[Australian Doctors] Insight into Emergency Medicine vs General Surgery

[PltDr]

I'm a current intern in Australia, but with resident medical officer positions beginning to open up, I am tossing up between which pathway to set myself up for in the future.

I'm curious when and how you decided on your specialty/area of practice. The perspectives of various fields seem so different as a student and now as a doctor, to the point now that I'm not sure which I would most enjoy. I'm currently tossing up between Emergency Medicine and General Surgery (particularly Breast & Endocrine) after narrowing down other fields I could not see myself doing.

I'd appreciate any advice on how you came to your decision, and for those in Emergency Medicine and General Surgery, to offer insight into what it's like practising as a Consultant.

For my reasoning of EM vs Gen Surg: I've always liked very hands-on things, looking at the big picture and doing, more than thinking. I've enjoyed both surgery and general medicine throughout being a medical student and working as a junior doctor, but haven't fallen in love with a particular area of yet. In general, I don't want to be so specialised or non-clinical that if I was to encounter a medical issue outside of my specialty, that I'd struggle to manage it acutely. As a side note, since I've had a major interest in aviation since childhood, I am also interested in aviation medicine, with plans to obtain an Australian Certificate of Civil Aviation Medicine later this year. Whether or not I'll practice this on the side in the future, I'm not sure, but I thought it'd be nice to have the added training.

Factors I'd like to consider in my career include:

• Family & life balance
• Availability of hands-on procedures
• Income vs hours worked
• Ability to practice privately
• General happiness in working in the specialty

I've narrowed down to:

• General Surgery (Particularly breast & endocrine subspec) due to ability and flexibility to perform a wide range of procedures in many environments as well as specialised procedures, while balancing a decent lifestyle (for surgery). I am told that this area would also allow elements of medicine in general patient care.
• Emergency Med due to (correct me if I'm wrong), better work-life balance, acuity of work and hands-on procedures, flexibility to move into other acute medicine such as Retrieval Medicine.

Any advice on how you came to decide your specialty +/- any advice re: the above fields would be greatly appreciated!

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[Domperidone]

The beauty of working in Australia is that you do have a bit of time to decide. So breathe! Whether EM or Surg, you do have time to decide.

And you're only on rotation 2!
Have you done either your core EM or surg rotations yet? Don't decide on anything until you have. What are you doing as electives in your intern year?

As disclaimer - I'm not a consultant. I'm a trainee, and for preserving anonymity, I prefer not to disclose which field on a public forum. Thus, take this as very general advice (with a grain of salt), with regards to deciding on how to choose something in the intern year, from someone who also had trouble deciding.

"Value" of the intern year in Australia for decision making:

Medical school in Australia doesn't always sufficiently help you decide on a field or offer nearly enough responsibility for you to really gauge what work in particular field is like. It merely prepares you for the intern year. IMO anyway. It's the intern year that helps you decide.

It's your resident year is the thing that can makes or breaks it for you in your decision - because then you spend most of your rotations in the field you want. Not necessarily all the time, but roughly.

It's not uncommon to see PGY2s then decide to change their direction again for PGY3 (I've seen BPTs change to GP or EM, or surg residents switch to BPT or EM. I've yet to see a BPT change to surg though). It's never a waste of time to have done an extra year in something unrelated to whatever it is you eventually end up in. No experience is bad in medicine. Not like that. So, if you end up still undecided by the time you submit an application, it's okay.

It's not like how early streaming works in the US or Canada, where they have to decide on vocational training (essentially the rest of their life) as final year students. So, don't stress.

Focus on working hard on your current rotations to get good reference letters for next year. Don't forget that you need those for next year. Focus on building your skills as an RMO and finding ways to shine.

Think about rotations for next year and checking the boxes for your fields of interest
Depends on the state and I find every state and hospitals have variations on what rotations they offer their residents.

