Surgical specialties with good job prospects?

[JohnGrisham]

1 hour ago, Aurelius said:

I guess I just have a hard time understanding how there can be increasing demand for surgical services and an ageing population but nothing being done to address these needs. Do we just accept patients will forever have to deal with increasingly long wait times? I guess I had a small hope there'd be increased government funding or something to alleviate this problem.

Because the government only cares about cost-control.  Medicine is expensive to administer, and already takes up a large amount of the governmental $$$ pie.  Yes patients will continue to deal with long wait times, with incremental changes here and there with technological efficiencies etc.

 

[Neuro-phys]

Just in the two Midwest cities that I have lived in the US, I have seen a number of Canadian trained specialist surgeons (mainly ortho) working down here - mainly cause they can’t find appropriate work (even after fellowship) up north. They usually find work in academic places (which can sponsor or sign off on their visas) and which pay significantly less and are thus harder positions to fill with US trained orthos.
 

 

[Edict]

On 5/11/2020 at 3:02 PM, Aurelius said:

Maybe it's just me being naive as a pre-clerk, but shouldn't the job market theoretically improve? Canadians are getting older and will require more healthcare while there is already a physician shortage across Canada. Wait times for surgeries are quite long and almost every surgical association expects them to get longer. Wouldn't there come a point in time where jobs would have to be created just so patients get timely care? Also it seems a lot of surgeons are on the older side, for someone entering medical school now, is it naive to expect a large number of surgeons to retire 10 years down the road and jobs opening up?

The reality though is that theres always an oversupply because we overtrain and on top of that we have a lot of IMGs and others who are kind of waiting in the wings, ready to take a job if there comes an opportunity and so in reality, there will never be a real shortage. Most Canadian jobs pay well in the global scheme of things and academic centers are able to hire foreigners directly if they choose and theres a never ending supply of foreign talent willing to take those jobs. There will never be a shortage of surgeons unfortunately. 

Do a quick calculation and estimate the number of surgeons in any surgical specialty, divide that number by 30 and you estimate the # retiring each year add lets say 3-5% to that number to factor in population growth (1-2% per year) and aging. Compare that to the number of trainees entering both CMG + IMG. I can guarantee you the number of trainees will be higher even after you adjust for attrition. Then you need to factor in the number of foreign fellows (many of whom would love a job in Canada), foreign staff superstars (direct hires into Canada), IMG surgical assistants (may not currently be qualified but would in a pinch be ready) and government funded residents (some of whom would like to stay in Canada of which only a few find loopholes to do so) and you can quickly see that there will never be a shortage. At the end of the day, attendings like this because it keeps residents hungry and hungry residents do more work. 

I will put in a plug for US jobs though. I don't believe that all US jobs are worse. Many are good jobs that Canadians chose to go to over Canadian job offers as well. There are some great jobs in the US and some bad ones but all in all, I think we tend to unfairly negatively portray US jobs as all bad when in many cases they are actually better paid with better hours and/or more research funding etc. In certain specialties, US jobs are paid double with more vacation than Canadian jobs and many mid-career Canadian surgeons have even left cushy secure Canadian jobs for US ones. It really depends on the specific job and the specific specialty, but all in all I wouldn't say one is inferior to the other. 

[jnuts]

On 6/1/2020 at 6:14 PM, Edict said:

The reality though is that theres always an oversupply because we overtrain and on top of that we have a lot of IMGs and others who are kind of waiting in the wings, ready to take a job if there comes an opportunity and so in reality, there will never be a real shortage. Most Canadian jobs pay well in the global scheme of things and academic centers are able to hire foreigners directly if they choose and theres a never ending supply of foreign talent willing to take those jobs. There will never be a shortage of surgeons unfortunately. 

Do a quick calculation and estimate the number of surgeons in any surgical specialty, divide that number by 30 and you estimate the # retiring each year add lets say 3-5% to that number to factor in population growth (1-2% per year) and aging. Compare that to the number of trainees entering both CMG + IMG. I can guarantee you the number of trainees will be higher even after you adjust for attrition. Then you need to factor in the number of foreign fellows (many of whom would love a job in Canada), foreign staff superstars (direct hires into Canada), IMG surgical assistants (may not currently be qualified but would in a pinch be ready) and government funded residents (some of whom would like to stay in Canada of which only a few find loopholes to do so) and you can quickly see that there will never be a shortage. At the end of the day, attendings like this because it keeps residents hungry and hungry residents do more work. 

