Average age of a surgeon..

[Lamborghini1315]

Ok i believe the average age is around 37 for a surgeon to be done with all their training. So my question is how many people believe in shortening our medical training at some point to compensate for long residency training? I came across this article that talks about older surgeons having a lower volume of cases and also might have a higher risk of mortality among their patients. Note: The article did not find a convincing linear relationship between age of a surgeon and mortality rate.

http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1856535

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[Winged Scapula]

Ok i believe the average age is around 37 for a surgeon to be done with all their training. So my question is how many people believe in shortening our medical training at some point to compensate for long residency training? I came across this article that talks about older surgeons having a lower volume of cases and also might have a higher risk of mortality among their patients. Note: The article did not find a convincing linear relationship between age of a surgeon and mortality rate.

http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1856535

What are you proposing to cut out?

Perhaps a few months of the end of 4th year could be consolidated but I don't see that there is a lot of redundancy in US medical training. Do I use my (former) knowledge of biochemistry in my daily practice? No, but I would venture that the skills learned and knowledge accumulated was helpful in some way.

You cannot make the case that older surgeons doing lower volume = higher mortality without looking at the cases they are doing. If an older surgeon has reached his peak and is doing a few big, multiple hour cases a week on sicker patients, its unfair to compare that to the young general surgeon who might be doing bread and butter stuff on healthy young adults. There is no convincing data that links surgeon age with patient mortality.

The mean age of 37 is skewed by a few people who spend either years and years getting an MD/PhD, in the lab or like myself, are second careers. Most general surgeons in the community are probably around 31 or 32 when they finish residency training assuming a 5 year program and coming right out of college into medical school.

At any rate, are you proposing or asking if we believe medical school or residency should be shortened so that surgeons get a longer career out of it? I certainly wouldn't, and as a matter of fact, would consider lengthening the training in some aspects as we find ourselves in an environment with increasing supervision and less autonomy.

 

[Celiac Plexus]

I certainly wouldn't, and as a matter of fact, would consider lengthening the training in some aspects as we find ourselves in an environment with increasing supervision and less autonomy.

I disagree. Lengthening training is not a good option. Most medical school graduates today have 6 figure debt. With rising malpractice, and falling reimbursements, and the rapid changes in technology/technique, lengthening training would is not a good option.

The residency system for general surgery has not changed in decades, while the field itself is no longer recognizable from what it once was. I am in favor of streamlining training a la the integrated pathway so that folks can choose surgical fields that don't require a decade of training during which they learn operations that they will never do.

 

[Castro Viejo]

The residency system for general surgery has not changed in decades, while the field itself is no longer recognizable from what it once was. I am in favor of streamlining training a la the integrated pathway so that folks can choose surgical fields that don't require a decade of training during which they learn operations that they will never do.

I agree. The trend is specialization and then sub-specialization. There really is no such thing as a "General Surgeon." He's a mythical creature and a dinosaur at the same time. While the ABS may disagree with me, my General Surgery training is almost exclusively Gastrointestinal Surgery -- and not necessarily all that is supposed to imply!

Some people in General Surgery education are already talk about how trianing will be cut down into a core three-year residency and then added to this foundation will be a variety of specialty residencies to complete one's training. The integrated Plastics and Vascular programs are an excellent example. So that the budding "General Surgeons" of tomorrow will do the core three-year program and take a "Gastrointestinal Surgery" completion route that spans two years and BAM! Board Certified Gastrointestinal Surgeon.

My training has not been the same as Winged Scapula's or Blade's or anyone else. The fact is my training is reflective of what my institution sees. The rest of it is stuff out of a book. It's just not the same. To expect that we're all General Surgeons in every sense of the word and uniform in our practice is just nonsense. It's impossible to expect that.

 

[Dr.Millisevert]

I disagree. Lengthening training is not a good option. Most medical school graduates today have 6 figure debt. With rising malpractice, and falling reimbursements, and the rapid changes in technology/technique, lengthening training would is not a good option.

Instead of changing the training pathways, maybe we should be attempting to have medical education (and university education in general for that matter) more heavily subsidised by the goverment. Also, requesting that residents are paid per hour as opposed to a flat annual stipend may help as well.

 

[Winged Scapula]

I disagree. Lengthening training is not a good option. Most medical school graduates today have 6 figure debt. With rising malpractice, and falling reimbursements, and the rapid changes in technology/technique, lengthening training would is not a good option.

It is certainly true that rising debt does preclude lengthening training for most people but I'd suggest we leave that out of the argument because its a red herring and isn't relevant to the discussion.

The residency system for general surgery has not changed in decades, while the field itself is no longer recognizable from what it once was. I am in favor of streamlining training a la the integrated pathway so that folks can choose surgical fields that don't require a decade of training during which they learn operations that they will never do.

I agree that integrated training is a great solution for surgical subspecialties. There is no reason that a Plastic surgeon needs to spend years doing Whipples although I do think that the longer training does provide skills which are useful regardless of one's specialty.

