Help me pick my specialty (surgical and tech savvy)

[bruh]

After 2 years of medical school, I have finally narrowed down my interest to a surgical specialty, and one that uses cool tech. Last week, I scrubbed in for a TLIF spine surgery with the Stryker protocol. It was the most exciting day of medical school for me. It was like a video game - they had the entire vertebral column mapped onto a 3D CT scan and the software would navigate the surgeon in screw placements by using the landmarks on the monitor. When the surgeon landmarked the wrong spots he'd get a red X and when he'd get the right spots he would get the green checkmark. Then he put the screws in a specific part of the lamina of the vertebrae using the 3D map.

My mind was blown, and I realized that I would enjoy doing this for the rest of my life. I felt a sense of comfort too because I know I would be good at that kind of surgery. Now my question is, where does this lead me to? This was an ortho spine surgeon, so I am assuming ortho is tech heavy? Are there other operations that use cool stuff? I shadowed some joint replacement surgeries but didn't see any virtual tools.

I have heard that vascular surgery, neurosurgery, and cardiac surgery are also very tech savvy. But I cannot imagine doing 7+ years of residency and dealing with bad outcomes and unhappy patients for the rest of my life. So, can someone help me find a specialty that is tech heavy but also not for the complete masochist?

[offmychestplease]

Ortho is 8-10 years after medical school which consists of residency + at least 2 fellowships +/- a graduate degree and then running around praying for a part-time locum position literally anywhere as it has the worst job prospects in all of medicine. The other fields you listed like Vascular, NSx, and CSx are also an 8-10 year commitment (with added pressure to get a PhD along the way) with not much better job prospects. 

Urology has better job prospects than these 4 fields as you can do outpatient clinical work if you aren't getting enough OR time (a job). They also do cool robotic surgeries and you can get away with 7 years of residency (residency and one fellowship, no grad degree) instead of 8-10. 

[bruh]

13 minutes ago, offmychestplease said:

Ortho is 8-10 years after medical school which consists of residency + at least 2 fellowships +/- a graduate degree and then running around praying for a part-time locum position literally anywhere as it has the worst job prospects in all of medicine. The other fields you listed like Vascular, NSx, and CSx are also an 8-10 year commitment with not much better job prospects. 

Urology has better job prospects than these 4 fields as you can do outpatient work if you aren't getting enough OR time (a job). They also do cool robotic surgeries and you can get away with 7 years of residency (residency and one fellowship, no grad degree) instead of 8-10. 

Even with 2 fellowships, Ortho would be 7 years. I know many ortho surgeons who did not do 8-10 years of residency. Also, I am doing the USMLEs this summer to prepare for possible move to the US for fellowships/jobs. So, I don't think it'll be as bad as you've painted it. Vascular, NSx, and CSx are pretty much gauranteed 8-10 years, however.

I'll check out urology. I think it's a great specialty. I just don't know if I want to be a penis doctor for the rest of my life haha. 

[offmychestplease]

Some ortho fellowships are 2 years. Plus, I said "at least." There are many new grads doing either 3 fellowships or more commonly 2 fellowships and a MSc/PhD and as you can see that easily puts you in the 8-10 year mark. And you have to also be ok with the job prospects (are you ok with part-time locums anywhere in the country after this extensive training length?). I do not know much about how ortho training translates over to the US so someone can correct me here but I think Canadians can only qualify for certain jobs in the US due to their Visa status? 

If you want the cool robotic surgeries + half decent job prospects + slightly shorter training length I don't think anything in medicine fits the bill better for you than urology. 

[Aetherus]

Depends what type of surgery you are interested in, but Ophthalmology is by far the most tech heavy field in Medicine. Tech is everywhere, both in Surgery and in clinic.

[premed72]

I hear urology has alot of innovative tech 

[ChemPetE]

Re Aetherus:

Point of order, surgery (and certainly opthalmology) is tech heavy, but I would still argue rad onc is tech heaviest. I know when they built McGill’s new hospital the most expensive piece of equipment was their Cyberknife machine. People don’t know we exist or what we do, but a linear accelerator vault equipped to radiosurgery spec (eg sub mm precision) is something to behold.

That being said, the tech in medicine in general is super cool, and I love learning about other specialty’s use of modern equipment.

[Snowmen]

For spine surgery, remember that all their surgeries pretty much end up being the same.

1) Get to the spine

2) Remove bits of spine

3) Add bits of metal

4) Suture over spine

The novelty factor wears off extremely quickly, especially at 11 am (when you've been awake for 29 hours like I have at times).

[bruh]

Just now, Snowmen said:

For spine surgery, remember that all their surgeries pretty much end up being the same.

1) Get to the spine

2) Remove bits of spine

3) Add bits of metal

4) Suture over spine

The novelty factor wears off extremely quickly, especially at 11 am (when you've been awake for 29 hours like I have at times).

That's most specialties anyways. ENT, Ophtho, Urology all work on the same organ. Other ortho specialties are even more repetitive, like arthroplasty and foot/ankle.

NSx and Plastics have more variety, however. 

