Surgical Oncology Fellow AMA

[Lem0nz]

Hi friends,

Post says all. In the process of job interviewing and would like some constructive distractions to occupy my mind during the waiting phase so please ask me anything - about surgical rotations, general surgery residency, general surgery attending life (I do some locums stuff on the side), surgical oncology, cancer, being a resident in surgery, being a fellow in surgery, how I broke a rib learning to snowboard in the alps as a 4th year, you name it.

I'm applying to hospital employed type jobs but the distinction between academic and private practice is incredibly blurry in surgical oncology and I've had to learn about all aspects of both so can probably field most any question.

Thanks! Appreciate any interest and distracting my ADD!

 

[Dunkthetall]

Do you know much about general surgery lifestyle in more rural areas?

And how does general surgery residency compare to surgical oncology fellowship in terms of hours, autonomy, and surgical volume?
Thanks for doing this!

 

[Lem0nz]

I guess it depends on what you consider rural. Do you have a city size example for me? Like I interviewed at Geisinger which is super rural but their hospital is also a fortress capable of nearly anything. Most places that have a general surgery residency aren't *that* rural. Compared to a major city, sure. I did my residency in the suburbs of Philadelphia north of Temple. We did a rural-esque rotation to a hospital an hour North with a population of 16k and maybe at best a 100k catch radius. I would say the pace of life is dramatically different, surgical techniques can be 5-10 years behind the curve and a lot of that can be due to equipment. Its not economical for smaller/rural hospitals to have lots of expensive specialized equipment. Doesn't mean that surgeons have bad outcomes or do the wrong operations, quite the contrary. They often have better anatomical knowledge because they've been doing true general surgery their entire career. But don't be surprised to see older techniques and bigger incisions. The pace of life is MUCH slower and more laid back. The complexity of the patients is generally lower. The acuity is not. There's stuff you have to transfer. And you will usually need to do away rotations at high volume places for things like peds, trauma, transplant, HPB. (This is common even in larger programs).

Surg onc fellowship lifestyle varies by program. Mine is probably, honestly, the easiest. I'm in a massive quaternary system that was originally a more of a giant health conglomerate (still is) but has really embraced its GME stuff and was such high volume they felt they could really deliver a unique experience in surgical oncology. Because of that we have a veritable army of PAs that do all of the "work" you would normally think of - orders, paperwork, discharges, dealing with floor stuff, pages, even consults. As fellows we are essentially treated as attendings. We have full autonomy for decision making, ordering studies, talking to patients and giving them direction of their care, path, calling families. Pretty much the only thing we don't do is the time out for legal reasons. In the operating room at my fellowship I have way more autonomy than I did in residency (and in residency I already had a ton of autonomy in my community program) - my attendings will often even let me go through with things they disagree with which predictably usually results in me making a minor mistake and making a vein bleed that they then expect me to fix. They're very invested in making sure once I leave fellowship, if I'm practicing alone, I have sound judgement, can get myself out of trouble, know when to call for help, and can learn from mistakes to become a better surgeon once I'm no longer under the training umbrella. Hours are better but again that's largely due to the PAs that were in place before the fellowship started. Volume at my program is too much for the fellowship to even begin to capture because we have no residents. We capture all of HPB/surg-onc/sarcoma, but only get about 1/12th of colorectal, head and neck, breast, etc etc. pick your sub-rotation. Could probably support at least 4 fellows (we have two) if not six because of not having residents. I have six months of fellowship to go, am actively not chasing cases anymore and focusing on what I find interesting, and have 350 cases in 1.5 yrs of fellowship. Minimum volume is 170 and I exceeded all of the categories probably like 9 months into fellowship. They also have done an excellent job teaching me complex robotics and I've done a couple skin to skin robotic whipples solo with the attending regaling us all of his exploits on his hunting trips. (Short version - he can't shoot a shotgun to save himself and never gets anything. He would die in the zombie apocalypse.)

 

[Dunkthetall]

I guess it depends on what you consider rural. Do you have a city size example for me? Like I interviewed at Geisinger which is super rural but their hospital is also a fortress capable of nearly anything. Most places that have a general surgery residency aren't *that* rural. Compared to a major city, sure. I did my residency in the suburbs of Philadelphia north of Temple. We did a rural-esque rotation to a hospital an hour North with a population of 16k and maybe at best a 100k catch radius. I would say the pace of life is dramatically different, surgical techniques can be 5-10 years behind the curve and a lot of that can be due to equipment. Its not economical for smaller/rural hospitals to have lots of expensive specialized equipment. Doesn't mean that surgeons have bad outcomes or do the wrong operations, quite the contrary. They often have better anatomical knowledge because they've been doing true general surgery their entire career. But don't be surprised to see older techniques and bigger incisions. The pace of life is MUCH slower and more laid back. The complexity of the patients is generally lower. The acuity is not. There's stuff you have to transfer. And you will usually need to do away rotations at high volume places for things like peds, trauma, transplant, HPB. (This is common even in larger programs).

