How much other surgery do u learn?

[DoctaJay]

For a medstudent that is interested in missionary work, general surgery seems very appealing cause you're trained in surgery in most parts of the body and you know a respectable amount of medicine. But I was curious how much ortho, ent, neurosurg, urology etc. you learn in modern gsurg programs. Do you learn enough ortho to be comfortable pinning a bone or enough plastics to fix a cleft palate on the mission field? How comfortable do you guys feel with these other procedures?

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[Winged Scapula]

For a medstudent that is interested in missionary work, general surgery seems very appealing cause you're trained in surgery in most parts of the body and you know a respectable amount of medicine. But I was curious how much ortho

None.

We had an Ortho residency. I suppose we could have done a 1 month rotation with them.

ent

I did a month of ENT and loved it (had to go to an outside hospital as we have an ENT residency). Would I feel comfortable with the procedures? Probably not - at least in tems of surgical anatomy. The techniques are not that different, but the head is not something general surgeons spend a lot of time working on.

neurosurg,

None. We had a neurosurg residency. I don't know anyone who did an elective with them.

urology etc.

None, although a few of my colleagues did a Uro elective (it was well known as easy) and we did take call for their patients out at the VA, but never did the cases.

Do you learn enough ortho to be comfortable pinning a bone or enough plastics to fix a cleft palate on the mission field? How comfortable do you guys feel with these other procedures?

It HIGHLY depends on the program. The ABS has certain general surgery requirements you have to meet which don't leave a lot of time for electives. Would you feel comfortable pinning and plating a bone after a 1 month elective? Probably with the techniques (I did a ton in medical school) but won't you gain in that short period of time will be WHEN and exactly WHAT plates to choose, etc. That is what makes a surgeon.

A month of plastics is also unlikely to provide you enough exposure to do a complicated cleft. Remember also that most electives are done as a junior resident - hardly the time when the attendings are handing over the knife and allowing you to do the case. Some smaller programs might give you more exposure and more electives, but in the end, you have to spend MOST of your time as a GS resident on GS services and its subspecialties.

There are some rural general surgery fellowships, like the one at Cooperstown, where you get some Ortho, etc. exposure. You might consider this or realize that on mission trips, there are generally enough thyroids for you to do and enough plastics and ortho guys around to handle the other stuff.

 

[tussy]

I did some missionary work at the end of my fellowship. I do not have enough ortho to comfortably handle complicated fractures, however it was never an issue. Where i was working in rural africa the conditions were never clean enough in the OR to put any plates on a bone - the locals managed them all with traction and the outcomes looked good.

Cleft surgery is extremely complicated and should definitely be left to the experts.

I did a fare bit of gyne surgery (it's not that complicated at all) - i did a couple days with a gynecologist and learned C-sections and hysts. It really isn't difficult and i feel very comfortable with these procedures.

While i was in africa i did some burn contracture releases, a few simple flaps, lots of gyne, some urology. Most of the time i did good old-fashioned general surgery.

If you are doing missionary work you should stick to what you are comfortable doing - there is no shortage of work and best to stick to what you are capable of doing and do no harm. it's hard to turn people away, but better than screwing up because you are out working outside your training.

 

[mercaptovizadeh]

I shadowed a missionary GS who also did a CT fellowship. He didn't touch elective neuro or ophtho, nor did I see any emergencies in either of those two areas. He had other surgeons come out for a few months and teach him one-on-one what they knew from their fields. He did a lot of ortho, obs, gyn, and uro, along with some plastic and ENT. He didn't do a cleft lip repair because he referred the people to a hospital in the country's capital fully devoted to cleft lip and palate. But yeah, he looked very comfortable with uro, obs, gyn, and ortho - in fact he looked a lot more comfortable with ob/gyn than the FM docs.

 

[DoctaJay]

That doc sounds like he is pretty amazing. I would love to work with him

 

[dynx]

For a medstudent that is interested in missionary work, general surgery seems very appealing cause you're trained in surgery in most parts of the body and you know a respectable amount of medicine. But I was curious how much ortho, ent, neurosurg, urology etc. you learn in modern gsurg programs. Do you learn enough ortho to be comfortable pinning a bone or enough plastics to fix a cleft palate on the mission field? How comfortable do you guys feel with these other procedures?

Ortho: we have to rotate in ortho clinic. So I know enough to know what needs to be fixed. If I see a trauma with a fracture/dislocation I can confidently NOT call ortho for a non-op fracture that doesnt need follow up and I can pop a dislocated joint into place. Thats about it. I couldnt fix jack if my life depended on it.

ENT: para&Thyroids, neck dissections, parotids are all standard training at my program (and I think most places). I've done some oral cancer which is cool. Would not have any idea how to fix a cleft palate, but I bet I could learn if I wanted.

Neurosurgery: we manage all neurotrauma. Craniotomy, craniectomy, flap retrieval, bolts...all of it. Its a royal f*cking pain in the ass. Even if I wanted to I couldnt do this after graduating so whats the point?

Urology: Yep. again pretty much all of it. We don't call urology for ureter transections which are thankfully pretty uncommon. we cover urology clinic our intern year so you see it all. If you see it in clinic its your case in the OR. The Uro guys will call us for cases and most will just let you do the case. The trick is avoiding nephrecomies not trying to get them.

Ob/GYN - anyone could take out an ovary. One more hysterectomy and Im going to vomit. C-sections....again, more than I ever wanted.

