Surgical Oncology for Medical Students, Residents, and Fellows: What is it, how do I get into it, how do I get a job doing it?

[Lem0nz]

Surgical Oncology for Medical Students, Residents, and Fellows:

Introduction: My name is Lem0nz and I’ve been on SDN for… almost a decade? Since before medical school, certainly. I had an interest in cancer surgery before I even started medical school. I went into medical school knowing I would do surgery, and by the middle of my third year surgery rotation, had chosen to go into surgical oncology after seeing their mastery of knowledge, scope of surgery, and complexity of their operations. In a nutshell, these guys were the smartest surgeons I had met doing some of the biggest, coolest surgeries I’d ever seen, and I wanted to do it. I’ve wanted to do this post for awhile but figured I would wait until I had most of the information necessary to really do it right, and I think I’m at a point where its as good as it will get. In my quest to become a surgical oncologist from medical school to attending I have had MANY questions that few people were willing or able to answer which are really vital things to understand when choosing a fellowship and a career, and I will try to address all of these below. For simplicity and navigation, I will break it up into sections that I have consistently come to SDN searching for myself and which there have often only been one or two threads with varying amounts of information, but invariably never enough. You are warned: I am a very wordy writer. This will be *long*. Please feel free to skip to the piece that interests you! That’s why I have broken it up into multiple posts in this thread.

I encourage my peers, both older and younger, to add their own experience and wisdom. I would be happy to add their own experiences into my post if they are willing to expand on this information. I want this to be a guide to what surgical oncology really is and what you can expect if you’re considering it from how to get into what life is like when you’re practicing. I hope to answer questions like “am I competitive”, “how much do I get paid”, “what do you actually do”, “what is an academic surgical oncologist”, “what is a private practice surgical oncologist”, “what is the difference between surg/onc and HPB”, “what is your lifestyle like”, etc. One of the problems with surgical oncology (and maybe this holds true for every discipline, but it seems very magnified in surg onc) is that each of these questions could be its own small book because surg-onc is one of the few fields of surgery that still operates head to toe, in potentially every body cavity, and can be as highly academic as a surgeon scientist running a government funded lab curing cancer to a community general surgeon who focuses on cancer and does 15,000 RVUs of ports and melanoma excisions a year (15,000 RVUs is an alot for those younger lurkers who aren’t familiar with how RVUs work). I want to try to address this mess as best I can with what I have learned.

My final introductory statement and huge caveat: I am a community practice, non-academic surgical oncologist. I trained at a community program, I went to one of the very few non-academic SSO fellowships, I will never be a professor. I’m very business oriented, interested in resident/fellow education, all of my research type endeavors are in safety/quality. This is atypical for an SSO fellow and as such my view is both unique and quite honestly not applicable to many types of practices and how the fellowship itself typically identifies. My very first section will address this and why I feel this post is both important and relevant coming from an atypical applicant. I cannot emphasize enough that this is my viewpoint, it is complete opinion, and it is incredibly subjective. That said, many people I’ve spoken to feel how I do about this fellowship, its training, and what it is trying to accomplish vs. what it is actually doing so I want to speak to it and prompt a discussion about it. Many people also wildly disagree with me. That’s fine, in fact, I love talking to them because that’s how you learn and grow!

Sections:

• How the heck did surgical oncology get here today? (For everyone! Residents, Fellows, and Attendings)
• What does a surgical oncologist do? What is their lifestyle? (For Medical Students, Surgical Interns)
• How do I become a surgical oncologist? Am I competitive/Application Process? (For Residents)
• What the actual heck am I supposed to get paid for doing this? What the heck is my actual job? What do I do!? (For Fellows)

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[Lem0nz]

How the heck did surgical oncology get here today? (For everyone! Residents, Fellows, and Attendings.)

I wanted to make this post the first portion because I think it informs the rest of what I have to say about surgical oncology very well. The first thing I think anyone discussing surgical oncology needs to think about, if not understand, is what is the goal of the complex general surgical oncology fellowship? I write out the full name deliberately there because that is what we call it, but I am not sure that that is what it is in many cases.

The CGSO fellowship became its own board certification around 2014-2015. If you go to the American Board of Surgery and look up the specialty definition (Specialty of Complex General Surgical Oncology Defined | American Board of Surgery) , it says something like this (paraphrased): A surgeon certified in CGSO has specific knowledge and skills related to diagnosis, multi-disciplinary treatment, and rehab of patients with cancer, especially those who are complex, requiring complex procedures, or rare and unusual cancers. They are trained with other specialists to interact as part of the necessary interdisciplinary collaboration required for the cancer patient. They participate in community outreach and assume a productive role in research. The term complex is intended to reflect the skills acquired by this discipline and the term general to differentiate their scope of practice.

I found this very interesting because in my experience this definition has in fact only defined a small subset of practicing surgical oncologists. In reality, I feel very strongly that the fellowship does not teach to this broad and sweeping scope that is described. Rather, it teaches to all of the facets described here but it does so with varying degrees of success. In general, the fellowships on a whole, considered together as a single body, are an experts at teaching and training surgical oncologists to do all of those things collectively, but very rarely does it train and produce an individual to do all of those things expertly. Often, the fellowship itself tends to tailor to several focuses and instead produces an individual who is highly highly specialized in just a few things. We do not produce true complex general surgical oncologists who can do it all – none of us are surgeon scientists, advanced hepatobiliary surgeons, sarcoma surgeons, colorectal surgeons, research powerhouses and intellectuals, technically gifted and fantastic surgeons, breast surgeons, skin cancer surgeons, *general surgeons*, surgeons who can operate in any body cavity on any cancer. Absolutely none of us is that person who is all of that. But nearly all of us are at least one of those things.

And this is both the strength, and the problem of the surgical oncology fellowship. We are telling the world that our surgeons are qualified to run research labs, start and manage cancer centers, do some of the most complex and challenging HPB surgeries, sarcomas, HIPECs, but also do some of the easier and/or more common cancers of head and neck, breast, general abdominal, that we can do cases that take 10 hours but that we can also operate at high volume and churn out 10,000+ RVUs – that are one of the few surgeons who will always be comfortable making big open incisions and knowing the anatomy and complexity of ‘everything’, but that we also are entirely capable of a robotic whipple, hepatectomy, and esophagectomy. The reality though is that mileage varies. Some of us are very research oriented, but I think a larger and quieter majority are quite burned out on research and used it as a means to an end to get into the fellowship. Some do in fact want to run their own basic science lab, but many do not. Some want to do big HPB/sarcoma surgery, many do not. Some of the fellowships have issues with actually getting practical operative experience and exposure for what falls in our domain. Some are competing with HPB fellowships even in their own institution, or transplant fellows. Some are competing with breast fellows or colorectal fellows. Some really do get a broad exposure. Some fellows are coming out of highly academic residencies where their operative experience was not great and they are not comfortable operating alone and may be entering fellowship needing to be taught how to operate. These are all things you need to know and consider when discussing the specialty of surgical oncology. There have been a great many people I’ve spoken to who feel that the surgical oncology fellowship should in fact be dissolved and that it should instead be HPB fellowships, breast fellowships, colorectal fellowships, ‘other’ (HIPEC/melanoma/sarcoma), foregut fellowships where the surgeons are world class experts at just one or two types of cancer. So I encourage you, if you’re discussing or considering surgical oncology, to really think about that. I’m not proposing what the right answer is because I don’t know, and smarter people than me don’t know. I just ask that you think about it.

Lastly, what I want to talk about, is what the country actually needs. I always propose this thought when I talk about this for others to consider: 75-90% of all oncologic operations in this country are performed by general surgeons. (I do not actually know what that number is, I just know it is not small, so I make it up and say that). Cancer operations happen day in and day out at small and large hospitals across America by people who are not fellowship trained, or not board certified in cancer surgery, or are trained in a different fellowship who takes ownership of that particular cancer (think colon cancer for colorectal surgeons – they have a very wide scope of practice of all sorts of benign disease, but also, cancer). Access to a high-volume center is not always guaranteed, and honestly, may be very difficult for a great many people in our country. Its great to say that every cancer operation should be done by a fellowship trained surgeon, but in reality, that is wildly impractical. Some patients cannot drive 5 hours for a whipple. Some patients cannot afford the subway fare to get 5 miles across New York to go to MSK. Some patients just don’t want to go anywhere else except for their local hospital – and when you read all of these papers saying people “need” or “must” or that its “unacceptable” for a general surgeon to be doing whipples in 2020, I think you need to take a step back and realize that the decision lies with the patient and patient autonomy is one of the founding principles of our craft. Other patients travel thousands of miles to go to a super specialist and some insurance networks have paid huge sums of money and will pay for their patients flights and hotels to bring them to these high volume centers to improve quality and outcomes. It is a very strange place we live in and system we have created. There is a need for the surgeon scientist who is trying to cure cancer, the super expert specialist who does one single operation but does it so well that costs and outcomes are remarkably better, the need for the general surgical oncologist who can do it all when patients don’t have a choice, and the need for the surgical oncologist educator who leads a cancer program and guides management and incorporation of evidence based medicine for general surgeons or fellowship trained surgeons who are not CGSO but are doing the bulk of cancer operations in a system. I think that, in reality, the breakdown of those four things is probably something like 20/20/30/30%. Maybe even 10/10/40/40%. But what we’re actually training with our fellowships and the sort of resident applications we’re recruiting to go into the fellowship would make one think that our goal and needs are closer to 40/40/10/10 tilted towards research and super-subspecialized world-class experts. Its an interesting problem that seems to get magnified every year as the fellowship becomes more and more competitive. The types of people applying to surg onc have years of research, an unspoken requirement of basic science background, top notch board scores, and residency programs with big academic names. The applicants who are excellent technical surgeons coming from high volume residencies but less research oriented are uniformly at a disadvantage. The applicant arms race is crazy, and it gets worse every year. Its interesting. Again, I don’t know if this is right or wrong, its just what I’ve seen going through the process and the vast majority of people I’ve talked to agree that this is a thing – what it means is a more nuanced discussion. But, please, take a minute to think about this if you are considering surgical oncology or asking questions like “what should my scope of practice be” or “how much am I supposed to be paid”. All of these things factor into figuring that out. None of it is spelled out. None of it is commonly talked about when interviewing for the fellowship or for jobs. Its quite honestly been a taboo subject every time I have hit an application-like process or asked my attendings when trying to figure these things out myself. If you want to be a surgical oncologist you need to be qualified and expected to be able to be a surgeon scientist researcher, who is blindingly smart and a world class expert who doesn’t care about money and willing to dedicate many extra years beyond the five of residency to get there. And honestly, how well you operate really never makes it into the equation until the very, very end. (And even then, sometimes, it doesn’t).

