The Real Surgery FAQs

[Winged Scapula]

**Disclaimer: This is a project in development. I will most likely take me several weeks to compose. Please be patient and let me know if there is something missing or incorrect.**

TABLE OF CONTENTS:

PAGE 1
Post 2)Applying to General Surgery Programs
3) Case Logs/Index Cases
4) Fellowships/Surgical Subspecialties
5) Integrated Programs
6) Preliminary vs Categorical Positions
7) Program Rankings
8) Dictating Operative Reports
9) Books for Surgery
10) Surgical Atlases
11) ABSITE
12) Moonlighting

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[Winged Scapula]

How do I apply for a general surgery residency position?

Like most other specialties, the application for general surgery is handled by the Electronic Residency Application Service (ERAS: http://www.aamc.org/audienceeras.htm) which processes your application and sends it electronically to the programs you've applied to.

The actual match is administered by the National Residency Match Program (NRMP: http://www.nrmp.org). Note that you must register for both ERAS and NRMP to participate in the match if that is the method your chosen program(s) use for applications. Not all programs participate, but the vast majority do.


What materials do I need to apply for general surgery through ERAS/NRMP?

Start off your 3rd year by having a CV constructed and updating it as needed. Don't worry if it doesn't contain much information now; no one expects it to. Keep it available for faculty when writing letters for you and for when applying. You can simply cut and paste it into ERAS.

You can submit your ERAS application as early as the first week of September. The site is usually open late July/early August, so you can start to work on the application then and submit it early when the site is open.

You should give your personal statement some thought during 3rd year so that you have time to write and rewrite it, as well as have numerous people look over it. Don't believe the advice that says no one looks at these or that it doesn't matter. A poorly written PS can significantly impact your application.


Can I submit multiple personal statements and personalize them for different programs or specialties?

Yes. ERAS will allow you to submit more than one personal statement and you can decide which version goes to which program.

This is true for LORs as well. You can designate certain letters go to certain programs which can be helpful for those who are applying to more than one specialty.

Can I submit a letter from a non-surgeon? How would that look?

Conventional wisdom has it that letters for surgery training programs should be from surgeons. Other fields that tend to hold weight with surgeons would be critical care, anesthesiology and gastroenterology. Letters from these specialties would also be acceptable (but no more than 1 in your application). Unless your pediatrics supervisor is well-connected in the surgical field that letter should not be included in your application. As for all other fields, letters from clergy, politicians and family friends are to be avoided.


How long should my personal statement be?

The conventional wisdom holds here, even with the newer electronic submission. Do not exceed 1 page; conversely, your PS should be more than a couple of paragraphs. This implies that you did not care enough to spend time on it, or were too disorganized to do so. Its your only opportunity to tell a PD more about yourself beyond your academic record.

Do they really read the Personal Statement?

Yes. See above.


What is the deadline for applications to General Surgery?

The most common program deadline is November 1st in the year preceding start of residency training. There are a few programs which have earlier deadlines, usually in mid-October. Please note that ERAS and NRMP may have later deadlines (commonly December 1st), but the individual program deadline is most important, as programs may not evaluate applications received via ERAS after their deadline (but as long as you've made the ERAS deadline, you will pay to have the application transmitted, which can be wasted money if it arrives after the program's deadline). Individual program information can be found on FREIDA (http://www.ama-assn.org/vapp/freida/srch/ ). As always, check with individual programs for specifics.

For further reading on the topic of being a surgeon see these links:

One of the best from the American College of Surgeons: So, you want to be a surgeon: a medical student's online guide to finding and matching with the best possible surgical residency.
http://www.facs.org/residencysearch/index.html
Sections include surgeon traits, residency interviews, surgical specialties, career lifestyle issues, and a fabulous searchable database of all surgical residencys with information provided by the PD's.

Further information for medical students from the American College of Surgeons.
http://www.facs.org/medicalstudents/information.html

The Accreditation Council for Graduation Medical Education
http://www.acgme.org/adspublic/program/
Fully searchable database from the ACGME for any residency with data regarding the number of positions (categorical and preliminary), number of filled positions, months spent at participating hospitals.

 

[Winged Scapula]

What are "index case/procedure" requirements? As far as I can tell, they are the case types you need to be board eligible. But aren't most cases (aside from really minor ones) going to contribute?

