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The DO | Patient Care | In the Field

Making the cut: How to specialize in general surgery

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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.”
Dr. Seman

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.

Decide early

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.

Dr. Parmely

“Training outside of the operating room is as important as what happens in the OR,” says general surgery program director John D. Parmely, DO (second from left), who with chief resident Kelly B. Gabel, DO, instructs students Ann M. Wells, OMS IV (left), and Megan M. Horner, OMS IV. (Photo courtesy of Dr. Parmely)

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.”

Getting seen

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.

11 Responses

  1. dirk lenaburg on Nov. 2, 2012, 4:51 p.m.

    Very informative, and also motivating. Thank you for the information! I continue to look forward to reading articles such as these in the future! Thanks again-

  2. James Scaloone on Nov. 2, 2012, 7:25 p.m.

    11/2/2012

    My business motto is: Make it as easy as possible for other people to give you want you want. I think that this applies to residencies too. I wrote this up and sent it to my medical school about 12 years ago and never heard anything from them. This was how I campaigned for an orthopedic surgery residency. Although I mention computers in this note, personal computers were very scarce at the time and all of my campaign was on paper or in person.

    Residency Campaigning

    The purpose of this effort is to give students some direction and guidance toward getting the residency of their choice. Getting a residency is not simply a matter of performing well at a job interview at the end of your internship. Too often students and interns do not make any preparations for obtaining a residency until the second half or last quarter of their internship. This gives interviewers the impression that the decision to become a specialist of that residency has not been considered in depth, and that the applicant is a poor planner.

    Optimally the presentation should be that you have had a longstanding interest in a particular specialty, that you have planned for years to get into that specialty, that you get along well with people from that specialty and with people in general and very specifically with people who the selection committee already gets along well with.

    Recommendations:

    1) Make decisions as early as possible:
    a. This allows the maximum amount of time to campaign for your residency.
    b. This allows you to do research about who to meet, what kind of recommendations you need, timing, etc.

    2) Research and Planning:
    a. Number and location of residencies. There are always a limited number of residencies available. Many programs will be active, but will not have an opening when you need one. It is possible to participate in D.O. or M.D. residency programs, however to be realistic, unless you have a military scholarship you have a much greater chance of getting an osteopathic residency. Therefore, make a list of all of the hospitals that offer your residency.
    b. Call or e-mail or write to every hospital that has that residency. (Writing is best. It gives them a tangible object to actually put in your file. Two or three years later, when someone looks at your file, there will be a stack of letters in it demonstrating that you have given this a lot of thought and planning, that it is not a last minute decision just to have something to do after your internship.)
    c. Ask for the office of the DME and ask if the residency program is active. Sometimes there is some form of problem with a program, and even though the hospital is approved for training those residents, the specialists who manage and teach that residency may have closed it or decided to change it. Ask the office of the DME for the names, addresses and phone, fax and e-mail information for at least the chief of that specialty, and, if possible, the other physicians who instruct that specialty at that hospital.
    d. Ask the office of the DME if they can start a file for you at that hospital. Tell them you are (and you are) very interested in coming to that hospital for an internship and if possible, for residency. Ask them to put your letter (see b above) in that file.
    e. Call the office of the chief of that specialty. (You do not necessarily have to talk to that physician, but that physician is going to be the most direct source of information.) Be prepared with a very short list of questions, expect to take less than 5 minutes of their time but be prepared to allow them to take much more of your time if they want to. Specifically: 1) introduce yourself; 2) ask if the residency is active and for how many residents; 3) ask what they are looking for in a resident. Half of the reason for the call is to show them that you are interested and put your name in play.
    f. Write to the office of the DME or the office of the chief of the desired residency and ask for a list of the members of the residency selection committee. (They may call it something different. What you want is a list of the people who select the residents for that specialty.) Also ask for the name of the chief of staff and the chief of surgery (primarily for surgical residencies), and very important, ask for the name of the secretary of the office of the DME and the desired residency. Ask them to please place a copy of this letter in your file.
    g. Now, you have several key pieces of information to work with:
    i. The type of residency you are campaigning for.
    ii. The names of the people who select the residents.
    iii. The names of the chief of staff and the chief of surgery or medicine.
    iv. A general idea of what they want in a resident.
    v. The names of the secretaries who will be handling your paperwork, including your application.

    3) Preparation and Campaigning:
    a. Make it easy: (My basic maxim for business and life in general: Make it as easy as possible for people to give you what you want from them.)
    i. If at all possible, set everything up on computer or on your portable form of storage. You should have:
    1. All of your names and addresses, preferably arranged in a manner that allows you to easily access them and add them to documents.
    2. Form letters.
    3. Notes:
    a. You may find out that a doctor who selects for a specialty was trained by someone that you can mention in a letter.
    4. Schedule/calendar:
    a. You may find that someone who can write a focused letter of recommendation will be in a hospital that you will rotate through in a few months. If meeting that person is on your schedule, you make a point of meeting them and making an impression when you are at that hospital, whether they are part of your rotation or not. If meeting them is not on your schedule try to find a way to set aside time to meet them.
    b. Narrow down the possibilities.
    i. If there are 15 hospitals that have your residency and will have an opening when you need one, you need to write to all of them. However, you should look into what each of those residencies has to offer and try to narrow your choices down to the top 5 that best meet your needs. This is not so you can do less work, it is