I quite frankly think that it is entirely disconnected from reality, but it fascinates me. Surgical oncology seems to be recruiting the equivalent of people who did residency and have PHDs and a large reason why is “because we can”, not “because we need to” or “because we should”. Surgical oncology is kind of elitist like that – neither right nor wrong, just the way it is. Weird, right?

Anyway, ONWARD to the things people actually care about!

 

[Lem0nz]

What does a surgical oncologist do? What is their lifestyle? (For Medical Students, Surgical Interns)

Ok, the nuts and bolts. To organize and make some sense of this, I’m going to start with what I feel like many of the elements of surgical oncology are for “what do we do”. Because its cute, I will describe our operative scope of practice (Surgical), and our non-operative scope of practice (Oncologist). Some of us are more oncologist than surgeon, and some more surgeon than oncologist, so again, how much of this some of us does can vary wildly. For lifestyle, we will divide it into academic vs. private. These divisions are artificial, arbitrary, and wildly oversimplified but it will give a good general idea of what we do if we worked in a perfect system that could define us with easy to understand labels.

What does a surgical oncologist do?

The Surgical (Operative) Part of a Surgical Oncologist:
There are multiple tracks that many of us go down that very quickly specialize us out of the “complex general” version of us into a super specialized surgeon. But, at least at the beginning, we are generally capable of being trained to do the following:

• Hepatobiliary Surgery: Think whipples, distal panc/spleen, bile duct or gallbladder cancers, right and left hepatectomies. Some of us will go up to and include very complex liver surgery such as trisegmentectomies, some of us draw the line at simple right and left hepatectomies. Some of us operate on cirrhotics, some don’t. Some operate with transplant backup and in concert/coordination with transplant oncology (which is its own developing field), some operate with transplant being their primary competitors. Some HPB fellowships and transplant surgeons actually do just as much pancreas surgery as surgical oncology – some no longer even do transplants and entirely do HPB resections including whipples and other pancreatic work. Some HPB/transplant surgeons end up being “the guy” who does sarcoma surgery because they just happen to be the one comfortable with large open surgery and technically can navigate large vessels, and there is no one else around so they can often more into pseudo-surgical oncologists. This is more common than you would think! Kind of neat. We also are generally expected to understand and be capable of all benign HPB surgery if you’re doing oncologic HPB surgery – think bad pancreatitis, pancreatic cysts, divisum, strictures, things like that. The reason why is that these operations are rare and its easier for us to do them than general surgeons who are trying to get away from operating on the pancreas or liver at all.
• Foregut and Thoracic Surgery: Think esophagectomy, total gastrectomy, wedges and lobectomies. It is not uncommon for us to also be the “foregut guy” for benign disease – think hiatal hernias, hellers, esophageal diverticulum, what have you. Its another weird and challenging place to operate in that we aren’t necessarily specifically seeking out or trained to do, but we have such good experience in the oncologic realm that we can often also do the benign stuff (this will become a recurring theme…). A special note to thoracic surgery: the fellowship, in general, is no longer training us to be thoracic surgeons and do lung surgery. Some still do! Some offer extra months or even years to do this! But we do not do cardiovascular fellowships and the thoracic fellowship itself is an offshoot of cardiovascular surgery fellowship. So lung surgery for us is, for all intents and purposes, no longer part of our scope of practice. Esophagectomies are slowly being turned over to thoracic surgery but it depends on the institution and it will likely for the foreseeable future remain a mix of 33/33/33 thoracic, surg-onc, and foregut surgeons doing those operations. You may or may not want to or be asked to do this in your final job. Some of us do it *with* the thoracic surgeons and its twice as fast and twice as fun! Look it up, it’s a cool way to do the operation.
• Melanoma/Sarcoma/Soft Tissue Cancers: For the life of me I’m not sure why we still lump melanoma in with sarcoma because they’re… not even remotely related in my opinion, but it is what it is and surgeons who super specialize into one often claim the other. This is probably because sarcomas are so rare and you can’t just be a sarcoma surgeon. Not enough patients. Some will also do the other skin cancers (Basal and squamous). They are also the referral point for the other rare skin cancers (think merkel cell). They may be working with dermatologists, plastic surgeons, or mohs surgeons, or they may be directly competing with these people. They may be expected to do their own melanoma skin exams, or may have never done a skin exam since medical school. Maybe they’re doing the primary resection up front for a small melanoma, or maybe they’re the guy doing the sentinel node and/or lymph node dissection for other surgeons.
• Breast Cancer: Some surg oncs will actually go entirely into breast cancer and do ONLY this (or breast/melanoma, another common pairing). These are high volume surgeons who are experts at this. Some others, breast is 25-50% of their practice. Some surg oncs don’t do any breast at all and have off loaded this to fellowship trained breast surgeons instead. Breast cancer is no longer as simple as it seemed in residency – it is wildly complicated now. Between neoadjuvant, oncoplastics, intra-op radiation, cosmetics, breast conservation being pushed to its absolute limits, new immunotherapy and chemotherapy, this is a highly lucrative and complicated field of oncology. Even if you aren’t doing breast surgery, many surgical oncologists find themselves in administrative roles and are overseeing other surgeons doing these surgeries and managing department protocols for things like same day biopsies, standards for pathology, pathways for neoadjuvant vs. adjuvant treatment, genetics involvement… etc. Huge, important part of our practice.
• Colorectal: Some surg oncs are doing FULL SPECTRUM colorectal surgery, including the benign stuff. But more often and more practically, there are a great many of us who got EXCELLENT training in fellowship and are routinely doing not only right and left colectomies, but LARs, low pelvic ileo-anal type surgery, and APRs. Colon cancer and breast cancer are the most common cancers, so if you go into private practice, those two often get paired up and may make up the bulk of what you do and allow you to pump out tons of surgeries and make tons of money. Some of us work in partnership with colorectal surgeons and don’t do colon cancer surgery at all – rather, we operate with them to do things like synchronous liver resections or complicated multi-visceral resections. Some of us compete with colorectal surgeons.
• HIPEC/Cytoreductive Surgery: As far as I know this is only done by surgical oncology. While most fellowships ensure exposure to this, some are not specifically designed or have enough volume that every single fellow graduating will be comfortable or confident in either doing this operation, or starting a program (many many places do not have an existing HIPEC program. Some states have no HIPEC surgeon at all, others have 5 separate practices. It would surprise you – there are major, massive population centers with no HIPEC surgeons and other tiny places with more than one). This operation is where you cut out metastatic cancer on peritoneal surfaces of the abdomen – think ovarian cancer, appendiceal mucinous cancers, other less common indications for gastric/colorectal. This field is still evolving, but for the most part these surgeons are operating with gyn-onc doctors very, very frequently. These surgeons also are almost never HIPEC only surgeons as the volume is usually not adequate to do just that.
• Endocrine Surgery: Very common for us to do thyroid/parathyroid for both cancer and benign disease. Also very common for us to do neck dissections for other cancers in the neck requiring it. Common for us to do adrenalectomies, or again, pancreas work for endocrine type disorders. If you do endocrine surgery in general you’re doing it for both benign and malignant disease. We can find ourselves working together or directly competing with urologists, ENT doctors, or other endocrine surgeons, and sometimes general surgeons who do a lot of this.
• Other: There are too many rare and weird things for me to list out, but at the end of the day if we’re not super specialized and embracing the “complex general” title, we are the guy who can operate on anything, head to toe, and we often do. We get called when other surgeons get stuck on benign or difficult cases even if there is no cancer because we have the expertise and do the hard ****. We find ourselves doing challenging, weird freaking cases because no one else can. Some of us do our own plastic surgery type reconstructions (think rotational flaps, muscle/pedicle flaps like sartorius flaps, skin grafts) and many instead co-operate with surgeons to do those parts for them. Some of us do our own vascular anastomoses (think sarcoma and vena cava resections, or weird vascular tumors), others get vascular help. Some of us *do* trauma or back-up trauma surgeons when people get shot and stabbed in the right upper quadrant. In general, we are versatile, we are smart and technically gifted, we are creative as hell, and we are super freaking cool. We are the MacGyver of surgery and its badass. (#humblebrag)

Some fellowships… may teach you to do all of those things with varying degrees of success, but in reality I’m pretty comfortable in saying that nearly every single fellowship does not teach their fellows to be experts at all of that and usually has deficiencies in at least one of those areas. Some fellowships actually track their fellows after their first year to do only one of those fields in their second year to be an expert and align with their academic/research interests and/or surgical interests. For example, my fellowship has one of the highest volumes of any SSO fellowship as a community type center and I will graduate with x3 of the minimum case volume requirements in every single category. However, I don’t feel confident in saying that I can be a world class HPB surgeon because even with transplant and HPB rotations our liver volume for formal resections (rights/lefts), trisegs, or complicated hilar dissection (think hilar cholangiocarcinoma) is low. I’ll have done about 20 of those cases which is still a lot and I can do a right and left hepatectomy out of fellowship, but doing more complicated things like a hilar cholangiocarcinoma or portal vein resection, I would quite frankly want help as my exposure to that was almost none. I also would not attempt to do oncoplastic breast surgery – I just didn’t do enough. I wouldn’t try to do an APR or ileoanal colorectal type surgery – anything beyond an LAR just isn’t what I want to do, or feel I got enough volume in. Could I technically do it? Yes. Could I do it with the same outcome as a colorectal surgeon or an HPB surgeon doing those complex things or a fellowship trained breast surgeon who want to an oncoplastic place? Absolutely not. But my fellowship has designed me to be able to do most of every single one of those categories. Others may come out of an SSO fellowship and only do one of those things and they *can* do those more complicated operations. I hope that makes sense.

