Which surg. specialty is best as far as lifestyle?

PA school.

This is a popular topic and a search will bring you a wide array of opinions.

Mohs surgeon, possibly surgical oncology or plastics, too.

deuist said:

Mohs surgeon, possibly surgical oncology or plastics, too.

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I hear colorectal and breast have pretty good lifestyles, but that is just hearsay from a resident I know.

transplant

-Goose- said:

I hear colorectal and breast have pretty good lifestyles, but that is just hearsay from a resident I know.

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True as long as you are not employed at a hospital which requires you to take general surgery call.

The best lifestyles in general surgery are those which involve a lot of elective/planned surgeries - ie, minimal emergencies and few really ill patients. Therefore, this would include, in most cases, Breast, Endocrine, Colorectal, Minimally Invasive, Surg Onc, Heptaobiliary (although the latter will have sicker patients).

Conventional wisdom has it that: transplant, CT, Vascular, Trauma and General Surgery have the worst lifestyles.

For the subspecialties, urology, ENT, Plastics can be good especially if you are not taking ER or trauma call.

I've been doing anesthesia for over six years and have never seen an emergency breast case.

One thing to keep in mind for all the medical students is that there is quite a bit of irritation that surgeons get from general ER calls that do not turn into OR cases. For example, some gastric bypass surgeons have to deal with ER calls for dysfunction after surgery that wakes them up at night, but does not necessarily turn into an OR case. These types of issues are good things to ask surgeons in various specialities, because this can have a major impact on your life that you may not perceive while in medical school. The ER is much more irritating than the OR.

mdjobexchange said:

I've been doing anesthesia for over six years and have never seen an emergency breast case.

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About 1 in 100 patients will be taken back to the OR for rebleeding...usually spasm related which you didn't see when you were closing. Not often, but it does happen (we did one during fellowship...sort of classic, she reappeared in the ED about 6 hrs post-op with a large swollen breast. We took about 300 cc of blood out).

In general, hardly ever any emergencies though.

As noted above, keep in mind the ER call. I hated bariatrics with a passion as a junior resident...I never got to the do cases but was always either on the phone or in the ER with a crying, vomiting, whining patient. It was very painful. So while MIS can be lifestyle friendly there are certain segments which are not.

Kimberli Cox said:

True as long as you are not employed at a hospital which requires you to take general surgery call.

The best lifestyles in general surgery are those which involve a lot of elective/planned surgeries - ie, minimal emergencies and few really ill patients. Therefore, this would include, in most cases, Breast, Endocrine, Colorectal, Minimally Invasive, Surg Onc, Heptaobiliary (although the latter will have sicker patients).

Conventional wisdom has it that: transplant, CT, Vascular, Trauma and General Surgery have the worst lifestyles.

For the subspecialties, urology, ENT, Plastics can be good especially if you are not taking ER or trauma call.

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Dr. Cox,
How does ortho surg lifestyle (non-trauma, of course) compare to the rest of the specialties you listed above?

nontraditional said:

Dr. Cox,
How does ortho surg lifestyle (non-trauma, of course) compare to the rest of the specialties you listed above?

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Ortho is a painful residency because of the workload and of course, the trauma.

However, as an attending you can find yourself a niche with a better lifestyle, such as Ortho Spine. You "pay" for that luxury by needing additional fellowship training which is competitive to get and the horror of the malpractice for this field. Peds Ortho the same.

Hand, if you don't do trauma can also be lifestyle friendly, but the drudgery and malpractice of workman's comp cases ("yes, I am CERTAIN that your job didn't cause this injury and that you have to go back to work"...practice saying 5 times daily).

Plus with ortho you get the advantage of consultlng all your patient's medical problems out!

Perhaps Tired could give us more info on lifestyle friendly ortho fields.

Blade28 said:

Oh the memories! The horror!

And supposedly they were all screened by Psych pre-op.

God I hated bariatrics.

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Yeah...what was up with that?

Almost ALL of the patients underestimate the pain, the post-op disability, the lifestyle changes that bariatric surgery entails.

Add that to baseline neuroses and other psychological disturbances from lifelong bias and you've got a horrible horrible night on call when on bariatrics.

Kimberli Cox said:

Ortho is a painful residency because of the workload and of course, the trauma.

However, as an attending you can find yourself a niche with a better lifestyle, such as Ortho Spine. You "pay" for that luxury by needing additional fellowship training which is competitive to get and the horror of the malpractice for this field. Peds Ortho the same.

Hand, if you don't do trauma can also be lifestyle friendly, but the drudgery and malpractice of workman's comp cases ("yes, I am CERTAIN that your job didn't cause this injury and that you have to go back to work"...practice saying 5 times daily).

