What surgical specialities do you think are the most and least 'cerebral'?

[Spinietzschon]

Hello,

Wondering from those with good real-world exposure; what are the most and the least 'thoughtful' surgical specialties? From taking a case through when it leaves your responsibility, which ones TEND (take the general trends not outlier institutions) to involve the most/least crossover-IM knowledge, most/least judgment calls rather than trained/experiential reactions, etc?

Please, don't say neurosurgery just cause I said 'cerebral'... 🙂

Thank you!

PS not to say one is harder/more merit-worthy/exciting/better etc - some routine could be comforting as well...! Thanks!

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[ESU_MD]

Few will argue that ortho is the least involved in complex medical care.

True general surgery can be pretty intense- icu management, postop nutrition& tpn, plus all the medical problems surgery patients have make for a cerebral experience.

Intraop intensity I would vote for cardiac, especially a big aortic circ arrest case

 

[45408]

I'd say vascular cases can get pretty intense, and I'd imagine that a liver transplant can get pretty hairy as well.

 

[MossPoh]

I still remember the orthopedic surgeon I shadowed back in the day. When he finished, the nurse asked him what medications the patient would need. His reply was, "shots and pills" as he walked out.

Not helpful in anyway, but just a classic memory. 😉

 

[ESU_MD]

a liver transplant can get pretty hairy as well.

especially the anhepatic phase!

 

[thedrjojo]

its a pretty good question. If you look to the surgical subspecialties, those that have their own training, i don't have much experience. Orthopods are the notorious nonthinkers, and the trauma service takes care of all ortho trauma patients with anything else going on, because as the ortho attending stated, he doesn't know what the diabetic medications do...

NS isn't as cerebral as you think either imo, but they do run their own ICU at my institution, so they are above Ortho.

As for GS specialties, you run the gambit. Your basic bread and butter GS doesnt have to be that cerebral if all they are doing is hernias, appy's, and gallbladders. but beyond that, all have the potential to be very cerebral when you are dealing with your sick patients. All transplant patients are very sick, but liver transplant patients end up in the ICU for several days while kidney transplant patients can be sent to the floor postop. Cardiac patients, you manage a lot on the CVS, but they are typically straight forward besides that. Trauma patients populate my ICU most of the time, and have multiple ICU diagonses. And then their is surg onc, where you deal with sick dying people with usually mutliple medical comorbities. All cerebral. Theres no escaping it in GS.

 

[ESU_MD]

I think you're right. In some bigger places with manpower(residents) the neurosurgeons run their own units and dont generate as many consults, thus being more "cerebral"

In places where there are no NS residents- these guys are pretty much out the door when the skin is stapled. These are the patients that show up in the night in the SICU with "no orders" or any sign-out! Thus, less cerebral.

 

[45408]

In places where there are no NS residents- these guys are pretty much out the door when the skin is stapled. These are the patients that show up in the night in the SICU with "no orders" or any sign-out! Thus, less cerebral.

Tell me about it. We've got a few of them that hardly know where the SICU is, other than that's where the PA pages them to so they can find out how their patient is doing.

 

[franceschino]

Hey guys,

Where do plastic surgery and ENT fit?

Thanks.

 

[DHT]

Hey guys,

Where do plastic surgery and ENT fit?

Thanks.

Plastics - Probably right next to ortho.

ENT - If you say that ortho/plastics is the least, and general specialties like Surgical Critical Care, Transplant, HPB, are the most. I would say ENT is right above ortho/plastics near the middle (next to Urology). Neurosurgery is probably slightly above or even with ENT/Uro, but still far below SCC, Transplant, HPB. As mentioned before, NSurg is less cerebral than most people think.

 

[45408]

Neurosurgery can be mostly spine work, which is also done by orthopedic surgeons in some places. Quite variable.

In the setting of ENT with complex facial reconstructions, it can be quite complex. Or you can just do minor outpatient procedures all day without much thought put into it. Much like surgical critical care would be very different than someone who just does inguinal hernias all day.

 

[ESU_MD]

Ent?? In the community they arent into the big cases, definetly not cerebral. In the cancer center though, they can be hard core. Often then known as "head & neck". Often fellowshipped via gen surg or plastics background. Free flaps and in-field airway management are in play takes some skills. Not many of these cats out there

 

[bronx43]

Since when did "practicing Internal Medicine" turn into "being cerebral"? There's a reason that nobody does ORIFs except Ortho, and nobody does radical necks except ENT, etc. Every surgical field has their niche, and every one requires an incredible amount of thought in terms of preparation and post-op management.