I will put in a plug for US jobs though. I don't believe that all US jobs are worse. Many are good jobs that Canadians chose to go to over Canadian job offers as well. There are some great jobs in the US and some bad ones but all in all, I think we tend to unfairly negatively portray US jobs as all bad when in many cases they are actually better paid with better hours and/or more research funding etc. In certain specialties, US jobs are paid double with more vacation than Canadian jobs and many mid-career Canadian surgeons have even left cushy secure Canadian jobs for US ones. It really depends on the specific job and the specific specialty, but all in all I wouldn't say one is inferior to the other. 

Agree with the above RE: US jobs (esp in ortho).  Even though academic jobs in the US are less desirable, they pay about the same as a standard Canadian position with the potential for more. Salaries go up by 30-100% in the community with underserved areas paying the high end.  Alternative revenue streams--e.g. surgical center co-ownership, stock and investment options--are also common. I had a conversation with one of my colleagues about leadership track positions and his honest answer was that income potential is equal or better as a surgeon so very few orthopods will bother. 

For anyone entering or considering orthopaedic training in Canada, my current advice is make sure you have an escape plan before you start and jump through the hoops in a time appropriate manner. I had to go back and do the USMLEs late in my residency and it wasn't fun. 

I think the US is reasonable, and increases to desirable if you have immigration rights (and can tolerate living here). 

Some food-for-thought about supply and demand below:

Supply-demand issues are complex and also need to anticipate changes in demand for the service.  The broad consensus in the US is that there is a massive under-supply of orthopods due to the predicted rising demographic demand for geriatric services (hips and knees mostly). I think it's common knowledge, but it bears repeating that elective procedures are revenue generators for hospitals in the US due to procedurally coded insurance reimbursement to hospitals. By contrast, in Canada funding for everything other than the surgeon and possibly the assist comes from the hospitals general fund.  Some alternative funding models exist for some procedures but there is usually capitation and efficiency incentivization which has the same effect as general budgeting. Though there are some cultural differences regarding willingness to undergo surgery, the demographics largely hold true in Canada as well as the US. The primary modulator of demand in Canada is the social willingness to fund surgical procedures filtered through the political lens. 

Access to the US training market is pretty similar to Canada and more Orthopods are trained in the US per capita. IMGs can/are trained more easily here as there is access for visa holders for training though specialty certification is limited to Americans and Canadians in the absence of a domestic residency in surgery.  But there's still a real labour shortage that's anticipated to worsen. Blaming over-training is oversimplifying the larger root cause analysis of over-educated underemployment for surgeons. 

That said, I've written darker posts about why Canada continues to train more surgeons than its willing to employ (not the same as what is needed) and advocated that Canada should decrease the number of trainees or take responsibility for finding other prospects for them.  I've advocated for an increased role for associated health professionals to pick up the gaps currently filled by residents. Certainly the comic disingenuousness of the ROS program needs to end. I'll still stand by most of those points.

However, I'd like to highlight the other side of the demand issue.  There's a market failure in Canada such that the demand for surgical services is moderated by the various governments.  Things could potentially change overnight due to political pressure or structural changes. That may be on the horizon, I don't really keep my finger on that pulse.   I do think the employment market will change in the future due to the underlying demographics but when that will happen is anyone's guess. 

There are lots of other odd things about the Canadian market especially in orthopaedics to factor in.  Average retirement age and work product efficiency jump to mind. All those factors need to be considered to get a real answer and predictive capability over the surgical labour market. 

[jnuts]

On 5/31/2020 at 10:33 AM, Neuro-phys said:

Just in the two Midwest cities that I have lived in the US, I have seen a number of Canadian trained specialist surgeons (mainly ortho) working down here - mainly cause they can’t find appropriate work (even after fellowship) up north. They usually find work in academic places (which can sponsor or sign off on their visas) and which pay significantly less and are thus harder positions to fill with US trained orthos.
 

 

Agreed.  It's not as though we're a significant part of the work force but it's not uncommon.  Permanent immigration status is key to getting out of academics. 

