why academic surgery?

[50Cent]

I don't understand the lure of academic surgery. You get paid less, you have less time for patient care, you have teaching responsibilities. Finally, in this day and age, because of technological advantages, its no longer true that to be the 'top guy' you have to be at a major center.

Other than the psychological comfort of being in an institution and the fact they may lack business savvy, why do surgeons choose to go into academic surgery?

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[droliver]

There are a # of reasons:

-some people love to teach & interact with residents
-many of the super-specialties require an academic framework to provide a referral base for their field
-interest in clinical or basic science research
-for some specialties having resident coverage for night call & emergencies can make a huge difference in your QOL (transplant, peds surg, trauma, CTVS, critical care)
-affiliation with an academic center can be prestigious & send referrals to your private practice
-most of the state of the art technology filters out from the academic centers
-depending upon your arrangement, the salary for many fields can be pretty close or even exceed many people in private practice depending upon your field & billing (this is certainly true for many of the super star faculty in oncology, NES, orthopedics, CTVS, and plastic surgery)


On the other hand. The financial model for academic medicine is crumbling @ many places due to declining reimbursements with the built in high overhead of teaching hospitals. Financial sustainability is a real issue @ many of the top programs that do not have huge endowments

 

[50Cent]

Thanks for the reply!

I'm interested in neurosurgery, especially pediatric. Are the majority of pediatric neurosurgeons in academic centers?

 

[droliver]

I'll speculate & say yes as most of the larger pediatric hospitals have close ties to or are part of University Medical Centers

 

[sandg]

I hope you all don't mind a pre-med asking a question or two.
Is it truly possible for those in academic medicine to be outstanding clinicians and outstading researchers? Given the comments made in this forum about the necessity of constantly practicing surgery to maintain surgical skills, is there any time left to conduct research? Coversely, are those in academic centers focusing on research great doctors?
I ask these questions because I think I would like to ultimately work in an academic hospital. Having only observed (not participated in) the workings of a teaching hospital, I think it would be rewarding to teach others at this level. Not to mention the saftey net of referrals and not needing to run you own business as droliver said. I still have not decided, however, whether research interests me as much, and given the choice between the two, I would rather maintain my proficiency as a clinician.
In short, can one work in academics with little to no research obligations?
Thanks everyone.

 

[Winged Scapula]

IMHO sandg, it is difficult to be a "superstar" clinician AND Researcher. While there are some superheroes out there that seem capable to doing the job of ten men, for most of us, being at the top of our game requires focus.

Does that mean that you can't be a successful academic physician who also has active research pursuits? Of course, not - happens every day in academic centers around the world. IMHO however you must rely on others for assist -you can't be in the OR full time and in the lab that many hours as well. Research assistants to do the grunt work, residents to start and finish cases, etc. will ease the burdens on your time. Also consider that some faculty take a research sabbatical to finish the work.

I believe you can be a good surgeon who produces good quality research but that you would find it difficult to be one of the few who are (inter)-nationally known for their clinical AND research skills.

 

[ArrogantSurgeon]

From what I've experienced thus far in med school, it seems as if the private practice surgeons are pretty much "looked down upon" by those in academia. Pure private surgeons mostly get the mundane cases from the general "community" that any seasoned surgeon worth his salt can handle half-asleep. The complex cases mostly go to the academic centers where the "superstars" are. Plus, private surgeons just don't advance the field like academic surgeons do through research output. As you may know, a surgeon's reputation in largely built by the research he does and advancements he makes (think of any superstar surgeon out there and chances are that he is/was an academic surgeon). There are thousands of outstanding technical surgeons out there that operate in obscurity due to the mere fact that they are not academics. This is not to say that one cannot have both private and academic obligations as a surgeon.

 

[pjr]

I don't think that academic surgeons consider private surgeons to be lesser surgeons. Certainly some do...that attitude (as a resident in an academic program that will be going into private practice) can be pretty tiresome. However, most people realize that there are good surgeons in private practice and good surgeons in academics, and bad surgeons in each area. Lifestyle versus pay scale has certainly been a consideration for many. While you don't make as much $$$ in academics, you have residents to deal with the brunt of the BS that can make a private practice hectic -- i.e. you aren't coming in at 2am to put a central line in a patient that the internist hasn't even seen yet, 'cuz your residents will do it for you. In addition, private surgeons have been shooting themselves in the feet for years, accepting lower reimbursement and compensating by working at more and more hospitals to make the same amount of money overall.

You also have to consider your career goals. If your goal is to be famous and be recognized at all the meetings and such, carving out a specific niche in academia is the way to go. If you want to spend the majority of your time taking care of patients and doing the things you learned to do in medical school and residency, without the hastle of trying to publish every few months and constantly kissing up to people in higher positions of authority to get your next step in the academic pedigree (assistant -> associate-> clinical professor, program director, etc) then private practice is more attractive. It's really a tradeoff for what you want to do...I don't see one as being better or worse than the other, just different.

 

[FliteSurgn]

private practice surgeons are pretty much "looked down upon"

The university surgeons that look down on private practice surgeons are just compensating for their own insecurity. A lot of the "superstars" that I have seen couldn't operate their way out a wet paper bag compared to a good community general surgeon. They rely on their fellows and assistants.