But I'm not so sure that the General Surgeon is dead. Call me a dinosaur but most of us here would agree that we didn't really start operating in ernest until our senior years of residency and many, not all, feel unprepared to go out into the world to be a general surgeon after that training. The increase in technology now means you have to be able to do both the open and the lap procedure, master management of ICU and sicker admitted patients. Unless general surgeons change the way the manage patients (ie, have hospitalists do all inpatient care), something will have to give in training. Perhaps we will see the day when a general surgeon no longer exists and appys and hernias are done by the acute care surgeon/trauma surgeon and all else is farmed out to subspecialists.

 

[Castro Viejo]

But I'm not so sure that the General Surgeon is dead. Call me a dinosaur but most of us here would agree that we didn't really start operating in ernest until our senior years of residency and many, not all, feel unprepared to go out into the world to be a general surgeon after that training. The increase in technology now means you have to be able to do both the open and the lap procedure, master management of ICU and sicker admitted patients. Unless general surgeons change the way the manage patients (ie, have hospitalists do all inpatient care), something will have to give in training. Perhaps we will see the day when a general surgeon no longer exists and appys and hernias are done by the acute care surgeon/trauma surgeon and all else is farmed out to subspecialists.

But that's precisely why the General Surgeon doesn't really exist, no?

You just can't do everything and be a master. Time and time again the people who track this kind of stuff write about how a specialist is always better at a certain operation or in taking care of a certain patient population than a general guy. That's why more and more Chief Residents are electing for a fellowship among other reasons.

I think many of my colleagues realize that General Surgery just doesn't give you the same kind of options as it once did, and when you're competing in a job market that values subspecialty training, your "basic" certificate in General Surgery just wouldn't qualify you for much of the work out there. So you'll probably, more often than not as a General Surgery graduate, seek fellowship, live as a community practice guy doing lumps and bumps, or be some slave to an academic machine that has you picking up after the Chairman's lumps and bumps or opening and closing for him.

 

[Winged Scapula]

But that's precisely why the General Surgeon doesn't really exist, no?

You just can't do everything and be a master. Time and time again the people who track this kind of stuff write about how a specialist is always better at a certain operation or in taking care of a certain patient population than a general guy. That's why more and more Chief Residents are electing for a fellowship among other reasons.

Of course and you and I have had this conversation many times before - that fewer and fewer general surgery residents are electing to go out and practice without fellowship training. The reasons are myriad: as I've stated it may be because one is training in a program where they just don't feel comfortable doing general surgery as a new grad, in other situations it may be the desire to master a smaller set of procedures and for others it may be a marketing decision (ie, public looking for fellowship trained surgeons).

I think many of my colleagues realize that General Surgery just doesn't give you the same kind of options as it once did, and when you're competing in a job market that values subspecialty training, your "basic" certificate in General Surgery just wouldn't qualify you for much of the work out there. So you'll probably, more often than not as a General Surgery graduate, seek fellowship, live as a community practice guy doing lumps and bumps, or be some slave to an academic machine that has you picking up after the Chairman's lumps and bumps or opening and closing for him.

Absolutely. The job market definitely is trending toward more superspecialization and as I've often admitted, my own fellowship training was designed to capture that market and that desire. I am MUCH more marketable because of that training, even if my surgical skills are not much different than they were after my residency.

But my point above about lengthening surgical training was made in reference to the OP who is suggesting we shorten surgical training so that the average age of a new surgeon is less. I agree that some specialists don't need years of general surgery, actively operating, to do a good job but I wonder about management of complications and worry that the superspecialized won't be able to manage them.

But where do you propose shortening surgical training? For the programs that are ward heavy, do you propose we cut out that training? While it was unpleasant, I cannot deny that those years spent on the floor and in the ICU instead of the OR, did offer something valuable. Training that is important for a surgeon.

Does a plastic surgeon need to spend years doing Whipples or colon resections? This is a hotly debated topic and I'm not sure where I stand on it. I do however think that general surgery training does need to change to fit the marketplace and new technology. But I'm not sure that the years of doing patient management, pre and post-op care, seeing patients over and over again, learning how to run an operating room, how to do an anastomosis safely, etc. is not valuable work - regardless of whether or not you become a plastic surgeon or a CT surgeon.

What it appears to me that people are proposing is to eliminate surgical prowess that is important in every surgical field. Being a surgeon is not just doing the procedures you commonly do, but also being prepared to deal with the complications of your procedures, including medical management, IMHO.

If we can peer into the future:Let's take the classic board question of the vascular surgeon doing an open AAA and finds an apple core colon lesion. Since that surgeon has now never been really trained to do bowel cases or oncologic procedures, he must now refer that patient elsewhere. Fine if you live in a big city with lots of colorectal surgeons, not so much for elsewhere.

What happens when ObGyn creates a large enterotomy? Who fixes it in a town without a colorectal surgeon? Since general surgery doesn't exist anymore, you have to call in a specialist which may or may not exist in your community.

I can see the increase in superspecialization working well in urban or large suburban communities where a medical community can support it. But what happens in Wyoming or rural northern California? Do all surgical patients need to be referred out to specialists in bigger cities? Is this what we're really advocating?

