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.

A med student loves open surgery, asks about the future of pediatric surgery

Dimitar [not his real name] writes [edited for length]: I am a medical student who has already applied to the field of general surgery and finished the interview process. I hope to become a pediatric surgeon because it is one of the last fields that allows for one to operate all over the human body and to be a true general surgeon.

However I have been struggling with something that I hope you can help me with. I love the technical aspect of surgery. I enjoy becoming better at tying knots, suturing, and various surgical skills, and above all I love traditional open procedures. I like to feel with my hands and not with those laparoscopic instruments, I like to see with my own eyes and not through a tiny little camera all through a tiny little port. My biggest fear is that everything will become robotic, and that an open procedure will be a rarity in the future. And pediatric surgery most of all is basically an advanced laparoscopic fellowship. I want to make clear that I do not hate laparoscopy, I just enjoy the open procedures much more. I understand that this is probably a very selfish thought as laparoscopy has better recovery times, less pain, shorter hospital stay etc., but I guess that is why we have websites like this where I can ask anonymously what I am to ashamed to asked in public with hopes of getting a non-judgmental response.

To sum it up, I feel like I was born to do surgery back in 1950 or something when everything was open. I would like to find a field that would allow me to operate all over the body and do it the traditional way. Other than trauma, and transplant, what are my options? Would general surgery ever get back to what is was before? If I don't learn to love this laparoscopic and robotic thing am I screwed?

Those are very good questions. Let's start with your worry that pediatric surgery "is basically an advanced laparoscopic fellowship." I'm not so sure about that. If you look at the statistics for residents who finished pediatric surgery fellowships in 2013, you will find that many open cases are being done. This link gives you all the information you need. By my estimation, more than half of all pediatric surgery cases done by fellows were open. That's the good news.

For some bad news, you need to get the full text of this American Journal of Surgery paper that appeared online in November 2013. Written by some senior pediatric surgeons, it gives some worrying information about the specialty of pediatric surgery. The number of complex cases being done by attending pediatric surgeons has remained static while the number of pediatric surgeons has increased. It looks like many pediatric surgeons, even in university hospitals, aren't doing enough complex surgery.

The other bit of bad news is that competition for pediatric surgery fellowship positions remains intense. Here are some data from the last five matches.

As you can see the number of applicants for each position ranges from 1.5 to 2, and the number of unmatched applicants is rather high.

Trauma surgery is not the answer. There are so few open trauma cases being done that in order for trauma surgeons to maintain their skills, the specialty has morphed into "trauma, critical care, and acute care surgery."

I may be wrong, but I don't see general surgery ever returning to the old days where open surgery ruled. Not only that, I think in the future more and more cases will be done with minimally invasive techniques, even if the robot turns out to be a bust.

So in answer to your final question, I think you will have a problem if you do not learn to love the laparoscopic approach.

I wish you the best of luck.

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.

Umbilical hernia repair: Choosing a surgeon and more

A reader writes (in italics). My comments are in normal text.

 

I am writing on behalf of an otherwise healthy 30-ish-year-old relative, who was recently diagnosed with an umbilical hernia, and another “just above it”.

She was diagnosed about a month ago, and was sent to see a surgeon (not sure what kind). The surgeon suggested a repair using mesh. She’s apprehensive moving forward with surgery based upon several reasons:

She felt rushed during the consultation. She wasn’t given much information regarding the procedure, wasn’t prepared with many questions, and failed to voice her questions/concerns. She has since tried to contact the office to get some questions answered but hasn’t gotten a response.

This is not medical advice. For that, I would need to examine your sister.

It was probably a general surgeon. You have mentioned three red flags—she felt rushed, she wasn't given much information, and the office has not called her back. I would suggest you get another surgeon.

She consulted Google and has read “bad things” online. She is concerned with the probability of having to have repeat surgeries.

Recurrence may occur after any hernia operation. For a small umbilical hernia, the risk should not exceed 5%. The infection rate for umbilical hernia repair is also fairly low, but if an infection occurs, a recurrence is likely.

Can you offer real information regarding the types of procedures out there? Are there superior methods, as suggested by many of the “scholarly” looking articles, which eventually turn into advertisements? Many tout methods such as Shouldice, Bassini/McVay, Tension-Free, etc. The info I have come across is conflicting and confusing.

The information on the Internet is confusing. The methods you mentioned are eponyms for groin hernia operations. They do not pertain to umbilical hernia repairs. There are three currently accepted methods of repairing an umbilical hernia—open suture repair, open mesh repair, and laparoscopic mesh repair. The mesh repairs involve insertion of a piece of artificial material to reinforce the abdominal wall. The theory is that the patient's tissue broke down once so why rely on it to fix the hernia? Recurrence rates (at least rates that are published) tend to be significantly lower when mesh is used.

I am unaware if there is a hernia sub-specialty, but if there is, what would be the best way to find such a surgeon? If not, is there an existing database that provides information that details the number of hernia surgeries performed by a surgeon?

There are some surgeons who specialize in repairing hernias. I don't know of a database listing the number of hernia operations performed by individual surgeons, nor is there any information on individual surgeons' recurrence rates. The latter information is usually unknown even to the surgeon because patients with recurrences tend to go elsewhere for repeat surgery.

Can you list questions she should ask her surgeon that will aid her confidence in the decision-making process? Her pain symptoms started about 2 years ago, and I fear what she risks by continuing to delay.

Questions that should be asked include the following: what type of repair should I have, how many of these repairs have you done, do you know your recurrence rate, what if I need to contact you at night or on a weekend.

Because she is symptomatic, she probably should have elective surgery. Not having surgery runs the risk of incarceration, or the trapping of a piece of intestine in the hernia. If this happens, pain would be severe and the hernia would not be reducible. Emergency surgery would be required and the risk of recurrence would be higher. If the bowel's blood supply is irreversibly damaged, some of it may need to be removed. This also increases the risk of complications.

I would find another surgeon to do the operation, preferably a general surgeon with expertise in hernia repairs. If the two hernias are not close together, the laparoscopic method might be best provided she has not had extensive prior abdominal surgery.

I hope this helps.