Future of General Surgery?

[Ellie321]

The last thread I found about this topic was in 2006. Any new thoughts/insights about the future of gen surg? Is there a trend towards pursuing additional specialization and fellowship training? If so, why?

Quite a few people seem to feel that gen surg is becoming less and less relevent. Is this because people are expecting a decrease in compensation for gen surg? Is the case load/patient population decreasing? I guess I don't understand how gen surg could possibly become phased out. If everyone becomes a a specialist and practices within a very specific niche, who will do the "bread n' butter" cases?

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[ACSurgeon]

The last thread I found about this topic was in 2006. Any new thoughts/insights about the future of gen surg? Is there a trend towards pursuing additional specialization and fellowship training? If so, why?

Quite a few people seem to feel that gen surg is becoming less and less relevent. Is this because people are expecting a decrease in compensation for gen surg? Is the case load/patient population decreasing? I guess I don't understand how gen surg could possibly become phased out. If everyone becomes a a specialist and practices within a very specific niche, who will do the "bread n' butter" cases?

Well, for one, a lot of specialists have to take gen surg call, especially early on in their careers. At my med school, the colorectal/hepatobiliary/ trauma took gen surg call and they all did bread and butter. Vascular/Cardiac surgery seems to have branched off far enough, that they don't do gen surg (at my school).

I guess this is mainly at academic centers. Not sure if private hospitals routinely require specialists to take gen surg call or not.

 

[ironxc]

What's important to understand is the drastic changes in reimbursement that are coming. Generally speaking, all procedure based specialties are going to face drastic decreases in income. This will be particularly true in an institution that decides to form an ACO. One of the stated goals of global payments is to increase the income and primary care doctors and decrease the payment to specialists. This includes general surgery.

People will still need general surgery for emergency cases, trauma, and some of the elective procedures no one else wants to do. But you will make far less than you think you're going to.

 

[Winged Scapula]

Not sure if private hospitals routinely require specialists to take gen surg call or not.

It really is hospital dependent. My residency academic medical center tried, for awhile, to make some of the subspecialists take gen surg/acute care surgery call. It was a disaster as the residents were trying to train some of these guys, who might not have been more than 10 years out of residency, how to manage diverticulitis, how to run a scope for a lap appy, etc. They soon reverted back to having only a few take GS call.

One of the local hospitals here requires anyone who is GS trained to take GS call. They wonder why they have trouble getting people on staff.

I don't go to that hospital since there are others who realize how stupid this is from a liability standpoint.

 

[filter07]

This is just my opinion based on a very limited sample of residents. I think general surgery will continue to specialize. I predict that many more unaccredited fellowships will form. Basically we'll have any sort of excuse to get undertrained surgeons more time to see enough cases and learn enough to pass boards. Right now the pass rate, based on my limited sample and national statistics, have decreased, and surgical skills and confidence are not at an acceptable level for a good number of chief residents (the latter is anecdotal). The most obvious example of what I'm talking about is laparoscopic surgery fellowship. Some people have used this fellowship to get better in general surgery, take some extra time to get cases, and study for boards.

A lot of niches will be created that was once considered bread and butter general surgery. Breast surgery, colorectal, laparoscopic are just the beginning in my opinion. Most of that is due to increasingly complexity and the ability to differentiate from GS in terms of compensation/lifestyle. Some of that is b/c surgeons just aren't trained adequately and need extra training of some kind.

That is just my opinion. It could be uninformed, or worse, wrong.

 

[Ellie321]

This is just my opinion based on a very limited sample of residents. I think general surgery will continue to specialize. I predict that many more unaccredited fellowships will form. Basically we'll have any sort of excuse to get undertrained surgeons more time to see enough cases and learn enough to pass boards. Right now the pass rate, based on my limited sample and national statistics, have decreased, and surgical skills and confidence are not at an acceptable level for a good number of chief residents (the latter is anecdotal). The most obvious example of what I'm talking about is laparoscopic surgery fellowship. Some people have used this fellowship to get better in general surgery, take some extra time to get cases, and study for boards.

A lot of niches will be created that was once considered bread and butter general surgery. Breast surgery, colorectal, laparoscopic are just the beginning in my opinion. Most of that is due to increasingly complexity and the ability to differentiate from GS in terms of compensation/lifestyle. Some of that is b/c surgeons just aren't trained adequately and need extra training of some kind.