Plus with ortho you get the advantage of consultlng all your patient's medical problems out!

Perhaps Tired could give us more info on lifestyle friendly ortho fields.

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Dr. Cox,
Thanks for your thoughts. I've yet to hear ortho surgeons complain about their lifestyle, but maybe it's because their enviable compensation is a sufficient mitigating factor.

nontrad

Kimberli Cox said:

Ortho is a painful residency because of the workload and of course, the trauma.

However, as an attending you can find yourself a niche with a better lifestyle, such as Ortho Spine. You "pay" for that luxury by needing additional fellowship training which is competitive to get and the horror of the malpractice for this field. Peds Ortho the same.

Hand, if you don't do trauma can also be lifestyle friendly, but the drudgery and malpractice of workman's comp cases ("yes, I am CERTAIN that your job didn't cause this injury and that you have to go back to work"...practice saying 5 times daily).

Plus with ortho you get the advantage of consultlng all your patient's medical problems out!

Perhaps Tired could give us more info on lifestyle friendly ortho fields.

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For me, one of the biggest problems with ortho is the monotony in private practice. Outside of peds and tumor (the latter being almost completely academic), it seems like pp is set up like one surgeon is 'the hip guy,' another one is 'the knee guy,' another is 'the shoulder guy.' Screwed up your hip the first time? Ok, send it to 'the revision case guy.'

While I'm not saying ortho pp should be set up differently (this is probably the most efficient way of doing things),but I do think this is a significant drawback, for me at least.

Case in point: I shadowed a ortho sports med doc this summer who purposely has completely limited his practice to scopes of shoulders and knees. No open cases, no simple primary TKAs, just scopes. I watched him do 8 shoulder cases in a row (at least some were left and some were right)...

Just my $.02

I think ophtho offers the best lifestyle of any surgical subspecialty. There aren't many eye emergencies and ophthalmologists work 40-50 hrs/week on average.

Kimberli Cox said:

Ortho is a painful residency because of the workload and of course, the trauma.

However, as an attending you can find yourself a niche with a better lifestyle, such as Ortho Spine. You "pay" for that luxury by needing additional fellowship training which is competitive to get and the horror of the malpractice for this field. Peds Ortho the same.

Hand, if you don't do trauma can also be lifestyle friendly, but the drudgery and malpractice of workman's comp cases ("yes, I am CERTAIN that your job didn't cause this injury and that you have to go back to work"...practice saying 5 times daily).

Plus with ortho you get the advantage of consultlng all your patient's medical problems out!

Perhaps Tired could give us more info on lifestyle friendly ortho fields.

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Has anybody seen any neurosurgeons successfully find such a niche for themselves? I'd assume it would be harder, since neurosurgical problems seem more medical and less...structural? (not the best description, sorry)

I know a resident who swears he's decided he can't take the "brain surgery" lifestyle anymore, and as soon as he's out he's decided he'll do just "elective spine and hydrocephalus." Is this a reasonable plan? It would be a nice fallback if one were to realize that it was all just a bit too much for them...but I must admit that it sounds too easy/good to be true.

Does something like breast surgery or endocrine surgery get boring after a while? How much variety is there in the cases you see? One of the surgeons I've talked to is also married to a surgeon, and they seem to have a good balance of work and family life. I want that after residency, so if I do fall in love with surgery during third year, I'd like to do something where the schedule is somewhat stable and predictable. At the same time, I enjoy the diversity of experiences that medicine allows for, and I'm wondering if you can still get that at such a level of surgical subspeciality.

Blade28 said:

And supposedly they were all screened by Psych pre-op.

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The Psych screen is to determine if they do not exhibit self-destructive behavior that will lead to an attempt to defeat the surgery. It doesn't screen out needy losers. Please keep this in mind when you approach these patients in the future.

RinaBe said:

Does something like breast surgery or endocrine surgery get boring after a while? How much variety is there in the cases you see? One of the surgeons I've talked to is also married to a surgeon, and they seem to have a good balance of work and family life. I want that after residency, so if I do fall in love with surgery during third year, I'd like to do something where the schedule is somewhat stable and predictable. At the same time, I enjoy the diversity of experiences that medicine allows for, and I'm wondering if you can still get that at such a level of surgical subspeciality.

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The joke in breast surgery is that there are just 4 operations: a right and a left, a partial and a full!

And while it is true that the number of different types of procedures are limited anytime you super specialize (it is more than 4), most surgeons will tell you that any case they do frequently gets boring occasionally.

The advantage to breast surgery that I find is that I enjoy the office encounters with patients, educating them and their families about breast disease and there are always less common cases interspersed throughout which make things more interesting.

Ask me again in 10 years.

