Gen Surg vs. Ortho for $$$

[drseanlive]

I definitely enjoy general surgery, and would see myself being quite happy in a general surgery subspecialty (i.e. vascular, etc).

BUT, it seems like everyone is always b*tching about not being paid enough in gen surgery...are surgical subspecalties that poorly paid?

I have had basically no exposure to ortho, but am hesitant to rule it out and I think I could like it..since it also is surgical..Frankly, my major reason for trying ortho would be a lifestyle/$$ thing.

My question is:

- does ortho really do that much better than gen surg subspecialties to justify going for it? Of course plastics can make more than ortho, but in general, is there a big difference between vascular salary/lifestyle and ortho for example??

I know this is a hard/stupid question...but the answer could effect my actions..

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[Winged Scapula]

Its not a hard question.

By and large, ortho procedures are paid much more than general surgery procedures. Theres an old joke about the fight that broke out when the discussion over how much surgeons should be paid for procedures came about. The joke goes something like the Orthopods showed up to the fist fight with a gun and the general surgeons didn't show up at all because they were in the ER taking someone's appy out for a few hundred dollars.

You can make decent money in general surgery but its generally done by volume as the procedures just don't pay like they do in Ortho.

 

[Habeed]

Well, I have to wonder how the rest of the joke goes... What did the plastics, uro, ENT, or neurosurg guys show up to the fight with?

 

[filter07]

Do Ortho. You will rotate in general surgery as an intern and get to see the night/day difference. You can always switch to gen surg from ortho. There will likely be at least one disgruntled categorical surgery resident that would jump at the chance to work with bones. Not so much the other way around.

 

[drseanlive]

thanks for the replies...i'm not sure how competitive i would be for ortho (avg boards/preclinical, but all H's in clinical rotation)

would dual applications to ortho and general and ranking of ortho programs first hurt my chances at all for general surgery?

I'm not sure how the match works, but if i were to rank like 20 ortho programs ahead of gen surgery knowing that they were a reach would i get screwed with a gen surg spot that i dont really want? or does it not hurt me to try?

 

[VincentAdultman]

thanks for the replies...i'm not sure how competitive i would be for ortho (avg boards/preclinical, but all H's in clinical rotation)

would dual applications to ortho and general and ranking of ortho programs first hurt my chances at all for general surgery?

I'm not sure how the match works, but if i were to rank like 20 ortho programs ahead of gen surgery knowing that they were a reach would i get screwed with a gen surg spot that i dont really want? or does it not hurt me to try?

You are getting a little ahead of yourself.

Since ortho and gen surg are quite different specialties, you should get some exposure with an ortho rotation early 4th year or during your surgery rotation (if you haven't done it yet). The lifestyle difference is not THAT significant, and picking a career based on compensation is a poor move.

If you still want ortho, apply just to ortho. You don't want to get deistracted with other rotations, letters of rec, personal statements, etc. Ortho is hard to get into as it is.

 

[Winged Scapula]

thanks for the replies...i'm not sure how competitive i would be for ortho (avg boards/preclinical, but all H's in clinical rotation)

would dual applications to ortho and general and ranking of ortho programs first hurt my chances at all for general surgery?

Only in the situation of general surgery programs knowing you are also applying to Ortho (which would happen if all your LORs were from Ortho attendings, your letters mention it, or you tell them).

I'm not sure how the match works, but if i were to rank like 20 ortho programs ahead of gen surgery knowing that they were a reach would i get screwed with a gen surg spot that i dont really want? or does it not hurt me to try?

You have the potential to match at ANY place (or no place) you rank. Therefore, if you rank a general surgery program number 21, and you don't match into Ortho, you may indeed "get screwed with a general surgery spot". Whether you want it depends on you, some would rather go unmatched.

 

[Winged Scapula]

Well, I have to wonder how the rest of the joke goes... What did the plastics, uro, ENT, or neurosurg guys show up to the fight with?

They aren't included in the joke. As I recall it was Ortho, general surgery and perhaps Radiology (because the image guided procedures pay more than actually operating on someone).

 

[BlondeDocteur]

FWIW, the richest doctors in New York are the private spine surgeons at HSS, each of whom charges $10,000 a level, books 3-4 cases at 5-6 levels per OR per day, and who run 3-4 ORs simultaneously with their fellows. No insurance, cash only.

They take home a cool $16 million a year, which is so far beyond what I thought any doctor could make in America that it's mind-boggling. Live on enormous estates in Greenwich and dictate their cases in their chauffeured car ride into the City in the AM.

