Interested in surgery, but missing the workups

[fiznat]

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Hey all,

I'm a MS3 currently on my surgery rotation. I'm liking it a lot and I could potentially see myself in this field, but I am a little concerned about something I've noticed. It seems that, at least at this hospital, the surgeons perform very little (if any) workups of their patients. Our patients are almost always consults that have been completely differentiated already, and it seems our job (here) is limited to simply doing the indicated surgery and making sure they don't get sick right afterwards. I'm finding myself a little unsatisfied by that.

Is this how it is everywhere?

 

[Jay K]

Hey all,

I'm a MS3 currently on my surgery rotation. I'm liking it a lot and I could potentially see myself in this field, but I am a little concerned about something I've noticed. It seems that, at least at this hospital, the surgeons perform very little (if any) workups of their patients. Our patients are almost always consults that have been completely differentiated already, and it seems our job (here) is limited to simply doing the indicated surgery and making sure they don't get sick right afterwards. I'm finding myself a little unsatisfied by that.

Is this how it is everywhere?

yes and no

some things are quite clear cut - appendicitis? cholecystitis? fracture? subdural hematoma? free air in the peritoneum? small breasts?

Surgeons, particularly on call, don't relish having to do an extensive workup, particularly if it isn't necessary; They want to operate, "fix it" and move on.

Certain fields may require more "work up" such as oncologic, pediatric cardiac or plastic reconstructive surgery to name just a few. Of course there are complex cases in all surgical fields which require more work up and/or planning prior to surgery, but day in and day out many of the cases surgeons do are routine.

There is the routine in every field, and efficiency and expediency rules the day, particularly in private practice.

 

[CrileDO]

yes and no

some things are quite clear cut - appendicitis? cholecystitis? fracture? subdural hematoma? free air in the peritoneum? small breasts?

Surgeons, particularly on call, don't relish having to do an extensive workup, particularly if it isn't necessary; They want to operate, "fix it" and move on.

Certain fields may require more "work up" such as oncologic, pediatric cardiac or plastic reconstructive surgery to name just a few. Of course there are complex cases in all surgical fields which require more work up and/or planning prior to surgery, but day in and day out many of the cases surgeons do are routine.
There is the routine in every field, and efficiency and expediency rules the day, particularly in private practice.

Not having to work up patients is one of the reasons that I loved surgery.

 

[blue2000]

So it can depend. On the one hand, I see a lot of patients who have clear cut surgical issues that need a pre-op visit, an operation and a post op visit. On the other hand, I see a lot of patients who either have a) a radiologic finding (gallstones) and some sort of symptom complex (vague abdominal discomfort) and it's up to me to determine whether these things add up to needing an operation. I also see patients who have had a minimal work up and when they come to see me it's clear that they need a lot more work up before going to the OR -- for instance a patient with known lobular breast cancer, who have suspicious micro calcifications distant from the mass, who need more of a work up to determine extent of disease, and then once I do that I open a Pandora's box of other issues that need to be dealt with. Also, on call there is a certain amount of "there is something wrong with the patient and I need a second set of eyes to see if I'm missing something," which can be mildly frustrating if there are no surgical issues and I don't know what's going on either.

 

[ACSurgeon]

Hey all,

I'm a MS3 currently on my surgery rotation. I'm liking it a lot and I could potentially see myself in this field, but I am a little concerned about something I've noticed. It seems that, at least at this hospital, the surgeons perform very little (if any) workups of their patients. Our patients are almost always consults that have been completely differentiated already, and it seems our job (here) is limited to simply doing the indicated surgery and making sure they don't get sick right afterwards. I'm finding myself a little unsatisfied by that.

Is this how it is everywhere?

General surgery has just as much workup as medicine does. We might not spend as much time verbalizing everything, but every disease has a differential diagnosis with vastly different management plans. Once we know what the diagnosis is, we start treating. Medicine on the other hand, after you know what the diagnosis is, you spend an extra 30-60 minutes discussing what it's not, and why, and how you would treat all the other things that it's not.

A lot of "workups" in medicine are more of a shot gun approach, labs/imaging studies/and consults and then you wait and see what gives you the answer.

 

[JayDoc06]

Guess what is waiting at the end of your glorious medical workup rainbow?

You get to consult someone else who knows more about it than you to actually take care of it.

 

[fiznat]

Guess what is waiting at the end of your glorious medical workup rainbow?

You get to consult someone else who knows more about it than you to actually take care of it.

At the end of who's glorious medical workup rainbow? What?

 

[JayDoc06]

The "workup" you are referring to that you are missing is just shotgun medicine that usually turns up either nothing or once something is diagnosed, someone else will get to take care of it. That's all.

"Our patients are almost always consults that have been completely differentiated already"

Also, a guiding principle in my practice is that the referring diagnosis is ALWAYS WRONG and I have to prove to myself that what I am being told is going on is actually the diagnosis. I bet at least 50% of what I am asked to see turns out to not be the referring diagnosis at all. Either the test results are misinterpreted or the correct test/study/procedure has yet to be done.

Or you rotate at an institution with brilliant referring physicians.

 

[fiznat]

The "workup" you are referring to that you are missing is just shotgun medicine that usually turns up either nothing or once something is diagnosed, someone else will get to take care of it. That's all.

"Our patients are almost always consults that have been completely differentiated already"

Also, a guiding principle in my practice is that the referring diagnosis is ALWAYS WRONG and I have to prove to myself that what I am being told is going on is actually the diagnosis. I bet at least 50% of what I am asked to see turns out to not be the referring diagnosis at all. Either the test results are misinterpreted or the correct test/study/procedure has yet to be done.

