MD For Surgical Subspecialties - did you miss the general knowledge?

[applicant0704]

Hey everyone! Im planning on applying into ophthalmology (currently on a research year) and am having some concerns.

Part of me wonders if i should pursue general surgery. I think fundamentally i love the OR, and part of me wonders if ill miss the acuity and inpatient aspect of gen surg, as well as being almost purely operative. Additionally, its nice having a general knowledge of surgical issues and being able to deal with them.

I decided optho primarily because of the cool eye pathology/surgeries, and lifestyle considerations. I have a lot of hobbies and dont want to let go of them, and family is very important. Im not a hugeeeee fan of the clinic, but its something i can do.

My questions for those who subspecialized (ent, uro, ortho), did you feel similarly to as I do, and did you get over it? Or am i crazy to even consider gen surg?

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[OnePunchBiopsy]

In general surgery now.

I really don’t like being dumped on. Even though I’m sure every subspecialty gets dumped on sometimes, in terms of surgery specialties GS gets a lot of it. The perception that general surgeons know medicine as well as surgery is what gets us called into the hospital at 2am. You’ll not have to worry about that in optho (most of the time).

You have to do a specialty that you get some gratification out of, even when you’re in the hard part of it. It’s good that you’ve found that in ophtho. You’ll know a lot about the eye than I ever will.

 

[Dr G Oogle]

Acuity and coming in to save the day is super fun as a student and resident and less so when you’re pushing 40 and have a family. I actually think you can have a very manageable life as a general surgeon with the advent of acute care surgery services but GS residency is very different from optho. Other than that it boils down to what bread and butter stuff is going to get you excited to come to work until it’s time to retire.

 

[OrthoTraumaMD]

If you like what you do, you won’t miss general work. I’m a subspecialist even within my own specialty, and I don’t miss any non-trauma ortho.

 

[Tenk]

I can count on one finger (not hand) the number of times I had an ophthalmologist see a patient in the middle of the night...

I would need more hands than Dr. Strange fighting Thanos for the number of times I've called a general surgeon in the middle of the night...

 

[operaman]

I think I had some similar feelings as a Med student. I really liked the critical care side of gen surg and the taking full ownership of all the medical as well as surgical issues. As a M4 I took all medicine rotations aside from my sub I and required surgery rotation because I wanted to learn as much of that as I could in hopes that I even within ent I could take that kind of full ownership.

What’s evolved after 5 years of residency is that while part of me still enjoys that taking ownership, it’s a lot less interesting than other more nuanced things within my own field. There’s also the time and EMR side of working up and managing medical issues that can really eat up a day when you already have a full day of stuff to do. Finally, there’s the issue for many of our patients of managing all those things outside the hospital. Our outpatient clinics just aren’t set up with a workflow that includes much outside our standard scope. I may be comfortable managing diabetes or long term antibiotics but our clinic isn’t set up to easily facilitate the needed lab draws for follow ups and our nurses aren’t as well versed in the education side around disease we don’t typically manage. All that means a LOT of extra time and headache for me while right down the hall are ID and Endocrine clinics that manage these things much better and more efficiently than I could with staff that are as good at those diseases as mine are with the esoteric side of our field.

I’ve also found that the nuance and thinking I enjoyed about the critical care and medical side of gen surg has been replaced by the deeply nuanced thinking in my own field. You don’t get as much of that as a student or even a junior resident but these days I find plenty of challenges just around my own field’s issues. I also enjoy the intraoperative challenges we have now that I’m given more leeway to make those decisions.

I think the surgical subs have plenty of acuity to scratch that itch but also agree with those above that while acute issues are fun as a student, they are much less so when you have more responsibility for the outcome. They are also less interesting as time goes on.

For example, complex neck trauma - multiple stab wounds with near total laryngotracheal separation, lacerated and avulsed vocal folds. Ideally would have butterflied the larynx and repaired the vocal folds, closed the laryngofissure over some kind of stent, and repaired/plated the framework defects. In reality, patient was actively trying to die from multiple other injuries so just threw big ugly sutures to close the framework and put in a trach and that was it. No nuance, just close big hole and put in tube. Patient did really well thanks to a bunch of general surgeons on trauma who managed her weeks of critical illness in the icu. the cool endoscopic laryngeal repair happened a few months later on an outpatient basis, not at midnight on a Friday.

 

[WedgeDawg]

I can count on one finger (not hand) the number of times I had an ophthalmologist see a patient in the middle of the night...

I would need more hands than Dr. Strange fighting Thanos for the number of times I've called a general surgeon in the middle of the night...

