Does Surg residency make you dumb?

[munchi]

Okay so don't laugh but I made the seeming mistake of applying to both G. Surg and IM for residency. Interviewed at quite a few very good to excellent programs in both fields, in fact most at the same schools. It is two weeks before the match deadline and I am still uncomfortable with my decision.

I am pretty sure I want to DO surgery. BUT I have this terrible fear of becoming known as a technician.

What I like about IM is that it is really intellectual. YOu are rewarded for how much you know and how you think.
In surg it seems it doesn't matter what you know. It is how hard you work. I have no problem with hard work. But in my value system, intelligence out weighs diligence any day.

Any insight from current residents or surgeons-to-be would be very helpful.

-munchi

---

Members don't see this ad.

 

[womansurg]

The surgery residents in our hospital usually stomp USMLE part 3 (higher averages than the IM residents), and there ain't much surgery at all on that test.

What kind of doctor you will be depends on you and how much you put into it. I continue to take New England Jounal of Medicine and Journal of the American Medical Association because I like to keep up with what's new in the general medicine, not just in surgery. (I'll bet not too many IM residents read Annals of Surgery). And surgeons are often some of the most knowledgable and capable critical care intensivists - we have to be because we care for some of the sickest patients.

The practice of surgery is very procedural. Hours and hours of your day are spent performing your technical craft. You need to have a true love for this as your basis, then you can build your practice philosophy into whatever you want. For instance, I incorporate quite a bit of health maintenance into my practice. My patients are counseled about cancer screening, alcohol and tobacco use, diet and weight guidelines, and safe sex. I also like to manage all of my own critical care patients, rather than consult a pulmonogist or intensivist. You can be whatever kind of practitioner you choose to be, regardless of your discipline.

 

[njbmd]

Originally posted by munchi
Okay so don't laugh but I made the seeming mistake of applying to both G. Surg and IM for residency. Interviewed at quite a few very good to excellent programs in both fields, in fact most at the same schools. It is two weeks before the match deadline and I am still uncomfortable with my decision.

I am pretty sure I want to DO surgery. BUT I have this terrible fear of becoming known as a technician.

What I like about IM is that it is really intellectual. YOu are rewarded for how much you know and how you think.
In surg it seems it doesn't matter what you know. It is how hard you work. I have no problem with hard work. But in my value system, intelligence out weighs diligence any day.

Any insight from current residents or surgeons-to-be would be very helpful.

-munchi

Hi there,
Most of the challenge of surgery is that you MUST be excellent in both medicine and surgery in order to be a good surgeon. Not only must we learn the ins and outs of taking good care of our patients, we must do so under all circumstances.

For example, recently we were called to consult on a patient in the medical intensive care unit. The patient had developed signs of an acute abdominal problem. The patient was taken to surgery where a ruptured sigmoid diverticulum was repaired and then the patient was transferred to the SICU where the surgical team continues to care for this patient. This gentleman has 38 problems listed on his medical problem list and with the addition of the 39th problem (ruptured sigmoid diverticulum), the patient is transferred to the Surgical service.

Far from "dumbing down", surgical residency has a tendancy to "ratchet up" your practice of medicine.

njbmd

 

[Foxxy Cleopatra]

Hi-

I agree with the other posters that you not only have the surgical aspect but also the medical managament to deal with in surgery. I found the unit to be particularly challenging. Not to knock on medicine docs because there are lots of great ones out there, but from what I see, I think I'd enjoy the work after residency much better as a surgeon. I feel that you do spend much more time during IM training discussing things, but once you get out on your own, (in general) IM is much more clinical work. Both are great professions, I just really like to operate and find both the OR and post-op management to be a huge and interesting challenge.

 

[task]

I really think that the degree to which you choose to incorporate medical management of your patients as a surgeon depends on where you train and ths philosophy there. Where I am (Parkland for IM) our surgeon's are many times reluctant to admit pt. to their service with stable but multiple medical problems. For the pt. that njbmd describes at UVa, I can guarantee you that pt. would be on a medical or MICU service at Parkland. At Parkland and the VA, all ESRD pt. admitted to the hospital are admitted to Medicine services. We fight and sometimes win the battle (I won one the other day) but >90% of the time those pt. our on our services. I don't dialyze, so why on my service? On the other hand, I went to med school at Louisville, and there the surgeons really were encouraged to assume the entirety of care for their patients, and consult out as needed. They were competent internists.

