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

A pre-med student asks some probing questions

Here are some questions from Lionel, a pre-med student.

What is something you wish you had known before entering medical school?

It would have been nice to have known what changes were going to occur over the 40+ years since I graduated.

If you had the opportunity to choose a specialty all over again, would you do surgery again?

Yes. While I have often envied the controlled lifestyles and flexibility of radiologists and anesthesiologists, I don't think I could have stood the sitting in the dark all day (radiology) or utter boredom 95% of the time (anesthesia).

If not medicine, what other healthcare occupation would you consider to be more rewarding?

It depends on how you define rewarding. It seems to me that being CEO of a hospital is more rewarding financially these days. I have blogged about that. Is it more satisfying on any other level? I don't think so.

Is it possible to carry a healthy relationship where the significant other is not a medical student? Would it be more/less difficult in residency compared to medical school? [this is one I'm mostly interested in especially since you are a surgeon]

I am living proof that it is possible to have a healthy relationship with someone who is not a med student or physician. I met my wife, who is a nurse, when I was an intern. We were married when I was a third-year resident and still going strong at 39 years.

What implications have enduring medical school/residency had on your personality?

I was always kind of a pessimist, but med school and beyond amplified that trait a lot. As some people have written about lately, med school and residency can induce cynicism, and I'm afraid I am a classic example of that.

Does every single day of the year feel stressful or are there days where you feel in control and free to relax?

Since I retired late last year, the days are not particularly stressful right now. When I was an active surgeon, just about every day was very stressful. It took at least the first five days of every vacation to unwind, longer if I had gone away and left a sick patient to be managed by someone else. Here's a link to a post I wrote about "collateral damage," which is about how complications affect surgeons.

I have always dreamed that being a physician would help me feel more connected spiritually to god/universe by seeing all the unfortunate people and being able to lend compassion. However, does being under constant stress distract a physicians focus from that feeling and does it make you just want to finish the job and go home?

There were many days when I just wanted to finish the job and go home. I would like to think though that I was able to get past that and offer my patients the compassion and support they needed.

What do you like/dislike the most about your journey thus far?

I liked the challenge of figuring out what was wrong with a patient and having the ability to fix it. I liked the feeling of satisfaction after helping someone who was really sick get better. Today I got an email from a former patient who is 10 years postop from breast cancer surgery and disease free. Hearing that is hard to beat.

I took every complication, whether it was my fault or not, very personally. That can wear you down. I didn't like the empty feeling that I got when I operated on a patient and found something like incurable cancer. It was frustrating not to be able to do anything about it. It is very hard to look someone in the eye and tell him that the surgery did not solve the problem.

Is medical school worth it?

A woman writes

I came across your blog as I was looking for "doctors with good hours." Here's my situation:

I'm a female currently applying to medical school. Besides the question of "Can I get in?" (which is haunting me right now since my MCAT score of 31 is scaring me...all my friends have gotten interviews but I still haven't heard a thing), I'm wondering if it's even worth it to go to med school.

The biggest things concerning me:

1) The money. I have no idea how I'm going to pay that all back. If I get into my state med school, my estimated cost for tuition is $120,000. If I get into an out of state school, I'm looking at minimum $200,000 for tuition alone. I didn't calculate school fees, test fees, books, transportation, or car payment (I'll probably have to buy a car) into either my state or out of state costs.

2) The inflexibility. I have a boyfriend, we're planning on getting married, and he has his career too. It seems like the next four years + 3 years + ? = uncertainty since I don't know where I'm going to med school, where I'd match, etc, and where he'd work in that meantime.

3) The time. I'd also like a family. I don't know how fair it is to get through med school and residency and then do a part time physician thing. Doesn't seem very smart to me.

My question is, Is there light at the end of the tunnel? Am I just imagining trouble, or is medical life as a physician not worth it? My alternate career is to become a nurse--get my master's in about two years (through an accelerated program), work, and advance upward, maybe to a Nurse Practitioner level.

Thanks for writing.

You have nicely listed some of the major challenges facing most women who are considering medicine as a career.

You are the only person who can decide if medical school is worth it for you, but let's see if we can think it through.

My first instinct is to tell you to carefully reread your email as if it had been written by someone else. After doing so, what is your reaction? After you do that, resume reading my reply.