Those of us who have eschewed the Gen Surg pathway tend to be kind of confused about why those guys seek out things like ICU care, vent management, etc. I suppose it's noble to want to take care of every aspect of your patients while they are under your care, but these are jobs that could just as easily be performed by Intensivists, anesthesiologists, Pulmonologists, etc.

I would be weary of pretending that medical practice (vice surgical care) makes you somehow more thoughtful than your colleagues. If their job was that easy, you'd be doing their cases.

So, basically your argument is that due to the institutional structure of specialization, no field is "more cerebral" than another. If that's the case, then it should apply to all fields, and PM&R is just as "cerebral" as cardiology. All comes down to predetermination of definitions.

And it's pretty obvious that the definition used in this thread seems to be along the lines of "breadth of all medical knowledge."

 

[bronx43]

General Surgery is a very thoughtful specialty. They operate, then do complex medical management and run their own ICUs.

Orthopods, on the other hand, are attractive to women...

Because...? I missed this lecture as a MS1. Either that or it just so happens that the GS department at my institution has far more playaz than the ortho department.

 

[DHT]

Because...? I missed this lecture as a MS1.

It was there, I'm pretty sure it is part of the standard curriculum for any US LCME accredited medical school. Are you a FMG perhaps?

Either that or it just so happens that the GS department at my institution has far more playaz than the ortho department.

Nah, they just think they are. McLovin comes to mind when I hear things like this.

 

[cpants]

I'd argue that pretty much all surgical specialties are pretty cerebral. Most surgeons do not have the arrangement where they get to operate and walk out the door turfing preop and postop management. Surgical patients are generally pretty sick players requiring a lot of thought to manage optimally.

Even if you did just show up to operate, don't buy into the stereotype that surgery is doing, not thinking. This isn't changing a tire. Surgery is extremely complex and each person's pathology and anatomy are different. In and out of the OR surgeons have to be able to problem solve and improvise in real time. Things can go downhill very very quickly which is not the case for the majority of medical illness.

 

[bronx43]

No, my argument is that your definition of "cerebral" means "knowledge of their own specialty, plus knowledge of Internal Medicine." Knowledge of IM does not imply some broad grasp of medicine/surgery in general. It's just another specialty. I don't call you stupid for not knowing how to template a hip replacement, so you might want to avoid calling me dumb for not routinely fiddling with the buttons on a vent.

If you really want to get dumb, I could probably make a decent argument that Gen Surg spends so much time on Medicine topics because Gen Surg itself really doesn't require as much thought or education as the other subspecialties...

What? You just repeated what I thought your definition was. Using what you just typed, one can conclude that there is parity amongst all specialties. Every field is as cerebral as any other field, due to specialization. Basically, PM&R is just as cerebral as transplant surgery.

And unless you can actually demonstrate that orthopedics requires more knowledge than GS (if it can even be consistently quantified), then knowledge of internal medicine AND general surgery obviously trumps just knowledge of orthopedics.

Hell, while we're at "dumb," why don't we bring in the midlevels as well. A CRNA isn't going to call you stupid for not knowing how to administer anesthesics, so you should avoid calling him/her stupid for not knowing how to perform orthopedic surgery. And ergo, a CRNA and an orthopod are equally cerebral. See how that works when your definition is predicated on specialization?

 

[dilated]

And unless you can actually demonstrate that orthopedics requires more knowledge than GS (if it can even be consistently quantified), then knowledge of internal medicine AND general surgery obviously trumps just knowledge of orthopedics.

You seriously can't see the irony in "if you can't mathematically quantify that ortho requires more knowledge than GS, then GS has internal medicine too so obviously it's more knowledge!"?

You can rank specialties by post-operative complexity and management if that's your interest, but that has little to do with how "cerebral" a surgical field is - I would prioritize intraoperative complexity and thinking over it. And even that's kind of a nonsensical effort because nobody really likes a specific surgical field because of it's "cerebralness". If you want complicated postop management, then that's fine but let's not act like that makes you Sherlock Holmes among the unthinking orthopods and urologists.

