My first week as a general surgeon

[womansurg]

One week now under my belt. To remind: I just completed my five years of gen surg training, and accepted a private practice position in a regional referral center in the northwest.

I had the interesting experience of being on call my very first day on the job. My partner calls me the day before:
"Hey! You wouldn't be able to cover me tomorrow by any chance, would you?"
"Well, sure. But you know, I don't even know my way around the hospital yet. I think you were supposed to introduce me and show me around tomorrow."
"O don't worry! I'll be around! I just want to spend some time with my son who's here from our of town. Just call me if you need anything."
"Sure, that'd be fine." Come to find out later that he spent the day on a boat out on the river, well out of beeper range.

So I got up early, drove to the ED's of the two hospitals that I cover, introduced myself to the docs and staff ("Oh, you're Dr. Womansurg! We thought maybe that was some kind of typo on the call sheet.") and headed into the clinic. Fielded office and hospital consults all day. Then got a late afternoon call from the local university town ED. Young man with RLQ abdominal pain.
"Sure, I'm happy to see him. But...I thought you guys had your own surgery group there?"
"Well, we do. But the parents want him seen by your group."
"Certainly. Send him down."

He arrives to the ED. Has a pretty good story and examination for early appendicitis. His abdomen looks like a road map of surgical scars. Previous blunt and penetrating trauma to the pelvis and GI tract. Multiple surgeries and revisions - at least five by their recollection. Questionable history of possible inflammatory bowel disease. CT of the abdomen (I have no desire to struggle my way into that abdomen only to find an exacerbation of IBD) is suggestive of appendicitis. We engage in a long discussion about goals and risks of surgery. I consent him for exploratory laparoscopy, possible laparotomy, possible appendectomy, possible bowel resection, possible ostomy. The OR crew is called in. I dictate on the ED doc's number - I don't have my own yet.

The janitor points me in the general direction of the ORs. I walk in and people stop and stare at me.
"I'm sorry. "Who are you exactly? Oh! You're the new surgeon!"

Patient is brought down and general anesthesia undertaken. I get a scope in at a virgin appearing area of the epigastrum. Massive abdominal wall adhesions - no surprise there. I do enough adhesiolysis to access the RLQ and place two more ports. Normal cecum and terminal ileum. Appendix with inflamed, indurated tip. It comes out easily.

I walk out into the hall and hail a person mopping the floor.
"Hey, where's the OR waiting room?"
He looks at me like I'm joking and points to an open doorway immediately behind me. I walk through it to find family members looking at me amusedly.
"I'm sure it's instilling great confidence in you that your son's surgeon can't find the bathroom around here," I laugh. "Surgery went fine..." yada yada.
Mom has a funny look on her face. "We should probably tell you. We're both nurses here at the hospital. My husband is a surgical nurse."

Skip a beat.

"I'm glad you didn't tell me."


So, all-in-all a good beginning for me. I went on to do several breast cases (including a sentinal node bx), an open colectomy for cancer, and a lap gallbladder. Next week so far I've lined up lap hernias (one inguinal, one ventral), a lap colon resection for benign disease, and a possible carotid endarterectomy.

I cannot adequately express to you how delighted I am with my life here and with my practice. All of those long years...everything is finally coming to fruition. There is a wonderful light at the end of that tunnel you may be living in.

-ws

---

Members don't see this ad.

 

[ckent]

Congrats on your first week as an attending womansurg. I suspect that you will have another post telling us all how wonderful it is to be an attending after you receive your first paycheck too, and compare it to your previous paycheck as a resident. I was kind of surprised to read that you would be doing a carotid endarectomy though. I thought that there were all of these rules regarding that procedure (like you have to do a certain amount per year and your complication rate has to be so low) that would prevent a general surgeon in private practice from being able to do it. Maybe it's just my state though.

 

[womansurg]

Originally posted by ckent
I was kind of surprised to read that you would be doing a carotid endarectomy

Things are very, very different once you get outside of metropolitan medical environments. Part of the attraction of this position, for me, was the breadth of the surgery which I will perform. An important compenent of informed consent is discussing the fact that fellowship trained subspecialists are available, and also that surgical outcomes may be related to surgical volume for both the individual and the hospital system. It's surprsising (or maybe not) how many local folks want you to do their surgery. They know and trust the local care providers and are willing to accept the limitations of your experience and/or training.