The Oncology (Oncologist) part of a Surgical Oncologist:
This is a little more interesting. You may be thinking that everyone in surg-onc goes into it for the operations. You would be WRONG! Some of us don’t! (A lot of us do, hah). More common, is that as our careers go on, a surprising number of us find ourselves pulled into leadership, administration, or research. Some of us find ourselves in these positions immediately out of fellowship. Some of us end up doing business type jobs (think CMO, or managing a practice), some become program directors, fellowship directors, or chairmen of surgery. You also need to keep in mind that when you finish fellowship you are almost always at least 35 years old. Often times older. Very, VERY rarely younger. You are starting your career often times MUCH later than your colleagues both in and out of surgery. Just something to think about. Plan on having kids and starting your family accordingly! So, in no particular order:

• Research: Some of us become true “Surgeon Scientists”. What does that mean? It means we run a lab, or dedicate 25-75% of our time to research and advancing the field of surgical oncology. This is often basic science or translational research. It can be looking at cells, tumor micro environments, immunotherapies. In fact, it is quite often one of those three things! Which is very strange because this is actually more the realm of medical oncology. If you apply the NIH’s surgical oncology fellowship (which is a research fellowship with 1.5 yrs in research and .5 in clinical surg onc doing operations, ish) you’ll find that many of their researchers used to be surgeons but now, for all intents and purposes, are medical oncologists delivering cutting edge immunotherapy. Its cool! Its different. Its weird. *Most* CGSO fellowships have at least one attending on staff who fits this role of surgeon scientist and has a lab. Many fellowships offer an additional research year to stay on and get paid to start or complete multi-year research projects. Many will help you get an academic job and to start your own lab when you finish to do stuff like this. Other types of research we can find ourselves in – safety/quality improvement. Informatics. Direct clinical research. These are somewhat less common but still fairly prevalent and I encourage you to imagine a residency program director or fellowship direct who has a 75% clinical/operative practice but also does research to help their trainees or just for funsies.
• Education: Many of us remain on staff at our fellowship or go to an affiliated hospital and either participate in resident training or fellow training because we’re the guys doing the rare operations to hit those hard to hit numbers. Super common. Many will be associate program directors straight out of fellowship, and some will go on to be program directors. These types of jobs often come with a research component to advance the cause of the trainees they’re teaching but it can be anywhere from 50% of their time to something they don’t actually get paid for and just do on the side.
• Business: Some surgical oncologists, particularly private practice, may find themselves in a huge business role. Running a surgery center, or a cancer center, or buying into a practice and managing employees. Something few get training for but find themselves doing anyway. You can also find this type of job directly out of fellowship which can be daunting, but more commonly this is 5-10 years into a private practice type route.
• Administration: I think I’m safe in saying over 50%, maybe closer to 75-80% of us, at some point find ourselves in our career being director of something. Maybe its director of HIPEC program, or robotic surgery, or pancreatic surgery. Maybe its director of surgical oncology service line. Maybe its director of oncology (overseeing surg onc, med onc, and rad onc). It can be vice president or president of cancer care for entire multi-state systems. It can be chairman of surgery. It can be chief medical officer. But its usually something, on some order of magnitude. It can be something you don’t get paid for and just have a title, or it can be that you stop doing surgery altogether and get paid 750k+ to just be an administrator. It varies wildly. It can take 10-20 years before you reach these sort of directorships, or it can be IMMEDIATELY out of fellowship if you’re the only surgical oncologist in a system starting a cancer surgery service line or a cancer center.
• Other: The sky is honestly the limit. If you want to quit surgery at some point (or even continue to do surgery but to a much smaller and limited scope) and go be CEO of a hospital, chief informatics officer, go run a quality safety department, go work in industry and stop practicing, retire at 50 and go travel the Earth… all entirely reasonable and possible. Surgeons rarely talk about this (and you almost never talk or think about it as a student or early resident) but take a minute and think 20-30 years into the future and ask yourself what you want to do. You might surprise yourself.

What is their lifestyle?

This is harder to put into easily defined categories but to make it understandable, we’re going to pigeonhole the **** out of it and pretend there’s only two types – stereotypical academic, and stereotypical private practice. This thought exercise does not work on real life – only 10% of jobs fall into those two stereotypes really well.

Academic/University Surgical Oncologist:
These surgeons are usually faculty for a fellowship, or at minimum, a residency. You are hired as a professor which starts as unranked, then assistant, associate, full, then usually after this you’re a director of either surgical oncology or an entire division of surgery, and it for the most part ends as being chairman of surgery. You are usually paid on the AAMC scale which is orders of magnitude less than the MGMA/private practice scale, particularly at first, but can completely disregard the scale as you obtain directorship type titles. You generally get either one day a week, or one week a month, for administrative/professional development time (either administration work or research time) but can have more. Surgeon scientists in particular can have 50 and in some cases 75% of their time being in research and not clinical practice (and some, like at the NIH, this can be 90-100). In general, you do not take trauma call. In general, you do not take general surgery call. You will often work with other boutique/bougie specialists for rounding (like pairing yourself with colorectal or foregut) so you don’t work more than a weekend a month or less. For the most part you have someone in house taking your first calls (residents or fellows) and rarely get woken up in the middle of the night. With the exception of your own complications from your own surgeries, there is no such thing as a surgical oncology emergency. These are in fact called general surgery emergencies and go to the trauma/ACS/EGS service and you get consulted the next day. You probably live in suburbia in a major metropolitan area. Your clinical practice is often very specialized to a subset of surgical oncology and you may work with multiple surgical oncologists who are specialized to the other parts that you aren’t doing. You work 3.5-4.5 days a week, don’t work at nights usually, don’t work weekends usually, can turn away consults that have nothing to do with your scope of practice, work from 8-4 unless you have meetings in the morning or the afternoon. You have to publish research papers to keep your job, and you have to do it frequently and well to advance in your job. There is usually a seniority component of advancing through your institution to the next professor rank and directorships, it isn’t just how good you are and how much you publish. In addition, other professors with more seniority or a “bigger name” from their research work or standings in national meetings and societies may get brought in and get those more senior type jobs over you and that’s normal. At some point you’ll be that guy and you may be changing institutions and being hired as your operative career is winding down to be the administrator. You attend lots of national meetings (they pay for it), you travel the world learning, researching, and teaching about surgical oncology, and you’re a part of lots of societies. It is very cool and very rewarding. It usually don’t pay that much, but for the work you do (comparatively speaking to our other surgeon colleagues) who have a metric crapton of call and emergencies, life is great. It *absolutely* pays enough for you to be comfortable, retire well, put your kids through college, provide for your family. But the million dollar house at 40 and the 20 million dollar retirement? Eh. On the bright side, these places are almost 100% all non-profits and you can get public loan forgiveness, often after only a year, because you spent NINE years at a non-profit from residency/research/fellowship getting here! Thanks Obama! Also, the retirement matching is often times very, very good in the public/academic realm. Another big perk is your referrals are often built into the system and you don’t have to put a *ton* of work into getting referrals. Still some, and its important, but much less than the private guys. Competition is also usually between you and a separate system in the same city or state, and you don’t tend to compete with people in your own organization. Your salary is usually guaranteed with a more minor productivity piece.

Private Practice:
These surgeons often end up places that have no residents and no fellows. You may be operating with a partner, but more frequently and typical is that you have a PA or NP (or sometimes an SA/RNFA) dedicated to you doing the operations with you and they never change from case to case. You generally don’t do any research or do it on your own free time because your paycheck is dictated by your volume or something called productivity. This can be where you are true private practice and you are your own boss and do your own billing, or it can be that you are employed by a hospital system where they calculate RVUs (which translate time an operation takes and complexity into a dollar amount). You may be hired as a specialist (like HPB), but more often than not you’re more of a complex general type person. Even if you are hired as a specialist, you usually don’t super specialize (so if you’re the HPB guy, you aren’t the liver only guy. You do liver, pancreas, and bile duct). Your practice is usually very, very busy. You almost always spend more time in the operating room than the academic guys. You will often do more minor operations than the academic guys because these are easy and pay well. Think breast lumpectomies, port placement, wedge resections and colon resections. Easy to churn out, pay super well. You may be doing your own endoscopies. There is OFTEN a general surgery component to what you do, as well as general surgery call. There is rarely a trauma component and trauma call (not common). The general surgery piece can be as much as 75% - some private practice surg onc guys are general surgeons who just also do the oncology operations for their group. This is more common in rural type practices. You get paid on the MGMA scale (there are other scales too that get averaged in) which is, again, an order of magnitude higher than the AAMC. In general, you get paid twice as much. But you’re also clinically usually twice as busy and take way more call than the other guys, and when you take call you’re often first call. So that Tylenol order from a nurse at 2am? That’s you big guy! IV infiltrated an hour later after you finally fell back asleep? Hahaha. Sucks to suck. You can find yourself in an administrative role much earlier than the academic guys as you’re usually the only surg onc in the system or surrounding area. That said, this administrative role often doesn’t pay as much as it does for the academic guys (sometimes, doesn’t pay anything extra). Depends on a lot of factors. And the administrative role is usually in addition to your existing clinical practice – you don’t get to slow down or have a ton of dedicated time to doing it (though you do get some extra time, it just usually isn’t as much). You work 4.5-5 days a week, take call more often and during the weekdays. But it is still way, way, way less than our general surgery/trauma/vascular comrades (usually. Sometimes it isn’t and you have equal call duties to them!). The lifestyle is still for the most part very cushy and nice. You’ll make way more money. You often times have to go out and meet your referral base and develop relationships with them, this is much more important for these guys. You may be competing with surgeons in the same system, same hospital, literally across the street. Your salary can be guaranteed at first, but more often is ENTIRELY based on productivity particularly after the first 3-5 years. “You eat what you kill” is the saying. But, and to some this is a huge perk, you are often your own boss. Even when employed, you generally get to run the show and are more reporting to CMO/CEO type people, not another surgeon or surgical department. And some people really dig operating alone and finally just doing the operation themselves with no residents or fellows in the way and no attending to tell them what to do – you’re the surgeon, and your only obligation is to the patient.