Of course it's peanuts compared to the real money in this town...

 

[NPR]

$10K a level * 5 levels * 3 cases * 3 ORs = $450K in cash per work day? Minimum?

I don't buy this. I'm sure there are plenty of people with back problems. I question how many of them are paying $50K cash for these procedures.

With that being said, let me begin filling out my ERAS application for ortho. 🙂

 

[drseanlive]

i think i worded my previous question wrong...here is what my question is regarding dual application to match ortho/gen surg:

lets say i would be happy in either field...but rank 20 ortho programs first...then i rank my picks for gen surg 21-30...if i dont match any of my ortho programs, does it put in at a disadvantage against someone who ranked only gen surg programs? Like, would my #21 gen surg pick be like my #1 rank if i didnt match anything 1-20?

 

[PenguinHead]

i think i worded my previous question wrong...here is what my question is regarding dual application to match ortho/gen surg:

lets say i would be happy in either field...but rank 20 ortho programs first...then i rank my picks for gen surg 21-30...if i dont match any of my ortho programs, does it put in at a disadvantage against someone who ranked only gen surg programs? Like, would my #21 gen surg pick be like my #1 rank if i didnt match anything 1-20?

This is how the algorithm works for the match.

 

[PenguinHead]

For example...

Applicant Ford would be very pleased to end up at State, where she had a very good clerkship, and believes they will rank her high on their list. Although, she does not think she has much of a chance she prefers City, General, or Mercy, so she ranks them higher and ranks State fourth. This applicant is using NRMP to maximum advantage.

Applicant Hassan is equally sure he will be able to obtain a position at State, but he too, would prefer the other programs. He ranks State first because he is afraid that State might fill its positions with others if he does not place it first on his list. Applicants should rank programs in actual order of preference. Their choices should not be influenced by speculation about whether a program will rank them high, low, or not at all. The position of a program on an applicant's rank order list will not affect that applicant's position on the program's rank order list, and therefore will not affect the program's preference for matching with that applicant as compared with any other applicants to the program. During the matching process, an applicant is placed in his/her most preferred program that ranks the applicant and does not fill all its positions with more preferred applicants. Therefore, rank number one should be the applicant's most preferred choice.

 

[drseanlive]

thank you for the link and info...if i am reading it correctly, I would be put at no disadvantage for general surgery programs if I didnt match ortho and had to resort to the backup gen surg...right?

In other words....if I didnt match ortho, and a gen surg program ranked me higher than someone else, I'd get that gen surg spot even though i ranked their program lower.

can someone confirm that i'm not misunderstanding the way it works?
thanks

 

[PenguinHead]

you are correct.

The only disadvantage is if programs find out you are ranking both, they may question your commitment to either.

But, if you're willing (and think you'd be "happy") w/ a general surgery spot if ortho doesn't work, then you would not be at a disadvantage by ranking the GS spots below your ortho spots.

 

[stonewall22]

i think i worded my previous question wrong...here is what my question is regarding dual application to match ortho/gen surg:

lets say i would be happy in either field...but rank 20 ortho programs first...then i rank my picks for gen surg 21-30...if i dont match any of my ortho programs, does it put in at a disadvantage against someone who ranked only gen surg programs? Like, would my #21 gen surg pick be like my #1 rank if i didnt match anything 1-20?

No, if you were ranked higher by programs than someone who only ranked surgery it doesn't make a bit of difference...even if you ranked 50 ortho programs and another 50 surgery programs you would still get your 100th pick ahead of someone who only ranked surgery if the program ranked you higher

 

[drseanlive]

very useful info...

How many letters of rec. are usually given?

Is it possible to select which program gets which letters or do they all automatically go out to everyone?

I'm asking because it would make sense to get two sets of letters- one for gen surg and one for ortho and send them only to the relevant programs..in an effort to not make the dual application obvious.

 

[PenguinHead]

I know you can do several different personal statements and choose who gets each one.

I think one would also be able to send different rec letters, but I'm not sure. Anyone done this?

 

[Winged Scapula]

I know you can do several different personal statements and choose who gets each one.

I think one would also be able to send different rec letters, but I'm not sure. Anyone done this?

You can specify which letters go to which programs. This is commonly done.

