So You Want To Be a General Surgeon

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So you want to be a general surgeon. You like the idea of being the generalist of the operating room and having the knowledge and skills for a wide range of surgical interventions. Or maybe it’s just a stepping stone for you to get to the subspecialization you’re after. Let’s debunk the public perception myths, and give it to you straight. This is the reality of general surgery.

 

What is General Surgery?

General surgery is the broadest of surgical fields, covering the surgical management of diseases from head to toe. This may include head and neck surgeries, to thoracic, to interventions inside the abdomen. Operations can range from removing cancer, to treating traumatic injuries, to restoring function to diseased tissue.

We think of surgeons most commonly in the act of performing surgery, but a big part of the work surgeons do is taking care of surgical patients. This includes diagnosing a patient’s illness, assessing various interventions, and caring for the patient before and after surgery. Examples include staging a cancer patient prior to surgical intervention or managing ICU patients who are postoperative yet remain very sick.

Even the busiest surgeons are in the operating room only a couple of days per week. The rest of their time is spent seeing new patients or postoperative patients in the clinic. If the surgeon is part of an academic center, they’ll also have to divide their time between academic responsibilities, including teaching and research. This brings us to an important method of differentiating a general surgeon’s practice.

Academic vs Community vs Private Practice

In academia, general surgeons tend to be more specialized, meaning they’ve done a fellowship after residency and are managing patients within a specific niche. At these larger academic institutions, you’re also more likely to see complex and rare pathologies that are infrequently managed at smaller community practices.

In community or private practice settings, general surgeons are more likely to operate without fellowship training, although several are still fellowship-trained. Compared to an academic practice, community and private practice general surgeons have higher average compensation.

Misconceptions About General Surgery

Let’s clear up some of the misconceptions about general surgery.

First, some think that general surgery is the specialty for medical students who want to be surgeons but aren’t competitive enough to match into a more desirable surgical subspecialty, like plastic surgery, neurosurgery, orthopedic surgery, and so on. The truth is that general surgery has a great deal to offer that is unique from other surgical fields, and for that reason attracts a large number of candidates.

Second, the challenging lifestyle aspects are often overstated, at least for when you’re a fully trained attending physician. Ultimately, your work-life balance comes down to the type of specialization within general surgery you pursue, in addition to the type of job you seek out. You have the ability to negotiate toward a true lifestyle specialty to something more stereotypically intense.

 

How to Become a General Surgeon

After medical school, general surgery residency is 5 years, although some programs have 2 mandatory research years built-in for a total of 7 years. The 7-year residencies are usually at academic residency programs and are preferred by medical students who are either seeking an academic career or want to apply to a more competitive fellowship.

As a PGY1, also known as your intern year, you’re usually not operating much, and are instead focused on managing surgical patients on the wards, meaning those staying in the hospital, usually requiring post-operative care. You ensure floor work is taken care of and act as the eyes and ears for the rest of the team who are usually scrubbed into cases or handling the clinic. Once you finish your work, you are generally welcome to join your team in the operating room and scrub into cases.

As a junior resident, meaning your PGY2 and PGY3 years, you’ll have one intern below you and one senior above you on any service. If new consults come in, you’ll be seeing them. If you’re in the operating room, you’re likely doing smaller or more straightforward cases, while the more complex cases are handled by the senior resident.

As a senior resident, meaning your PGY4 and PGY5 years, you handle the most complicated cases and have the most autonomy, both inside and outside of the operating room. That translates to making treatment decisions, putting plans into place, and operating with less supervision. In your chief year, meaning as a 5, when you are most senior, you will also have the added responsibility of handling light administrative work for the residency program, such as schedules and responsibilities for the residents below you.

Research years, if required by the program, are typically done after either PGY2 or PGY3. Residents typically maintain some level of clinical involvement during this time to keep their clinical acumen sharp, such as by taking call occasionally or covering overnight shifts.

In terms of competitiveness, general surgery is middle of the pack with 70 points in our MSI Competitive Index, ranking below vascular surgery and above med/peds. Of the surgical specialties, general surgery is the most attainable. The match rate is 84%, with the average USMLE Step 1 score being 235, and the average Step 2CK score being 247.

 

Subspecialties within General Surgery

After completing general surgery residency, you can further subspecialize with fellowship. Historically, any form of surgical specialization through fellowship always followed a general surgery residency. This is termed the independent pathway. If you wanted to become a plastic surgeon, you would first complete 5 years of general surgery residency, followed by 3 years of plastic surgery, for a total of 8 years.

As medicine has moved further toward specialization, combined pathway programs cropped up, whereby you would complete 3 years of general surgery residency followed by a few years of specialty training. For example, combined plastic surgery programs combined 3 years of general surgery residency with 3 years of plastic surgery, for a total of 6 years.

And finally, the integrated pathway is now gaining momentum, whereby you match and complete training in your surgical specialization from day 1 of residency. Neurosurgery and orthopedic surgery have done the integrated pathway for some time now, and there are no independent or combined options. Plastic surgery has followed suit, but there are still some independent and combined programs available, although they are declining in number. More recently, cardiothoracic surgery integrated programs have been cropping up around the nation. Integrated pathway programs are shorter and more focused on your ultimate specialization. However, they are usually substantially more competitive than going the independent pathway, and some are concerned about weaker training in the fundamentals of surgery.

Trauma / Critical care

To specialize in critical care you’ll complete a 1-year fellowship, although a 2nd year is usually completed for those who ultimately want to work at busy trauma centers. Trauma and critical care combine the best of both worlds – you get both high-intensity surgeries but also clock out when you’re not on shift. As a result, you get decent control over your lifestyle.

Typically these surgeons also have a component of their month for elective general surgery and emergency general surgery call, which can be flexible depending on the surgeon’s preferences.