In the real world, surgeons will defer management of medical issues to medicine docs and subspecialists. They don't have the time or the expertise to deal with these issues anymore.

One other thing to keep in mind. Surgeons can't be as good internists as internists are. I don't mean this as a knock to surgeons -- there are many surgeons out there who are excellent medicine doctors. But there are just as many who could give a crap about managing a patient's medical issues. But if you are in the OR all day, there is no way you could learn or develop the clinical acumen that internists develop with regards to the problems that their patients have. You have to follow the patient all the way thru his or her hospital course and the natural history of their disease in order to be good at managing that particular disease or condition -- whether it's a ruputured viscous or unstable angina. You are better at what you are used to and spend time taking care of.

There are compassionate internists and surgeons, and there are ones (of both types) who don't give a s***.

One other thing to keep in mind. If you like procedures and don't want to give up working with your hands, fields like GI, Cardiology and Pulmonary are very procedure intensive and in my opinion offer a good balance of the intellectual/cognitive skills that Internists' possess with the tangible/rewarding feeling that comes from procedures and hands on tasks. Just something to think about.

 

[task]

Let me clarify -- pt. with ESRD on HD who have a surgical issue as their reason for their admission. Here, the surgeons prefer to admit the patient and dump them on a medical service to manage them in house, then "consult" for the wound.

 

[surg]

task, are those general surgeons or the non-general surgeons that do that? In my experience, general surgery programs as a general rule, make a big point of taking care of their own stuff, while subspecialists (ENT, Urology, Plastics, Ortho, etc) tend to try to pass those things off to Internists.

At any rate, to the original question, I think if you stay in general surgery you will become a pretty fair general hospitalist style internist, though you will never be able to keep up with all the nuances of outpatient internal medicine (although I would maintain, few internists can keep up with both outpatient and inpatient either, hence the rise of internal medicine specialists!). You will never be as nuanced as an internist if you don't do it a lot, but you will be able to handle all the basic issues and virtually any critical care issue.

The best surgeons are intellectual and diligent. Any monkey can be a technician, the real art of surgery is in knowing when to operate and what operation to do. Don't let them fool you, general surgery is as cognitive as any field.

The level of care done by surgeons varies by program, but at our general surgery program, the number of people who transfer from general surgical services to medical services numbers probably less than 1/month across all our services combined. We do all our own critical care including ventilator and renal replacement therapy management (CVVH and CVVHD primarily because the renal fellows control the HD techs). The only consult I see called with any regularity is cardiology when people think someone might need to be cathed and the transplant nephrologists because it is part of the protocol since they follow them as an outpatient.

 

[droliver]

Originally posted by task
On the other hand, I went to med school at Louisville, and there the surgeons really were encouraged to assume the entirety of care for their patients, and consult out as needed. They were competent internists.

Thanks Task! I do feel I'm pretty competent as an internist. I am under no illusions however, that I can manage medical conditions long-term as well as my IM colleagues. On a short term basis I can handle most anything (though I am always impressed @ how much better the Renal & Endocrine guys do with ESRD & DM then I do). BTW my little brother is MD-PHD @ UTSW & likely to do IM there starting July

 

[dumbest premed]

I would highly doubt that it makes a person dumb with all of the new things they have to learn during the residency.

 

[task]

surg,

Actually, I am referring to General Surgeons where I am. Ortho is pretty much the same anywhere, from what I gather, but truth be told most patients are better off on a medical or general surgical service than an Orthopedic one in my opinion. Again, there are always exceptions (both ways).

droliver,
I think I met your brother while I was in the ER a couple of months ago. Really nice guy -- his wife is doing Rads here, if I'm not mistaken? Your brother is thinking of Heme-Onc, right?

Oh, and I hope you didn't take what I said the wrong way. I really think that the GS at Louisville are great at a lot of medicine issues. But more than that, it was the philosophy that "this is my patient and I'm going to take care of them and do the right things for them" passed down from Dr. Polk that I was most impressed with.

