undecided

[Deckard_9139]

I have a sense of what I want my career to look like, but in 2017 it's not clear how to get there after completing residency (nearly there...).

I'm looking to "do" general surgery (gasp!) -- private vs. local hospital/network -- with a broad swathe of bread and butter as well as more complex cases: Hernias incisional and inguinal, gallbladders, appendectomies, venous access, and a spectrum of thyroid, melanoma, and breast surgery. I'd like to do elective colectomies and rectal resections for cancer as part of my practice as well.

I expect to take a fair bit of emergency and/or trauma call though (hopefully) at a level 2 center in the latter case if that comes to be.

Obviously, what I'd be giving up is thoracic, vascular, plastic, bariatrics, and complex endocrine surg onc.

So the question: How to get there? I'd like to do the above in a reasonable location. I have no real desire to live in a major metropolitan center (or work for a giant corporatized hospital system), though I am limited geographically to somewhere along the northeastern seaboard.

Colorectal? MIS? "Transition to practice" fellowship? What are folks' thoughts?

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[TypeADissection]

1. Match into a general surgery residency.
2. Go through all the various rotations and keep an open mind.
3. By the end of your 3rd year (or sooner), you'll have an idea of what you like and don't like.

Keep an open mind. I came in wanting to be a general surgeon and go back to my hometown and that has since changed considerably. Just match somewhere that'll give you a broad experience and exposure to as much as possible so you can make the best decision.

 

[ACSurgeon]

I have a sense of what I want my career to look like, but in 2017 it's not clear how to get there after completing residency (nearly there...).

I'm looking to "do" general surgery (gasp!) -- private vs. local hospital/network -- with a broad swathe of bread and butter as well as more complex cases: Hernias incisional and inguinal, gallbladders, appendectomies, venous access, and a spectrum of thyroid, melanoma, and breast surgery. I'd like to do elective colectomies and rectal resections for cancer as part of my practice as well.

I expect to take a fair bit of emergency and/or trauma call though (hopefully) at a level 2 center in the latter case if that comes to be.

Obviously, what I'd be giving up is thoracic, vascular, plastic, bariatrics, and complex endocrine surg onc.

So the question: How to get there? I'd like to do the above in a reasonable location. I have no real desire to live in a major metropolitan center (or work for a giant corporatized hospital system), though I am limited geographically to somewhere along the northeastern seaboard.

Colorectal? MIS? "Transition to practice" fellowship? What are folks' thoughts?

I don't think general surgeons should be doing rectal cancer surgery in 2017, unless they're far enough away from a colorectal surgeon. Melanoma can be hit or miss in general surgery training. Endocrine should be possible, although hard to justify if you're a low volume surgeon living in a city with endocrine surgeons. Breast surgery is doable but you have to do a lot of CME to stay up to date.

Your options:
- do colorectal fellowship and hope your residency trains you well enough for everything else.
- surg Onc fellowship with "enough" colorectal cases. Is that even a thing? We'll have @SouthernSurgeon and @SLUser11 comment.
- go work somewhere rural with an excellent surgeon who can mentor you for the first 3-5 years of your practice and teach you how to do everything a general surgeon used to learn how to do...

 

[Deckard_9139]

I am a resident in general surgery; about 1/2 done with PGY3. I thought that was clear...

By some of the logic thus far posited, herniologists should do hernias, cholelithologists/cholecystologists should do gallbladders, elective colectomists should do elective colon resection. I find that not only frustrating from where I stand, but also unrealistic and nothing short of insulting to general surgery...

 

[mikeGR]

In 2017 it is pretty much universally accepted that thyroid surgery has better patient outcomes when done by surgeons with a consistently high volume of thyroid surgery, and rectal surgery (esp low rectal) when done by colorectal surgeons. Personally I would prefer my loved ones to also see a breast surgeon for a mastectomy and a surgical oncologist for melanoma surgery (esp with i.e. an inguinal lymphadenectomy). And since you mentioned it, although any general surgeon can do the simple ventral/umbilical/groin hernias well, the new emerging trend (that you laugh at) is abdominal wall reconstruction specialists (not fellowship trained, yet), who IMHO should be doing the huge complex recurrent incisional hernias (you will realize the difference when you see how they fix them).

Can any general surgeon do these cases? Probably. Can they do them as well as the specialists? Probably not- realistically, you cannot do everything really well. It just depends on how high a quality of care you want for your patients, and how realistic this is at the location you are practicing.

 

[Deckard_9139]

Believe me if there's one thing I'm not doing in response to the above, it's "laughing." Not sure what part of "frustrating" or "insulting" you equated with laughter.

If anything, the response to these trends is one of fear and concern, which I find alarmingly not re-capitulated among others in the field. It seems more and more like that the systems in place are hell-bent on training one-trick ponies (and trainees are all too happy with such an outcome), and you'll forgive me for expecting something more from both my training and career.

 

[SLUser11]

Believe me if there's one thing I'm not doing in response to the above, it's "laughing." Not sure what part of "frustrating" or "insulting" you equated with laughter.