Closing Thoughts:

I hope this helps for those medical students and surgical interns who have an interest in surgical oncology but don’t really know what it is. We don’t give chemotherapy or radiate people, but we truly are oncologists. The piece I didn’t put out there but is ALWAYS a part of both academic and private is that we do not work in a vacuum. Surgical oncologists are ALWAYS part of a team made up of medical oncology, radiation oncology, and other disciplines (GI, IR, radiology, etc.). We are often leaders of those teams because of our type A personalities and because our knife can be the only path to cure, but can also do the most damage compared to our colleagues. We are natural leaders and we are expected to be leaders, at minimum, in that role of the multi-disciplinary team. We know when and why and how our comrades deliver care to cancer patients and spend time in fellowship specifically learning what they do and how (a great deal of time in most places, at least 3-4 months of our two years of training). Surgical oncologists should never be technicians. Other doctors should never tell you when you should operate or not. That is your job and your duty to the patient. Other docs can certainly push you and inform your decisions and guide you, and if you aren’t listening to them because you think you know better because you’re the surgeon, you’re an idiot. Those guys are some of the smartest, and often smarter than us, doctors you’ll ever meet. Watch a med onc literally paste the research paper that guided why they’re giving a specific chemotherapy directly into the assessment and plan of their documentation and you’ll laugh at how much better they are than you at incorporating evidence into their practice. But at the end of the day you can really hurt someone or really help them and surgery is usually the only chance at cure for cancer. For that reason, we often lead these groups and the overall treatment plan and that’s why many of us find our way to directorship and administration over time.

Thoughts on Minimally Invasive:
This has nothing to do with lifestyle or academic vs. private or even your subspecialty – but training by institution does very wildly. For the surgery piece, some of us come out of fellowship and can do a robotic whipple or liver resection immediately, others only know how to do these open (and will continue to only do them open), others need additional training or proctoring by more experienced surgeons to accomplish this. Robotic surgeries for surgical oncology almost always take longer than their open counterparts and this can have big impacts on things like productivity and reimbursement. Laparoscopic vs. robotic is its own beast. Its beyond the scope of what I want to talk about. I only mention it because many places are looking to recruit minimally invasive surgeons now and it will probably become the standard in the next 5-10 years so you need to think about it. I’ll talk about it more in the “finding a job” and “what do I get paid” section for fellows.

 

[Lem0nz]

How do I become a surgical oncologist? Am I competitive/Application Process? (For Surgical Residents)

Alright, so you made it through that wall of text above me. Or maybe you didn’t and you skipped down here because you’ve already decided you want to go into surg/onc. Whatever the reason you’re reading this, this section will describe my experience in residency, the application process, some pearls of wisdom and some pitfalls, the interview process for fellowship, and what sort of programs are out there and how to choose which to apply to (spoiler: all of them). We will talk about board scores, research requirements, operative experience, away rotations, dedicated research years, and other less main stream adjuncts that can help get your foot in the door and get you an interview. For background on my ability to speak to this: I was a successful applicant (obviously), but have also gone through the interview process with my own fellowship twice now so have sat on the other side.

I want to start with a brief overview/forward that says even if you do everything I write down here, it is not a guarantee to get into surg/onc anymore. There was a day and a time when you could have someone who wrote a book somewhere pick up the phone and make a call for surg/onc and you’d get into the fellowship. That is only partly the case – and is quickly becoming less and less true. You can do 3 years of research and five years of residency at a major institution with tons of publications and great board scores and still miss the mark and not match. It may take you several years to figure it out and get in. You need to really want it, and you need to be dedicated to it, and you above all else you need to plan that you won’t make it and won’t get in, and you need a back-up plan. I say this because I didn’t match into fellowship on my first round and got a spot out of the match. My junior fellow is nearly ten years older than me and did two years of research at the NIH, a year of MIS fellowship in foregut/robotics after his residency, and had more publications than me but didn’t make it TWICE in the match. He was more qualified than I was for a surgical oncology spot but my fellowship was looking for something specific for their first and second fellow – he is now our third. Again, this doesn’t mean he was better, or I was better, or even that either of us had significant flaws in our application (we didn’t, our letters were amazing, we did the things and checked the boxes). It is simply a hard, very competitive match, and 75% of the people who bother to apply are overwhelmingly amazing candidates. The next 15% are very, very good candidates. Only about 10% applied and haven’t been taking it seriously for at least five years, if not longer, and those applications are thrown out. There are about 65 slots and 90+ applicants every year, that number keeps going up, so about 1/3 of people won’t match. And I can’t stress this enough, the vast majority of the people applying to surg/onc are already very, very competitive applicants. They are not just doing it to do it and seeing if they get lucky because they think surg/onc would be cool. There are maybe only five or ten of those applications a year that come through with no research, very slim CVs, bad board scores, etc. Some applicants ARE deficient in one of those areas and still match, but they have often made up for it by being absolutely amazing at everything else on their CV. So it doesn’t mean people with bad board scores don’t make, or people that had trouble with research and publishing don’t match, or people from community programs don’t match. It DOES mean that if you had one of those things, you probably absolutely crushed it at all the others if you got a fellowship spot. I want to emphasize it again: have a realistic back-up plan. I had *FIVE* back-up plans and went through THREE of them before I matched. I was realistic, I was a great candidate, and I got lucky. I do not think it is unreasonable to say that surgical oncology is as difficult as pediatric surgery now which was traditionally thought of as the most competitive fellowship. Particularly for some of the older and more prestigious places (looking at you MSKCC and MDA), you quite literally need to have a PhD or equivalent and have done some really amazing things *and* be perfect in every other way on your application to get in.

As an aside and a funny story – I did a month rotation as a Brennan visiting resident at MSK. It was an awesome experience. MSK, for you students or residents who don’t know, is one of the ivory towers of cancer care. Dr. Murray Brennan was knighted by the queen for his contributions to humanity through his research and advancement of sarcoma. *That’s* the sort of surgeons they have and that you work with there. Part of that scholarship is that Dr. Brennan meets each person who is chosen for the scholarship and has them sign a book and have a fifteen minute discussion about why you want to do surgical oncology, and what you think your time at MSK can do to help further along that goal. I was from a community residency program he had never heard of, and I was nervous as hell, but when he asked me what I wanted to do I was honest. I said that with my month at MSK I wanted to see what academic surgery was like so I would have a good idea of what the other parts of surgical oncology are, but in reality, I saw myself as a community surgical oncologist who would go start a cancer program and practice general surgical oncology and try not to subspecialize. That it would be amazing to go to a place like MSK though and that I really wanted to see what it was about. His reply was, “Well – I think we actually need more of you. It’s an admirable goal and there is a huge need for that. But quite frankly you’re too young to ever come to MSK – you don’t have a PhD so you’ll never get an interview here. But, what we can do is make sure that if you use your time here well, we’ll write you a letter that will absolutely open some doors.” And that’s what they did, and I’m grateful and would do it all over again. I tell that though because that’s what it takes to succeed in getting into academic surgical oncology – they are looking for the best and brightest who have research oriented minds and have done their penance in a basic science lab and been productive and engaged while they did it. That’s just the reality and you should know that if you’re considering surg/onc. Some very strongly believe in the research/scientific part of surgical oncology, others will tell you that it’s just a requirement and that maybe it doesn’t make sense since many of us won’t do research when we finish, but that’s the way it is. Depends on where you go and who you talk to.

Ok: let’s get into the meat of it. First things first: there are 60-70 spots per year, and in general a place will interview 30-40 candidates if they have a single fellowship spot. I’m guessing probably closer to 50-60 if they have multiple fellowship spots but I can’t confirm as my fellowship was one per year. If you’re an average amazing candidate you can probably expect to get 15ish interview offers, maybe more if you’re stellar. If you’re just good and still typical (did research years, no glaring flaws, but not a super star) probably about 8 interview offers. If you are atypical or have a flaw, 5 or sometimes less. (I got seven but two were outside the match).

Board Scores:
This is simple. You need good board scores. Will one bad score get you screened out? No. Will multiple? Maybe/probably. Surgical oncology fellowships in general certainly do not want to deal with the issue of you being able to pass your general surgery boards (you should have passed your written before starting), and they assume (ours does anyway) you will also be able to self-study and succeed at your surgical oncology boards as well, at least when it comes to book knowledge and the written side. Oral boards we still practice for both. What is good? Above 50th percentile on average is probably the relative floor. 70th+ percentile is good. 90th+ percentile is excellent. One or two 30s or higher can be looked passed if the other two are above 70th and the rest of your application is good. Keep in mind that the match is in fourth year so you may only have 3 sets of board scores – many others did prelim years or research years and may have 4-6 sets of board scores. This is fine, there’s no penalty for only having three numbers at all – at least 2 of those three numbers should be good though, or all 3 above 50th. Again, this is not a rule. It’s just a really easy and objective way to measure applicants and sort them initially on interview offers, and then on setting up the rank list before we start moving people up and down. If you have a score below 30 or more than one score below 50 it’s going to be a struggle and you are going to be much lower on the list.

Program Prestige:
Do you need to come from a University program or a place with a big name? Absolutely not. Does it help? Absolutely. You are at a disadvantage if you came from a community program no one has ever heard of. How much of a disadvantage? I’m honestly not sure. For my fellowship which was less academic more oriented towards general surgical oncology, wasn’t that big of a deal. We coo at the big named schools, but we also ask if that person will really know how to operate or will we be teaching them. This is the part where “who you know” comes into play. If you’re from a smaller program but one of your faculty makes a phone call and can vouch for your ability to operate (amongst all those other things), this is really powerful here, particularly coming from a place without a name. A place with a name gets the benefit of the doubt that if it was hard to get into the residency then you probably didn’t suck to begin with. Again, super subjective, but that’s what I saw both while interviewing and while doing interviews.