 

[drseanlive]

how many letters are usually needed for each? i'm assuming it would be best to get general surgeons to write letters for gen surg residency and orthopedic surgeons for their respective residency

 

[Winged Scapula]

how many letters are usually needed for each? i'm assuming it would be best to get general surgeons to write letters for gen surg residency and orthopedic surgeons for their respective residency

Usually 3, some programs may specify letters from Program Chairs, etc.

 

[BlondeDocteur]

$10K a level * 5 levels * 3 cases * 3 ORs = $450K in cash per work day? Minimum?

I don't buy this. I'm sure there are plenty of people with back problems. I question how many of them are paying $50K cash for these procedures.

With that being said, let me begin filling out my ERAS application for ortho. 🙂

Not minimum.

There are many, many, many New Yorkers-- some very rich, some only mildly so-- willing to pay $50,000 cash for the "best of the best" to do their back surgery. It's the mentality of the place.

 

[drseanlive]

i've been trying to justify wanting to do ortho over gen surg for some time now. I was hoping someone could shed some light on the situation..

Here are the reasons why I like gen surg better:
1) seems like there are more options in terms of fellowships (i'm all about keeping doors/options open)
2) the subspecialties (Vascular/CT/plastics etc) seem to achieve similar salaries
3) something about the gut and doing surgery on it is more appealing to me than 'bones'

the only reason i would try to go ortho is really a financial thing (they seem to make more money)...also i think many of us are 'achievers' who will always shoot for the reach rather than "settle"...which is another reason why i think many are driven to ortho..

i know you will say "do what makes you happy"...but lets be honest, who really KNOWS at this point....any thoughts??

 

[PenguinHead]

1) seems like there are more options in terms of fellowships (i'm all about keeping doors/options open)

Probably so, but there are a lot of options after ortho too, including plastics.

2) the subspecialties (Vascular/CT/plastics etc) seem to achieve similar salaries

Maybe so, but that's 5yrs vs 5yrs + ~2. I also wonder if the ceiling is lower on the other specialties, excluding plastics.

3) something about the gut and doing surgery on it is more appealing to me than 'bones'

Bones are infinitely more appealing than gut to me. Not as much poop.

the only reason i would try to go ortho is really a financial thing (they seem to make more money)...also i think many of us are 'achievers' who will always shoot for the reach rather than "settle"...which is another reason why i think many are driven to ortho..

Maybe true for some, but I think a lot of people love ortho and may actually dislike GS. You're right, though. It is hard to know what you really love right now with extremely limited exposure.

Choosing a life consuming career for the money is generally a bad idea. 300,000+happy >>> 400,000+unhappy

 

[maxheadroom]

3) something about the gut and doing surgery on it is more appealing to me than 'bones'

<shudder> poop

Never again

 

[Bombrainiac]

$10K a level * 5 levels * 3 cases * 3 ORs = $450K in cash per work day? Minimum?

I don't buy this. I'm sure there are plenty of people with back problems. I question how many of them are paying $50K cash for these procedures.

With that being said, let me begin filling out my ERAS application for ortho. 🙂

I think the numbers quoted here are actually referring to neurosurgeons in particular. One, at Columbia University, is a very accomplished neurosurgeon who is a leader in the national organization. Remember that ortho spine is a fellowship after residency, whereas neurosurgeons do about 65-75% of their training in spine during their residency and usually don't need a fellowship (and if they do, it's only a year). And neurosurgeons, especially in NYC, are ridiculously aggressive about their spine cases and can go intradural whereas ortho spine guys cannot. If I were going to do spine surgery, I'd go the NSURG route hands down. Plus, if there's ANY neurological risk, the case is yours anyway...but, then again, you've got to make it through a neurosurgery residency...ouch.

 

[homealone3]

I think the numbers quoted here are actually referring to neurosurgeons in particular. One, at Columbia University, is a very accomplished neurosurgeon who is a leader in the national organization. Remember that ortho spine is a fellowship after residency, whereas neurosurgeons do about 65-75% of their training in spine during their residency and usually don't need a fellowship (and if they do, it's only a year). And neurosurgeons, especially in NYC, are ridiculously aggressive about their spine cases and can go intradural whereas ortho spine guys cannot. If I were going to do spine surgery, I'd go the NSURG route hands down. Plus, if there's ANY neurological risk, the case is yours anyway...but, then again, you've got to make it through a neurosurgery residency...ouch.

