Want to operate...not sure on what

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gstrub

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So I am nearly positive about surgery...I mean I can't picture myself doing anything else and enjoying it. I am having some problems deciding just what type of surgeon fits me best, so I thought I'd post a few facts and maybe get some guidance. I rotate back to M3 in August (MD/PhD).

What are my interests?This is the problem. I originally was set on transplant because I thought the science was so cool. Then I considered trauma because of the pace/excitement. But then I thought why don't I just shoot myself in the balls...it might be as enjoyable. Neurosurgery would take the same time as transplant or CT, and ENT or Urology even less. But then the competiveness factor comes in...I (my wife) really want to live in a desirable area, so was considering programs like Vandy, UCSF, Stanford, etc. However I'm not sure of my chances in the subspecialties in these big name programs, where I am hoping my basic science background would help.

I don't have the tolerance to do plastics and deal with vain women and bumps on their noses at 17 years old that they believe are detrimental to their health. However a reconstructive fellowship following ENT may be an option.

I am not really thrilled with urology, but I admit I really don't know anything about the field, save operations on johnsons. I also know very little about optho.

I don't mind hard work and long hours, as long as it's not COMPLETELY absurd.

I don't need to be doing active research right away...but I would like to be in a field where research tangibly contributes, and where my PhD may open doors eventually.

I think I would be equally happy in an academic or private practice setting.

I can't stand not getting paid for what I'm doing. I don't need a million dollars a year, but I expect to be living a very comfortable lifestyle.


So....any thoughts? (Please don't refer me to the personality test...I took it. Neurosurg, thoracic, plastics, gen surg, and urology all tied for #1).

Thanks...
G

PS Stats: Step I 230, top 1/3 of class, few pubs (one in Science).
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Quick question...what made you decide on an MD/PhD program? Is there something about basic science that appeals to you?
 
When you return to MS 3 you might get some more surgical experience which will help you make your decision.

However, what it really comes down to now is:

General surgery vs a subspecialty

If we ignore the integrated programs, you either have to do general surgery first (ie, to get into transplant, trauma, plastics) or you match into a subspecialty out of medical school. If you choose the former, you have several years before you have to make up your mind. General surgery is still, for the most part, less competitive than ENT, Uro and Neuro although at places like Vandy, UCSF, etc. it will certainly be competitive.

Some gen surg specialties that have good lifestyle with better income would be surg onc, colorectal, even breast.

I find what is helpful is to think about what would be the worst thing you would do in each specialty and decide how bad that would be for you. In colorectal it might be dealing with poop, doing rectal exams, having IBD patients. In plastics it most likely will be consults for decubitus ulcers, etc.

You will never get to experience all fields of surgery before making a decision. I did no ENT before 3rd year of general surgery and found I really liked the H&N cases; I had never thought about it during med school.

So you have lots of time left before you need to make up your mind and instead concentrate on Gen Surg vs subspecialty.
 
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That's great advice, and I never really considered it in that way before. For me, I knew I wanted the foundation of a General Surgery residency (regardless of the fact that I was already interested in CT Surg). I liked the breadth of the general surgeon's knowledge, and the extensive armamentarium that one acquires after a rigorous five-year training period.
 
Dr. Cox,
Thanks...clearly this is the decision I am toiling with. I have already spent nearly a decade of my life after college (2yrs masters in genetics, now 7 year MD/PhD program), and am not sure I want to do another 5-7 in general surgery and then 2 more in a fellowship, before I make even 100k a year (remember I have a young family up and coming). I'll admit, the time till being independent is weighing on me, because I have been leaning toward general, but only in the context of a fellowship, and that means 9 more years. I could be an ENT attending in almost half that time. Additionally, I am not sure what the more important decision is at this time...how much time to spend, or what to specifically do?

Blade, I did MD/PhD for a variety of reasons. Mostly I liked the idea of learning the basic science behind a lot of medicine as well as the techniques to investigate it (not to mention the extra $250,000), but ask any G3 Md/PhD student to defend their decision of going into the program and you will not find much enthusiasm. There is an academic surgeon here with an active lab and he is a total badass, so maybe I was inspired.