Colorectal

Colorectal surgery is a 1-year fellowship for general surgeons who appreciate a decent lifestyle and a wide variety of procedures, from colonoscopies to small outpatient procedures to bigger cancer operations, including both minimally invasive and open cases.

Pediatric

Pediatric surgery is a 2-year fellowship whereby you essentially become a general surgeon for children. Compared to adults, your patients will bounce back faster from surgeries. Your bread and butter will include a large number of gastrointestinal surgeries, treating emergencies, and correcting congenital birth defects.

Within pediatric surgery, there is a high degree of specialization. For example, a neurosurgeon, orthopedic surgeon, or plastic surgeon can subspecialize in various pediatric-focused specialties. As a result of this specialization, it is often difficult to find general pediatric surgeon job openings. You might have to take a job in a part of the country you might not otherwise have chosen.

Breast

Breast surgery is a 1-year fellowship, focusing primarily on resecting cancer from the breast. The hours are considered less intense compared to other surgical fields and it is more conducive to a balanced lifestyle. You’ll be working in close conjunction with plastic surgeons who will be reconstructing the breast usually immediately after.

Vascular

Vascular surgery is a 2-year fellowship. With technological advances, many of your cases are endovascular, whereby you use wires and stents to fix issues within blood vessels, from the aorta on down. You’ll also be involved in reconstructing vascular supply to the body’s organs while working in tandem with other surgeons, such as during massive tumor resections, repairs after trauma, and so on.

Endocrine

Endocrine surgery is a 1-year fellowship whereby you’ll specialize primarily in surgeries of the thyroid, adrenal gland, and to a lesser extent pancreatic lesions, which are more often handled by hepatobiliary or surgical oncology teams. Endocrine has a great lifestyle, as there are typically few emergencies on-call, and working hours are considered favorable.

Transplant

Transplant surgery is a 2-year fellowship primarily focusing on kidney and liver transplants from deceased donors to live recipients. Less commonly, you’ll be performing pancreatic transplants or live donor liver transplants, whereby part of the liver is transplanted given the unique regenerative properties of the liver.

This is one of the most rigorous and challenging specialties from an hours and technical standpoint. Not only are liver transplants extremely lengthy and difficult to perform, but you can also get called nearly 24/7, as donor availability is usually unplanned and harvesting is highly time-sensitive.

Surgical Oncology

Surgical oncology is a 2-year fellowship focusing on surgical management of cancer throughout the body. Bread and butter cases include breast cancers, colon cancers, soft tissue cancers, such as sarcomas, and other abdominal cancers including the liver or pancreas.

It’s a competitive fellowship and the hours can be long and demanding, but those who are drawn to this line of work find it highly rewarding.

Minimally Invasive

Minimally invasive surgery, aka “MIS,” is a 1-year fellowship where you gain additional training in advanced laparoscopy and robotic skills. This often, but not always, translates to focusing on minimally invasive foregut surgery, bariatric surgery, and abdominal wall reconstruction. It’s more on the competitive side and is considered to have a good lifestyle after training.

You can also pursue fellowships in cardiothoracic and plastic surgery. Be sure to check out our pieces on those specialties if you want to learn more.

 

What You’ll Love About General Surgery

There’s a lot to love about general surgery. General surgeons are the ultimate physician or the “doctor’s doctor.” They can broadly diagnose, stabilize, and treat nearly any acute life-threatening condition and then take it up a notch by fixing the problem with their hands. If you could pick only one type of doctor to be stranded on a boat with, you’d want a general surgeon.

General surgery is immensely satisfying. You’re intervening to save someone’s life on the brink of death, curing cancer, transplanting organs, and more. These are some of the most exciting and deeply meaningful things you could ever ask for in a job.

Compensation is in the upper half of specialties, with general surgeons pulling in approximately $373,000 per year.

And there will always be a need for general surgeons.

 

What You Won’t Love About General Surgery

While general surgery is awesome, it’s not for everyone.

Training is lengthy, much more so than non-surgical fields. While your non-surgical medical school classmates are finished with residency and living their attending lives, you’ll still have another few years to complete.

The hours in training are also long. There will be plenty of early mornings, late nights, busy overnight call, and surgeries lasting several hours. And while there is some flexibility in your work-life balance after you finish training, know that the average surgeon still works 60 hours per week.

And finally, compared to other surgical specialties, general surgeons have the lowest compensation.

 

Should You Become a General Surgeon?

How can you decide if general surgery is right for you? They say that if you can find happiness in another specialty of medicine, then do that. Only do general surgery if you couldn’t imagine yourself doing anything else.

If you’re passionate about medicine broadly and like the idea of being a doctor’s doctor, general surgery might be for you. You should love working with your hands, thrive in having a serious level of responsibility for your patients, and crave and enjoy deep, meaningful connections with patients. The joke that surgeons just put patients under anesthesia and don’t interact with them couldn’t be further from the truth.

Are you hoping to become a general surgeon? To get into medical school and match into general surgery residency, you’ll need to score well on your class tests and standardized exams. As you look at resources and companies to work with, seek out those who are actual MD physicians, not PhD or other types of doctors that didn’t go to medical school. Look for those who have achieved stellar results themselves, a track record of success with positive ratings from customers, and a systematic approach so you know you’ll always receive high-quality service. If you decide on Med School Insiders, we’d love to be a part of your journey in becoming a future physician.

If you enjoyed this article, check out our So You Want To Be a Cardiothoracic Surgeon, Trauma Surgeon, and Plastic Surgeon pieces. If you’d like to see what being a general surgeon looks like, check out my second YouTube channel, Kevin Jubbal, M.D., where we’ll have a day-in-the-life episode of general surgeons in the future.

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