I love thinking back to medical school...the surgeons would lament about how you have to be at a university to do the big cases...community surgeons were inept...university surgeons are more cutting edge...etc. One of the most blatant examples of this being so untrue that it is comical is laparoscopic surgery. Community surgeons were the ones that picked it up and ran with it in the late 1980's to early 1990's. University surgeons denounced it almost as a whole. Therefore, they were so far behind the learning curve that it literally rolled right up and over them. Only now are universities starting to make up ground. And with the excpetion of a few laparoscopic gurus (university hired-guns), most community surgeons can still operate circles around their university brethren through the scope.

private surgeons mostly get the mundane cases from the general "community" that any seasoned surgeon worth his salt can handle half-asleep

This is a myth that is propagated by those same university surgeons. While it is true that some community surgeons don't do the big "horrendeomas", it's not because they aren't capable. It's because they choose not to do those cases. They have made a choice for lifestyle and will refer those cases to places that have slave labor...wait...those slaves are only allowed 80 hours per week now...whoops, those "superstars" are going to have to do more work themselves...lol.

I personally know a lot of community surgeons that perform the most complex surgical procedures that not even ArrogantStudent can call "mundane." They do Whipples, transhiatal esophagectomies, hepatic resections, advanced laparoscopic procedures, etc. And best of all, they do these quickly and efficiently because time is money. Their "obscurity" is to those in the universities not to their patients, families, or referring doctors.

 

[droliver]

Originally posted by FliteSurgn
While it is true that some community surgeons don't do the big "horrendeomas", it's not because they aren't capable. It's because they choose not to do those cases. They have made a choice for lifestyle and will refer those cases to places that have slave labor...wait...those slaves are only allowed 80 hours per week now...whoops, those "superstars" are going to have to do more work themselves...lol.

It's not lifestyle as much as it is reimbursements. Any case more then 2 hours is a money lose for general surgery & you don't get paid more for the complex global post operative care. Other reasons why many of those procedures are not done in community hospitals is that its becoming increasingly clear that outcomes on those morbid procedues you mentioned are better @ high volume institutions, which are more often the teaching hospitals in many areas. This message is increasingly filtering out to the refering physicians from the 3rd party payers and affecting referral patterns somewhat. The pressure for collecting those procedures in "super-tertiary" hospitals is increasing steadily with more published work on the subject

 

[50Cent]

I was told by a pediatric surgeon that the majority of complex pediatric cases in all specialties are taken in major academic centers.

 

[vuillaume]

I don't understand why people must dichotomize academic and community surgeons. The simple fact is that both are indispensible to society.

We need people to handle "bread-and-butter" cases just as much as we need people to cut out fascinomas. Take away either and surgical health care grinds to a halt.

To respond to the original question "Why Academic Surgery?"--Take these so-called "egghead poor technicians" away and progress will slow to an incremental pace. New modalities such as staging lung cancer with PET, or sentinel lymph node mapping would never have occurred outside of an academic setting. I really doubt anyone would argue their merit as state-of-the-art.

Much of our classical surgical understanding of fluids, electrolytes and resuscitation is thanks to Frannie Moore, legendary chairman at the Brigham. Transplant surgery? Only an academic surgeon operating in an academic setting such as Thomas Starzl is going to have made this the viable technique it is today.

The point is, with few exceptions, academic surgeons shape the state-of-the-art, that's their job; but community surgeons indispensibly disseminate and propagate that state-of-the-art, and that's how it benefits society on a grand scale.

When you choose a career, you balance your own desires in terms of lifestyle with the role you want to play. I think academic surgery is often the harder life--not that academics deserve medals for this choice--because they're tugged in many directions and they're paid less. On the other hand, the chance to train motivated and curious trainees, or sit on NIH study sections and shape the practice of surgery for future generations is pretty compelling too.

And yes, if you agree with FliteSurgn, academic surgeons get the privilege of being unable to operate their way out of a wet paper bag.

Both ArrogantSurgeon and FliteSurgn are way off with their dogmatism.

 

[ArrogantSurgeon]

There is a world of difference between being a glorified mechanic and an academic surgeon who actually advances the field. If you're not actively doing research, then you're not really doing anything to advance the specialty you're practicing in. Most anybody can get real good at operating if that is all they are doing day in and day out, but the real skill lies in being a good technical surgeon *AND* a proficient researcher who actually contributes to the knowldedge base of the field.

 

[FliteSurgn]

And yes, if you agree with FliteSurgn, academic surgeons get the privilege of being unable to operate their way out of a wet paper bag.

Don't get me wrong, I've seen plenty of community surgeons that can't operate out of that same paper bag.

There is a world of difference between being a glorified mechanic and an academic surgeon who actually advances the field.

Let your referring doctors know that you think they are glorified mechanics, I'm sure that will increase your surgical volume.

I don't understand why people must dichotomize academic and community surgeons. The simple fact is that both are indispensible to society.

I agree. I dichotomized university vs. community surgeons, but I still agree that both are indispensible.

I realize that I tipped the scale too far from center on my arguments, but it was to make a point. I was playing devil's advocate to the implied notion that if you aren't researching the latest Interleukin or cytokine that you are a slob general surgeon doing cases that anyone could do half-asleep.

My point of contention mainly revolves around the fact that most community surgeons don't bad mouth their university colleages, but the university surgeons seem to do so regularly. To glorify their own existence? The truth is that I know a lot of community general surgeons that participate in clinical research (NSABP trials, sentinal nodes, PET staging, novel surgical interventions, evidence-based practice management, etc.). In regard to PET and SLN, our local community surgeons adopted this technology much faster than the local university programs. So the claim that community surgeons are "glorified mechanics" who don't advance their field is unbased.

I think the most important thing is to do what you love. If you get excited about bench research then more power to you, but just don't get all high and mighty about it. If you love operating and don't want to see the inside of a lab, then you shouldn't have to be called a mechanic. Throw in some clinical research and you may have the best of both worlds. My two cents.😎