I think I am going to try and get some more OR/shadowing experience with the subspecialties. Perhaps the perspective will change things for me.

The issue I struggle with is that it is difficult to gain enough experience in a particular surgical field to say "this is definitely what I want to do" before you commit to it. And the different times to complete the different training you know ahead of time...
 
As someone who is older I'll tell you that while I understand the need to "get on with it", you will eventually be 40 or 50 or whatever and it would be better to do what you really want to be doing, rather than worrying about an additional 2-4 years.

That said, a family can make a big difference and is certainly one reason why people want to hurry up and finish so that they can give their family all the things they've been denied while you've been overworked and underpaid.

So no one is going to be able to tell you whether or not the extra time is worth it. You could extend the argument to say why "waste" your time doing surgery at all? You could be an FP or EM attending in as few as 3 short years. Obviously its not what you want to do, but the argument was made purposely ridiculous to show you that the length of training is not particularly important for most people with a supportive family and a dedication to do what they really want to do.

Probably the safest thing to do if you still can't decide is to at least apply for General Surgery. If you are dying and end up deciding to do ENT, you can probably get credit for your Gen Surg time; the opposite may not be true. It would be a plus if you matched at a prgram that had both...always easiest to switch tracks at a program that knows you.

So try and figure out what it is you you like about ENT or any other specialty. Is it working with children, or cancer cases, or lots of short cases vs long H&N ones, etc. At least knowing that will tell you a little bit more about your needs and interests as you move through your clinical years.
 
gstrub said:
Dr. Cox,
Thanks...clearly this is the decision I am toiling with. I have already spent nearly a decade of my life after college (2yrs masters in genetics, now 7 year MD/PhD program), and am not sure I want to do another 5-7 in general surgery and then 2 more in a fellowship, before I make even 100k a year (remember I have a young family up and coming). I'll admit, the time till being independent is weighing on me, because I have been leaning toward general, but only in the context of a fellowship, and that means 9 more years. I could be an ENT attending in almost half that time. Additionally, I am not sure what the more important decision is at this time...how much time to spend, or what to specifically do?

Blade, I did MD/PhD for a variety of reasons. Mostly I liked the idea of learning the basic science behind a lot of medicine as well as the techniques to investigate it (not to mention the extra $250,000), but ask any G3 Md/PhD student to defend their decision of going into the program and you will not find much enthusiasm. There is an academic surgeon here with an active lab and he is a total badass, so maybe I was inspired.

I think I am going to try and get some more OR/shadowing experience with the subspecialties. Perhaps the perspective will change things for me.

The issue I struggle with is that it is difficult to gain enough experience in a particular surgical field to say "this is definitely what I want to do" before you commit to it. And the different times to complete the different training you know ahead of time...
Click to expand...


I would just bag the whole surgery thing and do GI. Obviously you would have to do an internal medicine residency first, but you would learn a lot. GI has a great lifestyle and a wide array of procedures. There is an incredibly high demand for GI doctors, even in major cities. The job market is wide open.
 
rapid said:
I would just bag the whole surgery thing and do GI. Obviously you would have to do an internal medicine residency first, but you would learn a lot. GI has a great lifestyle and a wide array of procedures. There is an incredibly high demand for GI doctors, even in major cities. The job market is wide open.
Click to expand...

:rolleyes: Give it a rest already.
 
rapid said:
I would just bag the whole surgery thing and do GI. Obviously you would have to do an internal medicine residency first, but you would learn a lot. GI has a great lifestyle and a wide array of procedures. There is an incredibly high demand for GI doctors, even in major cities. The job market is wide open.
Click to expand...

Curious.

Just two days ago YOU were asking US about GI job opportunities, salary, lifestyle, etc. in comparison to surgery. Seems you've figured it out all by yourself.:rolleyes:
 
rapid said:
I would just bag the whole surgery thing and do GI. Obviously you would have to do an internal medicine residency first, but you would learn a lot. GI has a great lifestyle and a wide array of procedures. There is an incredibly high demand for GI doctors, even in major cities. The job market is wide open.
Click to expand...

:sleep:
 
I am starting to think ENT is the right way to go...my friend is a PGY3 ENT resident and parties more than me.

