Hand Surgery fellowship after General Surgery.

[digitalcascade]

I've followed this thread for a couple years, felt compelled to insert my experience:

GS @ privademic hospital
2 yrs research (PGY3/4) in peripheral nerve
Currently in hand fellowship at Kleinert

General surgeons continue to have a narrow window of opportunity into Hand. I had about 9 interview offers for fellowship. I'm 8 months into fellowship, and have had 4 reasonable interview offers for attending positions.

I think the attending job offers out there speak to the size of the window of opportunity. The ASSH job board has a fairly representative sample of the jobs out there; I'd arbitrarily guess they represent 30-50% of the current job openings. I'd estimate somewhere around 1-5% of the jobs out there are open to General Surgeons.

There are definitely many jobs out there for Orthopedic Hand Surgeons, I get notifications about ~1-2 new Ortho Hand job postings / week, all over the country, in desirable metros. I also get a similar volume of notifications for straight General Surgery jobs, even though I don't sign up for any of those notifications. My own offers (GS Hand) are either attractive jobs in college towns or less attractive jobs in bigger metros (Atlanta/NY). I know of several GS Hand Surgeons who went into solo practice because of the absence of groups that would take them.

I have a GS friend in hand fellowship and asked him if he would recommend Hand Surgery as a path for GS residents; his simple answer was "No," based on the difficulty of finding jobs after fellowship. I would answer, "only if you like Hand so much more than GS that you'd be willing to give up geographic options and pursue a career where you're always a second class citizen, in spite of a decade of training." For me, I really like Hand. =)

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[droliver]

Spent a number of long nights in the Kleinert Hand ER during residency in Louisville. Do not miss that bull**** at all.

As noted, not a lot of hand surgery jobs with groups that can't also do general plastics or orthopedics. Hand in community practice is almost 100% orthopedics in my metro area > 1M.

 

[Serous Demilune]

Wouldn't a gen surg with hand fellowship technically be qualified to take plastics call as well? Why wouldn't they be eligible for the plastics hand jobs (no pun intended)?

 

[Pir8DeacDoc]

Wouldn't a gen surg with hand fellowship technically be qualified to take plastics call as well? Why wouldn't they be eligible for the plastics hand jobs (no pun intended)?

Can't tell if serious. Do you understand that a plastic surgeon has at least 2 (and now 3) years of fellowship training? That would be liking saying a general surgeon could take call for a CT surgeon.

This further highlights the issue with a general surgeon being trained in hand. Who hires them? I've always been under the impression the general guys that do hand fellowship are trying to match into plastics fellowship. Otherwise how would you even be exposed to hand surgery as a general surgery resident to discover an interest? If you knew all along that's what you wanted then you should have done ortho or plastics. The entire thing is bizarre to me.

 

[Serous Demilune]

Can't tell if serious. Do you understand that a plastic surgeon has at least 2 (and now 3) years of fellowship training? That would be liking saying a general surgeon could take call for a CT surgeon.

This further highlights the issue with a general surgeon being trained in hand. Who hires them? I've always been under the impression the general guys that do hand fellowship are trying to match into plastics fellowship. Otherwise how would you even be exposed to hand surgery as a general surgery resident to discover an interest? If you knew all along that's what you wanted then you should have done ortho or plastics. The entire thing is bizarre to me.

There are fellowships for everything. Plastics, CT, vascular, trauma, colorectal, hepatobilliary. A general surgeon has to have training in all of these during residency. Otherwise what does a general surgeon even take call for in the first place?

 

[johndoe4]

Hi everyone,

This is my first post here on SDN, but I've used this as a resource for many years and I thank all the contributing authors for all the information and wisdom imparted on these forums. I am currently a general surgery resident at the PGY-2 level and have become very interested in hand surgery. I've begun research the prospect of matching into a hand surgery fellowship, and I've been disappointed to see that some programs do not want to train general surgeons. When I looked through the NRMP 2015 fellowship match data, there was only one program listed as "Hand Surgery (Gen Surg)" whereas the rest were listed as Hand Surgery (Ortho) or Hand Surgery (Plastics). Does that mean that there is only one program that accepts applicants who have completed general surgery residencies (Louisville) or am I mistaken? I don't know if anyone has such information, but is there a list of programs that accepts general surgeons for training? Thank you for your help.

 

[osler21]

Greetings all, I saw this thread and read through it with some interest as I am GS boarded and practice in hand surgery. I thought I might share my experience.

Med school and GS at prestigious intuitions, planning to go into transplant. PGY - 2 year realized that the planned path was marred by a good decade of being the downtrodden junior AFTER fellowship and furthermore I'd be doing the same 5 operations as well as a lot of vascular access over and over for an entire career. Looked around and saw hand as a potential fellowship. Liked the anatomy, the complexity and hardly gave it a thought as to what a career in it would be like. Hell, I had been ready to commit to a life as a transplant surgeon, figured I'd earn about the same amount of money and work about the same as a hand surgeon. Was I ever wrong about that.