Sadly, you will find that MOST cases you do, even as a mid-level resident do NOT count toward your totals. For example, none of the lines, trachs or PEGs will count, nor will amputations on vascular, excisional biopsies or lumpectomies of the breast, appendectomies, hernias, etc. don't count.

You need the minimum number of cases to graduate from your program and be considered board eligible. The following link gives you the minimum number and the types of cases that "count":

http://www.acgme.org/acWebsite/RRC_440/440_policyArchive.asp

 

[Winged Scapula]

What are the training options outside of general surgery?

We can divide this into those that are Surgical Subspecialties (ie, those that do not require full general surgery training) and Surgical "Super" Specialties (ie, those which require a full [or nearly so] training in general surgery; often called fellowships):

Surgical subspecialties are those which generally require 1 or 2 years of general surgery as preliminary training before going onto the advanced training. One usually matches to the preliminary general surgery year(s) at the same time as they do the advanced specialty training. Examples:

Urology
Orthopaedics
Otolaryngology
Neurosurgery
Integrated Plastic Surgery (really doesn't fit into either category; can be 3+3, 4+2, 2+3 denoting years of training in general surgery plus plastics)

Surgical "Super" Specialties (aka "fellowships"). These are generally entered into after at least 5 years of general surgery training. There are some programs which are beginning to offer integrated training - ie, Vascular and CT, in which one matches right out of medical school. However, these are few and far between, so for the time being, most of the fellowships or advanced residencies below are applied for during late general surgery residency and completed after finishing general surgery:

Cardiothoracic
Thoracic
Vascular
Surgical Oncology
Hepatobiliary
Colorectal
Transplant
Minimally Invasive
Bariatric
Breast
Endocrine
Trauma/Critical Care
Surgical Critical Care (without trauma)
Pediatric Surgery
Head and Neck (mostly take ENT residents, but some will take gen surg)
Independent Plastic Surgery
Burn
Hand (only a few programs take non-Ortho or non-Plastics trained residents)
Rural General Surgery (only a few programs)

These would be considered the most common of fellowships. There are lots of "super, super" specialties out there with training programs; ie, ECMO fellowships, Medical Authorship, and of course, each of the subspecialties also have further training programs (ie, Craniofacial, Aesthetic Breast, etc. for Plastics; Ortho Spine, Neuro Spine, Ortho Hand, Head and Neck, Pediatric ENT, etc.)

 

[Winged Scapula]

Are there any combined programs in surgery? I don't want to waste my time doing lots of general surgery!

An Integrated Program is one in which the student matches during their final year and begins a period of training in which the specialty is interwoven, or integrated, during a variable period of general surgery prerequisite training. Currently the most popular and well established of the general surgery integrated programs is for Plastic and Reconstructive Surgery in which the student matches during their 4th year and then enters into a "3+2, 4+2, 3+3, etc." Integrated program in which the first few years are spent doing general surgery with some plastic surgery rotations (the "prerequisite training") before moving onto dedicated specialty training. Programs offering these positions usually do so through the NRMP. Further information on such programs can be found there as well as at ERAS and the individual program web sites.

More recently, Integrated Programs for Vascular, CT and Thoracic Surgery have been contemplated. To date, Vascular programs seem to be the most organized and are offering positions. The following SDN thread will be of use in reading about these programs: http://forums.studentdoctor.net/showthread.php?t=343745
as well as Vascular Web ( http://www.vascularweb.org/_CONTRIB.../New_Vascular_Surgery_Training_Paradigms.html) which discusses the new ACGME approved programs in Vascular Surgery. It is important to note that many of these integrated programs do not lead to BE or BC in General Surgery because the physician will not have completed the full training in general surgery. Therefore, those who are interested in being boarded in general surgery should seek training in traditional fellowships.

Several other specialties have discussed Integrated training programs but have not proceeded with viable programs to date. This includes CT Surgery and Pediatric Surgery.

 

[Winged Scapula]

What is the difference between preliminary, designated and non-designated preliminary and categorical residency positions?


Preliminary: usually 1-2 years of training done at the beginning of your residency period that does NOT lead to board eligibility in general surgery.

Designated preliminary: a position designed or "designated" for an intern who needs 1-2 years of training before going on to a surgical specialty; ie, ortho, ENT, Urology, etc. Many surgical specialties require 1 year of general surgery before embarking on training in the field which leads to board eligibility. Thus, most general surgery programs will designate a certain number of preliminary positions for these candidates; they cannot be filled by non-designated applicants until all the designated positions have been filled.

