IM or Surgery?

what is your current level of training?

LGMD said:

Many students find it hard to decide between IM or Surgery...

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I think you are greatly overrepresenting the number of people who have this difficulty. I echo the above post; at what level of your training are you?

LGMD said:

Many students find it hard to decide between IM or Surgery, and I want to know what made you choose either field. I mean how did you decide?
I really like cardiology because of the medical aspect of it and procedures, but also like vascular surgery because of the endovascular procedures so if someone please post pros and cons of each .

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(Be forewarned, I rant a little on this kind of thing.)

I think the problem you're having is similar to the one a lot of non-surgeon doctors struggle with from time to time, especially those guys in procedure-oriented areas like interventional cards, interventional rads, GI, heck, even pulmonary, and renal to some extent. Everyone wants to be the doctor who's able to swoop in like a bad-ass and save the day with his hands and some well placed incisions. It's romantic. It's the Hollywood doctor. It's what lay people think about when they think about how this doctor or that doctor saved a life.

Look at the medical dramas on television or reality television series like those ER shows on Discovery. They depict physicians in a constant life and death struggle. It's cool to gown up, slap on the gloves, do the little dance with the tech and then drape the patient and crack the chest, lap the belly, or soemthing similar. That's the kind of drama I believe a lot of people go to medical school for, but find that the majority of physicians (those trained in IM instead) just sorta sit around all day, discussing social work issues, and running laundry-lists of medications just waiting for the clock to hit 4PM.

So what's my point? You want to be a surgeon, or at least have the look and feel about you, but you don't want to put in the kind of time necessary to learn the art in its full form. It's a common thing amongst the non-surgeons. That's why they become the interventional cardiologists, GI docs, renal docs, etc. That's why these interventioanlists and endoscopists keep moving toward doing more and more and pushing that envelope. 'Cause they want the glory too. A GI doc wanting to make the case that THEY should do NOTES? A renal doc telling me that THEY should be the ones maturing the AVFs that I create? An IR guy telling me that THEY should be deploying endografts to fix a AAA? Why else would the patient sitting in preop that I'm about to take to resect her colon refer to her GI doc as "my surgeon?" That's cause the GI doc lets her think that. He says things like "I'm going to do an operation on you to resect the polyp," when he really just means he'll scope her and snag the polyp stalk. Big deal. That's why the IR suite at my institution has "Surgery Suite," plastered all over the front entrance and why the Chief of IR told his kid (during a "take your kid to work day" at the hospital), "Daddy's a kind of surgeon. Come see where Daddy operates." Pathetic.

Sure, they like the feel of someone referring to them as a "surgeon," but they can't handle the complications at all. The boldness of non-surgeons, I think, is a problem when they become too arrogant. It's dangerous and irresponsible. Like my Chairman says, "If you go bear hunting, you better know what to do when you find a bear."

So in answer to your question, there shouldn't really be a struggle. If you want to be comprehensively trained to work with your hands and to be that superhero doctor, then become a surgeon. But you do it with the knowledge that your lifestyle will be significantly different from a medicine doctor and that sometimes you will be called upon as a last resort to fix a bad, bad problem that some lesser-trained doctor caused because he was too arrogant to realize he was headed in dangerous territory. And this often happens on a Friday or Saturday evening when you have dinner plans with your wife or friends.

There may be a bit of a blur between Interventional Cards and Vascular Surgery in your mind, but they are vastly different fields. Vascular Surgeons treat peripheral vascular disease medically, surgically, and sometimes with a stent or endograft. Cardiologists should really only be playing around in the heart with their catheterizations and stuff, but because of their greed, arrogance, and their first crack at vasculopaths, they've started to play around in the peripheral vacular system. It's not right and patients have terrible outcomes because of it.

The training time frame is about the same, although it's a little modified now.

