A Look Into General Surgery With A Program Director

Session 96

Today, Dr. Brian Smith, a general surgery program director at UC Irvine, talks about his journey to becoming a surgeon and what he expects from applicants to be competitive in his program. Find out what you can do to be more competitive as an applicant and as a medical student.

Please take a listen to all our other podcasts and get the resources you need. For medical students, we have the Board Rounds (with BoardVitals). For the premed students, come check out The Premed Years, OldPreMeds Podcast, and The MCAT Podcast.

[01:30] Interest in General Surgery

Brian’s interest in general surgery started in his first year of medical school. When he started medical school, he wanted to be a family practitioner. He liked the idea of continuity and being able to take care of the whole patient.

Very quickly after starting his rotations in the anatomy lab, he realized he had a tremendous love and passion for human anatomy. It was the first time he ever considered surgery. He knew that if he wanted to spend most of his career involved with human anatomy, then surgery would be a excellent way to do so.

'I quickly learned that the best way to really master something is to teach it.'Click To Tweet

[03:00] Traits that Lead to Being a Good General Surgeon

One of the basic traits of being a good proceduralist is that you like working with your hands as well as diagnosing or treating things.

Do you like working with your hands or do you like working with your brain? Once you’ve answered that question and you’ve moved down to “working with hands” halfway, then you begin to figure out you’re probably down the proceduralist path.

Brian’s inherent tendency is to enjoy fixing things. He used to enjoy working with his car. He likes tinkering with things. He has always had this inherent joy in taking a problem and giving it a definitive fix.

'General surgery is just that – you've got a huge variety of things you get to fix.'Click To Tweet

Surgery initially became the clear choice for Brian. But general surgery became his choice when he was sure he needed the variety. He enjoyed the variety that comes with general surgery.

[04:50] Risk of Running Out of Patients

'There will never be a shortage of general surgery patients.'Click To Tweet

As Brian puts it, one of the beauties of general surgery is they take care of the whole patient. They take pride in the fact that they’re really an internal medicine physician that operates. They’re able to manage the entire patient and at the same time be able to operate and fix their derangements.

'We're really an internal medicine physician that operates. We take care of the whole patient.'Click To Tweet

There’s a tremendous kinship with either family medicine or internal medicine who serves as the contractor for all of the patient’s ailments and really manage them all.

That being said, there’s a drive or movement in the direction of increasing subspecialization of current trainees. This is a trend that’s not going to dramatically change over the near future.

But for those people with broad interests and really like to take care of the whole patient, general surgery has that to offer. Brian was concerned that subspecialization would narrow down his knowledge base. And he didn’t want to give that up, hence, he chose general surgery.

[07:00] The Bread and Butter for General Surgeons

The bread and butter in 2019 is dictated by the community in which you serve. If you’re a general surgeon in the midwest and there’s not a lot of specialists in town, you’re more likely to do more than the general surgeon in downtown Los Angeles.

By and large, in the urban and suburban environments, the bread and butter for general surgeons is going to consist of gastrointestinal surgery, colons, gall bladders, hernias, endocrine surgery including thyroids, parathyroids, and adrenals.

Occasionally, they deal with the liver, spleen, skin (melanoma and skin cancers), and extremity work (soft tissue tumors).

'Breast surgery is definitely bread and butter for most general surgeons.'Click To Tweet

[08:20] The Most and Least Liked Things About Being a General Surgeon

Brian loves being able to take care of all the patient’s needs. He’s able to handle almost everything.

From an operative perspective, he loves being able to travel all over the body. He rarely does two of the same operation in one day. He’s constantly doing something different. And this forces him to keep up with the literature or current advancements in a specific area. It keeps him sharp and interested. And it never gets dull and boring.

On the flip side, what Brian likes the least about his specialty is more on the administrative aspects that come with surgery in 2019.

There’s a lot of time spent charting on the electronic medical record. It’s a wonderful thing, in and of itself. But it takes extra time that it becomes a distraction. Now he gets to have less time spent face-to-face with patients. It prevents him from having that human interaction and bonding that makes a good physician-patient relationship.

'Being a good listener is prerequisite to be a good clinician in almost any specialty.'Click To Tweet

[10:00] The Training Path and Career Trajectory

The medical student basically applies for general surgery where they will match into a categorical internship followed by residency. In general surgery, they don’t distinguish internship and residency because they’re a single continuum. The first year is just the internship.

There are six-year programs across the country where they will have one year of mandatory research. These are heavily focused on clinical outcomes research during the year of mandatory research.

There are also seven-year programs where there will be two years of mandatory research, most of which is basic science research.

The standard five-year programs are focused on training somebody to be clinically confident. A resident may or may not be expected to have some research productivity during that time.

