M4 - Considering switching from IM to surgery

[okudasai]

Hey all, wanted some advice on my situation. I submitted my ERAS app for IM, but have had this doubt ("what if?") at the back of my mind that I might better suited to surgery instead. Some practical questions: since I've already submitted, I am assuming this means that if I did end up deciding to do surgery, I would be delaying starting residency by a year since it is far too late to submit another ERAS for surgery at this point, especially considering that I have no LORs for surgery, and it would take a few months at the very least to get enough LORs to apply.

Some background on why I am doubting IM: I was interested in EM for a long time (premed scribe, EMT, loved my EM rotations in med school etc) but switched to IM for better flexibility through fellowships, more complex patients, continuity, and less social complaints (relatively speaking compared to EM that is). Started thinking about surgery after some reflection - I like working with my hands, I like being able to fix problems acutely (probably why I liked EM so much), and my personality might be a better fit for surgery. I will be honest and say that I did not enjoy my surgery rotations in terms of being in the OR, though I think my enjoyment was probably clouded by the surgery attendings I was assigned to. I am currently on a MICU rotation and while its not uninteresting, its not necessarily super enjoyable, though I concede that could just be academic medicine in general being dull.

If this all sounds like I am just experiencing the common doubts that come along with residency apps, or if this is something I should pursue more (attempting to shadow some surgeries, potentially doing a surgical rotation, etc.) would love some advice either way.

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[SkullbaseFoLyfe]

Its a tough situation honestly. The most concerning statement that youve made is that you didnt really enjoy being in the OR. Most surgical applicants find that this is the most enjoyable part of their rotations, and despite the associated negatives (longer residency, long hours, tougher work environment, etc...) feel drawn to the operating room. However, I must say that Ive always found it challenging that medical students are asked to decide on a career in surgery without ever really having done any operating. You must be able to imagine yourself as the surgical resident and decide that that is what you want.

Its also kind of concerning that you dont enjoy your MICU rotation and state that you think academic medicine is dull. Im not in medicine, but I would think that most students applying into IM find academic medicine enjoyable. I would think community practice would be much more routine and therefore more 'dull'.

Seems like youve got some stuff to figure out. What kinds of rotations do you have set for the rest of the year? Its tough that youre thinking about this so late. Not sure what the logistics of applying into a specialty after initial ERAS submission are. I remember someone in my med school applied into medicine and then decided to submit neurology apps a few months later and ended up matching neurology. Im assuming they used the same LOR, but maybe not? I would think very hard before deciding on a career in surgery. Based on your statements you seem like someone who would realize that surgery is not for them once you started residency.

 

[okudasai]

Its a tough situation honestly. The most concerning statement that youve made is that you didnt really enjoy being in the OR. Most surgical applicants find that this is the most enjoyable part of their rotations, and despite the associated negatives (longer residency, long hours, tougher work environment, etc...) feel drawn to the operating room. However, I must say that Ive always found it challenging that medical students are asked to decide on a career in surgery without ever really having done any operating. You must be able to imagine yourself as the surgical resident and decide that that is what you want.

Its also kind of concerning that you dont enjoy your MICU rotation and state that you think academic medicine is dull. Im not in medicine, but I would think that most students applying into IM find academic medicine enjoyable. I would think community practice would be much more routine and therefore more 'dull'.

Seems like youve got some stuff to figure out. What kinds of rotations do you have set for the rest of the year? Its tough that youre thinking about this so late. Not sure what the logistics of applying into a specialty after initial ERAS submission are. I remember someone in my med school applied into medicine and then decided to submit neurology apps a few months later and ended up matching neurology. Im assuming they used the same LOR, but maybe not? I would think very hard before deciding on a career in surgery. Based on your statements you seem like someone who would realize that surgery is not for them once you started residency.