 

[bronx43]

You seriously can't see the irony in "if you can't mathematically quantify that ortho requires more knowledge than GS, then GS has internal medicine too so obviously it's more knowledge!"?

You can rank specialties by post-operative complexity and management if that's your interest, but that has little to do with how "cerebral" a surgical field is - I would prioritize intraoperative complexity and thinking over it. And even that's kind of a nonsensical effort because nobody really likes a specific surgical field because of it's "cerebralness". If you want complicated postop management, then that's fine but let's not act like that makes you Sherlock Holmes among the unthinking orthopods and urologists.

Dude, read the previous couple of posts. The entire argument lies with the definition of "cerebral," as that's the central topic. Different people coming here with different definitions is like playing chess where you can make up the moves as you go. No discussion can be had unless everyone involved agrees upon the basic premise of the argument.
And just to clarify, I have no stake in this. I'm not in surgery of any kind. I just read through this thread and had to pick on a few logical issues I had with the arguments.

 

[badasshairday]

Where does vascular surgery lie in the pecking order of "cerebral" ranking?

 

[ESU_MD]

Where does vascular surgery lie in the pecking order of "cerebral" ranking?

From a technical aspect, the vascular guys used to be the ones who werent good enough to do cardiac but had enough skills to avoid having to be banished to the general thoracic world.

nowadays, they are masters of endovascular so that is a nice skill which places them in the big leagues, but I wonder what their bail-out capabilities will be when something goes wrong with some exotic thoracoabdominal fenestrated stent-graft and they have to open.

 

[ESU_MD]

Since when did "practicing Internal Medicine" turn into "being cerebral"? There's a reason that nobody does ORIFs except Ortho, and nobody does radical necks except ENT, etc. Every surgical field has their niche, and every one requires an incredible amount of thought in terms of preparation and post-op management.

Those of us who have eschewed the Gen Surg pathway tend to be kind of confused about why those guys seek out things like ICU care, vent management, etc. I suppose it's noble to want to take care of every aspect of your patients while they are under your care, but these are jobs that could just as easily be performed by Intensivists, anesthesiologists, Pulmonologists, etc.

I would be weary of pretending that medical practice (vice surgical care) makes you somehow more thoughtful than your colleagues. If their job was that easy, you'd be doing their cases.

I still have alot of pride in my surgical subspeciality field, but I have come to realize that almost anyone can do my job if they are willing to sacrifice the years of training and suffering, etc..

at the end of the day, we should all be proud. but realize we're all just trying to have a good life, make a decent buck and its a bonus that we can justify our living as altruistism "helping people"

The vast majority of docs (or PAs.CRNAs. AAs, RNs) dont sit at home trying to think of how they are "better" than the next guy..

 

[bronx43]

Have I seriously been arguing with a murse?

Okay, nevermind, I'm out...

Uh... no, bud. You weren't. It's called using hyperbole to convey a point.

 

[45408]

If you really want to get dumb, I could probably make a decent argument that Gen Surg spends so much time on Medicine topics because Gen Surg itself really doesn't require as much thought or education as the other subspecialties...

I'd like to see that.

 

[igap]

Plastic surgery is clearly the most cerebral specialty. Every case is different, and we work with just about every surgical specialty. We have to understand what everyone else is doing, and then plan what we are going to do.

Every other field teaches its trainees to do operations. In plastics we learn technique. Ah... contemplate that you cerebrally-challenged girly men.

 

[Black Surgeon]

Most cerebral = Pediatric cardiac surgery hands down, very few surgical specialties even come close. This field is unparalleled.

 

[ThePursuit]

... but I wonder what their bail-out capabilities will be when something goes wrong with some exotic thoracoabdominal fenestrated stent-graft and they have to open.

Well where I'm from, their "bail-out" capabilites are pretty damn impressive. The other day, Gen-surg was like !@#$, call vascular we messed something up... followed by vascular showing up and saving lives by diving into a blood-filled field and making it happen when it needed to happen. Not saying it was gen surg's fault, stuff happens to everyone.

At my program at least it's pretty clear that they're surgeons, not IR docs.

 

[DHT]

Well where I'm from, their "bail-out" capabilites are pretty damn impressive. The other day, Gen-surg was like !@#$, call vascular we messed something up... followed by vascular showing up and saving lives by diving into a blood-filled field and making it happen when it needed to happen. Not saying it was gen surg's fault, stuff happens to everyone.