'One of the beauties about general surgery is you're still tiny, potent stem cell. You can still differentiate into a number of different specialties.'Click To Tweet

You can train in general surgery and go out to practice. Or you can do a one-year fellowship in minimally invasive surgery, bariatrics surgery, thoracic surgery, or spend several years doing cardiac surgery. You may also combine cardio thoracic fellowship. You can go do a year of colorectal fellowship. Or you can do additional training in plastic surgery or a year of breast surgery or endocrine surgery.

You can stop after general surgery training and be the generalist, or you can still go down one of 10 or 12 different pathways now – some are ACGME-certified and a few are not.

You can get specialized fellowship training in order to be better at a particular subsection of general surgery.

Brian did general surgery but he also took one year fellowship in minimally invasive bariatrics surgery. That said, it’s not the entire focus of what he does. He still gets to be a general surgeon but he has that specialized niche training which he enjoys several days of the week.

[12:45] What They’re Looking for in Applicants

As previously mentioned, Brian is a program director for a general surgery residency. One of the first things they’re looking for is somebody with a broad interest and is eager to learn. These are inherent traits that they need the applicants to bring with them.

In terms of the more tangible level, they sort of move in this hierarchy of importance. First, applicants need to be academically qualified. Sadly, the best measure is still USMLE Step 1. Since not everybody has taken Step 2 by the time they apply, they can’t use it as diligently as they do Step 1. So do well in Step 1.

Ideally, they would then want to see somebody with a good, solid dean’s letter. They also look at how they’ve done on their clinical clerkships, how many courses they’ve honored, and how they did in surgery. They also look at how the applicants did in their internal medicine rotation.

Again, getting back to that kinship with internal medicine, somebody who’s broadly interested really likes to take care of the whole patient. To him, this is an appealing characteristic.

Then they look closely at letters of recommendation, research background, and personal characteristics, respectively.

'I'll never get to somebody's letter of recommendation if they're not academically qualified in the first place.'Click To Tweet

[14:40] Pass/No Pass for Step 1

Brian loves the idea of Pass/No Pass for Step 1 recognizing that students can have a bad day or they choke on the exam for some reason and they just don’t achieve their potential.

'It's a tragedy to think that somebody might not be able to join a specialty that they genuinely are interested in simply because of how they do on one exam.'Click To Tweet

The magnitude of the high stakes Step 1 is a problem that needs to go away. But that being said, Brian’s biggest concern is that we don’t have another good surrogate. There’s no other good, easily identifiable measure to help determine one’s academic qualifications.

Program directors need to look at an entire application and not just a Step 1 as a screening score, which many of them do. So he likes the concept of it not being a weeder or screener. But there should be a composite measure of one’s academic qualifications.

It doesn’t mean that if one doesn’t do well on the test, that they can’t be a fantastic clinician. In fact, Brian says, some of the real gems that he found are not the people that completely knocked Step 1 out of the park.

However, they also want to make sure that they did well enough on it so they won’t struggle on their in-service exams or passing their written board exam. As a program director, one of his endpoints for students is for them to be able to easily get out and obtain their board certification.

So while he likes the concept, he thinks additional surrogates are lacking which can serve as a good marker of academic qualifications.

[17:10] Why the Need for Academic Qualifications

'Part of being a fantastic clinician is having the book smarts and the knowledge to back up your clinical skills.'Click To Tweet

A good residency program does a phenomenal job of developing clinical skills. But in your average five-year program, a resident who doesn’t have a whole lot of book knowledge as a foundation can only continue to excel and do well until you get to the fourth year of residency.

In the fourth year, there’s so much clinical skill that now starts to rely on a solid foundation of knowledge. So you may be technically good in the operating room, but if you don’t have the knowledge foundation to back up those clinical skills, that deficiency starts to get a spotlight on it right around the beginning of your fourth year.

If that deficit in knowledge continues in the fifth year, it starts to be an anchor for a good resident. There’s a tremendous knowledge base that backs up any clinical superstar.

By academically qualified, it means being academically capable of sitting down and synthesizing and getting a tremendous knowledge base in their head. By doing so, they’re able to back up their decision making and their instincts they’ve learned as residents.

You should be able to establish that you have the study habits, the intellectual capacity, and capability to pack a lot of information into your brain about a particular specialty.

Brian explains that you can train almost anybody as a surgeon. What is a tougher challenge is training a clinical superstar.

[21:21] What Makes a Superstar Sub-I

A superstar sub-I will oftentimes be almost seamless with an intern. A lot of time in the third year is spent on just learning how to function comfortably in the hospital environment. Then you begin to know how to accomplish patient care on a regular basis.

'A good sub-I starts to put all of the things they've learned to actual practice, which is in reality what a good intern does.'Click To Tweet

A great sub-I is somebody who is functioning at the level of an intern. These are students that have a lot of charisma and are self-starters. They are able to figure out how to start a new rotation. They can quickly get up to speed with important details and facts. They’re able to identify key interactions that need to occur and execute those efficiently. You have to master how to be efficient.

