Tuesday, October 1, 2013

A UK Med Student Discovers Surgery, Has Questions

Gareth (not his real name) writes

I came across your blog a few days ago and I have been reading it since. I am a third year medical student studying in the UK. I am writing to you because I would be grateful if I could get some advice. I have always wanted to become a doctor, since I was veryyyyy young, but I never ever considered a career in surgery. Before medical school, I believed that surgeons were like butchers, not capable of any human attachment for the patient etc etc. I believed I would not be able to bear the responsibility to cut someone open given the fact that I am a very emotional person. However, my perspective changed when I was in the OR and saw my first surgery. It was a coronary bypass surgery and I loved it, I loved the idea of making the patient better in such short time and the fact that the surgeon was the one responsible for it, I suppose it must be very satisfying. Therefore, I have started to consider a career in surgery, however, I am still very unsure of whether I have the right personality type and skills to become a surgeon. I still tend to get very attached and moved by patients' stories and experiences and I don't know whether that would help me detach myself from the patient whilst operating. Also, most surgeons seem to be extremely confident and outgoing whereas I tend to be shy and not confident, even though I'm quite good academically. So I am really confused right now. Also, I have never had great hand skills, even though I took some introductory surgical skills courses and they went quite well. I seem to get a bit of tremor when I do practical stuff though, I guess that's because I get nervous. 

I'd like to ask you one more thing. If I do decide to go for a career in surgery, is there any point for me to try and take the USMLE and apply for a US residency after graduation? I heard surgery it's really competitive, I guess many schools don't even accept international applicants?

Thank you very much for your time and dedication. I admire the passion that you show.

Thank you for reading my blog and for writing. I am glad that you have realized what a rewarding career surgery can be.

First let's talk about the "surgical personality." There was a time when most surgeons could have been categorized into a couple of personality types. Those days are gone. Now that 40% of all surgical residents are women it is no longer necessary to be a certain type of individual. I know many surgeons who are quiet, thoughtful and introspective. You need to dismiss any thoughts about your personality type being incompatible with a career in surgery. Also it is not a bad thing for a surgeon to identify with and become attached to his patients.

The next myth is that one must have great dexterity to become a surgeon. In the old days some residency programs use to screen applicants by making them build model airplanes. I don't believe anyone still does that. Now it seems that video game skills are much more important since so many procedures are done laparoscopically. I believe that anyone can become a more than decent technical surgeon through practice. We all get nervous. This is a real person you are operating on. I have written that there is more to surgery than manual skills. It is very important to know who to operate on and when to operate on them as well as who not to operate on.

I have written before about the decreasing chances of graduates from non-US medical schools obtaining residencies in the United States. US medical schools are expanding their class sizes and a new schools are opening. It is not even clear that all us graduates will be able to obtain residency positions in the future. The most recent statistics from the match show that only about 5% of non-US citizen graduates of foreign schools matched into categorical general surgery positions. However, I do not believe you have anything to lose by trying. You will need to get an excellent score on the USMLE and of course, have good grades and recommendations. Although it is difficult, some trainees from the UK have been able to find fellowships in the US. I do not know how easy that will be in the next few years.

Good luck


  1. Gareth needs to get good dexterity eventually. The sooner, the better.

    Residents with good technical skills get to do more cases, and bigger cases, sooner. The rich get richer and the poor get poorer.

    It would be highly advisable for a person in Gareth's situation to buy a pair of loupes, and sew, sew, sew, while wearing them. Surgi-tel is easier on the neck. I found that strategy invaluable as a resident. (Should have done it earlier than I did.) The attending will not let you do the carotid endarterectomy or the Whipple unless you have ZERO tremor. Hours of sewing, while wearing loupes, will cut your tremor down to zero. (Use LONG instruments -- challenge yourself. Tying 50,000 one-handed and two-handed knots, and finding a good surgical mentor, are also essential. Persistence pays.)

    Fabrics, thread, "eye" needles, etc., can be used to create a dry lab for suturing that costs pennies, and that leaves a resident/med student independent of the largesse of the scrub nurses. One can make endless, sham, vascular and bowel anastomoses, etc. Years into surgical practice, I still do a little of this if I have a big case coming up.

    Yes we do a lot laparoscopically, but open skills are important also. When an open procedure -- or a conversion to an open procedure -- is indicated, good technical skills will calm the silly nerves.

    Regarding anxiety, the best cure is "facing one's fear." Years of med school and residency will slowly get rid of nervousness and anxiety.

    1. Very well said. I have nothing to add. Practice.

  2. http://www.ncbi.nlm.nih.gov/pubmed/17309970

    I don't know a lot of "outgoing" skills in this "surgical career prep" activity.

    1. Anon, I agree. Playing video games tends to be associated with a dark room and talking to virtual friends on line. That link is one of a number of papers that equate moving inanimate objects around with laparoscopic instruments and skill as a surgeon. I am not sure that is a valid assumption, but many people believe it.

  3. Not sure if "Gareth" will be reading the comments, but I thought I'd share my experience.

    I had not considered surgery as a potential career either. When I started medical school, I was thinking about family medicine, emergency medicine, or possibly neurology (my undergrad was in neuroscience.) I too thought there was a "surgical type", and I didn't seem to fit the stereotype. The guys in my class who talked from day one about becoming surgeons (and they were all guys) were nice enough - I certainly didn't think them "not capable of any human attachment" - but they were mostly louder and brasher and more outgoing than I was.

