General questions about surgery

[Postictal Raiden]

---

Members do not see this ad.

Forgive my naivety and ignorance, but I was wondering...

Which sub-specialty is the most similar to general surgery in terms of the job nature and type of cases?

Which sub-specialty has the most open surgery cases? (I know the trend is going toward minimally invasive)

Thank you,

 

[Poetic Silence]

Just a pre med here, but I have some exposure. General surgeons do mostly abdominal cases, so trauma, surgical oncology, colorectal surgery and pediatric surgery seem the most similar in types of cases. Hepatobilliary, transplant and cardiothoracic also come to mind. Vascular, hand and breast, however, seem to be in an entirely different realm of surgery.

The most invasive surgical specialties are outside my my collected tidbits of knowledge, though, perhaps transplant, trauma and cardiothoracic.

Hope you get some more answers. It would be nice to see if I wasn't too far off with my educated guesses.

 

[Winged Scapula]

Forgive my naivety and ignorance, but I was wondering...

Which sub-specialty is the most similar to general surgery in terms of the job nature and type of cases?

Which sub-specialty has the most open surgery cases? (I know the trend is going toward minimally invasive)

Thank you,

Just a pre med here, but I have some exposure. General surgeons do mostly abdominal cases, so trauma, surgical oncology, colorectal surgery and pediatric surgery seem the most similar in types of cases.

Pediatric Surgery is widely considered the last "true" general surgeon with its wide ranging types of procedures. *Most* general surgeons will not do Surg Onc except for Colorectal, Breast and Melanoma.

Hepatobilliary, transplant and cardiothoracic also come to mind.

These are typically not in the realm of general surgery practice and require additional training (i.e., fellowship) for hospital privileges to perform Txp and CT. Hepatobiliary can be done by GS although the scope of practice is limited and therefore, unlike GS.

Vascular, hand and breast, however, seem to be in an entirely different realm of surgery.

The vast majority of breast cases in this country are done by general surgeons; they are considered "bread and butter" general surgery cases.

Hand requires fellowship training, only a few of which are open to general surgeons, so its practice is not similar to general surgery. General surgeons are trained in Vascular surgery although many hospitals will require additional training to allow a GS to do Vascular cases.

The most invasive surgical specialties are outside my my collected tidbits of knowledge, though, perhaps transplant, trauma and cardiothoracic.

Trauma is increasingly non-operative or managed in the IR suite, so therefore, wouldn't necessarily meet the criteria for "most invasive". CT also has a number of thorascopic procedures.

Pediatric Surgery is the answer to the OP's query for question #1 and for most open procedures is probably still Transplant.

 

[Winged Scapula]

Moving to Pre-Allo (believe it or not, those questions, which are more appropriately placed there, will be answered by surgery residents and surgeons who check those forums).

 

[gyngyn]

Forgive my naivety and ignorance, but I was wondering...

Which sub-specialty is the most similar to general surgery in terms of the job nature and type of cases?

Which sub-specialty has the most open surgery cases? (I know the trend is going toward minimally invasive)

Thank you,

Ob-Gyn! You can't deliver at term through a laparoscope.

 

[Winged Scapula]

Ob-Gyn! You can't deliver at term through a laparoscope.

Maybe hand assisted laparoscopy! 😀

But anyway, Ob-Gyn is not a subspecialty of GS (which was the OP's question).

 

[MedPR]

Forgive my naivety and ignorance, but I was wondering...

Which sub-specialty is the most similar to general surgery in terms of the job nature and type of cases?

Which sub-specialty has the most open surgery cases? (I know the trend is going toward minimally invasive)

Thank you,

Neuro and ortho. I doubt you can do lapro on brain or bone.

 

[Winged Scapula]

Neuro and ortho. I doubt you can do lapro on brain or bone.

Ortho has lots of arthroscopy. Neurosx (not to be confused with Neurology) has lots of catheter based interventions.

 

[Postictal Raiden]

Pediatric Surgery is widely considered the last "true" general surgeon with its wide ranging types of procedures. *Most* general surgeons will not do Surg Onc except for Colorectal, Breast and Melanoma.



These are typically not in the realm of general surgery practice and require additional training (i.e., fellowship) for hospital privileges to perform Txp and CT. Hepatobiliary can be done by GS although the scope of practice is limited and therefore, unlike GS.