Thank you very much for your response! I should have been more specific, during my surgery rotation I was entirely focused on everything but the actual surgery. I was extremely focused on EM at the time and did not consider surgery to be a possibility, and spent most of my OR time day dreaming. I enjoyed being able to suture or tie knots and would be completely engaged during those moments, but otherwise spent most of my time wishing I could go home. With regards to the MICU, I enjoy the medicine aspects, such as diagnostic or management challenges, speaking to families and patients, admissions, doing physical exams and seeing the changes in the exam, labs and imaging as patients get (hopefully) better as a result of our interventions, etc. It is mostly that I don't view rounds as a very efficient way to learn or at least the way they are run at the MICU I am rotating at, and I zone out pretty quickly trying to pay attention to a presentation with info that could be gathered from just looking at the EMR.

I should add that a primary reason for my disillusionment with my MICU rotation is that at the hospital I am at, the ICU team does essentially no procedures. My understanding is that this is pretty unusual for even chest tubes to be done only by thoracic surgery, thoracentesis by IR only, etc. and that most ICU docs do a decent amount of procedural work in addition to medicine. Hopefully that explanation adds some context to my thought process.

My current plan is to contact the PD at my home program to see what my options are, if any, and also some of my surgery attendings to see if I could come scrub into some cases without the pressure of a shelf exam.

 

[LucidSplash]

I enjoyed being able to suture or tie knots and would be completely engaged during those moments, but otherwise spent most of my time wishing I could go home.

Pretty much everyone likes being able to suture or tie knots. But if you truly spent most of your time wishing to go home, I would not apply to surgery. That is not a good prognostic sign of suddenly being happy as a surgery resident or surgery attending. There’s another thread that was just posted about a surgery intern not even 3 months into intern year who has decided to go into radiology instead and also wants to try to switch to IM internship if they can this year. I think there is a heavy chance that could be you if you decide to apply to surgery.

 

[okudasai]

Pretty much everyone likes being able suture or tie knots. But if you truly spent most of your time wishing to go home, I would not apply to surgery. That is not a good prognostic sign of suddenly being happy as a surgery resident or surgery attending. There’s another thread that was just posted about a surgery intern not even 3 months into intern year who has decided to go into radiology instead and also wants to try to switch to IM internship if they can this year. I think there is a heavy chance that could be you if you decide to apply to surgery.

I think that you are almost certainly correct about me and surgery. It makes sense that some level of our procedures are enjoyed by everyone; I would have to enjoy much more than just that to consider a life in the OR. I think I might still do some shadowing just for my own peace of mind; worst case I would learn something useful, as I'm sure internists take care of surgical patients on occasion. Thank you for all you insight!

 

[TypeADissection]

The idea of being a surgeon is often far more alluring than the actual reality of being a surgeon. This is the crux in my opinion. Regardless, doesn't mean you can't still go on and have a kick-ass career in something outside of surgery. Just remember that it's just a job at the end of the day. Cheers.

 

[Lem0nz]

To start - I echo the other surgeons opinions here. From a purely practical standpoint its too late to switch now and you will be somewhat handcuffed in your applications by taking a year off and/or going through with IM and attempting to switch after a year of residency (that would be painful). There are a myriad of surgical type fellowships out of IM that will be satisfying if that's what you want to do without taking a risk you were very, very wrong and did in fact hate surgery that whole time.

That out of the way - I hated my time in MS3/MS4 as a medical student in surgery. Hated. Despised. I fell asleep holding retractors and thought surgical residents at my home institution were catty AF and pretty selfish (there were some exceptions that were my heroes, but they were the minority). But I spent three months in pre-med working with a general surgeon first assisting him throughout the city in non-academic settings where he let me really actually assist him and 'do surgery' so I knew that the feelings you're describing and the feelings I had were not my actual opinion of what surgery would one day be once I was an attending. So... a little validation. But without having that experience I wouldn't gamble on hating it because if you're wrong it will not only be a colossal waste of your time and earning potential, but it will be an extremely painful experience because of the volume of work a surgical intern will endure (and you may not be really doing all that much operating that year, either).

I write all of that mostly just to assure you that you might not be crazy and your feelings may be accurate, but there are so many really cool things out of IM in interventional cards, GI, pulm/CC, etc. that you can be very happy and not second guess yourself.