Now to apply to 50 programs...wahoo.
 
ENT is a great field (I'm clearly biased)...


I knew a lot of residents who partied when I was a med student. Many of them were just the type who didn't care if they were dead tired at work the next day. Not all of them were in cush residencies. ENT is a surgical field and thus the hours can get a little long and unpredictable. Just make sure you can manage that. Good luck!
 
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Was going to add, just because the PGY-3s in ENT are partying doesn't mean the 1s and 2s don't get beat down. :) (We do a lot of rotations with them in our first two years.)
 
Castro Viejo said:
:sleep:
Click to expand...


I am really enjoying myself on the surgery forum and I think I am here to stay. I think it is appropriate given the fact that I do such invasive procedures (endoscopic surgery of the GI tract). So if you guys don't mind, I am going to settle in and interject with frequent comments. Just consider me one of the group now. Thanks!
 
Everyone is welcome to join in, regardless of specialty. As you note, we share many of the same procedures and outlooks as GI, Cards, Anesthesiology, etc. and I for one welcome other people here. Every now and again I get tired of all the surgery types around here.

But you have to have more than 9 posts before we accept you in the club. I think 10 is the minimum where you don't have to give your last name, it takes 50 before you can come over without calling first, and a good hundred or so (preferably spread out over several weeks to months) before you don't have to knock when you come in.:laugh:

So, what is "endoscopic surgery of the GI tract?" I'm not trying to be obnoxious but I really have no idea what you are referring to (unless its NOTES, papillotomies, etc.)
 
he's kidding, right?
 
rapid said:
I am really enjoying myself on the surgery forum and I think I am here to stay. I think it is appropriate given the fact that I do such invasive procedures (endoscopic surgery of the GI tract). So if you guys don't mind, I am going to settle in and interject with frequent comments. Just consider me one of the group now. Thanks!
Click to expand...

I don't mind, but this is proof-positive that you've always wanted to be a surgeon but had to settle for GI.

"Endoscopic Surgery?" Really? Is that why all my patients refer to you as their surgeon? Does it make you feel good? Of course it does! :idea:

PC? This is why not being a moderator is great. :laugh:

Remember the old anti-dental wars I used to get involved with as a moderator on Pre-Allo and Allo? Ahh... Good times.
 
Endoscopic surgery? Haha. If you ask me, when you get right down to it only surgeons should be driving scopes. That's because they are the only ones that can fix it if they break it! I.E. if they happen to perf someone, they are the ones that have to go in there and clean up the mess. I love it (actually I don't love it but I am particularly entertained) when GI guys try to say that FM docs should never be allowed to drive scopes. That's like the epitome of hypocritical. Neither GI nor FM docs can fix someone if they make a mistake. Why do GI docs feel like they should be allowed to drive scopes if other medical doctors (not surgeons) shouldn't be allowed to? Neither can fix what they break. It just makes absolutely no sense to me. Either medical doctors should be allowed to drive scopes (including GI and FM as well as gneeral IM) or it should be only/strictly surgeons. That's the only two logical conclusions I can come to. And in all honesty, I lean towards it being strictly a surgeon privilege. Of course, when I was doing FM I felt like everyone should be allowed. But now that I am in the process of switching over to surgery, I feel like it makes more sense to only allow those privileges to those who can fix any mess they might accidentally make.

I'd be curious to hear the opinions of people on here in regards to this. Also I would be interested to hear about what the resident surgeons here are going to have as their policy in dealing with GI docs who perf the bowel during endoscopy procedures. Are you going to agree to repair all of them? Repair only those who you have a pre-existing agreemnt with? Start trying to avoid having to deal with repeat offenders (i.e. those who seem to have perf as a common occurence)? Where does everyone stand?
 
Tn Family MD said:
Why do GI docs feel like they should be allowed to drive scopes if other medical doctors (not surgeons) shouldn't be allowed to?
Click to expand...

Well, maybe it's because they did a 3 year fellowship.