That is just my opinion. It could be uninformed, or worse, wrong.

What do you think is causing surgery residents today to be less well-trained than in previous generations?

 

[filter07]

Work hour changes + increased complexity of patients + increasing number of surgical procedures to learn

In other words, jack of too many trades, master of none, in less time

 

[SLUser11]

What's important to understand is the drastic changes in reimbursement that are coming. Generally speaking, all procedure based specialties are going to face drastic decreases in income. This will be particularly true in an institution that decides to form an ACO. One of the stated goals of global payments is to increase the income and primary care doctors and decrease the payment to specialists. This includes general surgery.

People will still need general surgery for emergency cases, trauma, and some of the elective procedures no one else wants to do. But you will make far less than you think you're going to.

Not to be a punk, but most people who claim the future of general surgery is bleak usually have no true experience in the matter, and are simply regurgitating info they received from residents/attendings in an urban academic setting. It's possible that you are not one of these people, and have some real experience...if so I apologize.

This has been discussed multiple times in the past, and there is a huge workforce shortage for general surgeons. However, the top 10-20 largest cities are oversaturated with surgeons and have less opportunities. Also, Most subspecialists are not interested in general surgery call.

General surgery is still extremely relevant, and bread and butter cases will always exist. The reimbursement will change, and the field will become less profitable, but the sky is not falling, and surgeons will still ultimately make more money than primary care docs....but we'll be working a lot harder....

 

[ironxc]

Not to be a punk, but most people who claim the future of general surgery is bleak usually have no true experience in the matter, and are simply regurgitating info they received from residents/attendings in an urban academic setting. It's possible that you are not one of these people, and have some real experience...if so I apologize.

This has been discussed multiple times in the past, and there is a huge workforce shortage for general surgeons. However, the top 10-20 largest cities are oversaturated with surgeons and have less opportunities. Also, Most subspecialists are not interested in general surgery call.

General surgery is still extremely relevant, and bread and butter cases will always exist. The reimbursement will change, and the field will become less profitable, but the sky is not falling, and surgeons will still ultimately make more money than primary care docs....but we'll be working a lot harder....

Apology accepted.

There is actually some debate as to whether or not there is a REAL work force shortage in general surgery. The more likely explanation is that the current work force is poorly distributed around the country, with obvious saturation in desirable urban centers.

Whether or not there is a workforce shortage is frankly moot to the conversation of payment reform that is going to happen. If you aren't up on the realities of global payment systems as envisioned by large payers such as Blue Cross and the ACO model put forth in the recent health care legislation (PPACA), now would be a good time to start. Unless specialists and surgeons somehow magically develop the operational, financial, and negotiating skills to set up their own ACO's (never mind the high fixed cost investments of IT, hospitals, etc.) you will be making less than you think. Maybe a lot less depending on the surgeon's ability to negotiate the distribution of funds among the various specialties. This, of course, completely ignores the negotiation between the doctors and the hospitals to split the funds.

You raise a lot of other interesting points in this post (e.g. bread and butter will "always" be there, etc.), but that's all I have for now.

 

[SLUser11]

Apology accepted.

What's your personal experience with this? It sounds like you are a MPH or MBA student or recent grad. Are you in practice?

Anyway, the OP's question does not seem to be entirely centered on reimbursement, but instead the relevance of the general surgeon in health care. Outside of a select few "desirable" urban locations, there exists a huge need for general surgeons. Semantically and practically, that's a shortage regardless of it's cause.

So, to the OP: The case load and patient population are not likely to decrease significantly. The general surgeon still plays an important role in health care, but the glory days are over, so you should do it for the love of the game, not for big money.

As for super-specialization, this is definitely occurring, and has a myriad of causes. My current experience in a midwest town of about 600,000 people is that "niche surgeons" are more likely to feel a pinch than general surgeons, as someone who refuses to take ER call and specializes in left handed pinky finger surgeries may not have enough volume to stay busy.