Surg onc fellowship lifestyle varies by program. Mine is probably, honestly, the easiest. I'm in a massive quaternary system that was originally a more of a giant health conglomerate (still is) but has really embraced its GME stuff and was such high volume they felt they could really deliver a unique experience in surgical oncology. Because of that we have a veritable army of PAs that do all of the "work" you would normally think of - orders, paperwork, discharges, dealing with floor stuff, pages, even consults. As fellows we are essentially treated as attendings. We have full autonomy for decision making, ordering studies, talking to patients and giving them direction of their care, path, calling families. Pretty much the only thing we don't do is the time out for legal reasons. In the operating room at my fellowship I have way more autonomy than I did in residency (and in residency I already had a ton of autonomy in my community program) - my attendings will often even let me go through with things they disagree with which predictably usually results in me making a minor mistake and making a vein bleed that they then expect me to fix. They're very invested in making sure once I leave fellowship, if I'm practicing alone, I have sound judgement, can get myself out of trouble, know when to call for help, and can learn from mistakes to become a better surgeon once I'm no longer under the training umbrella. Hours are better but again that's largely due to the PAs that were in place before the fellowship started. Volume at my program is too much for the fellowship to even begin to capture because we have no residents. We capture all of HPB/surg-onc/sarcoma, but only get about 1/12th of colorectal, head and neck, breast, etc etc. pick your sub-rotation. Could probably support at least 4 fellows (we have two) if not six because of not having residents. I have six months of fellowship to go, am actively not chasing cases anymore and focusing on what I find interesting, and have 350 cases in 1.5 yrs of fellowship. Minimum volume is 170 and I exceeded all of the categories probably like 9 months into fellowship. They also have done an excellent job teaching me complex robotics and I've done a couple skin to skin robotic whipples solo with the attending regaling us all of his exploits on his hunting trips. (Short version - he can't shoot a shotgun to save himself and never gets anything. He would die in the zombie apocalypse.)

Yeah I was thinking of places with populations of less than 20k.
That’s interesting! Do you think we’re trending towards a time where future surgeons may need a “rural fellowship” to comfortably practice in these areas?

Why’d you choose surgical oncology over other specialities? And did you do two years of research?

Thanks again!

 

[Lem0nz]

No I don’t. Surgeons are less versatile and in general less competent than decades ago, but not so much that they can’t do the operations they’re comfortable with. I think what you’ll see is that “general surgery” will continue to shrink in its scope and patients will simply be transferred to a higher level of care or a tertiary center. For example, I think general surgeons will always be able to do appys, choles, and free air. But to improve outcomes and give patients access to MIS techniques, I won’t be surprised if you see hospital systems and general surgeons themselves in rural areas transferring out colon resections to places that can do them lap or robotic if they don’t have that ability in a small town hospital. Another example, I did some locums stuff in a very small town (pop couldn’t have been over 2k) and they didn’t operate on BMI over 35 or 40, can’t quite remember. Just transferred. The state was Wisconsin soooooooo. In the land of beer and cheese that is not a small percentage of your patients.

I chose surg onc very very early (MS2) because those surgeons were just the coolest freaking people. They were so incredibly smart and everything they did seemed to be backed up by research and data and science, not just “because that’s what I was taught”. The operations were a level of complexity clearly above others in surgery to me, and they were never ever the same.

I learned years later it came with the added perk that it is the most kind and gracious population of patients that exists. When you care for people with cancer they just love and appreciate you, even if it’s a bad outcome. They care that you’re trying at all to help them, and they can and often do look their own mortality in the eye, confront it, and display a degree of courage that makes you honored to be the one that’s going to go into them and cut out their cancer.

Its humbling. And awesome. And I feel like I make a difference. Like, *really* make a difference. Seeing a patient’s face when you tell them their cancer isn’t back after you cut it out on the one year follow up CT, or seeing their smile when it recurred three months later on a huge sarcoma and knowing that they’re smiling because at least they tried everything, they left their regrets at the door, and they’re going to make the best of the time they have left here with us...

