Medicine and Procedures

[docscience]

A bit of background: I am from Nigeria and hope to practice there one day (after I pay off all my loans...lol)

I would like to see patients, diagnose them with their ailments and try to cure with medication, lifestyle change, or surgical procedure.
I would love to do a surgical procedure on a patient who didn't have the money to take care of his/her appendicitis by going to another town (poor infrastructure, not enough money to travel, etc.)

What is a good specialty to go into for this lifestyle? A lifestyle where one can do medicine and procedure for the common folk...

Is this too idealistic for a career in medicine? Too idealistic to have good training for this? (just an M2 here)

Thanks for the ideas and thoughts.

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[sirus_virus]

A bit of background: I am from Nigeria and hope to practice there one day (after I pay off all my loans...lol)

I would like to see patients, diagnose them with their ailments and try to cure with medication, lifestyle change, or surgical procedure.
I would love to do a surgical procedure on a patient who didn't have the money to take care of his/her appendicitis by going to another town (poor infrastructure, not enough money to travel, etc.)

What is a good specialty to go into for this lifestyle? A lifestyle where one can do medicine and procedure for the common folk...

Is this too idealistic for a career in medicine? Too idealistic to have good training for this? (just an M2 here)

Thanks for the ideas and thoughts.

You can always join the red cross.

 

[Mr hawkings]

A bit of background: I am from Nigeria and hope to practice there one day (after I pay off all my loans...lol)

I would like to see patients, diagnose them with their ailments and try to cure with medication, lifestyle change, or surgical procedure.
I would love to do a surgical procedure on a patient who didn't have the money to take care of his/her appendicitis by going to another town (poor infrastructure, not enough money to travel, etc.)

What is a good specialty to go into for this lifestyle? A lifestyle where one can do medicine and procedure for the common folk...

Is this too idealistic for a career in medicine? Too idealistic to have good training for this? (just an M2 here)

Thanks for the ideas and thoughts.

I think IM plus maybe a subspecialty/fellowship (endocrinology, Infectious dz etc) would be your best option. You can also join some of the many organizations that do medical missions to third world countries and go on some of these missions. This will give you an idea about what it takes to work under those difficult conditions.
I would also strongly consider taking an away rotation in 4th year to study tropical medicine in Nigeria. The disease processes that may be considered "zebras" here are often the "horses" in other countries so i would not make that transition without recievening some pripr training from the folks there.
One last thing is that dont expect to make a whole lot of money doing this. I know you said you would do it after your loans are paid off but who knows when that would be. You'll be suprised at how fast time flies. the next thing you know, you are 10 years away from retirement and have not done what you set out to do.

Good luck.

 

[LadyWolverine]

If you truly hope to be a "jack of all trades" as you have described, I think you are going to be sorely disappointed with the practice of medicine in the US. Medicine here is so uber-specialized that it's rare to find someone who "does it all." You can do primary care, but then you can't be a surgeon. You can become a surgeon, but then you're unlikely to have the IM/primary care focus that you seem to desire.

The true generalist is a dying breed here in the US, unless you are willing to go into something like EM or FM, and/or practice in a rural/underserved area. There are some specialties that will allow you to do a blend of medicine and surgery, but they will be specialized in another way (e.g. by patient population, as in OB/Gyn).

I am currently in the process of coming to terms with this fact. It's a bit depressing to realize that you really can't "do it all," or even "do most of it." (It's very difficult to have continuity of care and really take care of a cohort of whole patients in this setting, when you are constantly consulting other specialists and making referrals for stuff that you *could* do, but can't because somebody else does it better, has more specialized training, and gets sued less.) The kind of doc that I originally wanted to be has been hopelessly outmoded by today's uber-specialization. I'm not saying that this is a negative thing - only that there have been trade-offs in the conquest of better medicine.

 

[smq123]

I would like to see patients, diagnose them with their ailments and try to cure with medication, lifestyle change, or surgical procedure.
I would love to do a surgical procedure on a patient who didn't have the money to take care of his/her appendicitis by going to another town (poor infrastructure, not enough money to travel, etc.)

What is a good specialty to go into for this lifestyle? A lifestyle where one can do medicine and procedure for the common folk...