Research (And Research Years), Publications:
So let’s just get this out of the way – for better or for worse, the standard is that you did two years of dedicated basic science or translational science with a basic component. This really ought to be done in cancer. Can you get away with doing less time (or no time), or doing it in a different field of study? Yes you can but that should be offset by something else. If you did an MD/PhD sort of deal that usually satisfies the requirement. If you’re going for a highly academic place maybe you did an MD/PhD or some basic science in undergrad and then did a year or two additional research in residency, that would be a huge plus to those places I think. You should have been productive in these research years with at least two first author publications and another 3-4 non-first author publications. You should go to a national meeting all of your research years (if not more than one), ideally present a podium type talk somewhere, somehow, and you should probably have gone to a national meeting at least 2/3 of your residency years if possible. Again, none of this is a hard or fast rule (seeing a theme?) – this is just what *most* people did. I will say that if your research was all over the place – like you did some in cancer, some in oncology, some in bariatrics, or something like that, that is usually totally OK and treated the same as someone who just did only cancer research. It’s only a slight ding if none of your research was in cancer, and even then only a slight ding. But if you first authored five papers and have 15 others listed, that’s perfectly adequate even if it wasn’t in cancer, especially if you can explain why (“my institution didn’t have the opportunity but all of these other guys did so I went for it”). Also disparities/population type research in surgery is an excellent surrogate for this and goes super far if you can’t do dedicated basic/translational cancer research. People really love that stuff and it’s very relevant.

Alternatives to Traditional Research:
So I recognize that not all of you actually have the opportunity to do research years and some residencies simply do not have the ability to allow you to do so. Are you out of luck? No, not necessarily, but it is a disadvantage. Can you do things to make up for it? Yes! What sort of things? Well, here are a few that stand out:
Non ACGME-SSO fellowship (such as MIS, HPB, research fellowship after residency though be careful with this as if you still fail to match you can have serious, profound issues with credentialing and finding a job if you haven’t operated for two to three years while doing research after residency. Most jobs want your op log for two years, so research years after residency can be dangerous and need to be very well thought out and you need another back-up plan if you don’t match when its done)
Masters degree during residency (This is what I did – I got a masters through night school in clinical informatics and safety/quality. I will say if you take this route that it should be research slanted – like statistics or working with databases, or safety/quality, something like that that will be useful to you succeeding in doing research as a fellow)
Publishing x2-3 the amount of papers that other traditional candidates do in major journals. If you’re able to the same amount of work a research fellow did and your papers have actual impact and were meaningful while doing it without dedicated years, that can really stand out. If you take this path you should realistically have published probably 6-10 first author papers and be on another 10-15. I don’t think that is an over exaggeration but perhaps other will feel differently.

Other Stuff (Awards, Committees, Chief Positions, Etc.):
If I’m being honest, I don’t think that this really makes it into the equation on if someone is going to offer you an interview. This is more used as topics of conversation for the actual interview if you do something cool and weird and have strange hobbies, or had a super cool award for something.

Away Rotations:
You should definitely plan on doing an away rotation, it should be at a different institution, and ideally a major cancer center. Things like the Brennan visiting resident are great though it sometimes can be hard to stick out and shine at a highly academic place like that where the attendings are really paying a lot more attention to the fellows, and the fellows have almost complete control/oversight over the residents. Other times though I still managed to get plenty of face time with my attending for the service I was on and we had a good time and he wrote me an absolutely stunning letter. But the short version is do an away, and get a fantastic letter from a well-known surgical oncology fellowship, even if you aren’t going there or don’t intend to go there. I don’t know how much doing an away at a specific place influences them choosing you over someone else – I imagine about as much as residency, which is they give some preference but it isn’t overbearing. Maybe others can speak to this more.

Letters:
You need a letter from your chairman, from your program director, and from whoever is heading up your surgical oncology department from your residency, +1 away letter described above. They should generally talk about you like you have exceeded the invention of sliced bread and are, in a phrase, the ****. Also if you did research time you should have another letter from them that makes you sound like you outshone everyone else in the lab. Having read a bunch of these letters, those are the things that stood out. And really, they should be fairly personalized. Your chair/PD/surg-onc mentor should have at least made it sound like they really took the time to get to know you and consider you not only an excellent and brilliant surgeon but a really great person to work with. This is what most good letters have done. This may mean that you actually offer to draft the letter for them first in some cases, but in my opinion (which is just that), it is best if they really actually know you that well and like you that much that they write that sort of letter themselves. You can tell, and it makes a bit of a difference. All of that said – everyone’s letters were really, really great, so what stood out more here was if you had a lukewarm, generic, or letter that had something not great to say about you. Those candidates in the last category got moved to the bottom of the list immediately. Lukewarm letters across the board get moved down.

The Interview:
I’m deliberately not going to speak to this very much because this is actually institution dependent I believe. Different fellowships want different things and they want to feel you’re going to fit well for what they do, how they run, and the product they churn out after two to three years. Mine fellowship put a huge emphasis on people who wanted to do clinical research and could operate already because that’s what plays to our strengths. I’m *positive* that others, if not most, put massive emphasis on how smart someone is and their research acumen. In general, the newer fellowships are teaching more broad based general surgical oncology and are less hardcore basic science research and more clinical/integrated research, and the older ones are more academic oriented and research heavy.

The Fellowships Themselves:
I don’t have many friends from my program who went into surgical oncology (I was the only one in my class) so I don’t have a lot of experience with this, but my senior fellow and junior fellow have friends in other programs and have told me that some programs struggle with a good HPB experience and that their fellows are not comfortable doing HPB surgery when they’re done, and gravitate towards colorectal/other abdominal, breast, melanoma, etc. I’ve heard some really struggle with research, that some really care how much effort you put into research, that some treat you like a resident and you’re putting in all the orders 24/7 and taking all the phone calls and get worked to the bone, that others are super cushy and easy, some let you moonlight, some don’t. I will say that at those pre-interview night dinners (thanks Covid) that the information you get is probably about 75% true and 25% rosy and they play down their weaknesses from the interviews I did, vs. what I’ve heard from other fellows. Which is fine, and normal. I would sum this up by saying that whatever a program describes as their strengths, they’re being entirely honest. Whatever they describe as their weaknesses, its probably worse than what they’re describing but most of the time not prohibitively so. In a few programs though if the rumors I’ve heard are true (they are rumors, but they seem to have some validity in how programs are maneuvering with new partnerships and rotations), some do struggle with certain types of operative experience, particularly the HPB component. Also I don’t know what the experience is like for the programs that track their fellows in the 2nd year into something more specific – I simply don’t know. You’ll have to find one and ask.

Closing Thoughts:
From the people that I have interviewed with in trying to find an attending job, I would close by saying that surgical oncology fellowships are training three breeds of people. The true general surgical oncologist that wants to go into either private practice or hospital employed and is ready to do big surgery and can operate, ones that have specific strengths or want to limit their scope (like not doing HPB, or doing HPB only) and sometimes are intimated by doing big surgery, particularly in a vacuum without a senior partner for several more years, and the academic super nerds who are looking to be super specialists and/or run a lab. The first breed is the minority, most of us are the second, the third breed is also a minority. I have heard lots of comments that people recruiting for positions where you’re the only surgical oncologist and/or the only HPB/sarcoma/HIPEC guy really struggle to find a person that can do that directly out of fellowship safely and confidently, and that have the business-practice building sense side that you really need to start a practice from scratch or run a cancer center from scratch as the only surgeon. Those are also really the jobs that I am primarily applying to. There are a generous number of jobs though that are looking for a breast/melanoma/colon type surgical oncologist or HPB only surgical oncologist or some other flavor that is coupled with general surgery and those are fantastic fits for many of us who need more time to develop. The academic type jobs seem to find the academic type people and they are advertised as such, and I think that a lot of the academia stuff happens internally or by word of mouth. I defer to attendings or fellows who know more about that.

 

[Lem0nz]

What the actual heck am I supposed to get paid for doing this? What the heck is my actual job? What do I do!? (For Fellows)

Ok, we’ll get right down to it here. If you made it this far you’re either very interested in being a fellow, a fellow, or a curious attending but you want to know my opinion on the job market from someone going through it (or you skipped down. If you skipped, props, I can’t even imagine reading all of that stuff I wrote). Here we’re going to talk about what sort of jobs there are, what you will be offered to get paid, what you probably should get paid, a little primer on RVUs, how the world and demand of minimally invasive surgery affects all of this, things like salary guarantees vs. productivity bonuses, sign on bonuses, academic/protected time, the works.

The first thing we need to get out of the way is that, outside of the academic places who have been employing surgical oncologists at their institution for decades, absolutely no one else has a definitive idea of “THIS IS WHAT A SURGICAL ONCOLOGIST IS AND SHOULD DO AND SHOULD BE PAID”. No one. Not one single job. I had a job interview at a younger university program who wanted a general surgical oncologist. I applied to a few academic type positions that wanted research minded people and professors. I interviewed at a for-profit system hiring faculty under their general surgery residency and paying under the AAMC model but had absolutely none of the benefits of a university employment model, no productivity, and expected general surgery call. I interviewed at a non-profit ACO who paid MGMA 50th with great benefits where I could get my student loans forgiven. Some places want you to do esophagus. Some don’t. Some want you to do liver. Some just want pancreas and send liver to transplant or a bigger center. One wants me to do full court press thoracic – esophagus, lung, the works, in addition to HPB, HIPEC, sarcoma, MIS (I really dig that place and may take that job, sounds like a ton of fun). Some have senior partners. Some, they want to bring you in to be the guy and you’re it – they’ve NEVER done big HPB, abdominal, or thoracic surgery and they want you to start it (that’s my other top choice – they looked awesome). Some will pay you 75th MGMA or even higher. Maine has been advertising for a while and will pay you a breezy 700k base salary, no big deal. Some want people to do general surgery and take general surgery call, some don’t. You need to think about all of this, and the short version is that each place is very radically different and has different needs and absolutely none of them can be easily compared to one another. They really, really can’t. They’re all different. So instead of doing that, if you’re looking for a job in surg/onc or want to know what the market is like, I strongly encourage you instead to just consider all of the component pieces of surgical oncology jobs and decide what is best for you. What you want most, what you can do and won’t bother you but doesn’t excite you, what you would find unpleasant but tolerable, and what you absolutely aren’t willing to do. That list is way more useful (and you can negotiate with it in your interviews! A lot of places will work with your strengths and wants, though some absolutely won’t and want you doing certain things).

