General Surgery - Why not specialize? (Help)

[ScottDoc]

I will enter med school next year and want to know if a general surgeon can do foot and ankle. If yes, then why don't I just go into Ortho (the training time seems to be the same amount of time)? I know, first get through school, but I am planning ahead. So to get back to the question... why do general surgery at all? Same for a colo-rectal surgeon vs. general surgeon what if/any benefits are there to doing general when one can specialize? It seems ambigous, doesn't it? (I am not saying anything bad, I am just naive I guess). Thanks all.

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[Teufelhunden]

I will enter med school next year and want to know if a general surgeon can do foot and ankle. If yes, then why don't I just go into Ortho (the training time seems to be the same amount of time)? I know, first get through school, but I am planning ahead. So to get back to the question... why do general surgery at all? Same for a colo-rectal surgeon vs. general surgeon what if/any benefits are there to doing general when one can specialize? It seems ambigous, doesn't it? (I am not saying anything bad, I am just naive I guess). Thanks all.

I'm not sure if I understand your question. Foot & Ankle is a subspecialty of Ortho, not General Surgery, i.e. if you want to be a foot & ankle surgeon, you first have to do an Ortho residency, then a fellowship in foot & ankle.

Colo-rectal surgery, on the other hand, is a subspecialty of General Surgery, meaning that you would first have to do a general surgery residency followed by fellowship training in Colo-Rectal surgery. However, General Surgeons seem to be heavily trained in surgery involving the colon/rectum, so I really can't fathom why such a subspecialty even exists (?) Anyway, I am completely ignorant about colo-rectal surgery. Perhaps someone more knowledgable can address this.

Back to your original question regarding "Why do general surgery?" The answer is simple, in order to subspecialize (plastics, vascular, CT, etc) you must first complete a general surgery residency (typically 5 years duration), then apply for fellowship training in the subspecialty you choose.

Hope this helps.

 

[ScottDoc]

so there is no vascular surgery residency? It is first general, then vascular fellowship?

But, does a general surgeon need to do a fellowship? Can they just practice? If so, what are the benefits?

 

[jmattwilson]

Of course general surgeons can practice. During residency you get exposed to every part of surgery (or at least most fields). General surgeons typically do abdominal cases with some peripheral stuff like breast cancers etc. One is definately more than competent as a general surgeon.

 

[jmattwilson]

Of course the pros and cons of any branch depend on many factors. In my opinion it is a matter of personal intrest in different organ systems of the body. If one loves the heart they gravitate to CT, if one loves the study of cancer surg onc is a nice fit, and if one is interested in acute abdominal processes general surgery fills the bill. Just my opinion though. Pay is less for general surgery but it certainly isnt shabby about 100k more than the average primary care doc.

 

[Pir8DeacDoc]

don't forget that your friendly general surgeon will handle such cases as lap choles, appendectomies, and the more benign stuff such as lipomas and sebaceous cysts. There really is a lot of opportunity for a general surgeon, especially in a small area that isn't flooded with subspecialists.

 

[Blade28]

From http://medicine.wustl.edu/~residenc/outside/spec/GS_info.html :

The fellowships available after General Surgery (5-7 years) include:

*Cardiothoracic Surgery
*Colorectal Surgery
*Pediatric Surgery
*Surgical Critical Care
*Surgical Oncology
*Transplant Surgery
*Vascular Surgery
*Critical Care Medicine
*Hand Surgery

 

[droliver]

Other ones available would also include:
Plastic Surgery
Hepato-billiary
Laparoscopic
ERCP
Non-cardiac thoracic
Burns
Head & Neck

 

[jmattwilson]

Other ones available would also include:
Plastic Surgery
Hepato-billiary
Laparoscopic
ERCP
Non-cardiac thoracic
Burns
Head & Neck

Dont forget Breast surgery. It is a 1 year fellowship subset of surg onc.

 

[jmattwilson]

Dont forget Breast surgery. It is a 1 year fellowship subset of surg onc.

I phrased that wrong it isn't a subset of surg onc, it is a free standing fellowship.