 

[Pir8DeacDoc]

ENT: para&Thyroids, neck dissections, parotids are all standard training at my program (and I think most places). I've done some oral cancer which is cool. Would not have any idea how to fix a cleft palate, but I bet I could learn if I wanted.

pretty surprising that your program does neck dissections and parotids (though I do wonder about the extent of your parotids and neck dissections). I don't think that's a typical thing for a general surgeon to be doing though I only have the experience of medical school and my residency hospital. Hell here even the plastics guys send us all the parotids and they are much more familiar with facial anatomy than a general surgeon.

That's an awesome experience to have and should serve you well in your future if you have an interest in the neck.

 

[Winged Scapula]

dynx...do you have other residencies in house? Sounds like a wide ranging exposure at your program. We did no ob-gyn or Neuro (except that neuro trauma was technically admitted to the trauma service, but most stuff, except the boring things like TPN and vent management was managed by NSgy residents).

 

[JackADeli]

....ENT: para&Thyroids, neck dissections, parotids are all standard training at my program (and I think most places). I've done some oral cancer which is cool. Would not have any idea how to fix a cleft palate, but I bet I could learn if I wanted...

At my GSurgery program, there were no ENT residents. We did the parotids, neck dissections and some glossectomies. Attending wise, the neck dissections were done by either the surge-onc or ENT attendings with GS senior residents. The glossectomies were predominantly done by the ENT with or without senior GS residents.

The thyroids and parathyroids were well over 98% the realm of general surgery in my program. The referal pattern resulted in all these cases going to the general surgeons and rarely ENT. This was to such an extent that GS residents did not do or cover ENT when they did an occasional thyroid parathyroid. They just weren't as experienced or adept. A 30minute GSurgery thyroid could be a 4 hour tour de force in a field of hamburger meat with ENT & the nerve probe..... I remember covering one (the one & only) of these ENT occassions. The attending specifically insisted the GS resident have had experience with the GS attendings that did these cases. When we started, the ENT attending promptly got lost and asked me to take over and show him how the other attending did it. We argued a little.... The ENT attending then called in another ENT attending, they struggled, pointing at a lump of fat for over an eternity convincing themselves it was the parathyroid. They then remembered I was in the room, looked at me and asked if I concurred.... I did not. I pointed out exactly were the parathyroid adenoma actually was.... it was removed (I suggested they could leave the lump of fat alone), and we closed 20 minutes later (or ~4 hrs 20 minutes after starting). They left three drains in the neck!!!

There are programs and centers that I would without hesitation refer to ENT and avoid GS all together for some of these. Ultimately, it is the referral patterns and experience. My experience just allowed me more experience and training.

Clefts were done by plastics. GS residents were in on these cases too.

JAD

 

[Pir8DeacDoc]

Surprising that an ENT would get that "lost" in the neck. Hopefully this was just a bad day or something because that's pretty embarassing.

 

[JackADeli]

Surprising that an ENT would get that "lost" in the neck. Hopefully this was just a bad day or something because that's pretty embarassing.

Not surprising to me. Unfortunately, not "just a bad day". Was common for these ENT docs when they did the occasional thyroid/parathyroid procedure. As noted, if you don't do large or regular volume, it can be surprising. I would also say, if you become overly dependent on the nerve probe, anatomy can loose familiarity. This is the same with US guided central lines. You need deliberate practice. Keep in mind, if my review course memory serves me right, the vast majority of re-operations for missed parathyroid adenomas..... finds the adenoma in a "normal" anatomic position. I am biased in my experience.... The non-resected parathyroids were the result of the ENT team. The referal patterns sent 98+% para/thyroid cases to two GSurgeons. They (GSurge) did over 250 thyroids and 250 parathyroids per year. The ENT guys did 1-2/month divided amongst 4 ENTs. The GSurgeons always had a pristine & dry field. Ent seemed to always have a red field while studying the depths of the puddles with the nerve probe....

However, I recognize the performance is a result of practice and operative experience. In other centers, the outcomes, performance, and referal patterns are probably flipped oposite with ENT king and GSurge having difficulties.... I suspect an ENT that grads from a high volume experience and enters a high volume practice will have excellent outcomes and a marked advantage over GSurgeons.

JAD

 

[dynx]

dynx...do you have other residencies in house? Sounds like a wide ranging exposure at your program. We did no ob-gyn or Neuro (except that neuro trauma was technically admitted to the trauma service, but most stuff, except the boring things like TPN and vent management was managed by NSgy residents).

limited number of other residencies. neurosurg not included.

 

[njbmd]

We had a complete cadre of other surgical subspecialties, urology, ortho, neuro and ENT. Since they all started out with us during the PGY-1 year, I had plenty of opportunities to get to observe and participate in procedures with these folks during the PGY-2 and PGY-3 years. We all helped each other during the PGY-1 years and later, we also loved teaching each other procedures. Also, I did a microsurgery course during my research year that has proven to be invaluable which is work doing for anyone who might want to do missionary work and applicable across specialties.

When I was on trauma (PGY-2 year), I would put in ventrics with the neurosurgery folks and reduce fractures with the ortho folks. There was usually plenty of time for these types of things. Also, on my tours through the VA (PGY-1 and PGY-2), I had plenty of experience with the ortho, ENT and plastics folks because we were the only surgical residents present. The ortho attending loved having one of us scrub a case with him or spend some time with him in clinic (he was next door to our clinic anyway).

To the OP: If you are interested in missionary work, make contact with the folks at your residency/medical school who do this type of work. I know that a couple of folks at my residency had extensive experience in places like Ghana, Haiti, Gabon and Ethiopia/Eritrea. They were always willing to share experiences with us and always wanted to recruit us for work with their organizations.