Just, damn. My patients are legends in class and grace. It’s just an experience of a life time, over and over. You’ll never find another group of people that can show you better what it means to live and love.

 

[Lem0nz]

I did not do any dedicated research years, but I did do a masters in informatics and patient safety/quality through night school in my 4th and 5th years of residency.

I get bored easily so many of the other fields felt very monotonous to me. I actually applied to trauma as my backup and everyone always tells me that those two things have nothing in common, and I disagree completely. They’re the only two fields in surgery left that let you operate everywhere, and that no operation is ever the same twice. Trauma doesn’t come in cookie cutter patterns and puzzle pieces, and neither does cancer. They obliterate fields, require multiple approaches, and can be real beasts of operations to do well. That level of challenge and being expected to operate in multiple places well is what I enjoy.

 

[Lem0nz]

And you don’t have to thank me, just keep asking questions and encourage your friends (and all you lurkers out there). I enjoy this.

 

[Philly145]

Could you explain the difference between an oncologist and surg-onc?

-An ignorant M0

 

[Lem0nz]

Sure, that ones easy. Medical oncology gives chemotherapy, immunotherapy, and hormonal treatment for cancer.

Surgical oncology uses a knife.

To complete the squad, we have our radiation oncology friends who like to taser things until they glow.

Modern cancer treatment generally uses all three to varying degrees. Medical oncology tends to be the backbone, while surgery tends to be the curative option. Radiation treats residual disease, hard to reach places, or people who aren’t fit enough for chemo or an operation.

 

[GoSpursGo]

Sure, that ones easy. Medical oncology gives chemotherapy, immunotherapy, and hormonal treatment for cancer.

Surgical oncology uses a knife.

To complete the squad, we have our radiation oncology friends who like to taser things until they glow.

Modern cancer treatment generally uses all three to varying degrees. Medical oncology tends to be the backbone, while surgery tends to be the curative option. Radiation treats residual disease, hard to reach places, or people who aren’t fit enough for chemo or an operation.

Two follow ups:

1) How are your discussions/interactions with med onc/rad onc when you all share patients and need to come up with a unified "plan?" How do you think your experience at your quaternary system will compare to where you ultimately practice, particularly if you're in a less academic practice?

2) Will you handle peds cases?

 

[Lem0nz]

The standard of care is moving to (or just is, depending on who you ask) to have all patients with a new cancer diagnosis discussed at a multidisciplinary cancer conference where at least those three, but often many more docs are all present at the same time. This holds true across all spectrums, academic to private practice. Some places are still working to adopt this model, others are very very well versed at it already, but I think everyone is at least trying to get there. Surgical oncologists are often hired to do just that in a system: develop this sort of multi-D approach to cancer because it improves outcomes. I won’t accept a job where I’m not either a part of that or working to actively build is - just being a surgeon is the way of the past. Coincidentally, very few jobs where you’re just a surgeon and not part of a team or building a team like that exist anymore.

And I love those conferences. You learn *a lot* every time.

I do not operate on kids. That is generally still done by peds surg, and often sub specialists inside of peds surg (like pediatric CT surgery, pediatric plastic surgery, there are some pediatric oncology type surgeons). But those are ultra rare, because solid organ malignancies in kids are ultra rare.

 

[bioboy23]

What has been your longest oncologic procedure? (If not the whipples, I guess)

 

[HopeIsStrength]

Surg Onc is such a cool freaking specialty. So many props to you for pulling off that pathway. Did you have to do a ton of research to get into a surg onc fellowship? How competitive woudl you say getting the fellowship was? More so or less so than landing your GS residency spot? Also what are hours like in fellowship and what do you anticipate them being like as an attending?

 

[Lem0nz]

Longest operation was 14 hours on head and neck. Anytime they have to do a mandible resection and reconstruction with scapula tip or fibula, those cases are painful and very, very long. Whipples are not that bad open, 3.5-5.5 hours is our normal spread. Robot whipples can be tedious, 5-8 hours. I also did time on transplant and combo liver kidney transplants are all day and all night affairs.

Surg onc was far more competitive than getting into residency was. I first authored three papers that were fairly high impact (was clinical patient safety stuff but some really cool work on how community hospitals can improve things with little to no budget), a basic science paper on muscle kinetics back in Med school too. My residency did not allow for dedicated research time off so I did a lot of work on the side and during the day in down time. Probably had another 4-4 publications I wasn’t first author on, 10-15 posters or oral presentations, and went to 1-2 meetings every year since 2nd year, plus that masters degree in 4th/5th year.

