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.

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.

A woman asks, "Should I be a nurse practitioner or a doctor?"

She writes [email edited for length]:

 

I don’t ever do this sort of thing, but your blog seems to be pretty legit, so I guess I’ll go ahead this once.[Quite a testimonial for my blog, don't you think?] I’m a post-undergraduate student seeking to become either a nurse (with likely continuation to a nurse practitioner [NP] degree) or a doctor.  The problem is I don’t know which way I should go.

I know I have the ability to get through medical school, but I’m not sure if it is worth it as far as cost and benefit is concerned.  I do, however, like the idea of the autonomy that comes with being a doctor rather than a nurse.  I have a very analytical mind, and would enjoy the diagnosing and problem-solving that comes with being a doctor.  In fact, I’m not sure I would be happy without the authority to determine and pursue treatment I had researched myself.

On the other hand, I really like interacting with patients and getting to know them personally. Ideally, I want a job where I help people solve their medical issues, diagnose, have autonomy, and interact regularly with patients.  My main question is, does this happen more as a nurse practitioner or doctor?

I’d also like to know if you think medical school is worth it with the rising cost of education and likely fall in salary (at least in the US with Obamacare). I’m practical and even if medical school is really what I want, I cannot justify going after a degree that won’t be worth the cost. On the same note, if there is a great shortage of doctors, will NPs be stepping up into doctors’ roles more often? Is such a role assumption legitimate? And what will this mean for the medical community and individuals going into medicine?

[Note: She is in her early 20s with very little debt right now, will finance future education with loans, is not married, but eventually wants to have a family.]

Thanks for the kind words about the blog. 

Here's what I think. It sounds like you want to do primary care. If that is so, why go to medical school? You might want to consider becoming a physician assistant (PA) too. The NP or PA route will be far less expensive. You will be able to start practicing sooner, which means earning real money and paying off any debts instead of deferring. 

Future doctor shortage or not, I think nurse practitioners and PAs will dominate primary care and also be given more autonomy. It is inevitable. The truth is, many PAs and NPs are not very closely supervised even now.

I hope that others will comment.