 

[Smurfette]

As a general surgeon, I can tell you that I am getting busy very quickly and am getting patients with a huge variety of problems. I don't only get lap choles, hernias and breast biopsy patients. Do I get called to see patients with things that aren't very interesting or that seem like a waste of time? Of course.....but now I get paid for it, and the referring doctor appreciates my consult, and thinks of me the next time they have something needing a surgeon. Not everybody wants to go to the fancy academic center and see a specialist---a lot of people seem to like the idea of going to a surgeon that knows their primary doctor or that their primary doctor can vouch for. Do I see things that I feel SHOULD go to our academic hospital? yes, and I will send them there. But not everything outside of appys, hernias and choles needs a specialist.

I can't really speak to absolute trends in the field as I am new to it. I think one of the major factors with general surgery is letting your referring docs know what procedures you do or don't do, so you can keep your skills up volume-wise for a particular kind of case by making sure they send you referrals. It's like what WS was saying----the specialists who haven't done an appy in years SHOULDN'T be doing them; those who do them routinely SHOULD be. Obviously there are things that should be sent to the fellowship trained folks and not handled by the general guy. There just needs to be a balance. And SLU is right....there is a huge demand for general surgeons outside of the big, oversaturated cities.

As far as being inadequately trained, there is a difference IMO between doing a fellowship to train for a subspecialty career and doing a fellowship because you feel you are not comfortable being in the OR. That is something that you need to look at in a residency program---do the grads feel like they could go straight into practice after residency with the training they got? Regardless of chosen path (fellowship or PP), everyone in my class felt we were well trained and could go into GS PP if they wanted to right after residency (and a couple of us did). And I trained at an academic center with it's own med school. But the OP is right, not every program graduates residents who feel the way my class did.

 

[45408]

As a general surgeon, I can tell you that I am getting busy very quickly and am getting patients with a huge variety of problems. I don't only get lap choles, hernias and breast biopsy patients.

If you'd humor me, what kinds of things are you seeing that constitute a good variety?

 

[Smurfette]

I think of it as stuff that is general surgery. You may not find it interesting, but IMO it is variety.

This week I saw several diverticulitis patients (one with abscess, one that wants resection after recurrence, one that got better with abx and went home), colon cancers (1 sigmoid, one unresectable metastatic rectal), breast stuff (the usual variety of cysts, abnl mammos, breast pain, palpable lumps. We have a breast surgeon in another town we refer some of the unusual stuff to), a hiatal hernia, a MALT tumor pt with radiation enteritis (random---not operating on that though), ventral hernia repair with separation of components, SBO (ex lap LOA), and the usual constellation of groin hernias, appys, wound stuff, choles, lipoma/cyst excisions and non specific abdominal pain requiring more work up. Sent out a pyloric stenosis baby as well (no peds surgeons here, so I get called to diagnose and transfer since our anesthesiologists won't do kids under a year. Not that I mind...I don't like peds. I will do peds appys and lumps and bumps in kids though). I sent something to our plastic surgeon this week too.

Helped out my partner with yet another hiatal hernia case this week and he had some other things on for the week including a thyroid and some vascular stuff (carotid, pseudoaneurysm repair), which I don't do. My other partner got a diverticulitis with fistula to the bladder that needed surgery and was trying to coordinate the case with urology. unusual to have so many diverticulitis patients in one week.

Hope that gives you a better idea.

 

[45408]

Thanks. Sounds like a pretty good mixture to me.

 

[blue2000]

I think of it as stuff that is general surgery. You may not find it interesting, but IMO it is variety.

This week I saw several diverticulitis patients (one with abscess, one that wants resection after recurrence, one that got better with abx and went home), colon cancers (1 sigmoid, one unresectable metastatic rectal), breast stuff (the usual variety of cysts, abnl mammos, breast pain, palpable lumps. We have a breast surgeon in another town we refer some of the unusual stuff to), a hiatal hernia, a MALT tumor pt with radiation enteritis (random---not operating on that though), ventral hernia repair with separation of components, SBO (ex lap LOA), and the usual constellation of groin hernias, appys, wound stuff, choles, lipoma/cyst excisions and non specific abdominal pain requiring more work up. Sent out a pyloric stenosis baby as well (no peds surgeons here, so I get called to diagnose and transfer since our anesthesiologists won't do kids under a year. Not that I mind...I don't like peds. I will do peds appys and lumps and bumps in kids though). I sent something to our plastic surgeon this week too.