If anything, the response to these trends is one of fear and concern, which I find alarmingly not re-capitulated among others in the field. It seems more and more like that the systems in place are hell-bent on training one-trick ponies (and trainees are all too happy with such an outcome), and you'll forgive me for expecting something more from both my training and career.

You come off as a bit antagonistic.

If you're a PGY3, you should have already received better advice from your mentors and co-residents than you can receive from the anonymous internet.

If you want to do general surgery, then do it. There are plenty of jobs out there, especially if you're not fixated on saturated markets (e.g. major metropolitan areas), although there's likely GS jobs there as well.

The hard part is sacrificing mastery of one specific tasks. You become a jack-of-all-trades, master of none...in the big picture, this is much more useful to society than a left pinky finger specialist, but your ego can't always handle it when the most appropriate thing to do is refer to a specialist...so you get general surgeons tackling cases they shouldn't, and this is where the problem lies.

Transition to practice is best if you don't feel quite ready, which could be technical reasons, decision-making, or business reasons.

Colorectal is for if you want to be a colorectal surgeon. Colectomies are certainly in the wheelhouse of general surgeons, but I likely do a much better one than most general surgeons, so if my family member gets a right colon cancer I'm obviously going to want a colorectal surgeon to take care of it. LARs/APRs should be left to specialists, as there's too much that can go wrong.

 

[dpmd]

I mean we are getting more and more data to show that patients do better in the hands of a specialist.

If your goal is to practice in a community without adequate access to specialists and provide a needed jack-of-all-trades service, that’s admirable. But at the same time surgeons in those setting should be mindful of their own limitations and not afraid to refer out complex cases.

If your goal is to practice in a community big enough to support a level 2 trauma center, and you want to practice advanced rectal surgery, endocrine, abd Wall, and trauma/EGS...then yeah, I’d say that’s hubris driven and not in the patients’ best interest as those patients will likely have access to specialists in the same community.

We have some community people and people with a trauma/egs background here who can comment more. @dpmd @balaguru

I trained at a program without some important specialists during much of my training (such as vascular and colorectal) and while we got that specialty exposure through outside rotations, it meant that our own attendings functioned in that role for patients in our facilities when transfer wasn't an option or when it wasn't needed because they were able to do it often enough to do it well. With the exception of melanoma surgery (and that may just be due to lack of referrals rather than refusing to do the case) this is the way many of the private practice guys practiced in this town when I went into private practice. However, I decided that there were enough people in town doing thyroids that I wouldn't have good volume and therefore I don't do them. Same thing with fistulas (I do ports and other line based venous access though). When I first started out I was willing to do APRs because the alternative was sending them to someone else in town who wasn't a specialist (and I got to do a fair number of them in my final year of residency with the colorectal surgeon who stayed briefly) or sending them out of town (which I did offer but patient's didn't really like to do) but now there is a colorectal surgeon in town so if I got referred one I would probably send it to him. I do colons, but not elective ones usually because I didn't do enough lap colons in training and don't get enough patients who are candidates for lap that would let me develop proficiency at it at this point. I suppose a colorectal fellowship would have let me do those colons and APRs more comfortably, but I felt adequately trained for the trauma and acute care surgery practice I initially had my eyes on doing (left trauma behind when I went to private practice and have not missed it despite thinking I would) so I didn't see the point in more training just to do the same type of job (and my employed position would have been for the same pay and call responsibilities so why on earth would I spend time earning less money just to come back to the same damn job). With my current practice I get tons of appys and choles which I enjoy doing, and a mixture of hernias, breast, and intraabdominal catastrophes that keeps things interesting while being profitable much more than I ever thought part time work would allow. But I know that just because I can probably figure out how to do a procedure safely doesn't mean I shouldn't refer out when appropriate and feasible.

 

[TypeADissection]

Believe me if there's one thing I'm not doing in response to the above, it's "laughing." Not sure what part of "frustrating" or "insulting" you equated with laughter.

If anything, the response to these trends is one of fear and concern, which I find alarmingly not re-capitulated among others in the field. It seems more and more like that the systems in place are hell-bent on training one-trick ponies (and trainees are all too happy with such an outcome), and you'll forgive me for expecting something more from both my training and career.

You mad bro? I'm good for giving you a hug or buying you a beer. Your choice. Cheers.

 

[dpmd]

I will confess that I did an altemeir one time after only having seen it on you tube, but in my defense I did tell the lady I had never done one and would be happy to refer her to a colorectal surgeon but she didn't want to go out of town and she really liked me.

 

[dr zaius]

I will confess that I did an altemeir one time after only having seen it on you tube, but in my defense I did tell the lady I had never done one and would be happy to refer her to a colorectal surgeon but she didn't want to go out of town and she really liked me.

This made me picture a dear elderly lady that used to come to the ED here every few weeks with terrible prolapse looking you deeply in the eyes and whispering, "I trust you." ...while resting her prolapsed rectum in a basin of sugar.