On top of the procedures I listed, I also assisted my partner on a carpal tunnel release (performed by the orthopods in my training center) and a lap assisted transvaginal hysterectomy (gyn domain). I will perform these procedures as well, so I thought it wise that I help out with a one or two at first.

Of course, my work load in the surrounding communities is somewhat relieved by the local FPs. They do nearly all the C sections and appys, as well as a few gallbladders.

 

[Winged Scapula]

Originally posted by womansurg
Then got a late afternoon call from the local university town ED. Young man with RLQ abdominal pain.
"Sure, I'm happy to see him. But...I thought you guys had your own surgery group there?"
"Well, we do. But the parents want him seen by your group."

LOL. Welcome to my hell. Every time I see that none of the surgical groups I cover are on call for the ER I breathe a sigh of relief...until the calls start coming in because:

a) the patient is known to one of my groups
b) the patient (for some reason) prefers one of my groups
c) the ER doc prefers one of my groups (gee...thanks for the favor) and recommends us
d) the on-call group doesn't take the patient's insurance
e) the on-call group wants me to come over and write their orders etc. (doesn't happen very often and I'm "allowed" to refuse since they don't have resident coverage)

Its getting so I don't even bother and check to see which group is on-call anymore. It doesn't seem to make a difference.

At any rate, congratulations on finishing your first week as an attending. It must feel overwhelming but pretty great...and to have FPs doing choles, appys, etc. Wow...pretty rural area?

 

[::Seabass::]

congrats womansurg

 

[DrMom]

Originally posted by womansurg
I cannot adequately express to you how delighted I am with my life here and with my practice. All of those long years...everything is finally coming to fruition. There is a wonderful light at the end of that tunnel you may be living in.

I'm so excited for you!

d@mn, my tunnel is still really long!

 

[surg]

Congratulations on your ascension to the storied world of being done. Hope to see you still sticking around here to keep us posted.

 

[njbmd]

Hi there Womansurg,
It was good to read about your first day as an attending and to hear that Kimberli gets the same feelings that I do when I am consult resident. I just started second year and I cover consult once per week. I have the back-up of my chiefs but I still feel like I might miss something. I have been scouring my books to make sure that I ask all of the right questions and do a thorough history and physical exam. So far, so good. With the 80-hour work week, I have gotten a combat promotion and it was scary at first.

I have also been doing some pretty heavy cases too. I am filling a job that previously went to a third year and I am at the beginning of my second year. My attendings all know where I am in training and have been pretty patient but my nerves have kicked in overtime. I keep telling myself that I wouldn't be doing this if my superiors didn't think that I was up to the task. Again, I have back-up and I greatly appreciate it.

It was great to snag a couple of colectomies at my level and I love operating all day. It is great to leave the ward stuff behind for the most part. I keep remembering what one of my mentors told me when I was a medical student. She said that second year would be the toughest year because you are expected to step up and know something. She was dead on.

Congrats on getting though and living to tell about it!


njbmd

 

[Pheo]

Womansurg,

Congatulations on your first week as a GS Attending. It sounds like you're pretty content. I myself just finished my first two weeks as a Urology Attending and this weekend I'm taking my first call. I love the practice I've joined. The entire office staff is extremely nice and my partners are very supportive.

My first case was last week - I performed a ureteroscopy for an impacted 7 mm distal ureteral stone. The case went fine and I was glad to get it under my belt. I also put in a catheter in the OR the other day. When I told my partner about it he asked me if I had torn out the face sheet so we could bill for the consult. It feels really strange getting paid for something you have done routinely for the past five years.

I cannot agree with you more about how great it feels to finally be out in practice. It is so rewarding and exciting taking care of your own patients.

Something I tell all the med students and younger residents I encounter is that every year is better than the previous year.

No question - there is a bright light at the end of the tunnel.

