community hospital general surgeons

[SurgeDO]

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i tried searching the forums for similar discussions but was unable to find any.

for general surgeons practicing in a community setting, how much variety do you have in your cases? i have a couple communiversity hospitals near my school where i follow some of the general surgeons around.

in my experience, the dynamic that i have observed is that these general surgeons are becoming "specialized" in certain operations. for example, all lap choles are being sent to Dr. X, Dr.Y is fixing all the PE hernias, Dr. Z is being sent all the inguinal hernias, etc.

admittedly as a medical student, my observations may just be grossly oversimplified. if not, is this a common thing in other areas?

i love general surgery for the diversity of operations and wide range of scope the training entails. i guess i am wondering if this wide range of scope and diversity becomes less practical and more theoretical once you enter practice. i am curious about the case diversity of the average general surgeon in an average-sized community.

 

[Smurfette]

I've commented multiple times on this as a general surgeon, but don't have time to search for my posts. I get good variety, but you need to ask specifics when you job-hunt what referral patterns are, how much volume there is of cases you like, and so forth.

That being said, most surgeons become known for being good at certain cases, or find that they really like certain cases. Even in academics, you get surgeons who are trained in their subspecialty, but over time, became known for one particular area of that subspecialty and it seemingly becomes their main focus even though they still do other things. Sometimes a few people in the community had operation x by a surgeon, and word spread (either among physicians, the public, or both), resulting in a higher volume of that type of case. It also depends on what kind of cases are prevalent locally---all general surgeons are going to get hernias, choles, etc. in large amounts because statistically, there are more of those cases that need to be done--so if you are at a place where colon surgeries are infrequent or certain types of things have a well-established referral pattern that you are unlikely to be able to become a part of, your variety will take a hit. Call/inpatient consults is also a way to get variety, but the trade-off is just that: you have to take call. I think most surgeons are likely to change jobs if they don't like the types of cases they are getting.

I get a variety (it pays as a general surgeon to get along well with the local GI group to get colon referrals and interesting GI things), but I still see a significant percentage of breast patients in the office because 1. I'm the only female surgeon in my town 2. the local OB/Gyn group sends me a ton of referrals after patients gave them good feedback about me and I bail the OBs out of trouble intraop from time to time and am pleasant about it and 3. patient word of mouth. There are other female surgeons in the general area who curb breast referrals by seeing a max of "x" breast patients a day or other things. I don't, because I am still trying to build my practice, I like doing breast stuff and cringe at another local surgeon who doesn't believe in needle biopsies of breast lesions and takes them all to surgery because he believes "all women just want it out anyway". Just about all my breast patients who need other surgeries come back to me, as do many of their family members.

 

[SurgeDO]

I've commented multiple times on this as a general surgeon, but don't have time to search for my posts. I get good variety, but you need to ask specifics when you job-hunt what referral patterns are, how much volume there is of cases you like, and so forth.

That being said, most surgeons become known for being good at certain cases, or find that they really like certain cases. Even in academics, you get surgeons who are trained in their subspecialty, but over time, became known for one particular area of that subspecialty and it seemingly becomes their main focus even though they still do other things. Sometimes a few people in the community had operation x by a surgeon, and word spread (either among physicians, the public, or both), resulting in a higher volume of that type of case. It also depends on what kind of cases are prevalent locally---all general surgeons are going to get hernias, choles, etc. in large amounts because statistically, there are more of those cases that need to be done--so if you are at a place where colon surgeries are infrequent or certain types of things have a well-established referral pattern that you are unlikely to be able to become a part of, your variety will take a hit. Call/inpatient consults is also a way to get variety, but the trade-off is just that: you have to take call. I think most surgeons are likely to change jobs if they don't like the types of cases they are getting.

I get a variety (it pays as a general surgeon to get along well with the local GI group to get colon referrals and interesting GI things), but I still see a significant percentage of breast patients in the office because 1. I'm the only female surgeon in my town 2. the local OB/Gyn group sends me a ton of referrals after patients gave them good feedback about me and I bail the OBs out of trouble intraop from time to time and am pleasant about it and 3. patient word of mouth. There are other female surgeons in the general area who curb breast referrals by seeing a max of "x" breast patients a day or other things. I don't, because I am still trying to build my practice, I like doing breast stuff and cringe at another local surgeon who doesn't believe in needle biopsies of breast lesions and takes them all to surgery because he believes "all women just want it out anyway". Just about all my breast patients who need other surgeries come back to me, as do many of their family members.

I appreciate the reply. This is good to hear.

 

[Winged Scapula]

It's funny - I actually know a fellowship trained breast surgeon who has a 100% breast practice...except she has several of her breast patients come back to her later to do their gallbladder, hernia, etc.

Does she do them?

 

[Winged Scapula]

She's young and until a year or so ago still had to do some EGS call, so she still feels fine doing them.

So she doesn't have a 100% breast practice then.

Hmmm...I guess I have a problem with someone calling themselves a breast surgeon but still doing general surgery (and I'm not the only one; it's been an issue in the field for some time). For some reason GS don't call themselves "colorectal surgeons" or "endocrine surgeons" if they re still doing other cases but it's ok for a female (usually) who does a lot of breast surgery (amongst other things) to call herself a breast surgeon. Marketing I would surmise.

