competition and GS residency

[drbruce]

I'm still at medical school and hope to get into a general surgery residency one of these days but I'm concerned that the 80 hr working directive has made this traditionally unpopular residency highly competitive. Do other students think the same.

I know this question has been covered in the past many times but we have seen quite a change in general surgery recently and all the responses from previous threads from a few years ago seem quite outdated. Of course, nobody can predict what will happen in the future, a comet might land on our heads, destroying any need for a residency placement but assuming our eventual destruction is still in the distant future (sorry, little drunk, attended a birthday party today) if your hospitals (i say "your" cos I'm UK student) are sticking to the 80hr per week rule, I can't see general surgery ever becoming unpopular again with med school graduates, the opportunities for a certified general surgeon is just too great to be ignored, especially now that it has become fashionable to enter plastic surgery through this route.

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[H_Caulfield]

Ha...I can't imagine general surgery ever being very competitive from this point on, mainly because of all the integrated programs.

I've heard many people seriously concerned that things are becoming so specialized that there will be very little work left for general surgeons. So, then, the main reason for people to enter a GS residency would be to grab a fellowship afterward. But in what? Plastics is now an integrated 5-year, thoracic has just been approved as an integrated 6-year, orthopedics and neuro have long been there, and there's serious talk of doing the same with vascular.

I don't think many people are trying to be general surgeons, and I think that specialized surgeons would much rather go the integrated route and cut 2-3 years off of their training.

 

[geekgirl]

Ha...I can't imagine general surgery ever being very competitive from this point on, mainly because of all the integrated programs.

I've heard many people seriously concerned that things are becoming so specialized that there will be very little work left for general surgeons. So, then, the main reason for people to enter a GS residency would be to grab a fellowship afterward. But in what? Plastics is now an integrated 5-year, thoracic has just been approved as an integrated 6-year, orthopedics and neuro have long been there, and there's serious talk of doing the same with vascular.

I don't think many people are trying to be general surgeons, and I think that specialized surgeons would much rather go the integrated route and cut 2-3 years off of their training.

disagree. gen surgery (as a track - even with a fellowship at the end) is the only path to true mastery. facility can come with specialization. but if we are to still be the people who you come to when the **** hits the fan and the specialists are out of their league, we must retain the general part of our training.

re: competitiveness, i think that'll continue somewhat. but things cycle. so who knows. also, surgery programs are rarely actually 80 hrs, so the end point lifestyle of surgeons will always differ from medical docs. that will be a selection in and of itself. and keep numbers from swelling too greatly.

 

[footcramp]

i don't think it's right to say that there is a trend towards more integrated programs. there are rumblings from many programs in integrated plastics to return to the traditional GS route. vascular was recently approved but only a handful of places have adopted to start 5-6 year programs so far. and for thoracic i'm not sure but the only place i know of with a fast-track to thoracic is wash u.

while many are concerned that the typical general surgery training model is outdated, there is still a question of how to improve it. earlier specialization is not a clear cut answer. as geekgirl mentioned, the thought among many program directors is that only those who have gone through a full general surgery residency have the technical skills and good judgment to really master a fellowship.

 

[Celiac Plexus]

General surgery continue to become more competitive. There were over 1400 US senior MD applicants this last year for about 1050 positions. I think there were a couple of unfilled positions after the match.

One can only speculate as to why there is inccreasing interest in this field. Besides providing training that incorporates a lot of medical/icu training, and one that prepares trainees for specialized (ie fellowship) training, there is the 80 hour workweek as well.

One thing that is rarely discussed is that as compensation is falling for many fields, general surgery income has increased slightly every year. The biggest income loss for general surgeons was in the early to mid 1990s, while other fields evaded cuts, and some even made substantial gains. Now other foelds are looking at cuts, and falls in reimbursement (heme/onc, radiology to name a few) General surgery starting offers for new graduates are in the 250k/yr range now... some of our chiefs this last year took jobs starting in the low 300 range, not including loan forgiveness, signing bonus, CME pay, and up to 10 weeks of paid vacation. And these jobs are not in rural settings either. As the population ages, there is more and more demand for general surgeons, which accounts for the growing trend of hospitals hiring general surgeons as emplyees, paying malpractice, loan forgiveness, bonuses, etc. This will have an inflationary effect on general surgery salries as they won't be so tightly tied to medicare reimbursement rates.

If you consider that the cost of a private medical education for 4 years exceeds 200k at most institutions (counting housing, books, etc), and that a great many students borrow to pay for this, it is understandable that students' career plans are influenced by economic considerations. In an era where CRNAs start at 150k/yr, and pediatricians start at 100k/yr, getting a medical degree is making less and less economic sense unless you choose a higher paying career.

And as for integrated tracks taking away general surgery applicants... that is not supported by ERAS data at this time. Consider that applications to general surgery have increased every year since 2001. If you count reapplicants, and FMGs, the total number of applicants to categorical general surgery last year approached 3000 applications for a little over 1000 positions. Further, there are currently no integrated vascular, or thoracic tracks at this time. And though approximately 70% of general surgery chief residents will pursue fellowship training, very few are seeking ct fellowships, and only a fraction are seeking vascular surgery fellowships (although that field is gaining interest). Fellowships such as pediatric surgery, surgical oncology, trauma, breast, endocrine, etc all require 5 years of general surgery and there is no talk of going to an integrated pathway for training in these fields.

To students considering a career in general surgery... you will be in great demand after your training, and you will be positioned well for fellowship specialization. Reimbursement is slowly increasing year-to-year, and though other surgical fields offer higher reimbursement such as neurosurgery, spine surgery, urology, general surgery is a diverse field that reimburses in the upper range of physician salaries.

 

[drbruce]

As an off the topic query, you mentioned that hospitals pay for the malpractice insurance premiums but I was under the impression that US surgeons had to bare the brunt of that responsibilty?

 

[ghost_its]

As an off the topic query, you mentioned that hospitals pay for the malpractice insurance premiums but I was under the impression that US surgeons had to bare the brunt of that responsibilty?

It matters whether you are practicing in a private outside practice, which is usually run basically as a small business, with the practice doing all its own billing for procedures and paying of bills including malpractice, facility costs, rentals, etc. OR you could be a "hospitalist" surgeon, hired by a hospital in which case sometimes your costs are swallowed by the system, but you only get paid a salary from the hospital (i.e. no control over the billing for your time). One beauty of the US system is that there is an immense variety as to how to set up your practice and it all depends on what you want out of it at the end. Unfortunately, medical students in the US do NOT have much exposure to this economic side of things and many times are not quite aware of what all the options are.

 

[Winged Scapula]

While time will tell, general surgery, like most other fields, has a cycle of popularity-unpopularity. As the low ebb of popularity was 6 or so years ago, general surgery was due for an upswing.

There are dozens of journal articles dealing with the concern that the upswing is due to the work hour restrictions. IMHO, while that may draw some who are attracted to surgery, in the end:

a) the realization that at many places, "restrictions" is a loose term
b) there are no "restrictions" as an attending; you work until the work is done - even in private practice
c) 80+ hrs is still a lot of time to work per week if you aren't truly in love with the field. I wouldn't be suprised to find the attrition rate actually higher these days as those who thought surgery would be tolerable with the work hour restrictions, found that it wasn't and that they didn't also realize that they still have to study when the go home.

Like most things, as it gets more competitive, the population applying will self-select, and those who fear they aren't competitive, will not even apply. Applications go down and the cycle starts all over again. In addition, as footcramp noted, while there has been talk of integrated programs for years, it has taken *forever* to get approval, they are by no means tried and true (he is correct in noting that there is a great deal of dissatisfaction in the PRS world with integrated programs) and I would be very suprised if there was a great movement in that direction. For most of us, the training of a general surgeon will not change significantly (except that it either must lengthen or become better organized) in the next generation.