Is this too idealistic for a career in medicine? Too idealistic to have good training for this? (just an M2 here)

Your best bets are probably trauma surgery, emergency medicine, and family medicine. None of them are perfect, but they all have some aspect of what you are looking for.

Your rotations as an MS3 will help you decide what you think fits your needs best and (more importantly) what appeals to you the most.

I think IM plus maybe a subspecialty/fellowship (endocrinology, Infectious dz etc) would be your best option.

Endocrine and ID are possibly the worst options for the OP, since these are two of the least procedural specialties in internal medicine. While I understand where you were coming from, the OP specifically mentioned procedures (especially things like appendectomies), and those are some of the least procedurally oriented fields out there.

 

[masterofmonkeys]

One of my family medicine attendings told me there are still 'dinosaur' family practice residencies out there where you can get trained in basic surgeries. He personally does some of them, including lap choles, appendectomies, and other 'simple' surgeries.

Heck, there are FP docs in this state that do joint replacements.

No idea which programs are best for that though.

 

[Tired]

\
Heck, there are FP docs in this state that do joint replacements.

If you know of hospitals that credential FPs to do arthroplasty, please give me their names so I can make a billion dollars off the lawsuit.

 

[MattD]

I'm vaguely recalling a residency track I heard about once that was something along the lines of a 'rural' family medicine program (maybe it was a fellowship?) that included significant enough surgical training that the 'middle-of-nowhere' doc could pop out an appendix or other simple yet emergent type cases. I can't for the life of me remember what this was called or if it's even something that still exists though. Might wanna do some searches on it and see?

 

[mjl1717]

If you know of hospitals that credential FPs to do arthroplasty, please give me their names so I can make a billion dollars off the lawsuit.

Yes, the guy is eyebrow raising and funny!

 

[mercaptovizadeh]

There's a surgeon at my medical school that did EM, trauma surgery, and a critical care fellowship. That's the broadest I've heard.

You could probably get really broad by doing several residencies, some of which might accept certain intern year rotations that overlap with other residencies. For instance, you could IM or peds (or both) and then EM or IM and/or peds and then surgery (although that sounds insane).

Realistically, you won't be able to practice more than one specialty or subspecialty in the US. In developing nations, however, you could certainly use all your skills. I know a surgeon (he's a Christian missionary) who was trained in cardiothoracic surgery but he does practically any emergent and many non-emergent surgeries (OB/Gyn, urology, orthopedic surgery, abdominal/general surgery, head and neck surgery, some plastic - no ophtho or neuro), and he also does a bit of internal medicine and pediatrics as well (they're short on primary docs at the hospital). He's a superb "generalist surgeon" - but he could never do the entire range of what he does in the US. Incidentally, he didn't do residencies in all those fields, but other missionary doctors there trained him in many of those surgeries and I guess he picked up basic medicine on the side.

 

[AggieSean]

I'm vaguely recalling a residency track I heard about once that was something along the lines of a 'rural' family medicine program (maybe it was a fellowship?) that included significant enough surgical training that the 'middle-of-nowhere' doc could pop out an appendix or other simple yet emergent type cases. I can't for the life of me remember what this was called or if it's even something that still exists though. Might wanna do some searches on it and see?

I don't know if they still do it, but I have several friends who went through FP at JPS in Fort Worth and they would do hernia repairs, choles, appys with the attending in the corner, not scrubbed in.

 

[docscience]

There's a surgeon at my medical school that did EM, trauma surgery, and a critical care fellowship. That's the broadest I've heard.

You could probably get really broad by doing several residencies, some of which might accept certain intern year rotations that overlap with other residencies. For instance, you could IM or peds (or both) and then EM or IM and/or peds and then surgery (although that sounds insane).

Realistically, you won't be able to practice more than one specialty or subspecialty in the US. In developing nations, however, you could certainly use all your skills. I know a surgeon (he's a Christian missionary) who was trained in cardiothoracic surgery but he does practically any emergent and many non-emergent surgeries (OB/Gyn, urology, orthopedic surgery, abdominal/general surgery, head and neck surgery, some plastic - no ophtho or neuro), and he also does a bit of internal medicine and pediatrics as well (they're short on primary docs at the hospital). He's a superb "generalist surgeon" - but he could never do the entire range of what he does in the US. Incidentally, he didn't do residencies in all those fields, but other missionary doctors there trained him in many of those surgeries and I guess he picked up basic medicine on the side.