 

[Lamborghini1315]

I disagree. Lengthening training is not a good option. Most medical school graduates today have 6 figure debt. With rising malpractice, and falling reimbursements, and the rapid changes in technology/technique, lengthening training would is not a good option.

The residency system for general surgery has not changed in decades, while the field itself is no longer recognizable from what it once was. I am in favor of streamlining training a la the integrated pathway so that folks can choose surgical fields that don't require a decade of training during which they learn operations that they will never do.

I agree, i don't remember where exactly i read this quote on a journal but it mentions how surgeons are more reluctant to practice compassionately due to resentment about their training and the points mentioned by celiac can be a big influence on a surgeon's practice. Isn't 60 like the avg age for retirement these days..so a guy who was done at 35 lets say is in practice for 25 years? That's a short span compare to other fields..

 

[Winged Scapula]

I believe the average age of general surgeon's retirement is around 63; I'm not sure its all that different from other physicians or other higher income people.

I think its reasonable to consider how many years you will have left to practice when you are older, but frankly none of us knows if we're going to survive the day, let alone to 65 or 70, so I don't think having a longer career is a good reason to shorten surgical training.

 

[Castro Viejo]

I can see the increase in superspecialization working well in urban or large suburban communities where a medical community can support it. But what happens in Wyoming or rural northern California? Do all surgical patients need to be referred out to specialists in bigger cities? Is this what we're really advocating?

In an elective situation, I think this is exactly what we're advocating and, increasingly, this is what the literature shows as being the right thing to do for more technically challenging operations and advanced care.

In an emergency situation, all bets are off and anyone wielding a knife can act.

I mean, that was the point of ATLS, wasn't it? To train even an FP to do perform an emergent surgical airway and other similar-acuity procedures if needed in the middle of Wyoming or the rural California?

 

[Winged Scapula]

In an elective situation, I think this is exactly what we're advocating and, increasingly, this is what the literature shows as being the right thing to do for more technically challenging operations and advanced care.

And that's fine for the technically challenging operation. I mean, I don't want a general surgeon doing my Whipple either.

But who is left to do the lesser challenging operations? Who is going to be doing your non-incarcerated inguinal or ventral hernia? Your lipomas? Your 'roids, your sigmoids?Your biliary colic?

If everyone is a specialist, where do these patients go?

In an emergency situation, all bets are off and anyone wielding a knife can act.

I mean, that was the point of ATLS, wasn't it? To train even an FP to do perform an emergent surgical airway and other similar-acuity procedures if needed in the middle of Wyoming or the rural California?

Sure, but we aren't talking about emergencies. The new acute care surgeons can take care of those, or any FP with a drill. But I wanna know, if we are playing taps for the general surgeon and GS training, then who is going to do the bread and butter stuff of GS? I don't know too many vascular surgeons who are willing to do them (except one...I've done a hernia repair with RA before).

 

[Celiac Plexus]

I'm not to the point where I am "playing taps" for the general surgeon. However, it is worthwhile to consider that gs residency training has not changed with the times.

WS, it seems that for you no residency training is too long. And even though, you believe gs residents should spend a portion of their training doing whipples, you wouldn't want one of them to do one on you. In that vein, consider the following:

By the time I complete my 5 year general surgery residency, I will have spent roughly 25% of it doing trauma, 20% being a non-operative intern (only 1 month of which was on the gi service), 15% on the vascular service, 10% doing whipples and complex oncologic surgery, 10% SICU/CTS service, and only 20% on the core general surgery service.

Now if I go out and do general surgery in today's market, I am not likely to get referrals for vascular surgery, complex oncologic surgery, or cardiothoracic surgery. And I have no interest in a career in trauma surgery, and if I have my way I will not be in a position to cover trauma surgery. That leaves me with the 20% of my residency (~1 year total) that I spent on the general surgery service that will be truly germane to my practice.

I do believe that my training in the different components of the ACS defined "general surgery" has been beneficial in some ways, but I fail to see how my general surgery training is optimally preparing me for today's surgical workplace.

Why does intern year have to be a year? Why not 6 months? Why do I need to spend 2 months as a pgy-2 on the CT service pulling chest tubes? Why do I need to spend a year doing trauma? We should at least have these questions being discussed and in the dialogue.

I think the integrated pathway will work very well with most surgical fields. 5 or 6 years is sufficient length to train any type of surgeon if the training is appropriately tailored. Unfortunately the "one size fits all" general surgery residency model is simply outdated. It's not beyond salvage, but it can be improved significantly and needs a major overhaul.

In response to the question "what will happen to general surgeons"? It's a fairly straightforward answer. Have a general surgery residency that accurately reflects general surgery today.

 

[dr.evil]

Well, I have to say my piece here because I've just recently graduated from surgical residency and I'm doing a "true" general surgical practice. It isn't dead. Granted, I'm in a smaller town of ~75,000 within a regional medical center but still, what would be considered rural america. Patients do not want to go 3-4 hours or further away from home to see some super specialist. In fact, they often are frustrated to drive the 1 hour to our facility.