[Edict]

On 6/22/2019 at 7:56 AM, user123456 said:

I don’t mind going through all the academics (fellowship/msc/phd) and working very hard. Just as long as there is possibility at a GTA/Hamilton/Calg/Vancouver hospital

If you are among the best in your surgical cohort (i.e. you work harder than your other co-residents) and you get along well with people, this is possible. Otherwise its not. Just being willing to go through all the academics is not enough. Doing a PhD is not enough, you need to be very productive during it. 

I think the answer is that it is doable, but you should not expect that if you go through the motions you will get a job there.

Not sure if this is what you are thinking but... if you are hoping to be in a big city because you like city life, I would think again. The people who are in the big city, work so hard they don't enjoy the big city. So either way, you aren't enjoying city life.  

[blah1234]

6 minutes ago, Edict said:

If you are among the best in your surgical cohort (i.e. you work harder than your other co-residents) and you get along well with people, this is possible. Otherwise its not. Just being willing to go through all the academics is not enough. Doing a PhD is not enough, you need to be very productive during it. 

I think the answer is that it is doable, but you should not expect that if you go through the motions you will get a job there.

Not sure if this is what you are thinking but... if you are hoping to be in a big city because you like city life, I would think again. The people who are in the big city, work so hard they don't enjoy the big city. So either way, you aren't enjoying city life.  

I completely agree. Yea, the odds aren't great as you have to assume you can outwork other driven and capable residents. The other end of medicine is simply not as structured as the first part. Networking and luck can start to play a disproportionate role. You can be an amazing candidate on paper but there can often be another person that the hiring committee is fixated on because of intangibles, politics, etc.

[garlic]

 

On 12/29/2020 at 6:50 PM, Edict said:

If you are among the best in your surgical cohort (i.e. you work harder than your other co-residents) and you get along well with people, this is possible. Otherwise its not. Just being willing to go through all the academics is not enough. Doing a PhD is not enough, you need to be very productive during it. 

I think the answer is that it is doable, but you should not expect that if you go through the motions you will get a job there.

Not sure if this is what you are thinking but... if you are hoping to be in a big city because you like city life, I would think again. The people who are in the big city, work so hard they don't enjoy the big city. So either way, you aren't enjoying city life.  

100% this. It is simply not enough to work longer hours than everyone else, be smart, be technically capable, etc. There are reasons why people say to only do surgery if you cannot imagine doing anything else. The road is long and you'll pretty much consider quitting on the daily. Just met a colleague the other day who is on his third ortho fellowship, after being on literal opposite ends of the country for his previous fellowships.

Also consider whether there is a certain idealization of these big cities/large centers. The cases may be higher volume, more difficult, more acute, etc. but the work environment can definitely be a shark tank

[1D7]

Luck will be the deciding factor (with the prerequisite of being great and affable). Specialty choice is also a factor... I don't know the specifics but I imagine cardiac surgery is more limiting than orthopaedic surgery, which is more limited than general surgery.

[MK.]

The discussion revolved a lot around job prospect for surgeons in teaching hospitals in urban areas (mainly GTA), but is the situation the same in rural/suburb areas and elsewhere in Canada? Do rural/suburb hospitals also expect residents to go through the same academic hoops to consider hiring them? And does anyone have some insights on the matter in Quebec?

(M'bad for asking many questions at once, I also fall in the "element of naivety/ignorance" yet not a fan of using a sledgehammer to crack a nut).

[AB27]

On 12/29/2020 at 6:50 PM, Edict said:

If you are among the best in your surgical cohort (i.e. you work harder than your other co-residents) and you get along well with people, this is possible. Otherwise its not. Just being willing to go through all the academics is not enough. Doing a PhD is not enough, you need to be very productive during it. 

I think the answer is that it is doable, but you should not expect that if you go through the motions you will get a job there.

Not sure if this is what you are thinking but... if you are hoping to be in a big city because you like city life, I would think again. The people who are in the big city, work so hard they don't enjoy the big city. So either way, you aren't enjoying city life.  

So what do the mid-pack residents do? Keep doing fellowships until youre hired?