.they work more like 20-30hrs a week. Or at least it seems that way in my community. I tried to call in a consult for an optho guy on a Wed right after lunch, the secratery picks up and "says sorry the doctor is on the golf course and will be unavailable till at least 5pm". Guess what the same thing happend on a Friday as well. I think I picked the wrong specialty.

speyeder said:

I think ophtho offers the best lifestyle of any surgical subspecialty. There aren't many eye emergencies and ophthalmologists work 40-50 hrs/week on average.

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Docgeorge said:

Bull $hit...they work more like 20-30hrs a week. Or at least it seems that way in my community. I tried to call in a consult for an optho guy on a Wed right after lunch, the secratery picks up and "says sorry the doctor is on the golf course and will be unavailable till at least 5pm". Guess what the same thing happend on a Friday as well. I think I picked the wrong specialty.

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Maybe he works nights.

Any specialty has its mundane problems, whether it is the routine office visit, routine mastectomy, routine pain procedure, our routine mengioma excision. You have to like the environment in which you do your routine thing(s) and something that lets you have the lifestyle you want, be it either money, time, or both. I like the type of people in the OR and I hated clinic, but I still enjoyed seeing patients. Hearing people 30 people a day talk about their problems drove me crazy. I wanted a good income and didn't like being bothered after I got home. I chose anesthesia.

Same goes for surgery. Some specialities spend huge amounts of time in the main OR and hospital, while some surgical specialties rarely step foot in the main hospital. Mohs guys do everything in their clinic usually.

It really depends on what you define as "lifestyle." Is it money, time, independence, or both? If you can tolerate the residency, do neurosurgery. I know it sounds ridiculous, but their specialty has done the best job of restraining their numbers and widening their scope of practice. Their procedures bill huge numbers of RVUs, so your bang for your buck in terms of money for time is way better than any other specialty. Lifestyle in residency does not always equal lifestyle after residency.

Breast surgery is pretty cush, but women's health does not pay as well as things that happen to old dudes. Old dudes get aneurysms, menigiomas, and spine disease, so it pays quite well. Optho is good too. Plastics is reasonably good, but many other specialties are horning in on their turf, like ENT, optho, gyn, and general surgery. Very few other people want to saw somebody's head open.

mdjobexchange said:

Any specialty has its mundane problems, whether it is the routine office visit, routine mastectomy, routine pain procedure, our routine mengioma excision. You have to like the environment in which you do your routine thing(s) and something that lets you have the lifestyle you want, be it either money, time, or both. I like the type of people in the OR and I hated clinic, but I still enjoyed seeing patients. Hearing people 30 people a day talk about their problems drove me crazy. I wanted a good income and didn't like being bothered after I got home. I chose anesthesia.

Same goes for surgery. Some specialities spend huge amounts of time in the main OR and hospital, while some surgical specialties rarely step foot in the main hospital. Mohs guys do everything in their clinic usually.

It really depends on what you define as "lifestyle." Is it money, time, independence, or both? If you can tolerate the residency, do neurosurgery. I know it sounds ridiculous, but their specialty has done the best job of restraining their numbers and widening their scope of practice. Their procedures bill huge numbers of RVUs, so your bang for your buck in terms of money for time is way better than any other specialty. Lifestyle in residency does not always equal lifestyle after residency.

Breast surgery is pretty cush, but women's health does not pay as well as things that happen to old dudes. Old dudes get aneurysms, menigiomas, and spine disease, so it pays quite well. Optho is good too. Plastics is reasonably good, but many other specialties are horning in on their turf, like ENT, optho, gyn, and general surgery. Very few other people want to saw somebody's head open.

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Shhhhh!! Thought I was the only one who realized this about neurosurgery. Let's keep it hushed until March, okay?

H_Caulfield said:

Shhhhh!! Thought I was the only one who realized this about neurosurgery. Let's keep it hushed until March, okay?

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January

mdjobexchange said:

Breast surgery is pretty cush, but women's health does not pay as well as things that happen to old dudes.

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Ah, but the office procedures in breast surgery are where all the money is made, and there are far more women who need a breast biopsy than there are old men with aneurysms/tumors.

That is true, breast cancer is all too common in this country.

Are you talking about FNA's in the office, or doing actual breast biopsies in the office?

Do you know how well these reimburse? I am curious to know. I do not see as much of the in office procedures, since I am in the OR mostly.

You can make pretty good money in the office, especially if you are in a decent sized group and can get your office JCAHO certified and then collect the facility fee. There are companies out there that will help 2 or 3 doc groups get that certification. Basically, facility fees tend to be higher than the professional fee. This is because the Hospitals have better lobbyists than the doctors and they have actually increased facility fees over the last 10 years, while doctors fees have gone down. This is why many doctors have either started, or bought into ambulatory surgery centers, so they can get a piece of that action.