65-75% spine during Neurosurg residency sounds like a stretch based on the discussions I've had with neuro residents. Not to mention, nearly two years of the typical seven year residency is spent doing research. Besides, the "easy money" isn't in the intradural cases, which tend to be more complex and have more complications; it's in the common laminectomy, fusion, etc. In addition, after orthopods complete a 1 yr. fellowship in spine they are very well suited to do this extradural work despite having less exposure during residency. This is particularly true because of their experience with bone and internal fixation throughout ortho residency that carries over into the operative aspects of spine surgery involving the vertebral column.

 

[AldousHux]

You also have to remember people can file their own insurance claims after the fact. Granted you have to have 50,000 to offer up of the bat, but for example, my insurance pays 70% of all costs after a 3000 dollar deductible for any surgery outside it's care plan.

Thus, 50,000 ends up costing me 17,100, which for the best of the best to fix my awful back, no longer as big a deal. And trust me, there's more than enough people in the upper east side and westchester-hell even long island at that-who are willing and able to pay that kind of cash. Or have their daddy pay it for them. 🙂

 

[SouthernSurgeon]

You also have to remember people can file their own insurance claims after the fact. Granted you have to have 50,000 to offer up of the bat, but for example, my insurance pays 70% of all costs after a 3000 dollar deductible for any surgery outside it's care plan.

I dont' think this is quite right (though I am admittedly pretty clueless when it comes to insurance reimbursements).

You can definitely file claims after the fact, but insurance companies aren't going to pony up 70% or more of whatever you tell them. Reimbursements are often set off of essentially a "going rate" - if the insurance company's reimbursement is (hypothetically) 10K they will pay based off of that; they won't just pony up 33K (as in your example) because you decided to go to a boutique or big name surgeon who charges a premium rate.

 

[homealone3]

I dont' think this is quite right (though I am admittedly pretty clueless when it comes to insurance reimbursements).

You can definitely file claims after the fact, but insurance companies aren't going to pony up 70% or more of whatever you tell them. Reimbursements are often set off of essentially a "going rate" - if the insurance company's reimbursement is (hypothetically) 10K they will pay based off of that; they won't just pony up 33K (as in your example) because you decided to go to a boutique or big name surgeon who charges a premium rate.

I agree; they may pay 70% of what's "reasonable and customary" (eg. 10,000) but not 70% of anything charged (eg. 50,000). Nevertheless, I would agree with AldousHux's assertion that there are many people in Manhattan (and around the world) that can afford to drop 50 grand on a surgery.

 

[Bombrainiac]

65-75% spine during Neurosurg residency sounds like a stretch based on the discussions I've had with neuro residents. Not to mention, nearly two years of the typical seven year residency is spent doing research. Besides, the "easy money" isn't in the intradural cases, which tend to be more complex and have more complications; it's in the common laminectomy, fusion, etc. In addition, after orthopods complete a 1 yr. fellowship in spine they are very well suited to do this extradural work despite having less exposure during residency. This is particularly true because of their experience with bone and internal fixation throughout ortho residency that carries over into the operative aspects of spine surgery involving the vertebral column.

Talk to some other neurosurgery residents. Neurosurgical residency experience varies, but the fact still remains that most of the work done by neurosurgeons in the community is spine, and over the course of a 7-year residency, a neurosurgeon is going to have more experience in spine surgery than an orthopedic surgeon who does a one-year fellowship. For instance, the vast majority of the big C-spine fusions, and those including the occiput, all go to neurosurgeons (many centers refer all cervical injuries straight to the neurosurgeons). Orthopedic surgeons do a fellowship to gain exposure. My point is that neurosurgery residents have that experience built into their residency...and it's a seven-year residency, instead of a one-year fellowship. Anyways. Most of the bread-and-butter cases just don't require that much expertise. A fourth-year neurosurgery resident can should pretty much be able to do all those cases (intradural and extradural). And a lot of case referrals go straight to neurosurgery if there is an neurological involvement.

The bone fixation experience that orthopods have with femurs and hips DOES NOT carry over into the spine world. The anatomy is different, the indications for surgery TOTALLY different, and the understanding of spinal biomechanics is completely beyond the scope of a typical orthopedic surgery residency. In addition, and this is just FYI, because most people wouldn't know this: most neurosurgery residencies actually DO NOT have 2 years for dedicated research. Some do, for sure, but most do not. And there are even a handful of 6-year programs.