So, in no particular order EXCEPT the first thing which is the most important:

Getting Good Outcomes:
I put this first because it is the advice I have been given from my fellowship, my senior mentors, the people I have interviewed with that I like, the people I have interviewed with that I don’t like, and the people I trust and have been mentors for nearly a decade. You need to have good outcomes. Even if you’re the person and you’re expected to do big surgery on day one out of fellowship, pump the breaks and strongly consider NOT doing big surgery first. There is ALWAYS someone who is hoping you are going to fail. Maybe it’s the private practice GI group. Maybe it’s the HPB surgeon across the street. Maybe it’s the surgical oncology senior guy who doesn’t think you ought to be doing robotic pancreas surgery. Maybe it’s the fellow who’s two years behind you but a native to the city who wants your job. Maybe it’s a competing health system. Whoever it is, they exist, they’re there, and they’re looking for you to have complications or bad outcomes to say “see, that’s why you shouldn’t go there, bring your business here instead.” Healthcare is first and foremost a business. Please understand that reality. Even for non-profits, for faith based places, for county hospitals, for university hospitals. You need patients, to make money, to pay for the things. Strongly consider starting slow. If you can do a robot whipple on day one, great, but maybe consider doing it open first because what happens if you have to convert? Do the nurses you just met know what to do? Do they know what instruments to hand you if you get into bleeding? Can they work with you under stress? Can your assistant? Take the time to consider all of this. Focus on being safe, getting good outcomes, and building up to the big cases, even if it means short term loss. It will give you a solid reputation; you will be able to market yourself, you will build confidence, your patients will have good things to say about you.

Scope of Practice:
Next: what surgery do you want to do? If you know you want to do HPB/sarcoma/HIPEC, those jobs are more rare than others but not as rare at least as I personally thought they would be. Most people advertising for a surg-onc job expect you to be able to do normal HPB (whipples, distal/spleen, biliary stuff, simple liver). Some expect you to be able to do major liver (right/left/extended), most will not expect you to do complicated liver (cirrhotic/triseg/crazy hilar) unless they have a senior partner or a plan if that goes sideways such as transplant backup or availability or a bigger referral place. Thoracic surgery is generally not expected and super rare. Esophagus is 50/50. Many places will NOT actually need you to do breast surgery – many have fellowship trained breast surgeons now. But if that interests you, there are PLENTY of jobs for that or they’re often willing to share. Many will NOT actually need you to do thyroid/para, but many *absolutely* need you to. It seems to be 50/50 and unlike breast, they either definitely need you to do it or definitely don’t. I see a lot less grey with the places I have applied on thyroid/para/neck. Many will want you to, at minimum, be the guy they can call for the really complex benign general surgery (the pancreatitis bombs, the messed up common bile duct, the horrible diverticulitis that blasted their pelvis into the next century). A lot want you to do some component of general surgery but in that same token, they will often let you pick what you want to do. Don’t want to do hernias ever again? Cool, but then you should expect to do gallbladders and appendixes and diverticulitis maybe. Some are looking for just a foregut/gastric cancer type guy, some are looking for just breast/melanoma, some are looking for just HPB but I will say that those jobs with this higher specialization and very limited scope, outside of academics, are very rare in the hospital employed/private practice setting.

Senior Partners:
Some people have more comfort level than others, but it is my personal opinion that it is vitally important that you have a senior partner that can bail you out of deep ****. They don’t have to be a surgical oncologist. My top two prospects each have something different: one has an old school HPB/transplant trained surgeon who only makes big incisions and won’t even do basic laparoscopy, the other has a MacGyver type general surgeon who does esophagus with high volume and does everything robotic. Obviously, pros and cons to both of these jobs. In one I will have a guy who can help mentor, teach, and proctor me for the really tough liver cases that I haven’t gotten enough exposure with and will allow me to vault forward into more complex surgery over the next few years. But he can’t really help me at all in developing and furthering my complex robotic skills from fellowship. The other can help me in all of my MIS/robotic endeavors, has sarcoma experience, but hasn’t done liver or pancreas surgery in 15 years. Neither has done HIPEC. But they’ve both (and others in both systems) have reinforced multiple times that they are there to support me and make sure I am not alone in trying to build and do those things. I strongly feel, and suggest, wherever you go that you have someone like this in your corner. It will set you up for success. At the same time, just make sure to take the time to understand who else you’re working with and if you’re going to be competing for cases with them. This isn’t inherently bad (like, growing program and hiring second surgical oncologist), but something you just have to be very mindful of. You may have a salary guarantee for the first 2-3 years, but what happens after that? Can their volume really support that second surgeon? Will it become competitive between you two or are there plans for profit sharing? Stuff like that.

General Surgery/Trauma/Weekend/Overnight Call:
Pretty self-explanatory. Do they want you to take general surgery call, do you want to take general surgery call, are you *willing* to take general surgery call, and when/how often/how much? What’s your role for trauma, if any? (It should be zero unless you specifically want it to be otherwise). Who are you rounding for on the weekends and who is rounding for you on the weekends? How often? Do you take first call overnight, or do you take call for the entire service/group who you share weekend call with, is it one week at a time, alternates daily, etc. There is no wrong answer to any of this, just make sure to ask! One place I interviewed with wanted me to do one weekend of general surgery call a month at two hospitals simultaneously and then one additional single weekday night per month, relatively minimal and not too bad. Two were zero emergency general surgery call – that went to an ACS team. One was 1:3 but their hospital was a specialty hospital that didn’t get much general surgery. And if you are on general surgery call – is it appendixes, gallbags, and free air? Are you doing those cases the next morning if you admit or are you just covering ER call and passing that to a partner so it doesn’t screw up your elective cancer stuff? Are you doing things like abscesses and hemorrhoids and vascular stuff (like honest to god general surgery)? Do you *want* to do that? Do you even remember how? (#heckle) Just think about all of those things and make sure to ask. If you’re doing 3 gallbladders and an appendix the next day you are really going to screw your schedule for what you want and were designed to do: cancer surgery.

Compensation:
(Did you scroll straight down to this part? …uh-huh.) Alright so here it is. The most taboo of all taboo subjects, because you are supposed to have gone into medicine to be a Saint and the money shouldn’t matter and it’s about the patients.

K.

There are two pay scales. The AAMC scale is what professors get paid on. This is available to be purchased at an absolutely insane ~$1,000 for individual use. Some participating university type institutions can get this for free. I tried very, very hard to get this from all of my contacts but no one could get it for me and no one had access. I don’t know what the numbers are, but I have a pretty good idea. AAMC does sort by specialty and RVUs and gives you 25th/50th/75th/90th percentile numbers. In general (so I’m told) it pays slightly LOWER than general surgery because it assumes you don’t take call. 50th percentile is probably 260-265k. The upper limit you should expect out of fellowship is certainly not going to be above 350k on AAMC and is realistically probably 300k. The lower limit is 200k. Most places will give you a guaranteed base salary for 3 years. Some will also have a productivity bonus, some won’t. We’ll talk about this in a second. Some things you should expect if you are getting paid under this model are:

• Protected time for research, education , or administration which can be as little as 20% (1 day per week) or as much as 75%, but is more often 25-50% depending on your research goals and if it’s a university vs. a cancer center.
• No general surgery call unless they’re paying you for it
• Residents or fellows to take call for you in the middle of the night and deal with the bull****
• Generous retirement matching
• PSLF should be a given or they should pay off your student loans, huge red flag if they are a for profit and they won’t tackle your loans

This is what I have been able to glean about academic/AAMC. Again, I defer to my academic colleagues if you’re out there. I only know what I know because of the one for-profit professor job I applied to which I have since turned down (which made me really sad because it was in my home city where my family lives). I investigated as much as I could, but they had none of the above and at the end of the day seemed like they were trying to take advantage of me and it just wasn’t worth it. (Other reasons when I get to hospital/capital support at the end too).

The other pay scale is MGMA. There’s actually 3 pay scales, MGMA, SCA, and AMGA, but most people just say MGMA. Even if they say MGMA though, the usual standard practice is to average all three of those scales and to the organization that is the MGMA pay scale. This data exists both for regionally (such as pacific, pacific northwest, southwest, Midwest, etc.) or nationally. State level data, to my knowledge, does not exist and/or I didn’t have access to it. MGMA data also comes with Work RVU data. We’ll talk about this in a second too once we go over base salary and productivity. Many large academic institutions are actually beginning to pay even their professor type people using MGMA to retain talent. 25th percentile is about 340k, 50th is about 420k, 75th is about 550k. So at the end of the day – that’s what you ought to be getting paid if you aren’t strictly in academics.

Now, this is where it gets more nuanced and this is VITALLY IMPORTANT for surgical oncologists. The problem is that we do a massive, massive scope of surgery that other surgeons do not. If you counted the TYPES of RVUs that we bill for, the scope of that is huge. It can include general surgery, vascular surgery, HPB, whatever. It’s like, literally, all of the coding book. Why is this important? Because those salaries, both AAMC and MGMA, are more or less based on RVUs comparing you to other surgeons. For many specialties RVUs is a really good marker for productivity, or stated differently, RVUs are the standardized way of knowing how hard you’re working.

In reality? RVUs are absolutely horrible at comparing surgical oncologists to one another.

The problem is that surgical oncology has a LOT OF OTHER THINGS that we do. MDC clinic? That doesn’t generate RVUs. Building a practice and talking to referring docs? That does not generate RVUs. Making system wide cancer guidelines, teaching? No RVUs. And even when we do get RVUs for surgery, they don’t always mean what you think they mean. A whipple may be worth 10 gallbladders, but a gallbladder is someone you meet for five minutes, take to surgery, and discharge the next day and can forget about. A whipple is in your hospital for a week. They required scans and visits ahead of time. They required MDC discussions. They required your participation in chemo and radiation decisions. The list goes on. And you may be saying – well, doesn’t the RVU system account for that because you have to do 10 gallbladders to equal that? …It does, and does OK at it. But now let’s talk about a robotic whipple. This operation takes 2 to 3 times as long. In most systems it has the same, or only marginally marked up RVU value compared to the open version. You can do at least two, sometimes three open whipples in the same time you can do a single tough robotic whipple.

Are you starting to see the problem?