Hours in fellowship are a thousand times better. 40-50 hours a week, almost never come in overnight, weekend rounds tend to be 2 hours a day and we share call with other specialties so call is like 1:4 weekends. Remember that there’s almost no real surgical oncology emergencies: those are all general surgery consults in the ER usually (bowel obstruction, bleeding tumors). Some of this easy hours is due to my fellowship being in an institution that was originally much more aligned with private practice style medicine with lots and lots of PAs. Some is just that onc is a better life. As an attending those hours will definitely go back up, but not to residency levels. Anticipate 40-50 hours/week in the hospital but another 10-20 on program building and practice management/documentation that I don’t currently do which can occur in or out of the hospital. Some attending jobs have attached general surgery call and some don’t. I’ll let you know in a week or two which I end up with, just finishing the process.

 

[Mnowledge]

I am applying Diagnostic Radiology. From a surgeon's perspective, what are your biggest frustrations with radiologists or radiology reports? What advice do you have radiology trainees to improve upon these?

 

[neriticzone]

How much head and neck does surg onc do versus head and neck trained otolaryngologists? Didn’t realize that surg onc did head and neck until recently. Do you learn micro as a surg onc fellow?

 

[Lem0nz]

I think the biggest issue we have with rads is not with the docs but the techs and making sure we clearly order the correct study with the correct thin cuts and contrast phases. Institutions having clear orders that delineate high res anatomical planning scans make a world of difference to clear that stuff up. Outside of that, it’s just communication, and it’s usually on us not on you. Keep your door open always and put on a smile when we interrupt your read for the 10th time in the last ten minutes, because we will. I’m blessed in that we generally have dedicated body imagers that sort of separate themselves out for our service lines, like we have a guy who is our go to for upper GI scans and since radiology is tied into our tumor boards so effectively, he either reads up front or rereads all our scans before tumor board so we’re always talking to the same people with the same expectations. Same with our IR team, we have an IR guy that does GI, one that does chest/neck, etc. It doesn’t mean that point person is always doing the procedure or the read, but they generally double check or interface with us so on both sides of the scanner the expectations are always the same, if that makes sense. Radiology always knows why we’re imaging and what our goal is, and we always know that we’re going to get scans, reads, and procedures that address our oncologic and surgical planning without having to explain that to each other.

So I guess my advice would be to find surgeons and radiologists who have that relationship in training and observe them closely, ask both of them how they developed that, and think ahead how you can develop that in your own practice one day. It is VASTLY more gratifying for both the radiologist and the surgeon when that relationship exists because you’re a part of the cancer team and you’re treating the patient alongside us, even if you aren’t giving chemo or cutting people. I’m told (and I believe) from our rads group that they feel it’s infinitely more engaging, fun, and rewarding that they feel like they’re treating people through their reads and advice as opposed to just churning through scans. Our radiologists will also tell us when we’re wrong, when there’s a better way, why there’s a better way, if there’s a better interval, etc. and make us consistently better surgeons through our own behavior as teachers. It’s invaluable and I love them for it.

 

[Lem0nz]

We do one to two months of head and neck. We are expected to be facile for all endocrine surgery (thyroid and para) and to be able to do at least level 2-6 neck dissections as we have to do them for a variety of reasons, but most often thyroid cancer and melanoma. We will occasionally be doing sarcoma or melanoma on the head/scalp/neck, we often do this with ENT as a team approach rather than one or the other. It is rare, probably almost never, that we do true facial surgery in surg onc and most surg oncs would be uncomfortable doing level 1 neck dissections I believe.

That said, we tend to find ourselves in administrative/direct type roles frequently where we may be overseeing ENT (amongst many many other specialties) as someone in charge of all surgical oncology service lines or even entire oncology departments, so basic knowledge of what ENT does and why including the Med onc and rad onc pieces is critical. Emphasis on basic knowledge, but it’s important still.

We do not do micro or free flaps. In general we don’t tend to do flaps at all except sartorious flaps or dermal flaps, and many of us won’t even do those and have plastics do all reconstruction. But some of us do mild to moderately advanced reconstruction by ourselves. Depends on your training. I think the majority do not.

I would add that in general surgery residency many places have little to no head and neck exposure so compared to even a generic ENT resident we are not as facile with the anatomy probably, but we have seven years of surgical technique when we finally get to ENT in fellowship so it’s not hard to teach us that in a relatively short time period because we don’t need to be taught surgery, just exposure, if that makes sense.

