Medicine in surgery?

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Wboyc

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I was wondering how much medicine is involved in the various surgical specialties. Do surgeons have the same medical capabilities as IM or its subspecialties? Or do surgeons have the ability to practice basic medicine only? Under what circumstances would surgery have to consult any of the medicine specialties, or would they be able to handle it themselves? I guess the gist of what I'm asking is, are surgeons the most complete doctor's out there? And if not, what other specialties would be considered some of the "best doctor's" out there, in terms of overall capabilities surgical or medical.

Sorry for the wave of questions, these have just been in my head and I haven't found sufficiently substantive answers. Not meaning to start a pissing match just genuinely curious. Thanks to any and all answers!

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I was wondering how much medicine is involved in the various surgical specialties. Do surgeons have the same medical capabilities as IM or its subspecialties? Or do surgeons have the ability to practice basic medicine only? Under what circumstances would surgery have to consult any of the medicine specialties, or would they be able to handle it themselves? I guess the gist of what I'm asking is, are surgeons the most complete doctor's out there? And if not, what other specialties would be considered some of the "best doctor's" out there, in terms of overall capabilities surgical or medical.

Sorry for the wave of questions, these have just been in my head and I haven't found sufficiently substantive answers. Not meaning to start a pissing match just genuinely curious. Thanks to any and all answers!

I think some surgical specialties are very capable with regards to complete perioperative medical management. Generally these are the specialties which do a lot of critical care/trauma training during residency, i.e. general surgery and neurosurgery. They're not managing things that require medical specialist interventions like MIs or doing their own dialysis, but they're probably not going to consult a hospitalist for BP control, pneumonia, or brittle diabetes.

On the flipside, the surgical specialists (ENT, urology, orthopedics) do very little critical care during residency (for me, one month as an intern) and are quicker to consult for "basic medicine". If a patient develops pneumonia, I can do cultures, start appropriate antibiotics (usually have to look it up), and start some interventions for the concomitant COPD exacerbation, but we'll probably end up consulting a hospitalist as well. I don't listen to lungs regularly, I don't know second and third line treatments for PNA, I don't have experience treating bad COPD, etc.
 
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I was wondering how much medicine is involved in the various surgical specialties. Do surgeons have the same medical capabilities as IM or its subspecialties? Or do surgeons have the ability to practice basic medicine only? Under what circumstances would surgery have to consult any of the medicine specialties, or would they be able to handle it themselves? I guess the gist of what I'm asking is, are surgeons the most complete doctor's out there? And if not, what other specialties would be considered some of the "best doctor's" out there, in terms of overall capabilities surgical or medical.

Sorry for the wave of questions, these have just been in my head and I haven't found sufficiently substantive answers. Not meaning to start a pissing match just genuinely curious. Thanks to any and all answers!

I think the most well rounded physicians are trauma/CC (I'm biased).
 
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A Heme/Onc colleague of mine once said "Medicine is knowing more and more about less and less"

Being considered the "best doctors" is a relatively immature and vain way to look at things.

We do basic management of patients' medical conditions preoperatively. A lot of times the medicine people lulz at the dumb things we rely on (my med school the common practice for hypertension was to start clonidine as first line agent!).

With the exception of critical care people, the further into the weeds of your specialty you get, the less the general medicine side of it interests you and the less you remember.
 
I was wondering how much medicine is involved in the various surgical specialties. Do surgeons have the same medical capabilities as IM or its subspecialties?
No. Internal medicine doctors go through a 3 year residency and their subspecialists go through multi-year fellowships. A 5-7 year residency in general surgery is not mainly medicine plus a little bit of OR time.

Or do surgeons have the ability to practice basic medicine only?
What part of any sort of well-practiced medicine is 'basic'? And if one think it's basic, it's because one doesn't know enough to think of the other possibilities.


Under what circumstances would surgery have to consult any of the medicine specialties, or would they be able to handle it themselves?
Nephrology - dialysis for ESRD patients in for other things or ESRD patients with AVFs/dialysis lines.
Heme/Onc- chemo for the surg onc patients or the steroids and orphan drugs for the ITP
ID - weird infectious with resistant bugs typically in complicated ICU patients
Pulm - on board with the lung transplants.
GI - they do ERCPs, EUS for pancreatic cancer here and long-term medical management of Crohn's and UC.
Cardiology - sick patients can have MIs, too.


I guess the gist of what I'm asking is, are surgeons the most complete doctor's out there?
Baloney. There is no 'super-human all-knowing doctor' who can practice everything from Neurosurgery to Rheumatology as they do on the TeeVee. All competent doctors are 'complete' doctors in their respective fields. That being said, some doctors know relatively less depth about a lot of topics (generalists), and some doctors know a greater depth about a fewer number of topics (sub-specialists).
General surgeons know how to practice general surgery which includes peri-operative medical management for a wide variety of conditions, but they are not whom you want to see as your PCP.