 

[Winged Scapula]

Well I think this is literally in the neighborhood of 5 cases over the past year? When I say 100% breast practice I meant that she takes no general surgery call and only sees new breast patients. I guess I don't see an issue with her operating on a handful of her patients that she already has a relationship with.

I agree - sounds like it's not a big deal in her case. However here locally and elsewhere in the country it is a big deal, where it's a lot more than 5 cases.

I see the issue for her as of one of liability; if she gets sued and is only doing 5 lap choles a year, that will be raised by the plaintiffs attorney as a significant factor, even if she was doing more last year or two years ago.

 

[SurgeDO]

I've commented multiple times on this as a general surgeon, but don't have time to search for my posts. I get good variety, but you need to ask specifics when you job-hunt what referral patterns are, how much volume there is of cases you like, and so forth.

That being said, most surgeons become known for being good at certain cases, or find that they really like certain cases. Even in academics, you get surgeons who are trained in their subspecialty, but over time, became known for one particular area of that subspecialty and it seemingly becomes their main focus even though they still do other things. Sometimes a few people in the community had operation x by a surgeon, and word spread (either among physicians, the public, or both), resulting in a higher volume of that type of case. It also depends on what kind of cases are prevalent locally---all general surgeons are going to get hernias, choles, etc. in large amounts because statistically, there are more of those cases that need to be done--so if you are at a place where colon surgeries are infrequent or certain types of things have a well-established referral pattern that you are unlikely to be able to become a part of, your variety will take a hit. Call/inpatient consults is also a way to get variety, but the trade-off is just that: you have to take call. I think most surgeons are likely to change jobs if they don't like the types of cases they are getting.

I get a variety (it pays as a general surgeon to get along well with the local GI group to get colon referrals and interesting GI things), but I still see a significant percentage of breast patients in the office because 1. I'm the only female surgeon in my town 2. the local OB/Gyn group sends me a ton of referrals after patients gave them good feedback about me and I bail the OBs out of trouble intraop from time to time and am pleasant about it and 3. patient word of mouth. There are other female surgeons in the general area who curb breast referrals by seeing a max of "x" breast patients a day or other things. I don't, because I am still trying to build my practice, I like doing breast stuff and cringe at another local surgeon who doesn't believe in needle biopsies of breast lesions and takes them all to surgery because he believes "all women just want it out anyway". Just about all my breast patients who need other surgeries come back to me, as do many of their family members.

i was thinking about this today. how do the colorectal guys handle general surgeons taking out chunks of colon? i know it is within the general surgeon's scope of practice, but i can imagine they catch some heat from the colorectal surgeons. my guy does 2-3 colectomies a month and says he has the opportunity to do more. is this something frowned upon in the surgery community?

 

[Dr.LeoSpaceman]

i was thinking about this today. how do the colorectal guys handle general surgeons taking out chunks of colon? i know it is within the general surgeon's scope of practice, but i can imagine they catch some heat from the colorectal surgeons. my guy does 2-3 colectomies a month and says he has the opportunity to do more. is this something frowned upon in the surgery community?

Probably best to get SLUser's opinion on this, but I don't see general surgeons losing bread and butter colorectal cases--especially in smaller/rural communities. And I think it would be a bit ridiculous for colorectal surgeons to get their panties in a bunch over it. It should absolutely be within a general surgeon's scope of practice to do the routine right hemi, LAR, etc. Now if you're getting into complex IBD cases, pouch reconstruction, colo-anal, etc., I think that's where colorectal surgeons play a more important role. The other argument would have been for colorectal surgeons being more facile with the laparoscope, but I think that's going to change with the current generation of trainees.

If your guy has the referral base to get those colectomies, good on him.

 

[dpmd]

In my community there is only one breast surgeon (who doesn't take all insurances) and no colorectal surgeon. I am really new to private practice here, but by virtue of being a female some stuff is being shunted to me (like breast, and female pts with butt stuff) in addition to regular stuff like hernias, colons, lumps/bumps. There are some things I didn't get enough exposure to in training so I am happy to let it get done by whoever does it in town (or to send it out of town if necessary), but part of that is that I don't care about being busy. If all I cared about was volume/money I would see a lot more variety, but I am more interested in meeting the needs of the community while still having free time. I get plenty of weird stuff on call besides the appys and choles, so for now I am content. I assist other surgeons at times (especially if I ask them to take something I am not comfortable with) so maybe as I get more gray hair I will be more bold about what cases I will do.

 

[SLUser11]

i was thinking about this today. how do the colorectal guys handle general surgeons taking out chunks of colon? i know it is within the general surgeon's scope of practice, but i can imagine they catch some heat from the colorectal surgeons. my guy does 2-3 colectomies a month and says he has the opportunity to do more. is this something frowned upon in the surgery community?