Or you rotate at an institution with brilliant referring physicians.

Okay, thanks. I'm not sure what's with the aggression as this is (I think) a pretty reasonable question considering the fact that I'm just a 3rd year med student trying to feel things out for the first time. I'm not in any position to judge the relative value of the internist's vs. the surgeon's workup, or who is performing "shotgun medicine" vs real medicine or whatever. I worked for a single month on a surgery rotation (my very first), and I noticed we took out a lot of gallbladders that fell into our lap with the standard lab work and imaging already done. That's all.

 

[LucidSplash]

Okay, thanks. I'm not sure what's with the aggression as this is (I think) a pretty reasonable question considering the fact that I'm just a 3rd year med student trying to feel things out for the first time. I'm not in any position to judge the relative value of the internist's vs. the surgeon's workup, or who is performing "shotgun medicine" vs real medicine or whatever. I worked for a single month on a surgery rotation (my very first), and I noticed we took out a lot of gallbladders that fell into our lap with the standard lab work and imaging already done. That's all.

There are a lot of things on both the "medicine" and surgery sides of the fence that are bread-and-butter, uncomplicated, etc. A lot of gallbladders look that way and I can see how you might get that idea only rotating on surgery for a month. I would say that the "medicine" equivalent is DKA or newly diagnosed CHF for our medicine colleagues - the standard initial algorithmic treatment is going to apply a lot of the time, but not always; there will be more complicated cases. The gallbladder is one of the most frequent general surgery cases performed so it's going to seem pretty simple to see/treat from a surgical perspective if you only rotate with us for a month. As a real-life example, admitted a man in transfer from OSH today who looked like a fairly standard case of biliary pancreatitis with an obstructed CBD (came to us as the transferring facility did not have GI/ERCP availability). Would expect him to go down the ERCP-stent-lap chole route. Except when they did the sphincterotomy for the ERCP, they evacuated a huge clot of blood and now he has a diagnosis of hemobilia... I've done 4 or 5 "standard" gallbladders this week on our acute care service but we've also seen/treated/done acute diverticulitis, c. diff colitis, diverticular stricture resulting in colonic obstruction, dislodged PEG tube, PEG PEG PEG TRACH TRACH TRACH, perforated PUD, intractable bleeding from a gastric ulcer that ended up as a total gastrectomy, RPLND for mop-up after treatment for seminoma, appendectomies for various indications, IVCFs, hernias of various shapes and sizes and locations (open and laparoscopic), etc etc etc.

There are plenty of workups in surgery, they just tend to be a little more focused than those of our medicine colleagues, IMHO.

 

[mercaptovizadeh]

Hey all,

I'm a MS3 currently on my surgery rotation. I'm liking it a lot and I could potentially see myself in this field, but I am a little concerned about something I've noticed. It seems that, at least at this hospital, the surgeons perform very little (if any) workups of their patients. Our patients are almost always consults that have been completely differentiated already, and it seems our job (here) is limited to simply doing the indicated surgery and making sure they don't get sick right afterwards. I'm finding myself a little unsatisfied by that.

Is this how it is everywhere?

Old school surgery probably did a lot more workup, but then again old school IM also did a lot more PE maneuvers to figure out things (rather than pan-lab testing). It's part of the problem/advances (your pick) with the hyperspecialization of medicine and new technology. There are plenty of patients you will see on IM who have already been partly worked up in the ED.

If you want an A-Z clinical experience (i.e. see the patient at initial presentation, perform all the workup and then give meds/perform procedure/perform surgery), then rural 3rd world medicine practicing as a general surgeon is your best bet.

 

[JayDoc06]

Looking back I can understand that I may have come across as aggressive, let me try to explain my perspective.

I find it interesting that surgeons are perceived as technicians and most cases just appear with their diagnosis, operation occurs, patient better, move on. As a third year medical student don't mistake ordering tests for a thoughtful "workup". I get called by medicine all the time for idiopathic GI hemorrhage, thousands of dollars in and no one has done a rectal exam for the bleeding hemorrhoid. So who worked the patient up? The one who ordered tests or the one who evaluated simple/common things and used a packet of lube and a glove? Conversely, I stare out the window of my office frequently trying to figure out what to do with patient X. I suppose that is one of the benefits and drawbacks of surgical sub specialization- complex problems and you are at the end of the algorithm- you have to figure it out AND physically follow through on your treatment plan. Surgery is very cerebral. I would argue that all technical errors are really errors in judgment. I do not know any above average surgeons who are not also above average intelligence.

Relying on the workup of others, trusting referral diagnoses and doing what is asked of you without thinking about a patient yourself is a fool's game, even for gallbladders. Yes, I agree that many things are nice and clean and placed on a sliver platter for the surgeon, but many are not.

I want young students, especially the ones who enjoy surgery (perhaps yourself) to not be fooled into thinking that becoming a surgeon means you no longer "work a patient up".

 

[dienekes88]

Hey all,

I'm a MS3 currently on my surgery rotation. I'm liking it a lot and I could potentially see myself in this field, but I am a little concerned about something I've noticed. It seems that, at least at this hospital, the surgeons perform very little (if any) workups of their patients. Our patients are almost always consults that have been completely differentiated already, and it seems our job (here) is limited to simply doing the indicated surgery and making sure they don't get sick right afterwards. I'm finding myself a little unsatisfied by that.

Is this how it is everywhere?

You are presuming that the diagnosis made by the other team is the correct diagnosis. This is not always the case.