 

[Celiac Plexus]

... the newish, so-called, "endocrine surgery" fellowship. These are starting to spring up. It seems like it's all about the parathyroid, thyroid, breast, and adrenals.

 

[ScottDoc]

Sooooooo,

If a person does not wish to do a fellowship then a general surgeon can still go to a field they enjoy? If they want a fellowship then they are specializing, right? Bottom line: you have 2 surgeons to choose from for a surgery on the neck. One is general and the other is a "specialist head and neck surgeon." When does one select the generalist and when does one select the specialist? Also, can a general surgeon just focus on certain areas of the body and be just as effective as a specialist?

I may be over-thinking this.........

 

[Pir8DeacDoc]

Of course a person can choose to focus on one area of the body and stick with that. One general surgeon at my facility does the vast majority of the endocrine cases that come through the door. He'll do a thryroid, parathyroid, or whatever else need be done. I don't know enough about this to be sure how one decides whether to have an ENT or a general surgeon do this surgery.

 

[Celiac Plexus]

My take on the whole fellowship question is this: all fellowships are not equal.

For example, some fellowships train you extensively for specialty surgery. For example, transplant surgery, plastics, advanced laparoscopy, CT... These fellowships take your general surgery training several steps beyond what you learned. In these fellowships, you are really learning new skills that general surgeons probably did not aquire in their residency.

Other fellowships are more of a marketing tool. For example trauma surgery, "breast fellowship", colorectal, surgical oncology, and perhaps even vascular (although with the new emphasis on endovascular treatment this probably belongs in the above category)... These fellowships give you much more exposure to fields that are already covered pretty well in the general surgery residency. So, if you plan on an academic career, then you probably need a fellowship in these fields as both a pedigree, as well as additional training to strengthen your skills. And if you plan to go into private practice as say a "critical care" surgeon, or a "breast" surgeon, a fellowship is more of a marketing tool. You can say, I am a "colorectal" surgeon and get more referrals for colon CA. Or you can say, I'm an "endocrine" surgeon and get a lot more referrals for thyroid and parathyroid cases that might otherwise go to an ENT guy. Though really, if you went to a balanced surgery program and got balanced experience, then you should already be able to handle these surgeries, and be able to build your practice accordingly whether you have a "breast fellowship", or not.

Just my take on the whole fellowship thing... It seems like the trend is for people to do more and more training though...

 

[aphistis]

Other ones available would also include:
Plastic Surgery
Hepato-billiary
Laparoscopic
ERCP
Non-cardiac thoracic
Burns
Head & Neck

At a functional level, what's the difference between an ENT and a GS with a head & neck fellowship? For that matter, why create the fellowships in the first place, except for a shortage of available ENTs (which doesn't seem likely considering the competitiveness of ENT)?

 

[droliver]

At a functional level, what's the difference between an ENT and a GS with a head & neck fellowship? For that matter, why create the fellowships in the first place, except for a shortage of available ENTs (which doesn't seem likely considering the competitiveness of ENT)?

Your question presupposes that ENT's are the only ones doing head & neck CA when there's a fair amount done by other Surgeons (General Surgery, Plastics, Peds Surgery, & to a lesser extent OMFS). The head & neck fellowships for General Surgery are mostly for people interested in doing more training in salivary gland and floor of mouth tumor resections. It's a bit more rare then in the past, but some General Surgeons & Plastic Surgeons still have pretty large series of parotid tumors going. (I'm doing a parotid tumor I found next week incidentally which is about the 4th one I'll have done b/w General & Plastic Surgery)

 

[Pilot Doc]

At a functional level, what's the difference between an ENT and a GS with a head & neck fellowship? For that matter, why create the fellowships in the first place, except for a shortage of available ENTs (which doesn't seem likely considering the competitiveness of ENT)?

To start, ENT is so competitive because the ENT powers that be constrain the resident output artificially keeping competition down (a la urology and derm.) But that's another story.

