General Surgery vs. Subspecializing

[Micro115]

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I'm currently interviewing for a general surgery residency position. I applied to many types of programs, but due to the number of interview invitations I've received, I must narrow down. My dilemma is deciding which programs to withdraw from. I think one of the main deciding factors is whether I want to obtain a fellowship after graduation, but how do I know whether I want to subspecialize this early in the game? I do really enjoy the variety of general surgery, but I want to keep an open mind to fellowships, including the more competitive ones, like peds surg. Thus, logically, I should limit the rest of my interviews to large university-based programs.

My concern is this: I really value the early operative experience in the smaller community programs. I think they produce excellent general surgeons. If I match at a large university-based program and I end up deciding on doing general surgery for the rest of my life, will my surgical skills be compromised in any way? Some programs don't get much bread & butter cases if they're large referral centers. Also, most of those programs may involve the competition with fellows, so the residents' operative experience may not be as extensive (at least in numbers) as the ones at community programs. Can anyone comment on the abilities of a general surgeon coming from a large university-based program?

Also, I know that some of you may suggest that I do another rotation in a surgical subspecialty, but my concern is that a one-month elective won't necessarily help me decide what I want to do for the rest of my life. The hands-on experience and responsibility of a medical student is so limited. I think most people make their final decision during residency anyway. Also, I prefer to spend the rest of my M4 year doing internal medicine electives to help establish a good foundation of knowledge on which I can care for patients during a surgical residency. If any of you think differently, though, I'd love to hear it.

Thanks.

 

[Sarcophageal]

First of all, I am an M4

I think this early operative idea is not a big deal. I am matching now myself, and I have put this idea in the stack with things not to worry about. Why?

Lately, I have been researching the attendings at my program and others to see where they trained and many train at university based programs, even elite programs. These are the people that hundreds of residents train from each year. So that being said, maybe communities let you operate early, but by going to a university program, you are not condemning yourself to a life of poor surgical skills with a great academic mind.

If that was the case, you would look at any place that has an Ivy league surgeon and say "Oh man I bet he didn't operate early and I wont go there."

I may be way off base, that is why I still have residency to look forward too.

 

[Winged Scapula]

Perhaps this will offer some additional insight.

Regardless of the type or location of the program you match into, you will never do all the possible cases out there. You may very well be asked to do something as an attending you've never done before (I saw this with many of my former Chiefs and friends).

Every program will get you the minimum number of required procedures; no one knows the answer as to how many cases *you* have to do to be proficient. Is 50 lap choles better than 5? Sure. But is doing 75 better than 50? Who knows.

While many university programs have more floor and ICU work in the early years, they are quite busy during the senior years. And while it is true that you may be doing less bread and butter cases than you would in a more community oriented program, the key again is not doing certain cases, but rather developing surgical skills which will guide you in any type of case you do. The skills developed doing a Whipple can be translated to other, simpler, more common cases. So I wouldn't worry about not doing enough "B&B" at a university program as most have community or VA rotations where you get that exposure and the cases you'll do at the big house will translate to other procedures.

Finally, a little anecdote...my program sent us on rotations to a local community hospital to get that B&B experience. It was the same attendings who taught at the local community hospital general surgery residency. These same attendings would often comment that while the community residents were more skilled in the early years (likely due to their greater exposure to the OR) but by the Chief year, there was no significant difference in skill level between the community and the university hospital residents.

 

[njbmd]

Perhaps this will offer some additional insight.

Regardless of the type or location of the program you match into, you will never do all the possible cases out there. You may very well be asked to do something as an attending you've never done before (I saw this with many of my former Chiefs and friends).

Every program will get you the minimum number of required procedures; no one knows the answer as to how many cases *you* have to do to be proficient. Is 50 lap choles better than 5? Sure. But is doing 75 better than 50? Who knows.

While many university programs have more floor and ICU work in the early years, they are quite busy during the senior years. And while it is true that you may be doing less bread and butter cases than you would in a more community oriented program, the key again is not doing certain cases, but rather developing surgical skills which will guide you in any type of case you do. The skills developed doing a Whipple can be translated to other, simpler, more common cases. So I wouldn't worry about not doing enough "B&B" at a university program as most have community or VA rotations where you get that exposure and the cases you'll do at the big house will translate to other procedures.

Finally, a little anecdote...my program sent us on rotations to a local community hospital to get that B&B experience. It was the same attendings who taught at the local community hospital general surgery residency. These same attendings would often comment that while the community residents were more skilled in the early years (likely due to their greater exposure to the OR) but by the Chief year, there was no significant difference in skill level between the community and the university hospital residents.