Not being a woman, I decided to outsource this. One of my daughters who is not a doctor, but has a master's degree in a science, is married and has two children said,

"It sounds like she doesn't really want to be a doctor..."

My wife, who is a nurse, agreed and said nursing is a career that allows you to do the things you wrote about.

Here are three posts I have written about this subject.

Choosing a medical specialty is difficult. And note the comments.

Surgery and work-home conflict.

A college student has second thoughts about medical school.

I will also ask my Twitter followers to read this and comment. I hope they do.

Is it possible to live a full life as a surgeon‏?

Neymar (not his real name) writes

Dear (Dr.) Skeptical Scalpel:

I'm writing this evening as a fourth year medical student wholly committed to pursuing a long and fulfilling life as a general surgeon. It's what I got into medicine for, and my love for the profession has only heightened in the arduous years of preparation and (nascent) training I've undergone thus far. I have had the fortune of living a very full life—travel, adventure, and a broad milieu of individuals have all shaped the form of the man I am now, and greatly influence the man—and surgeon—I hope to be in time.

Like many people in and outside of medicine, I reflect on what has been lost or what might have been lost along the path. At present, the balance sheet reflects a clear net gain. The opportunity cost, however, can be measured in the loss of time in wilderness, love and relationships and socializing that adds richness to my life. How do you advise young physicians pursuing such an ambitious and all encompassing professional course to maintain richness and fullness in their lives? How do you reconcile the personal forfeitures with the professional gains? And, most importantly, if one hopes to be a surgeon, are these questions worth considering or best left in the recesses of the mind?

Thanks for being a mentor to an entire generation of aspiring surgeons.

Thank you for writing and for the kind words.

The questions are definitely worth considering. I am not sure that my response will be applicable to your situation or anyone else's.

I chose surgery because it appealed to me more than any other specialty. Like most others of my era, I was young and had gone the traditional route—four years of college followed immediately by med school. I had experienced few adventures [in fact, none] and had not yet met my wife-to-be.

I never even considered what impact my choice would have on my personal life. The subject simply did not come up. I worked hard in medical school but had a great time. I think I had more fun in med school than I did in college.

My residency prepared me well for the rigors of a surgical career. I spent the first four years of my training taking call about half every other night and half every third night. As a chief resident, I was in call every night. Somehow I found the time to have a relationship and got married at the end of my third year.

My wife of 39 years is a saint. I have wonderful children and now grandchildren too.

I was fortunate in my career to have had the opportunity to supervise the training a number of surgeons who are helping people every day.

Although I'll never climb Everest, go an African safari, ski the Swiss Alps or do many other things that might be important to others, I've had an interesting and fulfilling life. Wilderness? Not so much. But love and relationships? I got 'em.

But it is different for the millennial generation. What I consider interesting and fulfilling might not be to you.

Surgery continues to evolve. I think it may be possible in the near future to have a career as a general surgeon and also have a manageable lifestyle. By the time you finish training, everyone will be in group or hospital-based practices. Or you could be an acute care surgeon with fixed hours.

You will have to decide what compromises to make such as deciding if leaving work at 5 pm is more important than staying late to operate on your patient who has a complication you created.

No one talks about this part—you will have to find partners you can trust with the lives of your patients. The roadside is littered with the corpses of group practices that didn't last because of productivity issues, attitudinal and/or philosophical differences among the surgeons.

For many surgeons, fulfillment is measured by the satisfaction of knowing you made a difference in someone's life.

Can you be a surgeon and have a rich and fulfilling life? You can, but it depends on how you define rich and fulfilling.

If you haven't read this post, you should.

How can I overcome a low USMLE Step I score?

Nemanja (not his real name) writes: I am a fourth year medical student at a US school. I am planning on applying to general surgery in the next month. I have a few concerns and questions about my application and competitiveness. 

I did very well years 1 and 2, all but one honors. I got a 209 on USMLE Step 1 and a 243 on step 2. The caveat about my step 1 score is as follows. I had a family tragedy 1-2 months prior to taking step 1. In retrospect I probably should have deferred and not taken it but hindsight is 20/20.

