Applicant worries about the future of surgery

A medical student writes:

I am a few weeks away from applying for residency training in general surgery. Lately I've been lamenting that I was not born in the 1950s. I worry that the physician that I became enamored with so early in life is looking more and more like the surgeon I may never become.

Increasing enthusiasm for innovation in surgical technology is subtly paving a road toward a time in which a surgeon may be rendered obsolete. The rise of the two M's—machines and mid-levels—may herald a very different future from that which I ever imagined.

I love to solve problems and stand (not sit!) above an anesthetized patient making use of my hands and tools directly. There has never been a higher challenge than surgery which involves clinical skills in diagnosis, peri- and intraoperative disease management, and a sense of duty, service, and sacrifice. And now, robotics calls into question why hands might ever need to be laid on patients, and time-honored sutures are replaced with Silicon Valley-prescribed tinker toys.

Many articles call into question the relevance of physicians, particularly surgeons, in the not-too-distant future.

Will mid-level providers take away many general surgery cases? Will opportunities to function as a surgeon be threatened by the relentless emergence of technological or perhaps financial pressures? Are surgical societies actively confronting these issues?

I see you have thought about this in depth.

The PAs I have worked with did a lot of rounding, H&Ps, clinic work, and discharge summaries. In the OR, they assisted and closed skin. In some specialties, they do more such as harvesting vein grafts and closing fascia.

Here's an interesting anecdote about a PA who excised a neck mass by himself. He smelled it, said it was a benign sebaceous cyst, and threw it away. When the mass recurred, a surgeon biopsied it and found squamous cell carcinoma.

I don't see robots operating independently for quite a while, if ever, although NASA apparently has a robot that can be inserted into the abdomen and perform an appendectomy while being controlled remotely.

There is much variability in the location of the appendix, the inflammatory response, and the location of surrounding structures. How can a robot can ever be programmed to do this supposedly simple operation without human guidance?

If NASA has a miniature robot, it may be possible to control it while standing next to the patient. Having never seen it, I just don't know.

Surgery will undoubtedly change a lot in the next 40 or 50 years. As I wrote here, it certainly has since the 1970s. It might change at a faster rate too. But surgeons have adapted well, and they will continue to do so.

Surgical societies have not exactly shined during all of these changes. When laparoscopic general surgery was introduced in about 1990, mainstream surgical leaders called it heresy and were slow to catch up. Conversely, few said anything about the introduction and widespread acceptance of the da Vinci robot, which has not been shown to improve outcomes despite all the fanfare and expense.

Someone (the feds?) will have to put the brakes on unproven technologies or the country will go broke.

So if you want to be a surgeon, go for it, but be prepared for change.

Board passage rates and residency program quality

I am 3rd year med student thinking of surgery programs to apply to next year. I came across this document on the American Board of Surgery website. It shows the qualifying exam and certifying exam first-time pass rates for general surgery residents between 2008-2013.

Is this a worthwhile marker for evaluating surgery programs and identifying top programs? Also, is first-time pass/fail on the QE/CE a measure of preparation to practice as a general surgeon upon graduation or is it poorly correlated with a graduate's ability to function independently?

I have a moderately competitive Step 1 score and I want to choose a program that would make me a general surgeon without needing to take a fellowship upon graduation.

[Note: The email was edited for length.] 

Thanks for asking a couple of really good questions. The answers are not black and white. On page 23 of its requirements, the Residency Review Committee (RRC) for Surgery states that board passage rate is one measure for evaluating program effectiveness, and "At minimum, for the most recent five-year period, 65% of the graduates must pass each of the qualifying and certifying examinations on the first attempt."

A quick look at the board passage rates in the ABS document shows that 31% of programs, most of which are community hospital-based, did not reach the magic 65% quota.

Two years ago, I blogged about the two major reasons why the 65% board passage threshold on the first try discriminates against community hospital programs. You can read the full piece here, but briefly one issue is that university hospitals attract smarter residents who are better test takers, and the other is that smaller programs are statistically more likely to have test result outliers.