In the real world, neurosurgeons and orthopedic spine surgeons work together. But, in my experience, I have seen more of the ortho guys take an interest in the deformity cases and that's the niche they have created. Otherwise, I know neurosurgeons who can practically make a living off of re-do surgeries coming to them from ortho spine guys. The same may happen in the reverse, but I've not heard of that scenario.
Bottom line: An orthopedic spine surgeon fresh out of fellowships cannot compete with a neurosurgeon fresh out of residency.

But, all that being said, an ortho spine surgeon who has been practicing for several years is extremely competant and those guys are fun as hell to operate with and they can teach you a lot.

 

[VincentAdultman]

Talk to some other neurosurgery residents. Neurosurgical residency experience varies, but the fact still remains that most of the work done by neurosurgeons in the community is spine, and over the course of a 7-year residency, a neurosurgeon is going to have more experience in spine surgery than an orthopedic surgeon who does a one-year fellowship. For instance, the vast majority of the big C-spine fusions, and those including the occiput, all go to neurosurgeons (many centers refer all cervical injuries straight to the neurosurgeons). Orthopedic surgeons do a fellowship to gain exposure. My point is that neurosurgery residents have that experience built into their residency...and it's a seven-year residency, instead of a one-year fellowship. Anyways. Most of the bread-and-butter cases just don't require that much expertise. A fourth-year neurosurgery resident can should pretty much be able to do all those cases (intradural and extradural). And a lot of case referrals go straight to neurosurgery if there is an neurological involvement.

The bone fixation experience that orthopods have with femurs and hips DOES NOT carry over into the spine world. The anatomy is different, the indications for surgery TOTALLY different, and the understanding of spinal biomechanics is completely beyond the scope of a typical orthopedic surgery residency. In addition, and this is just FYI, because most people wouldn't know this: most neurosurgery residencies actually DO NOT have 2 years for dedicated research. Some do, for sure, but most do not. And there are even a handful of 6-year programs.

In the real world, neurosurgeons and orthopedic spine surgeons work together. But, in my experience, I have seen more of the ortho guys take an interest in the deformity cases and that's the niche they have created. Otherwise, I know neurosurgeons who can practically make a living off of re-do surgeries coming to them from ortho spine guys. The same may happen in the reverse, but I've not heard of that scenario.
Bottom line: An orthopedic spine surgeon fresh out of fellowships cannot compete with a neurosurgeon fresh out of residency.

But, all that being said, an ortho spine surgeon who has been practicing for several years is extremely competant and those guys are fun as hell to operate with and they can teach you a lot.

You make it sound like we don't do any spine in our residencies, which of course is blatantly false.

 

[Bombrainiac]

You make it sound like we don't do any spine in our residencies, which of course is blatantly false.

I really apologize. I don't mean to make it sound like that. But, you've got to admit that your exposure to spine is nowhere close to the exposure that your neurosurgery counterparts get. Besides, if your program has orthopedic spine fellows, then THEY are likely the ones sniping the good cases and doing the majority of the case and not the residents (hence the point of doing an orthopedic spine fellowship).

I'm not bashing ortho residency at all. I have great friends who are ortho residents and I have a lot of respect for the field and what it takes to get there, but I'm just clarifying the difference between the experience in spine between neurosurgery and orthopedic residencies. In MY experience, there's a huge difference. Correct me if I'm wrong. I welcome the education.

 

[VincentAdultman]

I really apologize. I don't mean to make it sound like that. But, you've got to admit that your exposure to spine is nowhere close to the exposure that your neurosurgery counterparts get. Besides, if your program has orthopedic spine fellows, then THEY are likely the ones sniping the good cases and doing the majority of the case and not the residents (hence the point of doing an orthopedic spine fellowship).

I'm not bashing ortho residency at all. I have great friends who are ortho residents and I have a lot of respect for the field and what it takes to get there, but I'm just clarifying the difference between the experience in spine between neurosurgery and orthopedic residencies. In MY experience, there's a huge difference. Correct me if I'm wrong. I welcome the education.

Unfortunately, I know very little about the kind of spine training yall get in NSG. We have no fellows, so we get excellent spine experience.

I do know that the ortho spine attendings I have worked with are more than capable, and have seen nothing to lend credence to your assertion that a fresh neurosurg res graduate >> a fresh ortho spine fellow graduate.

That's my (limited) experience. I don't want to start a flame war or anything.