 

[Neopolymath]

Great thread. I have much respect for surg onc as I find it one of the last surgical specialties graduating "total surgeons" for lack of a better term. I was always impressed by the older surg onc attendings in the OR as they went from endocrine to liver to the robot etc. A different breed, truly.

 

[Lem0nz]

I agree. That’s another reason I love it actually. The jobs I’ve narrowed down to, I’ve offered to be the “disaster surgeon” who will take all the cases no one else wants. I love those operations where something perforated or is bleeding or some tumor bomb went off in someone’s belly. You really have to know your anatomy and how not to hurt someone, and not every surgeon can or wants to do that. It’s really cool.

 

[Banco]

Some great detailed responses here. Very helpful.

Were there other specialties you considered? Did you go into GS being set on surg-onc or did you continue to explore other possibilities in residency?

 

[Lem0nz]

I went into residency wanting surg onc the entire time. Probably one of the major reasons I was able to match from a community 5 year program that didn’t have dedicated research time. Let me use all five years to work on research and making sure I was competitive. I did apply to trauma and the NIH as backup options but didn’t end up needing them. Definitely need a backup plan if you’re serious about surg onc (or peds surg), or really any competitive specialty.

 

[Matthew9Thirtyfive]

I have zero questions. I just wanted to say I love the Portal 2 reference in your avatar.

 

[numbersloth]

I did not do any dedicated research years, but I did do a masters in informatics and patient safety/quality through night school in my 4th and 5th years of residency.

Is this typical? I thought almost all surg onc fellowships required 7 years with dedicated research years?

 

[Lem0nz]

Incredibly atypical. I don’t know that anyone knows the numbers, but if I had to guess, matching without at least one dedicated research year (even one is lackluster) is probably less than 25%.

 

[bioboy23]

Is it pretty much required to do research as a surg onc attending?

 

[Lem0nz]

No, it is not. That's actually one of the biggest gripes I have (and many fellows and attendings) have with surg onc as a fellowship. It bills itself as an ultra-selective highly academic surgeon-scientist fellowship, but in reality the vast majority of fellows (80%) go into practice with no more than 25% dedicated research time, and often even less than that. A great deal of us just do surgery and don't do research at all after fellowship. In general we DO all tend to participate in clinical trials, but that is definitely not the same thing - that is just enrolling patients into national studies that someone else is running to help with data accrual.

It is a huge disconnect between what is required to get into a surg onc fellowship, what you do and learn in a surg onc fellowship, and what you actually do once you're an attending. There *are* surgeon scientist type people who go into surg onc and come out and run a lab, but they are a minority. Think ~10%.

 

[Lem0nz]

Probably worth throwing this link out there to the other post I did which is a very comprehensive overview of Surgical Oncology for those interested in pursuing it as a career.

 

[Detailsmatter]

how's the job market for academic positions in major cities?

 

[Lem0nz]

There haven't been that many job postings for academic positions for people right out of fellowship that I've seen. I believe that a lot of places are probably hiring internally or by word of mouth for those types of jobs. The ones I do see tend to be for experienced surgical oncologists and they're department head type jobs. That doesn't mean they don't exist - there are a handful. Maybe 5 or so that are entertaining someone fresh out of fellowship. But there are not a ton that I'm aware of.

 

[CoeXistMD]

Thank you for offering your perspective on training and job searching.
Are you considering joining a group practice with other surgical oncologists or are you interested in growing your own practice becoming the surg onc referal surgeon in your hospital? Any pros and cons that you have considered regarding this?
Thank you.

 

[Lem0nz]

Interesting question. Most group practices or private practices can generally only support one surgical oncologist. The reason is that these tend to be located in suburban or more rural areas. In the major cities surgical oncology is usually done at a high volume cancer center (and even in many suburbs and smaller cities) which can sustain more than one surgical oncologist - but usually no more than two or three, and these cancer centers often also have other subspecialists that deal specifically with cancer (breast, endocrine, HPB, transplant, colorectal, uro-onc, ortho-onc, thoracic-onc). Some of these cancer centers only have one surgical oncologist who deals with the rare and weird stuff (think HIPEC, sarcoma, HPB/pancreas like stuff); they often quickly take on an administrative role in setting oncologic surgery standards for the system even if they aren't operating on every type of cancer and act as leaders/educators.