Non-designated preliminary: a position designed for candidates who are not required to do a surgical internship but rather have to do either surgery or medicine (ie, Anesthesiology, Dermatology); a position designed for candidates interested in general surgery board eligibility but who have failed to either match or otherwise secure a Categorical position (see below).

Categorical: Residency leading to board certification in general surgery (i.e., a 5-year or longer residency).


I am a preliminary surgical intern. Do I have to apply all over again for a position next year?

It depends. If you have a designated position, such as a first year in general surgery in preparation for a residency in Urology/Ortho/ENT etc, you should have matched for your PGY-2 position at the same time you matched into your preliminary year. If you didn't match at that time (during your 4th year) then you will need to either go through the match or find a position outside of the match.

If you have a non-designated 1 year preliminary position you need to try and obtain training for PGY2 and beyond through the match. Even if the program you are currently training at gives you reason to believe they will offer you a position for next year, unless you have it in writing, you need to go through the match again. Programs are not required to give you a contract until April 1 (90 days before the traditional July 1 start of residency) – a long time after the match. If you don't have a contract from them before mid-fall (when applications go in), you must apply or start looking for a position elsewhere.


How can I interview for these positions during internship?

Most programs will make you use your vacation time for residency interviews. It is difficult and you must try your hardest to get near-by interviews or to arrange them together to eliminate excessive traveling and use of vacation time.


Are preliminary residents treated differently? Do they have different rotations?

The conventional wisdom seems to be that this is the case, but this may be more urban legend than anything. Designated prelims are required to have certain rotations which may not be part of the General Surgery curriculum (ie, Rheumatology, Ortho and Plastics for the Ortho resident; subspecialty rotations for all designated prelims). An anesthesia resident doing a surgical prelim year may be offered less OR time and more time in the ICU or ER during his intern year. While others have claimed that non-designated prelims get less OR time and more scut work than the Categorical residents, I believe this to be program specific as it was not the case at my residency.


Is there a chance that I can get a Categorical position at the program where I'm currently a non-designated prelim?

Of course, unless you have been outrightly told otherwise by your program. In essence, the intern year can be a year-long audition. Many programs will keep on preliminary residents they like and think are doing a good job in an effort to move them into the categorical track. That may not happen until after 2nd year when many residents in university programs go into the laboratory; if there are fewer residents going into the lab than coming out, the program will be short a resident for that clinical year. This may be the opportunity for the preliminary to stay on and become a categorical resident. At less academic programs without lab research years, this may be more difficult to do unless someone quits or is fired.

As always, try and get something in writing, especially if you are in 3rd year as you must finish your final 2 years at the same program to be board eligible. Finally, please note that the American College of Surgeons (ACS) has decided that residents training in more than 3 different residency programs, starting in 2007, are NOT eligible for Board Certification. See the ACS website for further information: http://home.absurgery.org/default.jsp?policynumberofprograms&ref=certgsqe

 

[Winged Scapula]

Where can I find information on the best surgical programs in the US? Is there a ranking like US News and World Report?

There is no formal ranking for residency programs. Entities like US News and World Report use information like NIH and research funds to gauge the "best"; this may have little relevance to what the "best" surgical program is for YOU.

When ranking programs, medical students often use the following as factors in their decision (the order will depend on you and your needs):

geographic location
academic, research oriented program (may require some years in the lab)
fellowship match data
"feel" of the program when they interview, along with surmised happiness of the residents
employment for spouse/SO

Bottom line is that what might be the best residency for you, would not necessarily be so for the next person.

There are a couple of sources for residency reviews:

SDN is starting its residency interview database. It is not available for review yet, but current residents are encouraged to enter data.http://www.studentdoctor.net/residency/

Scutwork seems to be back up on-line and active; this probably has the most threads although many are old and written by medical students. http://www.scutwork.com

A new database specifically for general surgery residencies has been developed. I haven't used it but it may be worth a look: http://www.residencyreviews.info

You may also find the following information from the American Board of Surgery on individual program pass rates, helpful: https://home.absurgery.org/xfer/fyp2007summary.pdf

 

[Winged Scapula]

"My attending wants me to dictate the case we did together. I have no idea what to say. Are there any resources to help me?"