Vascular Surgeons train in one of several ways:
* Five or more years of General Surgery Residency + Two years of Vascular Surgery Fellowship
* Four years of General Surgery Residency + Two years of Vascular Surgery Fellowship
* Three years of General SUrgery Residency + Three years of Vascular Surgery Residency
* Five years of Vascular Surgery Residency

Interventional Cardiologists, on the other hand, train through three or more years of Internal Medicine Residency (including a "Chief Residency" in IM) + three years of Cardiology Fellowship + a year of Interventaional Cardiology Fellowship.

Good luck. Sorry for the rant, but it sometimes just drives me up the wall when these guys mess up because of their arrogance and disregard for the patient and expect you, the surgeon, to fix it up for them so they won't get sued. You're somewhat obligated, but I question the wisdom of this as I think it only allows them to try and get away with more since there's always a fall back guy.

it happens.

what about percutaneous valve replacements coming on the horizon? shiznit.

Castro Viejo said:

So what's my point? You want to be a surgeon, or at least have the look and feel about you, but you don't want to put in the kind of time necessary to learn the art in its full form.

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In a sense I don't entirely blame the physicians. After all, one of the well-known motivations for going into surgery is that the patient gets better (or dies) after surgery. But either way, it's very visual. Contrast that to IM where they can be doing a bang-up job titrating the meds of a NYHA III patient and that guy may not give a crap. People recognize procedure-based interventions. But, yeah, that being said, it seems like everyone wants the high-profile of a surgeon but not the committment (even some surgeons these days).
One thing that irritates me is how IR thinks that putting in perc drains is difficult. Like, I'll go down there and they act like they're the hotshots of the basement. They'll be like, "whatchu want? That thing? Yeah, we'll slap it in there, no problem. You're welcome." OK, you're cool. Um, you put a grid on a patient, imaged them, and then poked. This is real intense stuff here. Don't get me wrong, they're great at what they do; I just don't really think that what they do is very difficult.

Castro Viejo said:

There may be a bit of a blur between Interventional Cards and Vascular Surgery in your mind, but they are vastly different fields. Vascular Surgeons treat peripheral vascular disease medically, surgically, and sometimes with a stent or endograft. Cardiologists should really only be playing around in the heart with their catheterizations and stuff, but because of their greed, arrogance, and their first crack at vasculopaths, they've started to play around in the peripheral vacular system. It's not right and patients have terrible outcomes because of it.

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Awesome Post, Castro.

One of the biggest problems with Cardiology is that when they have a late-night problem with bleeding from a cath site, they'll just tell the nurse to page a surgery consult because they don't want to come in and deal with it. If you're too good to deal with the complication, then don't do the procedure.

doc02 said:

In a sense I don't entirely blame the physicians. After all, one of the well-known motivations for going into surgery is that the patient gets better (or dies) after surgery. But either way, it's very visual. Contrast that to IM where they can be doing a bang-up job titrating the meds of a NYHA III patient and that guy may not give a crap. People recognize procedure-based interventions. But, yeah, that being said, it seems like everyone wants the high-profile of a surgeon but not the committment (even some surgeons these days).

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It's absolutely insane. An "interventional nephrologist" I know introduces himself as a "nephrologic surgeon" to lay people. WTF? What the hell is a nephrologic surgeon? You stick a needle into some organ and all of a sudden you're that organ's surgeon?

So the time the ER doc called me down to deal with a chest tube he put into the right lobe of the liver, he was practicing hepatobiliary surgery?

*****s.

doc02 said:

One thing that irritates me is how IR thinks that putting in perc drains is difficult. Like, I'll go down there and they act like they're the hotshots of the basement. They'll be like, "whatchu want? That thing? Yeah, we'll slap it in there, no problem. You're welcome." OK, you're cool. Um, you put a grid on a patient, imaged them, and then poked. This is real intense stuff here. Don't get me wrong, they're great at what they do; I just don't really think that what they do is very difficult.

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Well all this posturing is meant to make you, the surgical resident, feel like they've got one up on you. Gimme a break. Any one of those guys would salivate over the idea of being able to do what you do on a daily basis. And they'd probably slobber all over your attendings, just hoping to gain validation and legitimacy from a real live surgeon.