Look for hospitals that have the rotations you need to fit either EM or Surg pathways when it comes to applications for next year. Ask about what supports they offer residents in terms of getting onto vocational training. Some hospitals have 0 :S and it's interesting to see how they try to side step this question.

If you want EM with a lot of exciting procedures, try to get to a trauma center. If you want breast and endocrine, find a place that is heavily focussed on this and allows residents to pass through. with some hospitals, they only allow interns on general surgery rotations and its related fields. (at these places, residents have to work on surgical subspecialties and the next time you get exposure is as a PHO or unaccredited registrar - whatever your state calls it).

Find hospitals that will allow you to do rotations in both surgery and critical care (or at least have the options). You could always email and ask, if the hospital doesn't list what rotations are offered to residents.

When you rotate on EM or surg, ask the consultants and definitely ask the other residents and registrars for advice. Ask what hospitals they recommend you do your resident years in. They're usually pretty candid on what hospitals are good, and which are dead-ends for getting into a specific college. Ask residents what rotations they can do as residents at your hospital and what they're like. Again, hospital specific, at some places the residents on EM rotations get to do a lot, at others, it's mostly manning walk-ins or short stay.

Tell the EM consultants and registrars you want EM. Tell the Surgeons you want Surgery.

Add this to your list - job availability as a consultant post-training
We're in the oversupply era in metropolitan areas now. Both those field will require you to train in tertiary hospitals unfortunately. So it will increasingly competitive. Surgery is already uber competitive. Hope you enjoy research.

There's also little point in putting all this time and work into training if you have to worry about job security as a consultant. Or at least, weigh up if it's worth it. Alternatively, you could go private. You can do private in EM or Gen surg, to what length I'm not sure. And jobs are likely limited with private EM - you'd have to find a private hospital to employ you. (That's me..assuming as a trainee by the way)

Don't be afraid to ask the trainees and consultants you rotate with what their outlook is on jobs after you finish training. You'd be surprise with how honest some of the answers will be.

Lifestyle
I'm not sure I'd equate friendly lifestyle balance with either field. EM is perhaps slightly better because it's shift work. Also depends what sort of EM you're after. If you do private EM, it's cruisey. Retrieval and trauma, forget it.

Look through the college websites & requirements
I would download the requirements for both colleges and starting going through them. To give you an idea of how many points are required for each and what they require. It may or may not put you off one field :S

If you're stuck, then at least you can to start work towards the applications in areas of overlap. Like getting that ICU rotation with is a tick box for both EM and surg.

How long do you want to spend just getting on a program?
That could be a factor if you're older. Average for surg now is PGY5-6 to just get on the college. But don't let it be the make or break reason to choose one over the other.

The advice I heard in medical school from an interventional cardiologist as well as a neurosurgeon is to not look necessarily at length of training when you choose a field.

When you train, you are working in that field. Don't always look at it as a means of an end. It's better to choose something where you enjoy the day-to-day job.

These guys both required 10-12 years to get where they are (for e.g. interventional cardio is roughly = intern + BPT 3 years + cardio AT 3 years + cardio fellowship 2 years + = nearly 10 years if not more).

 

[PltDr]

Thanks for getting back to me. The advice and guidance is definitely helpful.

My rotations this year cycle through General Medicine, ENT, Relieving, General Surgery & Emergency, so I should have a well rounded experience, although the two rotations I wished to experience are towards the end of the year, way past the RMO application dates.

My current plans for the moment were similar to what you've outlined - looking through College requirements and trying to cover the pre-requisites for entry during RMO years, while also getting experience in the above fields to help make a decision at a later stage. Hearing you echo the plans is reassuring for me to know that it is quite possible to approach it in this way.

I'm still particularly interested in knowing is what EM and General Surgery (or any surgery for the matter) is at the end of the training, as a consultant however, if you or anyone else is able to give any insight, either personally or anecdotally.