The vast majority of breast cases in this country are done by general surgeons; they are considered "bread and butter" general surgery cases.

Hand requires fellowship training, only a few of which are open to general surgeons, so its practice is not similar to general surgery. General surgeons are trained in Vascular surgery although many hospitals will require additional training to allow a GS to do Vascular cases.



Trauma is increasingly non-operative or managed in the IR suite, so therefore, wouldn't necessarily meet the criteria for "most invasive". CT also has a number of thorascopic procedures.

Pediatric Surgery is the answer to the OP's query for question #1 and for most open procedures is probably still Transplant.

Thank you everyone for your inputs.

WS,

I'm one of your big fans in this forum, and I highly value your opinions.

Using the "search" function, I learned that pediatric surgery is a highly competitive field, and applicants almost always have 1-2 years of research experience under their belt. I'm pursuing medicine through the DO route, due to few semesters of irresponsibility and naivety. Assuming I complete an MD GS residency, will being a DO hinder my chances of pursuing such competitive fellowships?

Also, what types of research do prospective surgery sub-specialty applicants participate in? when do they do it? after GS residency, during, or right after med school?

Finally, where do you see the future of open surgeries heading? are they becoming obsolete or will there always be necessity to perform those types of surgeries?

 

[MedPR]

Ortho has lots of arthroscopy. Neurosx (not to be confused with Neurology) has lots of catheter based interventions.

Really? Damn, I was excited to see open surgeries in those specialties. Thanks for the correction!

 

[Winged Scapula]

Using the "search" function, I learned that pediatric surgery is a highly competitive field, and applicants almost always have 1-2 years of research experience under their belt. I'm pursuing medicine through the DO route, due to few semesters of irresponsibility and naivety. Assuming I complete an MD GS residency, will being a DO hinder my chances of pursuing such competitive fellowships?

Perhaps. While doing an allopathic general surgery residency will mitigate it somewhat, there are still faculty and programs that are not inclined toward osteopathy, as ridiculous as it seems/is.

However, at this point, the concern is moot as you have an extremely long road ahead of you and most students change their mind about sub specialization.

Also, what types of research do prospective surgery sub-specialty applicants participate in? when do they do it? after GS residency, during, or right after med school?

If you are interested in a competitive GS subspecialty, then the research is typically done during "lab years" i.e., usually 1-3 years (most commonly 2 years) during your GS training. This would most often occur after the PGY-2 year.

The research would be in your field of interest; i.e., working in the lab of a Pediatric surgeon, or Transplant surgeon, etc. While the oft stated goal of lab time is to learn how to write a grant, run a lab etc. it really is a series of hoop jumps, and the expectation is that you will make connections in your field of interest and publish in that field. Research done during medical school is typically not of sufficient depth to establish the "cred" you need for these competitive fellowships and doing them after General Surgery training is too late.

Finally, where do you see the future of open surgeries heading? are they becoming obsolete or will there always be necessity to perform those types of surgeries?

Currently there are still some areas of the body which are not accessible to scopes or catheters or for which the open procedure is necessary. For example, I cannot image doing a Liver or Panc/Small Bowel transplant laparoscopically (although wouldn't be surprised if someone tried).

However, never say never...I have seen things which were categorized as "Advanced Laparoscopic" procedures with little requirement for training during GS residency become somewhat commonplace with more numbers required for the American Board of Surgery. And the advent of SILS (Single Incision Laparoscopic Surgery) came after my training (although many practitioners feel that the benefits are not real).

 

[Winged Scapula]

Really? Damn, I was excited to see open surgeries in those specialties. Thanks for the correction!

Please don't infer that because arthroscopy is common in Orthopedics that you won't see open cases. You will especially if you rotate at a hospital which does trauma. While the elective cases (knees and shoulders primarily) are often arthroscopic, orthopedic trauma is still mainly open. Even spine has become endoscopic in some situations.

You can come see my open carpal tunnel repair in a few weeks if you like.

And much of Neurosx is catheter based, but there is still a role for open procedures. However, "seeing" as a student is up for debate, unless you count "seeing" the back of the surgeon's head as he/she does a crani as seeing.

My point was that you overspoke when you mentioned Ortho and Neuro as specialities without much MIS presence.

