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how competitive of a residency is surgery?


Guest justanotherpremed

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Guest UWOMED2005

Thing with spearheading these kind of therapies is that we have absolutely ZERO clue whether they will work, or at least be supported by RCT.

 

That's the problem with doing most B Sc programs before meds. There, they try to teach you to use your brain to figure out if something would work.

 

In medicine, you've got learn to stop using your brain. I'm actually somewhat serious with that comment. Medicine is all about using what has been shown to work, not trying stuff that would make sense if it works.* There's been tons of things in medicine that have sounded good in theory but in reality killed people. And the consequences of experimental surgery are high: these are people's lives you are playing with, and often the status quo is better than the consequences. If you tell a doc in clerkship "we should do a stem cell transplantation" for a 90 yr old with a Parkinson's, you'll get laughed out of the Hospital.

 

I bring this up only because I've been guilty of it myself: using my knowledge to try and figure out what would medically make sense, only to get burned. It's not that medical therapies don't make sense, but when you try too hard to build from the ground up you often miss some minor detail that blows the conclusion apart.

 

BTW - how much off-service vs onservice residents gets varies a lot on the program: both in terms of specialty and location. I'm pretty sure UWO medicine residents ONLY do medicine, but rotate through the various services (nephro, gastro, cardio, etc.) I think Surgeons stick mostly to Surgical rotations (orhto, cardiac, general) but have to do at least one medicine rotation in PGY-1. I remember chatting with one of the PGY-1 gen surg guys who I believe did surgical consults in Sept to fulfill his medicine requirement. . . cracked can obviously correct me. As well, surgery residents will often have to fill off-service call - we had a PGY-3 neurosurg resident covering our CTU (ie Internal Medicine) floor back in October.

 

 

*Too bad, personally wish it was about trying new things. . . more interesting than trying the same old stuff that only works somewhat.

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Guest therealcrackers

Most of the services have mandatory off-service rotations in the first two years. Why? LMCC part 2... you have to demonstrate general competency in medicine to get your license.

 

I'm on OB right now (well, until tomorrow), and the new PGY-1 has just STARTED her on-service rotation, after 3 months of medicine and 3 months of surgery. She has 3 months of OB, then 1 month of NICU, and 1 month of ER and an elective.

 

Most of the surgery residents do 3 months on medicine; most of the medicine residents do 1-2 months on surgery. Just about everyone rotates through the ER at least once, the more interventional specialities (surgery, OB, medicine, etc.) have rotations in PGY-2 that take then through the ICU for a month or two. A lot will also cover radiology, outpatient clinics, etc. because you have to be generally competent around the time of your exam in the fall of PGY-2.

 

So anyone thinking surgery is competitive because of all the people who never want to do team medicine or radiology or ER again in any form is a little out of touch. At the same time, it helps to have someone going into say, gastroenterology, who knows what kind of surgical resection their patient might get if that nasty polyp in different parts of the colon turns out to be malignant. Cross-training (at least at the initial stages) is a good thing.

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Guest justanotherpremed

Can someone explain the precise differences between these?

 

thoracic = the esophagus, and lungs basically

 

here's the confusion, is it...

 

vascular - surgeon of the blood vessels? so If you were doing stents, etc, would that be done by a vascular surgeon? If you were relocating vessels from the leg, to another site.. due to a damage artery, would that be done by a vascular surgeon or a cardiac surgeon?

 

cardiac - surgeon of the heart? So this person only deals with the coronary arteries? coronary bypasses?

 

Thanks

:hat :smokin

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Guest Kirsteen

Hi there,

 

Judging by your number of surgically-related questions, it sounds like you have passion enough to invest in a textbook in the area. ;)

 

I'll tackle the vascular surgery bit, as I know at least a bit about it and its relation to stenting (given that I recently completed a study in the area). Yes, vascular surgeons deal in blood vessels. Although they can and do perform stenting procedures, an increasing number of these are performed by interventional cardiologists. (By the way, cardiologists are not typically categorized as surgeons, but as physician-internists.) Vascular surgeons would also do vessel relocation work, although I'm not sure if they tackle all CABGs (coronary artery bypass grafts) or leave some of them to cardiac surgeons. I'd guess the former.

 

Cardiac valve pathologies are one set of conditions that, if operated on, would fall more firmly into the realm of cardiac surgeons, but not vascular surgeons. A vascular surgeon generally would not touch a valve replacement procedure.

 

Do you mind if I ask from where your big interest in surgery comes?