I am unaware of any correlation between passing the boards on the first try (or the second or third tries) and a surgeon's ability to practice independently. In fact, another post I wrote discussed a paper that surveyed 4882 surgical residents. It found that community hospital trainees were more satisfied with their operative experience and more confident that they could work independently than those who trained in university programs.

But there is another consideration. Fair or not, programs with first-time board passage rates chronically below 65% are at some risk for both RRC probation, which is detrimental to recruiting, and possible discontinuation. It is difficult to quickly turn around a low board passage rate because the number of graduates is small in most community programs and the stain left by a failed first-time taker lasts five years.

So what should you do?

Perhaps you should play it safe and apply to community hospital programs with adequate first-time board passage rates.

Comments from surgical educators, current residents or recent graduates of surgical training are welcome.

A non-US citizen international student's chances of matching in surgery

"Brian," a medical student in Egypt, wrote me about obtaining a surgical residency in the US. Due to space limitations, I have edited the email. He will take USMLE Step 1 soon. He has no green card.

He read a previous post of mine about a US citizen international medical graduate (IMG), but still had several questions.

He asked what qualities separate an applicant matching in a categorical position from one matching in a preliminary position?

"Categorical" means, barring any performance or behavior issues, the resident will complete a full 5-year general surgery residency program.

What do students do on third-year surgery rotations?

A woman who has been accepted by a few medical schools and is trying to decide which one to choose asks

What extent of involvement should be expected for medical school surgery rotations? I have enjoyed shadowing general surgery and feel that a field involving some procedure may end up being my fit, or at the very least something to enjoy in medical school. I am curious as to the type of participation in procedures (suturing/closing for example) that is typically allowed as a student versus that allowed and expected as a resident. 

In most third-year surgery rotations, students can do some suturing of skin and maybe lacerations in the ED provided the student has practiced knot-tying and using instruments outside of the OR. Opportunities to suture in the OR are fewer these days because of skin stapling and the use of glue, which are both faster than suturing. Hardworking and interested students are far more likely to be rewarded with things to do by residents.

Otherwise, there's a lot of camera holding for laparoscopic cases and retracting for open cases. Students used to do H&Ps and write postop orders but the electronic medical record has curtailed those activities greatly.

Medical school has changed a lot over the years. As a fourth-year student in the early 1970s, I placed many subclavian central venous catheters—some of which were unsupervised. Six years ago, I was about to let an intern place a subcutaneous chemotherapy port in the OR. It was halfway through the academic year. I asked her how many subclavian catheterizations she had done. She said she hadn't done any but had seen one.

I can't say whether that lack of experience is common to most current med students, but I think it may be.

Of course, residents get to do much more as they progress through the years. Residents in community hospital programs tend to do more cases during their first 2 years and often will have performed more cases over the 5-year course of residency training than those in pure university based programs. Of course, there are exceptions.

If this is really a major factor in your decision-making process, I suggest you try to talk to some students at the schools that you have been accepted by and see what they have been able to do during their third-year surgery rotations.

You will probably find that students who do third-year clerkships at community hospitals affiliated with med schools get to do more hands-on work too.

The same goes for those applying to residency. If you really want to know what goes on, talk to some of the residents who weren't chosen to meet the applicants on interview day.

I hope some of our readers will comment.

US citizen IMG surgery prelim resident needs advice

Maicon, a non-designated preliminary general surgery resident, writes

I read with interest your post on matching rates for international medical graduates. I am a US citizen IMG, born here, but grew up (since 2 years of age) in another country and completed my medical school there a few years ago.

My USMLE scores are step 1 - 235, step 2 - 251, Step 2CS and Step 3 passed on first attempt. Knowing that general surgery was hard to get, I worked (unpaid) in the surgery department at a large Northeastern academic center.

I got a prelim spot at a decent program with a program director I respect. I worked my ass off, studied hard, and got in on research projects early.