At my program at least it's pretty clear that they're surgeons, not IR docs.

A similar thing happens at my program. The pediatric cardiovascular surgeons are like "Oh HOLY #$%! someone call Ortho right #@$@!#% now!" We waltz in (still laughing about the killer wedgie we gave to the medicine intern on the way over), gain control of the situation, ORIF the heart and slap a 1/3 tubular plate on the aorta. Afterwards before leaving to watch the end of Sports Center, we politely explain where they went wrong and give them a crash course on pediatric cardiac physiology.

 

[rigid]

A similar thing happens at my program. The pediatric cardiovascular surgeons are like "Oh HOLY #$%! someone call Ortho right #@$@!#% now!" We waltz in (still laughing about the killer wedgie we gave to the medicine intern on the way over), gain control of the situation, ORIF the heart and slap a 1/3 tubular plate on the aorta. Afterwards before leaving to watch the end of Sports Center, we politely explain where they went wrong and give them a crash course on pediatric cardiac physiology.

OH DAMN! Maybe i should reconsider my decision on foregoing ortho

 

[DHT]

Fixed that last part for you.

Thanks, sometimes I forget because I'm so used to farting everytime I enter or exit a room.

 

[DoctaJay]

I agree that each field is cerebral. When you look at the stuff that PGY 3 obgyn residents are learning it would appear way above anything that you would desire to learn or had learned in medical school.

Likewise as an ortho PGY-1 I am increasingly cognizant of the fact that my 4 years in medical school did very little to prepare me for ortho in terms of knowledge. A lot I'm reading about during grand rounds or journal club is very much over my head. It takes a smart person to learn this stuff, master it, and eventually teach it to others. I haven't looked at physics since the MCAT, but now I'm having to relearn that stuff in addition to learning about various aspects of biomaterials and biomechanics. So is plating a pelvis less cerebral than performing a gastric bypass, probably not.

While its fun to down other fields as being smart or stupid, the simple fact is that we each chose our field either because we couldn't stand the other fields (well at least I couldn't).

 

[ZagDoc]

ENT - If you say that ortho/plastics is the least, and general specialties like Surgical Critical Care, Transplant, HPB, are the most. I would say ENT is right above ortho/plastics near the middle (next to Urology). Neurosurgery is probably slightly above or even with ENT/Uro, but still far below SCC, Transplant, HPB. As mentioned before, NSurg is less cerebral than most people think.

We ordered a 24 hour urine metanepherines on one of our ENT patients the other day. BOOM.

All in jest. I think every field has their "area" that is quite cerebral. And it all depends on what you mean by cerebral. Does cerebral mean working up a differential for your patients acute renal failure? Does cerebral mean juggling multiple medical co-morbidities in a post-operative patient? Does cerebral mean the pre-operative planning that does into closing a large oncologic defect on a patient's face after a basal cell resection while still maintaining a good aesthetic outcome? Does cerebral mean working through challenging operations fraught with peril? Each of those requires thoughtful planning and execution of different types. One is not "better" than the other, and each field has varying levels of each type of "thinking".

 

[SLUser11]

We ordered a 24 hour urine metanepherines on one of our ENT patients the other day. BOOM.

That comment lost some of its sting when you spelled metanephrines wrong.

Hopefully you gave it as a verbal order....

 

[womp]

The limitations of human memory prohibits a truly broad medical knowledge. Otherwise family doctors would be king of medicine. There's a cost to breadth. Most medical students like the romantic idea of becoming a doctor who can do everything. But it's neither feasible nor necessarily wise.

Remember your Adam Smith. The division of labor is a good thing. I'm looking at my window bug screen right now, and it doesn't hurt my ego to say I have no idea how to make a wire mesh screen like that.

 

[nonbilious]

the question is, when the s*** gets f***ed up, who gets called most frequently.... and thats what i loved first about gs. After us, i would go with cardiology...

 

[Toennis]

I agree that each field is cerebral. When you look at the stuff that PGY 3 obgyn residents are learning it would appear way above anything that you would desire to learn or had learned in medical school.

can please you explain this? i believe you but i can´t imagine.

 

[franceschino]

Talking about who does what makes me wonder: in the US who would manage a PE or fast AF on a surgical patient?

 

[SocialistMD]

Talking about who does what makes me wonder: in the US who would manage a PE or fast AF on a surgical patient?