And if not, what other specialties would be considered some of the "best doctor's" out there, in terms of overall capabilities surgical or medical.
There is no 'best specialty' out there in terms of overall capability. There are generalists and specialists and each scoff at the other's breadth and depth of knowledge.
 
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Surgeons' medical management is basically on the level of duct tape. And I say that proudly. We can patch things up fairly well...but generally the goal is to get the patient to the real mechanic who will handle the long-term (i.e. post discharge) management plan. For example, I'm quite capable of managing acute post-op afib in the middle of the night. However, that does not stop me from getting their PCP/cardiologist on board the next day since they will be the ones to manage it as an outpatient. And medical specialties are also necessary when it comes to many advanced intervention as noted above (chemo, catheterization, dialysis, endoscopy in many situations).

So to answer the OP's question: No, surgeons' medical management abilities are not equivalent. I would say however that their ability to recognize when the opinion/expertise of a medical specialist is generally quite good. That may sound like an easy thing, but "knowing what you don't know" is one of the most challenging aspects of any medical specialty.
 
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I was wondering how much medicine is involved in the various surgical specialties. Do surgeons have the same medical capabilities as IM or its subspecialties? Or do surgeons have the ability to practice basic medicine only? Under what circumstances would surgery have to consult any of the medicine specialties, or would they be able to handle it themselves? I guess the gist of what I'm asking is, are surgeons the most complete doctor's out there? And if not, what other specialties would be considered some of the "best doctor's" out there, in terms of overall capabilities surgical or medical.

Sorry for the wave of questions, these have just been in my head and I haven't found sufficiently substantive answers. Not meaning to start a pissing match just genuinely curious. Thanks to any and all answers!


Surgeons loose all interest in general medicine soon out of Med school!!
In all seriousness, they are great at post op care( with better outcomes in some data) as long as things don't complicate( gets out of their comfort zone).

As a surgeon, your mind should be focused on the case in the OR at the time( sometimes hours at a time) and not be waiting for pagers from nurses from the Flor.

It's a simplistic way of putting it, but just know that not every post op patient gets a medicine consult.

I've never complained for a consult from a surgeon after I understood their position.
 
Can't speak for other specialities but in neurosurgery almost all programs require 4-6 months of critical care time. Our boards in general has a pretty decent amount of critical care medicine involved in it compared to other surgical sub specialities. I will admit, however, that the trauma/critical care docs in general have more expansive knowledge of general medicine.
 
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Simply put: a good surgeon is excellent at operating and doing procedures, and good at medical management.

A good medicine doctor is excellent at medical management. Depending on specialty/ experience, might be good or even excellent with a very limited number of procedures (eg EGD and colonoscopy for GI).
 
According to the ASA, complete perioperative medical management is becoming the realm of anesthesiologists, leaving surgeons to focus on what they love the most - cutting. In fact, the specialty may soon change its name to "anesthesiology/perioperative medicine." According to the ASA, nobody understands the physiologic insults to surgery better than anesthesiologists.

http://www.generalsurgerynews.com/V...d_id=552&i=February+2015&i_id=1148&a_id=29550
 
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According to the ASA, complete perioperative medical management is becoming the realm of anesthesiologists, leaving surgeons to focus on what they love the most - cutting. In fact, the specialty may soon change its name to "anesthesiology/perioperative medicine." According to the ASA, nobody understands the physiologic insults to surgery better than anesthesiologists.

http://www.generalsurgerynews.com/V...d_id=552&i=February+2015&i_id=1148&a_id=29550

Yeah... Surgeons have some issues with this, obviously. It is unlikely that anesthesia will be permitted to make themselves the "surgical home" for peri operative management without a fight from surgeons.
 
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Yeah... Surgeons have some issues with this, obviously. It is unlikely that anesthesia will be permitted to make themselves the "surgical home" for peri operative management without a fight from surgereons.

There's no way they could without surgeon by-in.

I could see a model all surgeons become like ortho and do nothing but operate and let anesthesia take care of patients. This would have to be incentivized heavily. Even then, most general surgeons are too proud of their commitment to their patients to let another doctor take over. It's the reason I didn't do ortho.
 
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There's no way they could without surgeon by-in.

I could see a model all surgeons become like ortho and do nothing but operate and let anesthesia take care of patients. This would have to be incentivized heavily. Even then, most general surgeons are too proud of their commitment to their patients to let another doctor take over. It's the reason I didn't do ortho.

Not just that, but this would be a nightmare for us ER docs. I see how it could make sense for scheduled, assembly line-type procedures (total hip, etc), but what about emergent cases? I have an acute chole in the ED and I call anesthesia who decides whether to take the patient to the OR or let it cool off? I can't imagine a surgeon would do well with being told by a nonsurgeon when and if he or she should or shouldn't cut.
 
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Not just that, but this would be a nightmare for us ER docs. I see how it could make sense for scheduled, assembly line-type procedures (total hip, etc), but what about emergent cases? I have an acute chole in the ED and I call anesthesia who decides whether to take the patient to the OR or let it cool off? I can't imagine a surgeon would do well with being told by a nonsurgeon when and if he or she should or shouldn't cut.