They don't call medicine one big turf war for nothing.

It boils down to who has control of the patient. You can make fun of the interventional cards, GI, renal docs all you want, but you have to remember that there is an incestuous relationship between the interventional and non-interventional IM specialists. It finally took an act of Congress to break up the imaging self-referral abuse that the cards were engaging in.

LGMD said:

Castro get over yourself and your arrogance.

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I suggest you show Castro's post to your father and other family members who are CT and vascular surgeons (per an earlier post of yours) and see if they don't agree with him.

It may seem arrogant to you, but until you have seen the problems caused by physicians who aren't trained to do a procedure or surgery, all the while insisting they are just as good as a surgeon, then you really have no idea. I cannot say loud enough, "if you cannot handle the complication of something you are doing, then you shouldn't be doing it!"

Besides, who's being arrogant here - the surgeon who doesn't try and manage complex medical problems because he knows that isn't what he was trained to do or the internist/IR/cardiologist/GI who assumes that he can do both (without adequate training) AND call himself a surgeon?

'Tis true. These days the wannabes want to be like real surgeons without paying their dues. Bring back the unlimited hours, pyramidal, attending-surgeons-can-do-and-say-anything-they-want-to-the-underlings-old-school-style and watch how fast the wannabes will flee from surgical training like rats from a sinking ship. When you soften the training to accomodate people who are more concerned about their "personal life" more than being a surgeon this is what ends up happening.

Great post Castro! A truly great rant.

Castro Viejo said:

majority of physicians (those trained in IM instead) just sorta sit around all day, discussing social work issues, and running laundry-lists of medications just waiting for the clock to hit 4PM.

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So true, so true. The exact reason I hated my medicine rotations. Never really felt like anything was achieved after a day of "work". More like standing around, tweaking medicines, and after a couple of days sending the patients home.

Castro Viejo said:

"If you go bear hunting, you better know what to do when you find a bear."

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Great quotation, I'll have to remember that one.

oh whats that......LGMD was asking ways to decide between IM and surgery.....you guys are straight forwardly making LGMD hate IM....
true surgeons !hahahahaaha...................

LGMD said:

Castro get over yourself and your arrogance.

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I know you think it's arrogance. I know you think, "Ooh, what a jerk. Those surgeons are just misanthropes and like to yell all the time."

Spend just six short hours being the General Surgery consult resident in any hospital, including my 900 bed hospital, seeing about 30-40 consults per call (Distended abdomen on a guy who had an MI and EMS was BVMing them like nuts in the field, patient tripped walking along the street on a curb and fell face first, or my personal favorite, 99 year old guy on Medicine in septic shock from urosepsis on every pressor known to man, on Xigris, but he has an a reducible inguinal hernia and no signs of intestinal obstruction -- does General Surgery need to urgently repair the inguinal hernia?), taking care of all the procedural mishaps from the non-surgeons (chest tubes in the liver, I'm a medical intern and I can't/don't wanna/don't feel comfortable putting in a Foley catheter, help this NG tube doesn't seem to want to go down into the stomach, or my favorite, patient died on Medicine but had a CVL stitched in, please come take it out), being called in as an intraop consult by GYN (Did we cause any enterotomies? Is this the fascia we're sewing closed?), and heck, even getting called at 2AM by the Radiology Resident, "Hey, I was wondering if you could come down here and look at this scan and tell me if you see appendicitis."

It ain't arrogance when the rest of the world puts you on that pedestal and asks you on a daily basis, "Please, please, please come fix my mistake."

I'm one of the most un-assuming surgeons you'll ever meet. Plenty of my friends are in the Medicine program. Plenty of my friends are Radiologists, Neprhologic Surgeons, and all that other non-surgery stuff, but while I may be a little strong in my opinions, I don't think they're that far off from what a lot of other surgeons feel.

If you don't think you can run with the big dogs, have fun being an internist or some other medicine doctor. Someone's gotta do that job anyway.

