Advice on deciding General Surgery (to Transplant Surgery) v Oto (to Facial Plastics)

[is0632894]

Hi all,

I am in a slight dilemma and would appreciate the input of any attendings or people pursuing the following fields. I appreciate any candid advice.

With the upcoming match application opening date approaching, I find myself split between the possibility of pursuing two different residencies, with the goal of specializing in the aforementioned fellowships (subject to change during residency of course). My career goal would be to be in academic medicine/in administration of department, but wouldn't mind having the option to go private if I so decided at a later time. In terms of application strength, I would be competitive for any program in GS and most programs for Oto.

1. General Surgery to transplant surgery has really been the goal for the previous year. I rotated on transplant on my core year rotation (we are a high volume transplant center) and I truly fell in love with the field. In terms of my interest, it blows everything else out of the water, I love the immunology, the pathology, the medicine, the complexity of the patients. My research has been in transplant and epigenetic, and I am known very well in the department and have strong letters from 2 well known transplant surgeons. I just am worried about the lifestyle long term. I don't want to work my life away, and I want to be involved with my family. I understand that I will have to work more in this career choice, but how much more is my question? My center doesn't appear to be too bad of a lifestyle for attendings, (fellows often take much of the load, but obviously it is more call than other GS fields) but I was wondering what it was like for other centers?

I also like the GS could be a route to plastics if I feel so inclined to pursue it, I haven't had a ton of exposure with plastics, but have had some on my oto rotation and the reconstructions are very interesting. Job market for transplant doesn't have nearly as many opportunities as oto as well.

2. Otolaryngology to facial plastics/head and neck. This was very recent finding, I happened to throw a advanced oto rotation in my schedule and really enjoyed the experience. In terms of academic interest, it's ok. Not nearly as interesting as transplant, but there could be some interesting things coming up in the field (esp facial transplantation, I know its quite a long ways from being mainstream). I like the technical aspects of the surgery as well as the anatomy. A Level I-IV neck dissection anatomy is the most beautiful anatomy you can see, followed closely by a clean dissection of the porta hepatis. (Sorry for the conjecture). I could see myself being satisfied in my professional career as an oto, but My personal life would be much better I believe. Although I love medicine, I work to live, not live to work.

Again any advice would be appreciated!!!!

I also apologize for the format of this post, I am slightly scatterbrained at the moment trying to think of things to put for each (posting on SDN was not a primary choice)

@Winged Scapula @ThoracicGuy @thedrjojo @aorticonduit- Sorry for tagging you, but I seen you commented on a previous transplant related post or surgery related post and would appreciate your input if you have the time.

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[thedrjojo]

I was doing fellowship at one of the top 10 busiest programs in the country.

The chief of the division in his 50s couldn't go on vacation an hour flight away without being concerned.

Plenty of people have left the field in their 40s or 50s, mainly not from a lack of loving the field and science, but from a lack of loving the life.

Depends really on what type of transplant you want to do. Kidney transplant gives you a little better lifestyle, but even that is worse than most other fields

 

[is0632894]

That's what I had figured. I know quite a few people I have talked to have considered at one point just transitioning to HPB.

I would want to do multi visceral and liver txp's primarily.

 

[Winged Scapula]

I was going to suggest you tag @thedrjojo ; he wouldn’t have responded so quickly if he were doing Txp.

My thoughts are that you’ve had limited experience with OTO. General surgery will offer you the widest variety of practice choices in terms of specialty and environment.

 

[HighPriest]

So, these are very, very different fields.

I can't comment on transplant surgery, you probably know as much or more about it than I do.

I know quite a bit about facial plastics/oto.

If you're going in to it for high speed stuff like facial transplants, you can just as easily to gensurg/PRS. Frankly, most of the face transplants so far have had either a PRS guy as the primary surgeon or at least on the team. You can do it with oto-facial plastics, but I doubt it would be any easier to make it a part of your practice as it would for PRS. And it's not easy no matter what route you go, because these are extremely uncommon surgeries being done on a case-by-case basis and essentially only at major research centers. No one is walking out of fellowship as the "facial transplant" guy. you CAN do them. People don't very often.

Head and Neck anatomy is fantastic. I'm biased, to be sure. Head and Neck Oncology are the guys doing the vast majority of neck dissections (you can do it without the fellowship, to be sure. I do them regularly.) HN oncology, like many oncology surgeons, have a tough lifestyle. That is primarily because of free flaps. Free flaps are interesting because of the technical and reconstructive aspects, but they effect your lifestyle because they take a long time and they can go down at 0300, and because of the way we manage them in the US that means you're in the OR at 0300. That being said, I imagine it's a better lifestyle than transplant. Most guys doing HN oncology burn out after somewhere between 5-10 years if they're doing flaps. They usually fall back to general ENT or perhaps endocrine surgery, etc.

You can do free flaps with a gensurg/PRS approach. That used to be the standard, but nowadays most free flaps are done by ENT/HN oncology (in large part due to better wound care techniques elsewhere that don't work as well in the head and neck.) There are a few centers where PRS is still doing most of the HN free flaps (like MD Anderson...unless things have changed there). In the community, it's still not entirely uncommon to have a general ENT do a resection and then a PRS guy come in and reconstruct

You can do a combined (or seperate) HN oncology and facial plastics fellowship. I know a few guys who did that. Most of them spend most of their time doing one or the other, and only a few are doing both in anywhere near equal proportions. The facial plastics tends to augment the HN oncology recon for obvious reasons.

Honestly, you can do just a facial plastics fellowship and then to free flaps. There wouldn't be much call to do neck dissections other than for vascular access. But you could do recon, cleft repair, etc. You would just have to find your market for that stuff, and you'll be competing with PRS guys. Depending upon where you train for facial plastics, the difference between facial plastics and PRS is that with facial plastics you won't be doing breast recon, hand, and probably not craniofacial (but you could do that last one if you played a well placed hand). Frankly, in a community setting you could put a flap anywhere, but in a tertiary/academic center the PRS guys will work outside the head and neck.

BTW, you can do PRS after an ENT residency, not just gen surg. But, if you don't want to decide between transplant and recon at the moment (which is reasonable because it's comparing choo choo trains to asteroids), you could do general surgery and decide later. You wouldn't be doing otology or sinus surgery, and probably not many neck dissections, but you could do the rest by doing either a PRS or transplant fellowship.