Why Surgery?

[brown04]

For anyone going into surgery or already in surgery, can you talk a little more about your motivation for becoming a surgeon? I am thinking that I would like to become a surgeon, but I would like to hear more about the life of a surgeon and why other people decide to become surgeons. thanks for the help.

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[mpp]

You'll get some good replies here but here is a nice website (link) that explains a bit about the career.

 

[DD214_DOC]

What is the FACS for? I've seen it a thousand times but still don't know.

 

[mpp]

FACS means 'Fellow, American College of Surgeons'

 

[fourthyear]

I like surgery b/c I like to see results from my work, and I am an impatient person who likes to see relatively immediate tangible results, and surgery fills that need. (This is why I didn't do internal med, family med, or similar feilds where you see slower results generally)

I also like the doctor-patient ineteraction, so I needed that also (this is why I didn't choose other procedure-oriented feilds like anesthesia or interventional radiology) .

I like the semi-long term relationship from the pre-op clinic, hospital time, then the post-op clinic and follow up to see the progression of my work (this is why I didn't choose ER)

I like the variety of patients - male/female, old/young (this is why I didnt' do peds, ob/gyn)

I like to interact in a team environment like the OR (this is why I did not choose more independent feilds like radiology or path - plus I find those feilds extremely boring.)

Hope this helps you some.

 

[supercut]

First and foremost, I love the OR. Since I hadn't been in the OR for several months, the first time I got back into the OR as an intern it felt SO good, from the moment I started scrubbing. I enjoy the comradarie of the OR as well as what we do there.

I enjoy the satisfaction of actually FIXING a problem. I like the way that surgeons tend to be able to just take charge of a situation. I prefer to act, not debate. I like being good at doing things, and treading where others cannot go. I like the being the one who is good at starting lines, doing chest tubes, etc and I like the fact that other people need me to do those things. I also kind of like the idea that when people get into trouble, often they wind up getting surgey to bail them out (OB dings the hypogastric vein, they call surgery. GI can't stop a GI bleed, call surgery. Someone drops a lung putting in a line, call surgery for chest tube)

I like that you see your results in surgery, but then you move on. You evaluate a pt preop, do the surgery, follow up post op and then don't interact with them again unless they need another operation. Your involvment with the pt is for a relatively short period of time . You don't have to worry about tracking all that health maintenance stuff. I also happen to be pretty good at mantaining a calm, reassuring demeanor in situations that scare most people to death. And even the most simple operation is pretty nerve wracking for most pts.

I also found during my rotations as a student that I just naturally have a mindset that is more like that of a surgeon than any other specialty.

There is nothing more satisfying than, say removing ischemic bowel from a really sick pt and watching them immediately start to get better (eg watching their acidiosis and hemodynamics improve before your eyes).

I picked general surgery because I like mucking around in the abdomen. The abdomen was my favorite part of gross anatomy (a class I loved!!). Abdominal operations are my favorite.

I choose surgey becuase I enjoy it, not because of hours. For me, I have to do what I love. I'm happier when I love my work even if I have less free time than I would be if I settled for something I didn't like as much because of the hours.

 

[Chimera]

Sorry to hijack the thread!

Being a current third year I'm currently debating a specialty choice.

The above has a lot of great answers....I find myself agreeing with most everything that has been said. But as I am currently rotating through the OR I get worried that I get bored with the operation about half way through the procedure or that being a surgeon I would become a glorified mechanic. I really want to use my "medicine and physiology" knowledge. (I don't mean to alienate with the preceding comment)

How much medical management is there in general surgery? I'm not talking about managing CHF post cabbage, but more acute medical management. Also for those of you who decided on surgery, how did you rule out the critical care in say the PICU, NICU, or MICU?

Thanks and sorry for so many questions.

 

[maxheadroom]

Chimera,

Choose surgery because you like to do something, not twiddle with vent settings and pressors. Seriously, critical care people are great at what they do, but most surgeons just don't want to deal with that kind of stuff. If you're into it, consider General Surgery and then Surgical Critical Care/Trauma. The Trauma/ICU guys say that they like managing the medical issues of their patients.

Umm . . . thanks for the update, Gas Man . . . we're all very happy for you . . . I guess . . .

 

[supercut]

Currently, Trauma/critical care is at the top of my list for what to do after residency.

I really enjoy the ICU environment, and I like gadgets. I like managing acute care issues. I also like the fact that very often in the trauma popluation, you can have patients that are sicker than stink and then they get better and go back to a normal lifestyle (not always, of course but much more often than your medical ICU population).