Awesome Post Castro Really reminds me of my motives.

doc02 said:

One thing that irritates me is how IR thinks that putting in perc drains is difficult. Like, I'll go down there and they act like they're the hotshots of the basement. They'll be like, "whatchu want? That thing? Yeah, we'll slap it in there, no problem. You're welcome." OK, you're cool. Um, you put a grid on a patient, imaged them, and then poked. This is real intense stuff here. Don't get me wrong, they're great at what they do; I just don't really think that what they do is very difficult.

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This reminds me of last week when an IR "surgeon" calls me and my resident in to see this guy he just did a retroperitoneal bx on. The guy's pissed out two units of blood and the IR is standing there kind of like WTF? The guys pressure is in the 80's and they are setting there watching him like that will make him better. Thankfully there were a couple "real" surgeons around to stabilize the guy. I realized then how I would hate to be that guy that can do stuff but that's it. It's like they can take a ****, but have to get someone to wipe them. No thanks. This guy gets admitted to someone else for a problem they didn't create because the IR can't admit, what BS.

I'll remind users to keep this civil and refrain from making comments about each other's personality. Besides, you cannot be suprised that when you make assumptions about a field ("many students have trouble deciding between IM and Surgery" - even the guys in the IM forum told you that wasn't true) or insult its practitioners, that we will react in a similar fashion.

One also has to wonder about your motives. You've asked the same question multiple times in multiple forums and appear to be inciting riot by posting Castro's response in the IM forum. We're not trying to hide anything but suffice it to say that it doesn't make for good bedfellows when you post a potentially inflammatory response in forum of people who hold a different opinion about a field.

Regardless of whether anyone thinks the other user is being arrogant, MIS is NOT the "wave of the future". MIS has been very successful in many areas and does continue to expand. However, many procedures which were envisioned to be easily done as a minimally invasive technique have proven not to be as successful as the traditional open procedure. And it is highly unlikely that every procedure will be:

a) amenable to the minimally invasive technique; just because you can do something doesn't mean that MIS is the best way

b) will be accepted by the medical community and the general public

If and when we get to the place where we can just wave a tricorder over a patient's body to diagnose and treat them, most of us will be long dead or at the very least retired (or frozen heads sitting alongside Ted Williams).

IMHO, there will always be work for those doing open procedures.

A fair question is, how often do complications needing surgery arise when interventionalists perform the procedure? If only a small fraction of cases result in surgical intervention, then that weakens the argument that only surgeons should be doing these procedures. Most places will have surgery backup if the interventionalists screw up.

Taurus said:

A fair question is, how often do complications needing surgery arise when interventionalists perform the procedure? If only a small fraction of cases result in surgical intervention, then that weakens the argument that only surgeons should be doing these procedures. Most places will have surgery backup if the interventionalists screw up.

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If you'll take just a few steps back, the whole idea might start to look stupid. If a procedure carries the risk of complications that need to be fixed by a surgeon, doesn't it just make a whole LOT of sense to have the surgeon perform that procedure to begin with?

Taurus said:

A fair question is, how often do complications needing surgery arise when interventionalists perform the procedure? If only a small fraction of cases result in surgical intervention, then that weakens the argument that only surgeons should be doing these procedures. Most places will have surgery backup if the interventionalists screw up.

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Why should surgeons have to ever back up interventionalists? They're so hot to trot to do the cases when they're uncomplicated and make them lots of moolah; but when something goes wrong, they're like, "whoops, oh well, call Surgery and get them into some eighteen hour case, meanwhile I'm going to bed and they can round on the patient for the rest of the week." Then they unzip their pants and make like it's happy hour.

H_Caulfield said:

If you'll take just a few steps back, the whole idea might start to look stupid. If a procedure carries the risk of complications that need to be fixed by a surgeon, doesn't it just make a whole LOT of sense to have the surgeon perform that procedure to begin with?