 

Cheers,

Kirsteen

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Guest marbledust

therealcrackers:

I only mentioned that there was another option to the direct entry 6-year cardiac surgery program - which is general surgery plus 3 years. Yes, most places in cardiac surgery are for the 6 year program - but theoretically one could take a much longer route through general surgery (and at least 2 programs are 6 years long = 9 years in total). Maybe not common, but certainly possible.

:hat

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Guest justanotherpremed

that's a tough question to answer.... in terms of pinpointing exactly when I became interested in something. I mean, can you pinpoint the one thing that made you be interested in a career as a physician? Personally, it all blurs together for me. Probably a cumulation of a bunch of independant factors (my undergrad major, recent talks I have attended, books I have read).

 

:hat :smokin

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Guest Ian Wong

The difficulty with trying to pigeon-hole which specialty does what, is that the boundaries are constantly changing and evolving. Licensure to perform a particular surgery isn't necessary limited to the specialty you graduated from, but is also tied into whether you can prove competency (through case logs) of experience in a particular procedure.

 

In other words, one vascular surgeon who has received the appropriate training in endovascular procedures during fellowship may be doing angioplasties and stenting at a given hospital. In contrast, a vascular surgeon who trained say 25 years ago when those procedures weren't widespread, and hasn't participated in these procedures since, would likely not be credentialled to do so.

 

Currently, (and I may be off on this), thoracic surgeons deal primarily with the mediastinum and the lungs. The mediastinum being that middle area of your chest between your two lungs (the heart sits in the mediastinum, but there's lots of other stuff in there as well). Lots of lung cancer, esophageal cancer, and other mediastinal tumours and anomalies.

 

Cardiac surgeons are primarily concerned with the heart, mainly CABG's, valvular repair, and septal defect repairs. Pediatric cardiac surgeons work with all the different congenital heart problems. There's more than enough cardiac work out there that they really don't need to go outside that anatomic region, although many of the older cardiac surgeons may also/were trained to do both thoracic and vascular surgery as well as cardiac surgery.

 

Vascular surgeons handle peripheral vascular work. Carotid endarterectomies, aortic aneurysm repairs, peripheral bypasses, that sort of thing. There is more than enough peripheral work for them without needing to go after the heart. Vascular fellowships are incorporating endovascular techniques now, and will therefore be entering the fray of catheter-driven therapies along with the interventional cardiologists and interventional radiologists.

 

You can toss in the interventional cardiologists as endovascular folks who make the majority of their money off diagnostic angiography of the coronaries, often followed by therapeutic angioplastic of any blockages. The next realm of therapy that may go endovascular is the placement of cardiac valves. Interventional cardiologists are also moving into areas outside the heart, and may do angioplasty and stenting of peripheral lesions in the renal arteries or carotids (carotid stenting).

 

The final group of interventional radiologists primarily do peripheral vascular procedures. Carotids, renals, vascular dialysis blockages, PICC lines, are all in the domain of the interventional radiologists. Radiologists may also do non-vascular work; including placement of feeding tubes (ie. G-tubes), percutaneous abscess drainage, ultrasound or CT-guided biopsies, etc. Other interventional radiologists may undergo additional train to do cerebral vascular work, the neurointerventional radiologist.

 

As far as discussing the motivations for going into medicine, might I suggest starting a separate thread in the General Premed forum? I think the topic has been covered there numerous times in the past, and it may be well worth browsing through the archived old posts.

 

Ian

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Guest UWOMED2005

Isn't amazing you can spend so many years (ie up to 10) years of your life training for something only to find the job you trained for no long exists?

 

ie we could (very hypothetically) be seeing this with Coronary Artery Bypass Grafting (CABG) and cardiac surgery. With advances in stenting/angioplasty, it's fairly conceivable CABG could become relatively obsolete 10 years from now (once again, very hypothetical example.) Hasn't that been the bread and butter of Cardiac Surgery the last ten years? In the meantime, if I decided I loved CABG I could spend years training in Cardiac surgery only to have that area dry up. That's actually one of the reasons a friend of mine is shooting for gen surg as opposed to cardiac.

 

Of course there'd still be valvuloplasty to get involved with, plus any new advances that cropped up in the next ten years. . .

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Guest cracked30

Unfortunately I think it's more likely that the infection hypothesis of CAD will turn out to be true and both specialties will be out of work.

 

Besides, you may not know this, angioplasty has some pretty terible complications. More than once I have seen them rupture the coronary arteries causing tamponade and death.

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Guest justanotherpremed

need some background information: what does CAD stand for - coronary artery disease?? if so, what does this hypothesis state and what are its implications for the aforementioned specialties?