We have no colorectal, vascular, oncologic, endocrine, trauma or breast surgeons. We do have CT guys but they want nothing to do with thoracic stuff.

So what have I done this year: a partner and I did a Whipple yesterday (god forbid a general surgeon do a Whipple but we did it ), an APR, a right upper lobectomy, several laparoscopic colon resections, gastrectomy, lap paraesophageal hiatal hernia/Nissen, I have a lap adrenalectomy on next week, I did a mastectomy-sentinel node-axillary dissection this week, numerous VATS for various reasons, numerous GSWs to the abdomen and one recently to the popliteal artery, amputations, dialysis access, thyroidectomy, carotid endarterectomy, etc.

I'm not trying to boast and say "look what I can do". I'm just saying that general surgeons exist outside of the metro. Sometimes maybe we go too far but I spend a lot of time telling my patients that they have other options to go to a superspecialist and they choose not to. A lot of this is the training you get and what you have seen and done, which is why I always think a high volume training program is better (but that's another argument).

I have to say that superspecialization may make your life a bit more controllable for sure. My life on call is pretty brutal really because I'm everyone's transfer bitch which is another reason general surgeons are bitter souls (and a reason I have contemplated going back and doing a fellowship).

Training will likely go to 2-3 years of general surgery then 3 years of subspecialization in the future. There will just be a general surgery tract and possibly a rural genenral surgery tract. I'll just be along for the ride and be one of those old guys that did it the old way.

 

[Winged Scapula]

I'm not to the point where I am "playing taps" for the general surgeon. However, it is worthwhile to consider that gs residency training has not changed with the times.

WS, it seems that for you no residency training is too long.

I'm sorry if I gave that impression because its clearly not what I believe and I freely admit that I might have done additional training had it not been too long (and me too old).

My point was that general surgery, the way we are teaching it today, is not effective. There is too much to learn and not enough time, or not enough time spent wisely. People are not only pursuing fellowships because of the declining reimbursement in general surgery or for marketing purposes, but because they don't feel prepared to practice general surgery after 5 years. I used to think it was just my program but after years of talking with residents here and elsewhere I've come to believe its epidemic. We are simply not training our general surgery residents effectively to be general surgeons in many cases.

And even though, you believe gs residents should spend a portion of their training doing whipples, you wouldn't want one of them to do one on you.

And that's because I believe the research that says that complex surgeries should be done at centers by surgeons who do them often. Most community general surgeons are not doing Whipples often enough to maintain their skills. I did more than twice the national average of Whipples as a resident and I don't know that I would feel comfortable doing one. I'm sorry but give me the guy who does a Whipple or two a week over the guy who does one every few months.

My belief that spending time doing Whipples as a resident was helpful was not because it necessarily gave you the skills to do a Whipple but that it gave you a lot of different skills - there are lots of anastomoses, clinical decision making and even ERCP skills (if working with a surgeon who does them). I just think its an operation where the sum is more than the parts. Do plastic surgeons need to do them? Perhaps not, but the skills learned in surg onc cases can be valuable in many other surgical subspecialties and for the general surgeon.

In that vein, consider the following:

By the time I complete my 5 year general surgery residency, I will have spent roughly 25% of it doing trauma, 20% being a non-operative intern (only 1 month of which was on the gi service), 15% on the vascular service, 10% doing whipples and complex oncologic surgery, 10% SICU/CTS service, and only 20% on the core general surgery service.

That sounds about right - give or take a few months here and there, although I did not spend 20% (or 1 year) of my residency on a non-op service and I did more Surg Onc.

Now if I go out and do general surgery in today's market, I am not likely to get referrals for vascular surgery, complex oncologic surgery, or cardiothoracic surgery. And I have no interest in a career in trauma surgery, and if I have my way I will not be in a position to cover trauma surgery. That leaves me with the 20% of my residency (~1 year total) that I spent on the general surgery service that will be truly germane to my practice.

I'm not sure that's true. Perhaps if you live in NYC or other areas crawling with specialists, it may be hard to get the referrals. But even in a town like Phoenix, the 5th largest in the US, general surgeons thrive. We simply do not have enough specialists (outside of all the Plastic surgeons in Scottsdale). A good general surgeon can be marketable, you just have to find the right market and spend some time marketing yourself. It doesn't have to be a town of 75,000 to be able to do vascular, complex oncology. CT Surgery? Well, I'd imagine there are very few of us who got enough training as general surgery residents to be able to competently do those cases and there are probably few hospitals that would give you privileges to do so. Its hard to see that the vast majority of the country is still taken care of by general surgeons and that specialists have not made in-roads in many places.

As dr.evil notes, patients, especially elderly ones, do not want to drive to where the specialists are. My patients complain everyday that I don't operate at the hospital in Sun City West because they don't want to drive any further east than my office. They certainly aren't going to drive out to Scottsdale to the Mayo. They want a general surgeon in their backyard. PCPs want to make their patients happy; some may be swayed by the credentials that fellowship training brings and I certainly have reaped the benefits of that but I don't fool myself and think that the patients would necessarily drive 45 minutes to see me. Its the reason why my office is on the west side and I live on the east side (ie, I commute 30 mins each way) - no on else is here, doing what I do and so I am very marketable. I don't know if I would be if I positioned myself where there was lots of competition.