 

[homealone3]

Talk to some other neurosurgery residents. Neurosurgical residency experience varies, but the fact still remains that most of the work done by neurosurgeons in the community is spine, and over the course of a 7-year residency, a neurosurgeon is going to have more experience in spine surgery than an orthopedic surgeon who does a one-year fellowship. For instance, the vast majority of the big C-spine fusions, and those including the occiput, all go to neurosurgeons (many centers refer all cervical injuries straight to the neurosurgeons). Orthopedic surgeons do a fellowship to gain exposure. My point is that neurosurgery residents have that experience built into their residency...and it's a seven-year residency, instead of a one-year fellowship. Anyways. Most of the bread-and-butter cases just don't require that much expertise. A fourth-year neurosurgery resident can should pretty much be able to do all those cases (intradural and extradural). And a lot of case referrals go straight to neurosurgery if there is an neurological involvement.

The bone fixation experience that orthopods have with femurs and hips DOES NOT carry over into the spine world. The anatomy is different, the indications for surgery TOTALLY different, and the understanding of spinal biomechanics is completely beyond the scope of a typical orthopedic surgery residency. In addition, and this is just FYI, because most people wouldn't know this: most neurosurgery residencies actually DO NOT have 2 years for dedicated research. Some do, for sure, but most do not. And there are even a handful of 6-year programs.

In the real world, neurosurgeons and orthopedic spine surgeons work together. But, in my experience, I have seen more of the ortho guys take an interest in the deformity cases and that's the niche they have created. Otherwise, I know neurosurgeons who can practically make a living off of re-do surgeries coming to them from ortho spine guys. The same may happen in the reverse, but I've not heard of that scenario.
Bottom line: An orthopedic spine surgeon fresh out of fellowships cannot compete with a neurosurgeon fresh out of residency.

I have two good friends, both in different Neurosurg residencies who confirm that the norm is about half and half for spine vs. intracranial work. I'm sure there are some residencies where 65-75% of the exposure is spine, but I would argue that they are the exception rather than the rule. And sure, nailing a femur or tibia does not prepare you to do spine surgery, but ORIF of many common orthopedic injuries/fractures certainly prepares ortho residents for their spine experience in comparison to neurosurg residents who have very limited exposure in bony/hard tissue fixation outside of the spine. I'm not trying to be abrasive, but your comment that orthopaedic spine specialists just out of fellowships cannot compete with neurosurg residents is completely asinine and misinformed. The facts demonstrate that ortho spine trained fellows compete very well if not better than neurosurg residents in attaining spots in dedicated spine groups and surgery centers. Many neurosurg residents also complete spine fellowships to effectively compete for these positions despite having received significant exposure during residency. There is a good bit of regional variability, but the numbers tell us that ortho spine specialists actually do a slightly greater proportion of the extradural cases on a nationwide basis. Albeit, there are definitely areas/cities where there is an unspoken rule that neurosurg will take the cervical cases and ortho the lumbar (a win-win situation financially). In community practice, when there are turf boundaries established, they are generally anatomic in nature as described rather than based on neurological involvement/deficits as is commonplace at many academic centers/residencies. Bottom line, fellowship trained ortho spine specialists are every every bit as qualified and marketable as neurosurg residents and you don't have to take my word for it, just look at the reality of the situation which shows equal extradural case volume of ortho spine if not greater in some areas. P.S. there are very few 6 yr. neurosurgery programs remaining; 1-2 years of research is standard.

 

[Bombrainiac]

I have two good friends, both in different Neurosurg residencies who confirm that the norm is about half and half for spine vs. intracranial work. I'm sure there are some residencies where 65-75% of the exposure is spine, but I would argue that they are the exception rather than the rule. And sure, nailing a femur or tibia does not prepare you to do spine surgery, but ORIF of many common orthopedic injuries/fractures certainly prepares ortho residents for their spine experience in comparison to neurosurg residents who have very limited exposure in bony/hard tissue fixation outside of the spine. I'm not trying to be abrasive, but your comment that orthopaedic spine specialists just out of fellowships cannot compete with neurosurg residents is completely asinine and misinformed. The facts demonstrate that ortho spine trained fellows compete very well if not better than neurosurg residents in attaining spots in dedicated spine groups and surgery centers. Many neurosurg residents also complete spine fellowships to effectively compete for these positions despite having received significant exposure during residency. There is a good bit of regional variability, but the numbers tell us that ortho spine specialists actually do a slightly greater proportion of the extradural cases on a nationwide basis. Albeit, there are definitely areas/cities where there is an unspoken rule that neurosurg will take the cervical cases and ortho the lumbar (a win-win situation financially). In community practice, when there are turf boundaries established, they are generally anatomic in nature as described rather than based on neurological involvement/deficits as is commonplace at many academic centers/residencies. Bottom line, fellowship trained ortho spine specialists are every every bit as qualified and marketable as neurosurg residents and you don't have to take my word for it, just look at the reality of the situation which shows equal extradural case volume of ortho spine if not greater in some areas. P.S. there are very few 6 yr. neurosurgery programs remaining; 1-2 years of research is standard.

