Prelim Year for DR (Medicine vs. Surgery); Some Interest in IR

[NecrotizingFasciitis]

Fourth year applying DR this cycle, but having an excellent experience on my IR elective right now. I could see myself very happy doing a mix of procedural stuff and reading as a career, with a predominance for reading. One of my IR attendings said that careers in IR tend to be either 10% reading and 90% procedures, OR 90% reading and 10% procedures (I can't remember the exact numbers he used, but it was a bimodal distribution with a significant difference.)

Wondering what peoples' thoughts are here. I asked a current resident who came from a surgical prelim wanting IR, an IR attending, and a resident who came from a medicine prelim wanting to do DR about what would be best for someone applying DR and here are the responses I have gathered:

Surgery Prelim: do medicine if you want DR because of better quality of life
IR Attending: do surgery prelim (no matter what, but especially if considering IR)
Medicine Prelim: do a TY (not an option for me because of strong regional preference for intern year); medicine otherwise

I'm the type of person that genuinely likes to be worked (masochistic, I know) and has some interest in doing IR in the future (maybe a fellowship or something), what do you think would be best for me for a prelim year? (medicine vs. surgery)

Thanks for the input!
-NF

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[odyssey2]

I don't recommend anyone do a prelim surgery year if they can help it. It's not going to make a big difference in terms of you being selected for an IR fellowship in the future. Even if you like surgery and are more procedure-oriented, you don't do much actual surgery in a surgery prelim year, you're mostly on the floors, but you'll just be worked harder and will likely be in a more malignant environment than a medicine year.

 

[PhysMatMan]

It depends on where you do your surgery year. Obviously, malignant programs are malignant but usually worse in surgery. I did a surgery year at a fairly nonmalignant institution, and I had a great experience. I also learned that I want as little call as an attending and probably more along the lines of 10% procedures.

Surgery
Pros:
Rotate in vascular, interact with IR, see trauma scans up close, see messed up belly anatomy up close, see anatomy up close, skip pointless rounding, little risk of running Covid icu, develop better understanding in reading emergent scans for surgeons, learn about your desire to do procedures or just appreciate them from afar.
Cons:
Usually worse schedule (can be okay if you have nightfloat), being worked for little learning, upper levels on power trips (worse in surgery I think), driving camera.

Medicine
Pros:
Better hours, learn more on rounds, seems like less acuity but I'm biased probably, develop better understanding in reading outpatient scans for medicine people, generally on the nicer side of people.
Cons:
More busywork, less procedures, long rounds.

 

[CallMeBigJeff]

It depends on where you do your surgery year. Obviously, malignant programs are malignant but usually worse in surgery. I did a surgery year at a fairly nonmalignant institution, and I had a great experience. I also learned that I want as little call as an attending and probably more along the lines of 10% procedures.

Surgery
Pros:
Rotate in vascular, interact with IR, see trauma scans up close, see messed up belly anatomy up close, see anatomy up close, skip pointless rounding, little risk of running Covid icu, develop better understanding in reading emergent scans for surgeons, learn about your desire to do procedures or just appreciate them from afar.
Cons:
Usually worse schedule (can be okay if you have nightfloat), being worked for little learning, upper levels on power trips (worse in surgery I think), driving camera.

Medicine
Pros:
Better hours, learn more on rounds, seems like less acuity but I'm biased probably, develop better understanding in reading outpatient scans for medicine people, generally on the nicer side of people.
Cons:
More busywork, less procedures, long rounds.

IM prelim more busywork than a Surgery prelim? That's hilarious

 

[Cognovi]

Both are workable for your preferences. At my program, there is a sizable minority of hardcore DRs who did prelims in surgery or medicine. Doing it at an academic center with a reputation for being non-malignant is the most important to get the right balance of seeing cool stuff and not being burned out.

On average, however, a surgery prelim will be working 10 more hours a week than a medicine prelim. That's a difference of 480 hours for the year! Think about it this way: if both the surgery prelim and medicine prelim did the same amount of busywork on the floor, would you volunteer to work an extra 480 hours if it were spent in the OR? You might see some cool stuff and have a better idea of how a general surgeon thinks, but note most of that time will be retracting, suctioning, camera driving, or skin closing.