Plus the adrenaline rush that comes with a trauma lap on a pt who is exsanguinating is second to none!

ICU is cool because you deal with the acute issues but no long term follow up. For example, ICU pts often have increased blood glucose (diabetic or not). You can manage that in the ICU with insulin drip and get tight control (and you should). But you don't have to worry about trying to get the diabetic pts to comply with a tight BG control regimine at home. Same thing with blood pressure, CHF and many other medical issues.


In fact, I originally considered Emergency medicine until I realized that most of what an ER doc deals with all day is primary care issues. The ICU generally has much more acute stuff going on regularly than many ED's do.

 

[bustbones26]

First off, let me make the disclaimer that I am not a surgeon or a resident, I am only a lowly MS3 but here is what I think about surgery. Anybody else can agree or disagree with me.

I think it really depends on your personality. I mean if you're a person that like to work with their hands, a kind of person that likes to fix things, then surgery or a surgical specialty is for you. One the other hand, if you're academic and like to know a little bit about everything, then maybe a medicine specialty is for you.

Now for my personal thoughts and observations. Allow me to summarize my third year internal medicine clinical clerkship for you:

Patient walks in for a 15 minute follow up appointment because they are diabetic. you think, this ought to be simple, its just a follow up visit. You interview the patient and find out that their sugar is running about 400, they only check their sugar twice a month, they drink 15 beers per day and live on a staple diet of burgers and pizza, they do not exercise, and ask then they ask you about some funky rash that has grown on their foot, and say, oh by the way, I get chest pain and shortness of breath every day now. 30-40 minutes later, while the waiting room is getting backed up with more of these 15 minute follow up appointments, your attending sorts out this train wreck. You could just book all of your patients for 30 minute appointments, but then your boss tells you that you wouldn't be seeing enough patients per day and would not be getting enough reimbursements this way.

Now, for surgery. You are not responsible for managing the patients care, you are only there to take care of their surgical needs. And do you think a surgeon is ever rushed in the OR? Do you think surgeons stop in the middle of a procedure and say, oh well, guess I'll finish tomorrow? No, they take their time!

This is one reason why I am considering surgery. If I were a surgeon, my only concern is that the patient needs their gallbladder taken out, not that they're overweight, smoke, drink, don't exercise, can't control their diabetes, blood pressure, don't take thier meds properly, etc. None of that stuff matters to me unless it prevents them from getting on the table.

Now some may gripe about the hours of being a surgeon. I admit, surgeons don't have the best hours, but I also believe that if you are a person that wants to open a private practice, you can self design your practice so that its not soo bad. As long as you're not worried about making big $$$$, it is possible.

 

[Eidolon6]

The best surgeons I have seen, think like medicine docs. They approach symptoms as constellations and narrow to a disease. They also understand the ramifications of comorbid disease on their patients, patient selection and procedure choice. They also know when they are in over their heads. The less skilled surgeons are the ones that seem to separate the disease from their patients and forget their limitations. I am not a surgeon but (future intensivist) I did seriously consider surgery over medicine. I do miss the OR and the feeling that something is fixed. What I don't miss is the repetition, the sense that floor decisions are often made by people flying by the seat of their pants, and an overall eagerness to dump patients ASAP.

As for medicine, if you want a cerebral specialty and a modicum of procedures, consider Cards, GI, Pulm/CCM where you can be a thinker and a bit of a technician. At my institution, the CCM guys are the most respected in the hospital. The surgeons consult them to manage their SICU and Trauma patients. Chest tubes, trans venous pacemakers, lines, IABPs, etc are placed and managed by them.

As for the downside....medicine residency. For what surgery has in terms of work hours, medicine has in tedium. Most surgery residents I know (esp the ones who have done vascular surgery) respect the kind of pain the medicine intern endures. But its finite...and thats why so many can endure 3 years (or 2 in some places) on their way to fellowship (beats 5-6 years gen surg before fellowship). I suppose if fast tracking was available when I applied for residency and CT surgery was 5-6 years instead of 7-8, my song would be different.

 

[LaCirujana]

Eidolon6--
You list your location as Utah. The only medicine residency I am aware of in Utah is the University of Utah program. Having been a medical student there and worked at LDS hospital prior to med school, I know surgeons/surgical residents at Utah are more than capable of placing their own lines, chest tubes, IABPs, pacers, etc (and generally, they do). At LDS hospital, it is true, that the Shock-Trauma and Med-Surg ICUs are run by CCM docs, but that is really a matter of politics rather than the need for the surgeons to "consult them" to manage critical care issues in their patients. Quite frankly, IHC demands such high volume out of those guys that they have to spend most of their time in the OR, so it's better for the patients to have someone in the unit watching them all the time, and there's no dedicated surgical ICU at LD. Pearl, Orme, Grissolm,and Morris are bloody brilliant guys, by the way--I learned a ton from them, but they're still not surgeons and don't completely understand all of the surgical concerns that we have .

