General Surgery and Specialization in the Future

[corproectomy]

Hello,

I've searched these forums for many months and haven't found any topics which answer my concerns.

My main concern is that there are a lot of combined programs emerging and the number of programs that allow for specialization after completion of a general surgery residency are diminishing, particularly in plastics. I've noticed that CT and vascular has gained an increasing number of combined training programs. I'm not particularly interested in general surgery as a non-specialist, so question is "Will there be, in 10 years down the line, opportunities for general surgery graduates to move onto CT or other specialties?"

If not, how bad is it to not match your first round? How does one navigate the match and scramble to best land a position in a surgical sub-specialty? Is it a feasible option to pursue these and maybe not match initially, but the year following (as an AMG, from my understanding, not matching makes you very unappealing the following round)? I've been interested in surgery since starting school, but the high risk of not matching in many specialties make general surgery seem like the most palatable option. However, I have a long time until I graduate and ultimately match.

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[thedrjojo]

CT and vascular surgery are further than 10 years away from being independent of general surgery. I won't say never, but there will be the opportunity to get a fellowship in either. Plastics is harder to predict, but I also don't see them going away as a fellowship. It's similar to a head and neck fellowship post gen surgery vs ent... There will likely be options for a gen surgeon dead set on doing reconstruction.

If you don't match round one, it gets much much harder to match subsequently. You get looked down upon, any flaws magnified, and typically you won't have time to make up any of the deficiencies that lead to your nonmatch the first time. Do not plan on this route, do everything in your power to avoid it at almost all costs. And this goes the same for preliminary, it is also not a horribly viable pathway... Sure, better than not matching anything, but not by leaps and bounds more.

 

[thedrjojo]

Furthermore, fellowships aren't going anywhere. The better question is, 10 years from now, will there be any opportunities for a non specialized general surgeon, or am I forced to do a fellowship?

 

[corproectomy]

Thank you for answering my question, I really appreciate it.

 

[Postictal Raiden]

Furthermore, fellowships aren't going anywhere. The better question is, 10 years from now, will there be any opportunities for a non specialized general surgeon, or am I forced to do a fellowship?

What do you think the answer to this question is?

 

[thedrjojo]

What do you think the answer to this question is?

yes.

Yes there will be opportunities for a non specialized general surgeon (there will always be people needed to do the bread and butter cases), but you still may be forced to do a fellowship (namely, an acute care surgery fellowship) to be competitive for all but really rural jobs.

 

[Postictal Raiden]

yes.

Yes there will be opportunities for a non specialized general surgeon (there will always be people needed to do the bread and butter cases), but you still may be forced to do a fellowship (namely, an acute care surgery fellowship) to be competitive for all but really rural jobs.

Thanks for the fast response.

How does acute surgery differ from trauma surgery?

 

[thedrjojo]

Thanks for the fast response.

How does acute surgery differ from trauma surgery?

trauma is traumatic stuff... gun shots, car accidents, etc.

acute care surgery is emergency room stuff... appendicitis, cholecystitis, free air, etc.

Many trauma fellowships are transitioning into Trauma and Acute care surgery fellowships to A) become more popular again B) get more operations for trauma doctors C) most hospitals are transitioning to this model of ER coverage.

 

[Smurfette]

Actually, the transition to the acute care surgery model is more in academic hospitals and larger trauma centers which is what most students and residents are exposed to. The vast majority of surgeons do not end of practicing in these type of centers. This coverage model is not so much true in smaller community hospitals where the general surgeons are taking call and still do elective cases, which are the bulk of their caseload and income. It may be a traditional call system or a model where the surgeon is on ER call a week at a time, but still has clinic and elective cases. Most community hospitals cannot support a different specialist for every field volume-wise (and especially not multiple people in each specialty to take "colorectal" or "surg onc" call to cover those particular patients on a rotating basis) and want surgeons who will do what is needed, even if it's not what they were fellowship trained in, unless it is something above and beyond local standard (i.e. transfer the patient who needs a whipple, but no reason to transfer a patient with diverticulitis who needs resection, while that weird, somewhat unusual case that can wait a day or two can go to the partner who has dealt with this type of case before). They may want somebody to "round out" their current group of surgeons....a lot of what I see job-wise is looking for surgeons comfortable with complex lap cases (i.e. not just choles or appys) or colorectal cases who don't necessarily have to be fellowship trained but are wanted to fill the void that is left as some other surgeons retire or don't want to learn new techniques, and are expected to participate in call with the others.