 

[Kuratz]

I did a surgery year. Happy with my decision. The extra hour I spent at work every day was worth the much more desirable work flow. Universally done with notes and rounding by 8am. Some days spend time in the OR, other days be on consults or the floor. If you know the program has benign seniors/attendings and isn’t constantly on fire with more patients than is appropriate then I think it is a worthwhile year and would recommend it. I hated IM though so I suppose if that’s your thing then yes pick IM for the better hours.

 

[PhysMatMan]

Busywork in the sense that I never had to do a prior auth, didn't have to call other institutions to get a million page OSH notes, just dumped most of the patient's discharge work on social work, and most of my efforts were directed toward patient care. I wrote informative but concise notes that were heavily templated. I generally did not have to include the patient's feelings or discuss all the possible things it could be, just one-liner, their abdominal exam, and what we were gonna do. Yes in a non-malignant surgery prelim you will work, but it is goal directed and not as much "busywork" as medicine. It's like they say, surgery is fitting 16 hours of work into 12, and medicine is fitting 5 hours into 10.

 

[NecrotizingFasciitis]

The resident I spoke with about this says a surgical year advances your understanding of imaging too cause surgeons always look at imagin so this person felt he was a lot further than others at the start of R1. He said the trade off though is the medicine prelims are much better at differentials for report dictation.

Any opinions on this? Does either really matter that much if rads residency will teach you this anyway?

 

[irwarrior]

If you are considering IR, I would do a surgical preliminary year. You have to identify the ideal surgical preliminary year .

You do learn a lot about anatomy, but also pathology of the organs you treat as well as what post operative complications to look for and the timing of those. Surgery year you look at a large volume of cross sectional imaging on diverse pathology and you have the potential to learn a fair amount of anatomy that year.

Surgical oncology (liver segmental anatomy (liver masses), post resection complications, pancreas (pancreatic masses including cystic neoplasms) post Whipple complications, colorectal cancer (staging/ role of chemo/rt etc), Trauma, Transplant, Thoracic, Hernias, bowel pathology, pediatric GI pathology, vascular surgery (vascular anatomy/cli/ pad/ carotid disease/ esrd/venous disease/lymphatic disorders) ,cardiac surgery (valvular disease, MI, CABG complications). The things you typically won't learn about are neurosurgical conditions, urologic conditions, ENT, ortho and gynecologic conditions. SICU gives you comfort with ill patients requiring ventilators, pressors, and mass transfusions.

It gives you a solid foundation in chest, abdomen and pelvis surgical pathology. If you are considering IR, it gives you the understanding of an operative or procedural workflow , improves your manual dexterity , improves your stamina and improves your overall confidence.

 

[Dave1980]

Surgery pre-lim will not help you in any meaningful way.

 

[odyssey2]

The resident I spoke with about this says a surgical year advances your understanding of imaging too cause surgeons always look at imagin so this person felt he was a lot further than others at the start of R1. He said the trade off though is the medicine prelims are much better at differentials for report dictation.

Any opinions on this? Does either really matter that much if rads residency will teach you this anyway?

I'm not a rads resident so I can't give you advice from personal experience, but the rads residents I've talked to say whatever differences exist at the beginning of R1 evaporate quickly as everyone adjusts to the learning curve. A resident who switched from surg to radiology told me she her procedural skills were far ahead of her DR coresidents after one year of surgery, so you may be a bit ahead when it comes to that, but again, I'm not sure the pain of a surg prelim is going to be worth whatever small advantage it gives you for R1.

 

[Dave1980]

The resident I spoke with about this says a surgical year advances your understanding of imaging too cause surgeons always look at imagin so this person felt he was a lot further than others at the start of R1. He said the trade off though is the medicine prelims are much better at differentials for report dictation.

Any opinions on this? Does either really matter that much if rads residency will teach you this anyway?