Why does intern year have to be a year? Why not 6 months? Why do I need to spend 2 months as a pgy-2 on the CT service pulling chest tubes? Why do I need to spend a year doing trauma? We should at least have these questions being discussed and in the dialogue.

I think the integrated pathway will work very well with most surgical fields. 5 or 6 years is sufficient length to train any type of surgeon if the training is appropriately tailored. Unfortunately the "one size fits all" general surgery residency model is simply outdated. It's not beyond salvage, but it can be improved significantly and needs a major overhaul.

In response to the question "what will happen to general surgeons"? It's a fairly straightforward answer. Have a general surgery residency that accurately reflects general surgery today.

And I agree with you. My question was sincere: if you are proposing cutting the length of surgical residency what do you propose to cut and what would be in its place? If you want residents to operate more (which I wholeheartedly support), how do you envision getting the residency programs to support this? Many places are loathe to hire physician extenders to replace the poor interns in doing floor work.

So, while I get what you see happening to general surgery but I'm not sure its happening in the vast majority of the country. There is still room for the general surgeon and I think the residency programs need to change to be able to produce someone with the skills to be able to compete. That means you have to be able to do MIS, Vascular, Surg Onc, etc. and there needs to be more time operating, more time doing actual patient management and less time doing non-productive work.

All I want to hear is a reasonable design for doing that.

 

[Castro Viejo]

But who is left to do the lesser challenging operations? Who is going to be doing your non-incarcerated inguinal or ventral hernia? Your lipomas? Your 'roids, your sigmoids?Your biliary colic?

Good point.

I suppose in my mind's new surgical training world, the "Abdominal Surgeon" would be the one to take care of the non-emergent hernias, the PRS guys take care of the lipomas (I mean, unless they're big it's usually an elective semi-cosmetic thing), the 'roids and sigmoids are the realm of the CRS, and biliary colic goes to the laparoendoscopist who can do it through someone's mouth or vagina.

If everyone is a specialist, where do these patients go?

I'm not talking about full abandonment of "General Surgery." I'm talking about re-tooling the training sequence so that those trainees who elect a different avenue of practice can get out earlier and learn a highly specialized body of knowledge. As you said, why would a Plastics man need to do all those Whipples when, for the most part, they never break the fascia? Similarly in regards to my future training, Whipples have only contributed a little bit to my understanding of access to the retroperitoneum. I'm not discounting what I've learned from General Surgery, I just think that given the true General Surgeon is, in most communities I think, nowhere to be found we're pursuing training that's irrelevant to the marketplace and the demands of modern healthcare.

Sure, but we aren't talking about emergencies. The new acute care surgeons can take care of those, or any FP with a drill. But I wanna know, if we are playing taps for the general surgeon and GS training, then who is going to do the bread and butter stuff of GS? I don't know too many vascular surgeons who are willing to do them (except one...I've done a hernia repair with RA before).

Although I knew him for only a few minutes, I can already tell RA is awesome.

I love hernia surgery. I'd probably do it just for kicks on the side like RA. That would, of course, go against my mind's new surgical world but I'm trained to do it.

 

[Castro Viejo]

We have no colorectal, vascular, oncologic, endocrine, trauma or breast surgeons. We do have CT guys but they want nothing to do with thoracic stuff.

So what have I done this year: a partner and I did a Whipple yesterday (god forbid a general surgeon do a Whipple but we did it ), an APR, a right upper lobectomy, several laparoscopic colon resections, gastrectomy, lap paraesophageal hiatal hernia/Nissen, I have a lap adrenalectomy on next week, I did a mastectomy-sentinel node-axillary dissection this week, numerous VATS for various reasons, numerous GSWs to the abdomen and one recently to the popliteal artery, amputations, dialysis access, thyroidectomy, carotid endarterectomy, etc.

Sounds like what one of my former Chiefs is doing. He went straight into practice in Florida and is doing the full scope of General Surgery. He told me about an aortobifem for a lesion that, by his description, sounded like it was TASC A. Why not convince the patient to go to a Vascular Surgeon for some wire work?

I know the General Surgeon still sort of exists, but I don't believe he does in most communities.

 

[Winged Scapula]

Good point.

I suppose in my mind's new surgical training world, the "Abdominal Surgeon" would be the one to take care of the non-emergent hernias, the PRS guys take care of the lipomas (I mean, unless they're big it's usually an elective semi-cosmetic thing), the 'roids and sigmoids are the realm of the CRS, and biliary colic goes to the laparoendoscopist who can do it through someone's mouth or vagina.

Ahh...NOTES. We'll see where that goes and with whom it goes.

So in your mind tha "abdominal surgeon" is doing only non-complex things for which there is not a subspecialty? He/she doesn't do the surg onc or vascular or colorectal stuff? Sounds like a pretty darn boring practice (and obviously I have a high tolerance for boredom). Any takers?