Tn Family MD said:
I'd be curious to hear the opinions of people on here in regards to this. Also I would be interested to hear about what the resident surgeons here are going to have as their policy in dealing with GI docs who perf the bowel during endoscopy procedures. Are you going to agree to repair all of them? Repair only those who you have a pre-existing agreemnt with? Start trying to avoid having to deal with repeat offenders (i.e. those who seem to have perf as a common occurence)? Where does everyone stand?
Click to expand...

You forget that a perforated bowel is a surgical emergency. I don't know that I would ever turn away a patient who could possibly die because I resented the GI doc doing scopes.


I know we're all into medicine hate right now....but does anyone honestly believe that GI docs shouldn't be doing endoscopy? That's ridiculous. If we break down the numbers, colon perforation rates are like 0.1-0.5% How many surgical procedures do we have with higher complication rates? Are we treating all of our complications?

Let's say a patient strokes during a carotid endarterectomy. Wouldn't we find it hilarious if a neurologist said we shouldn't be doing CEAs because we can't treat the complication?

What about someone who has a post-op MI? Doesn't cardiology treat our SURGICAL complication in that situation?


I can give a hundred more examples of how that reasoning is flawed.

Medicine is multi-disciplinary, and we can't be arrogant enough to think we can be experts in everything. When a complication occurs, we get the expert to address it. Medicine specialties treat our complications just as often if not more often than we treat theirs.

Basically what I'm saying is that if I hear one more broken record comment about "GI docs can't treat their complications," my head's going to f-ing explode. Please get some perspective, guys.
 
Tn Family MD said:
I'd be curious to hear the opinions of people on here in regards to this. Also I would be interested to hear about what the resident surgeons here are going to have as their policy in dealing with GI docs who perf the bowel during endoscopy procedures. Are you going to agree to repair all of them? Repair only those who you have a pre-existing agreemnt with? Start trying to avoid having to deal with repeat offenders (i.e. those who seem to have perf as a common occurence)? Where does everyone stand?
Click to expand...

Well, since this has been beaten to death, I suppose we can go another round. :)

I don't think a physician, whether surgeon or non-surgeon, can ethically turn away a patient with an emergency unless he was "uncomfortable" dealing with the issue at hand. For a General Surgeon perforation of the bowel by colonoscopy is par for the course. If you're not comfortable handling this, then you probably shouldn't be walking around telling people you're a General Surgeon. Given that, then you would be ethically obligated to treat the patient regardless of your feelings for the GI doc who drove the scope through bowel wall. That's just the right thing to do, hands down. There's really no way of getting around it and being a good surgeon.

So I wouldn't be able to turn it away. Not at all.

Now, I've seen situations in my training where a particular GI doc has a relationship with a particular private General Surgeon and refers all his elective stuff to the surgeon. But when there's a big screw up he calls the faculty service, and there's quite a bit of grumbling about this and resentment on the part of the faculty. Supposedly if that GI doc threw them a bone every once in a while, I guess they wouldn't mind so much, but handing them every disaster case is just un-cool.

But those are the personalities you sometimes deal with I guess. What to do in that case? I'm not quite sure about how to ethically handle it other than talking to that GI doc and asking him "WTF?" He's not really violating anything. He's just being obnoxious.

Bottomline, you should feel obligated to fix all the F-ups on other services if you're qualified. If you don't, then you're what my PD calls a "medical sociopath."
 
As SLUser mentions, the perf rate in the hands of a good endoscopist (regardless of specialty training) is extremely low. However, most of us will see at least a few during General Surgery training.

I think someone most general surgery residents don't appreciate is that GI fellows are required to do WAY more upper and lower scopes than we are and are *likely* better trained than most of us. I dont know what the FM requirements, if any, are.

In addition, it would be ridiculous to not have others doing scopes. There are just too many people who need them to be covered by general surgeons.

While I would prefer to have people not do procedures they can't fix, in the real world you have to understand that this happens and we have to rely on each other to help patients.
 
SLUser11 said:
Well, maybe it's because they did a 3 year fellowship.




You forget that a perforated bowel is a surgical emergency. I don't know that I would ever turn away a patient who could possibly die because I resented the GI doc doing scopes.