Layered on top of this is that minimally invasive/robotic complex surgery is what’s hot right now. It is what is wildly in demand and almost an expectation for places recruiting a surgical oncologist. My associate PD is a robotic surgeon attempting all of his cases with a robot approach now, and his clinic and operative week are SLAMMED. He is operating from 7am-5pm three days or more a week with clinic from 7-5 the other two days and then meetings before or after. He barely breaks 6,500 RVUs. A surgical oncologist who may just be doing ports, breast, melanoma, and colons can pull 12,000 RVUs and work less hours. If you’re just the HPB guy? You may not even hit 5,000 RVUs and maybe you only have one big case three days a week. The problem with compensation in surg/onc is that there are so many of us doing wildly different things that the RVU and pay scales don’t always make sense, and you need to really research this, and account for it when it comes time to negotiate a contract.

Let’s take the example (me) of you’re being recruited to start a surgical oncology service line from scratch which is what the two jobs I’m really interested in taking are. I need to go in, build a practice from scratch, build OR protocols, make business models for equipment purchasing for a HIPEC machine and liver retractors, intraoperative ultrasound etc., meet referring providers, develop an MDC clinic, build the documentation and order sets in the EMR… the list goes on, and on, and on. I actually wrote it out in project management software to organize it and it has 400 tasks so far, each of which is not a simple task (imagine trying to do a whipple in a hospital that never has and you have to get from pulling your attendings preference card to doing it with a robot. How many steps and how much work do you think that is?). My 400 task list is halfway done – it’s still a work in progress. How many RVUs do you think that list generates? *crickets*

So that brings us to salary guarantee and productivity bonus, and perhaps even more importantly, asking about what it looks like when it’s time to renegotiate your contract in 2-3 years. Unless you are going into a practice with a clearly established referral base and you are REPLACING a surgical oncologist who moved on, retired, or died and are quite literally picking up their practice where they left off (AND EVEN THEN), you should be asking for at minimum 2, more typically 3, and in some cases 5 years guaranteed base salary. This base salary should make up the bulk of your contract and the RVU piece needs to be carefully talked about and extensively discussed with whoever is hiring you and needs to reflect what your practice is actually going to be. If you’re a robotic HPB surgeon you had better get it in their heads up front that you’re never ever going to pull 12,000 RVUs, but that your value to the institution in marketing, quality of care to the patients, draw for the oncology service line, hospital resources and length of stay… all of those things will make the system more money. You may need to talk to them about a base salary for the entirety of your career depending on your scope of practice. Conversely, if you are going to do surgery that is complicated and you know is going to be high volume low risk, you may WANT a generous productivity piece, even right out of the gate. Maybe you want a 25th percentile base and then an RVU productivity type reimbursement for every RVU over the 25th. I don’t know what you want because I’m not you – I can only tell you that you really need to think about it before you get to contract negotiations. Personally, I want to start a surgical oncology service line and be hospital employed, I want it to be my baby and I want to be able to build it myself and make the rules, and I want to do all of that business type stuff with marketing and advertising and building relationships with my community. I like all that crap. I’m excited to start a HIPEC and robotic surgery program. You might hate it. You may want to wake up, do surgery, and go home and not think about it anymore. But for me, that’s what I want, and knowing that, I know I need to ask for a base salary above 50th percentile and tell them flat out that I’m not going to hit RVU metrics for the first two years, and maybe even longer. That my value to them will far exceed the RVU piece because of the administrative component, that I’m going to take the time to make sure we’re doing good billing and coding and documentation, that we’re doing outreach, that we’re expanding our patients coming into our system which generates more money for the med oncs, the rad oncs, the radiologists, IR, etc. That’s my value and what I bring to the table, and I need to be paid to reflect that. That I can do a robot whipple and it IS what is best for my patients, but that it takes x3 as long and that doesn’t mean you can’t pay me the same as the guy who only does them open but does twice as much. I need to be paid the same as him when you hit the bottom line dollar amount, but it needs to be in a different model.

I hope that makes sense and demystifies what you should get paid. The tldr version is that academic surg oncs should get 275k (ish) and the private practice guys should get 425 (ish). After a decade, that number should go up to 350k for academic and 500-550 for private. As your career winds down and you transition to admin, that salary can go up again particularly if you’re starting a new program or being recruited as an administrator deliberately, or sometimes it just stays the same but you get to operate less and live life more. I defer to my elders to correct this last paragraph on what you should be getting paid 10 years, 20 years, and twilight years into practice. Also, you should in general get anywhere from 30k to 100k in retirement match depending on how generous your institution is, and that is not included in the salary figures for the most part (I think).

Also, loosely related, in this day and age unless you’re true private practice/partner type job, everyone should pay for your malpractice w/ tail, licensing, DEA, blah blah blah. You should get 3-5k for educational expenses and conferences, and a week of conference time. You should get 4 weeks of vacation. Some places are offering 2 weeks, that’s a red flag. Some go up to 5-6, that’s a perk. Some give you like a set amount of days and if you couple it with weekends you aren’t on call you can stretch it out to be 5-6 weeks even if its technically 4 weeks of vacation. Your sign on bonus should be between 50-100k, most places offer 20 but they’re lowballing you. There should be 10-20k relocation assistance. Ideally it’s a non-profit so you can get PSLF for your loans because you did at least seven, if not 9 years of PSLF already from your training. Otherwise, ask about student loan repayment. CHECK the non-compete clause if this is your home town and you have family – make sure if you part ways for some reason you either are OK with leaving the city and state, or your non-compete is not so restrictive that you can’t get another job in the city. Some non-competes will mean you’re moving to another state, but if you’re the only surg onc in town and you quit (or they didn’t renew your contract), that isn’t really a big deal because it means you already decided to leave. But if you’re in a big city or even the suburbs and don’t want to go someplace new, this can be INCREDIBLY important. Laws enforcing non-competes vary by state but in general are enforceable.

Protected Time:
Varies. But academics should have a clear component of their contract spelling out how much time is protected and what it is for and what percentage of your job is clinical. I’m finding, interestingly, that many jobs in the hospital employed but non-academic realm are still giving one day a week or one week a month as protected time for admin or research type endeavors. I didn’t expect this, and it certainly isn’t every place, but it’s a cool perk.

Working at Multiple Hospitals:
I just want to mention this, make sure to think about it and be OK with it if this is the case. In particular consider what types of surgery you’ll be doing at both hospitals, what your call obligations are, and the travel time. If you’re doing an outreach clinic 20 minutes away, no big deal. But maybe you’re doing colon surgeries 30-45 minutes away (think big cities bad traffic) but major liver and pancreas at another hospital, and your colon surgery has a complication and you need to drive there. This can really ruin your day and make your life hell. Multiple hospitals is not a bad thing, and is honestly a very normal thing, but it deserves some thought and consideration in the grand scheme and should be discussed with your new employers before signing a contract on what type of surgery or clinic you’re going to be doing and where, and what the capabilities of those places are to support you in doing those things.

Residents/Fellows:
Also pretty self-explanatory – make sure you want them if you have them, make sure if you have them you want them. Don’t go to a place with residents and fellows if you don’t want to take the time to teach them. It’s ****ty and is a huge disservice to them. This should be a passion if you’re going to do it and it will make both their lives and yours exponentially better. Understand the call hierarchy at night and on weekends for this. Understand how consults work with your residency or fellowship. Be honest with yourself about YOUR comfort level in letting another doctor who is in training make decisions about YOUR patients. Ask how teaching is accounted for in your compensation as it does slow you down universally, though in some places not as much as you would think.

Dedicated PA or Co-Surgeons:
Understand who’s going to be assisting you. Make sure you’re OK with that. Some surgery we can do by ourselves. Others we absolutely can’t. Is it a PA doing that whipple with you and you’re walking back and forth from both sides of the table? Is it another surgeon who is trained in onco surgery? Is it just a regular general surgeon there to do what you ask but also is competent at doing surgery? Is it an RNFA? Robotic bedside assist? Surgical assist? Will this person be a part of your OR team and with you every case, or are you going to get a different person each time? Will it matter to you? (If you’re doing big surgery, it ABSOLUTELY matters. If you’re doing moderate to low complexity surgery, it probably doesn’t). Understand if this affects your billing or their billing, and how. Understand the difference between an assistant surgeon in billing and a co-surgeon; an assistant surgeon is just that, a co-surgeon is a surgeon doing a portion of the case that you can’t/shouldn’t be doing and does their own op note and separate part (think multi visceral resection like a colorectal guy taking out the colon while you do the liver, or a breast excision followed by plastics reconstruction).

Business and Administration:
I feel like I did a pretty good job of this in my example of myself in the compensation part, but to emphasize this again, take some time to really think about what your job is going to be. If you’re the only surgical oncologist, which isn’t uncommon in non-academic places (and even some academic places), you’re it. You have to come up with the business plans. You’re responsible for making sure people are billing and coding right. You need to make the standardized pathways and protocols. If you were taught to do something and its new and amazing and the institution you’re going to wants it but hasn’t ever done it before, it is going to be way more work than you think getting it from an idea to reality. How much do you really know about HIPEC? How much that machine costs? The perfusionist? The ICU taking care of them afterward? Chemo precautions? How much capital will your hospital invest? How much will insurance reimburse? How many patients are you expected to do per year? Will this generate revenue from med onc and rad onc too? Gyn-onc? Like… really think about that stuff. Very few people taught us the business of medicine but it is important on day one for a surgical oncologist, perhaps more so than even the ability to operate and operate well if you’re trying to start something new. This can be an incredibly rewarding experience and exciting time! But some people don’t want that sort of pressure or responsibility, so think about it.

Referrals:
Understand where your patients are going to come from. Is it PCPs, internists? GI? Med onc? All of the above? Is it competing hospital systems? Are you part of an ACO? Is it internal referrals from your system? Figure it out and ask. If you’re a new name doing something new no one is going to know you exist or what this new thing is or why their patients need it and that falls on you. You need to understand this ahead of time and plan accordingly.