[Aetherus]

3 hours ago, ChemPetE said:

Re Aetherus:

Point of order, surgery (and certainly opthalmology) is tech heavy, but I would still argue rad onc is tech heaviest. I know when they built McGill’s new hospital the most expensive piece of equipment was their Cyberknife machine. People don’t know we exist or what we do, but a linear accelerator vault equipped to radiosurgery spec (eg sub mm precision) is something to behold.

That being said, the tech in medicine in general is super cool, and I love learning about other specialty’s use of modern equipment.

Hard to compare tech between specialities but I can lay out a few really cool things in Ophthalmology and people can decide for themselves:

- Bionic Eye (Argus II) (https://secondsight.com/discover-argus/). Pretty much a microchip that is implanted that gives people back their sight.

- 3D Screen for operating (https://professional.myalcon.com/vitreoretinal-surgery/visualization/ngenuity-3d-system/)

- Surgical Robot (https://www.preceyes.nl)

- Intraoperative Optical Coherence Tomography (https://pubmed.ncbi.nlm.nih.gov/31240975/). Allows live time visualization up to a few microns in definition.

- So many different types of Lasers (Refractive surgery, Glaucoma, Retina lasers etc).

- Cataract Surgery and multifocal lenses.

I could keep going but many of the other tech is a bit esoteric but still very interesting.

[hamsterman11]

21 minutes ago, Aetherus said:

Hard to compare tech between specialities but I can lay out a few really cool things in Ophthalmology and people can decide for themselves:

- Bionic Eye (Argus II) (https://secondsight.com/discover-argus/). Pretty much a microchip that is implanted that gives people back their sight.

- 3D Screen for operating (https://professional.myalcon.com/vitreoretinal-surgery/visualization/ngenuity-3d-system/)

- Surgical Robot (https://www.preceyes.nl)

- Intraoperative Optical Coherence Tomography (https://pubmed.ncbi.nlm.nih.gov/31240975/). Allows live time visualization up to a few microns in definition.

- So many different types of Lasers (Refractive surgery, Glaucoma, Retina lasers etc).

- Cataract Surgery and multifocal lenses.

I could keep going but many of the other tech is a bit esoteric but still very interesting.

Thank you for linking these, never knew they existed! It looks dope 

[Sauna]

I was on the same boat as you in med school. Here is some of the cool Rad Onc tech that got me excited about the field.

Cool video showcasing modern rad onc treatments:

 

Cyberknife: 

Gamma Knife:

MRI-Linac:

 

SABR

Brachytherapy

 

[shikimate]

Call me a party pooper, but you sure you can keep up this level of enthusiasm 10+ years into your career?

I'd pick something where you feel pretty comfy doing the regular cases and get paid reasonably well for it. Something 10+ into your career you'll still be willing to go into the OR, do it, and feel good afterwards.

[rmorelan]

On 12/7/2021 at 9:43 AM, Aetherus said:

Depends what type of surgery you are interested in, but Ophthalmology is by far the most tech heavy field in Medicine. Tech is everywhere, both in Surgery and in clinic.

as a radiologist I am not sure I agree with the by far most tech heavy title there  I will just go back to developing AI for my 5 million dollar superconducting magnets. 

("my machines!")

Edited December 9, 2021 by rmorelan

[rmorelan]

On 12/7/2021 at 9:55 PM, Sauna said:

I was on the same boat as you in med school. Here is some of the cool Rad Onc tech that got me excited about the field.

Cool video showcasing modern rad onc treatments:

 

Cyberknife: 

Gamma Knife:

MRI-Linac:

 

SABR

Brachytherapy

 

not to sound like I am always plugging radiology but some of that is also done by radiology - after all we are the ones that do the biopsies by US/CT/MRI so we already are the experts on putting a needle exactly where we want it to go. One of the fun things in radiology is destroying directly tumours ha. 

Rad onc does some pretty cool things. It was my number 2 in CARMS. 

 

 

 

Edited December 9, 2021 by rmorelan

[ChemPetE]

Absolutely, there is a lot of crossover. Right now listening to dept rounds on state of the art MRI guided RT with AI adaptive autocontouring. Definitely a lot of room for AI to improve care and workflows in both of our fields. And would agree with you on needle placements, haha

Honestly at the end of the day, there is a lot of cross over tech, and lot of innovation done in many areas, which is to the benefit of our patients. Yay medicine!

[thestar10]

Rad Onc is surgery without the hard residency and hard lifestyle (imo). Cool tech AND i get to see my kids on a regular basis AND i sleep uniterupted each night.

Also, Only Rad Oncs will get this but my god the first video makes monaco look like an incredible piece of software instead of the garbage it is.

On 12/7/2021 at 9:55 PM, Sauna said:

I was on the same boat as you in med school. Here is some of the cool Rad Onc tech that got me excited about the field.