Helped out my partner with yet another hiatal hernia case this week and he had some other things on for the week including a thyroid and some vascular stuff (carotid, pseudoaneurysm repair), which I don't do. My other partner got a diverticulitis with fistula to the bladder that needed surgery and was trying to coordinate the case with urology. unusual to have so many diverticulitis patients in one week.

Hope that gives you a better idea.

I'm starting small town general surgery soon, and based on my future partner's case list, this looks pretty similar to me. And I LOVE it.

 

[tomwarren]

An interesting field of medicine. I am willing to be a general surgeon to help my community, but the pay is really bad. How should I have the money to travel outside of this country for an extended care of people in poor countries who need help or have experienced a natural disaster.

 

[LifetimeDoc]

An interesting field of medicine. I am willing to be a general surgeon to help my community, but the pay is really bad. How should I have the money to travel outside of this country for an extended care of people in poor countries who need help or have experienced a natural disaster.

Oh? How badly do you thing we are paid?

 

[DoctwoB]

My thought is that GS specialties will continue to branch off to form their own residencies (Plastics has, Vascular is in process, CT is next, and I've heard that Peds may follow).

Do you guys think that GS will eventually evolve into its own specialty of Abdominal Surgery?

 

[Smurfette]

My thought is that GS specialties will continue to branch off to form their own residencies (Plastics has, Vascular is in process, CT is next, and I've heard that Peds may follow).

Do you guys think that GS will eventually evolve into its own specialty of Abdominal Surgery?

I doubt it given the need for someone to do soft tissue "lumps and bumps", SLN biopsies/WLE melanomas and breast biopsies and the like (yes, there are breast fellowships, but I don't know if many breast-fellowship trained individuals want to work in more rural or less-populated environments...there's a LOT of breast cases to go around, and in a more rural environment they'd probably have to take GS call). Who knows how things will evolve over time, though.

 

[DeadCactus]

I've heard that Peds may follow.

I keep hearing talk of this. Is there much more to it than a rumor? Is it something that might pop up a decade from now or are there actual efforts to start such a program that could be up and running in 2-4 years?

 

[Chirurgia magna]

Work hour changes + increased complexity of patients + increasing number of surgical procedures to learn

In other words, jack of too many trades, master of none, in less time

Well, that's just an opinion as well especially the work hour reductions.

The one thing I noticed that is vastly different is resident autonomy. We have chiefs that don't even start until the attending is in the room. It used to be that the attending would call in and ask how things are going from the golf course while the senior and the junior resident would be doing the case. It kills me to see residents months weeks away from graduation and still don't do a case from beginning to end.

 

[Dr.LeoSpaceman]

Well, that's just an opinion as well especially the work hour reductions.

The one thing I noticed that is vastly different is resident autonomy. We have chiefs that don't even start until the attending is in the room. It used to be that the attending would call in and ask how things are going from the golf course while the senior and the junior resident would be doing the case. It kills me to see residents months weeks away from graduation and still don't do a case from beginning to end.

Blame JCAHO for that one. As far as I know, the attending has to be in the room for the Time Out. I've still see quite a bit of autonomy, but it's heavily attending (and resident) dependent. Some attendings don't feel like watching someone struggle, so since they have to be there anyway, they are quick to take over. Similarly, it's not a secret who the stronger residents/chiefs are, and they're certainly more likely to be left alone.

Not to mention that with the fragmentation of general surgery into niche specialties at academic centers, I'm not sure the case mix always lends itself to chiefs operating skin to skin. It's why I think finding a program that has access to a VA or community setting has become ever more important.

 

[pnle119]

... and surgeons will still ultimately make more money than primary care docs....but we'll be working a lot harder....

More importantly, we'll be doing what we love...operating

 

[badasshairday]

It's why I think finding a program that has access to a VA or community setting has become ever more important.

This is very true. I'm only a med student but did my rotation at one of the community hospitals loosely affiliated with my school rather than the main academic hospital. The interns were operating rather than just doing floor work. I watched an intern do an open appendectomy with the attending watching/instructing/assisting. He said he scrubbed into more cases in his 2 months at the community hospital than the previous 4 months at the academic hospital.

