Bariatric Surgery

[FreeWeezy]

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I'm hoping some surgery residents or attendings could give me some perspective on the future of bariatric surgery and also how to get into this area of practice. (I'm also considering bariatric medicine as an alternative but medical interventions for obesity are currently limited)

First what I know: I understand the roux-en-y is gold standard (with AGB also an option) and nothing else can cure diabetes in a week. I also understand that the severely obese are a high risk surgical population and have a number of psychiatric comorbidies which some surgeons hate.

First, do you think that this procedure is just a pill (or even a vaccine which seems in the works) from becoming obsolete or is there a real future in this type of procedure? Since I am interested in weight loss treatments more generally, I would not want to do a 6 year grueling GS residency and find that I am obsolete. Aside from the obvious demographics, how promising is weight loss surgery in the future?

Also, is General Surgery the only route to do bariatric surgery? I would really want to focus on this one area if I did GS. Could I do any of the other surgical sub-specialties (neouro seems the most interesting but any others?) and then train in bariatrics if it's still the best treatment for obesity? My reasoning would be I'd much rather be a neurosurgeon as a backup than do GS and see cases which don't interest me. Also, do you learn enough about bariatrics during GS or would you have to do an additional year training in bariatrics? If so, Is this a formal competitive sort of fellowship or just something anyone can do after residency under the supervision of someone in the field?

Thank you very much for any insight!

 

[filter07]

It is a common worry that one magic pill will obliterate an entire surgical field. The one that I can think of is gastrectomy for ulcer disease that was taken over by H2 blockers and PPIs. There are plenty of surgical fields that are in the same situation as bariatrics. For example if you treat atherosclerosis, vascular and CT surgery would be very limited. But if you have been following the science behind these things, you would realize that we are not very close to have a magic pill for obesity, and certainly not anywhere close to have a magic pill for atherosclerosis. Bottom line, I don't think fear of a magic pill should stop you from being a surgeon, especially a general surgeon that can treat a huge variety of problems.

Second, yes, general surgery is the only path to bariatrics. Getting into an MIS/bariatrics fellowship is easy. The fellowship is not "formal" as in, recognized by the board, but it can help you get hospital privileges.

I'm curious why anyone would want to do bariatrics only, and not the rest of GS, other than the obvious issue of reimbursement. Neurosurgery and bariatrics have very little overlap if at all, again, other than high reimbursement.

 

[FreeWeezy]

I'm curious why anyone would want to do bariatrics only, and not the rest of GS, other than the obvious issue of reimbursement. Neurosurgery and bariatrics have very little overlap if at all, again, other than high reimbursement.

Thank you so much for your insight!

It might because I'm just a first year and don't know too much about what general surgeons do and have the possibly misguided idea that they do mostly cases other surgeons don't want. Is this true? What else do they do and are they also in private practice? I imagine if I'm having knee problems, I'm going to go see an ortho guy instead of a general surgeon?

Mostly though it's because my primary interest is bariatrics (I'm also considering medical bariatrics through psych or IM) and only other surgical interest at moment is neuro. I've done obesity research and know the drug pipeline is pretty limited. But in the rare event that bariatric surgery becomes a thing of the past and I want to protect myself, why couldn't somone from neuro get into a MIS/Bariatrics Fellowship and get hospital privileges to do bariatric surgery or even have in office surgical suite?

Lastly, should it be worrisome for me to go into GS just wanting to do one type of procedure? Is this common or do most GS people hope to do a little bit of everything?

Thanks again!

 

[Buzz Me]

Lastly, should it be worrisome for me to go into GS just wanting to do one type of procedure? Is this common or do most GS people hope to do a little bit of everything?

PLEASE don't do this.

Keep an open mind throughout your MS3 rotations, then see what you like.

 

[FreeWeezy]

PLEASE don't do this.

Keep an open mind throughout your MS3 rotations, then see what you like.

Okay thank you! But what is the general expectation of those who go into GS? Do many do it because it is less competitive than sub-specialties? If they have board scores, honors, etc to match into surgical sub-specialties and still chose GS, do they prefer GS because it gives broad exposure to everything or is it because they want to do something specific like bariatrics that isn't part of the other sub-specialties?

Also, what procedures exactly do GS people do when in private practice in large cities?

 

[LucidSplash]

why couldn't somone from neuro get into a MIS/Bariatrics Fellowship and get hospital privileges to do bariatric surgery or even have in office surgical suite?

😱 Because if you spend your entire residency training to operate on the brain, spine, and nerves you have no business mucking around in the abdomen? Only GS trained surgeons are eligible for bariatrics/MIS fellowships.

 

[LucidSplash]

Also, what procedures exactly do GS people do when in private practice in large cities?