I strongly agree with the material that is in bold and the post above. The advantage that a strong university program gives you is the option to do a more competitive fellowship. It's difficult to know what you are going to be interested in when you start surgery. After around your third year or so, something generally sticks and it's good to have some options and to have some nationally-recognized mentors if you have decided on one of the more competitive fellowships.

I don't think that the folks who train at a university program are lacking in operative skill comparted to the community folks but they do have a distinct advantage when it comes to the more competitive fellowships. The educational opportunites are not bad either and you need strong ABSITE scores for the more competitive fellowships.

My program sent us to a smaller community hospital where we were essentially junior "attendings" during our clinical PGY-4 year. We got loads of experience in doing the routine general surgery work which was a very nice change from the Whipples and Pancreas transplants.

Your best strategy is to find a program that gives you a broad range of experiences coupled with strong academics in a location that you love. I am also a huge fan of being able to rotate through a VA hospital too. There is something about the VA rotations that help you to hone what you love in surgery.

The good thing is that other than for fellowships, any accredited program is going to give you the operative experience that you need and more. For me, the education factor was just as important as the operative experience.

 

[opr8n]

I am also a huge fan of being able to rotate through a VA hospital too. There is something about the VA rotations that help you to hone what you love in surgery. .

in my program
the va only serves to frustrate the hell out of you
yeah sure there are good b&b cases
and you usually get to do the case

but some attending s are alot more difficult to work with than others, and some attendigns would have been fired a long time ago if they werent part of s nationalized health care system (ie the VA)

Example
I did a 45 minute lap R colon at the community hospital one month
then a 6 hour open R colon at the VA
i was ready to hurt someone at the end of that case

of course this post has nothing to do with the title of the thread, sorry

 

[Amgen1]

If you have any leanings toward possible fellowships (esp a competitive one like peds surg), I would recommend a university based program.

I would further echo what others have said here. Scrubbing early does not always mean you will be a better general surgeon. Doing 300 (community prog) vs 200(univ program) lap choles may not make that much of a difference in your general surgery practice. However, doing 10 whipples (univ) vs 1 whipple (comm prog) may make you a better surgeon.

I would also say that as long as a university program has a county or VA hospital as a significant portion of their training you will get more than enough bread and butter cases. In addition, you will get more autonomy in your chief years

 

[leagueelbow]

I did a 45 minute lap R colon at the community hospital one month
then a 6 hour open R colon at the VA
i was ready to hurt someone at the end of that case

of course this post has nothing to do with the title of the thread, sorry

I get the feeling I was short-changed during my surgery rotation.

The lap colectomies I witnessed were usually in the range of 4-6 hours. Is there something special you guys are doing??

 

[SLUser11]

If you have any leanings toward possible fellowships (esp a competitive one like peds surg), I would recommend a university based program.

I would opine that there are only 2 fellowships (Peds surg, Surg Onc) where an academic program is required for match, and these same fellowships usually require a prestigious academic program.

I am very obviously biased, coming from a "hybrid program" myself, but I think strong university-affiliated community programs have better luck matching competitive fellowships than average academic programs. At least, that has been my experience.

I wouldn't interject, since this topic is extremely worn out, but I hate to think that students are not applying to community programs because they may want to do a fellowship. Most fellowships, including plastics, are more dependent on the quality of the program (and resident) than the type of program. We personally match a butt-load of residents into plastics (exactly 1 metric buttload to be precise).

Prospective residents should not allow the desire to do a fellowship to be a deal-breaker when it comes to places to interview. That being said, they should definitely find out where the program's graduates are going when they are finished, as there are plenty of crappy programs in both categories.

I would further echo what others have said here. Scrubbing early does not always mean you will be a better general surgeon. Doing 300 (community prog) vs 200(univ program) lap choles may not make that much of a difference in your general surgery practice. However, doing 10 whipples (univ) vs 1 whipple (comm prog) may make you a better surgeon.

I agree that scrubbing early is not necessary. I rotated at a community program where the interns operated from day 1, but their rotations were slow, and there wasn't much progression in responsibility, so by the end of 5 years, they were on par with an average academic operative experience.

However, many community programs have residents scrubbing early and often, with graduated responsibility, and complex HBP cases in the mix, and there is a distinctive difference in their operative experience by the end of 5 years compared to State U. If you graduate with 845 cases, for example if you are from Baylor-Houston, do you really have equal operative experience to someone with over 1300 cases? They would have 50% more cases than you.