Of course, in big cities, there is a bigger demand for fellowship trained folks, but this is variable depending on location and overall market. There is also the question of whether those who do acute care surgery fellowships would be willing to work in a non-level 1 or level 2 trauma center (i.e. the majority of hospitals in the US) as most of them want to be in a trauma-heavy location.

My own (admittedly biased and somewhat optimistic) opinion is that once all the fellowship trained folks have completely saturated the market and don't want to do things outside of their subspecialty, those who are willing to do a wider variety of cases are going to be in greater demand and have higher offers....many smaller community hospitals are now paying surgeons to take call (including home call), and the amount per night can be pretty sweet depending on location and acuity. I'm a non-fellowship trained general surgeon who's a couple years out from residency and in the last 10 days, I've done 2 lap colons, 2 open colon cases, 1 ex lap, 2-3 lap choles, lap ventral hernias, some breast cases and a handful of office procedures as well as maintained a full clinic schedule. My point is, don't let the academic hospital point of view skew the perception of what the "lowly community general surgeons" are doing on a regular basis.

Back on topic to the original question:
To the OP, yes, in 10 years you will still be able to go to a fellowship from the gen surg route. Keep in mind that some people get exposure to subspecialty fields during residency and realize that's what they want to do. If you're not competitive enough in med school for integrated CT, vascular or plastics, being a hard worker who impresses people in your GS residency can open doors for you into the related subspecialties for fellowship training and is often easier (read: less competitive) to do than trying to do so through the traditional match route as a ms-4. Or you may be able to get a spot midway through residency if something opens up at your own hospital in your field of choice at the right level of training. It's going to take a while to transition programs to the integrated model.

 

[SLUser11]

Someone needs to define "rural" before any more discussion occurs on this topic. I've found the "rural" tag on everything outside of the 5 major metropolitan areas in the US.

All over the US, general surgeons are in great demand....not just in podunk Nebraska. When I was in Houston, which I believe is currently ranked #3 or 4, there were plenty of general surgeons practicing there, and doing very well for themselves. Houston, of all places, is certainly saturated with specialists, so it would be much harder to find a job there doing colorectal than doing general surgery.

The hard part, however, is determining what case volume, case complexity, and case variety all these general surgeons have. Often, they are doing a lot less Nissens than they thought they would, and a lot more colonoscopies. Here is a recent article from JACS on the topic: http://www.ncbi.nlm.nih.gov/pubmed/24210145.

Some specific colectomy stats:
Only 11.5% of colectomies are performed by colorectal surgeons
General surgeons perform an average of 11 colectomies/year (14=70th percentile, 23=90th percentile)
The learning curve for lap colectomy is approximately 50-60 cases
Graduating resident experience with lap colectomy is improving (Median 2 cases in 1999 vs. 13 in 2008).
Currently, 30-45% of colectomies in the US are done laparoscopically.

What that means is that general surgeons are doing the bulk of the work....specialists perform a small portion of the procedures nationally, but actual case volume is quite variable among general surgeons......

 

[thedrjojo]

The question, is, what the ecosystem is going to look like 10 years from now, and that's hard to predict. 10 years ago (11),the 80 hour rule went into effect. Fellowship numbers were much different, as we're practice patterns and resident training. There is more and more shift to fellowship, or if not fellowship, tracking. It will be interesting to see how it plays out, but I feel the prospects of the unfellowship trained individual coming straight out of residency will get harder, not easier. Then again, I'm already in a geographic area that is problematic, and unfortunately believe I'm not going to a new geography any time soon