I posted about this somewhat in this thread: http://forums.studentdoctor.net/thr...lization-in-the-future.1056071/#post-14944525

The bulk of colon resections are done by general surgeons. Obviously, they are qualified to do so. In my opinion, volume determines quality...assuming one has been properly trained and remains current on literature....so a general surgeon doing 50 colons a year probably does an excellent job. Do I do a better laparoscopic colectomy or LAR than a general surgeon? Oh, probably...but it's not realistic to shunt all colon cases to specialists from a resource consumption standpoint. With current referral patterns, etc, it takes a patient population of about 100,000 to support one busy colorectal surgeon.

The pelvis, however, is a tricky area, and I have to admit that I believe any cancer within 15 cm of the anal verge should be treated by CRS if possible. The volume is simply not there for most general surgeons to remain facile, especially when it comes to pre and post-op care. Also, it's very hard to predict exactly which pelvic cases are going to be difficult, so only sending the "hard" ones to CRS may screw over a few patients.

@Winged Scapula, I have to admit I never thought about it that way, but there are plenty of people without specific fellowship training that call themselves breast, laparoscopic/MIS, bariatric, plastic, and trauma surgeons. When people without CRS training call themselves a colorectal surgeon, I certainly think it's fishy. But, there are fellowship-trained and colorectal-boarded surgeons who still do a decent volume of general surgery out of necessity, and they can call themselves whatever they want, as far as I'm concerned.

Here is what I said on the issue:
"All over the US, general surgeons are in great demand....not just in podunk Nebraska. When I was in Houston, which I believe is currently ranked #3 or 4, there were plenty of general surgeons practicing there, and doing very well for themselves. Houston, of all places, is certainly saturated with specialists, so it would be much harder to find a job there doing colorectal than doing general surgery.

The hard part, however, is determining what case volume, case complexity, and case variety all these general surgeons have. Often, they are doing a lot less Nissens than they thought they would, and a lot more colonoscopies. Here is a recent article from JACS on the topic: http://www.ncbi.nlm.nih.gov/pubmed/24210145.

Some specific colectomy stats:
Only 11.5% of colectomies are performed by colorectal surgeons
General surgeons perform an average of 11 colectomies/year (14=70th percentile, 23=90th percentile)
The learning curve for lap colectomy is approximately 50-60 cases
Graduating resident experience with lap colectomy is improving (Median 2 cases in 1999 vs. 13 in 2008).
Currently, 30-45% of colectomies in the US are done laparoscopically.

What that means is that general surgeons are doing the bulk of the work....specialists perform a small portion of the procedures nationally, but actual case volume is quite variable among general surgeons......"

 

[SurgeDO]

I posted about this somewhat in this thread: http://forums.studentdoctor.net/thr...lization-in-the-future.1056071/#post-14944525

The bulk of colon resections are done by general surgeons. Obviously, they are qualified to do so. In my opinion, volume determines quality...assuming one has been properly trained and remains current on literature....so a general surgeon doing 50 colons a year probably does an excellent job. Do I do a better laparoscopic colectomy or LAR than a general surgeon? Oh, probably...but it's not realistic to shunt all colon cases to specialists from a resource consumption standpoint. With current referral patterns, etc, it takes a patient population of about 100,000 to support one busy colorectal surgeon.

The pelvis, however, is a tricky area, and I have to admit that I believe any cancer within 15 cm of the anal verge should be treated by CRS if possible. The volume is simply not there for most general surgeons to remain facile, especially when it comes to pre and post-op care. Also, it's very hard to predict exactly which pelvic cases are going to be difficult, so only sending the "hard" ones to CRS may screw over a few patients.

@Winged Scapula, I have to admit I never thought about it that way, but there are plenty of people without specific fellowship training that call themselves breast, laparoscopic/MIS, bariatric, plastic, and trauma surgeons. When people without CRS training call themselves a colorectal surgeon, I certainly think it's fishy. But, there are fellowship-trained and colorectal-boarded surgeons who still do a decent volume of general surgery out of necessity, and they can call themselves whatever they want, as far as I'm concerned.

Here is what I said on the issue:
"All over the US, general surgeons are in great demand....not just in podunk Nebraska. When I was in Houston, which I believe is currently ranked #3 or 4, there were plenty of general surgeons practicing there, and doing very well for themselves. Houston, of all places, is certainly saturated with specialists, so it would be much harder to find a job there doing colorectal than doing general surgery.

The hard part, however, is determining what case volume, case complexity, and case variety all these general surgeons have. Often, they are doing a lot less Nissens than they thought they would, and a lot more colonoscopies. Here is a recent article from JACS on the topic: http://www.ncbi.nlm.nih.gov/pubmed/24210145.

Some specific colectomy stats:
Only 11.5% of colectomies are performed by colorectal surgeons
General surgeons perform an average of 11 colectomies/year (14=70th percentile, 23=90th percentile)
The learning curve for lap colectomy is approximately 50-60 cases
Graduating resident experience with lap colectomy is improving (Median 2 cases in 1999 vs. 13 in 2008).
Currently, 30-45% of colectomies in the US are done laparoscopically.

What that means is that general surgeons are doing the bulk of the work....specialists perform a small portion of the procedures nationally, but actual case volume is quite variable among general surgeons......"

i appreciate the reply. this is good to hear.