Do you really think that you've seen it all after 845 cases? I think that for the first 2000 cases or so, the resident/attending is always learning.

Something as simple as a lap chole or lap appy may be equal in both populations, but the complex laparoscopic procedures (lap colons, lap nissens, lap anything else), the alimentary tract procedures, etc, you continue to improve into practice, and more is better. So, the graduating resident with more cases is quite possibly the better technical general surgeon.

That being said, some community programs lack a surgical curriculum, and, after all, you can teach a monkey to operate. So obviously, a balance must be sought between the two extremes.

I get the feeling I was short-changed during my surgery rotation.

The lap colectomies I witnessed were usually in the range of 4-6 hours. Is there something special you guys are doing??

Did you do med school at an academic program? I have heard about (and experienced as a student) cases where a lap chole takes 3-4 hours, lap colons take 4-5 hours, etc. These long operative times are usually the result of lack of comfort or experience with the procedure. The counter-argument would be that the academic patients are more difficult, but this doesn't really apply to laparoscopic procedures, where a surgery so difficult should probably performed open....






Now, I must admit I am mostly playing devil's advocate here. My opinion should be taken with a grain of salt since I am defending my own career choice. I interviewed at excellent programs from both categories, and ultimately chose the university-affiliated community route. There are benefits and drawbacks to both situations, and the interviewee has ALOT of variables to consider when ranking these programs. Please see my previous post about what type of questions to ask on the interview trail.

Just keep an open mind, and don't burn any bridges before carefully considering the different options. There are several ways to go about becoming an excellent general surgeon.

 

[leagueelbow]

Did you do med school at an academic program? I have heard about (and experienced as a student) cases where a lap chole takes 3-4 hours, lap colons take 4-5 hours, etc. These long operative times are usually the result of lack of comfort or experience with the procedure. The counter-argument would be that the academic patients are more difficult, but this doesn't really apply to laparoscopic procedures, where a surgery so difficult should probably performed open....

I opted to do my surgery rotation at an affiliated community hospital.

Lap choles were usually completed in 20-30 minutes although there was a difficult case that took the senior resident ~90 minutes to get through.

But I went through quite a few lap colectomies that were in the 4-5 hour range. Two of them were done solely by the attendings. One of which is internationally renowned for his laparoscopic skills and the other who had undergone a fellowship in laparoscopy.

 

[SLUser11]

I opted to do my surgery rotation at an affiliated community hospital.

Lap choles were usually completed in 20-30 minutes although there was a difficult case that took the senior resident ~90 minutes to get through.

But I went through quite a few lap colectomies that were in the 4-5 hour range. Two of them were done solely by the attendings. One of which is internationally renowned for his laparoscopic skills and the other who had undergone a fellowship in laparoscopy.

That's sorta odd, but I guess not unheard of. Maybe the laparoscopy specialists are more willing to stick it out and struggle than convert to open.


The only lap procedures that should be taking that long are those that are still in development (Lap TMEs, Lap Pancreas, etc).

I do think it's interesting that your MI-fellowship trained "laparoscopic specialist" struggled, because I had a similar experience on an away rotation in med school.



Another thing that should be mentioned is that there are plenty of areas in the community where private practice surgeons gained most of their laparoscopic experience at weekend seminars, having trained before such procedures existed. A lot of these seminars were paid for/sponsored by the companies making the expensive laparoscopic equipment.

The doctors then went on to hone their skills on live patients. Some learned quickly, others did not. The ethics of such practice is questionable, but it definitely happens.

 

[flashman]

Couple of points:

There is nothing wrong with learning a new case at a course: in fact, it shows that the surgeon cares enough to really learn what they can. All of us will be in the position of learning completely new operations as attendings once in practice or we will not evolve.

Also, I believe that laparoscopy was developed in the community--not at universities. I heard a laparoscopic panelist say how when he went to duke for his laparoscopic fellowship as one of the first fellows he found that HE taught the attendings the cases--which he had learned from the community surgeons and it blew his mind. Universities are full of dinosaurs who do not always adopt the newest things.

 

[Miami_med]

There are a few University Programs that seem to generate total case numbers that are similar to some of the most aggressive community programs. There are definitely some University programs that generate over 1000 cases/average even today. These tend to be University Programs with a big county/VA component or a private hospital component with a lot of bread and butter GS. Some have all three. I think that you probably can get the best of both worlds. Also, some of the "affiliated" programs may provide you with the same benefit and a chance to name drop a University if you want. I agree that it's confusing. I'm going through a little bit of the same thing myself.