I'm not talking about full abandonment of "General Surgery." I'm talking about re-tooling the training sequence so that those trainees who elect a different avenue of practice can get out earlier and learn a highly specialized body of knowledge. As you said, why would a Plastics man need to do all those Whipples when, for the most part, they never break the fascia? Similarly in regards to my future training, Whipples have only contributed a little bit to my understanding of access to the retroperitoneum. I'm not discounting what I've learned from General Surgery, I just think that given the true General Surgeon is, in most communities I think, nowhere to be found we're pursuing training that's irrelevant to the marketplace and the demands of modern healthcare.

I think that's a perfectly valid point and one I agree with. Don't get me wrong...just because I think there is some usefulness in general surgery training doesn't mean that I don't think it doesn't need major retooling. Maybe there is no need for a true general surgeon anymore, its just that in my market I see the need and I see the desire is still there among medical students and residents.

While Whipples may not have contributed much to your understanding of how to access the retroperitoneum, what about the simple skills of opening the belly, assessing the patient's clinical status, and of course, the anastomoses? You don't have to do Whipples of course, to do all of those things, and it was only an example but I'd like to think that I learned something from every operation I did, even if I'll never do them again.

Although I knew him for only a few minutes, I can already tell RA is awesome.

I love hernia surgery. I'd probably do it just for kicks on the side like RA. That would, of course, go against my mind's new surgical world but I'm trained to do it.

Oh, RA didn't do the hernia repair "for kicks" but rather because it was a patient of his with an ax-bifem and he didn't trust anyone else to be near his graft.

You aren't going to be allowed to do the hernia in your mind's new surgical world. You cannot advocate for superspecialization and the end of general surgery and then try and claim those operations for yourself.

 

[Celiac Plexus]

And I agree with you. My question was sincere: if you are proposing cutting the length of surgical residency what do you propose to cut and what would be in its place? If you want residents to operate more (which I wholeheartedly support), how do you envision getting the residency programs to support this? Many places are loathe to hire physician extenders to replace the poor interns in doing floor work.

How about cutting intern year in half? There is no good reason why an intern period must be 12 months. After 6 months (or less) an the educational yield of being an intern is low. 6 months saved.

How about eliminating 6 months of trauma? Again, the educational yield is quite low after 6 months at a busy trauma center. 6 months saved.

Most programs could also find another 6 months to cut from various rotations. Does a future cardiothoracic surgeon need to spend 1-2 months doing an endoscopy rotation? Not all programs have a formal endoscopy rotation, but you get the idea.

This would leave a core surgery training of 3.5 years. Add 2.5 years of focused training in the field of one's choice and there you have a 6 year integrated pathway. Heck, for an example of an integrated vascular surgery residency, check out Stanford's 5 year program. It can be done. Not just for vascular surgery, but for cts, surg onc., laparoscopy, etc.

I think the residency programs need to change to be able to produce someone with the skills to be able to compete. That means you have to be able to do MIS, Vascular, Surg Onc, etc. and there needs to be more time operating, more time doing actual patient management and less time doing non-productive work.

We are in agreement on this point. Though my posts/concerns are relevant for those who do not plan on being general surgeons, but plan on being "specialists". For those folks (~70%) of gs trainees, the issue is not how do I fit all of general surgery into 5 years, but how do I get core surgical training + specialty training into 5 years.


I have to go now and get ready for another trauma call.

 

[Castro Viejo]

Ahh...NOTES. We'll see where that goes and with whom it goes.

My personal belief is it'll go with surgery. And I further believe that if GI decides to try and wholesale muscle surgeons out of NOTES, surgeons should refuse to back them up. And I don't believe this to be unethical as the true blame for poor ethics would be on the part of the internventionalist who cannot handle his own complications.

So in your mind tha "abdominal surgeon" is doing only non-complex things for which there is not a subspecialty? He/she doesn't do the surg onc or vascular or colorectal stuff? Sounds like a pretty darn boring practice (and obviously I have a high tolerance for boredom). Any takers?

There will be takers. If you accredit it, they will come.

While Whipples may not have contributed much to your understanding of how to access the retroperitoneum, what about the simple skills of opening the belly, assessing the patient's clinical status, and of course, the anastomoses? You don't have to do Whipples of course, to do all of those things, and it was only an example but I'd like to think that I learned something from every operation I did, even if I'll never do them again.

Well I agree that I've learned a little something from every case I've been inolved with in my career, but as you point out, I learned many of these things from other more common, more bread and butter cases as well. The Whipple is an interesting operation and one that is technically and somewhat mentally challenging, but the true mechanics of it are lost on someone who won't be doing many of them in practice.

Personally I'd like to see how the integrated vascular program will teach a new crop of vascular surgeons how to do all this stuff that you sort of take for granted in your five-year General Surgery training.

Oh, RA didn't do the hernia repair "for kicks" but rather because it was a patient of his with an ax-bifem and he didn't trust anyone else to be near his graft.