    because some of the people who may be willing to write letters of recommendation for you will not be willing to give you one you can copy 15 times or to type 15 separate ones for you.
    c. Letters are tangible and will be placed in your file if you can get someone at the office of the DME or the secretary of the desired residency to start a file for you.
    d. You should be computer literate enough to have some form of universally utilizable storage medium with you when you are going on your clinical rotations.
    e. Letters: you will probably find it easier to work up form letters for many of the types of letters that you will want to write:
    i. Letter of interest to the hospitals that have the type of residency you want.
    ii. Letter to the office of the DME expressing interest in the hospital and its educational programs, both internship and residency, and asking them to start a file.
    iii. Letter to the office of the DME asking for the names of the internship selection committee, the chief of staff, the chief of surgery or medicine and the name of the secretary for the specialty that you want.
    iv. Letter to the secretary of the specialty you want asking for the names of the people who select the residents for that specialty.
    v. Letter of interest to the committee of the specialty. If you are lucky, they will actually read it during the committee meeting since it is addressed to the committee.
    vi. Letter of interest (addressed to the office address, not to the hospital) to each and every member of the group of people who select the residents for that specialty.
    vii. Sample letters of recommendation.
    viii. Letter of recommendation forms. This would be some kind of quickie note that you could use for people who you meet too casually to get them to work up a formal letter, or people who, in your opinion, will not take the time to write a letter for you even if they say they will. You make out the form with your name and a few other details like the date of your rotation at the hospital and have a few lines of blank space where they can write a note, or even a check list of how they rate you in different categories.
    f. Letters of recommendation:
    i. The osteopathic community is relatively small. Almost every hospital you go to will contain someone who knows at least one of the people on the committee that you are trying to persuade to select you.
    ii. A residency application will typically ask for 2 or 3 letters of recommendation. You will send 20 or 30. This not only tells the reviewers that you can get that many people to write a letter for you (even if it is just a form), it tells them that you can get along with people.
    iii. The second form of letter of recommendation is not to the committee. It is sent by you or by the author of the letter directly to a member of the committee or the DME or to his buddy at the hospital where you want to have a residency. This is a very powerful tool if you can get it.
    iv. The third form of letter of recommendation is from people who are not associated with the specialty you want to get into or the selection process or even education. This contemplates letters from any hospital administrators, nursing directors (good to ask them when you are on nights and are being oh-so-nice when called at 0310), priests, rabbis, community service associated personnel, etc. You have to be careful with these because if there are too many of these and not many from people in the specialty you want a committee may not take you seriously.
    g. The buddy letter:
    i. This is the most preeminent reason for all of the research you will do about who knows who from one hospital to another. You look ahead to where you want to be and find out the names of the people who will make decisions about your future. You then take this list of names with you (you can start with your clinical instructors now at the school and in any of your rotations and
    during your internship) so that when you feel you have enough rapport with someone who might write you a letter, you can ask
    them to look at the list of your first, second and third choices for residency and see if they know anyone on the selection committee, etc. If not they can write a general letter of recommendation. If they do know someone, ask them if they will write both for you, a general letter to the committee and a personal letter to the buddy.

    Remember that most people who want a residency are generally stressed and really busy and put off deciding what to go into and miss about 2 years of opportunities to get letters from people they meet. They are so busy that they get the application form and send in the bare minimum number of letters. You want your application file to be big enough to stand out but not be tedious to review. You want to be a familiar name to them but not an annoying familiar name, which can be a difficult and narrow situation to obtain.

    Details can be important. For my residency there were 47 applicants. I wrote in the application that my hobbies included painting and woodworking and stated what I liked to make and why. I did not know ahead of time that the chief of Orthopedics, Dr. Jay Wiersma, was an avid woodworker and that he was a strong believer that that kind of hobby kept a surgeon eye-hand coordinated with regard to performing the same kind of motions as in orthopedic surgery. I later learned that this small fact was one of the reasons he wanted me to come for an interview.

    James Scalone, D.O.
    Orthopedic Surgeon

  3. Another DO on Nov. 2, 2012, 11:56 p.m.

    She will be divorced by 40 and dead by 50 if she works that much.

  4. William E. Franklin, DO on Nov. 5, 2012, 3:43 p.m.

    Dr. Semen is not just an outstanding physician, she is a high quality human being. “Another DO”, I don’t think you need to be predicting calamity in her life. What’s the deal with that, anyway?

  5. Another DO on Nov. 7, 2012, 7:21 p.m.

    I wish her the best. Just an observation I have made over the years. Tell me you haven’t made it as well Doctor?

  6. William E. Franklin, DO on Nov. 8, 2012, 1:23 a.m.

    Well….do you suppose you’re going to win a prize if “you’re right”? Do you think the DO magazine is going to extend a Pulitzer prize for insightful blogging if you “win”? Again, I have to ask…what’s the deal with that?

  7. Residency: Prepare Early on Feb. 14, 2013, 11:52 a.m.

    [...] General Surgery Anesthesiology Physical Medicine and Rehabilitation (PM&R) Pediatrics Osteopathic Manipulative Medicine (OMM) Dermatology Emergency Medicine Obstetrics-Gynecology (Ob-gyn) Internal Medicine Radiology [...]

  8. Yeah I scored a 740... on March 9, 2013, 7:25 p.m.

    I agree with Dr. Franklin. She has worked hard and is doing the best she can to balance her life demands. It is transient disrespect to predict such a daunting future on her behalf.

  9. Ryan Freemyer on July 2, 2013, 9:52 p.m.

    To get into general surgery residency in todays competitive environment you must apply and have a pulse. Fluent English is helpful but optional

  10. gold on Dec. 5, 2013, 1:31 a.m.

    hi all ..
    hope u r going up
    well , wonna ask about if the surgeon having such chronic medical problem like DM , HTN, epilepsy or Addison disease ..
    how can he performm his duties ??

  11. rania mostafa on Oct. 8, 1:43 p.m.

    do you have any beneficial online course for general surgeon

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