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.

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 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.