I know we're all into medicine hate right now....but does anyone honestly believe that GI docs shouldn't be doing endoscopy? That's ridiculous. If we break down the numbers, colon perforation rates are like 0.1-0.5% How many surgical procedures do we have with higher complication rates? Are we treating all of our complications?

Let's say a patient strokes during a carotid endarterectomy. Wouldn't we find it hilarious if a neurologist said we shouldn't be doing CEAs because we can't treat the complication?

What about someone who has a post-op MI? Doesn't cardiology treat our SURGICAL complication in that situation?


I can give a hundred more examples of how that reasoning is flawed.

Medicine is multi-disciplinary, and we can't be arrogant enough to think we can be experts in everything. When a complication occurs, we get the expert to address it. Medicine specialties treat our complications just as often if not more often than we treat theirs.

Basically what I'm saying is that if I hear one more broken record comment about "GI docs can't treat their complications," my head's going to f-ing explode. Please get some perspective, guys.
Click to expand...

I couldn't agree with you more. Any physician (medical or surgical) can create a complication that they are unable to deal with. A general surgeon might damage a ureter and a urologist may have to be called, a urologist might transect the iliac artery or damage the bowel and perhaps a vascular surgeon or general surgeon might be needed-obviously I am not a surgeon so I don't know the specifics of who can repair what (maybe a urologist can deal with these things, I don't have enough experience to say). In any event, I think procedure volume is a critical issue. A GI doctor can do as many as 60-70 colonoscopies per week. So there is a tremendous amount of experience. There is nothing inherently different between a surgeon and an internist or a neurologist etc....in terms of innate coordination and ability to learn a physical task. In other words, the person who is doing the most of a particular procedure (regardless of who they are) is the one who is probably best at it. Doing colonoscopy has a lot more than "driving a scope." Large flat polyps (3-4 cm with indistinct margins) are often encountered that need to be resected piecemeal. We often do EMR of submucosal lesions (GIST and carcinoids). Getting the scope to the end safely is one thing, resecting large flat lesions with cautery and argon plasma coagulation without going through the wall is another thing. I am kidding about being an endoscopic surgeon, but in all seriousness, doing colonoscopy and removing lesions is not the easiest thing in the world....it takes lots of volume to get good at it.
 
Castro Viejo said:
Well, since this has been beaten to death, I suppose we can go another round. :)

I don't think a physician, whether surgeon or non-surgeon, can ethically turn away a patient with an emergency unless he was "uncomfortable" dealing with the issue at hand. For a General Surgeon perforation of the bowel by colonoscopy is par for the course. If you're not comfortable handling this, then you probably shouldn't be walking around telling people you're a General Surgeon. Given that, then you would be ethically obligated to treat the patient regardless of your feelings for the GI doc who drove the scope through bowel wall. That's just the right thing to do, hands down. There's really no way of getting around it and being a good surgeon.

So I wouldn't be able to turn it away. Not at all.

Now, I've seen situations in my training where a particular GI doc has a relationship with a particular private General Surgeon and refers all his elective stuff to the surgeon. But when there's a big screw up he calls the faculty service, and there's quite a bit of grumbling about this and resentment on the part of the faculty. Supposedly if that GI doc threw them a bone every once in a while, I guess they wouldn't mind so much, but handing them every disaster case is just un-cool.

But those are the personalities you sometimes deal with I guess. What to do in that case? I'm not quite sure about how to ethically handle it other than talking to that GI doc and asking him "WTF?" He's not really violating anything. He's just being obnoxious.

Bottomline, you should feel obligated to fix all the F-ups on other services if you're qualified. If you don't, then you're what my PD calls a "medical sociopath."
Click to expand...

Hey sunshine, her is a link to a video showing a GI doctor repairing his own perforation with endoclips....lots of reports of this in the literature. Wow, a GI doc (internist!) repairing his own complication, imagine that! http://www.daveproject.org/ViewFilms.cfm?Film_id=619
 
So this proves my theory...as the number of replies to a post on SDN approaches 20, the probability of the thread resembling a game of "telephone" approaches one...
 
Jeez, lighten up. I was just trying to razz the dude up a few posts calling himself an endoscopic surgeon. Of course I understand that as surgeons you have to (either implicitly or explicitly) agree to fix up everyone else's f-up's. It's just part of the duty, I guess, and I understand that. I was just trying to get a rise out of the GI dude. Back to the original discussion.
 