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I'm just playing devil's advocate. A response would be, are there enough surgeons to perform all of these procedures and what's the most cost-effective approach? Take for example the colonoscopy. There's an inherent risk of perforation that may need surgical intervention yet we allow GI docs and even nurses to do them (I've read of an NP in Alaska who has done thousands of them). The wait would be months if only surgeons performed them. In a recent article regarding virtual colonoscopy in the NEJM, 3163 patients underwent traditional colonoscopies but only 4 needed surgical intervention. The argument of only allowing surgeons to do these procedures sounds like the argument of should we give everyone who comes to the ER with a headache an MRI to rule out brain cancer. We could, but it would not be cost-effective because the chances of the person actually having brain cancer is miniscule.

If there's an NP somewhere doing colonoscopies, she'd better be good at them. Meaning, 0% complication rate and 100% sensitivity. That's like if you gave a colonoscope to a random person off the street and was like, "here ya go, champ, this goes into the butt, run along now." I don't know how they roll in Alaska, but if I was called by an NP who said she perfed a colon doing a colonoscopy, I'd just spend the next two hours laughing into my phone. Then, I'd hang up abruptly and change my number.

doc02 said:

If there's an NP somewhere doing colonoscopies, she'd better be good at them. Meaning, 0% complication rate and 100% sensitivity. That's like if you gave a colonoscope to a random person off the street and was like, "here ya go, champ, this goes into the butt, run along now." I don't know how they roll in Alaska, but if I was called by an NP who said she perfed a colon doing a colonoscopy, I'd just spend the next two hours laughing into my phone. Then, I'd hang up abruptly and change my number.

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... and the patient would die.


Last year, one of our professors told us about (the urban legend?) a GI doc who was doing colonoscopy in his office. He nicked an artery pulling off a polyp with the scope and had a huge bleed. Story was, he had to stick his hand (fingers?) in there to stop the bleed. The doc had his nurse call 911 & EMS carried the two lovebirds to the ER like that.

I doubt whether or not the story is true, but could you imagine being the one to bail him out?

-Goose- said:

... and the patient would die.

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Um, so? People say that stuff in the medical field all the time. They're like, "OK, you have to accept MY premise that this is how things are going to be ...and now you react to it! Go!" If you're so concerned about the patient, then the time to be concerned is BEFORE you hand a scope to an NP. It's all nice for you to hand it to the NP and then AFTERWARDS say, "woah, let's think about the patient ...guilt trip, anyone? That's what I thought! Yes!!" What if I started letting my secretaries perform colonoscopies and then called you because one of them perfed a colon or maybe missed a huge lesion? I guess you'd be like, "ah, interesting ...tell me more!!" I'd love to prank call some of you guys. "Hey, my two-year-old was doing an LP and ..." "Woah, uh, what?" "What? What's wrong? You got something against that?" "No, it's just that -" "THINK OF THE PATIENT, MAN! GET IT TOGETHER!!!" "Oh, right!"

LGMD said:

Castro, while I see where you're going with this, you know you sound like you are complaining in your post. I imagine people really have you up on a pedestal. Great post, my hat is off to you, cry me a river on the way out. Maybe you can't or don't want to see that surgery is not the same it was before, with all its glory, and it makes you feel bad or something. Or you may have a problem accepting that minimally invasive techniques are the way of the future.

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I know it's hard for you to understand just how a surgeon feels on a daily basis, but until you've done it, I doubt you ever will. And for a third-year medical student your level of presumption, I would consider, is much more arrogant than whatever you perceive about me when reading this thread.

Tired said:

I was taught that what makes a good surgeon is not necessarily the ability to fix all your own complications, but the ability to anticipate said complications and recognize when they have occurred. If GI occassionally perfs bowel, but they know when they've done it and know to call surgery, then what's wrong with that? I mean really, it's just more money in the pocket of the surgeon.

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Because some mistakes just can't be fixed or carry some disgusting morbidity and the patient is the one who lives with it. Now what was all that for? So that the GI, IR, Interventional Cards guys can line their pockets with some extra cash? That's just not right. There's no way you can convince me why a non-surgeon should even be doing anything invasive.

