Options for POST general surgery residency (besides fellowship obviously)

[Ski2Doc]

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I am an MS3 and am STRONGLY considering a surgical field. I actually like General Surgery a lot, but am afraid that i will be forced to specialize even if i don't want to (since specialties generally have better lifestyle, reimbursements, and arguably are more in demand).

My main question is the path that i can take after GS if i want to STAY in GS.
I am thinking of distinguishing along the lines of:
1) hospital employed (i guess thats referred to as academics here), vs
2) large group practice employed (less call than smaller group i assume), vs
3) small group practice employed vs
4) partnering in a group, vs
5) solo practice

(I know solo sounds ridiculous but some fields like ObGyn have this, that a few of them "partner" to cover each other. In essence providing an ungrouped group, while each one has a solo practice (maybe not solo but ONE partner).


***** What are the advantages or disadvantages of each of these paths, besides some obvious ones?
Especially in regard to lifestyle, VACATION time throughout the year(i am a hard worker, dont mind doing 60hr weeks or taking call Q3 IF i have a lot vacations), benefits including pay of malpractice, variety of cases, and last but not least of coarse, reimbursement. *****


Sorry long post, but I am really going crazy thinking of my future and making a wrong decision.

 

[H_Caulfield]

I am an MS3 and am STRONGLY considering a surgical field. I actually like General Surgery a lot, but am afraid that i will be forced to specialize even if i don't want to (since specialties generally have better lifestyle, reimbursements, and arguably are more in demand).

My main question is the path that i can take after GS if i want to STAY in GS.
I am thinking of distinguishing along the lines of:
1) hospital employed (i guess thats referred to as academics here), vs
2) large group practice employed (less call than smaller group i assume), vs
3) small group practice employed vs
4) partnering in a group, vs
5) solo practice

(I know solo sounds ridiculous but some fields like ObGyn have this, that a few of them "partner" to cover each other. In essence providing an ungrouped group, while each one has a solo practice (maybe not solo but ONE partner).


***** What are the advantages or disadvantages of each of these paths, besides some obvious ones?
Especially in regard to lifestyle, VACATION time throughout the year(i am a hard worker, dont mind doing 60hr weeks or taking call Q3 IF i have a lot vacations), benefits including pay of malpractice, variety of cases, and last but not least of coarse, reimbursement. *****


Sorry long post, but I am really going crazy thinking of my future and making a wrong decision.

Sorry to completely ignore your question, but I thought it worth pointing out that your concerns are precisely why the integrated specialty programs are so popular. I thought fishing around in the abdomen would be cool, but had every surgeon and resident I know tell me to run like hell from a field that beats you down as hard as any during residency...and then pays you like an internist. Thought of ortho, ENT, or neuro? Oooh, what about those integrated vascular programs? There should be more than, like, FOUR of them by the time you apply next year.

I was told by an attending that if I did general surgery I'd virtually be forced to do a fellowship, unless I planned on practicing in the middle of nowhere. I'm not saying he was necessarily right, but it was enough to get me thinking about tacking on a 2-3 year fellowship...which made me ask myself why, if I were going to spend 7-8 years, I didn't just do something like neuro.

 

[SLUser11]

I thought fishing around in the abdomen would be cool, but had every surgeon and resident I know tell me to run like hell from a field that beats you down as hard as any during residency...and then pays you like an internist.

I was told by an attending that if I did general surgery I'd virtually be forced to do a fellowship, unless I planned on practicing in the middle of nowhere.

Those places with "desirable" locations but crappy work environments and questionable curriculums are the same places that have unhappy surgeons and residents telling you to run away from general surgery. In my experience here on SDN, there is a large concentration of this in the NE, specifically New York.

An important point to mention is that the way they do things there is not the only way that it is done. There are plenty of programs, both community and academic, with happy residents and excellent training. You just have to look for them, and not be one of those people who HAS to train in NY.

As for the "Getting paid like an internist" comment, general surgeons in private practice have excellent earning potential. If you want an extravagant amount of $$ immediately in practice, then you will most likely have to move to podunk Oklahoma, but if you want to make $200-250K, that is very obtainable in a regular sized city.

And finally, nobody is "virtually forced" to do a fellowship, or be banished to smallville. There are plenty of unhealthy gallbladders, etc. in the big cities. Still, it is an issue of supply and demand, so if you move to a place with a saturated surgeon population, then you will be scrapping for money, etc. If you are OK with living outside of the 5-10 largest cities in the US, you can probably have a little more freedom to do what makes you happy.

 

[H_Caulfield]

SLUser is about 4 years ahead of me and has a much better idea of what he's talking about, so I'd recommend you listen to his comments and ignore mine. My post had a few sweeping generalizations and exaggerations.

there is a large concentration of this in the NE, specifically New York..

right on 👍

 

[Winged Scapula]

Echoing SLUser's comments:

Those of us who trained in the NE are certainly vocal about the "malignancy" (for want of a better term) of the training but this is by no means indicative of training everywhere or even at every program in the NE/NY. Thus it is possible to train at a humane program which educates you and produces a good quality surgeon.