There isn't really a head & neck GS fellowship, not to my knowledge anyway. GS does no serious head work (cancer whacks, etc). The main neck procedures are thyroids, parathyroids and carotid endarterectomies (CEA's). CEA is a general/vascular operation with no significant ENT presence. The same holds for some more esoteric vascular work. The neck endocrine work is the only major component of a specialized GS neck training, which is more likely to be a comprehensive endocrine fellowship covering adrenals, insulinomas, etc. This is an area rather like ortho spine /neuro spine. To answere your question: on a functional level there is not much difference between an ENT and a GS neck endocrine surgeon. Why create the fellowships? Because they are interesting, well compensated, low morbidity surgeries!

 

[Docgeorge]

There was a really good paper by Dr. Hiram Polk and friends from Louisville in Anals of Surgery (March or May of this year) that tracked graduates of the program from 1970 onward they had some interesting finding about specialization. They found that most of the graduates were practicing broad based GS, even a lot of the fellowship trained folks stated that they still practiced broad based GS.

 

[droliver]

There isn't really a head & neck GS fellowship, not to my knowledge anyway. GS does no serious head work (cancer whacks, etc).

Actually there still are a few H&N fellowships outside of ENT around, but there's not a great deal of interest in it (both for pragmatic & financial reasons). There's a lot of general surgery history involving resection of Parotid masses and squamous cell CA of the lips/oropharynx/tongue. As the field of ENT has matured in recent years, fewer General & Plastic Surgeons do it (or have an interest in doing it). Some people still do get pretty heavy exposure to it depending upon your training program & a very few will go on & subspecialize in it. Actually talking to a number of ENT's, fewer of them have any interest in doing many H&N tumors & funnel them to tertiary centers ("Too much time, too little $$$")

 

[Bovie9]

I will enter med school next year and want to know if a general surgeon can do foot and ankle. If yes, then why don't I just go into Ortho (the training time seems to be the same amount of time)? I know, first get through school, but I am planning ahead. So to get back to the question... why do general surgery at all? Same for a colo-rectal surgeon vs. general surgeon what if/any benefits are there to doing general when one can specialize? It seems ambigous, doesn't it? (I am not saying anything bad, I am just naive I guess). Thanks all.

FYI- Podiatry can also do foot/ankle.

 

[thenavysurgeon]

its interesting that head and neck cancer issues are still heavily tested on the gen surg written and oral boards...reflects the now historic presence of general surgeons in this field...

 

[neutropeniaboy]

Head & Neck

...ugh!

 

[neutropeniaboy]

Actually talking to a number of ENT's, fewer of them have any interest in doing many H&N tumors & funnel them to tertiary centers ("Too much time, too little $$$")

I'd agree that the interest has dwindled, but the field has devoted followers. I think the biggest things directing people away from head and neck are reimbursements and an increasing number of studies that demonsstrate that chemo/XRT has the same outcome as surgery. Who'd want the scars/deformity? And, who in good conscience would offer a surgery for a condition that could be treated equally with medicine?

 

[Leforte]

I think the surgery vs. radiation dilemma is common in several areas, and many people still choose to take the knife route...

For instance, why would someone undergo a modified radical mastectomy when they can get a lumpectomy and radiation with the same long-term outcome? Yet many women choose to undertake the MRM instead of breast preservation treatment.

Perhaps the same is true in H&N - people choose their own treatment course among several options, especially if the outcomes are same.

 

[neutropeniaboy]

I think the surgery vs. radiation dilemma is common in several areas, and many people still choose to take the knife route...

I think it may be the "quick and easy" answer to the issue. Instant gratification. As we all know, surgery has definitive results -- immediately. People see that as a solution to the problem. As much as you can tell them about doubling time and the fact that their tumor has been there for probably for years, they seem to have no concept of "micrometastases" or whatnot.

Not to start a flame war about what's worse than losing a breast, but women can get implants and wear baggy shirts, etc. It's hard to cover up the fact that you've had your larynx taken out and have a bulky pectoralis flap up there...what would you choose? Lose the box or XRT? I'd choose the latter.