 

[HEENTdude]

This is very true. I'm only a med student but did my rotation at one of the community hospitals loosely affiliated with my school rather than the main academic hospital. The interns were operating rather than just doing floor work. I watched an intern do an open appendectomy with the attending watching/instructing/assisting. He said he scrubbed into more cases in his 2 months at the community hospital than the previous 4 months at the academic hospital.

All that glitters is not gold.

I rotated at a similar community hospital and the PGY4's there barely touched the patient. Of course, the patient population in the area was middle-class to affluent and I'm assuming this was the reason the surgeons didn't let the resident do as much.

 

[SLUser11]

All that glitters is not gold.

I rotated at a similar community hospital and the PGY4's there barely touched the patient.

It doesn't sound very similar, other than the fact that it was a community hospital. At your hospital, the residents did very little. At BAHD's hospital, the interns were operating quite a bit and seemed to prefer that experience to their academic hospital.

I think that an "all that glitters is not gold" approach to residency is important, but applies just as much to students enamored by a famous program's big names and bright lights.

Even though I know you were quoting Shakespeare, I still ended up with Robert Frost in my head. Stay Gold, Ponyboy...

 

[maxheadroom]

On the Plastics side I've seen both. I've seen academic places where the residents operated like maniacs and academic places where the residents held hook on the staff's "private patients." I've seen community rotations where the residents had a fantastic operative experience and community rotations where the residents served as a glorified PA.

This stuff is all program-dependent.

 

[rigid]

Hey, To give you an idea of how things are like in Australia,

CT, Vascular, Peds are already their own separate specialties (which do require some time spent training in general surgery, usually 1+5 or 2+4) and general surgery has effectively been split into sub-specialties such as Upper GI surgery, Colorectal and breast/endocrine.

In public hospitals the general surgeons are mainly sub-specialised however they still share the call for bread and butter cases, so they will all have lap choles, appendicectomies and hernias etc but they also get their own operations in their field of interest such as whipples, rectoplexy, thyroidectomy etc and all the teams share the trauma call.

Hope that gives some insight on possibilities for the future

 

[Toennis]

in germany the general surgeon is the little abdominal+little plastic+little ortho person whilst the abdominal surgeon maintains a separate specialty who does the difficult abdominal stuff plus the endocrin stuff

 

[thedrjojo]

All that glitters is not gold.

I rotated at a similar community hospital and the PGY4's there barely touched the patient. Of course, the patient population in the area was middle-class to affluent and I'm assuming this was the reason the surgeons didn't let the resident do as much.

Exactly. My program is University/Public Hospital, Community Private Hospital, and VA. The time split is about 50% at the university, 33% at the Private, and the rest at the VA. We traditionally get about 50-60% of our volume from the private hospital, but with various levels of autonomy (as an intern I did a Lap Chole with the attending holding the camera and only occasionally stealing the instruments, I also did a Robotic VATS lobectomy where I retracted the lung.. ive also done a lap appy skin to skin and a breast biopsy skin to skin, but I've also retracted or held the camera for those exact same cases), where as our university/public hospital, our chairman shows up to sign the time out and thats about it... consults overnight are called into the chief resident who then decides what and when to talk to the chair about it, usually the next morning. The VA is also great about autonomy. I think it is important to have that balance though, since if you never see the right way to do things, you develop bad habits.

IMHO, the decline in skills/pass rate is 100% to do with lack of autonomy, and has little to do with the work hour stipulations.

 

[Med0123]

Bump, this thread was interesting.

Do you guys know what is the current state of cancer research on breast/colorectal cancer?
I am asking the question because when there will be more understanding of molecular pathways of the genesis of these neoplasia and big advances toward a biochemical cure I think THEN there will be serious concerns on the future of general surgery and its redefinition will be mandatory...

We used to do lobectomies for TB, then we started using drugs.
ObGyn used to do hysterectomies for cervical neoplasia, but HPV vaccine was developed.

At the same time, there will always be bread and butter cases... but with how many surgeons will we have to share the bread?