A great sub-I reads about their patients and knows their patients backward and forward. A student will never have a better opportunity to solidify in their own mind all the details of the disease process as they will when they have a patient with that disease process.

[24:19] What Medical Students Shouldn’t Do

Brian explains that the fastest way medical students shoot themselves in the foot is when they treat those beneath them with disdain.

For instance, the medical student comes into the operating room and talks down to the circulating nurse or disrespectful to the ICU nurse. Nurses that do the same thing over and over for years know what they’re doing very well.

When medical students fail to recognize the knowledge and the expertise in the rest of the team involved in the patient’s care, oftentimes, they shoot themselves in the foot.

'Mistreating the support staff is the kiss of death.'Click To Tweet

[25:55] Mistakes Medical Students Make with Their Application

If your Step 1 is not a true reflection of what your knowledge and skills are, then study up and take Step 2. Let Step 2 prove that Step 1 was not an accurate reflection of what you’re capable of.

'People oftentimes fail to look at Step 2 as a meaningful shot at redemption.'Click To Tweet

Somebody with average performance on a sub-I is somebody who’s not going to do really well. Failing to recognize that the sub-I really is your audition and treating it as such is such a huge misstep.

[27:40] How Important Are Elective Rotations

'Outside rotations are critically vital to maximizing one's chance of matching in a program that they're really happy with.'Click To Tweet

An external rotation is a very easy way to get an interview at that institution. Especially for people with mediocre applications, they need to do external rotations to maximize the likelihood that they’re going to perform at a really high level. This increases their chances of getting an interview.

Brian encourages their students to do two external rotations and fill the rest of them in at their school of medicine.

If your passion is simply based on one rotation you really like and go do general surgery, Brian hopes you have the maturity to recognize that it may mean there are a whole lot more rotations that you’re going to go through that might grab you equally.

[32:50] The Influence of Great Mentors

Mentors have a lot of ability to sway or influence that “organic chemistry” with a specific specialty. If you really have a good mentor, then you’d naturally be drawn towards that specialty. And this is often how people end up deciding where they’re going to apply for a residency.

There is something very appealing with having really great mentors, particularly when you get the trainees actively involved.

'When people become masters of things, they tend to really love those things.'Click To Tweet

Brian pushes people to become content experts in general surgery early on in their residency. And this oftentimes naturally translates to falling in love with it.

[34:30] Women in General Surgery

Brian explains there are a lot of female general surgery mentors. Regardless of what lifestyle, you need to start with the specialty you love. There’s no specialty within medicine that anybody is going to enjoy doing for 30 years if they’re not passionate about that particular specialty.

'Regardless of the lifestyle you're looking for, you need to start with the specialty that you love.'Click To Tweet

Once you have found something you love and enjoy, you can always find a career setting that allows you to balance work and life in a manner that works well for you.

Brian has worked with amazing female clinicians who are even technically better than many of their male counterparts. Men and women have equal opportunities in general surgery.

That being said, females may be more reluctant to choose a surgical career because they don’t necessarily see people having as much of the balance they’re looking for.

Ultimately, find your passion and get trained in something you love. If doing it gives you the work-life balance that works for you. You will find that opportunity somewhere out there.

Brian encourages female students to give general surgery a try. You can have it all. But having it all means doing something you love in the process. Then finally find the balance that works for you.

Additionally, one of the beauties about being a specialist or proceduralist as a female is being able to work 2-3 days a week. But you still can make the same amount of money you would make 5 days a week as a primary care physician. This gives you financial liberty. It gives you more options to create the balance of work and life you’re looking for.

[38:25] Overcoming Bias Against DOs

Brian thinks a lot of the bias is now starting to fall by the wayside. It’s still important to take USMLE so it’s easier for you to be compared to somebody else. Do those external rotations and sub-I’s. Have competitive board scores.

At the end of the day, a DO with a mediocre Step 1 but was an absolute clinical superstar on their sub-I, is way more appealing than somebody who’s got a 265 on Step 1 and just an average sub-I participant from a top medical school.

'I'm looking for gems. I'm not looking for showpieces for my program.'Click To Tweet

Brian is looking for people who are engaging for him to work with and train over the next five to seven years. They have to be easy to teach and fun to operate with. Be charismatic and be eager to learn.

[40:05] Final Words of Wisdom

Get out and spend some time shadowing. This is very important early on in the first and second year of medical school. This will give you a genuine flavor for what experience looks like in many of those specialties.

On your third year, pay attention to sorting out where you want to be. Do you want to take care of patients with your brain or with your hands?

Once you decide you want to become a proceduralist, you want to figure out whether you want to do something surgical or non-surgical with your hands.

Ideally, you want to be able to figure these out by springtime of your third year, then you can start your sub-I’s in the fall. Start looking for mentors in the specialty.

People who figure out what they want to apply for late in their third year are at an inherent disadvantage. So try to sort things out earlier on the third year where your passions lie.


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