Now, the reason why it occurs is an entirely different discussion and has nothing to do with medicine or patient care at all. (Hint: It's about money and referral base and threats of taking one's patients to a surgeon who won't take a bite outta the colonosocopy pie)

Remember the story about Icarus? And how he was so arrogant and didn't heed the advice of his dad about flying too close to the sun and he plunged to his death? Well, these non-surgeons are being dangerous with the things they do only in their case they've got the safety net of a surgeon standing by to bail them out.

Tired said:

But this concept applies to a host of procedures, including common procedures done by General Surgeons themselves. There is an inherrent risk of transecting the superior laryngeal nerve in thyroidectomies, which (at least in places I've trained) requires repair by Plastics. Does it then follow that only Plastics should do thyroidectomies? Should orthopaedic surgeries be taken over by Vascular? Should Gyn do no surgeries at all, since they occassionally nick the bowel?

I was taught that what makes a good surgeon is not necessarily the ability to fix all your own complications, but the ability to anticipate said complications and recognize when they have occurred. If GI occassionally perfs bowel, but they know when they've done it and know to call surgery, then what's wrong with that? I mean really, it's just more money in the pocket of the surgeon.

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You are correct. One major Difference between intervensionalist doing a procedure, and a surgeon is that when there is a complication we are there. We recognizing it and call for assistance at the bedside with a specific question or concern. We don't have a nursing call, or call from a remote location with a "can you go figuire this out for me"

We have a few GI docs perf a colon (it happens), and they typically admit the patient, and we manage. And I think that is okay.

Often we need help of IR for our patients with postop abdominal abscess. Our complication.

I think many in this thread feel that often an interventialist starts a relationship with a patient. Does his procedure, and then has a complication that is delayed in its diagnosis. This doctor then abandons his/her patient.

I thought this debate about whether interventionalists should be doing invasive procedures has already been settled. From IR to interventional cards and now interventional GI and renal, it's kinda hard to put the genie back in the bottle. As some traditional surgeries are usurped by the interventionalists, surgeons will have to evolve with the changes.

IR bails out surgeons sometimes too. draining abscesses for surgeons which occur post-operatively? draining a gallbladder in the patient who has a high operative risk. anyway, just being devil's advocate. we all work together!

That's not a bail-out. If IR went on strike tomorrow, we could still drain our own abscesses. Don't confuse the two things. The fact that IR can place a percutaneous drain is not a "bail-out" because we can drain the abscess, too. It just would be a more morbid procedure to re-enter the abdomen. That's like saying Cardiology "bails" us out of CABGs on single-vessel coronary disease. If you want us to do them, we'll do them. In contrast, if we decide not to help out these other services, they're screwed. It's not a matter of "we could do it, but there are better ways." It's more like, "oh, shizz."

LGMD said:

All hail the can-do-everything surgeon. You may call it bail out or not but at the end, all services are necessary (even those that need your stellar backup) and all work together towards better patient care.

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All services are not necessary. Before you reflexively think that I'm just being arrogent, why don't you stop and think about what I actually wrote? We can drain an intra-abdominal abscess, it would just be at a much higher morbidity level. Therefore, nobody is arguing that doing it percutaneously is better. However, I don't consider that a "bail out" -- it's a better way to do it, not "since you're up s**t creek without a paddle, I'll step in and save your a** since I'm a nice guy." Trying to act like that's the same as when we have to ACTUALLY bail out other services is silly.

LGMD said:

Could you please tell us all which services are not necessary? If they are present in the hospital they must be a need for them, one way or another.

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doc02 may have been talking about service in the terms of a procedure rather than a service as in department. Let's take IR for example.

Every procedure IR does can be done by someone else.

They are present in the hospital because they provide a service, one which may be better for the patient but they are NOT NECESSARY. Patients had abscesses drained and many other things long before IR even existed.

No one is arguing with you that we don't need each other, but doc02 has a very valid point in that the services or procedures they do can be accomplished in a myriad of other ways. However, when another service perforates an organ or hollow viscus, there is no way of repairing that except for calling surgery.