 

[idiot07]

Don't hold your breath 90% of solid tumors that are cured, are cured by surgery, and it's not going to change anytime soon. A pure pharmaceutical cure for most solid tumors is a long, long way off for a variety of reasons. Not all tumors have the same driver mutations meaning there's probably no magic bullet targeted for any given cancer type. Drugs often have trouble penetrating into large tumors that may be poorly vascularized. Even today targeted or gene tailored therapy is mostly used in the adjuvant or salvage setting where it is more effective. Finally, surgery is probably a bargain compared to many of these drugs which may be $10,000 a dose.
If for some reason this did happen, there's enough diverticultitis, sbo, goiter, reflux, appendicitis, choleyctitis to go around. Your brought up the example of TB. When abx came along people thought the discipline of thoracic surgery was dead. Then came the rise of lung cancer and the development of open heart surgery. Pathology changes, the need for surgeons doesn't.......Until the machines take over.

 

[doc05]

there's enough diverticultitis, sbo, goiter, reflux, appendicitis, choleyctitis to go around.

not really. general surgery is becoming more and more fragmented. and not just in academic centers.

 

[naus]

All that glitters is not gold.

I rotated at a similar community hospital and the PGY4's there barely touched the patient. Of course, the patient population in the area was middle-class to affluent and I'm assuming this was the reason the surgeons didn't let the resident do as much.

I think you're using that Shakespeare quote wrong. It would be more applicable for a Big Name place.

 

[traumadoc1985]

I am 1 of 4 attending surgeons at a very small hospital 50 beds give or take, and they make all of us surgeons take gs and trauma call, no matter what your specialty is, we have one female surgeon who is actually had a fellowship in breast surgery they make her take gs and trauma, Mine is in oncology and they make me take gs and trauma, the other two are gs/trauma surgeons but I think I take call more then either one of them. LOL

 

[Dr.LeoSpaceman]

Do you guys know what is the current state of cancer research on breast/colorectal cancer?

I'd say breast cancer is probably the area to look to since there is such an incredible amount funding that goes into it. And even with some of the major advances that have been made, we're not really close to "surgery-free" cure.

Winged Scapula may smack me down on the numbers, but something like 60% of Her2 positive ductal carcinomas treated with AT + herceptin show pathologic complete response. The issue is that you don't know who is in that 60% until after you resect the tumor bed since even MRI's sensitivity in detecting complete response is fairly poor (~60%).

So while much research is leading towards less surgery (i.e. Z11 which has made headway in significantly reducing the number of ax dissections that get done by the true believers), it's still not really close to ending the role for surgery in cancer. If anything, it's helped develop the role for the surgical oncologist, who is meant to have an understanding of the multi-modality treatments for cancer.

EDIT: And actually, there may be some situations that have seen growth in the role of surgery where the treatment previously was thought to be chemotherapy only. I think the theory advanced by Joan Massagué and others that primary tumors may use endocrine-like pathways to spur growth of metastatic deposits lends weight to the idea of resecting primary tumors in the face of metastatic disease.

 

[Med0123]

EDIT: And actually, there may be some situations that have seen growth in the role of surgery where the treatment previously was thought to be chemotherapy only. I think the theory advanced by Joan Massagué and others that primary tumors may use endocrine-like pathways to spur growth of metastatic deposits lends weight to the idea of resecting primary tumors in the face of metastatic disease.

Wow never heard of that but I will definitely look into this theory! Is this new?
It seems a little bit counter-intuitive tho because numerous studies have shown the non-inferiority of chemo alone vs. chemo+surgery. Do you know which kind of tumours mets would be the most responsive to chemo+surg on hte primary cancer?

 

[Dr.LeoSpaceman]

Wow never heard of that but I will definitely look into this theory! Is this new?
It seems a little bit counter-intuitive tho because numerous studies have shown the non-inferiority of chemo alone vs. chemo+surgery. Do you know which kind of tumours mets would be the most responsive to chemo+surg on hte primary cancer?