 

[okudasai]

To start - I echo the other surgeons opinions here. From a purely practical standpoint its too late to switch now and you will be somewhat handcuffed in your applications by taking a year off and/or going through with IM and attempting to switch after a year of residency (that would be painful). There are a myriad of surgical type fellowships out of IM that will be satisfying if that's what you want to do without taking a risk you were very, very wrong and did in fact hate surgery that whole time.

That out of the way - I hated my time in MS3/MS4 as a medical student in surgery. Hated. Despised. I fell asleep holding retractors and thought surgical residents at my home institution were catty AF and pretty selfish (there were some exceptions that were my heroes, but they were the minority). But I spent three months in pre-med working with a general surgeon first assisting him throughout the city in non-academic settings where he let me really actually assist him and 'do surgery' so I knew that the feelings you're describing and the feelings I had were not my actual opinion of what surgery would one day be once I was an attending. So... a little validation. But without having that experience I wouldn't gamble on hating it because if you're wrong it will not only be a colossal waste of your time and earning potential, but it will be an extremely painful experience because of the volume of work a surgical intern will endure (and you may not be really doing all that much operating that year, either).

I write all of that mostly just to assure you that you might not be crazy and your feelings may be accurate, but there are so many really cool things out of IM in interventional cards, GI, pulm/CC, etc. that you can be very happy and not second guess yourself.

Thank you so much for your perspective! I enjoyed alot of the non OR work that interns did and did not mind it. I am currently in a pulm/CC rotation and I most enjoy the procedural, active parts of like putting in lines, codes/rapids, etc; I was interested in doing EM for a long while before IM. I like the medicine management aspects as well, but probably not as much as the acute, hands on stuff.

Sadly every time I observe in the OR I find my attention drifting unless I force myself to pay attention, conversely whenever I am more involved such as with suturing/suctioning I am more engaged and interested. My guess is that this sort of "half interest" will not be sufficient to sustain me throughout all of my surgery training and beyond.

In conclusion, I think as everyone has already mentioned, IM will likely satisfy my desire for more procedures and hands on work with the number of fellowship options it offers. I might still do some trauma surgery shadowing or even a rotation to put my mind at ease. Worst case, I would take a gap year and reapply though I think that is pretty unlikely at this stage. I imagine that applying to prelim/categorical surgery programs by late October or early November would be far too late to match anywhere?

 

[LucidSplash]

but there are so many really cool things out of IM in interventional cards, GI, pulm/CC, etc. that you can be very happy and not second guess yourself.

Plus OP can then spend their life feeling superior to surgeons for having made a smarter choice. 🤣 I am mostly joking, I have amazing proceduralist colleagues and we help each other out all the time. But there are definitely a few on this board and other social media that like to gloat about lifestyle of those specialties over surgery.

 

[Lem0nz]

Plus OP can then spend their life feeling superior to surgeons for having made a smarter choice. 🤣 I am mostly joking, I have amazing proceduralist colleagues and we help each other out all the time. But there are definitely a few on this board and other social media that like to gloat about lifestyle of those specialties over surgery.

I've been pleasantly surprised to find my proceduralists are incredibly protective of me. They definitely all have better lifestyles than me but they are generally actively working to minimize how often I have to touch people and go out of their way to diffuse things or deal with them before it gets to me. I wonder how much of it is this institution, how much of it is the people, and how much is just dumb freaking luck to be with a good bunch of doctors who get it.

But yea they have way more time off than me. XD One of our interventional GI guys works every other week. I'm like... how tf did you even get them to agree to that contract?

 

[Lem0nz]

I imagine that applying to prelim/categorical surgery programs by late October or early November would be far too late to match anywhere?

Yea its too late. Don't try. You will at best have so-so success at a low tier program and at worst will just go unmatched with no good backup plan.

 

[okudasai]

Yea its too late. Don't try. You will at best have so-so success at a low tier program and at worst will just go unmatched with no good backup plan.

Thank you for the info; so on the off chance I decide on surgery I would have to take a gap year is what it sounds like if I wanted to have any real chance of matching.