 

[MedPR]

If Laproscopic is the preferred for a specific surgery, are residents still being trained to do them the old fashioned way? For example, say surgery A is done almost always laproscopically except in a few cases where certain complications prevent it. If the resident never encounters a case with those complications, will that resident ever be trained on doing the surgery open? If not, what happens if sometime down the road they encounter a patient with those complications. Will they just do their first open surgery on that patient and not worry about it?

 

[Winged Scapula]

If Laproscopic is the preferred for a specific surgery, are interns/residents still being trained to do them the old fashioned way? For example, say surgery A is done almost always laproscopically except in a few cases where certain complications prevent it. If the resident never encounters a case with those complications, will that resident ever be trained on doing the surgery open? If not, what happens if sometime down the road they encounter a patient with those complications. Will they just do their first open surgery on that patient and not worry about it?

Programs are required to train their residents in both open and laparoscopic cases but getting cases the "old fashioned" way can sometimes be difficult depending on the patient mix. And I would be loathe to call open surgery "old fashioned" as that implies that it is somehow lesser. There are definitely indications for starting a case open or conversion from laparoscopic to open and that shouldn't be seen as old fashioned or a failure.

We didn't do a lot of appys or gallbladders at my program, so we spent a few months rotating out at a community hospital with a private practice surgical group where we got those numbers for our case logs and did a lot open as the patients tended to be older, and sicker upon presentation. Our PD did a lot of open hernia repairs and alternated between the types of open repairs so we could get that experience. The American Board of Surgery (ABS) requires a certain number of laparoscopic cases and advanced lap cases as well as specific Biliary cases (which will of course almost all be Lap Choles). Current surgical residents could speak to current ABS case log requirements.


The ABS still asks about PUD surgery although most US GS residents have never seen one, let alone done one. I did a Antrectomy and Vagotomy during my residency and other residents came to watch because they were so rare. Perhaps there will come a day when the open procedures become obsolete, but for now the open variations of laparoscopic cases are still expected to be taught during residency. You may not do a lot of open gallbladders but in 5+ years, you should see (and do) a few.

But you raise a relevant point about "what if you never see X?" This is why surgical programs are concerned about work hour restrictions without an increase in training time. if you aren't there, you aren't there...ie, you may miss the chance to do those cases. You can't see or experience everything so most of us will tell you how much we learned our first 5 years out. You WILL see things as an attending that you never saw in residency. Its the nature of the beast. The anatomy and procedure doesn't really change whether you're doing it laparoscopically or open, just the approach does.

 

[MedPR]

Programs are required to train their residents in both open and laparoscopic cases but getting cases the "old fashioned" way can sometimes be difficult depending on the patient mix. And I would be loathe to call open surgery "old fashioned" as that implies that it is somehow lesser. There are definitely indications for starting a case open or conversion from laparoscopic to open and that shouldn't be seen as old fashioned or a failure.

We didn't do a lot of appys or gallbladders at my program, so we spent a few months rotating out at a community hospital with a private practice surgical group where we got those numbers for our case logs and did a lot open as the patients tended to be older, and sicker upon presentation. Our PD did a lot of open hernia repairs and alternated between the types of open repairs so we could get that experience. The American Board of Surgery (ABS) requires a certain number of laparoscopic cases and advanced lap cases as well as specific Biliary cases (which will of course almost all be Lap Choles). Current surgical residents could speak to current ABS case log requirements.


The ABS still asks about PUD surgery although most US GS residents have never seen one, let alone done one. I did a Antrectomy and Vagotomy during my residency and other residents came to watch because they were so rare. Perhaps there will come a day when the open procedures become obsolete, but for now the open variations of laparoscopic cases are still expected to be taught during residency. You may not do a lot of open gallbladders but in 5+ years, you should see (and do) a few.

But you raise a relevant point about "what if you never see X?" This is why surgical programs are concerned about work hour restrictions without an increase in training time. if you aren't there, you aren't there...ie, you may miss the chance to do those cases. You can't see or experience everything so most of us will tell you how much we learned our first 5 years out. You WILL see things as an attending that you never saw in residency. Its the nature of the beast. The anatomy and procedure doesn't really change whether you're doing it laparoscopically or open, just the approach does.