Again, from the breast cancer literature:
http://www.ncbi.nlm.nih.gov/pubmed/20012891
http://www.ncbi.nlm.nih.gov/pubmed?term=16702580%20

As for why that's the case, I think it has a lot to do with circulating cancer cells and/or cancer stem cells and the idea of "self-seeding". For some interesting reading, I'd try:
http://www.sciencedirect.com/science/article/pii/S0092867406014140
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2810531/?tool=pubmed

As for colon cancer, I'm not aware of a good paper that shows a survival benefit for resecting the primary + chemo vs. chemo alone in situations where curative resection is not feasible. But even traditionally I think there has been a role for resecting the primary not with curative intent, but to prevent complications associated with it (bleeding, obstruction, perforation, etc.) And now that chemo is better at treating systemic disease, I think resection of the primary for those reasons become more valid. Plus, this doesn't even begin to address the idea of regional therapies (HIPEC, liver perfusion, etc.) which are chemo based, but require "surgical" delivery.

So again, while biologic/chemical therapies may continue to get better, I always think there will be a role for surgery even if that role is substantially different.

 

[Zoom-Zoom]

As for colon cancer, I'm not aware of a good paper that shows a survival benefit for resecting the primary + chemo vs. chemo alone in situations where curative resection is not feasible. But even traditionally I think there has been a role for resecting the primary not with curative intent, but to prevent complications associated with it (bleeding, obstruction, perforation, etc.) And now that chemo is better at treating systemic disease, I think resection of the primary for those reasons become more valid. Plus, this doesn't even begin to address the idea of regional therapies (HIPEC, liver perfusion, etc.) which are chemo based, but require "surgical" delivery.

So again, while biologic/chemical therapies may continue to get better, I always think there will be a role for surgery even if that role is substantially different.

I like this discussion.The future of cancer in general is kind of intriguing. It seems like most CNS or hepatobiliary tumors could be left alone entirely whereas colon or gyn or lung cancers might require surgery anyway. I wonder if breast would just be shunted straight to plastics rather than a two stage removal -> reconstruction?

I like the idea of intra-operative chemo and particularly radiation -- seems like it could benefit surgeons to implement intra-operative radiation technologies before rad onc makes its way into the OR. As treatment modalities become more available for practitioners in the future, certain specialties could take full control of specific diseases and their treatment. It will be interesting to see if any types of cancer become completely non-operative despite newer inventions and increasingly minimally invasive options for patients and surgeons.

There's also the question of how practical it is to actually phase surgery out of an existing treatment protocol. Especially with serious cancers. How long would that actually take in real life, even if the data is good?

 

[thedrjojo]

I like this discussion.The future of cancer in general is kind of intriguing. It seems like most CNS or hepatobiliary tumors could be left alone entirely whereas colon or gyn or lung cancers might require surgery anyway. I wonder if breast would just be shunted straight to plastics rather than a two stage removal -> reconstruction?

I like the idea of intra-operative chemo and particularly radiation -- seems like it could benefit surgeons to implement intra-operative radiation technologies before rad onc makes its way into the OR. As treatment modalities become more available for practitioners in the future, certain specialties could take full control of specific diseases and their treatment. It will be interesting to see if any types of cancer become completely non-operative despite newer inventions and increasingly minimally invasive options for patients and surgeons.

There's also the question of how practical it is to actually phase surgery out of an existing treatment protocol. Especially with serious cancers. How long would that actually take in real life, even if the data is good?

brachytherapy... radiation already makes its way into the OR.

Why do you say that most hepatobiliary cancers could be left alone? As it stands right now, hepatobiliary cancers have the most extensive of surgeries (Whipple/Liver Transplant... liver transplant showing some great survival benefit)

There are some cancers that are completely non-operative, namely lymphomas/leukemias, and others that even for early stages, radiation/chemo has the foothold (anal, laryngeal), partially cause the operative alternative is so radical.

 

[Jay Gatsby]

Interesting discussion, old sport.

 

[Dr.LeoSpaceman]

brachytherapy... radiation already makes its way into the OR.

Throw in intraop radiation after breast conserving therapy. From a patient standpoint, it's a much better option. One shot and you're done--no need for 6 weeks of daily trips to the rad onc office.

 

[Winged Scapula]

Throw in intraop radiation after breast conserving therapy. From a patient standpoint, it's a much better option. One shot and you're done--no need for 6 weeks of daily trips to the rad onc office.

While the early results of the TARGIT trial are promising, let's not forget that IORT for breast is not widely available, nor is it an option for women who are younger, with larger tumors or positive axillary nodes.

Node negative women who meet certain criteria are much more likely to be able to access PBI with brachytherapy.