I will argue with the OP's comment that the surgical subspecialties are "arguably more in demand" than a general surgeon. With over 70% of surgical residents going on for fellowship training, there will be a significant need for the general surgeon over the already great demand. Ten minutes with a surgical journal will let you see all the ads begging for general surgeons. If you have some vascular, laparoscopic or bariatric training to boot, you will have jobs coming out of your ears, much more so than the surgical subspecialists I would venture.

As SLUser said, "getting paid like an internist" is somewhat of an exaggeration. I suppose you could make that little, but even I, in a "low paying specialty", make than average general surgeon and certainly more than the average internist.

How much you make and how much vacation you get depends on what you negotiate and what your walking away points are. I traded vacation time for some sick leave (which was not offered originally), more CME time and other things important to me. I have friends who have twice as much vacation time as I, large signing bonuses, etc. - then again, one of them now immensely dislikes her co-workers whereas my partner and I have developed a wonderful friendship. Hopefully, you'll find a position with lots of vacation time, good pay, good working relationships, etc.

If you are employed by a hospital, expect to make less than in PP where no one limits your earning potential. If you want to work 140 hours per week, currently there are no restrictions to you doing so (although there is talk of policing attending work hours as well).

Thus, in essence there is no way to answer your last few questions. Some hospital positions will pay a lot, some not as much, malpractice varies from state to state (WIDELY) as well as what type of procedures you do (you will pay more to do bariatrics and plastics typically), call schedules will vary from some to a lot to none, variety of cases and reimbursement/salary. Private practice has the most potential to make more but if you are in a saturated market, do not work hard, do not keep up with billing and coding or perform higher paying procedures, you might be better off in a salaried position.

Solo practice is feasible but a lot of work; you can find hospitals which will assist you in setting up your practice if you are in an area of need. Phoenix, the 5th largest city in the US, turns out to be an area of need, at least for my specialty and my partner had no trouble getting a hospital to write her a big fat check to open a practice and getting the same hospital to write her a big fat check when it came to recruiting a partner (me). What most fail to understand is that job hunting is not like residency where you are told what the salary is and you sign without negotiating. It would behoove every resident here to learn that, and perhaps even read some books or take some courses on the art of the deal so you don't get suckered with your first job.

Finally, the world of surgery changes rapidly and what is true now may not be 5 or 10 years from now. I had an OB-Gyn tell me yesterday that I was going to be out of a job because "there won't be any biopsies anymore" and "cancer will be treated medically, not surgically". News to me, but then again, she then went on a tangent/rant about me not taking call, about how the BC process for MD surgeons is less stringent than for DO OB-Gyns, etc.🙄 Point is - who knows what the future will hold.

 

[JayDoc06]

Keep in mind that those surgeons with whom students and residents work are generally an attending/faculty surgeon because they are good/specifically trained at something or small group of things (ie completed a fellowship). A small percentage of academic surgeons are "only" general surgeons. Therefore, they see the world not only through the lens of their training experience but also they work in academia.

There is nothing more in demand than a general surgeon who treats a variety of conditions well. Look at how many hernias and gallbladders are done each year. I don't care what the perceived demand for specialists might appear to be. There is no data (as far as I know) showing a surgeon with a piece of paper on their wall saying they did 12 months of special laparoscopic training will injure the common bile duct less often than a general surgeon. Or that a colorectal surgeon gets more lymph nodes or has a lower leak rate than a general surgeon. If you want options for a career, general surgeons are always in demand. You can live anywhere you want, a town of 10,000 can support a general surgeon (or so I've been told). That same town couldn't support a specialist. As more and more people specialize, there are fewer and fewer young general surgeons, the demand is there.

Anyway, always take into consideration your source when evaluating information.

 

[Winged Scapula]

Excellent point work repeating JayDoc.

Most medical school faculty have never been in PP, worked in the community and have little to no idea about what goes on out there. Hence, their distorted view of what is feasible.

The vast majority of surgical care in this country is done by general surgeons in community hospitals. They do everything from bread and butter hernias, breast cases, gallbladders, appys, etc. to vascular, colorectal, advanced laparoscopic and other cases.

While I'm not sure I'd want someone in the community who only rarely operates on the pancreas to do my Whipple, frankly, I always said that I'd rather have a good community general surgeon do my chole or appy than the university faculty surgeon (who typically sees fewer of those).

Consider the source OP when you are being told things like:

" you need to do a fellowship"

" there is no role for the general surgeon"

" you won't make any money as a general surgeon", etc.

Those guys have little to no idea what they are talking about.

 

[BlondeDocteur]

Chiming in from the land of hyper-specialization, I completely agree. There's just not much role for a generalist anything in New York, especially Manhattan-- both due to market saturation and to a demanding patient population which prefers specialists.

However, most of us know how anomalous that is. The national demand for general surgeons is skyrocketing, due to the fact that at nearly all academic programs the majority of general surgery graduates pursue fellowship (i.e. shrinking entry into the labor pool), and to the aging/retiring of the rural general surgery workforce (i.e. increasing exodus from the labor pool). Combine this with a growing national population, particularly with an aging population, and I would think the future is very, very bright for a general surgeon almost everywhere.

I wouldn't even agree with the "top 5-10 American cities" statement-- I'd say outside of Boston, New York, San Francisco and potentially Chicago, the market for general surgeons is very good. The aforementioned cities are simply hypersaturated with doctors (particularly NY and SF) so new MDs have to carve out niche practices to get established.