On a general surgery patient, it would be general surgery and general surgery (with a possible cardiology consult if (a) it couldn't be broken or (b) an etiology couldn't be easily found). I can't speak for the surgical subspecialties.

 

[Smurfette]

PE--gen surg. Why would someone else need to manage this?
AF--gen surg starts immediate mgmt, but calls cardiology in AM (or patient's primary, if primary is following for a patient with a ton of complicated medical problems) to weigh in or tweak med regimen. Actually, in PP, I will call cardiology (one of the cardiologists is almost always there, they don't seem to mind these consults ($$) but I'm not always in-house and don't have residents) but I will give initial orders to try and break the AF. From my experience, CT surgery always managed their own patients in afib.

 

[45408]

New onset a-fib probably buys a cards consult, but RVR with a history of a-fib and normal troponins might not.

 

[JackShephard MD]

Bump.

I thought this thread was interesting, any more comments on this topic?

 

[Chakrabs]

I think people are underselling neurosurgery a little here. Cerebrovascular patients after a subarachnoid bleed are pretty damn complex. Combatting vasospasm in the ICU setting is tough especially when patients are comatose and/or vent dependent. Tumor surgeries can result in a slew of endocrine and fluid changes than require a fair amount of time and effort to solve as well. And how many other specialties have to manage intracranial HTN in addition to all the other standard ICU stuff as well?

 

[C5toC9]

NS or GS

 

[PRS]

I am really liking ortho's argument here. There is something to be said about not having to spend your career rehashing what you learned as a MS1/MS2, instead figuring how to ORIF it harder/better/faster/stronger than the next guy.

 

[Birdnals]

Surgical oncology has to be up there no? Seems like a lot of intellectual work along with the obvious surgeries.

I've been shadowing an interventional cards guy and if you guys consider that surgical then that's definitely seems cerebral. A lot of detective work and then procedures.

Something that's been interesting me lately is acute care surgery. Is the "managing the ICU" portion just more babysitting or do these guys also do a lot of the "cerebral" and diagnostic work as well?

 

[Winged Scapula]

I've been shadowing an interventional cards guy and if you guys consider that surgical then that's definitely seems cerebral. A lot of detective work and then procedures.

We don't. Procedures are not surgery.

Something that's been interesting me lately is acute care surgery. Is the "managing the ICU" portion just more babysitting or do these guys also do a lot of the "cerebral" and diagnostic work as well?

It depends on the particular environment. If its a closed unit, where only the SICU team manages the patients, then the day to day work is done by them; if open, then by the admitting physician (+/- consultation to other specialists). In my program the surgeons managed their own patients in the ICU (except for the sub specialties like Ortho, PRS, etc who used the SICU team to do the day to day work). Now out in practice, it depends on the particular surgeon as to whether they wish to have someone else manage the patient.

 

[naus]

I am really liking ortho's argument here. There is something to be said about not having to spend your career rehashing what you learned as a MS1/MS2, instead figuring how to ORIF it harder/better/faster/stronger than the next guy.

This doesn't make any sense. Aren't you still rehashing ORIF for the next 30 years?

If you want to be good in any field, you're going to be doing a lot of rehashing until you can do it correctly in your dreams. Personally, I really liked my M1 and M2 years, I kind of feel like it's why we went to medical school and separates us from the midlevels and PAs.

 

[JackShephard MD]

I am really liking ortho's argument here. There is something to be said about not having to spend your career rehashing what you learned as a MS1/MS2, instead figuring how to ORIF it harder/better/faster/stronger than the next guy.

This doesn't make any sense. Aren't you still rehashing ORIF for the next 30 years?

If you want to be good in any field, you're going to be doing a lot of rehashing until you can do it correctly in your dreams. Personally, I really liked my M1 and M2 years, I kind of feel like it's why we went to medical school and separates us from the midlevels and PAs.

Agreed. Some people are actually interested in medicine... gasp!

General medicine is interesting, I mean, being able to take care of patient's wide range of medical issues sounds more interesting to me than doing you 360th ACL repair for the year. It would be nice to know how to handle a medical emergency from out of the blue rather than having to call for back up.

General Surgery is a very thoughtful specialty. They operate, then do complex medical management and run their own ICUs.

Orthopods, on the other hand, are attractive to women...

lol, exactly. I guess if you need help in that area then go into ortho.