Word up. I'd probably feel the same way.

You aren't going to be allowed to do the hernia in your mind's new surgical world. You cannot advocate for superspecialization and the end of general surgery and then try and claim those operations for yourself.

I know.

 

[droliver]

Does a plastic surgeon need to spend years doing Whipples or colon resections? This is a hotly debated topic and I'm not sure where I stand on it. I do however think that general surgery training does need to change to fit the marketplace and new technology. But I'm not sure that the years of doing patient management, pre and post-op care, seeing patients over and over again, learning how to run an operating room, how to do an anastomosis safely, etc. is not valuable work - regardless of whether or not you become a plastic surgeon or a CT surgeon

I couldn't agree more, but it's difficult to make the students and residents with "integrated blinders" on understand this. All these skills and disciplines you learn are building blocks for becoming a better doctor (as opposed to some narrowly focused super specialist).

The skills I learned taking care of and doing complex liver, transplant, vascular, and trauma cases are what become your "vocabulary" for reconstructive surgery techniques. I convinced there's definately something lost by truncating traditional gernalist-->specialist training be it vascular, hearts, plastics, etc....

Don't forget at the end of the day that the factors driving the change to integrated models are manpower & economic for the division or department rather then conviction that we've suddenly figured a better way to do things for these specialties

 

[Southpaw]

What are you proposing to cut out?

Perhaps a few months of the end of 4th year could be consolidated but I don't see that there is a lot of redundancy in US medical training. Do I use my (former) knowledge of biochemistry in my daily practice? No, but I would venture that the skills learned and knowledge accumulated was helpful in some way.

Sorry to hit on just this one point of the discussion, but as a 3rd year this is where I can chime into the discussion. I see a great deal of redundancy in medical school and believe the training could easily be fit into 3 years. Duke has packed clinical and classroom training into 3 years for a long time and I haven't heard anything about their graduates being less qualified for residency training.

 

[Lamborghini1315]

Sorry to hit on just this one point of the discussion, but as a 3rd year this is where I can chime into the discussion. I see a great deal of redundancy in medical school and believe the training could easily be fit into 3 years. Duke has packed clinical and classroom training into 3 years for a long time and I haven't heard anything about their graduates being less qualified for residency training.

That's interesting, i am really amazed by the arguments made on this thread. I personally know that my interest in GS is pretty strong..so by the time i am in residency i want to be sure if my career as a GS would be equally fruitful as one of the sub specialties. I concur with celiac on his point of cutting down some internship time and in other areas that could perhaps be spent for a fellowship or even prolong training in areas that seem to be more bread and butter for general surgeons. Its imperative that the residency programs do alter their training emphasis to areas more beneficial to general surgeons in comparison to some areas that might be rarely seen by a general surgeon in a day to day practice.

 

[dienekes88]

There will be takers. If you accredit it, they will come.

I'm not even in med school yet, so my opinion hardly counts.

Shouldice hospital in Canada treats hernias exclusively. Apparently, the excitement is in trying to attain perfection.

I wonder how many CABGs Dr. Craig Smith at Columbia-Presbyterian has done. I'm gonna guess ~50 bazillion. Does it get boring? I don't know. He still does them, so it can't be too boring. Maybe I should ask him...

 

[Blade28]

Shouldice hospital in Canada treats hernias exclusively.

Don't forget that many of their "practitioners" aren't trained surgeons, but rather physicians from other fields that have had hernia-specific training.

 

[BlondeDocteur]

I wonder how many CABGs Dr. Craig Smith at Columbia-Presbyterian has done. I'm gonna guess ~50 bazillion. Does it get boring? I don't know. He still does them, so it can't be too boring. Maybe I should ask him...

Dr Smith, bless him, hardly sees the inside of an OR. Too busy being the administrator/ device developer to the stars, I suppose. But your point is a good one, except a CABG has a wee bit more variety and in situ problem-solving than an inguinal hernia repair.

 

[dienekes88]

Dr Smith, bless him, hardly sees the inside of an OR. Too busy being the administrator/ device developer to the stars, I suppose. But your point is a good one, except a CABG has a wee bit more variety and in situ problem-solving than an inguinal hernia repair.

I guess they're kinda opposite ends of the complexity spectrum. However, the "non-complex things for which there is not a subspecialty" that Winged Scapula mentions are kinda in between (I think... I don't even know what those things are). You could totally get people to chase a 3-year surgery-lite residency focusing on a couple procedures so that they're really good at them.

Just thinking aloud... maybe that attending could cover the ED in tandem with the ED-attending. It'd be the same shift-type work as Emergency med. For elective procedures, they might even be able to work almost reasonable hours. Maybe this could be an answer to the "can I be a surgeon while working less than 50 hrs/wk"-threads.

 

[Winged Scapula]

It will be very interesting in the next few years to see what happens to general surgery. ACS News arrived yesterday and they are predicting a shortage of 7,000 general surgeons by 2050.

I'll prolly be demented by then (if family history holds), so just keep reminding me when I said there was still room for general surgery in this world and not everything needed to be subspecialized.

