Medicine vs. surgery: liking something vs. being good at it

[Skarl]

Help me decide between medicine (likely cards) or a surgical subspecialty.

In terms of performance, I definitely felt like a stronger student on non-surgical clerkships with my presentations, people skills, and ability to advance care for patients. My evals frequently stated I was performing above my level of training e.g. "performs at the level of an intern" and I consistently received positive feedback. I feel like medically oriented specialties favor strong oral communicators and critical thinkers, and these were skills I already possessed through prior academic/professional experiences. It wasn't hard for me to effectively assess patients, present on rounds, triage/troubleshoot patient care tasks etc. I felt that I was naturally good at these and progression/growth came easily, which made these rotations enjoyable.

However, I don't really enjoy rounds and feel that a lot of time spent on medical rotations were non-medical/social, overly reliant on consultants/specialists and at times it didn't feel like we were really doing anything substantive. I really enjoyed my surgery rotation for this reason. I liked the efficiency and task-oriented personality of surgeons I'd worked with as well as the technical challenges and immediacy of treating patients in the OR. I saw that surgery was like a craft with certain techniques/skills passed on from attending to resident, etc. and found this very motivating (I would come in on off days to scrub with certain attendings to learn technical skills). I really enjoyed being in the OR and could see myself as a surgeon.

The problem is I don't feel like the technical skills of surgery came as naturally to me. I would practice suturing at home with foam but button-hole during real cases (e.g. doing a running subcuticular) in non-ideal circumstances (little room, patient moving from simultaneous closure, bloody field.) My speed was slow and I took much longer than my residents/attendings to do simple closures. I didn't have precise control of the needle tip and sometimes created unnecessary trauma when handling tissue. I felt clumsy transitioning between movements and have even accidentally poked my senior when closing in a tight space side-by-side. I also noticed that the OR brought out my aggressive/assertive side, for better or worse. I think the OR selects for students who speak up and project confidence, and often felt like I had to "fight" for opportunities to practice closing, help with cases, etc. While most surgeons/staff were kind and enthusiastic to teach, with others I felt I had to be quick to project confidence and "toughness" so I wouldn't be overlooked or assumed to be incompetent/easy to pick on. I had to do this as well on medical rotations but likely not as often.

Honestly it's important to me that I am "above average" in the field I go into. If I become a surgeon I want to be technically skilled relative to my peers. I also want to be in a specialty where I am happy and genuinely enjoy my job. I feel that in part surgery is just not something your average medical student has translatable skills in already (vs. the pre-med path ideally hones your reasoning, communication, and people skills) and that the experience of a medical student in both fields differs from that of an attending or even a resident. I do really enjoy the OR and still feel motivated to improve, but feel frustrated at how slowly that improvement comes and wonder if I might just be better off getting through 3 years of IM and specializing in cards. I do find the CV system very interesting in that it is intuitive/based on fundamental physiologic concepts, and somewhat "surgical" in terms of personalities in the field and treatments offered. I don't necessarily agree with the trope that I can only see myself in the OR and nowhere else but I do enjoy being in the OR more than other settings (hospital, clinic, etc.)

tl;dr liked surgery and the OR, but better at medicine as a med student. Is this a sign?

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[operaman]

Your skills sound pretty typical for a clinical student. Student skills seem to depend on a combo of how much you practice with how much your attendings and residents let you do. You will blow past even the best student in the first few months of residency.

I think the biggest keys for developing technical skill are practice, reading, and going to a good programs with great teachers. Even then, you’re going to take a few steps back in your skills when you start as an attending and you’re all alone. That’s where I am at this point and I get better and faster every day. Many of my mentors have said they truly learned to operate in their first 5 years after training, and I’m seeing now what they meant. It’s a long process and those chief residents are PGY5-7s while the attendings have been practicing their tiny niche for even longer.