At the University Hospital, surgical and trauma patients are managed by surgical critical care specialists. (But you probably already knew that).

Overall, though, I agree with your assessment, though, that the best surgeons are those who are capable of thinking like medicine docs. My mentor (a surgical critical care specialist, incidentally) advised me to think of myself as an internist who can operate, which has served me well thus far.

 

[Eidolon6]

No one is doubting the skill of the surgeons here (although I occ. have issues w. their attention to detail ), but you are right, the volume is such that patient care is an issue. Where I trained, I had the best experience on CT surgery. Note I said that I loved surgery, so this is not an indictment, but the politics of the STRICU/MSICU aside, the surgeons at LDS don't have the time to manage their ICU patients when they are in the OR. My feeling is that CCM has evolved beyond general surgery and general internal medicine as its own specialty and that surgeon's don't have the braintrust on some procedures. CCM guys are trained to do ICU relevant procedures as well as surgeons. And as you said, they may not have surgical understanding, but a lot of the surgeons lack a basic medical understanding...and thats my point. CCM can bridge some of that so the quote " the operation was a success, but the patient died" doesn't ring true so frequently.

A doctor's folly is to think he exists in a vacuum.

 

[droliver]

I'm going to have to jump in on this.... ICU care for the most part is much less complicated then what everyone is trying to make things. It's just a matter of paying attention to things that actually make a difference. There are few things that have come along in recent years that make such a difference, despite several million rats being sacrifed in the process. The "latest & greatest _____" (vent setting, sepsis drug, PPI, nutritional supplement,way to diagnos...fill in the blank) do very little (if anything) to improve care. The most important advance to me in recent years is the emergence of standardized clinical pathways which do tend to minimize oversites in routine care for DVT/GI prophylaxis, nutrition, patient positioning/OT&PT issues, etc....


For what its worth, I've noticed that just about every CCM resident, attending, & private practice CCM I've ever seen have little grasp on the care and pathophysiology of people who are surgical & trauma patients as they're often different animals then the patients they do most of their training on in a # of signifigant ways. In a similar vein, I think IM/CCM background do bring a lot to the table with their background of longstanding medical comorbidity maintainance. For acute tx. of most of these issues though, I don't know that this really distinguishes them from Surgical Critical Care backgrounds

 

[Winged Scapula]

Originally posted by bustbones26

This is one reason why I am considering surgery. If I were a surgeon, my only concern is that the patient needs their gallbladder taken out, not that they're overweight, smoke, drink, don't exercise, can't control their diabetes, blood pressure, don't take thier meds properly, etc. None of that stuff matters to me unless it prevents them from getting on the table.

Thank you for your disclaimer...it gets you off the "hook" somewhat from the above statement!

You SHOULD be concerned about the above factors. What happens if you allow a patient to continue to smoke after a free flap? Guess what...it frequently necroses. You should be concerned if they smoke and request that they quit before this (and many other) procedure(s).

Blood pressure? Diabetic management? Guess what? Patients have these problems ALL THE TIME pre and post op. Sure, some hospitals have medical consultants who manage all this stuff so you, the surgeon, don't have to be bothered with the mundane medicine stuff. But many don't, so expect to be called when your patient's pressure takes a dive or their blood sugar skyrockets after you start TPN (What? Yes, you might have to right the orders for it and correct the electrolyte balance as needed.) If your patient's blood surgar is wildly out of control, expect your surgical wounds to heal poorly, expect post-op infections. The best surgeons are not only good technicians but good all-around physicians and take care of all of their patient's needs (within reason).

 

[Mango]

To answer the original question, here are my reasons for choosing surgery:

Internal Medicine: Take a history, do the physical, order labs, think through a differential and make a diagnosis. THEN: Prescribe a drug you will never see, change a dose, D/C a med, THEN: come back the next day, or the next month, and repeat the whole process.

Surgery: Take a history, do the physical, order labs, think through a differential and make a diagnosis. THEN: (if necessary) go to the OR, put your hands on the patient, and fix their problem.

To me, this is the difference that makes all the difference between the two ends of medicine. I think parts of Internal medicine are cool as hell, but when it comes right down to it, I'd rather stand at a table cutting for four hours, than sit at a table rounding for four hours!