 

[mitchconnie]

It will be very interesting in the next few years to see what happens to general surgery

I was informed last week that the ABS voted to eliminate the requirements for index arterial cases in general surgery residency programs. So no requirements to do aorta, fem-pop, carotid, etc. Apparently there will still be a minimum number of "vascular" cases but it can be veins, filters, access and other minor stuff. This is just a recognition of the obvious reality that surgeons really shouldn't be dabbling in major arterial surgery. I think that the ABS may finally be catching up to 21st century medical practice.

Sounds like what one of my former Chiefs is doing. He went straight into practice in Florida and is doing the full scope of General Surgery. He told me about an aortobifem for a lesion that, by his description, sounded like it was TASC A.

And this sort of ridiculous shenanigans is why the change is LONG overdue.

 

[Castro Viejo]

I was informed last week that the ABS voted to eliminate the requirements for index arterial cases in general surgery residency programs. So no requirements to do aorta, fem-pop, carotid, etc. Apparently there will still be a minimum number of "vascular" cases but it can be veins, filters, access and other minor stuff. This is just a recognition of the obvious reality that surgeons really shouldn't be dabbling in major arterial surgery. I think that the ABS may finally be catching up to 21st century medical practice.

And this sort of ridiculous shenanigans is why the change is LONG overdue.

I have heard this same thing with regard to the ABS' change in the Vascular Surgery component of General Surgery training. I think it's the right thing to do.

But what I don't quite understand, given their recognition that Vascular Surgery practice is quite different in 2008 medicine, is why they flat out haven't allowed Vascular Surgery to form a separate and independent Board of Vascular Surgery? There is a "Vascular Surgery Board of the ABS" which administers and essentially accredits Vascular Surgery programs, but not something entirely independent of General Surgery.

Is this just another mechanism to halt the cannibalism of General Surgery?

 

[jubb]

I understand the specialization of surgery and better outcomes associated with it, but doesn't any surgeon have to broad range of skills to fix anything that comes his or her way. I could understand it better if thoracic surgery was becoming splitting off more than vascular surgery. There are vessels everywhere in the body, in the abdomen, in the extremities in the chest. It seems like a portion of vascular surgery is required by all surgeons. You can't have a stat consult for a vascular surgeon when a medical student or intern puts a trocar into the aorta, the problem needs to be fixed right then. I don't wanna be afraid of vessels. I guess I just see thoracic as being it's own specialty before I'd see vascular being it's own specialty.

I just wish I could practice surgery the way it was practiced 20 years ago, lots of money, lots of variety. I want vascular, thoracic, and trauma as part of my job description. I guess I'll yield to patient outcomes dang it.

 

[mitchconnie]

I just wish I could practice surgery the way it was practiced 20 years ago, lots of money, lots of variety. I want vascular, thoracic, and trauma as part of my job description

I think that you may be misreading the situation. In many cases there is just as much or more variety in practice now than 20 years ago. Take a look at vascular surgery. 20 years ago there wasn't really that much to learn--carotid endarterectomy, Open AAA repair, leg bypass, vein stripping. Easy to learn during surgery residency or a one-year fellowship. Now there is endovascular AAA repair, endovascular thoracic aneurysm repair, carotid stenting, thrombolysis, foam sclerotherapy, subintimal angioplasty, stents of all kinds, radiofrequency ablation, laser ablation, cryoplasty, coil embolization of endoleaks, subfascial endoscopic perforator surgery, diagnostic angiography, etc. And in many cases vascular surgery is taking back cases from thoracic surgery--like thoracic aortic aneurysms and occlusive disease of the supra-aortic vessels.

In a single day, I may go from a big abdominal case in the OR to the cath lab for a carotid stent then to the office for an outpatient cosmetic vein procedure--all totally different environments. So the variety is still there if you pursue the right training pathway.

 

[jubb]

I think that you may be misreading the situation. In many cases there is just as much or more variety in practice now than 20 years ago. Take a look at vascular surgery. 20 years ago there wasn't really that much to learn--carotid endarterectomy, Open AAA repair, leg bypass, vein stripping. Easy to learn during surgery residency or a one-year fellowship. Now there is endovascular AAA repair, endovascular thoracic aneurysm repair, carotid stenting, thrombolysis, foam sclerotherapy, subintimal angioplasty, stents of all kinds, radiofrequency ablation, laser ablation, cryoplasty, coil embolization of endoleaks, subfascial endoscopic perforator surgery, diagnostic angiography, etc. And in many cases vascular surgery is taking back cases from thoracic surgery--like thoracic aortic aneurysms and occlusive disease of the supra-aortic vessels.

Very good point. I'll still long for the old days though.

 

[Lamborghini1315]

It will be very interesting in the next few years to see what happens to general surgery. ACS News arrived yesterday and they are predicting a shortage of 7,000 general surgeons by 2050.

I'll prolly be demented by then (if family history holds), so just keep reminding me when I said there was still room for general surgery in this world and not everything needed to be subspecialized.

That made my day..i hope i am going into a high demand market when i match.