A guide to working in... General surgery
Clinical tutor Dr Michael Daly provides some top tips on why you should choose general surgery as a specialty
One of the greatest dilemmas in medicine is choosing where you’ll be happiest devoting your considerable talents for the next four decades. For many, the demographic variability of general practice strikes a chord, while the lure of creating a resilient therapeutic alliance attracts others to fields like psychiatry, and the rapid pace and acute presentations of emergency medicine appeals to the dopamine chasers amongst us.
Occasionally, you find a colleague who thrives on the compulsive perfection of performing a textbook procedure, manipulating anatomy or physiology in real-time, as in anaesthesia. Then there are those among us who would much prefer an academic career, married to the stimulation of shaping the eager minds of students, tenured colleagues and every grade in-between. In this sense, general surgery earns its adjective.
The sheer scope of the field is truly incredible. Generalists are many things, but rarely disinterested.
Most general surgeons are caffeine aficionados; rising early and reviewing their current inpatient load at daily handover meetings by 7.30am.
“General”: adjective Affecting or concerning all or most people or things; widespread.
This allows the opportunity to catch up on any overnight drama, which might have included any number of events, such as an emergent CT for yesterday’s hemi-colectomy patient, out-ruling an anastomotic leak after they developed a persistent tachycardia and increasing pain, and discussing any new referrals that non-surgical teams have asked you to review. The round then proceeds, with dynamic and usually Socratic teaching on anything from the minutiae of classical anatomy to the latest developments in pharmacology, before a surgical team breaks off for theatre or outpatients.
Outpatients can be incredibly rewarding as it’s here that you see the tangible effects of your work; whether it is a routine follow up of a perforated appendix or pre-assessing a patient’s global fitness for a proposed and potentially challenging bariatric surgery. General surgeons are not simply technicians; they continue to review patients who have been with the team for up to five years after their initial operation. Discharging a patient in this situation is very rewarding, and it’s definitely a highlight of the job.
From time to time outpatients will consist of purely surgical work with a minor operations list. This is an excellent opportunity for junior colleagues to practise the core clinical competencies of independent operating by tackling sebaceous cysts, squamous and basal cell carcinomas and a whole host of other local lesions.
Depending on the geography of your institution, the on-call commitments will vary as an NCHD. Typically in the same duty you might be called to theatre to assist with an emergency laparotomy, resuscitate a GI bleed, discuss management of a compartment syndrome in a ventilated patient in ICU, provide support for your junior colleagues with the ward inpatients, offer specialty advice to the community physicians, negotiate with radiology about the acuity of scans and admit referrals from the Emergency Department.
I would like to see the day when somebody would be appointed surgeon somewhere who had no hands, for the operative part is the least part of the work.Dr Harvey Cushing, American neurosurgeon
Generalists are sometimes called upon to provide vascular, paediatric and orthopaedic support, especially in secondary centres, so abdominal pain, while being your bread and butter, is not the only presentation you must be familiar with and comfortable managing. It can be a long and tiring shift, with many peaks and troughs of anxiety, but at its core it’s invariably gratifying. You are rarely alone in this endeavour. Surgeons are team players and work with a varied and knowledgeable team which includes physiotherapists, occupational and social workers, specialist nurses, anaesthetists, intensivists and the theatre staff.
Surgery is not for everyone, but those who appreciate providing compassionate, appropriate, and ultimately effective treatments in an intensely personal sense will gravitate towards it. Students who are passionate about applying the theoretical to the practical and enjoy practice-based learning in a dynamic and professional environment thrive in this specialty. Surgery is a significant life event for the majority of patients and therefore interpersonal skills and empathy are highly valued commodities in trainees, as is the ability to self-reflect.
It is a highly competitive field, and you should try and get as many operating and inpatient attachments as you can, whether it’s by way of a formal rotation, voluntary elective or signing up for team audits with your local general surgeon.
History is written by those who show up, so angle your internship with a definite slant towards the specialty, and it never hurts to start revising for the MRCS as soon as you can.
Letters of recommendation go a long way, and a safe, professional and knowledgeable intern will be much sought after for entry into core surgical training whether in Ireland or abroad.
Surgery is not for everyone, but those who appreciate providing compassionate, appropriate, and ultimately effective treatments in an intensely personal sense will gravitate towards it
Operating is but one aspect of the job, and while it can be incredibly rewarding, the role of the surgeon itself is one with many different facets, all of which must be mastered to provide comprehensive care. General surgical disease affects all people and is always concerning. To be in a position to alleviate it is a lifelong privilege.
Dr Michael Daly is Clinical Tutor at the University of Otago, Wellington, New Zealand.