 

[droliver]

Task,

yes that's my little brother & he is a nice guy. I think I must have inadventantly hit him too hard in the head as a child or something for him to get the med-onc bug (as we both would have been 4th generation surgeons otherwise ). After 8 years as a med student doing his MD-Phd + likely IM @ UTSW I think he'll be eligible for tenure or something there. Please introduce yourself again if you run into him. BTW it's cold as balls here in Louisville presently

 

[task]

droliver,

Guess all those beatings as a kid set him down the right path

Geez. This place loves the MD/PhDs -- ought to set him down the path for Chief right away.

I was on the Courier website last night checking out local sports coverage on the Cards and saw multiple pics of ice, snow, and crappy weather. I do miss Louisville, but not right now. It's in the 60s here in Dallas.

Stay warm.

 

[scutking]

Task-

As a surgery resident at UTSW/Parkland, I've got to disagree with your comments about us asking you guys to manage complicated medical patients. I'd love it if you could elaborate, because it simply isn't true. We'll call renal if an inpatient needs dialysis and we'll call cardiology if a patient develops chest pain, dysrhythmias, or bumps their troponins. That's medicine for you. Furthermore, don't get me started on the number of consults we get on a weekly basis from the medicine services for patients with "abdominal pain" or other surgical issues that your collegues want us to just "briefly evaluate" because they aren't sure what to do with them. I spend enough time in the CCU and MICU to know this quite well. For every consult you get to evaluate an ESRD patient requiring dialysis, I get a consult to place a chest tube on a CCU patient with an empyema. With our workload, this usually occurs somewhere around 3am when I could be getting a hour of sleep before starting my next day. My point is - it goes both ways my friend. One thing I enjoy about UTSW it that medicine and surgery have a strong, professional working relationship and I have several friends in your department. We've all got to work together, and your comments are not helpful.

 

[droliver]

How about we just stipulate that UTSW is one of those few institutions with both superior IM & surgery training programs & leave it at that

 

[task]

I definitely agree with droliver

However, while I agree with scutking in terms of you guys appropriately consulting medicine subspecialty services like Cards, Renal or GI, for patients you have on your services, don't forget all the consults to medicine for help with managing pretty basic things like diabetes and hypertension, to other things like managing periop MIs or recommendations for antibiotic use. Not to mention patients with medical issues who are on your services with other stable medical issues that might need tuning while in house -- like RA or CHF for example. I'm on medicine wards at the VA now and while I was MROC one night had to go over to the SICU to evaluate and begin management for two pts. with periop MIs. One was an ENT pt with a huge squamous cell that left him with no airway and a trach with poor hemostasis, and one was on Vascular just out from a R CEA. "ASA, Beta-blocker, RPPP control. Can't do heparin or antiplatelet agents. Will opt for conservative management at this time." Sorry, but no Cards fellow or CCU resident came over to do that in the middle of the night. Absolutely Cards saw them immediately the next morning, but the Medicine consults do you guys plenty of favors day and night.

I have never consulted surgery to evaluate belly pain unless I was concerned for a surgical issue. I don't call surgery to see a patient because I'm not sure "what to do with them". I cannot speak for my colleagues. I do call surgeons to comment on clinical issues that I don't often see or have experience dealing with. I think that is perfectly reasonable.

Not to mention, when I was AOD in January and February, I really enjoyed the 12:30am visits from the Surgery ER to try to admit (dump) pts with stable medical problems but surgical reasons for hospitalization because they have "CHF" or because they have diabetes with sugars in the 200s. Not to mention, you guys can admit GIBs as well as we can -- "well, I figured this guy needs medicine follow-up anyway, so why don't you admit him?". Or the lady with horrible fournier's gangrene and completely stable medical issues having to go to an "MICU or at least another medical service" in case her one of her medical issues became unstable.

I won't even go near the ESRD on HD thing. There is apparently a reason why a ESRD on HD pt. with completely stable medical issues but who has a thigh abscess and is going to the OR needs to be on my service as a medicine resident post-op.

