Making the cut: How to specialize in general surgery
This is the seventh in a series of articles profiling medical specialties. The first article focused on anesthesiology, the second on physical medicine and rehabilitation, the third on osteopathic manipulative medicine, the fourth on dermatology, the fifth on emergency medicine and the sixth on obstetrics-gynecology.
With the demand for general surgeons in the U.S. increasingly exceeding supply, especially in rural areas, career prospects remain bright for physicians in this specialty. But long and unpredictable hours temper general surgery’s appeal.
“To succeed as a surgeon, you have to love it because it is such demanding work,” says Joseph J. Stella, DO, the program director for the osteopathic surgical residency at Geisinger Wyoming Valley Medical Center in Wilkes-Barre, Pa. “It’s very gratifying to be able to technically perform an operation successfully.
“And the satisfaction you get when you extend someone’s life is unbelievable. I have many thank-you cards on my desk from patients and their families. They are so grateful. You can’t put a price tag on that.”
General surgeons need to be masters at multitasking, says Susan J. Seman, DO, the program director of the osteopathic general surgery residency at Sinai Grace Hospital in Detroit. Practicing as both a trauma surgeon and a general surgeon, Dr. Seman works 120 hours a week, drawing on support from her husband, parents and in-laws in taking care of her two children, now age 9 and 11.
“I can work for 42 hours straight, come home, shower, make dinner, go grocery shopping, do my billing, work out, help my kids with their homework and be in bed by midnight,” Dr. Seman says. “It’s almost like a game to me. It’s very rewarding to feel like you’ve gotten all that done.
“I’m utilizing every moment all the time, which is fun. I clearly don’t like sitting down.”
Although the lifestyle of a general surgeon is not for everyone, most of the 49 AOA-approved general surgery residencies fill, and many have become highly competitive. Osteopathic general surgery residents also sometimes pursue competitive subspecialty fellowships in everything from plastic surgery to oncological surgery. At Botsford General Hospital in Farmington Hills, Mich., roughly half of the osteopathic general surgery residents go on to subspecialize, says program director John D. Parmely, DO.
“I can work for 42 hours straight, come home, shower, make dinner, go grocery shopping, do my billing, work out, help my kids with their homework and be in bed by midnight.”
While some residents use their fellowship training to hone specific skills and broaden their marketability as general surgeons, others do not. A tremendous need exists for “bread and butter” general surgeons, who remove gallbladders, repair hernias and perform appendectomies, notes Adam B. Smith, DO, the president of the American College of Osteopathic Surgeons (ACOS). In rural areas, such surgeons may also perform hysterectomies and do other procedures that are usually done by other specialists. Because osteopathic general surgeons tend to train in community hospitals, they are especially well-prepared to fill this niche, Dr. Smith says.
A 2011 salary survey by Medscape indicated that general surgeons in the U.S. earn an average of $265,000 a year. Their pay is in the midrange for all medical specialties but among the lowest of the surgical specialties. “Still, we’re in the top 5% of U.S. wage earners,” Dr. Smith observes.
But subspecialization can boost a surgeon’s earnings substantially, points out Dr. Seman, whose own income doubled after she became a certified trauma surgeon.
Ideally, students would know whether they have some interest in general surgery before applying to osteopathic medical school. This way, premedical students can focus on DO schools associated with hospitals that have general surgery residencies. Then when they serve their core rotations as third-year osteopathic medical students, they will have the opportunity to be seen and mentored by general surgery program directors, Dr. Smith says.
But it is rare that premeds know what specialty they will pursue. “I didn’t know for sure what I wanted to do until my rotating internship,” says Dr. Smith, who practices general surgery in Fort Worth, Texas. “All I knew was that I didn’t want to do pediatrics.”
To be sure, osteopathic medical students at any school can successfully match into AOA-approved general surgery residencies. But students in some locales may need to more aggressively seek out shadowing opportunities and elective rotations in the specialty, Dr. Smith says.
Although the details still need to be worked out, the recent agreement between the AOA, the Accreditation Council for Graduate Medical Education (ACGME) and the American Association of Colleges of Osteopathic Medicine to work toward a single unified accreditation system by 2015 should expand training opportunities for future osteopathic general surgeons.
While Dr. Smith didn’t decide on his specialty until after med school, this is typically not an option for general surgeons today. Medical students really need to select a specialty in their third year because this is when they line up their fourth-year electives and audition rotations, Dr. Smith says.
By spring of their third year, students apply for audition rotations that take place between July and November of their fourth year. Some osteopathic medical schools require month-long rotations, which means that their students can audition at only a handful of hospitals. “The time frame is extremely compressed for students, who have to set up their rotations strategically so they get into hospitals with programs in their specialty of interest,” Dr. Parmely says.
Medical students match into general surgery residencies, which are five-year programs, in their fourth year. Some programs do accept physicians who are doing rotating internships, but they may have to repeat their first year, Dr. Stella says. Because the Centers for Medicare and Medicaid Services does not like to pay for gratuitous training, it is difficult to transfer into general surgery residencies from other programs. All five years of a general surgery residency must be completed for a DO to become a board-certified general surgeon.
On the other hand, general surgery residents have been known to transfer into nonsurgical specialties with shorter training periods, especially internal medicine, if they find they can’t cope with the demands of surgery.
To avoid such mismatches, osteopathic medical students who are considering general surgery should become involved in the ACOS Student Osteopathic Surgical Association (SOSA), Dr. Smith suggests. SOSA chapters at osteopathic medical schools bring in general surgeon guest speakers, arrange for shadowing opportunities, and sometimes expose students to suturing and tying techniques and proper operating room behavior, among other surgical basics. Students can also take part in the annual SOSA convention, which includes lectures and a residency fair.
In addition, the American College of Surgeons (ACS) provides a checklist for medical students who are thinking about surgery as a specialty:
- Do you like working as part of a team?
- Do you embrace responsibility?
- Do you take satisfaction in watching your patients improve daily?
- Do you relish acquiring technical skills and learning about new technologies?
- Do you like solving problems?
- Can you think on your feet?
“First and foremost, surgeons are trained, not born,” the ACS states on its website. “Facility with knot-tying and sewing is handy, but some of the most wise and revered surgeons in practice today were not known for their dexterity when they were medical students or junior surgery residents. Intelligence, professionalism, conscientiousness, creativity, courage and perseverance on behalf of your patients are the critical factors.”
General surgeons are results-driven. “They like the immediate gratification you get from surgery,” Dr. Stella says.
Contrary to popular notions, surgeons don’t require a Type A personality, notes Dr. Stella, a cardiothoracic surgeon. “I’m more of a Type A, but that just means I talk before I think,” he jokes. “My partner is more of a Type B, so he’ll actually think before he talks. I’ve learned to like the quiet people a little bit more because they don’t blurt everything out.”
Although osteopathic general surgery residencies have always been competitive, program directors report a surge in applications in recent years. “At Botsford, we’ve gone from 40 or 50 applications to 160 applications a year for four positions,” says Dr. Parmely, who oversees 20 general surgery residents altogether. He attributes the rise mostly to the increasing number of DO graduates, as new schools open and class sizes expand. “The schools are cranking out more and more graduates, who are applying for a limited number of residency spots. So there is a huge supply-and-demand nightmare in osteopathic graduate medical education,” he says.