[indefatigable]

 

42 minutes ago, MK. said:

The discussion revolved a lot around job prospect for surgeons in teaching hospitals in urban areas (mainly GTA), but is the situation the same in rural/suburb areas and elsewhere in Canada? Do rural/suburb hospitals also expect residents to go through the same academic hoops to consider hiring them? And does anyone have some insights on the matter in Quebec?

(M'bad for asking many questions at once, I also fall in the "element of naivety/ignorance" yet not a fan of using a sledgehammer to crack a nut)

I think the job situation in Quebec has improved as a lot of programs had residency positions drastically cut - eg ortho, neurosurg..  (although they are much more competitive in Quebec than rest of Canada)

I’ve heard of multiple residents getting community jobs upon graduation.  

I believe that the French language is a moderate to strong barrier for non-francophones in surgery (Higher in medicine) which means supply of surgeons is almost Quebec dependent and therefore more controllable (outside of McGill).

i think the job situation, even in community, for the rest of Canada is more competitive which can mean extra training/fellowships.  Obs/gyn is an exception as one can get hired right after residency...  but others  may be able to give better insight 

[Edict]

On 5/14/2021 at 11:48 AM, AB27 said:

So what do the mid-pack residents do? Keep doing fellowships until youre hired?

Yes, depends on the specialty, some people do fellowships or clinical associate until they are hired, oftentimes waiting for someone to retire. Others will go to the US if the job market is good, some will go out more rurally and work there. Some may do a part of their specialty that pays less or has a better job market but may not be their true interest. 

In other circumstances some people even become surgical assistants, some go into research etc, but often times this is because they desire a specific location (spouse or preference) but don't have the skills/work ethic to make staff there. 

[Edict]

On 5/14/2021 at 11:41 AM, MK. said:

The discussion revolved a lot around job prospect for surgeons in teaching hospitals in urban areas (mainly GTA), but is the situation the same in rural/suburb areas and elsewhere in Canada? Do rural/suburb hospitals also expect residents to go through the same academic hoops to consider hiring them? And does anyone have some insights on the matter in Quebec?

(M'bad for asking many questions at once, I also fall in the "element of naivety/ignorance" yet not a fan of using a sledgehammer to crack a nut).

I think rural/community hospitals tend to hire based on clinical skills/networking/personality. Oftentimes, if you have good clinical skills that can be attested to by either established staff or you do a locum there, and people get along with you, you can get hired. Research essentially does not matter at all if the role they are hiring you for is a non-academic role. In Canada, efficiency matters in community hospitals, so being able to do things well in a timely fashion is also a plus. 

What this means is that you can definitely get a job without fellowship (if by the end of residency you are ready to take on a staff job). However, not everyone who graduates from residency truly feels ready to take on a staff job immediately and so some still will choose to do a fellowship first. 

[emulgent]

any update/changes on this as of 2023 into 2024. What's the market like for neuro, ortho now?

[shikimate]

our city has vacancy for 2 plastic sx but can't find anyone this year. Other than being a smaller place, our place gives them lots of OR, procedural room, and the plastic surgeons here make a fortune. 

[Edict]

The job market is not likely to get any better than it is now in surgery. The last of the boomer generation is retiring within the next 5 years. Unclear what this means for anyone considering entering training in the next few years, but as the population of Canada keeps growing, I imagine certain specialties will continue to be busy. 

Ortho job market is pretty decent right now, most people do 1-2 years of fellowship but most if not all find jobs. 

Neuro job market is pretty good as well, not as clear on the job market but a lot of neurosurgeons are choosing to work in the US as well. Some programs are hiring non-Canadians on staff in academic centers, which is a sign that job market is pretty good for Canadians (i.e. they are getting jobs they want).  

Biggest caveat in surgery is, no R1 is guaranteed a job, medical school does not prepare you to be a surgeon, so even when someone says the job market is good, it doesn't mean everyone who enters residency will be able to obtain a good job. Programs will hire international fellows into attending positions before they hire a local grad who they do not believe would make a good surgeon in their program. 

I recommend doing it if you want to and worry about the job market later. Nothing can predict the job market in 7 years when you finish. 

[hero147]

19 hours ago, Edict said:

The job market is not likely to get any better than it is now in surgery. The last of the boomer generation is retiring within the next 5 years. Unclear what this means for anyone considering entering training in the next few years, but as the population of Canada keeps growing, I imagine certain specialties will continue to be busy. 

