Thyroid/Endocrine surgery

[675R]

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I am interested in treating thyroid patients, perhaps surgically, but it seems this area of work is a bit spread out amongst ENTs/general surgeons. Read the prior threads, seems endocrine is a somewhat fought over area of procedures, and I am wondering how beneficial the endocrine fellowship is for general surgeons.

If thyroid/parathyroid were to be my area of interest, would it behoove me to pursue breast/endocrine fellowship to make my skillset more marketable (and of course also do general surgery). I have seen some ENTs that do thyroid, but it doesn't seem to be the best specialty for me if I am not totally all about those other critical areas of the head and neck.

Really any information that is up to date (some of the threads on here are ~10 years old) on the climate for endocrine surgery, turf wars, and prospects would be great!

 

[Slack3r]

I am interested in treating thyroid patients, perhaps surgically, but it seems this area of work is a bit spread out amongst ENTs/general surgeons. Read the prior threads, seems endocrine is a somewhat fought over area of procedures, and I am wondering how beneficial the endocrine fellowship is for general surgeons.

If thyroid/parathyroid were to be my area of interest, would it behoove me to pursue breast/endocrine fellowship to make my skillset more marketable (and of course also do general surgery). I have seen some ENTs that do thyroid, but it doesn't seem to be the best specialty for me if I am not totally all about those other critical areas of the head and neck.

Really any information that is up to date (some of the threads on here are ~10 years old) on the climate for endocrine surgery, turf wars, and prospects would be great!

Seems like you have your answer.

 

[675R]

Seems like you have your answer.

Absolutely. Now granted, I am a medical student and what we study is markedly different than what actually being on the job is like. Time and time again you hear of stories where a physician falls in love with something they had written off or had no idea of during preclinical years, but I think my main concern here is going into X speciality with the idea of wanting to REALLY do mostly a small component of that speciality. No desire to set myself up for mental burnout here.

But then again, this isn't much different if I take the general surgery route.

 

[675R]

Endocrine is still a pretty niche academic specialty. In the community I get the impression the overwhelming majority are performed by either general surgeons or ENTs, not anyone with subspecialty fellowship training.

The problem with the endocrine academics is that they all want to be adrenal/pnet specialists - which isn't realistic as there just isn't enough volume of that to go around (and the pnets are probably better taken care of by a HPB surgeon rather than someone who does 5 whipples a year for insulinomas.

This certainly seems to be the consensus, although I have read threads where (anecdotally) thyroid is largely ENT based. From what I have read in the literature, it isn't so much the speciality that's critical for outcomes but what percentage of a particular physician's work is thyroid, etc. A general surgeon who does 90% thyroid may be much better than an ENT with less experience.

So I guess I am just looking for as much personal insight into the matter as possible, although I do appreciate the occasional quip like the previous poster made. My goal would be to somewhat be the go-to-guy for thyroid/parathyroid due to 1) experience 2) quality of patient care. But I am wondering how that would best be done (general surg/ent etc), if I should also look into breast so that I can expand my skillset, etc, etc

I am willing to do research but I am more of a working type individual, so I would most likely not be pursuing academics.

 

[675R]

Also, I think willing to work in a rural/underserved area would help greatly in my endeavor and it is something I am considering.

 

[VisionaryTics]

This certainly seems to be the consensus, although I have read threads where (anecdotally) thyroid is largely ENT based. From what I have read in the literature, it isn't so much the speciality that's critical for outcomes but what percentage of a particular physician's work is thyroid, etc. A general surgeon who does 90% thyroid may be much better than an ENT with less experience.

So I guess I am just looking for as much personal insight into the matter as possible, although I do appreciate the occasional quip like the previous poster made. My goal would be to somewhat be the go-to-guy for thyroid/parathyroid due to 1) experience 2) quality of patient care. But I am wondering how that would best be done (general surg/ent etc), if I should also look into breast so that I can expand my skillset, etc, etc

I am willing to do research but I am more of a working type individual, so I would most likely not be pursuing academics.

High volume of thyroid cases means having good relationships with local endocrinologists. They control referrals for the most part, and you can get a good stream of thyroid going as either an ENT or general surgeon. However, it is very rare for anyone (ENT or gsurg) to do 90% thyroid. I've seen a few ENTs who do about 50% thyroid, and do either general or head/neck as the remainder of their practice.