Cancer Center/MDC Group, Ancillary Services, Hospital Administration Support, Capital Support:
I’m running out of steam so I just want to add some plugs that you need to make sure the place you’re going to actually has what you think it has and/or what you’re used to from fellowship to DO the things you were trained to do. Did you stop and make sure GI can do EUS? Do they have a Pet machine? Can they get Dotatate? Is the IR guy that dude who can get a wire through a sliver of hay, or is it a diagnostic rads body imager who just does pus drainage because no one else in the group wants to do the abdominal stuff? Do med onc and rad onc work with you in your institution, or are they private? Heck, same for all those other services I just talked about. Will they refer to you if you refer to them, or do they have preferred providers? If your system and new job *doesn’t* have those things, is there hospital administration support to get them and pay for them? Are they talking to you about making a capital budget before you start, or are they saying lets tackle that after you’ve been here for a year or two? I’ve found that last piece to be particularly telling on their “true enthusiasm”, if you will, to invest in you and your practice.

Where do I look for job postings?

SSO Job Board: Surgeon Jobs - Society of Surgical Oncology's Career Center
Type in Surgical Oncologist in Keyword or Job Title Box

Practice Link: Physician Oncology - Surgical Jobs on PracticeLink
Click that link

DocCafe: Job Search - Advanced · DocCafe.com
Click that link or select Surgery-Oncology on specialty

Word of mouth
Internal Hiring
Friends
Conferences (If we ever have them)
Indeed.com, glassdoor.com, linkedin.com (less specific, harder to use, but found a couple jobs that were there and not other places)

Physician Recruiters (hit and miss)

Of note – when using any of those big recruiting sites, if you can track down the actual organization, they often have their own website and job posting and will get back to you sooner if you email them directly or apply through their website.

Big insurance websites or national cancer enterprises like blue cross blue shield, cancer centers of America, etc. will often also have some postings for surgical oncology jobs and may not be listed (but usually are) on those other places.

 

[mikeGR]

Excellent topic, great guide for the youngins. Happy to share my thoughts as well.

My professional profile is a bit different. Born and raised abroad, I first visited the US at the tender age of 24 (gen surg sub-I). I’ve always been excited about research and it’s one of the reasons I chose medicine. I did my residency in a “county-style” university-affiliated hospital and combined surg onc/HPB fellowship at a huge, academic, and high-volume program. I’m now in my first year of surg onc/HPB practice at a university program in a smaller city.

I wholeheartedly agree that the scope of CGSO is very wide, and one cannot be excellent at everything. There are significant advancements in almost every field every year, and it is impossible to master everything. As noted above, people have been wondering what the CGSO fellowship really is about, since there are now separate accredited HPB, endocrine, breast, and colorectal fellowships. In reality, if we assume that endocrine, breast, and colorectal oncology will be covered by the respective fellowships, then a CGSO grad will realistically be dealing with melanoma (lots of cases, in some areas there is competition with gen surg or even plastics/derm), sarcoma (pretty rare, and honestly most of these should be referred to tertiary/quaternary centers), gastric/GEJ cancer (also somewhat rare), CRS/HIPEC (increasing volumes) and perhaps HPB, if you are in a high-volume program or a combined SSO/AHPBA program.

The problem with this, as the OP eloquently described, is that many community hospitals that serve a large percentage of the population do not have the luxury to have endocrine + breast + CGSO surgeons, let alone HPB on top of the above. Therefore, the surg onc will do all the above. However, with the current selection process, SSO fellowships are heavily biased towards academically driven residents, because every program wants to train the future leaders, not the future community surgeons who are the backbone of the rural healthcare system. So, two years later, you end up having a bunch of SSO grads looking for the rare perfect academic job in a large city, while the community programs cannot fill their general surg onc (or even HPB) spots. I interviewed at a community program (with its own residency and affiliated med school), 3-4hrs from 3 major metro areas, which has been looking for a GI/HPB surgical oncologist since I was a 1st year fellow. They are in a tricky spot because HPB grads are not really oncologists and SSO grads aren’t typically comfortable enough to be the only HPB surgeon in town. Their offer was about 25-30% better than average and they have been looking for at least 2 years (and are still looking as far as I know).

 

[Lem0nz]

Bwahaha. I hit the character limit on my last post.

Closing Thoughts:
My god that was a lot of typing. I’m sorry I’m so long winded. I hope this was helpful. If you haven’t figured it out, I’m a community complex general surgical oncologist who wants to do HPB/sarcoma/HIPEC and big GI, have an interest in esophagus and I’m feeling out lung cancer, and love robotic surgery. I don’t want to do breast and thyroid but will if they ask. And I’ve found some really, really cool job opportunities. Would love to start a residency one day at one of them as it’s a passion, and I don’t need to really get paid for that and want to keep my clinical practice busy. Not big into research, but super super love safety/quality, the business of medicine, and informatics. Have a masters in informatics safety/quality, and planning on an MBA in the next five years. Definitely see myself as an administrator in twenty years. Really excited about big surgery, love the challenge, love working and being able to own both the good and the bad of my outcomes, and want to run a cancer center out of the gate. That’s me in a nut shell, and I hope that my journey helps illuminate and demystify surgical oncology for some.

I enjoyed writing this and look forward to others thoughts, both surgical oncologists and other disciplines and how they are the same or differ from surgical oncology!

 

[Lem0nz]

Excellent topic, great guide for the youngins. Happy to share my thoughts as well.

My professional profile is a bit different. Born and raised abroad, I first visited the US at the tender age of 24 (gen surg sub-I). I’ve always been excited about research and it’s one of the reasons I chose medicine. I did my residency in a “county-style” university-affiliated hospital and combined surg onc/HPB fellowship at a huge, academic, and high-volume program. I’m now in my first year of surg onc/HPB practice at a university program in a smaller city.

I wholeheartedly agree that the scope of CGSO is very wide, and one cannot be excellent at everything. There are significant advancements in almost every field every year, and it is impossible to master everything. As noted above, people have been wondering what the CGSO fellowship really is about, since there are now separate accredited HPB, endocrine, breast, and colorectal fellowships. In reality, if we assume that endocrine, breast, and colorectal oncology will be covered by the respective fellowships, then a CGSO grad will realistically be dealing with melanoma (lots of cases, in some areas there is competition with gen surg or even plastics/derm), sarcoma (pretty rare, and honestly most of these should be referred to tertiary/quaternary centers), gastric/GEJ cancer (also somewhat rare), CRS/HIPEC (increasing volumes) and perhaps HPB, if you are in a high-volume program or a combined SSO/AHPBA program.

The problem with this, as the OP eloquently described, is that many community hospitals that serve a large percentage of the population do not have the luxury to have endocrine + breast + CGSO surgeons, let alone HPB on top of the above. Therefore, the surg onc will do all the above. However, with the current selection process, SSO fellowships are heavily biased towards academically driven residents, because every program wants to train the future leaders, not the future community surgeons who are the backbone of the rural healthcare system. So, two years later, you end up having a bunch of SSO grads looking for the rare perfect academic job in a large city, while the community programs cannot fill their general surg onc (or even HPB) spots. I interviewed at a community program (with its own residency and affiliated med school), 3-4hrs from 3 major metro areas, which has been looking for a GI/HPB surgical oncologist since I was a 1st year fellow. They are in a tricky spot because HPB grads are not really oncologists and SSO grads aren’t typically comfortable enough to be the only HPB surgeon in town. Their offer was about 25-30% better than average and they have been looking for at least 2 years (and are still looking as far as I know).

Thanks Mike! I'm definitely interested on your thoughts on my last post that I just finished - if you think there's anything I should add or correct. You probably know way better than I do what the academic side looks like.

I would also say that it isn't just the rural healthcare system, but even most of the suburban population areas that share this problem. They don't want or need surgeon scientists, they need general surgical oncologists.

Also I think that bears emphasis: SSO grads are not typically comfortable enough to do HPB surgery by themselves out of fellowship (particularly liver which has more volume issues). Unless you did an additional year of fellowship for HPB +/- transplant, you should realistically be looking at places that has a senior partner to continue your training while in practice. This is an important consideration for both residents applying and fellows. Residents interested in big HPB surgery may be better served with an HPB fellowship, or doing both fellowships and applying to do one and then the other back to back. Or just be very careful with your job selection.

 

[mikeGR]

Thanks Mike! I'm definitely interested on your thoughts on my last post that I just finished - if you think there's anything I should add or correct. You probably know way better than I do what the academic side looks like.

I would also say that it isn't just the rural healthcare system, but even most of the suburban population areas that share this problem. They don't want or need surgeon scientists, they need general surgical oncologists.

Also I think that bears emphasis: SSO grads are not typically comfortable enough to do HPB surgery by themselves out of fellowship (particularly liver which has more volume issues). Unless you did an additional year of fellowship for HPB +/- transplant, you should realistically be looking at places that has a senior partner to continue your training while in practice. This is an important consideration for both residents applying and fellows. Residents interested in big HPB surgery may be better served with an HPB fellowship, or doing both fellowships and applying to do one and then the other back to back. Or just be very careful with your job selection.

So, with regard to the HPB fellowships, the majority are 1-yr fellowships. I believe that after this 1yr, the grads are probably comfortable with bread and butter HPB, but to do really big or complex cases (ie some hilar cholangios, really complex parenchymal-sparing resections for CRLM, ALPPS, LAPC etc - let alone robotics or lap on top of that) you still need to have some backup locally, whether it's surg onc, transplant, or other HPB.

Regarding the job prospects, your post was extremely thorough. I was mostly looking for academics, but sort of looked at less academic places too. My experience with the benefits and other terms of employment (call, protected time, residents etc) was similar to yours. The guaranteed base is usually for 2, maybe 3 yrs. I think the difference in compensation is not quite as pronounced as you noted:
- MGMA now breaks down the data by region, practice type, and years out of practice. Per last MGMA, median salary of surg oncs right out of fellowship are very close for academic and non-academic practices and around 300k (numbers are based on pretty small sample size). Median salary for 2+ yrs in practice are almost 100k extra (150k for non-academic).
- AAMC data for asst prof surg onc positions are pretty similar to MGMA (academic) for starting salaries.
- From anecdotal personal/friends' experience, the range for academic jobs was 225-325 (I heard rumors that one academic powerhouse was offering significantly less, not confirmed), but usually closer to the 300s I would think. Less academic jobs generally 350-375, depending on location and other factors.