 

[LucidSplash]

Thank you for the info; so on the off chance I decide on surgery I would have to take a gap year is what it sounds like if I wanted to have any real chance of matching.

If you decide to do this, the best chance would be to NOT graduate. Take a research year to delay graduation. Your chances of matching to surgery are exponentially better as student than as someone who graduated and then took a research year. Many schools will allow you to take a research year and maintain student status.

 

[LucidSplash]

I've been pleasantly surprised to find my proceduralists are incredibly protective of me. They definitely all have better lifestyles than me but they are generally actively working to minimize how often I have to touch people and go out of their way to diffuse things or deal with them before it gets to me. I wonder how much of it is this institution, how much of it is the people, and how much is just dumb freaking luck to be with a good bunch of doctors who get it.

But yea they have way more time off than me. XD One of our interventional GI guys works every other week. I'm like... how tf did you even get them to agree to that contract?

Yes definitely. Again this is MOSTLY a joke. My proceduralist colleagues are generally really great. People IRL tend to be better than online but online everyone is all about how much smarter they are than surgeons for choosing a proceduralist specialty over surgery. But it’s a little like being in love and getting married. You know it might not be the best logical decision fiscally, but it’s not always about that for everyone.

 

[Lem0nz]

But it’s a little like being in love and getting married. You know it might not be the best logical decision fiscally, but it’s not always about that for everyone.

And let's be real - when it comes to sexy time, surgery puts out WAY more than medicine. That's not even an opinion, its just a fact. Definitely worth carrying your metaphor to its complete conclusion. The sex is better in surgery. It definitely isn't all about the money.

 

[TypeADissection]

And let's be real - when it comes to sexy time, surgery puts out WAY more than medicine. That's not even an opinion, its just a fact. Definitely worth carrying your metaphor to its complete conclusion. The sex is better in surgery. It definitely isn't all about the money.

I'll have what @Lem0nz is having. In fact, make that two!

My wife will often comment about the mistress that is vascular surgery. After some of the weeks I've had, my wife acts more like the mistress with how little I see her during those times.

 

[LucidSplash]

I'll have what @Lem0nz is having. In fact, make that two!

My wife will often comment about the mistress that is vascular surgery. After some of the weeks I've had, my wife acts more like the mistress with how little I see her during those times.

In fellowship, I was mentioning to someone that I was going to miss a dinner for an on-call case and one of my attendings overhead and said something like “oooooo, who is that your new beau?”

The dinner was a rep dinner with the other trainees. As I told that attending “let’s be serious, I am dating my fellowship. Adding in anyone else would be too demanding.”

2 years into practice, kinda the same. But the dating field for a female vascular surgeon is an entirely different conversation. 😂

 

[TypeADissection]

But the dating field for a female vascular surgeon is an entirely different conversation. 😂

Citing Lem0nz Law: All female vascular surgeons are hawt.

Ergo, your struggles must clearly be related to your suitors not being able to keep your interest or becoming too emotionally clingy. That's when you hit the secret bat signal so that someone can page you and thus providing you a clean exit strategy.

 

[ACSurgeon]

Thank you for the info; so on the off chance I decide on surgery I would have to take a gap year is what it sounds like if I wanted to have any real chance of matching.

OP- had you been a third year describing everything you described, I would have said surgery is most likely not for you, but what the heck do a sub-I in July so that you never wonder “what if.” As a fourth year post-ERAS saying everything you’re saying, I’m entirely sure you’re having normal level doubt as someone about to commit to one specialty. You’ve done good picking something with many fellowships so you’re far from stuck. Stick with IM and find a fellowship you like and don’t look back.

Too many red flags in your post to name all, but some of the ones I didn’t see highlighted by my esteemed colleagues:

- Emergency medicine was your original main interest. Students who think EM and surgery are at all related usually don’t have a good grasp on what it means to train in surgery or become a surgeon. Students with a strong interest in EM because of the EM procedures would be 100x better suited for IM/procedural fellowship or IR.