That would be ideal...a "generalist surgeon" who could scrub in for most procedures...that would be the coolest type of surgeon to be in my opinion.

 

[Dirt]

You all seemed to miss the fact that he wants to do this back in Nigeria. Things are probably a bit different there.

I would say go for an IM/EM residency.

 

[TMP-SMX]

FP. You can still do some training in surgery during residency at some places.

 

[mercaptovizadeh]

That would be ideal...a "generalist surgeon" who could scrub in for most procedures...that would be the coolest type of surgeon to be in my opinion.

The advice he gave me was:

1.) The two pillars of medicine are internal medicine and surgery. [Implication for developing countries work: consider these residencies in particular]

2.) General things are generally needed. [Implication: don't become a pediatric cardiac anesthesiologist or radiologist who specializes in PET scans if you want to work in a developing country]

I'd say that a lot of EM is triaging and there are definitely overlaps with IM/surgery.

If you really want the most general background, it would be dual residencies in Med-peds (4 years) and then general surgery (5 years). Compare this 9 years of training to that of a neurosurgeon (7). Once you're in the field, you can try to pick up more medical knowledge and learn additional surgeries/subspecialty techniques relevant to other fields. Obviously, certain things you won't be able to do, like eye or brain or complicated vascular surgeries, but this would give you the broadest background.

Remember that for surgery you need a full hospital available. Medicine/pediatrics, especially in developing countries, allows you to be much more mobile.

 

[docscience]

so could one say that subspecialists like urologists/radiologists in general/ENTs etc. are less effective in developing nations?
as far as establishing a public health effort?

would a med/peds residency be the best kind of specialty to pursue?

i would love to do simple procedures that don't require a full fledged operating room...any other ideas?

when would the best time to go back and visit be? after third year so that i have an idea of a hospital system? the economics side? the diagnostic side...etc.

i wonder how they diagnose in developing countries where physicians don't have access to a lab...or do they? they must have a microscope right?

 

[TMP-SMX]

Why would you do Med/Peds when you can save time and do FP? Plus you would have more flexibility to choose what you want to study.

 

[FatPigeon]

Why would you do Med/Peds when you can save time and do FP? Plus you would have more flexibility to choose what you want to study.

Because doing "FP" brings you up to about the same level of knowledge that my gossipy aunt has after reading "women's health" magazine over the past few years. Their "procedures" boil down to wart freezing and punch biopsies, which a creative person could do just as effectively at home with an ice cube and some scissors (with about the same outcome).

If the OP wants to do real medicine, I'd say IM is the minimum. It sounds like he/she is really interested in having a broad foundation, and that, in my opinion, leaves only IM or general surg as the starting (or ending) point.

 

[mercaptovizadeh]

Why would you do Med/Peds when you can save time and do FP? Plus you would have more flexibility to choose what you want to study.

How could you possibly have the same expertise in medicine if you did it in a residency where you're expected to know how to do procedures, Ob/Gyn, and peds, as someone who was fully devoted exclusively to IM in the same timeframe? There's a reason FPs can't do medicine fellowships, except maybe geriatrics - they just don't know enough.

If he wants to work in the developing world, he will be dealing with infectious diseases to a level that perhaps even "only" IM/peds would not suffice in the absence of ID training, much less FP.

Where I worked, it was clear that the cardiothoracic surgeon knew more medicine than the FPs and was better able to deal with infections (not just post-op, mind you) and even Ob/Gyn than the FPs were.

The OP seems a bit conflicted. He likes procedures but wants mobility. That's pretty hard to find. Lots of IM fellowships do procedures that are more mobile than a fixed OR, but that's specialization and that's not what he's looking for.

Again, probably the best would be something general like IM and/or peds and/or general surgery and then he can pick up some procedures he feels comfortable with from other Western physicians working in the field. Once he identifies a target area to work in, he will be better able to identify what's feasible in terms of surgeries, procedures, diagnostics, etc.

 

[TMP-SMX]

You can do a 6mo-1yr fellowship in OB, Sports Med (probably not that helpful), Geriatrics (not helpful), and limited ED training after FP. Of course it is true that ID would be important overseas but FP may have more diversity of training than IM. Though I've seen HIV fellowships for FP which is kind of interesting.