I didn't mean to imply that open surgery is inadequate or lesser than the newer methods. I certainly don't feel that it is. Thanks for the info, it's good to know that there are requirements in place to ensure residents learn the different methods.

As far as hour restrictions go, are residents allowed to "volunteer" and stay in the OR or observation area to at least see something that would otherwise take them over their limit?

 

[Winged Scapula]

As far as hour restrictions go, are residents allowed to "volunteer" and stay in the OR or observation area to at least see something that would otherwise take them over their limit?

Nope.

That's a slippery slope that many residents and attendings have attempted over the years. Its not a big leap from someone saying, "hey there's a cool case going on and you don't *have* to stay, but..." and the assumption that its required or will somehow affect your evaluation if you don't stay. Coercion to go over hours is definitely a no-no.

Residents have tried to claim that they are "off the clock" and that the hours "don't count" honestly, many would rather stay and aren't really all that tired and could possibly benefit (assuming the case was something truly innovative/rare or educational). But the ACGME/RRC doesn't see it that way and worries about residents being coerced into working over hours. It happens.

Programs have various ways of dealing with this from badge swipe/time clock, to reporting of hours by a 3rd party, to having residents lie. Some are adamant that residents leave the hospital grounds, others would allow you to observe (but not be scrubbed in as that would be interpreted as working).

 

[Postictal Raiden]

Nope.

That's a slippery slope that many residents and attendings have attempted over the years. Its not a big leap from someone saying, "hey there's a cool case going on and you don't *have* to stay, but..." and the assumption that its required or will somehow affect your evaluation if you don't stay. Coercion to go over hours is definitely a no-no.

Residents have tried to claim that they are "off the clock" and that the hours "don't count" honestly, many would rather stay and aren't really all that tired and could possibly benefit (assuming the case was something truly innovative/rare or educational). But the ACGME/RRC doesn't see it that way and worries about residents being coerced into working over hours. It happens.

Programs have various ways of dealing with this from badge swipe/time clock, to reporting of hours by a 3rd party, to having residents lie. Some are adamant that residents leave the hospital grounds, others would allow you to observe (but not be scrubbed in as that would be interpreted as working).

Thank you WS for the valuable information.

I'm wondering, because of the size of incision, do laparoscopic surgeries require more technical skills and more time consuming than traditional open surgeries?

Also, as an attending physician, how do you handle situations where things in the OR don't go as smoothly as you anticipated? did residency provide you with the mindset on how to confront such challenges?

My knowledge of medicine, let alone surgery, is very limited. Therefore, I apologize for asking "dump" questions.

 

[Winged Scapula]

Thank you WS for the valuable information.

I'm wondering, because of the size of incision, do laparoscopic surgeries require more technical skills and more time consuming than traditional open surgeries?

I would venture they require a *different* set of surgical skills mostly related to the use of the instruments. The size of the incision is not the limiting factor. Visualization can actually be better with laparoscopy in some cases.

During the learning curve they can be more time consuming and there are some which are going to almost always take longer (i.e., a minimally invasive thyroid almost always takes longer than an open thyroid); there are some which are quicker (i.e., a routine lap chole is faster than an open cholecystectomy, mostly related to the closing of the abdominal incision).

Laparoscopic surgery would not have taken ahold the way it did if it were wholesale more time consuming, especially out in private practice where "time is money".

Also, as an attending physician, how do you handle situations where things in the OR don't go as smoothly as you anticipated? did residency provide you with the mindset on how to confront such challenges?

I think its partially training (residency and fellowship), confidence, personality and experience. There are some for whom complications always seem to be a disaster; most of us can point to an attending with whom we worked who seemed freaked out when something went wrong. I enjoyed working with my former PD because his confidence allowed residents to do the case; he knew (and we knew) that if we ****ed it up, he could fix it.

In practice, I find myself thinking about potential complications and how I would fix them. Just 2 weeks ago, I had a difficult case where radiated tissue and tumor was stuck to a large vessel. So in my mind, as I very carefully dissected tumor off the vessel, I was thinking about what suture I would need to repair the vessel if I did tear it or whether I should consult Vascular to do the repair (our malpractice attorneys tell us we should, even though I'm trained and qualified to repair a hole in a vessel), was looking at the scrub table to make sure there were enough lap pads around, if she had the vascular clamps, and was careful to tell the scrub tech not to vigorously stab the suction tip into the wound.