Currently, I'm not too worried currently about work hours, lifestyle and training length in getting in, since I've always been stubborn enough to continually work at a goal until I've achieved it no matter how long it takes, provided I love it enough. The main reason I ask about life as a consultant is because my current decisions and plans are based upon being a recent graduate from an undergraduate medical degree, with no real, strong commitments yet such as my own family, children. However, when these commitments do become more apparent in the future, I'd like to know whether and to what extent balancing work-life and family life becomes much harder.

For instance, does shift work for EM carry onto night shifts as a consultant? Or typically daytime/evening rosters? If nights are included, how often? Does it get harder to recover from the circadian rhythm shifts/fluctuating roster times, or do you get used to it?

For Gen Surg (or any surgery), does life become more or less busy as a consultant? Or do you have more control, to work as much or as little as you'd like? How often would you still be on call as a consultant?

For the moment, I can see myself working in the above two fields, but future family life and commitments also play a part on my decision. I can deal with being busy and having to balance my life, but if I'm working 24/7 like a stereotypical neurosurgeon, I don't think I can forgo my family and other commitments to that extent.

Have you got any advice in regards to family/life commitments and balancing work in those careers?

 

[Domperidone]

So, I'll try to answer what I can.
I kinda prefer not to answer regarding consultant experience as I'm not one. It'd be giving you 2nd or 3rd hand information, which isn't particularly fair.

Good Qs! Remember to ask on rotations
Just remember to ask these questions for when you do go on your EM or surgical rotations. You will get at least one friendly consultant (particularly on surgery) who will sit down with their residents to chat. Surgeons in particular love to go on coffee runs after rounds etc. If they seem less approachable, at least the registrars will be around. They're a wealth of info too.

So long as you tell people what your aspirations are, you would be surprised by how much they will want to help you. Particularly if you work hard, you're reliable - then they'll like you and want to help as much as they can with the limits of time they have.

Anecdotally..
Job availability also depends on state. Hence why, I strongly recommend you ask people local to where you are. EM or ICU may not have as many consultant positions, because you have to work out of a hospital with a substantial ED or ICU. Many rural hospitals may not be able to employ a FACEM, and rural ICUs are more like HDUs. whereas, you will find rural general surgeons.

In case you haven't thought of it - rural secondments
If you do general surgery, as a reg, RACS may send you rural up to 6 months of the year, and possibly remote. Versus subspecialties tend to require larger hospitals that regional at minimum.

In the very worst case scenario, I've known trainees with small kids who were sent rural by RACS. Some would just commute 1.5 hrs both directions daily no matter what, for others, the commute was > 5 hrs. So it meant being away for them and missing out on things for months at a go. Not sure if you've considered this.

EM vs Surgery (very superficially)
EM - based on what I know - consultants don't have to do night shift per se. It's just rostered day and evenings. however, they do have to be on-call, which means if a major trauma or something substantial comes up they do have to be on-site. It's no different for surgical consultants.

Work life balance
Generally, some things are common sense for the gen surg fields. Hours are relatively better for breast or endo. Transplant and trauma are going to be crazier, and have longer and more unpredictable hours.

Work life balance...
I'd love to say..it's doable, but if you want work life balance, then you really gotta pick something that will offer it to you. It probably wont' be surgery, and certainly not during training anyway.

I keep throwing it out there re: training with regards to gen surg, because on average you get in as a PGY5 or PGY6, which means by the time you finish it will be PGY10. Fellowship another 2 odds years normally follows. You could wait till you're finished training to have kids, but you probably will be at least mid-late thirties if you're in undergrad med.

It's not balance, it's more like..do what you can. If you're lucky, the hospital may let you job share. I know two general surgery registrars (both female) currently doing that. I can't guarantee that all hospitals will or all the surgical fields allow this. It does mean that they will take longer to finish their training.