ABSITE: 1st year - 90th percentile (highest in our class), it got me a 2nd year at the same program, 2nd year - 79th percentile.

Did a ton of research with a couple of publications and presentation, and won a teacher award by med students. My evals were good, and I got great recommendation letters. I thought I covered my bases.

My program doesn't have a spot for a 3rd year and am unable to find one, despite the good intentions of my mentors. It is frustrating that, try as I might, I am still out of a residency on June 30th of this year.

Should I continue to pursue the surgical field, do a research fellowship which I have seen from previous blogs/articles doesn't help much, do a subspecialty fellowship (Cardiothoracic ICU/critical care/Burns), or switch to medicine or FP? From, your previous posts, I feel you will probably suggest to switch.

Thanks for reading my blog and for your email. I am sympathetic to your plight. I've seen it many times.

I wish I was still running a program. It sounds like I could have used someone like you.

If you have no financial or other pressure to get on with your life and are young enough, I suggest you take a fellowship in one of the clinical areas you mentioned such as critical care. An accredited one is preferred because you could take the board exam when you finally get through a 5-year GS program. Even a non-accredited fellowship in a clinical area is better than doing research. Your chances of obtaining a categorical spot are enhanced by taking care of patients instead of test tubes.

 If you do a good job with the fellowship, you might be able to sneak into a categorical slot somewhere. Make sure you take the ABSITE again too. The scores are really important.

Have your program director keep an eye on the program directors' list serve. Categorical slots open up frequently—even into June.

Good luck.

A college junior wonders if she will get into med school

[Email abridged and edited.] A 21-year-old married woman, who is a junior at a large public university, has always wanted to be a doctor. She had some family and mental health problems (panic attacks, depression) which have affected her grades. She has a current GPA of 2.8, but when recalculated by including grades in repeated courses and deleting the poorer grades as her college allows, her GPA is 3.3. She and her husband have a combined $24K of student loan debt.

She feels very strongly that her family and mental health are no longer issues and is getting A's in science courses that she previously did poorly in. She says, "I seriously feel like a completely different person. I feel capable of getting good grades. However, people keep telling me that I might not even make it into med school because of my low GPA. The thing is though I don't care what I have to do. I am so passionate about learning and helping people. My dream has been to work and eventually have a free clinic on the side to help people who can't afford healthcare. That's why I'm in this. But is there a chance I can even get in? I know that's what I want, but people (peers, degree advisors, and my anatomy professor) keep bringing me down."

This is a very difficult question to answer definitively. I really can't speculate on your chances of being accepted to medical school. Your level of commitment is outstanding.

There is one missing variable—your MCAT scores.

You may want to take the MCAT at the next available opportunity. Great scores would be encouraging. Poor scores would seal the deal. You would have to move on to something else.

Your combined debt is low and you are young, both of which will allow you to spend a little extra time beefing up your GPA.

If you are thinking about applying to offshore medical schools, please do some research. As US medical schools expand their classes and new schools open, there will be fewer residency positions for offshore graduates. If you look at Table 1 on page 2 of the 2013 match data for International Medical Graduates (IMGs), you will see that 2420 US citizen IMGs failed to match to a residency position. It's only going to get worse as I noted here.

Have you considered another option such as becoming a physician assistant? The path is shorter, and PAs are becoming more and more autonomous. It might help you to look at a post of mine from a couple of months ago on "Ask Skepticalscalpel" called "Should I be a nurse practitioneror a doctor?" Read the many comments because they are pertinent.

I hope this is helpful to you. Check back here for comments as they are often more useful than what I write.

Help! My friend didn't match in orthopedics ... again

Maicon [not his real name] writes

My friend wanted to be an orthopedist, but his grades and USMLE scores were just average for medical school—Step 1 was 215. He applied last year, got some interviews but didn't match. He started a research fellowship in ortho at an academic center and re-applied. I tried to tell him to defer applying until he finished the fellowship so he could have something to show for it other than, "I started a fellowship and working on blah blah blah." This year, he got fewer interviews and failed to match again. During all this, I had advised him to also apply to general surgery, but he always resisted. He now has decided to try for an unfilled general surgery preliminary position.