So when things don't go smoothly I think about why and how to fix it. If its a system problem, I go to management (e.g., toward that end, I am giving an inservice to the OR staff at one hospital this Wednesday to help remedy some problems with the staff misunderstanding a new procedure I'm doing) and try and educate staff or find a work around. If its a technical problem, I assess what I did and how I can improve. And I have lots of colleagues I can run things by when faced with something unusual.

The first 5-10 years out in practice are a huge learning curve for all of us.

 

[plauto]

Just my 2 cents...laparoscopic cases are in many instances just as exciting as open ones as you get HD view of undisrupted anatomical structures...

 

[Omppu27]

Please don't infer that because arthroscopy is common in Orthopedics that you won't see open cases. You will especially if you rotate at a hospital which does trauma. While the elective cases (knees and shoulders primarily) are often arthroscopic, orthopedic trauma is still mainly open. Even spine has become endoscopic in some situations.

You can come see my open carpal tunnel repair in a few weeks if you like.

.

Arg, you live all the way in Arizona... Can you get a live feed goin? 👍

 

[JJMrK]

Really? Damn, I was excited to see open surgeries in those specialties. Thanks for the correction!

Go check out a total knee if you get the opportunity.

 

[45408]

Just my 2 cents...laparoscopic cases are in many instances just as exciting as open ones as you get HD view of undisrupted anatomical structures...

There's no doubt that they're often/usually better for students, but your view isn't necessarily better when you're the one operating and have a good view. Wearing loupes gives you a magnified stereoscopic view of the field, and you can manipulate most tissues a lot more with your hands than with laparoscopic graspers.

 

[MedPR]

Go check out a total knee if you get the opportunity.

Thanks. If I get in this cycle I'm going to cold call every ortho I can and see if they'll let me observe.

 

[debvz]

laparoscopic cases are in many instances just as exciting as open ones as you get HD view of undisrupted anatomical structures...

...or, they are exciting because you get a HD view of newly disrupted anatomical structures.

A laparoscopic red-out tends to get my heart rate up.

 

[Poetic Silence]

The first doctor I ever shadowed was a general surgeon who let me scrub in for a procedure. A cholectomy (sp?) done via laparoscopy. I thought it was the most amazing thing I'd ever seen at the time. I was a HS junior at the time (small rural town) and I always thought all surgeries were open. It was amazing to see the techniques and how minimally invasive such a procedure can be.

I'm hoping to see a head and neck or otology case soon.

 

[JJMrK]

The first doctor I ever shadowed was a general surgeon who let me scrub in for a procedure. A cholectomy (sp?) done via laparoscopy. I thought it was the most amazing thing I'd ever seen at the time. I was a HS junior at the time (small rural town) and I always thought all surgeries were open. It was amazing to see the techniques and how minimally invasive such a procedure can be.

I'm hoping to see a head and neck or otology case soon.

Gallbladder (cholecystectomy) or colon (colectomy)?

 

[Poetic Silence]

Gallbladder (cholecystectomy) or colon (colectomy)?

Oh, that's right. Cholecystectomy.

 

[Postictal Raiden]

I have more questions regarding general surgery I hope some of the attendings or residents could answer.

1. What does a typical OR day look like? All surgeries? invasive procedures? rounding?
2. What types of consults do general surgeons get called for?
3. What are examples of common surgeries/procedures?
4. How is rural general surgery different from practicing in large cities?
5. What would happen if the surgeon on call gets called for two different cases at the same time? (i asked this before and the answer was that residents or other attendings at the academic institutions can cover, but how does this work out in the pp?)

Thank you,

 

[Postictal Raiden]

Anyone? WS? TheProwler?

 

[Winged Scapula]

I have more questions regarding general surgery I hope some of the attendings or residents could answer.

Sorry didn't see this...

1. What does a typical OR day look like? All surgeries? invasive procedures? rounding?

It will depend on the practitioner. Some have half-day office, half-day in the OR. I hate doing that because invariably you run late, disrupting the other half. But right now I do 2.5 days in the OR and 2.5 days in the office.