Cool video showcasing modern rad onc treatments:

 

Cyberknife: 

Gamma Knife:

MRI-Linac:

 

SABR

Brachytherapy

 

 

[zoxy]

This is a digression, but the pervading wisdom seems to be that RadOnc is dying due to pharmaceutical advances in med-onc and an oversupply of trainees relative to jobs. That's why it never filled between 2010-2017ish and there were years when 30 percent of the spots went unfilled. However, I was speaking to a RadOnc family friend a year ago who said that Rad-Onc's demise had been greatly exaggerated and the job market has gotten much better recently. I was wondering how much truth there is to his statements.

 

 

[Sauna]

19 hours ago, zoxy said:

This is a digression, but the pervading wisdom seems to be that RadOnc is dying due to pharmaceutical advances in med-onc and an oversupply of trainees relative to jobs. That's why it never filled between 2010-2017ish and there were years when 30 percent of the spots went unfilled. However, I was speaking to a RadOnc family friend a year ago who said that Rad-Onc's demise had been greatly exaggerated and the job market has gotten much better recently. I was wondering how much truth there is to his statements.

 

 

Quite the opposite actually! The advances in med onc such as immunotherapy, targeted therapy, and hormonal therapy are driving patients back to rad onc. There are many cancer sites (ie breast, prostate) that are becoming more of a chronic disease and as these patients live longer they develop more mets (bone, liver, brain, etc.) that are resistant to systemic treatment and require radiotherapy or SBRT. 

Every specialty in cancer care has its limitations and that's why we work together to provide patients with the best outcomes. You'll find very few cancers that are treated with systemic therapy alone, and those are mainly liquid. This is because chemo/systemic therapy won't help you much if a solid tumour remodels it's extracellular matrix and blocks off all the drug with walls of collagen/glycoproteins, or if the cancer creates an endless maze of vasculature surrounding and within the tumour that all the drug diffuses out before reaching all of its targets, or if the cancer metastasizes to the brain and your drug can't cross the BBB, etc. you get the point. You need local treatment at some point whether that's surgery or radiation (or both). 

As for the competitiveness of Rad Onc in CaRMs, it's a mix of poor job market + popularity. Not many med students (let alone residents/attendings) know much about the speciality, and out of those who discover it, some are turned away by the job market. The job market problem has been (and is being) addressed and actually looks very promising. We've kept the number of residency spots the same for the past decade to avoid over-saturating the job market, and the most recent data from CARO 2021 actually looks pretty good. Almost everyone has gotten a job and it's projected to continue improving for at least the next 5 years and even reach a point where demand > supply. There is talk of actually increasing residency spots again to prepare for this. 

 

[ChemPetE]

23 hours ago, Sauna said:

Quite the opposite actually! The advances in med onc such as immunotherapy, targeted therapy, and hormonal therapy are driving patients back to rad onc. There are many cancer sites (ie breast, prostate) that are becoming more of a chronic disease and as these patients live longer they develop more mets (bone, liver, brain, etc.) that are resistant to systemic treatment and require radiotherapy or SBRT. 

Every specialty in cancer care has its limitations and that's why we work together to provide patients with the best outcomes. You'll find very few cancers that are treated with systemic therapy alone, and those are mainly liquid. This is because chemo/systemic therapy won't help you much if a solid tumour remodels it's extracellular matrix and blocks off all the drug with walls of collagen/glycoproteins, or if the cancer creates an endless maze of vasculature surrounding and within the tumour that all the drug diffuses out before reaching all of its targets, or if the cancer metastasizes to the brain and your drug can't cross the BBB, etc. you get the point. You need local treatment at some point whether that's surgery or radiation (or both). 

As for the competitiveness of Rad Onc in CaRMs, it's a mix of poor job market + popularity. Not many med students (let alone residents/attendings) know much about the speciality, and out of those who discover it, some are turned away by the job market. The job market problem has been (and is being) addressed and actually looks very promising. We've kept the number of residency spots the same for the past decade to avoid over-saturating the job market, and the most recent data from CARO 2021 actually looks pretty good. Almost everyone has gotten a job and it's projected to continue improving for at least the next 5 years and even reach a point where demand > supply. There is talk of actually increasing residency spots again to prepare for this. 

I would echo this. There are a LOT of expected retirements, along with expected increase in incidence of cancer with aging demographics, and prevalence of cancer with more effective systemic agents. I have seen the shift in the job market only improve since I was a med student with my own eyes.
 

US is in the opposite position where despite the former, there has been incentive to fractionate a lot and their workforce models depend on that. However, they are only now being incentivized to adopt hypofractionation with bundled payments, and they have been ++overtraining whereas in Canada we contracted training spots and resisted transfers for at least a decade. US rad onc workforce is heading to a worse spot to where Canada was (for longer; people will ‘find’ jobs in the US but they will be really underpayed and very crappy ones), but in Canada the job market has been better managed due to the previous problems so the market forces affecting the US don’t apply here. It is very hard even for accomplishes US physicians to find employment in Canada if you’re not a citizen or PR, with the exception maybe Toronto academics. So keep that in mind anything on SDN on rad onc job market doesn’t apply to Canada

 

http://www.caro-acro.ca/wp-content/uploads/2020/07/CARO-Human-Resources-Report-2019.pdf

Not the most recent version that exists but the one I can find the quickest while I sip my coffee before I head to work: