What is HBP or transplant like as a career path?

[Ezekiel20]

Hi, I'm a final year student with a career in surgery on my mind..

I'd love to do neurosx, paed sx or ortho if I can get in, and I have long regarded gen surg as a 'safety net'..

I like both upper GI and colorectal surgery, but recently started wondering about sub-specialties like HBP and transplant surgery.


My only exposure to these sub-specialties were a few days of observing/scurbing into HBP and transplant surgery during a surgical term.


Insights into these sub-specialties in terms of future prospects, necessity of research, lifestyle etc would be greatly appreciated.



Cheers, from down under

🙂

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[ESU_MD]

Insights into these sub-specialties in terms of future prospects, necessity of research, lifestyle etc would be greatly appreciated.

Liver transplant- just about every patient has hepatitis C. If you like scrubbing in on Hep C cases and risking getting stuck by a sharp and ending up NEEDING a liver transplant. then this is the field for you!!

I would never scrub another Hep C case again if i could avoid it.

 

[Winged Scapula]

Hi, I'm a final year student with a career in surgery on my mind..

I'd love to do neurosx, paed sx or ortho if I can get in, and I have long regarded gen surg as a 'safety net'..

Not really the way to win friends around here, but we'll let that comment slide. 😉

I like both upper GI and colorectal surgery, but recently started wondering about sub-specialties like HBP and transplant surgery.

My only exposure to these sub-specialties were a few days of observing/scurbing into HBP and transplant surgery during a surgical term.

Insights into these sub-specialties in terms of future prospects, necessity of research, lifestyle etc would be greatly appreciated.


Cheers, from down under

The following is based on training in the US; not Oz.

Neither are very popular fellowships in the US and as such, research is not necessary, especially for transplant, to be able to match into them.

That being said, many US transplant surgeons do run active Immunology labs and are very into it, so it wouldn't hurt.

Lifestyle? For transplant it sucks:

1) except for living related donor kidneys, most transplants are still done at odd hours, as are the harvests, with little notice. When you are on call, you should expect every dinner to be interuppted and never be able to see a movie all the way through (at busy centers).

2) the patients, especially the liver patients, are notoriously difficult, needy and tend not to follow medical advice.

3) Hep C? Yep, its a reality that many, if not most, of your patients will be positive, will have an IV drug history, etc.

4) its hard to do anything except kidneys in smaller regional centers. Therefore, if you want to do livers, pancs, small bowel, etc. you'll have to be at a major medical center. If you are a small town guy, that can be a problem.

5) there aren't a lot of jobs either. I have a friend who just finished his Transplant fellowship; he ended up staying on there as faculty, although his fiancee lives hundreds of miles away and he would rather be closer to her (and avoid being treated like the faculty bitch because you're the new guy).

6) Once a transplant patient, always. Expect that no one will ever want to manage your patient or operate on them. Thus, when they hit the ER with a non-transplant related problem you will get called. When they need a non-transplant surgical problem you will be asked to do the case (at least if its general surgery). You will be consulted even if the patient thinks of coming to the hospital.

HPB has better lifestyle because most of your cases will not be emergent. The patients are a little better in character but they can be sick as &^*$ depending on what you do to them. Like transplant, you have to be at a regional center. There is no room to do only HPB (and no general surgery) in Podunk, USA. You will not be busy enough. Most HPB people do general surgery as well, at least until they get senior enough. Its interesting work and research is more important than for Txp, but again, not necessary.

 

[sponch]

Liver transplant- just about every patient has hepatitis C. If you like scrubbing in on Hep C cases and risking getting stuck by a sharp and ending up NEEDING a liver transplant. then this is the field for you!!

I would never scrub another Hep C case again if i could avoid it.

i got stuck on a case where the patient had active hep c with a pretty high viral load. i was pissing my pants for 6 months. worst experience of my life next to a month of being a student on inpatient medicine. 😉

 

[Ezekiel20]

Yes I've seen a few 10-hour liver transplant cases myself (elective, emergency, living donor and cadaveric) but it's not so much the actual operation I was interested in knowing more about, but what the field is like as a career, with job prospects, etc.


Thanks Kim for your input. I said gen surg was a safety net for me because, as you know, us Aussies value lifestyle more than the average American, and so gen surg is much less competitive to get in over here. My apologies for that comment though..