For OR days, start time is 730 and hospitals will require that you show up around 20 minutes before the case. If I have patients to round on, I might get there earlier, but generally see them between cases.

My Mondays are a mix of invasive procedures (ie, biopsies) and OR cases; Wednesdays are my big cases and Fridays for "lumps and bumps". Sometimes we actually stick to that schedule.

I bring my laptop and do charts on my EMR between cases; when the cases are done, I go home/gym/whatever.

2. What types of consults do general surgeons get called for?

A wide variety of things. Most will take ED call and will be asked to see patients with an acute surgical problem (ie, cholecystitis, appendicitis, abscess) or post-op patients who return to the ED with a complaint (instead of coming to the office 🙄 ).

There are calls from the MICU for patients with mesenteric ischemia, patients who need vascular access for dialysis or IV medications or a chest tube (that will vary by community; in some places, IM does those themselves), or GI bleeds. The Med/Surg floors may call with patients with bowel obstructions, diverticulitis, pancreatitis (this may also vary; in my residency, those patients were admitted to surgery rather than medicine), acute or chronic wounds, incidental breast/thyroid/skin masses.

Medical Oncology may consult for port placement to administer chemo or for perirectal abscess or wounds in patients who are immunosuppressed.

Then in your office you will see patients referred from the ED or their PCP with non-urgent surgical problems (breast mass, hernia, biliary colic, mild diverticulitis, thyroid masses, skin lesions, etc.).

There are simply too many things to list and it will depend on your community (ie, in some places only ENTs do thyroids, in others it may be the general surgeon)..

3. What are examples of common surgeries/procedures?

Again, it will somewhat depend on the community (in some, general surgeons will do ENT, vascular work, etc and in others, those will go to specialists). But common procedures would be:

colon resections
appendectomies
cholecystectomies
breast biopsies/mastectomy
lymph node dissection/excisional biopsies
thyroidectomy
splenectomy
skin and soft tissue excisions (lipomas, melanomas, BCC/SCC)
incision and drainage of abscesses
hernia repair - ventral/incisional/inguinal/umbilical/femoral/epigastric

4. How is rural general surgery different from practicing in large cities?

You may be able to do a wider variety of procedures because of the lack of competition from subspecialists. There are some rural and acute general surgery fellowships which train general surgeons to do basic Ob/Gyn, burr holes/cranis, basic Ortho. Then again, you may find that patients will go to the "city" for their non-emergent procedures because of an assumption that the specialists are better. However, it is not unusual to see old school general surgeons in smaller towns do pancreaticoduodenectomies, vascular procedures and more complex colorectal surgery, things that would be done by a specialist in the "city".

5. What would happen if the surgeon on call gets called for two different cases at the same time? (i asked this before and the answer was that residents or other attendings at the academic institutions can cover, but how does this work out in the pp?)

It works the same way in PP.

First, it is unlikely that you will have 2 equally sick patients who need emergent surgical intervention (ie, implying that if you don't operate on both RIGHT NOW, one will die). But on the off chance that you get 2 urgent surgical consults at the same time, you see both, decide which one needs surgery first and get them ready to go.

If you are on call, in the OR or otherwise indisposed and a call comes in for an urgent surgical consult, if you can't cover it, you have them call whomever is on second call.

Remember it is extremely unusual these days to be in *solo* private practice. Therefore, you could ask the hospital to call your partner (keeps any potential money in the practice) or to call other GS that have privileges at the hospital if the patient truly can't wait until you can go and see the patient.

While the above is a generalization, you will find that GS is a field with a lot of variety in practice. Hope this helps.

 

[Postictal Raiden]

Sorry didn't see this...



It will depend on the practitioner. Some have half-day office, half-day in the OR. I hate doing that because invariably you run late, disrupting the other half. But right now I do 2.5 days in the OR and 2.5 days in the office.

For OR days, start time is 730 and hospitals will require that you show up around 20 minutes before the case. If I have patients to round on, I might get there earlier, but generally see them between cases.

My Mondays are a mix of invasive procedures (ie, biopsies) and OR cases; Wednesdays are my big cases and Fridays for "lumps and bumps". Sometimes we actually stick to that schedule.

I bring my laptop and do charts on my EMR between cases; when the cases are done, I go home/gym/whatever.