In terms of training, I think for general surgery it varies hugely by program. For example, some programs have really busy sections of endocrine and do a ton of thyroid/parathyroid. Some programs (my hospital) get practically none and the general surgery residents get their minimums at the VA (where thyroids are split 50/50 with ENT). ENT minimum thyroid/parathyroid to graduate is 22. General surgery need 8 endocrine (including thyroid/parathyroid/adrenal/etc).

Also, I think willing to work in a rural/underserved area would help greatly in my endeavor and it is something I am considering.

As above, you need a good stream of referrals from endocrinologists. I doubt you could support a thriving thyroid practice relying solely on local rural referrals.

 

[Apollyon]

ENT minimum thyroid/parathyroid to graduate is 22. General surgery need 8 endocrine (including thyroid/parathyroid/adrenal/etc).

These numbers just make me chuckle a little, because I think of the radio in my new truck. The high end of the volume isn't "25" or "40" - it's 38. Yeah, nice round number, at that!

"Ours goes to 11!"

 

[675R]

High volume of thyroid cases means having good relationships with local endocrinologists. They control referrals for the most part, and you can get a good stream of thyroid going as either an ENT or general surgeon. However, it is very rare for anyone (ENT or gsurg) to do 90% thyroid. I've seen a few ENTs who do about 50% thyroid, and do either general or head/neck as the remainder of their practice.

In terms of training, I think for general surgery it varies hugely by program. For example, some programs have really busy sections of endocrine and do a ton of thyroid/parathyroid. Some programs (my hospital) get practically none and the general surgery residents get their minimums at the VA (where thyroids are split 50/50 with ENT). ENT minimum thyroid/parathyroid to graduate is 22. General surgery need 8 endocrine (including thyroid/parathyroid/adrenal/etc).

As above, you need a good stream of referrals from endocrinologists. I doubt you could support a thriving thyroid practice relying solely on local rural referrals.

This makes quite a bit of sense. My thyroid was removed by a general surgeon who does more than 50% of his work treating thyroid/parathyroid, but originally I was referred by my endo to see an ENT. It seemed liked my endo wanted to insist on going the ENT route, but the referral had nothing but reviews for nose jobs!

Keep the advice coming! I am interested in thyroid for personal reasons and this may be my chance to offer something to the medical community/patients. I just don't know if I should plan to do a fellowship (endocrine? surgical-onc?) in general surgery, or pursue ENT with general as a fallback. Of course I will be asking the ENTs and surgeons that I know, but can always use more insight.

 

[doc05]

I suggest you set your sights on something realistic. with that in mind, to become the "go-to" guy for anything, especially a desirable operation like thyroids, means that you need to have established yourself in practice for years. like 10 or more. you need good relationships with referring docs, which is usually endocrinologists.

whether you go gen-surg route or ENT (I recommend ENT, because most gen surg residents don't get enough head/neck experience), is less important. remember that once you start practicing, you'll be lucky to see 2 thyroids per year, because they will go to the already-established surgeons in your area.

 

[675R]

I suggest you set your sights on something realistic. with that in mind, to become the "go-to" guy for anything, especially a desirable operation like thyroids, means that you need to have established yourself in practice for years. like 10 or more. you need good relationships with referring docs, which is usually endocrinologists.

whether you go gen-surg route or ENT (I recommend ENT, because most gen surg residents don't get enough head/neck experience), is less important. remember that once you start practicing, you'll be lucky to see 2 thyroids per year, because they will go to the already-established surgeons in your area.

Absolutely, it's a goal or aspiration. The best way to achieve something unrealistic is short term goals. And so far one of them seems to be pursue ENT.

 

[Slack3r]

I suggest you set your sights on something realistic. with that in mind, to become the "go-to" guy for anything, especially a desirable operation like thyroids, means that you need to have established yourself in practice for years. like 10 or more. you need good relationships with referring docs, which is usually endocrinologists.

whether you go gen-surg route or ENT (I recommend ENT, because most gen surg residents don't get enough head/neck experience), is less important. remember that once you start practicing, you'll be lucky to see 2 thyroids per year, because they will go to the already-established surgeons in your area.