    When it came time to pick our clerkship "track", i.e. schedule of third/fourth year rotations through the different core and optional specialties, I picked a very non-surgical track. Nearly all my surgical stuff was in fourth year, after the residency match application date.

    Then I did a surgical rotation, and fell in love. (With surgery - I'd already met my husband!) I had to do some last minute shuffling to get another rotation before the match deadline (to be *sure* I really wanted this crazy specialty, as well as to try and get another reference letter!) I am now a neurosurgeon.

    And along the way, I realized there is a surgical type, and I'm definitely it: I don't just want to diagnose the problem, I want to get in there and try and fix it. As you noted, there's a certain instant gratification to surgery: you do something, and you know pretty quickly whether it's worked or not. It is very satisfying when it goes well - and yes, when it goes badly, whether through any fault of yours or not, it is emotionally difficult. It hurts, when a patient you care about has a bad outcome. Part of the (long) training to be a doctor and a surgeon involves learning how to manage that - not how to become emotionally walled off, but how to deal with it. And this is not limited to surgery, of course - internists, GPs, oncologists, almost every specialty will at times have to deal with breaking bad news, managing heartbreak and tragic life circumstances and depressing diagnoses - but it's tougher when you're "hands on" directly responsible. (On the flip side, it is FANTASTIC when a patient who was nearly dead when you met them walks into your office and tells you how great their summer was and that they've just had their second child, and you think, "I did that. I cut them open, fixed the problem, and saved their life. Holy cow.")

    As regards the technical stuff and the tremor: some trainees have more natural aptitude ("great hands") than others, but I agree that technical skills can be learned by almost anyone with sufficient practice. I suspect it is easier to teach the technical aspects to someone like "Gareth" than it is to teach compassion or listening skills to someone who lacks or doesn't value them...

    My advice to "Gareth": get a bit more exposure to surgery, see if you can find any trainees or consultant surgeons who seem to break the stereotypes and talk to them about their experiences, and don't worry about being the "wrong" personality - if you love surgery, I'd say by definition you have a surgical personality. :)

  4. Gwynned, thanks for the thoughtful comments and the sound advice and for being a loyal follower.

  5. I am currently a successful surgical resident at one of the (IMO) best residency programs in the country (US). I have wanted to be a surgeon since I was 16 when I shadowed a family friend who was a local surgeon in my small hometown, for many reasons on which I have spent years reflecting. Most interactions with surgical practice (not necessarily surgeons) reinforced my desire to study surgery over the years.
    However, I don't have the so-called "surgical personality". This is not a self-assessment--I was told this by 2 attending surgeons during medical school. The first told me I don't have the "surgical personality" and the second told me I don't have the "swagger" of a surgeon. Neither had interacted with me for more than 5 minutes and neither had worked with me--these comments were during meetings I had regarding advice in applying for surgical residency. Also, these were in direct opposition to the opinions of the more respected surgeons whose support I did have.
    Similar to Gareth, I tend to be academically ahead of my colleagues but tend to be reserved and analytical rather than loquacious and over-powering. This may be something that Gareth and I can work on but I rather enjoy the fact that I differ from my surgical colleagues in this aspect. And the fact that Gareth starts his inquiry with the stereotype that surgeons tend to lack attachment to patients is an indicator that we need more “personalities” like Gareth in the field.
    The use of the word “butcher” in any conversation about surgeons causes me to cringe. Modern surgery is an intellectually and technically demanding profession. Also remember the tremendous amount of trust a patient places in a surgeon when placed under anesthesia (not in the anesthesiologist he or she has never met before or the administrator of the hospital but the surgeon). This is a surrender that I don’t think anyone can appreciate until they have come under the scalpel and a responsibility most cannot understand.
    So the 2 points I would ask Gareth to take from these ramblings:
    1. Don’t let misconceptions about “surgical personality” dictate your future. Be the unconventional surgeon. Be discriminatory regarding whose opinion you hold in high regard. Success is determined after a body of work, and ability to predict success can be notoriously inaccurate.
    2. What is really required to be a surgeon is good judgement in light of patient values. Practice is integral and judgement is the one thing that you can practice before starting a surgical residency. Technical skills, operative procedure, and surgical decision making will come with time if you are dedicated. As Gynedd mentioned above, these can be taught much more easily than can good judgement.

    PS: Regarding applying to US programs, do it. The training is great and although the direct to categorical spots are limited, there is ample opportunity to be a preliminary intern for one year after which you will be somewhat more competitive for categorical spots.
    PPS: An aside re: technical skills, any reason we don’t have a fundamentals of open surgery but we do have an FLS??

    1. Thanks for your comments. This is particularly valuable because you have something in common with Gareth. I am glad you support my answer to him. You sound like you have a good attitude.

      In answer to your question, the focus is completely on laparoscopic surgery these days. I worry that open surgery will be forgotten. I don't know if you ever go on Sermo, but a recent post on that site lamented the fact that a recent graduate of a surgical resident asked a more senior surgeon for help because he had never done a modified radical mastectomy. Yikes.