There is a lot of learning and mistakes that go into dictations. Some attendings won't have you dictate because its a legal record and its more work for them to correct your mistakes, but you NEED to learn. And its best to start as early as possible.

While there may not be a standard script at your stage, you will develop one for the routine operations you do as an attending.

Some tips:

Identifying information: Start off by identifying yourself and spelling your name. "This is Dr. Kimberli S. Cox, spelled K-I-M.., dictating an operative report on John Q. Public, Medical record number xxxx, on (date).

Details about the Case (similar to what you would write in your brief operative summary)
Attending: xxxxx
Assistants: spell all names, give titles or PGY #s
Procedure: name of operation and/or procedures performed; since this can be used for billing, make sure you name anything billable (ask if you don't know)
Anesthesia: general vs local, regional blocks
Estimated Blood Loss: (get from anesthesia)
IV Fluids: ditto
Urine output: ditto, if measured
Specimens: whatever you took out
Drains: if any
Complications: if any

Then go on to the Indications for the procedure. For example:

Jane Q. Public is a 55 year old female who presented to Hospital X with a Class 5 Mammography and a right breast stereotactic biopsy postive for invasive ductal carcinoma. After a discussion with the patient regarding her treatment options, including right partial mastectomy with sentinel lymph node biopsy and possible axillary dissection versus Simple Mastectomy with Axillary staging, the patient has given her consent for the former. She understands the risks, benefits and alternative and freely gives signed and verbal consent.

Procedure:

Here you state what you actually did. My example would be something like:

The patient was brought to the operating room, properly identified and placed in a supine postion on the operating room table with her right arm extended at 90 degrees. A time-out was performed in which the patient, procedure and laterality were confirmed by the attending surgeon and anesthesiologist. She had previously undergone injection with Technetium-99 in the Nuclear Medicine Department of Hospital X as well as mammographic-guided wire localization in the Women's Imaging Center. These were tolerated without complications.

After satisfactory induction of general endotracheal anesthesia, bilateral sequential compression devices were placed on the patient and a Foley bladder catheter inserted. The localizing wires were snipped short to prevent dislodgement. The Neo-probe 2000 was used to mark an area of radioactivity around the right breast. The maximum in-vivo count was xxx. Five ccs of methylene blue was injected intradermally into the right breast. Her right chest was then prepped with Betadine and draped in the usual sterile fashion. Using the mamographic images provided as guidance, a skin incision was made at xxx o' clock using a number 15 blade. The deeper tissues were then divided using Bovie electrocautery....

blal blah blah

Then at the end, always include some statement such as:

At the end of the procedure, all sponge and instrument counts were correct times two per OR nursing staff. The wound was cleansed, dried and dressed with Steri-strips and a sterile occlusive dressing. The patient was awakened from anesthesia and transported to the recovery room in stable condition (provided that is true). Dr. Attending was present and scrubbed for the entire/significant/difficult portions of the procedure (whatever is true).

The restate your name, the patient's name and med rec number, the date and the attending you are dictating for. If they give you a confirmation number, always write it down, so if it comes up that you "didn't do the dictation" you have some backup to show.

There are books with some sample dictations and you can probably find some on-line as well. Here's one thats pretty popular and I believe there is also an electronic version as well: http://www.amazon.com/Operative-Dict.../dp/0387955895

As always, make sure that you did what you are dictating - ie, if there are deviations from standard, you must mention these. Ask the attending if there are things you don't need to mention (ie, if the initial instrument count was incorrect, but then you found the needle on the floor, you don't necessarily need to comment on that. It only provides fodder for any potential lawsuits later and doesn;t change the outcome of the case.).

Eventually, what you do will become standard in your mind and practice - ie, the same way every time, so your dictations will become rote.

 

[Winged Scapula]

There are many books, handbooks, review books and atlases for surgery on the market; choosing the right one for you can be a challenge. Like any other field, the right book is one that you will USE, and not just look pretty on the shelf.

