surgical specialty considerations

updated this post so ill republish it.

i added “again” because i previously blogged about this here. i took this online test that predicted what specialty i might be doing. it was a very superficial consideration, hardly well thought out. i suppose this is a question that should be, with good reason. the advice out there is to decide as early as possible as a student (even for undergraduate medical students). 

i was chatting to a Cambridge-educated urology registrar after outpatients one day, and he asked me about my interests for the future. He obviously knew i was interested in surgery because we attend a weekly surgical research group meeting / journal club. So he advised that in considering surgical subspecialities, its important to think about (1) lifestyle issues (2) where the specialty is heading in the future (3) the kind of care and cure you can be providing patients. i think these 3 broad concepts can be applied to any specialty consideration process. 

Let me further illustrate:

(1) lifestyle issues: its clearly different when i am merely a medical student, not earning cash, not married, not having kids, etc as opposed to being a resident, possibly married and possibly having a knocked-up wife in my hands. throw in housing loans? all that financial stuff i clearly have no clue abt. 

throw in my growing interest for adventure racing, and hence the money that might be spent on expensive gear like mountain bikes, surf skis, racing kayaks, running shoes, swim suits, competition entry fees, interstate flights to take part in these competitions, 2-3 day getaways at a holiday resort, etc etc. may i mention that training takes time too? how am i to train if i am working 80-hour work weeks? so i have to put these into the equation and somehow sort them out.

which kind of surgeon works the hardest? is it possible to balance a full-on family life with a successful practice plus personal time-consuming sporting endeavours? something’s gotta give. no one is superman. i’m just not sure which one’s gonna give. i just pray for an understanding wife. for starters. and maybe as bones wax old, the adventure racing will give. seemingly successful sportsmen-doctors are plentiful. some even go on to elite levels. Fifth-year medical student from Monash David Zalcberg qualified for Beijing 2008’s men’s singles and team table tennis (Monash News). South African bush doctor Paul Liebenberg, who practises in rural Australia, is competing in the Last Desert (now) to be the first in the world to complete the 4 Deserts in 1 calendar year. Captain Atopic is also a keen racer.

 would my current hobby be just a fad for me? what do i like to do? what is a viable hobby that one can pursue now and yet do it when you’re 60? these are questions you might ask yourself as i did ask myself. hobbies change. med students/doctors are smart multi-talented multi-skilled individuals, some more so than others. Mexico Medical Student is a keen music enthusiast. The list goes on.

Lifestyle issues for a general surgeon was addressed over at Scrub Notes

Q: How did you stay sane during training?

A: I didn’t, actually. I just worked all the time. I gained 25 pounds, and developed varicose veins and plantar faciitis so painful, I took analgesics constantly. My blood pressure went up, and despite my best efforts, I could not eat healthy as a resident. I developed prediabetes, and basically ignored my physical needs altogether. It is a show of weakness to express the need for the requirement of basic human needs as a surgical resident. Going to the bathroom was a big deal, actually. My only saving grace was the fact that I was only in my mid/late 20s, and my body tolerated the abuse…abuse that would be difficult (perhaps impossible) to physically recover from for someone a bit older.. 

(2) where the specialty is heading: consider cardiothoracic surgery. is it an up and coming specialty as before? or has interventional cardiology and the widespread use of aspirin and heart screen / primary prevention programs throughout the nation gradually shrunk its role? i don’t know. but i have a strong suspicion its shrinking. while people will still need CABGs, valve replacements, etc, there ARE alternatives. stenting, for example, has grown, a lot.

how about colorectal surgery? will there be a drug that alters the nature history of ulcerative colitis in the near future? i doubt so. monoclonal antibodies like infliximab indeed has revolutionised the treatment of IBD, particularly Crohn’s colitis, but surgical treatment is still curative for ulcerative colitis. about 80% of Crohn’s patients will develop complications requiring surgery within 10-15 years. colon cancer will still require colectomies in 30 years time. no drug will miraculously cure colon cancer. (perhaps i shouldn’t make such a sweeping statement. i would say its UNLIKELY.)

or consider urology? benign hyperplastic prostates still need TURPs done. i can’t see in my limited vision a drug for prostate cancer coming up. neither can the urology registrar. you have a consistent ‘rice bowl’.

how about plastic surgery? wound debridements still have to be done. there will still be idiots who run through their big toes with the lawn mowers. or workplace accidents involving cutting and slicing machines. dogs make still bite their owners or strangers. shit happens. its a profitable specialty, but you put in many many long hours as well. the plastic surgeons i see in hospital don’t do cosmetic procedures at all, but they still drive jaguars and porsches. that must be pretty good. i went in one saturday for a day full of elective plastic surgical cases and they did a record 18 cases. the surgeon slot in a comment while debriding to the keen medical student and said,

“if you ever want to work in a never ending specialty, choose plastic surgery…”

Cosmetic surgery is a subspecialty of plastic surgery, and there is heavy competition in USA with many resorting to strong advertising campaigns to boost business. Certainly a popular choice, and strongly advocated by my dad, but i always gently resisted, quietly thinking to myself, that is not what i got into medicine for. Will such resisting be futile? Only time will tell.