Though Med-Peds is a good option to then go on to ID if you want a diverse training in adult, pediatric, and infectious medicine for 6 years. Though ID certainly is not that procedure based so the OP may find the training lacking.

 

[smq123]

Because doing "FP" brings you up to about the same level of knowledge that my gossipy aunt has after reading "women's health" magazine over the past few years. Their "procedures" boil down to wart freezing and punch biopsies, which a creative person could do just as effectively at home with an ice cube and some scissors (with about the same outcome).

How could you possibly have the same expertise in medicine if you did it in a residency where you're expected to know how to do procedures, Ob/Gyn, and peds, as someone who was fully devoted exclusively to IM in the same timeframe? There's a reason FPs can't do medicine fellowships, except maybe geriatrics - they just don't know enough.

I think both of you are being unfair to FPs.

- If the OP truly wants a broad background in order to effectively work in a developing country, FP is a much better start. He will be exposed to pediatrics (which you don't get in IM) and pregnant women (which you don't get in IM). There are a lot of senior IM residents who can't even do a decent pelvic exam.....at least you get a lot of exposure to women's health in FP. And who would YOU rather have around when your wife starts going into labor - an IM (who hasn't delivered a baby since 3rd year of med school), or an FP (who needs a certain # of deliveries in order to graduate)?

- The reason why FPs can't do medicine fellowships may have something to do with knowledge base....but it also has a LOT to do with the fact that such specialization directly contradicts the FP philosophy. FPs are generalists - the AAFP mission statement basically says as much. If they were to specialize in cards, pulm, or GI, then they wouldn't be generalists anymore.

- FPs DO a lot of procedures besides just wart freezing. As I mentioned before, they learn a lot of OB/gyn procedures - diaphragm placement, IUD placement, SVDs. Some may even be doing Essures, although I can't be 100% certain.

- Since FPs have to rotate through surgery, OB, and peds, they actually seem to have an idea of when/how to consult. The IM people at my institution are pretty good, but some of their surgery or OB consults are just... Even at other institutions that are IM powerhouses, their residents will consult for the weirdest things. I mean, a 3 AM "stat" consult for "vaginal bleeding" (which turned out to be her monthly period ), or a 5 PM consult for a "stat Whipple" is kind of ridiculous.

 

[LadyWolverine]

a 5 PM consult for a "stat Whipple"

lol

 

[Firebird]

this is a very simple answer...

do a year of internal medicine, then do surgery. your yr of medicine will give you at least some skill in primary care and managing chronic medical conditions. your five years in surgery will enhance this, plus give you surgical skills to perform procedures. just realize that by doing this, you'll not be trained well enough to pick out the internal medicine zebras, nor the endemic infxs dz that you'll see abroad

 

[cpants]

I think general surgery is the way to go. It will be extremely valuable to patients in your home country to have a talented well trained surgeon on hand. While medicine is important, and I'm sure they need that too, a lot of the medicine you will learn in the US just won't be applicable. It seems like half of American medicine these days is controlling lab and BP numbers in fat people, and then treating them for diseases caused by them being fat, drunk, and full of tobacco. Not exactly the stuff you will see in a third world country.

 

[docscience]

i have thought about that
i wasn't exposed to too much medicine in nigeria (i was young also)...I am only an M2, but it seems like we use a lot of lab. medicine.

what "kind of medicine" do you think I will see in third world countries? tropical medicine specialty like diseases?

so ideally would you say a tropical medicine residency + general surgery (obviously without logistics in mind)

 

[cpants]

You will see a lot of infection, nutritional deficiencies, and then all the normal stuff that people will get anywhere: genetic disorders, endocrine problems, cancers (different types though), blood disorders, etc. You will see a lot of problems at advanced stage which we rarely see in the western world. You will have a lot less fat person problems: cards, stroke, joint issues, gout, diabetes, etc.

I don't know if there is an ideal route to take, but something like general surgery with a lot of independent study for the other stuff could be a good choice. I don't know much about tropical medicine, but I'm sure that would help a lot with all the crazy bugs you are likely to see in the third world.