Your program will likely choose a MAJOR textbook to use for residency education and as its preferred reference book. If many of your faculty are chapter authors, expect that book to be the "chosen one". Do not buy a major textbook before starting residency, especially if you are a Categorical - it may be purchased for you. The BIG NAMES you will hear are:

- Cameron:Current Surgical Therapy (http://www.amazon.com/Current-Surgi...3284111?ie=UTF8&s=books&qid=1179269832&sr=8-1)
- Greenfield's Surgery:Scientific Practices and Principles (http://www.amazon.com/Greenfields-S...3284111?ie=UTF8&s=books&qid=1179269896&sr=1-1)
- Schwartz's Principles of Surgery (http://www.amazon.com/Schwartzs-Pri...3284111?ie=UTF8&s=books&qid=1179269955&sr=1-1)
- Sabiston Textbook of Surgery (http://www.amazon.com/Sabiston-Text...3284111?ie=UTF8&s=books&qid=1179269991&sr=1-1)
- ACS Surgeryrinciples and Practice (http://www.amazon.com/ACS-Surgery-P...3284111?ie=UTF8&s=books&qid=1179270073&sr=1-1)
- Mastery of Surgery (http://www.amazon.com/Mastery-Surge...3284111?ie=UTF8&s=books&qid=1179270138&sr=1-1); almost more of an atlas

By far and away, the most comments from SDN users are about Cameron and Greenfield. Here are some suggestions/advice from SDN surgical residents, fellows and attendings:

TEXTBOOKS

Cameron - Current Surgical Therapy: "easily the fastest read if you need to figure out what to do with someone. NO basic science to speak of. The book gets updated virtually every year so hang on to old editions as the following book may have chapters written by totally different people."

"Cameron's Current Surgical Therapy is easily the favorite of most of my colleagues. Very easy to read with to the point chapters. It does not have the extensive chapters on basic science material that some of the others have, but you really never read that stuff."

"Cameron, Cameron, Cameron. This book rocks. I use it daily. Definitely all clinical and minimal basic science though."

"To me Cameron's is a little too basic. Maybe I feel that way because I didn't really look at it until I was further along in my residency though. I was also annoyed by the lack of attention to detail. When I read it a few years ago, I couldn't help but notice lots of errors. One of my junior residents just got the new edition and he's already pointed out several errors to me. Those errors, albeit small, still make the text hard for me to rely upon. IMHO, a book that's through this many iterations just shouldn't have that problem."

"Cameron's is usually the most succinct & easy to read while being the most up to date due to its shorter publishing cycle ."

"Cameron seems sort of superficial to me. Also, due to the large number of contributing authors, there's a lot of variance in chapter quality. Some of the chapters seem more interested in focusing on the authors' own esoteric considerations, rather than giving the reader a good grasp of the material. On the plus side, since the new edition just came out this year, it's fairly current."

"Cameron is a good book, but not for first year. It's more an opinion book and doesn't have the background that the others have."

"A lot of people like Cameron, but that's more for upper-level residents than interns - you need more basic science and background pathophysiology type stuff that Sabiston and Greenfeild emphasize more than Cameron (which is much more of a clinical and operative managment emphasis)."

Greenfield: "I've been reading Greenfield periodically. It's pretty solid. Covers the basic science aspect, and the clinical aspect well."

"I think Greenfield probably does the best job with covering basic science..."

"During internship, I read the Basic Science Section of Greenfield which more that prepped me for ABSITE and kept the pimp questions answered. This is essentially the first half of that text."

"I also bought Greenfield (probably too much basic science)..."

There are a few random and scattered comments about Sabiston, Schwartz, ACS Surgery and Mastery of Surgery in this thread: http://forums.studentdoctor.net/showthread.php?t=189749

 

[Winged Scapula]

An atlas is a book which gives you more details, including drawing and/or pictures of actually HOW TO DO an operation. The favorites are:

ATLASES

- Zollinger's Atlas of Surgical Operations (http://www.amazon.com/Zollingers-Su...3284111?ie=UTF8&s=books&qid=1179270604&sr=1-1)
- Chassin's Operative Strategy in General Surgery - there are volumes for surgical subspecialties as well (http://www.amazon.com/Chassins-Oper...3284111?ie=UTF8&s=books&qid=1179270819&sr=1-1)
-Skandalakis and Skandalakis (Surgical Anatomy and Technique; http://www.amazon.com/Surgical-Anat...3284111?ie=UTF8&s=books&qid=1179270977&sr=1-1)

Some comments from SDN users about these:


Zollinger:" like Zollinger although it doesn't have everything [in the way of subspecialties]"

"Zollinger is just too little text for my taste."