That would never happen. In the theoretical model described, the surgeon would see the patient pre-op and even post-op, but would only think of the surgical problem (e.g. wound check and advancing diet after an abdominal operation).

From an ER standpoint, it seems like the community hospitals already have it where the ER doctor makes the diagnosis and calls the surgeon to operate. I've seen patients get posted to the OR schedule and come to pre-op without being seen by the surgeon. These are usually clear cut appendicitis or cholecystitis, but it still makes me cringe.
 
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That would never happen. In the theoretical model described, the surgeon would see the patient pre-op and even post-op, but would only think of the surgical problem (e.g. wound check and advancing diet after an abdominal operation).

From an ER standpoint, it seems like the community hospitals already have it where the ER doctor makes the diagnosis and calls the surgeon to operate. I've seen patients get posted to the OR schedule and come to pre-op without being seen by the surgeon. These are usually clear cut appendicitis or cholecystitis, but it still makes me cringe.

Yea....I feel like if you want to take a scalpel to someone, you should probably lay hands on them first.
 
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Seeing as I can't get anesthesia to either 1) limit IVF on hemorrhoidectomy patients to prevent postoperative urinary retention/foley or 2) keep up with fluids on a bowel prepped laparotomy or 3) even think about extubating a straightforward case in someone who has COPD written someone in a dark corner of their chart or 4) not look at me cross-eyed when I ask them lay off the pressors (see scenario 2) intraop in a case where bowel perfusion might be marginal and you know, important; I can't imagine a scenario where they can take care of my patients better than a surgical intern with dreams of being a plastic surgeon.

What patients need from us is the best index operation possible, there is no substitute for that. All the rest is just decimal points.

If a patient says "Dr lungs said if I ever need an operation I will die" I call pulmonary AHEAD of time. Acute MI- cards, dialysis- renal. It's not hard but admittedly in private practice, a complicated medical patient can ruin your day/week and having appropriate consultants on board to handle other issues is absolutely appropriate. I think in the end, surgeons CAN handle most everything, residency training has this mindset, at least mine did. Hospital dynamics determine how this works and rogue surgeons find themselves outside looking in if they don't practice with other specialties. If I limit my "medical management" consults to truly complex medicine issues, I find myself getting better consults and therefore less bs.

So yes, a good general surgeon is probably the "best doctor", LOL. Joking aside though, a surg critical care doctor can probably handle the most stuff, well.
 
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That would never happen. In the theoretical model described, the surgeon would see the patient pre-op and even post-op, but would only think of the surgical problem (e.g. wound check and advancing diet after an abdominal operation).

From an ER standpoint, it seems like the community hospitals already have it where the ER doctor makes the diagnosis and calls the surgeon to operate. I've seen patients get posted to the OR schedule and come to pre-op without being seen by the surgeon. These are usually clear cut appendicitis or cholecystitis, but it still makes me cringe.
I am guilty of seeing patients for the first time in preop, but by that point i have already seen all their labs, vitals, and imaging and determined things are pretty straightforward. After my h+p i am perfectly willing to say i was wrong if there is a reason i shouldn't be operating (this has rarely happened). And if there is something that makes it not straightforward then i am more likely to examine first (or maybe just add them to follow and plan to see them before i start the first one). But since i cover 3 hospitals when i am on call, if i didn't do things the way i do i would end up running back and forth a lot more and patient care would get delayed
 
I am guilty of seeing patients for the first time in preop, but by that point i have already seen all their labs, vitals, and imaging and determined things are pretty straightforward. After my h+p i am perfectly willing to say i was wrong if there is a reason i shouldn't be operating (this has rarely happened). And if there is something that makes it not straightforward then i am more likely to examine first (or maybe just add them to follow and plan to see them before i start the first one). But since i cover 3 hospitals when i am on call, if i didn't do things the way i do i would end up running back and forth a lot more and patient care would get delayed

If surgeons trust residents and PAs to help make diagnoses pre-op, trusting an ER doctor should be ok...
 
If surgeons trust residents and PAs to help make diagnoses pre-op, trusting an ER doctor should be ok...

Except you know your resident or PA and how far to trust them, the ED doc is a random yahoo
 
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Except you know your resident or PA and how far to trust them, the ED doc is a random yahoo
I have gotten to know most of them and know who knows peritonitis and who doesn't. I know a few from residency even. But yeah sometimes i get some bozo who gives me no good info but usually i can find enough elsewhere in the part of the chart online that i can get it sorted. The worst is when i have to decide whether or not to get out of bed to look at stuff or trust that things are fine to wait till morning. I was on 4 times in one week and went in for every call. By the end of it i wanted to die and became more judicious after that. Funny part is in the first month i did some er i and d's during the night and came in for other stuff that ended up impressing lots of the ed folks so i have this really good reputation with them even though nowadays i am more likely to just wait till tomorrow for stuff that comes in after dinner time.
 
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