After that poor step 1 score, I did well on my clinical rotations. I received a high pass in surgery and honors in 4 other clinical rotations with no grade less than a high pass. I expect to receive strong letters of recommendation from my program director and clinical faculty. I am interested in applying to programs in the northeast portion of the US.

How can I let a program director know about my situation (e.g., in my personal statement, in my dean's letter). Some of the people at my institution have led me to believe that this is an important part of my story and something that may provide an explanation for a below average step 1 score. I am afraid that I will be filtered out due to my step 1 score from many university based programs. What do you think is my best approach to this situation? 

Your question is a good one. I am sorry about your family tragedy. 

I suggest you explain it in your personal statement and ask the dean to mention it in his letter too. You need to emphasize the fact that your Step II score is very good. Strong letters of recommendation will help.

If you search PubMed for "USMLE Step I," you can find a fair amount of information about the weight program directors put on it. One paper says it is the single most important factor used by PDs to screen applicants. Another says that a Step I score of < 200 is associated with a higher risk of failing part I of the general surgery board exam.

Here is a link to a PDF from the NRMP about match outcomes. If you go to page 84, you will find some interesting data about the 2011 general surgery match.

I have some screen shots for you. 

Here's a table listing some summary statistics.

This is a graph indicating that a USMLE Step I score of 209 gives you about a 75% chance of matching in surgery.

But here is a chart showing that a Step II score of 243 gives you a very good chance of matching. No graph was provided.

The message is very clear. Get the PDs to look at your Step II score

You may want to apply to some community hospital-based programs to be safe. I think you will match in a categorical position.

Good luck. Please let me know how things turn out.

Are program directors the reason that surgical residency training is a mess?

A resident writes: "You have been a program director (PD). I read your article about residents not being confident about surgical skills and you conveniently blamed resident work hours limits/resident work ethic for this. I ask you how come PDs are not responsible for the training they provide? How can they get away with telling residents/fellows on what the residents/fellows can say/write on evaluations that accredit the program? How can they get away without providing adequate training/exposure in lap/robotic surgery? How come we don't teach surgeons how to teach surgical skills? Just because one is a good surgeon does not mean they can teach surgical skills to others. After all Michael Jordan was a great basketball player, but that does not necessarily imply he would make a good coach. In fact I would argue that average basketball players make better coaches."

 

Great questions. Let's see what I can do to answer them.

I "conveniently blamed resident work hours limits/resident work ethic" for the lack of confidence in their skills that >25% of general surgery residents have. That problem was not created by program directors. Most PDs hate it. It certainly is a contributing factor to the lack of resident confidence.
We are responsible for the training we provide. We must sign a form attesting to the competence of our graduating residents. I cannot speak for current PDs, but I felt very responsible for the residents when I was a PD.

I never told a resident what to write on an evaluation. I understand that may happen, but the evaluations are submitted on line anonymously to the accrediting body, the Residency Review Committee for Surgery. The residents are free to say whatever they want and no one will be able to trace it back to an individual. In my experience, the residents did not hold back on their complaints.

I agree with you that we are obviously not training residents well enough in some areas such as advanced laparoscopic surgery. That is difficult to understand and explain. It must be true because so many graduates of five-year programs feel the need to take extra training. I think it is somewhat harder to teach minimally invasive surgery. I always felt I could control what the resident was doing during open operations; for laparoscopic procedures, not so much. But we should be doing a better job in that area.

And it's not just laparoscopy or the American College of Surgeons wouldn't have established "Transition to Practice" fellowships. See my previous blog about this. There is also the problem of too much supervision which I mention in that blog.

I have news for you. In most cases, surgeons are not taught how to teach anything, let alone surgical skills. For many years, it has just been assumed that any surgeon (or any doctor in any specialty) is an excellent teacher. Of course, this is not so.

However, teaching is not particularly valued or rewarded an academic medicine. On the other hand research is, especially research that brings in grant money.

Teaching is also a problem in community hospital programs because attending surgeons are busy trying to stay afloat financially.

I agree with you that Michael Jordan and most other superstars of sport would not make good coaches. It may be similar in surgery. I don't think that has been investigated, nor is such a study likely.

In case you haven't read any of my previous posts (search "surgical education" on the Skeptical Scalpel blog) on this subject, I am pessimistic about the future of surgical education.