Chassin: "My favorite expositive atlas. To me, it is the best mix of pictures and text for an atlas. New edition came out this year. Only covers general surgery. You'll need supplements for any subspecialties you rotate on."

" I love the Chassin - Operative Strategy text."

Skandalakis: "...i've found really helpful are: Skandalakis Pocket Manual of Surgical Anatomy and Technique (it's actually too big to fit into a pocket)..."
"
For a cheaper, more portable "atlas" (ok its not really an atlas but has lots of drawings and how to stuff) check out Skandalakis and Skandalakis."

Mastery of Surgery is not hawked as an atlas but in reality it is, with lots of text. Worth checking out, although probably falls into the realm between textbook and atlas - not enough of either, but good details on actual procedure.

 

[Winged Scapula]

The ABSITE, or American Board of Surgery In-training Examination, is offered once a year on the last Saturday in January. All categorical surgery residents in the country take the exam on the same day although there are some allowances for illness and religious reasons made.

Some programs require designated Preliminary residents take the exam and others do not. Non-designated Prelims who are vying for a categorical position and offered the opportunity to take the exam should, as this will be a factor in application review.

It is a multiple choice examination, currently completed with pencil and Scantron-type paper, and approximately 225 questions. Recently two different versions of the exam have been produced: one for junior residents which is more basic science oriented and the more clinically oriented senior examination. Scores are reported in percentile fashion and a report is given to each resident which shows individual performances in each area tested.

Classically, the exam focuses on liver, biliary and pancreas; trauma and critical care; breast, endocrine and head and neck. This reflects the current focus of the ABS Board Qualification examination as well. However, all areas of general surgery are "fair game" and in the junior exam, many basic science questions on nutrition, surgical physiology and some cell biology may be expected. Surgical subspecialties such as Orthopedics, ENT, Urology, Gynecology and Plastics will appear on the examination as well. These areas are "low hanging fruit" which can make a significant difference in a resident's score...if you get these questions correct where most others don't, your score will be all the better for it.

Like the USMLEs, programs are not supposed to use the exam for the purposes of resident advancement, but many do. Your program can tell you if a certain score is required to advance to the next year or avoid remediation.

There are many good resources for the ABSITE; the following tend to be the most popular:

ABSITE Killer: out of print; 30 pages (1 page per specialty) of bullet points. Well worth getting from a senior resident for a quick night before review.

The ABSITE Review: Steven Fiser - available on Amazon; high yield, much better (IMHO) than his recent additions, The Senior ABSITE Review and ABSITE questions

RUSH Review: probably harder than the actual exam; very dense, detailed

Michigan State ABSITE Review: not as thorough as others, compiled from years of examinations; not sure if there is a new one to reflect change in format of exam

SESAP: written for the ABS Qualifying Examination, but a good review as the ABSITE becomes more clinical. Expensive.

Physiological Basis of Surgery: textbook, best for junior exam.

General Surgery ABSITE and Board Review by Blecha and Brown: stinks, IMHO, as do their other books. Error and typo filled. Read my Amazon review to see what I *really* think.

Surgical Review: errors as well, and very basic. Would only use for a easy introduction before getting into more detailed studying; probably not sufficient for senior exam.

Finally, the ABS is VERY concerned about their product and vigorously pursues anyone who sells, posts or otherwise shares test questions with other users. Therefore, let this serve as a warning that they DO monitor SDN for these violations and that posting of such will result in the threads being removed.

See this thread for further details: http://forums.studentdoctor.net/showthread.php?t=189802

 

[Winged Scapula]

Moonlighting, or working outside of your regular residency duties, is a popular way to make extra money.

Howeer, moonlighting counts toward the 80 hour limit if done at your home institution. So, general surgery residents are generally precluded from moonlighting and many programs will prohibit it, even on days off or vacation (whether that is enforceable or not, is up for debate. But the wise resident will not anger the faculty "Gods". )

In your research year(s), if you have a full and unrestricted medical license a DEA #, and the permission of the department, you can moonlight. You can often make 50 - 110 dollars an hour covering ERs, and being on-call to run codes. Doing so, you can easily double your residency salary.

It is a nice way to make some extra cash, but there are considerations. Making that extra money will push you into a higher tax bracket. You will have to pay more in taxes. Since you are often working outside of your residency, you must make sure you are covered by malpractice with a tail after you leave.