Upper GI appeals to me more than colorectal because it seems more challenging, but I was worried about the tendency to have to sub-specialise when doing upper GI in a tertiary centre (whereas I get the impression that one can still do 'general' colorectal surgery - for example during my overseas elective I met a professor whose ONLY operation was billroth II partial gastrectomies, whereas the A/Prof of surgery at my hospital in sydney does at least 10 different operations).

But then again upper GI seems a very researchy field, and I've seen surgeons who gradually cut down on clinical work to concentrate on research, which is not something I want for myself.


Thanks again for the responses, and more input from other forumites would be greatly appreciated!

 

[Winged Scapula]

Thanks Kim for your input. I said gen surg was a safety net for me because, as you know, us Aussies value lifestyle more than the average American, and so gen surg is much less competitive to get in over here. My apologies for that comment though..

No apologies necessary. I was just having a go at you.

Upper GI appeals to me more than colorectal because it seems more challenging, but I was worried about the tendency to have to sub-specialise when doing upper GI in a tertiary centre (whereas I get the impression that one can still do 'general' colorectal surgery - for example during my overseas elective I met a professor whose ONLY operation was billroth II partial gastrectomies, whereas the A/Prof of surgery at my hospital in sydney does at least 10 different operations).

Hmmm....since many residents in the US graduate without ever having done one of these, seems a strange thing to specialize in. Although B2 are done for multiple problems, with the (Aussie discovery!) of H pylori the need for anti-ulcer operations with B2 reconstructions has fallen *way* off. But to each his own.

But then again upper GI seems a very researchy field, and I've seen surgeons who gradually cut down on clinical work to concentrate on research, which is not something I want for myself.

Are you sure they haven't cut down because there just isn't as much work anymore? If you do reflux surgery, laparoscopically, there is work but if your main focus is stomach and esophagus, again, there isn't nearly the amount of work (esp if you don't do lap Nissen/Toupets etc) there was a generation ago.

At any rate, colorectal can probably be done much more easily in the community, whereas to superspecialize in the upper abdomen, HPB or transplant does require a bit more of a urban center. Then again, you can make a job in most places if you know the market.

Transplant surgery as I mentioned above is easy to match into, but its not so easy to find a job. There just isn't a need for a lot of them. They aren't wandering the streets with a tin cup like the CT surgeons, but job prospects are not plentiful if the ads in the mags, websites and word on the street are any indication. As I noted, the lifestyle for Txp sucks.

HPB and Upper GI are also fairly specialized. I'd imagine that you'd get a lot of general surgery type job offers with an "interest in Upper GI or HPB" but to be able to have a practice just doing those could be hard. You have competition for both from general surgeons, Txp surgeons (who do HPB), Surg Onc (who do both) and the Upper GI or HPB fellowship trained surgeons.

You may know that in the US over 70% of general surgery residents go on to fellowship and the vast majority of the fellowship matches are in 4th or 5th year, so there is no need to make up your mind at this point. HPB, Colorectal, Txp, Upper GI, etc. are all fellowships done after general surgery. In Surg Onc you could do HPB and Upper GI but it is HIGHLY academic with research requirements, so probably doesn't fit you.

So I'd back off a little on deciding your future since it may change along the way as you do different gen surg rotations.

Thanks again for the responses, and more input from other forumites would be greatly appreciated!

I read that as fomites.

 

[Ezekiel20]

Hmmm....since many residents in the US graduate without ever having done one of these, seems a strange thing to specialize in. Although B2 are done for multiple problems, with the (Aussie discovery!) of H pylori the need for anti-ulcer operations with B2 reconstructions has fallen *way* off. But to each his own.


Are you sure they haven't cut down because there just isn't as much work anymore?

I've just checked my operating theatre logbook and they were actually Billroth I partial gastrectomies, not II. And I am of Korean background and met the professor during my elective in Seoul.

As you know, gastric CA is much more common in the far east asian countries. He did up to 6 Billroth I's /day, with a dedicated team of residents and fellows who stagger-start the operations with 1 hour intervals, and the professor coming round and doing only the important bits.

I just did a medline search and found 111 articles he authored. All in world-class journals too.

The above is a picture of a plaque in the hospital lobby, which says that the professor and his team were the first in the world to perform 20,000 gastrectomies.

I read that as fomites.

Even as a final year student, I still have heaps of time before deciding on a career path. The earliest time Oz docs can train in a surgical specialty is in our 3rd year out from uni.

But I thought it wouldn't hurt to ask around and hear what people have to say.


Thanks again Kim 👍