I realize this is an elaborate discussion however you would be doing a major service for many applicants of this kind who have nothing to go on other than delusions or conspiratory paranoia.

Sad to say, but this happens every year.

The advice to do a year of orthopedic research was misguided. He has just wasted a year of his life.

I'm not sure what goes on in orthopedics. However, in a recent post on how general surgery program directors select residents, I noted that previous research experience was extremely low on the list of criteria as was having done a preliminary general surgery year.

I wonder how many who do a research year succeed in getting an orthopedic residency position. My guess would be less than 5%, if at all.

He should be honest in his application for the general surgery non-designated preliminary position. The program directors will know the truth anyway. The good news is that there are over 450 unfilled positions this year and not enough bodies to fill them.

The bad news is that these positions can be dead ends in many cases. That is, your friend could do a year or two of preliminary surgery and then have no access to a third-year categorical spot. Another issue is that in some programs, non-designated prelims are treated like second class citizens by being given all the scut rotations.

There is some hope though. Here's a paper that found an amazing rate of success for non-designated prelim surgery residents obtaining categorical positions, but it's from Mass General. Abington Memorial Hospital reported surprisingly good outcomes. Yale's results weren't quite as good. UC-Denver also had some mixed results. There could be some publication bias here. Programs with dismal records of placing prelim trainees may not have chosen to report their experiences.

If he does obtain a preliminary spot, he must work very hard and do very well on the general surgery in-training examination in the hope that someone drops out or is cut from a categorical position and that he will be selected to replace that individual. If not, he will chalk up one or two more wasted years.

A backup plan for a different specialty career should be in mind in case he is unable to eventually secure a categorical general surgery position.

My feeling is that if an applicant doesn't match in a dream specialty, he should forget about a year of research, scrap that dream, and move on.

As always, comments are welcome.

A med student asks about rural surgery training

Lionel, a first-year med student at a US school, writes

I'm really passionate about rural surgery and the idea of having a wide variety of procedures that you have to be able to take care of—ortho, c-sections, urology, ENT, abdomen, etc. But the thing is, everyone I talk to says this is an unreasonable expectation to have going forward as current training isn't conducive to learning all those things in 5 years, given the number of fellows present and the general trend towards super-specialization these days. Yet, I read about massive needs for rural general surgery. It doesn't quite add up. 

What is your take on this? Also, how do I go about pursuing a career as a rural surgeon in this academic/training environment? Community program? Academic program? I know Cooperstown, Oregon and Gunderson have rural surgery fellowships but I haven't heard anything about them or how to determine if you need to pursue this extra training.

Good questions.

An email exchange yielded more background information. He went to college in a rural area, has worked in an orphanage on a farm, and spent some time with physicians in rural Africa.

He has thought things through very well and seems quite committed to becoming a rural surgeon.

In medical school, he plans to do one elective in rural surgery and another at a hospital that serves as the primary clinic/surgical center for 160,000 people in a poor African country.

He is also going to spend a summer doing research at an academic center just to get an idea of what that is like.

I sent him some links to papers on the subject of rural surgery most of which he had already seen.

Here is what I think.

If you choose the right program, you would not have to take an extra year of fellowship to become a competent rural surgeon. For example, the Oregon program includes a year of rural surgery in their five-year curriculum for those who wish to do it.

There are some other programs besides the ones you named, and there may be more by the time you are ready to choose a residency. You might also think about programs with international rotations.

If you are truly committed to becoming a rural surgeon, a pure academic program is probably not for you. You are not likely to get enough diversified subspecialty experience in such a place. A community hospital program that offers a chance to rotate on some of the subspecialties and OB would be better, and there will be few or no fellows competing for cases.

I hope that some readers will contribute other perspectives to the discussion.