the hospital can demand whatever the market will bear to staff itself at the level if deems appropriate. Unlike residency, you do have the option to say no and go practice elsewhere, but there just aren't many hospitals that need surgical coverage so badly to waive ER call requirements.

now can someone rank these same fellowships in order of difficulty (meaning getting a spot). that would be cool

rainking,

i hope we've dispelled you of the myth that a surgeon does not have to take ER call if he/she chooses to. Its simply a fact of life, if one maintains hospital privlidges (which everyone in a responsible practice maintains, btw).

the one way i've seen very busy cosmo oriented surgeons avoid taking ER call is the following

1. hire a junior partner, and make him take all of your ER call
2. pay another surgeon to take your ER call

There are communities with so many docs hungry for business that a surgeon will find that he is not 'invited' onto a particular call schedule, because these cases generate some income (if you're lucky), but this is rare.

BTW, a breast surgeon in a metropolitan practice will probably be taking general ER call. In a less metro practice, he will definetely be taking call. There is usually way too much pressure from other surgeons to get on the call schedule and do you're share of the work. Where I did my training (major academic center), there was a 'breast surgeon' who did not take ER call, but that is because his clinical incompetence with ER cases was legendary, and he was a 'breast surgeon' be default.

Now you know the facts of life.

xTNS

Leukocyte said:

Like Dr. Rey?

Sorry Dr. Cox, I know how much you hate him! (Just Kidding)

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I was thinking of myself of course (since I will refuse to take General Surgery call as a Breast Surgeon and make lots of other demands as well)

But thank you for putting Dr. Rey into my head at bedtime...I'll probably dream about his muscle scrubs tonight.

Dream about burning them.

footcramp said:

just my guess but i'm thinking
most competitive: pediatric, plastics, oncology
somewhat: transplant, minimally invasive, endocrine, hepatobiliary, colorectal
not really: ct, vascular, trauma

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interesting...i thought vascular was harder

From what I understand (might just be where I'm at), vascular is not terribly difficult to get, especially if there is a program at your....eh...program. It might vary depending on where you go, or I might just be totally wrong.

mysophobe said:

From what I understand (might just be where I'm at), vascular is not terribly difficult to get, especially if there is a program at your....eh...program. It might vary depending on where you go, or I might just be totally wrong.

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no you are probably right...my source was a word of mouth convo with an individual who i "thought" knew what he was talking about

GuP said:

interesting...i thought vascular was harder

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I thought colorectal was also not that competitive since there isn't too much demand?

If colorectal dudes also have to take gsurg call, then how is it a significantly easier lifestyle? I know their own patients don't usually have complications, but still ..
and how much percentage of a colorectal surgeon's practice is on average the rectal/butt stuff versus the intestinal issues?

Dunno...all the colorectal procedures are done by general guys here. I don't think I've ever met a colorectal fellow or attending.