Going to med school and becoming a surgeon when you're older

A 34-year-old attorney writes I have a good salary, am married, and have two children. My whole life I've been drawn to medicine (I'm an EMT, have experience on the job with trauma related injuries, etc.) and have always enjoyed it. However, I have a Bachelor's in English literature, so I've always put it as unattainable to become a doctor. Now, once again, I'm considering doing one of the post bac premed programs out there and going for it.

Am I insane? At my age, I'll likely be 41-42 by the time I'd complete medical school, then residency. I'd love your opinion.

Let's do some math. You are 34. Most post bac premed programs take at least a year if you go to school full-time. Assuming you can get into a program this summer, you will be applying to medical school for a class starting in the fall of 2017. You will be 36 years old when you start.

Four years of medical school plus five years of general surgery residency and you will be 45 years old. If you want to take a fellowship in something for a year or two, add those years on.

What are you going to do for income while you are pursuing your medical degree? And let's not forget the tuition cost of the post bac program and medical school, living expenses, and your paltry salary for the 5 years of your residency.

I wrote a post about this four years ago. It was about a then 30-year-old man did not get into medical school until 2014 which means he is now in the middle of his first year at the age of 34.

My discussion of the "cons" of doing this is much more expansive in that post. Just remember that tuition costs have risen much faster than inflation and will continue to do so in the foreseeable future.

I can't tell you not to do it and it certainly has been done by others, but I strongly advise you to give it a lot of thought.

He replies Thanks for the response. Unfortunately, you paint the bleak reality I was afraid of. As I likely won't make cutoffs for the good post bac programs this year, you'd have to add another year to the equation.

What if I went for a less rigorous residency like emergency medicine? Or what if I consider having the military pay for medical school?

Does this change anything? Your post is so bleak, it definitely gives pause.

The family issue is a tough one. I'm fortunate to have about $200k in liquid assets, but it's still a big financial hardship.

$200K might just about cover your tuition for the post bac year and 4 years of med school.

Yes, emergency medicine will save you a couple of years, but it is very competitive.

Remember one thing about the military. Once you are in, they own you. They can send you to remote bases in the states, Afghanistan, or wherever they want. You cannot believe anything they tell about your ability to choose an assignment.

Readers, please comment if you agree or disagree.

Academic vs. community hospital for surgery residency

Here's question from a senior med student at a state school. She has excellent grades, USMLE Step 1 and 2 scores > 245, has co-authored 4 published papers, and was elected to AOA. She writes

I am looking to re-locate to a large city for residency as a number of my family members live there. I have interviewed at the large academic centers in the city as well as their community affiliates. I have also been involved in research and always assumed I would enjoy the biggest "named" institution possible. As I have interviewed, I truly feel that I would get better training (and be happier) and the academic-affiliated community programs in that city. However I have been told my several advisors at my home school that this would be "career suicide" and it would be "idiotic" not to take the best name that I have a chance at matching at. As far as fellowship, I have literally no idea what I want to do. Maybe surgical oncology, maybe transplant? Maybe vascular, maybe nothing?!

What is your insight into this? Should I seek what I perceive to be the best training/fit or should I rank the higher name academic programs for the sake of my career?

Here's my opinion. Be advised that it is strictly my opinion and may be neither popular or correct.

You should have no problem matching at any affiliated community hospital program and probably have a very good chance to match at every academic program in the city you want to be in.

I hope you have properly researched your top choices and are confident that the residents are happy and doing a lot of cases. Also you should be sure that the leadership of the program is stable. I suppose your mentors your school want you to take the academic track because that's what they did. It also enhances the reputation of the school when its students match in big name programs.

You remind me of me except I didn't have the publications you do. I took the "comfortable" choice for residency and never regretted it. I trained in the same city you are looking at. It's a great place to live.

I see it this way. Suppose after a couple of years in a community program, you decide you want to be an academic surgeon. After you residency, you can always take a fellowship in something at an academic medical center.

But if you go with a university program and are miserable, then what do you do? Five years (plus a year or two of research) is a long time to be miserable.

I went into more detail about this in a post three years ago.

Listen to your heart. Go for the place that you feel most comfortable with.

I strongly suggest ranking all of the programs you feel you can live with—just in case.

Good luck and let us know how it turns out.




Readers, feel free to disagree or agree as you see fit.

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.

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 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 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

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.