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To those who know alot about surgery or in it.

Discussion in 'Medical Students - MD' started by Trowa, Sep 12, 2002.

  1. Trowa

    Trowa Member
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    Hey,
    I have a question for people who are in a surgical residency or who know alot about getting into one like ortho or ENT. I have a 2nd year friend at another med school. He has alway been interested in doing medicine as opposed to surgery. But this year he has really expressed interest in going to surgery. The only problem that he discovered was that he is a carrier for hep B. It is not active so he is okay, but obviously he is still able to pass it. iI guess now he is really bummed because his dean says no surgical program will accept him. I feel really bad and I want to help him or give him some optimistic advice, but I am not interested in surgery, so I have no idea about it. For those who know, is that true that he can never do surgery becaue he is a carrier? Or are their programs that will not really consider it. I mean, he is in med school after all and will do rotations. Any feedback would be great. Thanks
     
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  3. DuneHog

    DuneHog Senior Member
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    You bring up a very difficult and interesting situation that is seldom talked about. Hepatitis is a scary disease - more so for hep C than hep B, but you friend is in an interesting situation.

    I think that a lot of people feel that you shouldnl't operate on patients if you know you have a bloodborne illness like hep b, c or HIV. That said, there are a lot of surgeons out there that are hep pos. And even more out there that are probably hep pos but would never get tested so they can avoid having to deal with the situation your friend is in. Needle sticks etc happen ALL the time in surgery. I was amazed on my surg rotation how often this happened. It really scared me. And I have never seen a surgeon go through the whole needle stick procedure and get serially tested for hep and HIV. I think the reason is that they don't want to know the results. I actually brought this up with one of the senior surgeons at my institution. He told me that he knew he was hep b pos. He has never been tested for hep c because he was afraid to find out the results. He still operates full time.

    I'm sure that there are no data, but it would be interesting to know what percentage of surgeons are hep b or c pos. Most younger surgeons were vaccinated for hep b, but I would guess it is really common among older surgeons - probably greater than 50%. And I would bet that anyone who does liver transplants has at least a 75% chance of being hep c pos.

    I'm not sure I have an answer for what your friend should do. I guess that my best advice would be to go with what the dean said. I think that even if surgery programs accepted your friend, he would always feel guilty about the possibility of infecting patients. However, from a logistical standpoint I don't see how a residency program would ever know about your friends hep b positivity unless he told them. It's actually confidenctial because it is part of his medical record.
     
  4. Airborne

    Airborne Senior Member
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    DuneHog:

    I'll have to seriously disagree with you on a few points. Although HCV is an emerging epidemic (with nearly 1-2% of American affected) I wouldn't call it "scary". Indeed, recent evidence suggests that only 1/3 progress to cirrhosis and 1/3 have NO fibrosis over a 30 year period (do a PubMed search on Poynard and DiBisglie).

    Perhaps to bring this into perspective we should consider another liver related disease... 20% of Americans have non-alcoholic fatty liver disease (NAFLD), and 3% have steatohepatitis (a servere form of NAFLD), of which nearly 50% will develop fibrosis. Obesity is a major risk factor for NAFLD, and it can be argued that in the near future NAFLD may surpass HCV in terms of the number of people that will need orthotopic liver transplantation (d/t the rise in obesity). Moreover, recent evidence now shows that HCV in isolation may NOT be that bad - only when combined with another risk factor (ie overweight or alcohol) that it progresses... Thus in the overall scheme, HCV may not be as bad as we are lead to believe - time and more longitudinal studies will tell.

    Unfortunately, needlesticks are common in surgery (you either have had one or you will get one). However, the data suggests that if you are un vaccinated for HBV, a hollow bore needle stick with HBV carrys a 30% chance of seroconversion... This can be compared with 1-3% for HCV and 0.5% for HIV... Although HCV converts to chronic disease MUCH more than HBC (approx 80% vs 5%), chronic HBV leads to far more HCC than HCV.

    I wouldn't know about the implications for operating, as I am an MSIII... I would defer to posts mentioned by droliver that indicate an individual who is HbEAg positive may have difficulty obtaining hospital priviledges.

    However, perhaps it best if your friend talk to an informed individual (ie Hepatologist or Transplant Surgeon) regarding his status...

    Airborne
     
  5. droliver

    Moderator Emeritus 10+ Year Member

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    Airborne- wonderful & informative post!


    Hepatitis B was historically one of the occupation hazzards of being a surgeon & was a very frequent cause of death among surgeons up until the later part of the 20th century. Talking with my attendings, it was not uncommon for them to have colleagues that had to periodically take leaves of abscence when their hepatitis flared up as recently as the 1980's. With the widespread adoption of HBV vaccination fewer & fewer people have been infected & even when infected some people develop immunity & clear themselves so their no longer a carrier. While their are no universally codified rules per se. about whether you can work or not with HBV, there is a de facto prohibition by the hospitals risk mangement policies (same for HCV,HIV,etc..) just about everywhere. At the very minimum (assuming you can get a facility to let you operate) you have to have very detailed discussions with patients re. the possibility of infection & this again serves as a deterrent. Medical liability has really extinguished the surgeon with conditions like these from being able to continue working.
     
  6. Spidey

    Spidey Leorl's official stalker
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    There are so many negatives to being a surgeon it is a wonder there are any out there at all. When I started down this pre-med path Surgery was always my #1 choice... for many reasons but mostly because I like to be able to see an immediate result from my work. But it seems like almost every day a new negative thing about surgery is brought to my attention.
     
  7. droliver

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    I did an organ harvest last night for transplant & had a chance to talk to one of my transplant surgery attendings about the hepatitis issue. He says that the CDC recommendations do not absolutely require you to stop operating with any of these blood-bourne diseases (HBV,HCV,HIV) & they suggest (but not require) you to discuss it with patients when you give consent. He agreed though that in a practical sense Hospitals would probably refuse you privledges becuase their liability would be huge. He also said that there are a number of states who have drafted laws to address this & in fact DO prohibit you from operating with certain diseases
     

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