I’m 6 months into residency and already need 2 hands to count the number of middle of the night ophtho consults I’ve asked for. Luckily, the ophtho residents at my program are super friendly and always willing to help out at 2 am!

 

[Tenk]

I’m 6 months into residency and already need 2 hands to count the number of middle of the night ophtho consults I’ve asked for. Luckily, the ophtho residents at my program are super friendly and always willing to help out at 2 am!

Academics =/= community practice. There are very few true ocular emergencies and they are also relatively very rare.

 

[applicant0704]

I think the surgical subs have plenty of acuity to scratch that itch but also agree with those above that while acute issues are fun as a student, they are much less so when you have more responsibility for the outcome. They are also less interesting as time goes on.

Are you planning to fellowship train? Ideally, I hope to fellowship train and work in an Academic setting. I imagine it gets even worse in terms of general knowledge. I remember an ortho attending telling me that when he was on call, if the problem wasn't associated with what he subspecialized in, he would call his colleague who did.

But, for example, some of the endocrine surgeons in gen surg who did primarily thyroids/parathyroids would still do appendectomies and cholecystectomies when on gen surg call... but the gen surg call was what made the lifestyle worse I imagine.

Other than that it boils down to what bread and butter stuff is going to get you excited to come to work until it’s time to retire.

And yeah I get that. Cataracts aren't mind-blowing, just as I imagine tonsil and ear tubes arent to an ENT, or appys and choles to a gen surg? But the diversity of fellowship training was one of the biggest attractions.

Thanks for all the input btw. I very much appreciate!!

 

[operaman]

Are you planning to fellowship train? Ideally, I hope to fellowship train and work in an Academic setting. I imagine it gets even worse in terms of general knowledge. I remember an ortho attending telling me that when he was on call, if the problem wasn't associated with what he subspecialized in, he would call his colleague who did.

But, for example, some of the endocrine surgeons in gen surg who did primarily thyroids/parathyroids would still do appendectomies and cholecystectomies when on gen surg call... but the gen surg call was what made the lifestyle worse I imagine.


And yeah I get that. Cataracts aren't mind-blowing, just as I imagine tonsil and ear tubes arent to an ENT, or appys and choles to a gen surg? But the diversity of fellowship training was one of the biggest attractions.

Thanks for all the input btw. I very much appreciate!!

I am doing a fellowship as I hope to work in academics but I’m not so attached to the idea that I’m willing to live somewhere i don’t like just to be an academic. So I may end up with a more general practice. Time will tell!

I think the academic setting is a bit odd and the tendency to refer things to your partners is less that you as a sub specialist can’t manage a general problem but rather that why would you when your partner is a true expert in that area. Even if you do some general work there’s still a lower threshold to get help when help is so readily available.

That said, a number of my staff will take on acute issues outside their subspecialty if they have to. It really comes down to what you’re comfortable managing and what you actually want to manage.

 

[OnePunchBiopsy]

I’m 6 months into residency and already need 2 hands to count the number of middle of the night ophtho consults I’ve asked for. Luckily, the ophtho residents at my program are super friendly and always willing to help out at 2 am!

Residents are there to be helpful. Odds are the attending wasn't even woken up.

 

[dienekes88]

Hey everyone! Im planning on applying into ophthalmology (currently on a research year) and am having some concerns.

Part of me wonders if i should pursue general surgery. I think fundamentally i love the OR, and part of me wonders if ill miss the acuity and inpatient aspect of gen surg, as well as being almost purely operative. Additionally, its nice having a general knowledge of surgical issues and being able to deal with them.

I decided optho primarily because of the cool eye pathology/surgeries, and lifestyle considerations. I have a lot of hobbies and dont want to let go of them, and family is very important. Im not a hugeeeee fan of the clinic, but its something i can do.

My questions for those who subspecialized (ent, uro, ortho), did you feel similarly to as I do, and did you get over it? Or am i crazy to even consider gen surg?

For whatever reason, we are indoctrinated to think that somehow by being a generalist, we are better doctors. But separate that from what you actually want to do with your life. Don't be someone else's idea of a great doctor. Specialists definitely have their role on the team.

Acuity and coming in to save the day is super fun as a student and resident and less so when you’re pushing 40 and have a family. I actually think you can have a very manageable life as a general surgeon with the advent of acute care surgery services but GS residency is very different from optho. Other than that it boils down to what bread and butter stuff is going to get you excited to come to work until it’s time to retire.

Agree with above.

 

[DarkHorizon]

No... I call the hospitalist for that.