In the last week I or someone from my team (monday and tuesday elective general surgery, this wed-thurs emergency general surgery) has scrubbed on:

various types of colectomies (open and lap), partial and total, with and without creation of an ostomy, loop or otherwise
exploratory laparotomy with the above and below
small bowel resections
I&D of abscesses... almost anywhere on the body
inguinal, umbilical, ventral hernia repairs (open and lap) including separation of components
lumpectomy, total mastectomy, modified radical mastectomy, biopsies
colonoscopies, egd
filter placements
too many appendectomies and cholecystectomies to count
trachs, PEGs
amputations
peritoneal dialysis catheter placement
removal of foreign body from various places
ports, tunneled central lines of various types

I think that's it for the past week. I don't think we had any perfed ulcers w/graham patch, gastrectomy/antrectomy with vagotomy, VATS. Others can add on I suppose.

The one from a couple months ago was really special - guy who had a gastrocutaneous fistula after having PEG out... for five years. Never saw anyone, just let it blow up and rupture/drain pus every 6 months or so. Finally developed nec fasc and came in septic. Think he might also have had some dead bowel. Came in to the EGS service.

Oh, and was fully insured.

 

[FreeWeezy]

In the last week I or someone from my team (monday and tuesday elective general surgery, this wed-thurs emergency general surgery) has scrubbed on:

various types of colectomies (open and lap), partial and total, with and without creation of an ostomy, loop or otherwise
exploratory laparotomy with the above and below
small bowel resections
I&D of abscesses... almost anywhere on the body
inguinal, umbilical, ventral hernia repairs (open and lap) including separation of components
lumpectomy, total mastectomy, modified radical mastectomy, biopsies
colonoscopies, egd
filter placements
too many appendectomies and cholecystectomies to count
trachs, PEGs
amputations
peritoneal dialysis catheter placement
removal of foreign body from various places
ports, tunneled central lines of various types

I think that's it for the past week. I don't think we had any perfed ulcers w/graham patch, gastrectomy/antrectomy with vagotomy, VATS. Others can add on I suppose.

The one from a couple months ago was really special - guy who had a gastrocutaneous fistula after having PEG out... for five years. Never saw anyone, just let it blow up and rupture/drain pus every 6 months or so. Finally developed nec fasc and came in septic. Think he might also have had some dead bowel. Came in to the EGS service.

Oh, and was fully insured.

Thank you for such a detailed response. It sounds really interesting. And I'm imagine it's not uncommon during residency or as a hospital based attending. But if you prefer private practice, would anyone really walk into your office asking for a small bowel resection?

It sort of goes back to my question of wouldn't the guy with knee problems just go see an ortho surgeon? Do people go into GS wanting to do a bit of everything and is private practice even feasible in major city with several academic medical centers?

 

[Winged Scapula]

Whew...where to start?

1) BARIATRIC SURGERY
The only route to practicing Bariatric Surgery is via General Surgery. While it is not required to do an MIS/Bariatrics Fellowship, it may give you more bargaining power when it comes to employment.

Train in a fat state like Pennsylvania (where I did my residency) and you will do more than enough Bariatrics during residency without needing a fellowship.

The fellowship is not competitive. And while it is possible to do some apprenticeship, IMHO no one in their right mind would do a non-accredited fellowship when there are legit fellowships available. These fellowships are ONLY open to General Surgeons.

2) NEUROLOGICAL SURGERY AND BARIATRICS
As noted above, these are about as far apart surgical specialties as possible. NO hospital will give operating privileges to a Neurosurgeon who has not done General Surgery training, has never operated on the abdomen for obvious reasons (at least obvious from our vantage point).

Please wait until you do your rotations and see what interests you but as we've noted time and time again, you simply cannot do two different specialties and do both of them well. This is especially true when picking something as disparate as Neurosurgery and Bariatrics.

3) GENERAL SURGERY
Let me guess, you are training at an academic institution, or have been talking to other MS-1s or your basic science faculty which is where you have gotten your ideas about General Surgery?

General surgery residents may have, on average, lower Step 1 scores than some of the surgical subspecialties, but there are many GS residents who chose the field not because it was less competitive but because they actually liked it. And there are many who would be competitive for the most competitive surgical specialties out there but preferred GS. To assume otherwise is insulting.

General Surgery offers the broadest based trained with the most fellowships and career options of all surgical specialties.

General Surgeons don't just do "stuff other people don't want to do." As you can see above, there is a long list of operations that GS does. One of my buddies did 3 thyroids and a splenectomy today, in addition to the chole. The list above also doesn't include vascular (which many general surgeons still do), foregut surgery and melanoma and other skin and soft tissue excisions. It is popular to think of General Surgery as only "butt pus" but nothing could be further from the truth. It is a dynamic and varied field.