 

[maxheadroom]

"Now, for surgery. You are not responsible for managing the patients care, you are only there to take care of their surgical needs. And do you think a surgeon is ever rushed in the OR?"

Gotta say you're wrong here, also.

1. Surgeons can and should manage all aspects of their patients' care. Obviously we won't run dialysis and things like that, but you'll write SSI, TPN, and all the other crappy orders.

2. Yes, surgeons are rushed in the OR. Hospitals only make so much $$ per case. If you take longer than your colleagues to do a lap chole, you can bet that the hospital will start pressuring you to get the work done more quickly.

I think you need to work with some general surgeons and see how it really is. Your view of the surgical lifestyle is a bit off-center.

 

[droliver]

Originally posted by bustbones26
Now, for surgery. You are not responsible for managing the patients care, you are only there to take care of their surgical needs.

I'm going to jump on the pile with this one. There are some surgeons & some subspecialty surgeons who feel this way, but they are not good Doctors for the most part. A tremendous part of your maturity and judgement comes from integrating these comorbidities into your planning and treatment. The really good general surgeons are absolutely Zen-like on these things, & you'll tend to notice that they have the fewest disasters post-operatively & they recognize and diagnose problems sooner

 

[Eidolon6]

I'm going to have to jump in on this.... ICU care for the most part is much less complicated then what everyone is trying to make things. It's just a matter of paying attention to things that actually make a difference. There are few things that have come along in recent years that make such a difference, despite several million rats being sacrifed in the process. The "latest & greatest _____" (vent setting, sepsis drug, PPI, nutritional supplement,way to diagnos...fill in the blank) do very little (if anything) to improve care. The most important advance to me in recent years is the emergence of standardized clinical pathways which do tend to minimize oversites in routine care for DVT/GI prophylaxis, nutrition, patient positioning/OT&PT issues, etc....

droliver, I don't think that critical care is necessary more complex than other specialties, but it does involve assuming control of multiple organ systems, some at differing degrees dysfunction, and involves a degree of specialized training to do properly, perhaps more than is found in general surgery, anaesthesia, or medicine residencies. It is an accredited specialty with some merit. I will refer you to some data that suggest that high intensity, intensivist modeled ICU care is superior to low intensity ICU care in absence of in house intensivist or intensivist consult. SEE "Physician Staffing Patterns and Clinical Outcomes in Critically Ill Patients--A systematic review" JAMA Nov. 6 2002 288(17) 2151-2162 which suggests that intensivist staffing (in both medical, surgical and combined ICUs) reduces ICU mortality and hospital and ICU LOS. Granted, this is a meta-analysis of observational studies..but RCT modeling would be difficult in this setting...as is clinical research in the ICU setting. It may just be that people who staff the ICU have the time to "pay more attention to things"

I can see how one would feel that ICU care has not advanced as for example, the relative mortality of sepsis (50%) has not changed for 30 years, however, classification and recognition of sepsis has changed in that time and manifests some impact on the inherent statistics. Pressure control ventilation and optimization has reduced time on vent, improved patient comfort and associated complications. Trends in reducing ICU paralysis and sedation has also improved time of stay in the ICU as well as reduced complications such as CCPN, ICU delirium, VAP. These are recognized by people dedicated to ICU care (just some examples). I'm not sure what your basis of comparison is to state that trends in ICU management have not impacted patient care? As for protocolized ICU care, data is very supportive for improvments in morbidity/mortality, LOS. I certainly can't (and wouldn't) argue that point.

As for trauma/surgical pathophysiology. I can see trauma having various nuances that would be challenging without experience. Then again, management of a 23 yo lupus patient with lupus nephritis, DIC, and lupus pneumonitis, for example, has its nuances too....now just put her little osteoporotic body in an MVA....lines get blurred. Some IM/CCM programs have a good bit of cross training with surgical ICU management (esp. Pittsburgh). I think the combination of pulmonary and CCM has some problems just in terms of the training styles at various programs depending on weight given to pulmonary and CCM since they are vastly different. The best part about the CCM field is that embraces (and accredits) the difference/similarities between the fields and facilitates cross training between them. I do still believe there is a common language between critical care types that is evolving on its own. At least the research and studies seem to suggest it.

Again...thanks for making me think.