Ortho job market is pretty decent right now, most people do 1-2 years of fellowship but most if not all find jobs. 

Neuro job market is pretty good as well, not as clear on the job market but a lot of neurosurgeons are choosing to work in the US as well. Some programs are hiring non-Canadians on staff in academic centers, which is a sign that job market is pretty good for Canadians (i.e. they are getting jobs they want).  

Biggest caveat in surgery is, no R1 is guaranteed a job, medical school does not prepare you to be a surgeon, so even when someone says the job market is good, it doesn't mean everyone who enters residency will be able to obtain a good job. Programs will hire international fellows into attending positions before they hire a local grad who they do not believe would make a good surgeon in their program. 

I recommend doing it if you want to and worry about the job market later. Nothing can predict the job market in 7 years when you finish. 

Keep in mind some non-Canadians can ONLY work in academic centers. So I don't know if I would call that a sign that the job market is pretty good for Canadians. The majority of Canadian grads want to do community from what I can see. 

Also requiring 2 fellowships to find a job in ortho sounds horrendous. I don't know if I would call that decent. 

[Edict]

21 hours ago, hero147 said:

Keep in mind some non-Canadians can ONLY work in academic centers. So I don't know if I would call that a sign that the job market is pretty good for Canadians. The majority of Canadian grads want to do community from what I can see. 

Also requiring 2 fellowships to find a job in ortho sounds horrendous. I don't know if I would call that decent. 

To each their own of course, but I did say that the job market is as good as it will get for a while. 

The surgical job market will never equal that of most other specialties because surgical jobs require a lot of resources like OR time and hospital facilities that are limited by government funding. On top of that there are many international fellows waiting in the wings to take a job, so even if we train fewer residents, it doesn't mean that the job market will open up. 

With that being said, to me, 2 years of fellowship versus 1 is no real difference. We never fault a student from taking a gap year, or a student from choosing a 4 year vs 3 year med school. One could argue a 2 year fellowship affords increased skills and potentially a better job, it is actually not a bad investment of time at all. 

I understand why people want to finish asap, especially if they are non-trad. However, the further you go out from school the more you realize that work is fluid and set structures are no longer a big deal. Other industries don't have these expectations like us, we don't really care if it takes a law associate 7 or 8 years to make partner, in fact we probably don't even know what the standard really is. It really is the same for residency/fellowship too. What I believe matters more is what you actually do day to day and whether or not you enjoy it, it really is the journey not the destination. 

[emulgent]

.

Edited November 20, 2023 by emulgent

[hero147]

14 hours ago, Edict said:

To each their own of course, but I did say that the job market is as good as it will get for a while. 

The surgical job market will never equal that of most other specialties because surgical jobs require a lot of resources like OR time and hospital facilities that are limited by government funding. On top of that there are many international fellows waiting in the wings to take a job, so even if we train fewer residents, it doesn't mean that the job market will open up. 

With that being said, to me, 2 years of fellowship versus 1 is no real difference. We never fault a student from taking a gap year, or a student from choosing a 4 year vs 3 year med school. One could argue a 2 year fellowship affords increased skills and potentially a better job, it is actually not a bad investment of time at all. 

I understand why people want to finish asap, especially if they are non-trad. However, the further you go out from school the more you realize that work is fluid and set structures are no longer a big deal. Other industries don't have these expectations like us, we don't really care if it takes a law associate 7 or 8 years to make partner, in fact we probably don't even know what the standard really is. It really is the same for residency/fellowship too. What I believe matters more is what you actually do day to day and whether or not you enjoy it, it really is the journey not the destination. 

A year is not a big deal in the grand scheme of things 100%. But financially it is a gigantic hit that people don't think about. It's also the reason why I don't think medicine is as fluid as you make it out to be. Some 7-9th year law associates have been known to get a pay cut when they become a 1st year partner. The difference in income is miniscule. The difference between a first year staff and a final year resident/fellow is massive. Almost 10 fold in extreme cases. 

Medicine also seems to be one of those fields where attendingship supercedes all in terms of chain of command. Residents and fellows can often work for people with less clinical experience than them for a fraction of the pay. 

[emulgent]

@jnuts could you comment on the lifestyle of attending ortho physicians within Canada to your knowledge. What are typical hours?