Finally, believe it or not, many patients PREFER to see a community practice general surgeon over one at the academic mecca. As a matter of fact, should I need my gallbladder or appendix out, I'm not going to Mayo for it, I'm going to choose one of my very bright and skilled community surgery colleagues to do it. Patients prefer community surgeons for many reasons:

- referral from their PCP (who is not likely to be at the academic hospital)
- not feeling like a "number"
- insurance purposes
- impression (probably accurate) that community general surgeons do more of the bread and butter surgery
- no students/residents in many cases
- location/distance

So yes, in answer to your question: is it currently still viable to have an active community general surgery practice, even in a large city. General Surgeons take call; so while someone needing a bowel resection may not walk into your office, you can bet you might see them in the ED as a consult. Lots of GS business comes from referrals *and* ED call.

 

[LucidSplash]

Thank you for such a detailed response. It sounds really interesting. And I'm imagine it's not uncommon during residency or as a hospital based attending. But if you prefer private practice, would anyone really walk into your office asking for a small bowel resection?

It sort of goes back to my question of wouldn't the guy with knee problems just go see an ortho surgeon? Do people go into GS wanting to do a bit of everything and is private practice even feasible in major city with several academic medical centers?

You're going to see an orthopod for your knee. No one is suggesting otherwise - these days, for the most part, only orthopods do anything with bones/joints (hand subspecialists with a PRS or GS background being the most glaring exception to that rule).

Also, FWIW, I'm a "academic-affiliated" program (or as I like to call it "communiversity"). I get to see both academic and community models rotating both at the main "big" hospital in town as well as the smaller ones.

Its going to be pretty tough to build a single practice, fresh out of training, on a single procedure - unless you joined a practice and took over the exclusive role of a single retiring doc and I think that'd be pretty tough to find. In the main group practice here in town, there is one guy I know of that does almost exclusively bariatrics... now. He had a general surgery practice for years and only recent decided to transition to bariatrics only. Also, it had to fit with the practice plan of his partners. I anyone could sustain themselves as a GS or even fellowship trained MIS doing JUST bariatrics from the beginning. Most of my attendings (in their academic-center AND smaller community-hospital cases) who have self-specialized into an area typically did GS for years before narrowing their scope.

Also, you'll find that a lot of GS, even in PP, will need to take call. Depending on where you maintain privileges and the size of the town (you've specifically mentioned big city) even a PP guy can find himself doing some SBR.

I think its great that you have an interest in surgery but its clear you'll have to really spend some time exploring ALL the surgical specialties and subspecialties during your clinical years to get a handle on what is out there. You will not survive a 5-year general surgery residency if you truly only enjoy one type of procedure - and you're too early in the process to know what you really like. Having an area of interest is awesome but its too narrow a focus to sustain a career from the beginning.

 

[LucidSplash]

General Surgeons don't just do "stuff other people don't want to do." As you can see above, there is a long list of operations that GS does. One of my buddies did 3 thyroids and a splenectomy today, in addition to the chole. The list above also doesn't include vascular (which many general surgeons still do), foregut surgery and melanoma and other skin and soft tissue excisions. It is popular to think of General Surgery as only "butt pus" but nothing could be further from the truth. It is a dynamic and varied field.

Yep. In my case I left out vascular cases because we have a separate vascular service and I was listing my experience in the last week. But some of our general guys also do vascular and the guy who does the most oncologic/skin/soft tissue excisions just did ports on Monday and Tuesday this week. Several of our staff do Nissen, elective splenectomy, endocrine... just didn't have any this week!

 

[Winged Scapula]

Yep. In my case I left out vascular cases because we have a separate vascular service and I was listing my experience in the last week. But some of our general guys also do vascular and the guy who does the most oncologic/skin/soft tissue excisions just did ports on Monday and Tuesday this week. Several of our staff do Nissen, elective splenectomy, endocrine... just didn't have any this week!

Oh I knew you were just pointing out what you did this week (but figured the OP might not). Still good case mix...thanks for listing!

 

[Winged Scapula]

Y
Its going to be pretty tough to build a single practice, fresh out of training, on a single procedure - unless you joined a practice and took over the exclusive role of a single retiring doc and I think that'd be pretty tough to find. In the main group practice here in town, there is one guy I know of that does almost exclusively bariatrics... now. He had a general surgery practice for years and only recent decided to transition to bariatrics only. Also, it had to fit with the practice plan of his partners. I anyone could sustain themselves as a GS or even fellowship trained MIS doing JUST bariatrics from the beginning.

It may depend on the market.

I have a friend here from residency (different program, but we used to moonlight at the same hospital in PA), who does exclusively Bariatrics. There are a few groups here who do the same and are, by all appearances, successful. So I believe it can work with the right environment, skill set and marketing.