I can place my own chest tubes, and have done so thus far. I am certain I will have to call you guys for help with a chest tube at some time in the remainder of my residency. The only time I have called a sugeon to place a chest tube was for a empyema that was pretty medial by CT. The CVTS fellow actually came and placed it himself. But, if I have one that I'm not so sure about, you'll be damned sure I'll call you guys for help -- you probably do more in a day than I do in 3 months.

Calling renal for initiation of dialysis is different from admitting the patient to a medical service.

Despite what you guys may think, we have a pretty rigorous training program ourselves, so please don't talk about sleep or lack of sleep. No, we are not a surgical residency program. You guys are supposed to be q4 now or soon enough anyway.

Am I saying every single surgeon at UTSW does the above -- absolutely not. Am I quoting situations I personally have experienced -- absolutely. There are plenty of you guys/women that are absolute professionals, great to interact with and a real pleasure to know. I have a lot of friends in Surgery department. But attitudes passed from staff on down are hard to break as well. And I'm not the only one with the above examples.

 

[hotbovie]

I'm just finishing a month in a medical ICU. Earlier this year I did a month in a surgical/trauma ICU. I can defintely say NO a surgery residency does NOT make you dumb (even though the medicine residents constantly bashed surgeons).

At my institution, surgeons are MUCH better at critical care than the medicine folks are. I have seen several patients on the medicine service go underresucatated. Several times patients came in with septic shock, and got some fluids but then pressors before things like EDVI got within normal range (in fact, when I asked the medical critical care fellow about the EDVI, he waved his hand and said "thats not important" whereas the surgical critical care fellow taught me that it was one of the most important values from the swan). These patients still don't have adequate urine output by the next morining (compared to septic pts I saw managed by surgery, they got back to decent UOP within 8 hours). The worst example of this is a patient I had on the MICU with a GI bleed. No bleeding from upper GI tract or from colon. A tagged RBC scan and angiography located the bleed to jejenum. Surgery was called 16 hours after the pt was admitted. By this time the pt was severely coagulopathic from getting 6 units RBC without and FFP or even without having coags or chemistries checked. Plus, the pt had relative hypotension (normal SBP of 170, stayed at 110 for most of this 16 hours) and developed shock liver. Finally, the branches of his SMA were so constricted from being underrecusstated that IR couldn't embolize the bleed. He couldn't go to the OR for a full 24 hours while his coagulopathy was corrected.

Also, I've seen medicine interns and residents standing around during a code looking up the ACLS protocols. Meanwhile, a surgery intern happend by a code while this was going on, and after watching a painful struggle with the line, offered to help with line placement. He wound up basically taking over the code cuz the medicne resident (PGY2) didn't know what to do.

In fact, the attending for critical care in the MICU (a medicine guy)told us one day that surgeons do the best research in critical care

Yes, medicine residents are better at managing the subtleties of chronic problems like CHF or DM. But if I wind up in the ICU, I sure hope I am under the care of surgeons. Or at least that's the way it is at my institution.

 

[droliver]

I'm not sure that most IM are as helpless as hotbovie has experienced in the ICU. I have however noticed a similar pattern over & over (& over & over......) that there is a HUGE misunderstanding of how to treat patients in neurogenic, septic, & hypovolemic shock by Internists (both in & out of training). For whatever reason there is often a complete disconnect that these patients often require huge fluid resuscitations as initial treatment of their condition. A lot of this has to come from the diffrent patient populations between surgical & medical patients you commonly see in the hospital. Many surgical patients have medical commorbidities which we learn over time to handle, but the reverse is not neccessarily true & I think they get treated wrong in many cases.

 

[task]

I think this is all a matter of perspective. hotbovie and droliver are speaking of their experience at their own institutions. I am speaking from my experience at my own institution. Are their places where surgery residents are better at critical care than medicine folks -- sure. Are there places where medicine folks are better at critical care than surgery folks -- absolutely. Are there places where the two are both strong -- correct again.

hotbovie -- Where I train, Medicine residents carry the code pagers and run the codes.

Furthermore, as you well know, there is more to critical care than fluid resuscitation. It is the ability to manage a critically ill patient keeping in mind/having experience managing all a patient's multiple medical problems that distinguishes (in my humble opinion) a Medicine person's ability to better guide critical care management. Medicine people, at least where I am, are much better at this than surgeons are. Pounding a patient with fluids with abandon is all well and good, but forgetting or not thinking that they might have a depressed EF, especially if they're older, is not.