The jobs I have been interviewing for are the latter - I would be the only surgical oncologist in the system for all the places I've applied and they are tertiary or quaternary referral centers where my emphasis is on HPB/sarcoma/HIPEC/melanoma. The reason I like this type of job is - little to no general surgery call, more emphasis on benign but serious open/complex general surgery issues which are elective, focus on HPB/pancreas/sarcoma/HIPEC which are what I enjoy, and with the exception of really complicated general surgery problems I'm only doing cancer operations. I also don't mind, but also don't particularly enjoy breast/thyroid/parathyroid/colorectal. Some of these jobs require you to operate on some or all of those things. In a group/private practice those are honestly probably going to be the bulk of your practice and you will only occasionally do the upper GI tract cancers and sarcomas, and may not do HIPEC at all.

As opposed to highly academic jobs where you may be just doing a single service line - like ONLY pancreas, or ONLY stomach, etc. I don't want to do that at all.

 

[Skarl]

Thanks for your very helpful answers in this thread!

What should students focus on during training to inform whether they might enjoy an academic or private/community practice oriented career more? Are most academic surgical oncologists performing basic science research (as opposed to more clinical/epidemiological/outcomes related research)? Finally, what would you say are differences in lifestyle/career between surgical oncologists and subspecialty oncologists (e.g. head and neck cancer, urologic oncology)?

 

[Lem0nz]

Of course, happy to help and love to chat.

Another good question. I think at the med student level if you're considering surgical oncology you should really seek out research opportunities in a basic science lab. It does *NOT* have to be a cancer lab. Can be an animal lab, bug lab, gene lab... whatever. The idea is to understand the type and scope of work and way of thinking and what a day in their lives looks like, and also hopefully get some publications on their CV. My own experience was pre-med and 1/2nd years of MS where I worked in a lab doing muscle mechanics/kinetics research. It had no medical application what-so-ever, was pure biomechanics, but the tools (fluorescent microscopy, animal dissection and specimens, enzyme harvesting, etc.) gave me a really good idea of what that world was all about.

Why is that important - because people in oncology, particularly surgeons, are INCREDIBLY active in the immunotherapy and tumor microenvironment arena. A TON of research is done on that, by surgeons, who are running basic science labs studying those very things. Or looking at tumor markers. Or looking at tumor targets for drugs. You get the idea. To answer your next question - are most surgical oncologists doing this?

Now. Take this with a grain of salt - my experience is from surgical oncologists who I met while interviewing mostly who are program director type people and I'd say about half to 2/3 of them had basic science labs. But the average surgical oncologist is a 75/25 clinical/research allocation for their work time. If you have a basic science lab and are a true surgeon scientist that can be closer to 50/50. If you're 75/25 or higher on the clinical side you are probably doing translational or clinical research studies.

Last question - specialists (ENT-onc, uro-onc, ortho-onc) work WAY more hours, get paid WAY more money (x2), and generally wish that they could just do cancer operations but can't. The problem is that many of these specialties require help with call coverage so they're in multi-specialty practices within their own discipline (like, 10 orthopods but only one is ortho onc). This means they're also in the ER call pool. For urology this means they're still doing LOTS of cystoscopes, foleys, stents. For ENT they're still doing LOTS of video DLs in the office and trachs. All of our non gen-surg type specialists who are cancer fellowship trained or cancer practice oriented all have those call burdens and "regular" duties inherent to their specialty. Surgical oncology definitely CAN have that same obligation with general surgery, but I would say that's actually becoming more rare. Lots of surg oncs don't take general surgery call, and there is not really such a thing as a surgical oncology emergency - those are called general surgery emergencies. Also, those non-gen surg sub-specialists usually have a smaller scope of cancer operations. Like our uro onc team is 5 people, but one does all the prostates, two do all the kidneys, one does all the bladders, one does the weird penis stuff (yikes). Our ENT guy essentially does the same like 4 operations - face/parotid dissection, laryngectomy, neck dissection, weird mouth resections. Sure, there's 10,000 variations inside of those things, but you can boil it down to that. Ortho onc does pathologic fractures from cancer, extremity sarcomas and bone cancers which are exceedingly rare tumors. Surg onc has way way more realms that we're trained in and capable of doing. Does that mean we all do? No. But there are definitely still true general surgical oncologists who operate head to toe and are fascicle in 40-50 very distinct operations. Also the money discrepancy usually has nothing to do with their cancer practice and is because of call, scope, cystos, normal joint replacements, whatever. The cancer piece is usually a passion and not the primary driver of income. Our urologists make WAY more on their cysto days where they churn out 20 cystoscopes in a single day than 3 nephrectomies. Same with the ENT guy - every time he does an office cancer surveillance visit he has to do a video direct laryngoscopy which takes like maybe five minutes but its a billed procedure every visit, for nearly every patient.