Somebody recently told me that surgeons who do procedures at ASCs where they have partial ownership will only get 70% of the professional fee. Has anybody else heard about that?

mdjobexchange said:

Are you talking about FNA's in the office, or doing actual breast biopsies in the office?

Do you know how well these reimburse? I am curious to know. I do not see as much of the in office procedures, since I am in the OR mostly.

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FNA's, tru-cut core biopsies, etc...

Needle-core biopsies bill ~$127. If you have an ultrasound in your office and use it to perform a core biopsy in the office, it reimburses ~$240-395, depending on the coding (not sure what moves it from CPT 19102 to 19103). FNA's bill ~$143.

If you have a clinic of 15 new patients, it would be easy to imagine you would have at minimum 5 patients who could benefit from a clinic biopsy (this is based on my experience in clinic). 5 * $240 = $1200, plus the billing for the consult, etc...

Partial mastectomies bill $320 and MRM's only bill $920. You can make the same amount of money on a clinic day as you can on an operative day, and (as rapacious as it sounds) rebill many of the women you saw in clinic when their pathology comes back as something requiring a further procedure.

Yeah, but does that offset the torture of having to look at old women's breasts all day? The answer is no.

SocialistMD said:

FNA's, tru-cut core biopsies, etc...

Needle-core biopsies bill ~$127. If you have an ultrasound in your office and use it to perform a core biopsy in the office, it reimburses ~$240-395, depending on the coding (not sure what moves it from CPT 19102 to 19103). FNA's bill ~$143.

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It depends on where you are, but the Medicare reimbursement is a bit more than those quoted above (ie, Core needle, or 19102, is around $200). We usually bill 2 x Medicare; of course, you won't be paid that much but it is a fairly common practice and sometimes you DO get that much.

A 19102 code is for a core needle biopsy, generally a hand held manual device similar to the Tru-Cut. 19103 is for vacumn assisted or rotating core biopsies...bigger cores, more expensive equipment, but reimbursement is around $550 (all numbers reflect 2007 Medicare rates).

In office procedures are where the money is to be made in breast surgery. For example, let's say you have a patient with an ultrasound abnormality. You can charge for the Level 3 office visit (fairly nominal), for the ultrasound examination (to find the lesion) - $75, ultrasound guidance during the procedure (yes, you can charge twice) + biopsy - $200, or $550 (if doing a vac assisted or rotating biopsy).

If your community of radiologists allows you to use their stereotactic machine or you can afford your own (around $250K), they reimburse around $1200, although rates are supposed to be coming down significantly.

If you have a clinic of 15 new patients, it would be easy to imagine you would have at minimum 5 patients who could benefit from a clinic biopsy (this is based on my experience in clinic). 5 * $240 = $1200, plus the billing for the consult, etc...

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In the "real world" those numbers are probably a little high and it is highly dependent on your practice and the community. If you have an academic practice, especially one at a cancer center, it may be very likely that you can biopsy 1 in 3 patients, particularly surgeons who have created enough of a practice that they can demand only to see the BiRads 4 and 5 patients and not deal with breast pain, fibrocystic breasts and the BS consults for "palpable masses" which are just normal breast tissue. In some communities, the radiologist controls biopsies...the Ob-Gyn finds an abnormality, refers the patient for imaging and the radiologist then self-refers for a biopsy. In other communities, such as Northern NJ where I trained, the radiologists would not biopsy a patient without them having seen a surgeon first...so WE controlled who we biopsied and who we didn't. Frankly, we just could not possibly biopsy all the patients who needed them in a reasonable amount of time.

But in the community, especially in private practice where you are dependent on referrals, you do not have the ability to turn away the stuff that doesn't get biopsied, so our rate might be more like 1 in 5. Out of the patients I saw today, 2 had breast pain, 3 needed to go to the operating room (already biopsied), 2 wanted excision in the OR rather than biopsy and 1 wanted an FNA which I did in the office (for a rate of 1 in 8).

Partial mastectomies bill $320 and MRM's only bill $920. You can make the same amount of money on a clinic day as you can on an operative day, and (as rapacious as it sounds) rebill many of the women you saw in clinic when their pathology comes back as something requiring a further procedure.

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Exactly...we lose money in the operating room, or driving there. In most states it is not hard to make good money doing breast surgery as long as you are facile with imaged guided biopsies and can turn the patients over quickly. Surgeons also should be aware of the political battles from radiologists over these procedures and their attempts to block surgeons from doing image guided procedures. Due to a certification process, we have won back the right to be reimbursed by insurance companies as surgeons could show they met the same qualifications that radiologists did.