GS institution was a major hand center and got to know the hand surgery leadership. Took research year and linked up with national hand guy and wrote papers for him and scrubbed a lot. Took AO basic course and started learning basic orthopedic surgery principals during GS chief year. In the mid 2000s matched at a highly regarded orthopedic hand fellowship.

It was really tough. Despite all of the above I really had no idea what I was doing and had to pass written and oral GS boards while at the same time learning orthopedic hand surgery. Some crossover from GS training but most of it indirect and involving immunity to stress. I learned a lot but to this day there are aspects of fracture care that the orthropods understand in ways better than I do because of their residency background. Did additional hand/ortho training in Europe.

Took job at hand group that soon merged with large Ortho group. First year did 600 cases. Currently do around 900 cases/year. At the time starting salary was 210K offered partnership at two years. Buy- in to partnership cost 500K. As full partner for last 6 years in large Ortho group in desirable metro half of income from professional fees and end up at the high end of national average for that part of income, the other half of income is passive income from groups ancillary services (MRI, operating rooms, therapy, etc..) Call is Q8, (every 8th weekend and one weeknight every other week,) start most days at 8 and rarely doing clinical work after 4pm. Do about 14,000 wRVU's year all UE to mid humerus. Don't teach except for some FP residents which is a bummer, would like to have fellows.

The key to hand surgery, what makes it such a phenomenal place to spend a surgical career, is something that I couldn't conceive of as a resident. Specifically, that the overwhelming number of cases can be done in an outpatient ambulatory surgery setting. Because of this if you own and run your own surgery center you can do lots of cases (it's not unusual for me and my partners to do 10 cases between 8 and 2) is a short time. A busy hand practice if you own your own OR's, MRI, hand therapy and are linked up with a large orthopedics group can produce an investment banker's income stream without the requirement of living in New York with work hours most financial services guys could only dream of. I find the surgery and patients interesting, get to have breakfast with my children and be done with work at 4pm most days. Once again the key is to own and run your own outpatient surgery center which allows rapid case turnover and to avoid hospitals at all costs.

In summary, it is possible to go from GS to hand surgery and build a life in medicine that is agreeable. However, while I'm happy to post my experience traveling from GS to orthopedic hand surgery this is a somewhat uncommon path and perhaps not easy to duplicate.

 

[wolverinepwns]

I'm bring this back. its been years since Ive posted here, I think I was pre-med. Anyways, Im currently a 4th year GS resident, and very interested in Hand surgery. I would sincerely prefer not to do a 3 year plastic fellowship just to do Hands (or to do a Hand fellowship). I was wondering there are any updated info on GS friendly hand fellowships? cheers.

 

[ram006]

I'm bring this back. its been years since Ive posted here, I think I was pre-med. Anyways, Im currently a 4th year GS resident, and very interested in Hand surgery. I would sincerely prefer not to do a 3 year plastic fellowship just to do Hands (or to do a Hand fellowship). I was wondering there are any updated info on GS friendly hand fellowships? cheers.

I had a similar thought process during general surgery but ended up in plastic surgery and will be applying to hand next year. The pathway from gen surg to hand is certainly no longer common or a "backup" if you don't match into plastics as it once was.

There are a few things to consider.

Your odds of matching into hand after surgery are not zero, but they are very slim. You're competing against of a bunch of Ortho/Plastics residents that get more exposure during their training and will likely have (or be perceived to have) a better foundation to build upon. Some programs won't review applications from general surgery. We get screened the same way IMGs get screened.

I contacted one program I thought I would have a shot at because the PD trained at my GS program. He flat out told me they are "no longer taking GS residents because they spend half the year teaching them how to do a proper hand exam." Actual quote. I remember it well. Regardless of whether or not that applies to you, that is the perception. The hand fellowship at my current institution has also, as a rule, stopped reviewing applications from GS residents.

You also have to consider the market after you're done training. Ortho dominates the hand market in both academics and private practice. How useful do you think a general surgery trained hand surgeon is to an Ortho group? In an hospital employed position you may be useful, but then how likely do you think it is a hospital will let you get out of taking gen surg call? Most people that like hand don't like perforated diverticulitis. You may be someone who is willing to do both but I can tell you from my own experience that once I got away from gen surg call I realized how brutal it was... and I'm still taking first call for hand throwing on splints at 2AM because the EM attending "doesn't feel comfortable doing it."

If you go into it knowing all that and still want to proceed, my best advice is to approach whoever is in charge of your home fellowship and become their guy/gal. Once you get your foot in the door, I'm certain you can find someone who has built a successful practice to model yourself after. I just wouldn't expect the offers to be flooding your inbox.