 

[peachrings]

How difficult is it to match into a Surgical Oncology fellowship from a low/mid-tier/community general surgery residency?

 

[Lem0nz]

Without two years of dedicated research nearly impossible. For me it was a factor of absolute dumb luck and outside the match. I was still a VERY competitive applicant and had multiple publications and a masters degree I did during residency but its just not what most surg onc programs are looking for or care about.

With 2-3 years of dedicated research, challenging but very very do-able with excellent ABSITE scores and 5-10 publications; you will probably match. But ~30% probably still won't match even with those things. Maybe higher than 30%. Match rate for IMGs is also abysmal - when you add in COVID, Visas, shifting political winds, and limited training spots, many aren't even considered except as a last resort (or just not considered at all). The fellowship is so competitive the programs simply don't have to compete and generally don't want to take on the extra hassle or uncertainty.

 

[AnatomyGrey12]

Thank you for all of your posts, they have been very informational. Surgical oncology is a specialty that has piqued my interest in the last few months, and I would like to go to a program that leaves that door open. Is it a red flag if a program has a robust surgical oncology lab but in the last 10 years no one has gone into surgical oncology?

 

[Lem0nz]

Not necessarily. Matching is far more on the applicant than on the program. If said labs are making you productive and you publish, and do well on your Absite, you’ll probably match. If you need more specific information or want to share where you’re applying can do it privately if you think that would be helpful.

 

[Dunkthetall]

What do you think of one to two year HPB fellowships? I’ve been reading about them, and a doctor thinks they won’t last much longer because they’ll get squeezed by surgical oncology and transplant, who they think can do the surgeries better.

 

[Lem0nz]

Not sure. Surg-onc can't do HPB better than HPB - my experience is that they're about equal or tilted in favor of surg-onc for pancreas, and HPB is better at liver, but I have no data or evidence for that. Surg-onc however is FAR more versatile where HPB is a horribly limited space to operate in that generally cannot support a pure HPB practice on patient volumes. Transplant can operate on the liver better than both, there is no question, though often times much less well versed in the minimally invasive space. Transplant+Surg/Onc combo makes an HPB surgeon entirely unnecessary in an institution though, that's a true statement.

 

[Lawpy]

This is a pretty great thread, esp as someone like me who's potentially interested in surg onc

 

[Lawpy]

Longest operation was 14 hours on head and neck. Anytime they have to do a mandible resection and reconstruction with scapula tip or fibula, those cases are painful and very, very long. Whipples are not that bad open, 3.5-5.5 hours is our normal spread. Robot whipples can be tedious, 5-8 hours. I also did time on transplant and combo liver kidney transplants are all day and all night affairs.

Surg onc was far more competitive than getting into residency was. I first authored three papers that were fairly high impact (was clinical patient safety stuff but some really cool work on how community hospitals can improve things with little to no budget), a basic science paper on muscle kinetics back in Med school too. My residency did not allow for dedicated research time off so I did a lot of work on the side and during the day in down time. Probably had another 4-4 publications I wasn’t first author on, 10-15 posters or oral presentations, and went to 1-2 meetings every year since 2nd year, plus that masters degree in 4th/5th year.

Hours in fellowship are a thousand times better. 40-50 hours a week, almost never come in overnight, weekend rounds tend to be 2 hours a day and we share call with other specialties so call is like 1:4 weekends. Remember that there’s almost no real surgical oncology emergencies: those are all general surgery consults in the ER usually (bowel obstruction, bleeding tumors). Some of this easy hours is due to my fellowship being in an institution that was originally much more aligned with private practice style medicine with lots and lots of PAs. Some is just that onc is a better life. As an attending those hours will definitely go back up, but not to residency levels. Anticipate 40-50 hours/week in the hospital but another 10-20 on program building and practice management/documentation that I don’t currently do which can occur in or out of the hospital. Some attending jobs have attached general surgery call and some don’t. I’ll let you know in a week or two which I end up with, just finishing the process.

But to clarify, all the neuro/brain cases are done exclusively by neurosurgeons right?

 

[Lem0nz]

But to clarify, all the neuro/brain cases are done exclusively by neurosurgeons right?

Yes.

 

[DanOKT]

Thanks so much for this AMA!

You reference working part-time in your write-up (which I also found extremely helpful!), though I am a little curious about the mechanics. I very much want to have the option to prioritize family time as an attending, and I'm willing to do so at the expense of salary. Is there any practice structure where I could pick up entirely elective cases ie breast, thryoids, paras, neck dissections, adrenals, melanoma truly part time ie 30-40 hours/week, obviously with a pay cut?