All that to say, don’t use your skill level now as any kind of bellwether. Focus on what you like and what you could see yourself doing for a career. Then get the best training you can get and find a practice where you can keep growing and learning.

You will never be great at everything - no surgeon is. You may not think of this as you bounce around as a student, but academic surgeons have their tiny areas of focus and get really good at what they do. You just happen to bounce around as a student so it seems like everyone is amazing, but you’re getting a very skewed experience seeing primarily sub-sub-specialists all the time.

 

[Skarl]

Your skills sound pretty typical for a clinical student. Student skills seem to depend on a combo of how much you practice with how much your attendings and residents let you do. You will blow past even the best student in the first few months of residency.

I think the biggest keys for developing technical skill are practice, reading, and going to a good programs with great teachers. Even then, you’re going to take a few steps back in your skills when you start as an attending and you’re all alone. That’s where I am at this point and I get better and faster every day. Many of my mentors have said they truly learned to operate in their first 5 years after training, and I’m seeing now what they meant. It’s a long process and those chief residents are PGY5-7s while the attendings have been practicing their tiny niche for even longer.

All that to say, don’t use your skill level now as any kind of bellwether. Focus on what you like and what you could see yourself doing for a career. Then get the best training you can get and find a practice where you can keep growing and learning.

You will never be great at everything - no surgeon is. You may not think of this as you bounce around as a student, but academic surgeons have their tiny areas of focus and get really good at what they do. You just happen to bounce around as a student so it seems like everyone is amazing, but you’re getting a very skewed experience seeing primarily sub-sub-specialists all the time.

Thank you. I appreciate the perspective of the training process as well as specialization and how that colors my perception of others' technical skills.

I do see your point about not using my current skills as a bellwether. At the same time I feel personally frustrated being "pretty typical" as I've been evaluated as above average to well above expectations in other non-surgical skills (albeit these skills translate to surgical services when not in the OR). What makes someone an "amazing" internist/cardiologist? The gulf between my skill level and attendings/senior residents just seems much more apparent in the OR.

 

[operaman]

Thank you. I appreciate the perspective of the training process as well as specialization and how that colors my perception of others' technical skills.

I do see your point about not using my current skills as a bellwether. At the same time I feel personally frustrated being "pretty typical" as I've been evaluated as above average to well above expectations in other non-surgical skills (albeit these skills translate to surgical services when not in the OR). What makes someone an "amazing" internist/cardiologist? The gulf between my skill level and attendings/senior residents just seems much more apparent in the OR.

1) you’re exceeding expectations in all the things you’ve actually had practice doing. Bodes well for the same being true in the OR as you gain experience.

2) people say stuff like that to med students all the time, yet for some reason every intern has absolutely no idea what they’re doing on July 1st. Don’t read too deeply into the praise.

3) there aren’t any generally accepted skill benchmarks for students in surgery, while there are in other areas. A student should be able to take a history, do an exam, present their findings and come up with a reasonable A&P by the time they’re done - enough to be ready for highly supervised practice. There’s no equivalent for surgery because the experience varies so widely, and there’s no good way to test it either other than the most basic of skills.

4) all the technical struggles you mention stem from nobody really teaching you and giving you real time feedback on your technique. They tell you that you’ve button holed but haven’t pointed out what caused it - almost always something your non-dominant hand is doing. Needle control is usually just how you’re holding the instrument and where you’ve grasped the needle. These are all very basic things you’ll fix in 10 minutes with a decent teacher.

5) the technical skill of doing surgery is not really the hard part. It’s the decision making in the office, patient selection, operative planning, managing complications - those are the tough parts. The technical parts are easy to learn. And also the parts that nobody but you will ever see anyhow.

6) much of your practice in a surgical sub is in the office. Patients know you and Judge you on your clinic because they’re not awake for your surgical prowess. Referring docs judge you on both your outcomes and on how much their patients like you. If you’re already ahead of the game in the medicine-ish areas, then you’re ahead for a major part of surgery as well.