Pheo

 

[GoodMonkey]

sounds great, ws ... congrats!
like drmom - my tunnel is very very long. glad to hear these so-called "lights" at the end of them really do exist!

 

[ArrogantSurgeon]

Originally posted by GoodMonkey
glad to hear these so-called "lights" at the end of them really do exist!

It could be a train.

 

[north]

Pheo,

Could you talk a little about your life as a private practice urologist so far? I've always thought urology could be pretty cool, but have had some lifestyle reservations about it. How will your private practice hours be for the next few years? Thanks.

 

[MacGyver]

For the attendings on board, please tell us your salary. Just a rough estimate will be appropriate.

 

[womansurg]

Originally posted by MacGyver
For the attendings on board, please tell us your salary. Just a rough estimate will be appropriate.

Common starting salaries for GS are in the 200K range, plus incentive bonuses.

 

[Apollyon]

"Things are going great
And they're only getting better.
I'm doin' all right, gettin' good grades
The future's so bright
I gotta wear these shades."

 

[womansurg]

Originally posted by Apollyon
"Things are going great
And they're only getting better.
I'm doin' all right, gettin' good grades
The future's so bright
I gotta wear these shades."

Haha! Way back when, my friend and I were applying to med school at the same time. Things were really starting to come together: we did okay on MCAT, grades were looking okay, we started getting some decent interview offers coming in... We were so happy; it felt like the whole world was opening up for us. We used to dance around after hours in the laboratory where we did research, and sing this song at the top of our lungs...

little did we realize what lie in store...O the horror...the horror...

 

[md03]

Glad to see you back on the board, Womansurg. Congrats on the new job!

Your story is not too dissimilar from my first week as an intern (you are at a much higher level, of course). Issues I encountered included having to start sliding scale insulin on one pt and a heparin drip on another. However, I had no clue HOW to do so ( and I wasn't given any guidance). Fortunately, as a student, I had written down a sliding scale in my Maxwell guide. So I had the numbers, but figuring out how to get the order into the computer order system was a nightmare (took me about 40 minutes to figure that out...including a useless call to the computer support, run by computer geeks with no medical training...the guy kept telling me how to get to the insulin drip screen NOT sliding scale). Same story with the heparin drip, only I hadn't written down one of those as a student. So I had to find another pt with a heparin drip and copy the printed out orders into the screen on the computer (once I found it, which took a while)

The place I'm doing my residency is MUCH bigger than where I went to school. So far, when I go to the ED or OR, there is always a different set of people and they always demand to know who I am. However, yestererday one of the trauma attendings also told a story of being in the OR trying to get room cleared for an exlap on a GSW and someone demanding to know who HE was, so I dont' feel so bad now. (he's been there for several years, too)

 

[Pheo]

North,

My schedule consists of office hours 5 half-days a week - 4 in the afternoon and 1 day in the morning. The other half days I will either be in the operating room at one of 3 hospiatls or at our ambulatory surgery center where we perform smaller cases such as cystos, prostate biopsies and vasectomies.

My days in the morning when I go to the OR will essentially begin when my first case is scheduled (earliest @ 730). My days in the office usually end around 4 - 5pm.

The next 3 - 6 months will probably be somewhat slow since I am in the process of acquiring patients to build up my practice.

Judging from what I see, my partners usually start their day @ 730 - 800 and work until 4 - 5pm (rarely past 6)

In terms of call: I joined a 5 man group so there are 6 of us total. The call schedule is 1 in every 5 weeks (the oldest guy does'nt take call) which is great. I'm just finishing my first weekend on call and it really has'nt been that bad. I did have to go into the ER Friday night to put in a catheter (which in retrospect I probably should've had the ER physician take care of) and I saw a patient yesterday with a testicular mass, but other than that I've essentially been fielding patient calls all weekend.
Urology call when I was resident was never overwhelming and although there may be a difficult evening every once in a while I suspect this will also be the case as an attending.

One thing that invariably happens in probably every surgical subspecialty is an OR case that comes in that is not necessarily a true emergency but has to go within 24 - 48 hours. These cases usually have to go afterhours because all the guys are busy during the day. For instance, last week we did a radical nephrectomy on a huge right renal mass that was invading the renal vein. The patient had gross hematuria and was clotting off his catheter. We started the case around 5 and ended at 830pm.