The lifestyle friendly fields = GP, psych etc. are just that, the only realistically lifestyle friendly ones that are routinely 9-5. For everything else it's just variable, as in maybe some days are 7 am to 5-6 pm, other days could be longer. It will never be routinely 9-5 like GP will with odd weekends or none at all. EM is at least shift work however, so sometimes it could 7 nights on or 7 nights off - you get a taste of this as an intern anyway. So relative to surgery or med, it's slightly better.

One extra resident year won't hurt you
Don't freak out about anything, until you've actually tried it.

Do the rotations and see what you think then. There is no harm in doing a resident year and figuring it all out afterwards. A lot of people change their minds and decide lifestyle is more important to them and choose GP after 1-2 resident years and that's okay. For others, see as it an extra year to get more points or research. You probably need to start worrying a tad more once you're a resident about what path to choose, but as an intern you have breathing room.

For both EM and surgery, it's not like either of those colleges will let you go straight in right after intern year anyway. Both have exams you have to sit etc. Prior to starting the resident year, you can try to swap rotations with other residents after the hospital allocates them.

 

[PltDr]

Sorry for the late reply, and again, thank you for your advice.

Your information is incredibly helpful for me, having come from a non-medical background.
Timing-wise, I agree, I'm not in a rush to get in and out of training as soon as possible, and extra years as an RMO would benefit me with experience regardless.

Your information's given me a sense of direction at the very least so I can begin to work towards a goal with further training, research etc. I'll definitely consider the potential long placement times in rural areas for General Surgery, but having been working towards a pilot license, I would be open to rural placements for periods of time and hopefully this would be less of an issue in the future.

Thanks again for your help, I now have a rough direction to heads towards for next year and the near future.

 

[Domperidone]

Sorry for the late reply, and again, thank you for your advice.

Your information is incredibly helpful for me, having come from a non-medical background.
Timing-wise, I agree, I'm not in a rush to get in and out of training as soon as possible, and extra years as an RMO would benefit me with experience regardless.

Your information's given me a sense of direction at the very least so I can begin to work towards a goal with further training, research etc. I'll definitely consider the potential long placement times in rural areas for General Surgery, but having been working towards a pilot license, I would be open to rural placements for periods of time and hopefully this would be less of an issue in the future.

Thanks again for your help, I now have a rough direction to heads towards for next year and the near future.

All the very best!

I forgot to mention the surgical unaccredited or PHO year and working towards that for PGY3 or 4 (when you feel ready). If you end up deciding on surgery. Some hospitals may send you rural for part of this period (if you're not already doing a full year at a rural/regional site). The benefit is that you always get to do more when you're rural anyway. Don't forget to check where the hospitals you're applying to may send you on external placements. In case if you haven't already considered this.

Getting a pilot's license or cert for aviation medicine will make your application and CV more interesting. Any extra things relevant to med will help you stand out.

I agree with you about the extra experience being helpful to you as a resident. All of it makes you more well rounded and confident as a registrar later. that's my take on it anyway.

That said, other people will have different views on this. Which I'm just remembering now. The idea was so that you would not 'waste' time the years following. But I don't know. I still find it such a conundrum with applications coming out mid way through internship. it happens to many people that the rotations they really wanted to try out to make a choice doesn't come up until after application close.

It's also starting to become an issue with getting into RACS at PGY3, when most accredited trainees are now PGY5-6 when they start. It's a gap of 2-3 years more of honing skills as a PHO/unaccredited reg or resident that looks after the wards and post op care. As a resident, you get a chance to gain more exposure to other surgical subspecilaties, which you can't do as an accredited trainee dedicated to 'one' field. Not that I would ever tell someone to turn down RACS at PGY3, that'd be so dumb. However, it is tougher in the long run if you get in earlier than the rest of the cohort.

So, it's really good that you're not actually feeling rushed right now.

And at least you're stuck between EM and surg. Both ED and ICU resident rotations help you with both colleges. As compared to classic med v.s. surg, or O&G vs psych or something.