Spine. 2006 Apr 1;31(7):831-7.
Confidence in spine training among senior neurosurgical and orthopedic residents.

STUDY DESIGN: A cross-sectional survey of senior neurosurgical and orthopedic residents.
OBJECTIVE: To evaluate the confidence of senior orthopedic and neurosurgery residents in performing spinal surgical procedures and their need for further training. The content and exposure to spine training as well as anticipated practice profile were characterized. Neurosurgical residents reported significantly higher levels of confidence for all 25 surgical procedures.
CONCLUSIONS: Training in spine surgery constitutes a considerably larger proportion of neurosurgery residency than orthopedic residency. Neurosurgery residents graduate with significantly higher levels of confidence to perform spine surgery, while orthopedic residents report significantly higher need for additional training in spine surgery.


My point has been taken WAY off base. I'm not saying that fellowship-trained orthopedic spine surgeons are not well-trained. My point is that orthopods NEED the fellowship, while most neurosurgeons do not. And even still, a one-year fellowship does not amount to 7 years of training where at least 50% of your work is in spine, let alone if a neurosurgeon decides to do a spine fellowship. From my experience, the neurosurgery residents often teach the ortho spine fellows. You do the math. An orthopod fresh out of fellowship just DOES NOT have the experience in spine that a neurosurg resident has coming out of residency. The orthopods can compete for jobs, sure, and they do more extradural cases, because that's ALL they're allowed to do. Neurosurgeons go intradural and extradural, and they often work together with the ortho spine guys. Deformity is usually handled by ortho, neurological deficits and intradural pathology is handled exclusively by neuro (not to mention that ortho guys are not covered for that kind of thing). Heck, one of the best spine surgeons in the country, Vacarro, is an orthopedic surgeon who is in the neurosurgery department at Jefferson, teaching neurosurgery residents how to do spine surgery. Orthopedic spine surgeons are great, BUT they need more exposure during residency. Most orthopedic residency program directors and the orthopedic journals tend to agree. Don't anyone get their feathers is a ruffle. You orthopedic surgeons can rest easy that you're still great and skilled and very smart. No one is bashing you. I would argue that an orthopedic spine surgeon who has been practicing for some time actually becomes better at certain spine surgeries than a general neurosurgeon who has to split his time between cranial and spine cases. And a neurosurgeon who does only spine work usually works hand-in-hand with the ortho spine guys. The combination of the two is a very lucrative and fun endeavor. So I'm not bashing ortho spine surgeons, but, it's important to understand the subspecialty of spine surgery and the training involved.

 

[ddmo]

Spine. 2006 Apr 1;31(7):831-7.
Confidence in spine training among senior neurosurgical and orthopedic residents.

STUDY DESIGN: A cross-sectional survey of senior neurosurgical and orthopedic residents.
OBJECTIVE: To evaluate the confidence of senior orthopedic and neurosurgery residents in performing spinal surgical procedures and their need for further training. The content and exposure to spine training as well as anticipated practice profile were characterized. Neurosurgical residents reported significantly higher levels of confidence for all 25 surgical procedures.
CONCLUSIONS: Training in spine surgery constitutes a considerably larger proportion of neurosurgery residency than orthopedic residency. Neurosurgery residents graduate with significantly higher levels of confidence to perform spine surgery, while orthopedic residents report significantly higher need for additional training in spine surgery.