- day dreaming about leaving as a student. As a student, you’re young, naive and ambitious. If you couldn’t be disillusioned into thinking it’s so awesome to be there for 60-70 hours/week as a student you’ll hate your life as a junior resident constantly pushing 80 hours a week.

- timing and making decisions in haste. Not a good career move in my opinion.

As an ICU doctor myself, I can tell you that my medical ICU friends do percutaneous tracheostomy, bronchoscopy, intubations, central lines, arterial lines, chest tubes, thoracentesis, paracentesis, put sutures to stop bleeding, and are just overall amazing smart doctors. Your ICU experience is far from typical.

GI and interventional cardiology crank through procedures in much more efficient settings that the operating room. Doesn’t seem as glamorous but when your passion is to work with your hands, it’s frustrating when you spend an hour operating and two hours waiting for the OR to turnover. So, don’t dismiss these IM based procedural specialties.

At the end of the day, you’ll never know what any specialty would have been like. You’ll only truly know the specialty you’re in and even then, you’ll only know what your experience is. You can always wonder “what if”, but you should be content knowing had you done something else, you would only know that specialty and potentially still wonder, “what if”.

 

[LucidSplash]

Citing Lem0nz Law: All female vascular surgeons are hawt.

Ergo, your struggles must clearly be related to your suitors not being able to keep your interest or becoming too emotionally clingy. That's when you hit the secret bat signal so that someone can page you and thus providing you a clean exit strategy.

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[okudasai]

OP- had you been a third year describing everything you described, I would have said surgery is most likely not for you, but what the heck do a sub-I in July so that you never wonder “what if.” As a fourth year post-ERAS saying everything you’re saying, I’m entirely sure you’re having normal level doubt as someone about to commit to one specialty. You’ve done good picking something with many fellowships so you’re far from stuck. Stick with IM and find a fellowship you like and don’t look back.

Too many red flags in your post to name all, but some of the ones I didn’t see highlighted by my esteemed colleagues:

- Emergency medicine was your original main interest. Students who think EM and surgery are at all related usually don’t have a good grasp on what it means to train in surgery or become a surgeon. Students with a strong interest in EM because of the EM procedures would be 100x better suited for IM/procedural fellowship or IR.

- day dreaming about leaving as a student. As a student, you’re young, naive and ambitious. If you couldn’t be disillusioned into thinking it’s so awesome to be there for 60-70 hours/week as a student you’ll hate your life as a junior resident constantly pushing 80 hours a week.

- timing and making decisions in haste. Not a good career move in my opinion.

As an ICU doctor myself, I can tell you that my medical ICU friends do percutaneous tracheostomy, bronchoscopy, intubations, central lines, arterial lines, chest tubes, thoracentesis, paracentesis, put sutures to stop bleeding, and are just overall amazing smart doctors. Your ICU experience is far from typical.

GI and interventional cardiology crank through procedures in much more efficient settings that the operating room. Doesn’t seem as glamorous but when your passion is to work with your hands, it’s frustrating when you spend an hour operating and two hours waiting for the OR to turnover. So, don’t dismiss these IM based procedural specialties.

At the end of the day, you’ll never know what any specialty would have been like. You’ll only truly know the specialty you’re in and even then, you’ll only know what your experience is. You can always wonder “what if”, but you should be content knowing had you done something else, you would only know that specialty and potentially still wonder, “what if”.

Thank you for your insight, your post pretty much convinced me to stay away from surgery at this point. I appreciate you pointing out all the red flags in my story, seeing them all laid out helped me make sense of my future a great deal.

 

[Lem0nz]

Citing Lem0nz Law: All female vascular surgeons are hawt.

Ergo, your struggles must clearly be related to your suitors not being able to keep your interest or becoming too emotionally clingy. That's when you hit the secret bat signal so that someone can page you and thus providing you a clean exit strategy.

In my n of 1 experience, all female vascular surgeons are hot AF.

But 95% of them were also super mean.

