Wednesday, December 29, 2004

Why I Do what I Do....
A reader emails:
I've always held career aspirations in the life sciences, but made sure to test these against other possibilities while in college. The end result: I still wanted to be a doctor, despite how much I've been told I'd be better off in research and won't have a life for the next 7-9 years. While I was volunteering in an emergency room, I had the fortune of working with some great ER docs who let me watch everything they did and loved explaining every step of the way. As a result of my hours in the ER and mechanical inclinations (I was always a fan of pulling stuff apart when I was growing up to see the guts and machinations of everything from TVs and radios to grandfather clocks) I am seriously considering surgery as a career choice. I couldn't tell you a subspecialty yet, but I've entertained the ideas of orthopedics, plastics, craniofacial, cardiothoracic, and neuro (though like many I'm sure, I have an inherent doubt in my ability to work in such a mentally demanding and complex field, not to mention the $383,000 insurance premiums!).

So I wanted to get your story on surgery: how you 'fell in love' with it, the pros/cons, if you were one of the ones who knew before matriculation or if you decided late in schooling, how this career choice affected your choice in clinical rotations, what your views on the future of surgery are, etcetera.

While it may seem cheesy, I have always wanted to be a physician. Even when I was younger I was really in to it. My grandparents gave me a paperback copy of Gray's Anatomy when I was nine or ten years old. This was fairly constant throughout high school until my junior year when I, for reasons I cannot recall, wanted to become an architect or civil engineer. I was even accepted in the College of Architecture at Georgia Tech. Then my girlfriend (now my wife) was in the hospital during my senior year for a prolonged illness. She recovered and I then changed my mind, my major, and my college. I worked in the emergency department of my local hospital during college and shadowed physicians during vacations. I was exposed to the community practice of cardiology, family practice, emergency medicine, internal medicine, pulmonology, orthopedic surgery, general surgery, and pediatrics. This gave me tremendous insight about medicine as a career. I had few illusions about what the "workaday life" of a physician was all about.
So after acceptance to medical school I was bouncing between cardiology and orthopedics. I wanted a specialty that would allow me to make a direct and immediate impact on patients and would allow me to care for patients of various ages and conditions. General surgery was somewhat a secondary concern until I started my third-year clinical rotations. I started with neurosurgery, perhaps the hardest rotation for students at the Medical College of Georgia. During that rotation I was taken under the wing of an intern who allowed me to place lines, taught me about TPN, and was the major force in getting me into general surgery. My fourth year was spent doing subinternships and away rotations in surgery.
My take on the future of surgical training is that the residency programs will have to extend the length of clinical training to six years due to the limitations placed on the programs by the 80-hour workweek. The residents probably aren't going to be able to get the case numbers they need.
As far as surgical practice, specialization will increase, this will be brought on by the increased popularity of fellowships, even though seventy percent already do. This will lead to what would be thought of as mutually exclusive events: surgeons becoming more specialized and more generalized. In the major metropolitan areas surgical care will become more specialist delivered while in rural areas more subspecialst care (especially endoscopy) will be delivered by general surgeons.
There will be a new subspecialist, the "emergency surgeon". This is already evolving from trauma/critical care surgeons in academic centers who are expanding their practice, and liking it. From the January 2004 Journal of Trauma:Trauma and Emergency Surgery: An Evolutionary Direction for Trauma Surgeons
Background : The success of nonoperative management of injuries has diminished the operative experience of trauma surgeons. To enhance operative experience, our trauma surgeons began caring for all general surgery emergencies. Our objective was to characterize and compare the experience of our trauma surgeons with that of our general surgeons.

Methods : We reviewed records to determine case diversity, complexity, time of operation, need for intensive care unit care, and payor mix for patients treated by the trauma and emergency surgery (TES) surgeons and elective practice general surgery (ELEC) surgeons over a 1-year period.

Results : TES and ELEC surgeons performed 253 +/- 83 and 234 +/- 40 operations per surgeon, respectively (p = 0.59). TES surgeons admitted more patients and performed more after-hours operations than their ELEC colleagues. Both groups had a mix of cases that was diverse and complex.

Conclusion : Combining the care of patients with trauma and general surgery emergencies resulted in a breadth and scope of practice for TES surgeons that compared well with that of ELEC surgeons.

So the community general surgeon will gradually fade away, due to diffusion of surgical subspecialists out of the large cities, and general surgeons who "self-specialize" in their own practices.
This site "So You Want to be a Surgeon" from the ACS is something that interested students may find helpful
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