A wide variety of things. Most will take ED call and will be asked to see patients with an acute surgical problem (ie, cholecystitis, appendicitis, abscess) or post-op patients who return to the ED with a complaint (instead of coming to the office 🙄 ).

There are calls from the MICU for patients with mesenteric ischemia, patients who need vascular access for dialysis or IV medications or a chest tube (that will vary by community; in some places, IM does those themselves), or GI bleeds. The Med/Surg floors may call with patients with bowel obstructions, diverticulitis, pancreatitis (this may also vary; in my residency, those patients were admitted to surgery rather than medicine), acute or chronic wounds, incidental breast/thyroid/skin masses.

Medical Oncology may consult for port placement to administer chemo or for perirectal abscess or wounds in patients who are immunosuppressed.

Then in your office you will see patients referred from the ED or their PCP with non-urgent surgical problems (breast mass, hernia, biliary colic, mild diverticulitis, thyroid masses, skin lesions, etc.).

There are simply too many things to list and it will depend on your community (ie, in some places only ENTs do thyroids, in others it may be the general surgeon)..



Again, it will somewhat depend on the community (in some, general surgeons will do ENT, vascular work, etc and in others, those will go to specialists). But common procedures would be:

colon resections
appendectomies
cholecystectomies
breast biopsies/mastectomy
lymph node dissection/excisional biopsies
thyroidectomy
splenectomy
skin and soft tissue excisions (lipomas, melanomas, BCC/SCC)
incision and drainage of abscesses
hernia repair - ventral/incisional/inguinal/umbilical/femoral/epigastric



You may be able to do a wider variety of procedures because of the lack of competition from subspecialists. There are some rural and acute general surgery fellowships which train general surgeons to do basic Ob/Gyn, burr holes/cranis, basic Ortho. Then again, you may find that patients will go to the "city" for their non-emergent procedures because of an assumption that the specialists are better. However, it is not unusual to see old school general surgeons in smaller towns do pancreaticoduodenectomies, vascular procedures and more complex colorectal surgery, things that would be done by a specialist in the "city".



It works the same way in PP.

First, it is unlikely that you will have 2 equally sick patients who need emergent surgical intervention (ie, implying that if you don't operate on both RIGHT NOW, one will die). But on the off chance that you get 2 urgent surgical consults at the same time, you see both, decide which one needs surgery first and get them ready to go.

If you are on call, in the OR or otherwise indisposed and a call comes in for an urgent surgical consult, if you can't cover it, you have them call whomever is on second call.

Remember it is extremely unusual these days to be in *solo* private practice. Therefore, you could ask the hospital to call your partner (keeps any potential money in the practice) or to call other GS that have privileges at the hospital if the patient truly can't wait until you can go and see the patient.

While the above is a generalization, you will find that GS is a field with a lot of variety in practice. Hope this helps.

Thank you very much.

 

[Xlorgguss]

Wow this was a very great and informative thread. Thanks so much! I have a related question. Since SDN doesn't have a designated cardiothoracic forum, I was curious as to how rural cardiothoracics could work. I know that there is the trend of having a blended residency where residents see more cardiothoracic cases. Some of them have you do a few years of general and then cardio and then I believe certain programs are just cardio. So my question falls, if you are a cardiothoracic surgeon and are dual board certified in cardiothoracic and general surgery, how common is it to do some general surgery surgeries and procedures and what specifically could they do. Would this differ in a private practice? I am guessing that more rural areas would allow for a wider scope of practice? If one wanted to do a practice like this (with a good blend of cardiothoracics and some general surgery) would the traditional route of doing general surgery residency (5 years) and then a cardiothoracic fellowship (2 or 3 years) be preferable over the integrated 5 year programs? And as a bonus question, if you were to do the integrated program (amusing dual board certification) would an MIS fellowship be beneficial and more marketable? (can cardiothoracics do MIS fellowships?)

Thanks!

 

[Winged Scapula]

I know that there is the trend of having a blended residency where residents see more cardiothoracic cases.

These are referred to as Integrated programs.

Some of them have you do a few years of general and then cardio and then I believe certain programs are just cardio.

Nope. None of them are straight up CT surgery only. You either do the traditional Independent route with 5+ years of General Surgery followed by a CT Surgery fellowship (leaving you Board Eligible for both) or the Integrated CTS residency which includes a variable amount of time in General Surgery (usually 3-4 years). See the AATS info page.