As a simple example, I had a gentleman on my service, 72 with critical AS (AVA of 0.7cm2) with a nl EF, DM, CRI and PVD who was admitted to me for further w/u and management. We cathed him and had him teed up for surgery the next day. His WBC was 13 the day prior to surgery. Naturally, CVTS wanted the guy to not be infected before they did his valve. We had already cultured him up and checked a CXR and found no source of infection. What we had asked vascular to do was take the guy to the OR to take off his two black toes that we felt were the source of his white count. Vascular didn't believe the toes were the source of his white count. Finally, after the CVTS fellow agreed with us, Vascular came by and took off his two toes. Three days later, they took him back to the OR and did a BKA. CVTS wanted 2-3 weeks of good healing at the stump before they would do his valve. We can't rehab the guy until his valve is done, and he can't be fit for a prosthetic because his leg had to heal. His wife can't take care of him at home with his one leg, so he stays on my service waiting for bad stuff to happen to him (since I have taken off his leg and since I can fix his valve, he should be on a medicine service, right?). Two weeks go by, and I call CVTS and Vascular to come reassess the guy so he can finally get his valve. Over those two weeks, his stump looks great, is healing well, and things look on target. The next day, Vascular takes him back to the OR for an AKA. Somebody decides to pound him with fluids, and he can't be extubated in the PACU.

I get called to the SICU to help manage the pt. -- he's getting harder and harder to ventilate, and now his oxygenation is compromised. I walk into his room and notice he has a bag of NS with 40meq of K being bolused. His JVP is up to his jaw, he has an intermittent S3, he has wet crackes bilaterally and his remaining foot is edematous. I ask the nurse to stop the fluids, then I ordered a chest xray, gave him 60 of Lasix IV, and went up on his PEEP, only temporarily. Why only 60 -- remember, as much as the guy is overloaded, he is preload dependent, and his pressures were 120s systolic. I wanted to be a little careful, figuring I could give him more as he tolerated. Over the next two or so hours, he peed off 1.5 L, became much easier to ventilate, his oxygenation improved, and he was extubated a little later. Some BASIC lessons learned here -- don't POUND someone with critical AS with fluids, even with a nl EF, and don't give someone with CRI potassium in their IVFs.

Medicine docs and Surgeons have some different approaches to things like fluid resuscitation. I think part of this stems from the fact that most sick medical patients have comorbid conditions that we are better at dealing with like bad kidneys, lungs, and hearts. Not all surgical patients have these issues.

For some reason, all surgical patients get S-G catheters. The only time I find S-G caths useful is in a septic pt. with BAD CHF. Multiple studies have borne out that hemodynamically guided management of patients is often deleterious to that patient because the clinician ignores the clinical exam/picture and focuses on the Swan exclusively. Not to mention that S-G cathters are not benign beasts.

It's not a matter of who is smarter or better, but what one has experience dealing with.

 

[task]

I think this is all a matter of perspective. hotbovie and droliver are speaking of their experience at their own institutions. I am speaking from my experience at my own institution. Are their places where surgery residents are better at critical care than medicine folks -- sure. Are there places where medicine folks are better at critical care than surgery folks -- absolutely. Are there places where the two are both strong -- correct again.

hotbovie -- Where I train, Medicine residents carry the code pagers and run the codes.

Furthermore, as you well know, there is more to critical care than fluid resuscitation. It is the ability to manage a critically ill patient keeping in mind/having experience managing all a patient's multiple medical problems that distinguishes (in my humble opinion) a Medicine person's ability to better guide critical care management. Medicine people, at least where I am, are much better at this than surgeons are. Pounding a patient with fluids with abandon is all well and good, but forgetting or not thinking that they might have a depressed EF, especially if they're older, is not.