 

[docscience]

p.s. i can't find "tropical medicine" in the frieda residency search

 

[mercaptovizadeh]

p.s. i can't find "tropical medicine" in the frieda residency search

I spent 2-3 months in a very poor densely populated country probably with an infrastructure comparable to Nigeria's.

What struck me was how much neoplasia there was, oftentimes freakier than what you'd see here because people would put off seeing the doctor until late (one case comes to mind: lady with a huge thyroid tumor which had almost completely occluded the trachea when she came in). So, tumors is clearly not something rare in non-industrial societies, which was a silly impression I had had. In developing countries, surgery may be a suitable therapeutic modality, especially since there are a lot of benign tumors, but chemotherapy and radiotherapy is unlikely to be feasible.

There was definitely a lot less of the autoimmune/allergy/asthma diseases, or if people had them it was not severe enough for them to seek help. I don't think I saw any cases of asthma, connective tissue disease, or allergies.

There was a ton of trauma. People hit by speeding trucks, people knocked over into fires, people who were crushed by walls falling on them because of elephants on the rampage. Lots of amputations, lots of burn victims. Again, something that surgery takes care of.

There was a good amount of kidney and gall bladder stones. A good amount of nutritional issues and anemias. (Pre-)Eclampsia.

I did not see any stroke or heart attack patients while I was there, which is quite remarkable.

And finally, and perhaps most importantly, infection. Everything ranging from "flesh-eating bacteria" (necrotizing fasciitis) and fulminant Hep A to hepatic encephalopathy due to Hep B, peritonitis, malaria, pyomyositis, wound infections, tuberculosis, worms, etc. I did not see any lrabies, leprosy, plague, dengue, or yellow fever (Asia doesn't have that one), but I'm sure that in places like Nigeria you might and probably will see cases of that.

So, in summary, I would probably say the most useful specialties are IM and then an ID fellowship or general surgery, with surgery probably being the more versatile of the two, because you could probably pick up some ID stuff on the side, whereas an ID can't do surgery.

Just make sure that where you're going has facilities. Knowing general surgery is useless in the absence of imaging, equipment, OR, etc. If you confirm that that's availiable, you could have the greatest impact as a surgeon.

 

[docscience]

wow...thanks for that post
that is a lot to think about...thank you

now i have to figure out how to be a tropical medicine/surgeon

lol

 

[Dr Serendipity]

Hi DocScience, regarding your search for a specialty that does office-based procedures and medicine, I think the other posters have given good advice and described a broad range of specialties that may fit you.

In addition to choosing a medical specialty you may want to consider doing additional training in public health, specifically in infectious disease and tropical medicine. There are masters programs in public health designed specifically for doctors interested in practicing medicine in developing countries. These programs are invaluable in teaching you to deal with problems you will never or rarely treat in the US. i.e. cholera, TB, malaria, dengue, etc. I know that Tulane University has an accelerated masters program in public health for interested doctors. Emory University also has a masters program in public health with close ties to the Center for Disease Control which is excellent. You can also check these forums in the public health section.

Best of luck to you!

 

[scube]

That would be ideal...a "generalist surgeon" who could scrub in for most procedures...that would be the coolest type of surgeon to be in my opinion.

general surgery is the last man of all seasons in medicine. (stole this wording from elsewhere on SDN, ) FP can learn how to do surgeries but most don't have time to or get to do enough of them to be really good at them so they don't. I wouldn't be comfortable do a procedure non-emergency that I didn't do quite often.

THis is from an urologist I talked to recently. he is board certified in gen surg and urology.
General surgeons can get malpractice insurance that covers them treating patients medically. Surgery specialists cant get that coverage. He had to give up the medical side of his practice.

 

[AmoryBlaine]

You will see as you get into residency that the body of knowledge in medicine today is such that you need to just pick one field and go with it. Ideas about doing multiple residencies or trying to be two different kinds of doctor will probably fail. Idealism is not going to keep very many people going through a second residency when they are an intern again at 32 taking q4 ICU call while making 45k after turning down job offers in their first field.

The age of the generalist has passed and it is not coming back. To be a generalist today (EM, IM, FP) doesn't mean that you "manage everything." It means that you manage a limited number of things and appropriately consult. You will see in your training that you are asking pretty specific questions of your consultants and doing so because you are tapping their expertise.

If you are not a genius who requires no sleep you will see that getting good at one field is challenging enough.