 

[375RGRRGT]

not really. general surgery is becoming more and more fragmented. and not just in academic centers.

I can't speak for the other states but I attend a very small public medical school. There are 4 small medical centers in the state. GS is sometimes your only option more often then not.

I did a 6 month rural rotation during my 3rd year which was nearly exclusively IM and GS so I ended up with about 5 months solid OR time that year with old school GS's.

It was interesting because it was broad spectrum - trochanteric rod placement, ulner nerve transposition, cranial lift, burr holes, ACL repair, everything abdomen, lots of gyn, etc. Contrast this to urban/suburban practice and I was pretty much heartbroken.

On the other hand it is a safer practice field for the med student to enter for job security I predict since DNP's are expanding and 17 states (mine included) in the US grant DNP autonomy. NBME essentially calls this "equating" for primary care fields but to me it is either
1. dumbing down of the M.D./D.O. to a midlevel education or
2. increasing the value of a midlevel education

This is a concerning issue for medical students that go through a lot of work and pressure only to realize that their degree granted (approx 17k-21k hours of education) is equal to one with 1/6 to 1/7 of the time and effort.

In summary - surgery may have reduced reimbursement rates via sequestration, increased subspecialization and fragmentation or whatever but it is hard to imagine that DNP's or PA's will be granted autonomy in surgical practice.

 

[Winged Scapula]

In summary - surgery may have reduced reimbursement rates via sequestration, increased subspecialization and fragmentation or whatever but it is hard to imagine that DNP's or PA's will be granted autonomy in surgical practice.

That is why surgeons need to be more protectionist than our Anesthesia colleagues. I was appalled to read this thread: http://forums.studentdoctor.net/showthread.php?t=950842

If we've got Anesthesiologists doing spine surgery (and NSGY and Ortho has allowed this to happen), how long is it before they convince someone that an CRNA can do it?

And this weekend there was an insert advert in US News and World Report showing an CRNA doing Interventional Pain Management; my PM & R friends are up in arms about it on FB. But someone had to allow this to happen without questioning the credentialing committees.

IMHO we have always been too passive in these sorts of things, thinking someone else will do the job of complaining for us or that it "won't/can't happen".

 

[Ski2Doc]

Doesnt it make sense that as surgeon reimbursement drops the hospital will have to make up that difference, at least partly.
the hospital makes good money off surgeries, in a recent article i read in GSN, 60% of total payments. they wouldnt want to have to refer an appy, so in order to keep cases in house they will have to increase payment.

Does anyone agree with this logic?

 

[375RGRRGT]

Doesnt it make sense that as surgeon reimbursement drops the hospital will have to make up that difference, at least partly.
the hospital makes good money off surgeries, in a recent article i read in GSN, 60% of total payments. they wouldnt want to have to refer an appy, so in order to keep cases in house they will have to increase payment.

Does anyone agree with this logic?

Maybe to a certain extent but at what point is there a diminishing return. Further more the prices set are usually based off of the lowest payer (medicare/medicaid in many cases) as a % RVU and as the saying goes "he who has the gold sets the price."

Not to mention that the hospital risk management team prefers "experts" because expert testimony in the case should something go wrong is "in its own words." Does congress pull random people off the streets to testify on the economy or something else? It is inherent in our American culture to rely on experts and we tend to view experts with respect rather than "generalists" based upon the responsibility we give them.

 

[ACSurgeon]

Doesnt it make sense that as surgeon reimbursement drops the hospital will have to make up that difference, at least partly.
the hospital makes good money off surgeries, in a recent article i read in GSN, 60% of total payments. they wouldnt want to have to refer an appy, so in order to keep cases in house they will have to increase payment.

Does anyone agree with this logic?

I'm not sure what you're getting at. General surgeons will always do appy's, hernias and chole's, etc. I think this thread is referring to more broad based gen surg where surgeons did more "specialized" cases. Hospitals do thrive off surgeries but you have to keep in mind that:

1) rural surgeons will probably always do more than surgeons in urban settings

and

2) community hospitals are hiring more fellowship trained surgeons than before (so that even simple breast cases end up being outside of a general surgeon's league at community hospitals in large cities).

So, it's not that the hospital will lose money, it's that the scope of practice of a general surgeon is becoming narrower.