As a simple example, I had a gentleman on my service, 72 with critical AS (AVA of 0.7cm2) with a nl EF, DM, CRI and PVD who was admitted to me for further w/u and management. We cathed him and had him teed up for surgery the next day. His WBC was 13 the day prior to surgery. Naturally, CVTS wanted the guy to not be infected before they did his valve. We had already cultured him up and checked a CXR and found no source of infection. What we had asked vascular to do was take the guy to the OR to take off his two black toes that we felt were the source of his white count. Vascular didn't believe the toes were the source of his white count. Finally, after the CVTS fellow agreed with us, Vascular came by and took off his two toes. Three days later, they took him back to the OR and did a BKA. CVTS wanted 2-3 weeks of good healing at the stump before they would do his valve. We can't rehab the guy until his valve is done, and he can't be fit for a prosthetic because his leg had to heal. His wife can't take care of him at home with his one leg, so he stays on my service waiting for bad stuff to happen to him (since I have taken off his leg and since I can fix his valve, he should be on a medicine service, right?). Two weeks go by, and I call CVTS and Vascular to come reassess the guy so he can finally get his valve. Over those two weeks, his stump looks great, is healing well, and things look on target. The next day, Vascular takes him back to the OR for an AKA. Somebody decides to pound him with fluids, and he can't be extubated in the PACU.

I get called to the SICU to help manage the pt. -- he's getting harder and harder to ventilate, and now his oxygenation is compromised. I walk into his room and notice he has a bag of NS with 40meq of K being bolused. His JVP is up to his jaw, he has an intermittent S3, he has wet crackes bilaterally and his remaining foot is edematous. I ask the nurse to stop the fluids, then I ordered a chest xray, gave him 60 of Lasix IV, and went up on his PEEP, only temporarily. Why only 60 -- remember, as much as the guy is overloaded, he is preload dependent, and his pressures were 120s systolic. I wanted to be a little careful, figuring I could give him more as he tolerated. Over the next two or so hours, he peed off 1.5 L, became much easier to ventilate, his oxygenation improved, and he was extubated a little later. Some BASIC lessons learned here -- don't POUND someone with critical AS with fluids, even with a nl EF, and don't give someone with CRI potassium in their IVFs.

Medicine docs and Surgeons have some different approaches to things like fluid resuscitation. I am by no means stingy with fluids for patients who need to be resuscitated, but I do spend more time thinking about how much I'm giving and when to back off in those patients with a depressed EF, bad kidneys, etc. I think part of this stems from the fact that most sick medical patients have comorbid conditions that we are better at dealing with like bad kidneys, lungs, and hearts. Not all surgical patients have these issues.

For some reason, all surgical patients get S-G catheters. The only time I find S-G caths useful is in a septic pt. with BAD CHF. Multiple studies have borne out that hemodynamically guided management of patients is often deleterious to that patient because the clinician ignores the clinical exam/picture and focuses on the Swan exclusively. Not to mention that S-G cathters are not benign beasts.

It's not a matter of who is smarter or better, but what one has experience dealing with.

 

[VAspa]

words of wisdom: surgery is the completion of the internist's education.

 

[womansurg]

Originally posted by task
For some reason, all surgical patients get S-G catheters. The only time I find S-G caths useful is in a septic pt. with BAD CHF. Multiple studies have borne out that hemodynamically guided management of patients is often deleterious to that patient because the clinician ignores the clinical exam/picture and focuses on the Swan exclusively. Not to mention that S-G cathters are not benign beasts.

I've seen this attitude (about SG use) transported to our institution with surgeons trained at large institutions, so I know what you speak of. For instance in the case of one surgeon, every patient undergoing an AAA repair, regardless of underlying cardiac status or general medical condition. I've seen 2 deaths from SG use which were obviously correlated - although it's hard to know if detrimental changes in care management have caused others. Once an ICU nurse blew out a pulmonary artery while ckecking PCWP, and another time a paitent air embolized through a stuck valve on the insertion site of the cordis. Both patients died.

I place PA catheters in post op patients after large cases primarily when I see oliguria unresponsive to fluid challenges and when I have persistent hypotension in a patient with myocardial dysfunction.

In my own experience, I can echo the response of droliver, in that I've placed many, many dialysis catheters in septic or hypovolemic shock patients cared for by IM - a rare situation in our own patient group. Generally, an overresuscitated patient can be diuresed, but recovery from hypotensive organ dysfunction is more problematic. The corollary to this would be that ARDS can be precipitated by aggressive over-resuscitation, and I have seen that happen.