I'm willing to date all 100% of them to find the 5%. And also clearly am open to light abuse after having chosen this career.
@LucidSplash - I'm free Monday night after my specialty written boards are done. As long as you promise to show me at least as much respect as you would a PGY2 (heavily chastise me when I screw up but pretend like I might have some potential eventually) I'm in.

 

[LucidSplash]

In my n of 1 experience, all female vascular surgeons are hot AF.

But 95% of them were also super mean.

I'm willing to date all 100% of them to find the 5%. And also clearly am open to light abuse after having chosen this career.
@LucidSplash - I'm free Monday night after my specialty written boards are done. As long as you promise to show me at least as much respect as you would a PGY2 (heavily chastise me when I screw up but pretend like I might have some potential eventually) I'm in.

Super mean or just direct like the average surgeon but doing it while female? 😬

So far none of my residents have cried so at least I’ve got that going for me. 😂

Poor OP we have really hijacked their thread. My apologies!

 

[Lem0nz]

Super mean or just direct like the average surgeon but doing it while female? 😬

Fair question. Actual answer is 50/50 - there are some who are just mean, and some who just have zero patience and are so direct you feel like they slapped you with words for no apparent reason.

We definitely came through for OP, we're allowed to derail at this point.

 

[LucidSplash]

Fair question. Actual answer is 50/50 - there are some who are just mean, and some who just have zero patience and are so direct you feel like they slapped you with words for no apparent reason.

We definitely came through for OP, we're allowed to derail at this point.

So essentially about the same personality distribution as male attendings. 😁 🤷🏼‍♀️

 

[Lem0nz]

So essentially about the same personality distribution as male attendings. 😁 🤷🏼‍♀️

I always found male vascular attendings to generally all fall into some sort of weird camp of "IDGAF but you're really stupid please stop speaking to me." Like, they aren't chill per say but they just feel that they have no control over anything and just hate all of it and have resigned themselves to a life of misery. Whereas the ladies will rage against the dying of the light and take every fight with brass knuckles ready to go.

 

[LucidSplash]

I always found male vascular attendings to generally all fall into some sort of weird camp of "IDGAF but you're really stupid please stop speaking to me." Like, they aren't chill per say but they just feel that they have no control over anything and just hate all of it and have resigned themselves to a life of misery. Whereas the ladies will rage against the dying of the light and take every fight with brass knuckles ready to go.

I wonder how much of my perspective comes from the fact that I only have integrated vascular surgery residents, and the occasional VS fellow, rotate with me. I imagine if I had a mix of reluctant general surgery residents who hated my specialty and only the occasional one who was interested, I would be a little more irritable. And I’m plenty irritable, just generally not with the residents. 😂

 

[Lem0nz]

I wonder how much of my perspective comes from the fact that I only have integrated vascular surgery residents, and the occasional VS fellow, rotate with me. I imagine if I had a mix of reluctant general surgery residents who hated my specialty and only the occasional one who was interested, I would be a little more irritable. And I’m plenty irritable, just generally not with the residents. 😂

I don't think it would be any different. Gen surg residents fall into two camps - want to be vascular surgeons, hate vascular surgery. But we all recognize the need for us to suffer through vascular (both you as attendings and us as residents) and in general we're pretty serious about getting whatever you as an attending need us to do done to your satisfaction so we have to interact as little as possible and in return you guys usually let us off the hook when we do not go above and beyond for pretty much... anything. If all I do during an EVAR is get femoral vessel exposure and then you fiddle with a bunch of wires and some giant ass tube thingy we're both pretty happy. I'm never going to do that in real life and its quite frankly faster for both of us for you to do it and creates less pain. I'll still take the pieces of vascular that are translatable to general surgery super seriously (like the vessel exposure piece) and the attendings were entirely acceptable of that mentality. And when they have a vascular inclined resident then they went all out with the teaching.

I would say that was 95% of all GS resident/vascular attending interactions. There was the occasional person who hated vascular so much they did a **** job because they had the entitled "I'm not going into vascular and this is a waste of my time" attitude. Those kids got dragged over the coals and did not have a good month. Attendings turned them into piñatas. Bwahahaha. Idiots. Was their own damn fault.