Lastly, be aware of what people around you tell you what you're suited for. Sometimes they know long before you do, what you'll eventually go into or should go into. Based on your personality and working style etc. Doesn't always work, but it can help you out.

 

[sean80439]

Lastly, be aware of what people around you tell you what you're suited for. Sometimes they know long before you do, what you'll eventually go into or should go into. Based on your personality and working style etc. Doesn't always work, but it can help you out.

This is sooooo true.

 

[woopedazz]

Do a surgical RMO year and take a 3 month ED rotation in there. Look at what the seniors do moreso than just your job.

Want to sit and read ECGs, listen to intern histories, work shifts and be embroiled with politics = go ED.
Want to live at work and have less support = go Gen Surg.

Jokes aside, I also thought about doing both specialities. They're both decent. Look at what the seniors do.

 

[PltDr]

@Domperidone: At the end of the day, I suppose if I chose surgery, I don't want to become the stereotype that can only manage their field and struggle with the basics, so the additional years of experience would be helpful in that regard, and in EM in general. Given the time it's taking these days for people to get into training programs because of the bottlenecks, I think some years as an RMO doing ED, ICU and additional trauma based courses in the interim while I get more experience and make a decision would be useful regardless because of the crossover between the college requirements, as you outlined.

Your last line is definitely something I can see being true. It always seems easy to tell for friends which fields they would be suited to, and more or less has lead me onto the path of surgery or ED/retrieval etc as opposed to physician or psychiatry training. I definitely can't see myself doing physician or psychiatry, and my friends can also agree to that.

@Woopeddazz: I think for now, that's my current plan. Surg RMO if I can get it, and combine crossover fields like ED/ICU with surgery and trauma courses in the interim until I decide and get more exposure.

Out of curiosity, what did you pick in the end?

 

[Domperidone]

@Domperidone: At the end of the day, I suppose if I chose surgery, I don't want to become the stereotype that can only manage their field and struggle with the basics, so the additional years of experience would be helpful in that regard, and in EM in general. Given the time it's taking these days for people to get into training programs because of the bottlenecks, I think some years as an RMO doing ED, ICU and additional trauma based courses in the interim while I get more experience and make a decision would be useful regardless because of the crossover between the college requirements, as you outlined.

Your last line is definitely something I can see being true. It always seems easy to tell for friends which fields they would be suited to, and more or less has lead me onto the path of surgery or ED/retrieval etc as opposed to physician or psychiatry training. I definitely can't see myself doing physician or psychiatry, and my friends can also agree to that.

@Woopeddazz: I think for now, that's my current plan. Surg RMO if I can get it, and combine crossover fields like ED/ICU with surgery and trauma courses in the interim until I decide and get more exposure.

Out of curiosity, what did you pick in the end?

You'll be fine however it goes

For sake of others interested. The unaccredited surg or pho year has an emergency equivalent, "provisional" year.

It's the emerg SHO or critical care year or critical SRMO year. Every state has a different name for it. It's generally for PGY3 and consists of emerg, ICU and anesthetics. Or half emerg, half something else etc. depends on state. As it is a year that all 3 of those fields look for on a CV in some regions, it becomes highly competitive and sought after.

For example:
https://www.amaq.com.au/icms_docs/221130_dr-alex-markwell-staff-specialist-dem-royal-brisbane-and-women’s-hospital.pdf

https://www.cicm.org.au/CICM_Media/CICMSite/CICM-Website/Resources/Positions Vacant/AMR-CC-ICU-Advertisements.pdf

Both colleges require Australian PR or citizenship.
I forgot to ask what your background was.

Out of curiosity, what did you pick in the end?

You're welcome to PM me if it's really killing you.
I try to preserve my anonymity as much as I can on the public side to these forums. There's a lot of people who 'lurk' in the threads without posting.

Also, hence all the disclaimers to take everything I say very generally and to talk to as many residents or registrars around you as much as possible.