So my question falls, if you are a cardiothoracic surgeon and are dual board certified in cardiothoracic and general surgery, how common is it to do some general surgery surgeries and procedures and what specifically could they do.

It is not common at all for the following reasons:

1) CT surgeons (or pretty much any subspecialist) don't want to do general surgery
2) while doing CT surgery training, your general surgery skills have eroded
3) ED call for General Surgery (see #1)
4) to be good at something, you have to do it frequently (see #2)
5) you can forget about referrals from general surgeons in town who have patients who need CTS

But technically, you could general surgery hospital privileges for general surgery and CT surgery.

Would this differ in a private practice?

Nope. Same issues as above.

I am guessing that more rural areas would allow for a wider scope of practice?

Perhaps. But remember that a specialty is hard to do in a truly rural setting. Does your hospital have an ICU with appropriately trained nurses? Do they have appropriate surgical equipment and trained OR staff? Do they have a perfusionist, a cardiologist, etc on staff/in town?

Then again, what SDNers typically define as rural (ie, anything less than 250,000 population from what I've seen) may not be really rural. CT surgery, like a lot of subspecialties requires a lot of infrastructure. Regardless, the above still holds: you aren't likely to find anyone doing both GS and CTS and doing both well, in any environment.

If one wanted to do a practice like this (with a good blend of cardiothoracics and some general surgery) would the traditional route of doing general surgery residency (5 years) and then a cardiothoracic fellowship (2 or 3 years) be preferable over the integrated 5 year programs?

Yes, if only because you will not be General Surgery Board Eligible doing an Integrated 5 year program(btw, they are usually a minimum of 6 years) and won't get hospital privileges to do General Surgery.

And as a bonus question, if you were to do the integrated program (amusing dual board certification) would an MIS fellowship be beneficial and more marketable? (can cardiothoracics do MIS fellowships?)

Thanks!

Good Lord man. How long are you planning on staying in training?

1) no one NEEDs an MIS fellowship if they have trained in a modern residency program
2) MIS won't help you with CTS
3) most MIS programs are heavily skewed toward bariatrics
4) the only benefit for MIS (conventional wisdom here) is for people who want to do "advanced" laparoscopic like Lap Heller Myotomies and other foregut stuff and even that's pushing it
5) you do not need an MIS fellowship to be more marketable in most communities; general surgeons are highly in demand straight out of residency

 

[Xlorgguss]

Wow, thank you so much for the input, I really appreciate it! I suppose the colloquial is correct in that you don't want to spread yourself too thin and being a jack of all trades but a master of none. The reason I was curious about the general surgery alongside cardiothoracics was the concern of interventional cardiology and how that has effected the scope of practice of cardiothoracics. I really do appreciate the time to answer my questions, since I've been curious about it for a while!

 

[Winged Scapula]

Wow, thank you so much for the input, I really appreciate it! I suppose the colloquial is correct in that you don't want to spread yourself too thin and being a jack of all trades but a master of none. The reason I was curious about the general surgery alongside cardiothoracics was the concern of interventional cardiology and how that has effected the scope of practice of cardiothoracics. I really do appreciate the time to answer my questions, since I've been curious about it for a while!

You're welcome.

And while IC has certainly changed the face of modern treatment of coronary artery disease, please be aware that for patients with multi-vessel or left main disease, there is superiority of CABG over PCI. In addition, diabetics (who often have diffuse disease) have a lower risk of post procedure MI, CVA and death after CABG when compared to drug eluting stents. Thus, PCI is not the right choice for everyone.

Finally, CTS is not just bypass. There is valvular surgery, pediatric/congenital hearts, transplant, lung/thoracic and esophageal work. IC has not made significant advances in those arenas.

 

[EndersRebutal]

Hey Winged Scapula, No real questions just want to say thank you for taking the time to answer question and in such detail. Your post are always really insightful and always appreciated.

 

[SpecterGT260]

Really? Damn, I was excited to see open surgeries in those specialties. Thanks for the correction!

"Open" is a relative term. There are still open surgeries in neuro. Cervical spine and tumors come to mind. But open means about a 2" hole in many cases

Sent from my DROID RAZR using SDN Mobile