You know what's sad? If you read my post, I clearly state that a percutaneous drain is BETTER and LESS MORBID. But since I disagree with that guy, he's like, "I refuse to read what you're writing, let's just yell at each other for a while." Are we dating or something? If so, we have to move to Massachusetts and prance around.

LGMD said:

All hail the can-do-everything surgeon. You may call it bail out or not but at the end, all services are necessary (even those that need your stellar backup) and all work together towards better patient care.

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Not true. Services within the institution exist for a variety of reasons, sometimes the least of which is patient care.

As for working together towards better patient care, I'll agree with that when I see the cardiologists back off and stick to only hearts, the IR guys resist the urge to stent things they have no clue about, and if the GI guys ever say, "You know what, we're not the best qualified people in the hospital to do NOTES. We should just stick to our basic endoscopes."

Only THEN will everyone be working toward the patient's best interest and not whether or not they can afford their Maserati's payment next month.

The idea that even the majority of physicians are working together for "patient care" is ludicrous.

I'll remember that the next time I see a dentist advertising face lifts, or a dermatologist doing liposuction.

Kimberli Cox said:

I'll remember that the next time I see a dentist advertising face lifts, or a dermatologist doing liposuction.

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Some of these derm chicks can probably make good money being masseuses, however. That should be part of their training.

I don't know about you guys but I would never, ever, ever, ever go into Medicine in this life. I was disgusted by most of the internists I interacted with as a medical student. While most of the old (above 50 or something) internists were nice and great educators, most the young ones (being attendings for a few years) I encountered were jerks and a**holes (females included). While surgeons are either nice or nasty, they are honest about it. If you suck at something, they are frank with you about it and tell you'd better improve your skills/knowledge. On the other hand, internists are like "it's okay," "that's fine", "no problem", "you're fine" and smiling at you then talk S**T about you behind your back. I abhor IM.

Don't give surgeons so much credit.

There are just as many chickens in surgery (or at least a few) who will tell you nice things to your face and then rip you a new one on your evaluation.

Castro Viejo said:

Not true. Services within the institution exist for a variety of reasons, sometimes the least of which is patient care.

As for working together towards better patient care, I'll agree with that when I see the cardiologists back off and stick to only hearts, the IR guys resist the urge to stent things they have no clue about, and if the GI guys ever say, "You know what, we're not the best qualified people in the hospital to do NOTES. We should just stick to our basic endoscopes."

Only THEN will everyone be working toward the patient's best interest and not whether or not they can afford their Maserati's payment next month.

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I seriously doubt many GI docs are going to be interested in NOTES. My understanding is the reimbursement on a Lap Chole, and a Colonoscopy is roughly $300 (is that about right Dr. Cox?). In the time it would take to yank a gallbladder through someones stomache or anus they could preform 5 or 6 colonoscopies.

doc02 said:

All services are not necessary. Before you reflexively think that I'm just being arrogent, why don't you stop and think about what I actually wrote? We can drain an intra-abdominal abscess, it would just be at a much higher morbidity level. Therefore, nobody is arguing that doing it percutaneously is better. However, I don't consider that a "bail out" -- it's a better way to do it, not "since you're up s**t creek without a paddle, I'll step in and save your a** since I'm a nice guy." Trying to act like that's the same as when we have to ACTUALLY bail out other services is silly.

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To fan the fire, most surgeons could actually perform the less invasive abscess drainage if we had access to the imaging machinery. There is a surgical-driven initiative at Baylor for surgeons to perform the cholecystostomies and their complication rate is right on par with that of most interventional groups now that they have access to the ultrasound.

When we have other services help out, it is because they have technology we don't have that make things less morbid or because it allows us to spend our time helping other patients who need the OR time; it is never because we can't take care of the complication ourselves. That is the thing that makes me the proudest about being a general surgeon; I can do any of the "life-saving procedures" (at least to temporize things), I can take care of critically ill patients and I can manage my own complications when they arise. No other specialty can say that.