So I'm in a similar time frame as you, as I am a PGY3 doing 2 years of clinical research in the lab of the transplant division chief at my residency, so I have definitely drunk the coolaid and am heavily leaning towards transplant (went into residency leaning towards surg onc vs transplant). I'll give you some of my pros and cons:
Pro's:
-Of all the surgeons, the best and most intricate knowledge of hepatobiliary anatomy, as well as the most complex surgeries on the HPB system (if you go to a program that does livers, even moreso if you go to a program that does pancreas and livers). This is a big reason for my shift from Surg Onc to Transplant, as someone who would like to focus mainly on hepatobiliary. HPB may be able to argue this, but doing all those donor hepatectomies and pancreatectomies, and the hepatectomies in the recipient, on the coagulopathic, cirrhotic patients is, in my view, is more difficult than the cancer only patient
-Immensely academic, multidisciplinary, and scientific (ie, a major thinking mans field): you listed many of these aspects as con's, but I personally find them as pros. As someone who actually liked medicine, likes managing the patient, dealing with critical care issues, having a team approach, major advances in caring for the patient, and great areas of potential research, I am greatly drawn to this field. Very similar in that regard to surg onc, and what initially attracted me to surg onc/HPB/transplant.
-Grateful patients and an internally rewarding specialty: the touchy feely stuff, and any surgical field you are passionate about can be internally rewarding, having grateful patients also helps
-It's not general surgery: Again, your biggest reservation is one of my pros. Not that I do not like the bread and butter cases. Hernia's and Chole's etc, those are my cases now, and I do enjoy doing them, and learn greatly from them. But if I want to subspecialize and carve out my little niche, I want to be able to focus on that and not be on the hook for the general stuff as well. Another negative part of Surg Onc, is that at my program, the surg onc guys are required to take gen surgery call, which can mess up their elective surgery schedule(our private hospital we also go to, the surg onc guys are not on gen surg call, but a few of the vascular guys do take gen surgery call). Again, not why I am spending an extra 4 years (2 in lab, 2 in fellowship) to gain a specialized skill set for.
-Future job prospects: I put this as a pro, but its really a toss up. The number of liver transplant jobs isn't the greatest for grads, but the field of transplant as a whole isn't going anywhere, and the demand is only going to increase. Besides the massive backlog of waitlisted people, the epidemic of obesity and diabetes in this nation that is only getting worse will further strain and increase the need for kidneys, pancreas, and, livers (by 2020, the #1 cause for liver txp will likely be NASH caused by diabetes and obesity, not HepC). And as medications increase to improve rejection, improve outcome, and methods of optimizing donors increase, the donor pool will hopefully increase due to more marginal donors and donation after cardiac death, and living related / unrelated donation.
Cons: Lifestyle: This has got to be the biggest turnoff to the field. The middle of the night start times for the procedures which last 6, 10, 12+ hours, while exciting as a 28 year old, can be maddening as a 58 year old. And depending on how many people are in your group and how busy your opo is / how many programs are in the opo, your call schedule can be just as bad. At my institution there are 3 surgeons (was as many as 5 in the mid 2000's, 4 as of 2010. Thus, during the weekday, all 3 of them are technically on call. One for donor, one for recipient, and the last as 2nd attending for the recipient (since we have no fellows, the 2nd attending comes and assists primarily on the hepatic artery anastomosis, but also if the case gets out of hand, where as if it were a place with a fellow, that might be avoided). Over the weekend, the donor surgeon is also the 2nd attending, so they have 1 in 3 weekends entirely off.
-Operative load: again, with all the non operative stuff required, and the simple nature of the field, you don't have the number of operative cases many other specialties enjoy. The busiest program in the nation does about 200 livers a year. But how many attendings is that split between? looking at the web site, there are 6 (I actually expected more). so if each were to do equal (you think Ronald Busuttil is taking the same number of late night procurements as the attending that graduated fellowship in 2010?), thats 33 donors and 33 recipients each, or only 66 cases per year. Now, thats a gross underestimate, and consider if they do elective HPB, some pancreas and small intestine cases, some take backs, etc, and its probably closer to 100-150. That still only works out to be like 2 cases a week, and thats an example of a really busy place. Our program, they do 50-60 transplants a year, so thats 20 transplants each, plus 20 donors, plus if you add in take backs, elective cases, etc, they may be able to push it to 75-100 cases in a busy year. There are some general surgery guys who can get close to 100 cases a month if they are hustling, and if pretty much any other surgeon (besides Trauma/CC) doing 2 cases a week would spell doom.
-Job search: As stated above, getting your foot in the door with transplant is a bit hard. In our OPO, there has been very little turn over in the past 10 years, so if you wanted to become a liver transplant surgeon in NJ, you were SOL. Plus the fact that there are only a handful of places that do transplant, many in metropolitan areas, those adverse to city life will also find getting a job more difficult.
Those are some of my thoughts on the matter, as you can see, I have thought a lot about it, and if applying today, would definitely be applying to transplant fellowships. Hope this helped