Thyroids are a desirable surgery? Why?

 

[675R]

I believe they're relatively short procedures and the reimbursement WAS good (someone mentioned that has since changed). So there are multiple specialties that can and will do the procedure. I was just trying to figure out what the best route to my goal would be. Will offer the advice of my general surgeon in a few days

 

[doc05]

Thyroids are a desirable surgery? Why?

nice anatomy, clean operations, no bowel. virtually all elective, even urgent cases don't go overnight. generally healthier/younger patients, usually discharged same day or next morning.

and for docs that do a lot of them, the cases generally go very well. and if you don't do a lot of them, then you probably shouldn't do any.

I recommend the ENT route because general surgery training can be very hit or miss in head/neck, and that exposure is usually only thyroid/parathyroid. In real life, cases don't get handed to you on a silver platter. if you train in ENT, you'll be fully trained in head/neck, and be able to deal with all head/neck issues. this will be important for all the "vague" neck mass referrals you may get. this will also allow you to do more involved operations, like radical necks, etc, that general surgeons almost never do.

 

[675R]

My doc is an endocrine general surgeon, said it all very much depends on the area where you practice in regards to who does what. Where I am currently, the bulk of thyroid referrals are not to ENTs apparently (but to endocrine and general surgery). It still doesn't answer my question if it's worth planning for endocrine fellowship or just staying general but I can't imagine it would hurt.

It seems a good idea would be to prepare for ENT with general surgery as a backup (and have another backup to that!)

 

[Fah-Q]

Do you really want to train for 5-7 years in order to do one operation?

 

[Pir8DeacDoc]

Please pass on ent if your only desire is to do thyroid surgery. It's a part of what we do but nowhere near all that we do. You need to have a drive to be an otolaryngologist or a general surgeon first and a thyroid surgeon second. You will be miserable otherwise, no matter which field you choose

 

[675R]

Do you really want to train for 5-7 years in order to do one operation?

I would like to ask that people don't jump to conclusions. That is not what was said although perhaps I was unclear.

We all know very well there are people who go into X speciality because "that's what my dad did!" or because "my mother had a heart attack" or "I've wanted to do this since I was 15!". There are also plenty of doctors I know personally who fell in love with a speciality because "the attendings were way chiller in this field" or picked something like EM because "surgery track was too long and I still get to do procedures". I also know an ENT who does only ear and largely only one kind of procedure- this is not the norm, but let's be honest here.

I've also had plenty of hospitalists at my old job tell me they hated their life and to pick lifestyle, lifestyle, lifestyle. I just ask to not be shut down when I ask some pretty benign questions. This is going to upset the ENTs in here but the students I know pursuing your field have no more noble reason to do it than I would. It is a surgical field with a more 'desirable' lifestyle. That's why (anecdotally) most people I've met are interested in it.

 

[675R]

Please feel free to private message me regarding personal comments.

 

[vhawk]

Do you really want to train for 5-7 years in order to do one operation?

I went into general surgery because I wanted to do Whipples. Something wrong with that?

 

[vhawk]

Was gonna say - a lot of subspecialists end up doing only a single operation or a small range of operations.

I mean I certainly am not foolish enough to think that my whole practice (or even 50%) will be Whipples, but that IS why I went into general surgery and thats what my ideal practice would be probably. I dont think its a particularly foolish reason to go into general surgery, but just realize that it takes a long time to build your "dream" practice. I love general surgery and would be happy doing anywhere between 25-100% HPB/onc stuff

 

[doc05]

I went into general surgery because I wanted to do Whipples. Something wrong with that?

well, as bad as the outcomes are, I'd say yes.

 

[el_pistolero]

Was gonna say - a lot of subspecialists end up doing only a single operation or a small range of operations.

I thought someone who does Whipple also does all sorts of cancer resections (apart from CNS malignancies), so there's a good variety of (cancer) cases anatomically speaking. After all, aren't surgical oncologists supposed to be 'the general surgeons of academics'?

 

[el_pistolero]

Well only a portion of whipples are done by surgical oncologists. Some are done by transplant surgeons, others by those who do only a dedicated HPB fellowship.