My point has been taken WAY off base. I'm not saying that fellowship-trained orthopedic spine surgeons are not well-trained. My point is that orthopods NEED the fellowship, while most neurosurgeons do not. And even still, a one-year fellowship does not amount to 7 years of training where at least 50% of your work is in spine, let alone if a neurosurgeon decides to do a spine fellowship. From my experience, the neurosurgery residents often teach the ortho spine fellows. You do the math. An orthopod fresh out of fellowship just DOES NOT have the experience in spine that a neurosurg resident has coming out of residency. The orthopods can compete for jobs, sure, and they do more extradural cases, because that's ALL they're allowed to do. Neurosurgeons go intradural and extradural, and they often work together with the ortho spine guys. Deformity is usually handled by ortho, neurological deficits and intradural pathology is handled exclusively by neuro (not to mention that ortho guys are not covered for that kind of thing). Heck, one of the best spine surgeons in the country, Vacarro, is an orthopedic surgeon who is in the neurosurgery department at Jefferson, teaching neurosurgery residents how to do spine surgery. Orthopedic spine surgeons are great, BUT they need more exposure during residency. Most orthopedic residency program directors and the orthopedic journals tend to agree. Don't anyone get their feathers is a ruffle. You orthopedic surgeons can rest easy that you're still great and skilled and very smart. No one is bashing you. I would argue that an orthopedic spine surgeon who has been practicing for some time actually becomes better at certain spine surgeries than a general neurosurgeon who has to split his time between cranial and spine cases. And a neurosurgeon who does only spine work usually works hand-in-hand with the ortho spine guys. The combination of the two is a very lucrative and fun endeavor. So I'm not bashing ortho spine surgeons, but, it's important to understand the subspecialty of spine surgery and the training involved.

The lines between nsg spine and ortho spine are different at every hospital, which impacts training during residency. For example, in my hospital Spine is about 99% ortho. The spine service is all ortho, and covers all the consults and the ER. This means that as an orthopaedic resident on call, every night we must see spine consults and handle spine issues; which is probably why so few go into spine, because we get an early exposure to the typical spine patient. You are correct in that we do not have as much operative spine experience during residency compared to nsg; and that is just a fact. But that is because our field is so broad and there are so many fields we must be exposed to during residency. And this is the reason for fellowship. I can say that the spine fellows get ridiculous OR time and are very competent when they are finished, at least at my institution. They are trained in all extradural stuff including cervical with occiput. It should also be emphasized that they are better prepared for correcting complex deformity such as major scoliosis cases compared to a neurosurg graduate.

Overall, there is a reason that the Spine Society is comprised of orthopods and neurosurgeons, because they both treat the same diseases pertaining to the spine and the variability in their skill is more related to the individual than their residency path; in my opinion.

Also, it should be emphasized that a medical student should not enter either residency to be a spine surgeon and make money. Rather, they should choose Ortho because they like fixing bones and studying musculoskeletal disease; or neurosurgery because they enjoy the brain and nervous system. Over time they can refine their tastes based on their experiences during residency.

 

[homealone3]

Spine. 2006 Apr 1;31(7):831-7.
My point has been taken WAY off base. I'm not saying that fellowship-trained orthopedic spine surgeons are not well-trained. My point is that orthopods NEED the fellowship, while most neurosurgeons do not. And even still, a one-year fellowship does not amount to 7 years of training where at least 50% of your work is in spine, let alone if a neurosurgeon decides to do a spine fellowship. From my experience, the neurosurgery residents often teach the ortho spine fellows. You do the math. An orthopod fresh out of fellowship just DOES NOT have the experience in spine that a neurosurg resident has coming out of residency. The orthopods can compete for jobs, sure, and they do more extradural cases, because that's ALL they're allowed to do. Neurosurgeons go intradural and extradural, and they often work together with the ortho spine guys. Deformity is usually handled by ortho, neurological deficits and intradural pathology is handled exclusively by neuro (not to mention that ortho guys are not covered for that kind of thing). Heck, one of the best spine surgeons in the country, Vacarro, is an orthopedic surgeon who is in the neurosurgery department at Jefferson, teaching neurosurgery residents how to do spine surgery. Orthopedic spine surgeons are great, BUT they need more exposure during residency. Most orthopedic residency program directors and the orthopedic journals tend to agree. Don't anyone get their feathers is a ruffle. You orthopedic surgeons can rest easy that you're still great and skilled and very smart. No one is bashing you. I would argue that an orthopedic spine surgeon who has been practicing for some time actually becomes better at certain spine surgeries than a general neurosurgeon who has to split his time between cranial and spine cases. And a neurosurgeon who does only spine work usually works hand-in-hand with the ortho spine guys. The combination of the two is a very lucrative and fun endeavor. So I'm not bashing ortho spine surgeons, but, it's important to understand the subspecialty of spine surgery and the training involved.

Alright, enough of the pissing contest. I completely agree that ortho residents need a fellowship to be proficient in spine and my argument was never otherwise. My assertion is that after completing fellowship ortho spine surgeons in general are every bit as qualified and marketable as NS residents right out of training, NOT only after several years of practice as you assume.