I know there are a couple plastics trained hand surgeons on this forum that chime in every now and then. But I'm not sure there is a gen surg trained hand surgeon. Do you know @Winged Scapula ?

 

[Winged Scapula]

I had a similar thought process during general surgery but ended up in plastic surgery and will be applying to hand next year. The pathway from gen surg to hand is certainly no longer common or a "backup" if you don't match into plastics as it once was.

There are a few things to consider.

Your odds of matching into hand after surgery are not zero, but they are very slim. You're competing against of a bunch of Ortho/Plastics residents that get more exposure during their training and will likely have (or be perceived to have) a better foundation to build upon. Some programs won't review applications from general surgery. We get screened the same way IMGs get screened.

I contacted one program I thought I would have a shot at because the PD trained at my GS program. He flat out told me they are "no longer taking GS residents because they spend half the year teaching them how to do a proper hand exam." Actual quote. I remember it well. Regardless of whether or not that applies to you, that is the perception. The hand fellowship at my current institution has also, as a rule, stopped reviewing applications from GS residents.

You also have to consider the market after you're done training. Ortho dominates the hand market in both academics and private practice. How useful do you think a general surgery trained hand surgeon is to an Ortho group? In an hospital employed position you may be useful, but then how likely do you think it is a hospital will let you get out of taking gen surg call? Most people that like hand don't like perforated diverticulitis. You may be someone who is willing to do both but I can tell you from my own experience that once I got away from gen surg call I realized how brutal it was... and I'm still taking first call for hand throwing on splints at 2AM because the EM attending "doesn't feel comfortable doing it."

If you go into it knowing all that and still want to proceed, my best advice is to approach whoever is in charge of your home fellowship and become their guy/gal. Once you get your foot in the door, I'm certain you can find someone who has built a successful practice to model yourself after. I just wouldn't expect the offers to be flooding your inbox.

I know there are a couple plastics trained hand surgeons on this forum that chime in every now and then. But I'm not sure there is a gen surg trained hand surgeon. Do you know @Winged Scapula ?

Excellent assessment.

The road to a general surgery trained hand surgeon has always been difficult but I totally agree with you now that it is becoming almost improbable for all the reasons you listed. I did a hand rotation myself as a PGY three and realized that the training and job opportunities we're going to be limited for me.

I'm not aware of any member at least not an active one who is a general surgery trade hand surgeon. Those that I know trained more than 10 years ago and as you and I both suspect, the training opportunities and job market have changed.

 

[VincentAdultman]

Going into hand from general surgery would just be an exercise in torture for both you and your hand mentors. It's like learning an entirely different skillset compared to what you did for the last 5 years save the couple months you may have done on a plastics rotation.

 

[digitalcascade]

Excellent assessment.

The road to a general surgery trained hand surgeon has always been difficult but I totally agree with you now that it is becoming almost improbable for all the reasons you listed. I did a hand rotation myself as a PGY three and realized that the training and job opportunities we're going to be limited for me.

I'm not aware of any member at least not an active one who is a general surgery trade hand surgeon. Those that I know trained more than 10 years ago and as you and I both suspect, the training opportunities and job market have changed.

Figured I should update my information at least to clarify your point about "not aware of any member who is a general surgery trained hand surgeon." That is definitely what I am. In the 3 years since fellowship, I've gotten serious job offers in: Tampa, Charlottesville, Scottsdale, North Jersey, Phoenix, and SE Michigan. I currently work in a metro area > 4 million population. I do consider myself super lucky to have a stable job in a big city in a field that I really enjoy, which is dominated by orthopods & sometimes plastic surgeons.

Objectively, there are about a dozen general surgeons that get certified in Hand Surgery every year (Google "absurgery hand pass rates"). I'm on a mailing list of 25 other general surgeons around the country that have specialized in Hand. So yes, there is a very small contingent. However, it is a nonzero population.

 

[Winged Scapula]

Thank you for the update. I was not aware we had any SDN members who have followed your path so I’m glad to be proven wrong.

Since it sounds like we’re the same metro area, you should come introduce yourself LOL

Figured I should update my information at least to clarify your point about "not aware of any member who is a general surgery trained hand surgeon." That is definitely what I am. In the 3 years since fellowship, I've gotten serious job offers in: Tampa, Charlottesville, Scottsdale, North Jersey, Phoenix, and SE Michigan. I currently work in a metro area > 4 million population. I do consider myself super lucky to have a stable job in a big city in a field that I really enjoy, which is dominated by orthopods & sometimes plastic surgeons.

Objectively, there are about a dozen general surgeons that get certified in Hand Surgery every year (Google "absurgery hand pass rates"). I'm on a mailing list of 25 other general surgeons around the country that have specialized in Hand. So yes, there is a very small contingent. However, it is a nonzero population.

 

[droliver]

Plastics going from 2 to 3 years for traditional models has pretty much killed the interest in becoming PGY 9's by doing additional fellowships.