 

[TheEyesHaveIt]

Great thread. I have a question for those who chose to go into surgery.
As a rule, does general surgery mean a life of lap choles, bowel resections, breast biopsies, I&D's and appendectomies or can one tailor his or her surgical practice without having done a fellowship? Also, is it possible (or likely) to obtain a fellowship if one matches at a non major academic center (im interested in peds surgery)? Not to get greedy, but one more question are most academic programs 6-7years? Oh, and what is a fast track program?
thanks.

 

[chicagosurgres]

To answer your question Eyes:
The types of cases you do when you become an attending are obvious related to any fellowship training done after residency. Most general surgeons start their practice doing every type of cases including the less glamorous lumpectomies, I and D's and the like just to get busy and develop a referral base. After 3 to 5 years one can start to be more specific and usually by then have a junior partner do the less glamorous cases while you can focus more on the specific areas you have an interest in such as advanced laparoscopic procedures etcetera. There will alway be plenty of appys and perirectal abcesses that you have to take care of in the middle of the night no matter how established you are. In regard to your other questions. Most of us at academic programs end up doing 1 to 2 years of research stretching the training out to 6 or 7 years, and some centers actually require a mandatory lab time. Fast track programs are a new concept where the general surgery portion of training is shortened to 4 years with an additional 2 to 3 years then spent within that field. The only programs I know of that are heading this direction are vascular and cardiothoracic surgery, but the debate still remains whether these surgeons are board eligible for general surgery...the early talk is that they will still be able to sit for general surgery boards...someone might have more updated info on this. Just because you are in a community program does not mean you cannot get a coveted fellowship, but it means you will have to be creative. Even residents from academic programs find peds surgery and surgical oncology fellowships difficult to match to. I would recommend that if you are going to go after peds surgery spend some away time in a lab at a good academic peds surgery program to get to know people (because it really is all about who you know) and also to get published in the field. Hope this is helpful.

 

[Pilot Doc]

1. As a rule, does general surgery mean a life of lap choles, bowel resections, breast biopsies, I&D's and appendectomies or can one tailor his or her surgical practice without having done a fellowship?

In many places, general surgeons do a wide variety of procedures. See Womansurg's recent post about her first week in practice. The more rural or underserved your population, the wider the scope of practice, generally.

2. Also, is it possible (or likely) to obtain a fellowship if one matches at a non major academic center ? I'm interested in peds

ABSOLUTELY! The whole, "I have to match at hopkins or MGH or else I'll be draining abscesses my whole life" mentality is excessive. Lots of people get fellowships from all sorts of programs. Some specialties are an exeption to this, Peds being a prime example. It's a very small, competitive field.

3. one more question are most academic programs 6-7years?

general university programs= no, Major research insitution / "big name" = yes

4. Oh, and what is a fast track program?

Currently a mythical creature.

 

[droliver]

Originally posted by chicagosurgres
To answer your question Eyes:
Fast track programs are a new concept where the general surgery portion of training is shortened to 4 years with an additional 2 to 3 years then spent within that field. The only programs I know of that are heading this direction are vascular and cardiothoracic surgery, but the debate still remains whether these surgeons are board eligible for general surgery...the early talk is that they will still be able to sit for general surgery boards...someone might have more updated info on this.

The CTVS is closer to fruition on this (in re. to whether you'd be able to double board with the abbreviated program). The Vascular one has been a huge political struggle b/w the ABS & the Amer. Board of Vascular Surgery which wants to break away & establish its own board.

 

[md03]

Why surgery? For me, there is nothing more satisfying that being able to acutally FIX (rather than manage) a pts problem.

Example 1: pt with acute cholecystitis or appendicitis: pt is in agony pre op. Post op they wake up and immediately feel better

Example 2: Pt with gunshot wound or major GI bleed (GI deems "too unstable to scope"): NO ONE ELSE can help the pt EXCEPT for a surgeon. These people's lives are saved only by prompt, decisive action. They often have a bit of a rough post op period but very often are returned to their functional pre op status.

Surgeons also must be able to practice medicine. We must manage our pts comorbidities while they are in our care. Failure to do so can adversely affect outcomes, as already pointed out. However, the pts are in our care for a much shorter period of time. Once they are sufficiently healed from their surgery (time varies with pt, procedure and how comorbidities affect healing) we turn them back over to their PCP who can take care of their "by the way, there's this funky fungus on my foot" problems.

Sometimes it's appropriate to recruit the help of various medicine folks while our pts are in our care. That doesn't mean we never manage medical issues.

I can honestly say that, so far as an intern, every time I've been on call, I've been called by the nurses to deal with MEDICAL issues on pts (BP, arrythmias, low UOP, high or low blood glucose, seizure activity, chest pain, SOB...) rather than surgical issues.