 

:hat :smokin

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It used to be thought that atherosclerosis, or "hardened arteries" were simply a matter of excess fat clogging your arteries. Now it is basically thought to be the result of inflammatory processes. But what sets off the inflammatory process in the first place? In some atherosclerotic plaques, bacteria like chlamydia have been found, so some researchers have hypothesized that an infection starts the inflammatory processes that lead to atherosclerosis and coronary artery disease.

 

(Can you tell I'm procrastinating from studying for my CV exam?;) )

 

So if the root cause of CAD is infection, and we already have good ways of dealing with infections, we can take care of the root cause and put the PCI and CABG folks out of business, right?

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Guest UWOMED2005

Sounds a lot like theory surrounding duodenal and gastric ulcers. Ten, maybe 15 years ago it was thought these were caused by 'stress,' alcohol, coffee, and spicy food. Then in the early to mid 90s someone found that a species of bacteria, Helicobacter Pylori could be implicated in a great number of ulcers, and antibiotics (actually, usually a combination of antibiotics and stomach acid lowering medications, such as amoxicillin + biaxin/clarithromycin + Pantoloc/Pantoprozole) became key to treating ulcers.

 

It would be rather remarkable if an antibiotic (doxicycline or tetracycline for chlamydia) could be used to treat atherosclerosis. Then again, as we've seen with peptic ulcers, things aren't usually that simple. . . not all ulcers can be attributed to H. Pylori and antibiotics aren't always curative.

 

The only way to resolve this academic stuff in medicine is TIME. It will be fascinating to see what develops over the next ten to fifteen years in this area (heck, for all we know, ten years from now we might find out atherosclerosis in fact can be reversed by chewing double bubble) but this definitely demonstrates how advances in knowledge/medical technology can have huge impacts on careers in surgery, not to mention medicine in general.

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Guest Ian Wong

It would be so convenient if the solution were that simple. Still, we've never been able to find a convenient one-shot cure-all for any disease, particularly one as prevalent as CAD. Despite enormous investments in research, people still die of cancer, AIDS-related complications, heart attacks, strokes, pneumonia, everything else. Heck, like Chris Rock once said in a monologue, we can't even cure Athlete's Foot!

 

I'll be the first one cheering if they discover that athero can be prevented by treating for infectious agents and avoiding the resultant inflammatory response. But I wouldn't go around worrying if I were a cardiologist thinking I might go out of business; there are enough diabetic, hypertensive, obese, sedentary individuals out there, particularly in North America, that treating vascular diseases and their complications will go on beyond our lifetime.

 

Ian

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Guest UWOMED2005

And in terms of the cardiac surgery, they could always do what my friend's dad did when he got burnt out from 20 years of 80 hr weeks and delivering bad news to patient's families.

 

They could go into hair transplant surgery. :D

 

Great hours and very lucrative - apparently my friend's dad gave himself an Xmas bonus of $1 million a couple years back. Not to mention partient appreciation. . . apparently he finds the hair transplant patients MORE grateful for his services than the general surgery patients whose lives he saved!! :eek

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Guest justanotherpremed

what about ophthalmology..... i think cataract removal would be very rewarding.... the patients need it ( i don't think there are any non-surgical methods to get rid of a cataract ).... and there is a very high success rate... what else would an ophthalmologist do? if you wanted to , could you just do cataract removals all day every day? can you just do it in an office, or do you need an o.r.? i've been told the surgery only takes 20-30 minutes :hat :smokin

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Guest UWOMED2005

Yeah, theoretically an ophthalmologist could get into cataract surgery only and make a killing. I think the record at UWO is 4 minutes for the procedure, my understanding is that some of the ophtho guys book the procedures 10 or 15 minutes apart (you can't keep up 4 minutes/operation for the whole day!)

 

Problem is, you still need ophthalmologist to do assessments of macular generation, diabetes checkups, correct strabismus in kids and deal with some of the rarer stuff. If every ophthalmologist practiced by the pocket book, there'd be nobody left over to do these consults! My understanding is that the London ophthalmologists have as a group worked out some system of revenue sharing to make sure the guys who enjoy less lucrative aspects of the field such as neuro-ophthalmology don't go broke, and the guys who enjoy cataract surgery don't have to spend as much time doing consults they're not as interested in.

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Guest warpath5

cracked30,

I don't know about Canada, but in the States, laparoscopy is also a specialty in urology (usually combined with endourology). In fact a lot of the advances in laparoscopic surgery these days are coming for urology. The Urology Division at my school has and endourology fellowship, and they do laparoscopic partial and radical nephrectomies, pyeloplasties, pyelotomies,prostatectomies, etc.The guy I did research with only does laparoscopic and endourological procedures.

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