Difficult surgeries: who gets it?

[Grurik]

Lately I have thought some about surgery and have realized that I find it fascinating that surgeons can specialize in certain procedures that is found difficult. I think that is not the case in a medicine specialty since treatment plans are similar, in surgery the manual work has to be done as well.

In my home country (not the US or an English-speaking country for that sake) there are surgeons specialized in one surgery, of course they handle general surgery issues as well, since the volume in their specialized surgery are low. Thus, people from all over the country are referred to these surgeons.

However, I have wonder some about what makes these guys. I mean, is it interest or the manual skills that determine who perform the surgery? I guess not everyone is interested in performing difficult surgery. It all comes down to the question if anyone who has completed a surgery residency are capable of learning difficult surgery?

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[thedrjojo]

Lately I have thought some about surgery and have realized that I find it fascinating that surgeons can specialize in certain procedures that is found difficult. I think that is not the case in a medicine specialty since treatment plans are similar, in surgery the manual work has to be done as well.

In my home country (not the US or an English-speaking country for that sake) there are surgeons specialized in one surgery, of course they handle general surgery issues as well, since the volume in their specialized surgery are low. Thus, people from all over the country are referred to these surgeons.

However, I have wonder some about what makes these guys. I mean, is it interest or the manual skills that determine who perform the surgery? I guess not everyone is interested in performing difficult surgery. It all comes down to the question if anyone who has completed a surgery residency are capable of learning difficult surgery?

The program director at my program (Transplant Surgeon) always jokes that he could teach a monkey to sew the common bile duct, but he wants to train us to think as well as operate. There is definitely a level of skill someone has in operating, which can not be taught (like anything, including medicine which is not just similar treatment plans, there are some people who are highly, highly specialized in medicine just like surgery), but for the most part, most competent surgeons, particularly if you do a procedure enough times, would have the technical ability to do most any surgery. I think the desire to go into the field of question (be it transplant, cardiac, colorectal, or whatever you want to consider a difficult procedure) is just as important, because you have to have the drive and motivation to do the case 50, 100, 1000 times to become an expert in it, as well as deal with its evaluation, management, and care, which sometimes can be just as if not more taxing than the procedure itself.

 

[Grurik]

The program director at my program (Transplant Surgeon) always jokes that he could teach a monkey to sew the common bile duct, but he wants to train us to think as well as operate. There is definitely a level of skill someone has in operating, which can not be taught (like anything, including medicine which is not just similar treatment plans, there are some people who are highly, highly specialized in medicine just like surgery), but for the most part, most competent surgeons, particularly if you do a procedure enough times, would have the technical ability to do most any surgery. I think the desire to go into the field of question (be it transplant, cardiac, colorectal, or whatever you want to consider a difficult procedure) is just as important, because you have to have the drive and motivation to do the case 50, 100, 1000 times to become an expert in it, as well as deal with its evaluation, management, and care, which sometimes can be just as if not more taxing than the procedure itself.

Thanks for taking your time answering and your thoughtful comments 🙂

You're right about medical specialties, I expressed it clumsy admittedly. In many cases I guess the surgery of these "superspecialized" isn't more difficult than to actually find out the diagnosis, which hold true also for those in medicine.

From your post I guess that interest of performing a specific surgical procedure/working with a certain disease is what really matters and not that you are "scouted"/choosen into it.

Are there many surgeons that wants to limit the number of procedures so that they get specialized in only a few and have a low number of bread and butter cases? I guess in academic settings it is almost a must?

 

[thedrjojo]

Thanks for taking your time answering and your thoughtful comments 🙂

You're right about medical specialties, I expressed it clumsy admittedly. In many cases I guess the surgery of these "superspecialized" isn't more difficult than to actually find out the diagnosis, which hold true also for those in medicine.

From your post I guess that interest of performing a specific surgical procedure/working with a certain disease is what really matters and not that you are "scouted"/choosen into it.

Are there many surgeons that wants to limit the number of procedures so that they get specialized in only a few and have a low number of bread and butter cases? I guess in academic settings it is almost a must?

No problem.

As far as your last question, mostly anyone who fellows is "limiting the number of procedures so that they get specialized in only a few". And in many instances, it is only the specialized that do these procedures. For example, the only doctors doing CABG's are CT surgeons. You won't (unless I am mistaken) find any "general surgeons" performing CABG's or any cardiac surgery. That is probably the most extreme of the examples, as for most other body area, you can have a general surgeon perform basic tasks, but the more complex procedures are typically handled by specialists (for example, general surgeons will perform colectomies, but total proctocolectomy with J pouch will be likely referred to a specialist). Maybe hepatic surgery is also along the lines of cardiac surgery, but that I have less experience with (Any General Surgeons out there performing hepatic resections? Even wedge resections? Unlikely any gen surgeons are doing trisegmentectomies).

As far as your question about academics, yes, in order to get into academics, most people have advanced training and are specialized... but academic hospitals do need people to do the bread and butter cases too (at my program, our "general surgeons" that do bread and butter consist of the former chair who has no fellowship training, the head of "laparoscopic surgery", the surg onc guys who have to take general call, and the trauma attendings who also have to take general call). The other subspecialities don't have to take bread and butter cases, including Transplant, CT surgery, and Vascular Surgery. However, if you want to be specialized and have a narrow focus of practice, you don't necessarily have to be in academics. Cardiac Surgeons, if you can find a job, practice widely in the community setting. Same with vascular. Same with Breast Surgeons. Some specialties, like Transplant, Oncology, gravitate more towards academics, but there are some non academic positions for them. The requirement to do general call or the "bread and butter" cases depends greatly on the situation. At the private hospital we rotate at, which does have a "University" designation and thus I guess can be considered an academic center, a few of the vascular surgeons voluntarily take general call, the oncologists don't have to take any general call, and there are several non fellowship trained 'general surgeons", but a significant portion of general call is taken by minimally invasive trained and trauma trained individuals.

 

[cpants]

I know a few general surgeons who will do hepatic resections, even relatively complex ones. Trisegmentectomies, probably not. I also know a lot of general surgeons who will do pretty much any open vascular operation. Colorectal too, there are a lot of guys who will do any big bowel whack. Generally these guys are a little older and were trained before everything got so subspecialized. Back then general surgeons did all the big cases and you had a chance to do them as a resident, especially if you had an interest in it. Now, you are unlikely to scrub on many big liver resections as a resident. I think one problem that can come up is that some of these guys are relying on pretty old training, and may not be up on the less invasive or newer techniques. The surgeon you choose could mean the difference between a huge midline laparotomy and an ostomy vs. 4 or 5 lap ports and a reanastomosis, which to me, is no small difference. Also, I'd prefer to have my surgery from someone who has been doing 30 of these a year for the last few years than someone who has been doing 2 a year for the last 30.

 

[45408]

Some of our surgeons demonstrate better technical skill than others, but from my experience, the most crucial quality is judgment, both before reaching the OR and while in the OR. Like thedrjojo said, we have to be able to think.

Surgeons who specialize in difficult cases are sometimes much more highly technically skilled than the rest of us (think pediatric cardiac surgeons), but other times, it's knowing what to do and when, as well as being willing and capable of handling challenging situations, that really is important.