I suspect there will be those kind of nights every once in a while, but probably not as often as you would see in some of the other surgical specialties (ie gen surg, ortho).

I hope this gives you some insight into the lifestyle of a community urologist. I will probably be able to give you a better indication as to my daily schedule in about 6 months. Good luck!


Macgyver - Urology starting salaries

According to the urologyjobsonline web site, Eastern metros are ranging from 150k-180k while salaries in the Midwest are 220k-250k. From my experience this past year the starting salary for a urologist in either the NY or DC area is a bit lower - I would have to say in the 120 - 150 range.

Pheo

 

[north]

thanks a lot for the reply, Pheo. It's tough as a medical student to know what life is like in private practice because all we see is academic medicine. It sounds like you're pretty happy. I've heard of several recent urology residency grads who are working like dogs in their first couple of years. I believe they've joined smaller groups than you, like 2-3 guys total. Does this have a big bearing on what your life is like (i.e. a larger group being better), or is it more normal to work long hours right out of residency and then scale back as you get older? Did you consider this sort of thing when choosing a group to join?

in regards to your mention of the inevitable case that goes afterhours even though it's not an "emergency" but that's when you have time to do it- how does that get assigned? Does whoever is on call do the case (did you say you were on call for a week at a time)? Do you do it since you're the new guy? sorry if it seems like I have a lot of questions, just curious about how things work in the "real world".

also, as a side note my friend says he thinks there's urology practices where the group members all work 4-day weeks. i don't believe him. just curious if you ran across this at all on your interviews. thanks so much for your input.

 

[ArrogantSurgeon]

WS,

I should really be asking this when you are at least a few weeks into your job...but may I ask approximately how many hours you are working per week? And has it been pretty consistent on day to day basis? Thanxs.

 

[Pheo]

North,

When you're a medical student it's hard to imagine what life is like as a resident let alone what its like in private practice. I had those same questions not too long ago.

All of my partners work very hard. They see on the average 20 - 30 patients in one half-day office session and are busy with cases the remainder of the time. I am expecting and planning on working very hard for the next two years in order to get my practice going and also to learn as much as possible from my partners, but honestly I don't think I'll be working that much harder than the other guys. The amount of work, including call is pretty evenly distributed among the five guys.

As far as the actual call schedule - it certainly does make a difference whether you join a smaller vs larger group. I interviewed with a couple of solo practice urologists where call would be 1 in 2. They told me call would be relatively quiet but regardless, you are bound to the immediate area and can't really go away. I take 1 in 5 call in this practice meaning I'm on call one out of every five weeks (for a week at a time). I would much rather have a busy call and be on call infrequently than have an easy call and be every other.

All five guys take an equal amount of call - in other words the new guy (me) does not get dumped on. In fact, I did not come across any practices where the guy coming in took more call than the established partners.

In terms of who gets assigned the cases that come in - whoever is on call that particular week acquires the patient and does the case. On the larger cases two of us usually scrub.

I did come across a few practices where the partners only work 4 days a week. I did'nt interview with these so I can't really elaborate.

Pheo

 

[mustangsally65]

I just thought I would bump this up for the person(s) with the rural general surgery question. Apparently the OP does a lot of non-traditional GS cases.

I also had a question, and didn't feel like starting my own thread for it. What is the prep for most laparoscopies? I realize they differ between practices and each surgeon has his/her own preference, but do they all get pre-op bloodwork? Bowel preps? chest X-rays? most of the info I found on the internet was non-specific and just said that these would be done if your surgeon felt like they were necessary. I was wondering if there was any rule of thumb within the profession.

thanks.

 

[Blade28]

Awesome story, don't know how I missed this thread the first time around.

 

[Vincristine]

Being 4 months into this 5+ year road, I'm thrilled to read these stories....the thought of getting a job some day is amazing. Of course it's hard to imagine that I'm 1/3 of the way done with internship!

Congrats Womansurg