Tn Family MD said:
Jeez, lighten up. I was just trying to razz the dude up a few posts calling himself an endoscopic surgeon. Of course I understand that as surgeons you have to (either implicitly or explicitly) agree to fix up everyone else's f-up's. It's just part of the duty, I guess, and I understand that. I was just trying to get a rise out of the GI dude. Back to the original discussion.
Click to expand...

Don't flatter yourself my friend. Stick to treating otitis media and following up on throat cultures.
 
rapid said:
We often do EMR of submucosal lesions (GIST and carcinoids).
Click to expand...

Really? "Often"?

Interesting, because GIST especially is pretty rare. And then consider that only small lesions may be hacked out via an endoscope, and the # gets even smaller. You should publish your experience, it sounds like you're an international leader in the field.
 
gasnewby said:
Really? "Often"?

Interesting, because GIST especially is pretty rare. And then consider that only small lesions may be hacked out via an endoscope, and the # gets even smaller. You should publish your experience, it sounds like you're an international leader in the field.
Click to expand...

Wow, you are so insightful!! Don't be such an ignorant fool. Most GI doctors do not do EUS (endoscopic ultrasound). To assess and remove a submucousal lesion, EUS must be done first. Hence, the "few" doctors that are doing EUS are getting lots of referrals from other GI doctors who discover these on routine endoscopy and colonoscopy. So these "few" doctors actually see a relatively large # of these lesions. It is a referral phenomenon. Do you need a lesson in epidemiology? Are these concepts too difficult for you to grasp?? Why don't you stick to "hacking" out gallbladders and putting in NG tubes for small bowel obstuctions.
 
rapid said:
Wow, you are so insightful!! Don't be such an ignorant fool. Most GI doctors do not do EUS (endoscopic ultrasound). To assess and remove a submucousal lesion, EUS must be done first. Hence, the "few" doctors that are doing EUS are getting lots of referrals from other GI doctors who discover these on routine endoscopy and colonoscopy. So these "few" doctors actually see a relatively large # of these lesions. It is a referral phenomenon. Do you need a lesson in epidemiology? Are these concepts too difficult for you to grasp?? Why don't you stick to "hacking" out gallbladders and putting in NG tubes for small bowel obstuctions.
Click to expand...

Yes, one of my former attendings doesn't let the GI guys do EUS on his patients. They're consistently wrong.

Sorry, when you said "we do lots of EMR," I thought you were referring to your personal practice, especially after you called yourself an "endoscopic surgeon." Now you're not even an endoscopic ultrasonographer. :laugh:
 
gasnewby said:
Yes, one of my former attendings doesn't let the GI guys do EUS on his patients. They're consistently wrong.

Sorry, when you said "we do lots of EMR," I thought you were referring to your personal practice, especially after you called yourself an "endoscopic surgeon." Now you're not even an endoscopic ultrasonographer. :laugh:
Click to expand...

I am not sure what you are trying to say. You seem to have poor reading comprehension and writing skills. I already told you that I do EUS. The paragraph above sounds like it was written by an 8 year-old. Who does the EUS on your patients if the attending doesn't let the GI doctor do them because "they are always wrong?" So I guess your patients don't get EUS even if they really need it? Please, tell me the name of your hospital so I can tell everybody I know to avoid it. You are displaying massive ignorance and making yourself look like a fool. I suggest you keep your comments to yourself.
 
rapid said:
I am really enjoying myself on the surgery forum and I think I am here to stay. I think it is appropriate given the fact that I do such invasive procedures (endoscopic surgery of the GI tract). So if you guys don't mind, I am going to settle in and interject with frequent comments. Just consider me one of the group now. Thanks!
Click to expand...

yeah, he gets a little defensive. if i did a medicine residency, started a medicine fellowship, and wanted surgeons to consider me an endoscopic surgeon, i suppose i'd have an inferiority complex too. i'm not sure why he's so hell-bent on getting this approval. possibly had some bad experiences as a medicine resident or medical student? he needs a hug.
 
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