(3) the kind of care and cure you can be providing patients: the example the uro reg i was speaking to was an upper GI surgeon. the big surgeries are things like Whipple’s. how many years have they got after? contrast that with colorectal surgeon caring for colon CA patients. survival after 10 years are starkly different. you get to see your patients alive after several years. you don’t earn your big bucks from patients you know will die before you change your porsche 911 turbo over to an audi r8 (sorry for the xs motor references; i just read reviews). you might want to have some continuity of care. that’s something i desire as a doctor. something i actually got into medicine for in the very first place.

Intraoperative photographs of a Whipple procedure with extended lymphadenectomy (credit)

If you like quick results,  as a general surgeon, you can do procedures like lap appy and chole that will instantaneously give relief to the patient.

an exercept from dr wendy brown’s testimonial on the RACS site:

“… And they fixed people! They weren’t just changing pills around, they were making people well, and really changing their lives. 

I still love the fact that I am able to really help people with my job. Even the simplest operation that I perform, such as an appendicectomy, solves a problem for someone….”

 

(4) generalist vs specialist. this is one i read from “The Ultimate Guide to Choosing a Medical Specialty“. A MUST READ for all medical students.

The author couldn’t have classified it any better (IMHO):

 

1. Some are based strictly on an organ system, like the brain (neurosurgery and neurology), the heart (car- diology), and the male genitourinary system (urology). 
2. Others provide comprehensive medical care for specific population groups, such as women (obstetrics and gynecology) and children (pediatrics). 
3. Another set of specialties share in common the fact that they are hospital-based services. Its members include radiology, pathology, anesthesiology, and emergency medicine. 
4. Medical specialties can also generally be divided into two main groups: primary care (long-term comprehensive care) versus secondary/tertiary care (referral-based care). Generalist specialties like family practice, internal medicine, and pediatrics are considered primary care fields. More specialized areas such as gastroenterology, dermatology, and cardiothoracic surgery fall into the latter category. 

 

surgically speaking, there’s general surgery being the generalist component of surgery. however true general general surgeons are a dying breed. i think its sad. other have blogged about this problem before. the RACS’ SET programme currently has 9 surgical specialties: 

• • Cardiothoracic Surgery (CTS) 
• • General Surgery 
• • Neurosurgery 
• • Orthopaedic Surgery 
• • Otolaryngology Head and Neck Surgery (OHNS) 
• • Paediatric Surgery 
• • Plastic and Reconstructive Surgery  
• • Urology 
• • Vascular Surgery 

 

the enthusiastic fellows over at Adelaide has prepared a pre-SET guide for med students. good stuff. thank guys!

(5) Emergency

I used to have concerns about EM. My top turns off point was the lack of patient follow up. Duly rebutted by future EM physician Caroline Vines:

Re: EM… Yeah, it’s true you don’t get patient follow up in the sense that you don’t get to make the calls regarding their care once they leave the ED, but there is always the opportunity to follow up with them while they are in the hospital – all it requires is the energy to walk upstairs to the ICU or floor and check in on them.  I’m okay with not following patients over the long term (although with our emergency care system these days we get a lot of homeless and low income who repeatedly come back to the ED – not necessarily a good form of continuity of care…).  

She stated several salient points re her choice which i thought meant she’s extremely clear about her choice just before residency interviews. 

The reasons I’ve chosen EM are that I like the acute care aspect, the variety of patients and diseases, working with my hands, and  also the public health aspect of it (in the US our system has reached a point of crisis).  I also like the career flexibility  to go outside the hospital and practice wilderness medicine – I really want to be a ski patrol doc at some point in my life.  Finally, you’re right that it is a “generalist specialty” in that we specialize in being able to handle anything that walks in the door in any given moment and I think that is a useful specialty for working internationally or domestically in underserved areas. 

 

her advice certainly did not fall on deaf ears. its very exciting as a medical student to consider career choices. i feel very blessed to have the opportunity to even be able to study medicine. meanwhile, i’ll keep an open mind. who knows i might switch interests to radiology (just like Scrub Notes) or nuclear medicine, or rehab medicine. you never know. . . some doctors i spoke to have told me about colleagues who used to swear they will be doing this specialty in the future but turned up doing something entirely different! maybe all the SurgeXperiences coordinating will make me realise i don’t like surgery after all! 

next year (year 4 of 5) at Monash will be a year of exclusion. i will speak more about that soon. thanks for reading.

——-

when did YOU decide on your specialty? was it during med sch? or after a particularly inspiring rotation with a beloved mentor? pls share with us in the comments section.

—-

---

Possibly related posts: (automatically generated)

• RN’s with Surgical Precision Wanted, in Phoenix, AZ.
• Surgical specialties and sub-specialties