This person is full of it. Maybe he was better for like 1.5 days.

 

[NecrotizingFasciitis]

This person is full of it. Maybe he was better for like 1.5 days.

Ya I kinda wondered.... but I’m not gunna be that guy that pisses a resident off at a program I’m interested in haha

 

[piii]

Surgery prelim is not too bad if you are at the right program. Big IF though. I’m at a great institution. For my first few months I’ve worked ~60-65 hrs a week, half of my week days are wedge days where I’m home by 3. Culture is actually great. Program pays for step 3, > $200 per month for food. 4 weeks off. Meanwhile the medicine residents are working 6 on 1 off with “short call” days until 6pm and 4 hours of rounding.

 

[NecrotizingFasciitis]

Surgery prelim is not too bad if you are at the right program. Big IF though. I’m at a great institution. For my first few months I’ve worked ~60-65 hrs a week, half of my week days are wedge days where I’m home by 3. Culture is actually great. Program pays for step 3, > $200 per month for food. 4 weeks off. Meanwhile the medicine residents are working 6 on 1 off with “short call” days until 6pm and 4 hours of rounding.

I’m in the very early stages at looking at prelims (there are only prelim med or prelim surg programs in the specific city I would like to match for intern year) and don’t know much about the programs in my area yet (still struggling through trimming down rads programs off my ERAS list), is this information usually available on websites or should I reach out to residents around here for info like this on both prelim medicine and prelim surg?

 

[qxrt]

My experience has been that surgery prelim will not help you become a better IR in any meaningful way. If you are bad at procedures, doing a surgical prelim year will not help you improve significantly. And learning how to manage patients in the SICU on pressors and ventilators sounds nice in theory, but in the real world, you will almost certainly never be in a situation where you are the primary (or even secondary) person managing those. Not in academics, not in private practice.

The only reason I would say to do a surgery prelim is if you think you'd enjoy it more than a medicine prelim. Quite a few IR training programs have the misguided assumption that surgery prelim will make you a better IR.

Talking about how a surgical prelim is going to be more useful for IR than a medicine prelim is like the intern asking whether reading about how to interpret CTs and X-rays in their intern year before their diagnostic radiology residency will give them a leg up. It won't make a significant difference.

 

[irwarrior]

Seeing number of trainees who have done surgery as opposed to IM or TY, I believe proper surgical training makes most trainees (not all) better equipped to do well as an IR. So many things that strong surgical training equip an IR for. The day to day existence of high end IR more reflects a surgical based service. In general when selecting candidates for IR, we tend to search for those who are surgical minded as they are a better fit for the current day IR training paradigms. Those who enjoyed and thrived in the surgical internship are more likely to enjoy and thrive in a busy IR training program.

I also have started many a patient on pressors and drips in the IR suites and that has averted potential code situations, so I think that it is really important to acquire strong clinical skills and feel comfortable dealing with sick patients.

 

[akaMondo]

I'm a DR resident, interested in IR and was coming into residency, and I did a surgical prelim year. I CANNOT recommend it enough. I just can't. Yes, I worked my ass off. It was way harder than a TY. But it also made me a better resident, better physician, and better person. I scrubbed so many cases and became very efficient with my time. I got to put in a TON of ultrasound guided central lines, which has helped me infinitely as I start doing ultrasound guided procedures - both IR and DR. There were other benefits I didn't expect - composure during procedures that can only come with practice, and a way to carry yourself/approach procedures that gives attendings confidence in letting you do things and knowing you will ask for help when you reach your limits. I also became familiar with post-op complications and what we're worried about on imaging - especially important for things that are a bit higher level that we didn't cover in med school (surg onc, bariatrics).

I wouldn't trade my surgical intern year for anything, and I'd do it 100 times over if I could. It made me so much better. Granted, I was at a community program where I wasn't scutted out but rather treated like any other intern, but still. I'd recommend it to anyone and everyone, including those people interested in DR only. I have consistently heard from attendings that the residents who did surgical prelim years are typically stronger coming into residency. I'm sure that gap closes, but again. I can't recommend it enough.