 

[Lucca]

Not sure. Surg-onc can't do HPB better than HPB - my experience is that they're about equal or tilted in favor of surg-onc for pancreas, and HPB is better at liver, but I have no data or evidence for that. Surg-onc however is FAR more versatile where HPB is a horribly limited space to operate in that generally cannot support a pure HPB practice on patient volumes. Transplant can operate on the liver better than both, there is no question, though often times much less well versed in the minimally invasive space. Transplant+Surg/Onc combo makes an HPB surgeon entirely unnecessary in an institution though, that's a true statement.

Are there many transplant + onc surgeons? that sounds like 10-12 years of post grad training almost no?

 

[Lem0nz]

Thanks so much for this AMA!

You reference working part-time in your write-up (which I also found extremely helpful!), though I am a little curious about the mechanics. I very much want to have the option to prioritize family time as an attending, and I'm willing to do so at the expense of salary. Is there any practice structure where I could pick up entirely elective cases ie breast, thryoids, paras, neck dissections, adrenals, melanoma truly part time ie 30-40 hours/week, obviously with a pay cut?

I think you could do a 30-40 hour/week breast practice very easily. Maybe not at first right out of the gate, but there is so much demand and so many openings I bet you could pull that off no problem. 4 day work week, 8-4 or 8-3. Two clinic days, two OR days. You would have to figure out something for rounds but most pure breast jobs do not expect general surgery call.

Most endocrine surgeons start their career doing general surgery call. That might be a harder practice to swing right out of the gate and you'd have to work towards that over time I think.

I would target an endocrine fellowship or a breast fellowship though. Would not bother with surg/onc - it will not get you that lifestyle or that tailored/limited practice (it could, but is not worth the effort at all).

 

[Lem0nz]

Are there many transplant + onc surgeons? that sounds like 10-12 years of post grad training almost no?

Not really, no. Transplant is its own niche and is all consuming. If you do transplant training and then don't actually do transplant then you'll probably switch to an HPB/general surgery practice (though some do add sarcoma and general abdominal oncology to that. It's technically all covered in general surgery residency and they have the technical skills, certainly). I have heard of one or two people who did transplant as a 'gap year' to make themselves more competitive for surg-onc, but that's super rare and pretty painful.

I don't know anyone who would do transplant after onco voluntarily unless they wanted to do just liver, and even then there are probably better ways to do that and get there.

 

[Detailsmatter]

Not sure. Surg-onc can't do HPB better than HPB - my experience is that they're about equal or tilted in favor of surg-onc for pancreas, and HPB is better at liver, but I have no data or evidence for that. Surg-onc however is FAR more versatile where HPB is a horribly limited space to operate in that generally cannot support a pure HPB practice on patient volumes. Transplant can operate on the liver better than both, there is no question, though often times much less well versed in the minimally invasive space. Transplant+Surg/Onc combo makes an HPB surgeon entirely unnecessary in an institution though, that's a true statement.

For whatever it’s worth I agree with this. At my institution there’s no HPB service but transplant covers transplant obviously and also all HPB cases. Just don’t know how common that is everywhere else

 

[Matthew9Thirtyfive]

Are there many transplant + onc surgeons? that sounds like 10-12 years of post grad training almost no?

I think he meant if a hospital has a transplant surgeon and a surg onc doc, then they wouldn’t need an HPB surgeon.

 

[Lucca]

Not really, no. Transplant is its own niche and is all consuming. If you do transplant training and then don't actually do transplant then you'll probably switch to an HPB/general surgery practice (though some do add sarcoma and general abdominal oncology to that. It's technically all covered in general surgery residency and they have the technical skills, certainly). I have heard of one or two people who did transplant as a 'gap year' to make themselves more competitive for surg-onc, but that's super rare and pretty painful.

I don't know anyone who would do transplant after onco voluntarily unless they wanted to do just liver, and even then there are probably better ways to do that and get there.

ahhh ok I think I misunderstood what you meant originally.

By the way, above when you discuss specialist onc surgeons (ENT/uro/ortho etc) and say they work more but make more because of cross-call, etc. in practice. Does that apply to academics? I imagine a lot more general ENTs and such would be around so less cross-call needed but more academic / admin / research / teaching duties. I'd be interested to know how surg onc vs specialist onc surgeon lifestyle is in academics, if you're familiar.