The ideal of a "general" surgical oncologist is unfortunately a fading one. Super-specialization is increasingly common in academics.

Within surg onc most people end up with some sort of focus - melanoma and sarcoma, gastric, breast, colon, liver, pancreas, etc. Very few "do it all" surg onc people and those that do tend to be the old guard.

That was... rather disappointing to hear. 🙁 Obviously super-specialized care for a complex disease like cancer is great for the patients, but one thing that interests me about surgical oncology is the broad range of complex operations it offers. On the other hand, it's pretty much tied to academics, which is also my interest...

I've always thought a surgical oncologist who focuses his/her practice in intraabdominal malignancies can operate all over the abdominal viscera. I mean, like, colorectal cancer (lower GI tract) metastasizes to liver (upper GI tract) and vice-versa to a lesser extent (HCC colon mets), so those who subspecialize on lower GI/colorectal malignancies will eventually have to be comfortable with liver resections as well..

 

[TraumaLlamaMD]

Where I went to med school, I saw multiple cases where a colorectal surgeon would take part of the colon, then tap out so a HPB trained surgeon could do the liver resection.

 

[el_pistolero]

I guess that's because where I live, there's no official separation between upper and lower GI tract surgery. Such subspecialization training goes by the name "visceral and digestive surgery", so those who have completed it are able to perform various complex operations on upper GI, biliary tree, and colorectal. I'm pretty sure in practice there's informal subspecialization of upper and lower GI tract surgery, with community digestive surgeons geared more toward colorectal practice and those in academics focus in either HPB or colorectal.

Thank you very much for your answers, much appreciated!

 

[vhawk]

well, as bad as the outcomes are, I'd say yes.

Debbie downer.

 

[vhawk]

That was... rather disappointing to hear. 🙁 Obviously super-specialized care for a complex disease like cancer is great for the patients, but one thing that interests me about surgical oncology is the broad range of complex operations it offers. On the other hand, it's pretty much tied to academics, which is also my interest...

I've always thought a surgical oncologist who focuses his/her practice in intraabdominal malignancies can operate all over the abdominal viscera. I mean, like, colorectal cancer (lower GI tract) metastasizes to liver (upper GI tract) and vice-versa to a lesser extent (HCC colon mets), so those who subspecialize on lower GI/colorectal malignancies will eventually have to be comfortable with liver resections as well..

It depends on where you go. And like I said, I still expect to do plenty of other operations, I'm just saying that the REASON I went into surgery was to do Whipples. In probably 50-60 major academic centers in the US, this sort of general surg onc person doesnt really exist. There is an endocrine guy who does thyroids and adrenals, there is a melanoma guy, there is a sarcoma/HIPEC guy, there is a liver guy/guys/transplant, there is a pancreas guy or two. In the remaining bigger academic centers, the sort of general surgical oncologist you are talking about does exist, partly because of volume. There isnt enough of any one operation to do JUST that, and there isnt enough volume to support 5-6 surgical oncologists.

Out in the community, plenty of surgical oncology still gets done, it just gets done in a catch as catch can fashion, and its a minority of the practice of general surgeons. Now whether this is appropriate is a whole different can of worms, but I think thats a fair, broad, general breakdown. You can still be a general surgical oncologist, you just cant do it at MSK.

With that being said, "general surgical oncologists" operate on about 20 different cancers, of the hundreds and hundreds of cancers, so you still wont be doing renal cell very often, or gyn malignancies, or thoracic stuff, etc. So EVERYONE is sub sub specialized in some sense.

 

[DoctwoB]

My tertiary/quaternary center is interesting, we have 4-5 surg-onc guys who are still somewhat generalists, they'll do foregut, appendix, colon, debulking/HIPEC, melanoma, some breast, some liver (usually mets, not primary hcc), and the occasional whipple, (though there's a dedicated PB group that does the majority of whipples). They're not brand new grads, but hardly old timers either. There is a liver group, PB group, and transplant group (gets very little non-transplant volume) and they all compete somewhat for referrals, so their case load has as much to do with who they can get referrals from.

Bottom line is that it is very center dependent.