So you want to become a specialist surgeon? Here’s how!

A specialist surgeon is someone who focuses on a particular field of medicine such as cardiology, neurology, or another specific medical field. All specialist doctors have many years of education and training in their chosen areas. But before you learn how to become a surgeon who specializes in a single discipline, there are preliminary steps you need to take.

First, you will need to become a medical doctor. Becoming a medical doctor requires, depending on the state/country you live in, that you obtain a premedical science degree and follow it up with a medical degree. More often than not, your undergraduate degree will take about four years, and medical school will require another four.

Second, it is beneficial to gain real-world experience for several years as a general practitioner before going into a specific branch of medicine.

Third, you’ll have to apply for admission as a candidate to the training program of the surgical department of a medical school. The admission criteria for a trainee as a general surgeon are strict, and competition is usually fierce. This training could last from five to eight years. At that point, you can become certified in that field of surgery.

What are the attributes that I need to become a surgeon?

Successful surgeons possess specific characteristics and outlooks that contribute to fulfilling careers. Although a strong desire to become a surgeon is paramount, and the tenacity to persevere through ten or more years of formal training is essential, you must possess other attributes as well. Without them, a career in surgery may prove challenging and unrewarding.

In addition to the ability to think on your feet, problem-solve and work well under high levels of stress, you must also be able to manage:

• Crises and emergency situations.
• Long and grueling hours.
• Extended periods of absolute concentration without breaks.
• Working with your mind and your hands.

You must also possess:

• Physical dexterity. Although you can acquire a certain amount of dexterity through practice, some of it is an innate ability. If you have had difficulty with dexterity throughout your life, surgery may prove difficult for you.
• Respect for the human body and human life. Although the field of surgery may provide you with a very comfortable lifestyle, to be successful, your primary motivation must be a love of and respect for the human body and human life. Without it, patients may see you as less than genuine and not trust you.
• Love of anatomy. A thorough knowledge of anatomy is the foundation of surgery.
• Intelligence. If you struggle with your studies despite putting in effort daily, you may benefit from submitting yourself for psychological assessment to ascertain if you have the intellectual capacity to become a doctor or a surgeon.

Basic Principles Applied in Surgery

Regardless of the surgical specialty, or type of surgery performed, every surgeon applies fundamental principles in the operating room. Because it contains innate properties, human tissue reacts to injuries in predictable ways. So, over time a set of guidelines evolved to promote optimal healing. Commonly referred to as the basic principles of surgery, every surgeon, regardless of specialty or type of surgery performed, follows them in the operating room.

• Diagnosis and preoperative assessment. An incorrect diagnosis may result in inappropriate, ineffective and possibly unnecessary treatment.
• The consideration of alternative non-surgical treatment modalities. Because most surgery is invasive, it should be the last resort.
• Proper treatment planning. It is said that good surgeons always operate twice. They visualize and plan the operation mentally before doing the actual surgery. Assisting the surgeon in this planning process are tracings, computer assisted simulations, model surgery, etc.
• Minimum invasion. When possible, consider alternatives to open surgery.
  • Scope-assisted surgery versus an open surgical procedure.
  • Interventive radiology/angiography.
  • Surgical procedures to the heart requiring the opening of the chest are being replaced in some instances by minimally invasive procedures performed by accessing the inside of an artery and performing the relevant procedure with radiographic (X-ray) assistance.
  • Good visual conditions.Surgeons must be able to clearly see the area they’re working on.
  • Exposure of the surgical site. This takes place when the surgical incision is made, and dissection is performed to reach the intended surgical site.
  • Retraction is the “pulling” away of tissue to offer the surgeon maximum exposure to the surgical site.
  • Surgical assistants and nursing staff have noted that successful surgeons always seem to complain about the light.
  • Suctioning and sponging. This is necessary to remove excess blood which may obscure the operative field.
  • Some noted physicians in history were handicapped by blindness, but not so with surgeons.
  • Handle tissue gently causing as little injury as possible. This amounts to having respect for the human body as well as an understanding of the processes involved in the repair and healing of wounds.
  • Proper control of bleeding within the limits of:
  • Minimal electrocautery.
  • Minimal suturing.
  • Minimal sponging.
  • Every action must be purposeful. For safety and economic reasons, in the operating theater, time is of the essence. Do not waste time in the OT.
  • Sterility and asepsis. All surgical instruments must be sterile (the complete absence of microorganisms), and the operative field must be as aseptic (minimizing and weakening microorganisms) as possible.

Other principles applied are not surgical in nature, but are still critical to patient comfort, trust and confidence.

• Anatomical considerations.A surgeon needs to have a detailed knowledge of the structure of the human body.
• Physiological considerations. A surgeon must have a comprehensive understanding of how the human body functions.
• Patient considerations. It’s critical for surgeons and members of the surgical team to take into account the fears and preconceived ideas of the patient about surgery and its outcomes.
• Social.Certain diseases are more prevalent in specific socioeconomic groups than in others.
• Religious. The transfusion of blood or transplantation of organs is a taboo in some religious groups.
• Financial.What are the economic implications of the proposed operation to the patient/healthcare organization?
• Expectations. What is the expected outcome and success of the procedure?
• Communication. It is essential the patient understands the parameters, risks, and limitations of surgery and anesthesia. Providing information on scars and other conditions that may be present after surgery is necessary so that the patient is as prepared as possible for the operation and what may transpire when it is finished.
• Information. This includes data about the proposed procedure and any alternatives. The patient must also be informed about any potential pain or discomfort that may be experienced, as well given pre- and postoperative instructions.
• Implications.Will the patient be able to continue with normal activities e.g., studies/work/sport/hobbies? If not, will the condition be temporary or permanent? Does the patient need a medical certificate?
• Complications.What can go wrong during and after the operation?
• Prognosis.What is the success rate of the surgical procedure, and for how long will the benefits of the operation last?

Various Disciplines in the Field of Surgery

The American College of Surgeons recognizes multiple surgical specialties [1]. As you consider the type of specialty that is best for you, it’s helpful to review your available options.

• General surgery is performed by surgeons trained to manage surgical procedures covering almost any area of the body. Within general surgery are subspecialties that include the following:
• Colon and Rectal Surgery is also known as proctology. The focus is on the diagnosis and treatment of disorders such as inflammatory bowel disease, pelvic floor dysfunction and colorectal cancer.
• Ear, nose and throat surgery,also known as otolaryngology – diseases and disorders affecting the ears and structures within the respiratory system.
• Maxillofacial and Oral surgeryalso includes dental surgery – treatment for patients with face, facial skeleton, mouth and related organs injuries, diseases and disorders.
• Neurosurgery – disorders involving the brain and spinal cord. Read the Path to Becoming a Neurologist or Neurosurgeon.
• Obstetrics and gynecology – medical and surgical care for pregnant patients, including the development of the fetus and disorders of female reproductive organs.
• Ophthalmic surgery – diseases and disorders of the eye, vision, and contents of the eye socket.
• Orthopedic surgery – anything having to do with the musculoskeletal system including bones, muscles, and joints. Subspecialties of orthopedics are:
  • Foot and ankle
  • Hand – includes upper extremities.
  • Joint replacement – mostly the hips and knees, but can include the ankles and shoulders.
  • Oncology – treatment for benign and malignant tumors of the musculoskeletal system.
  • Pediatrics – orthopedic conditions in children.
  • Spine – manages the care and treatment of back problems.
  • Sports – focuses on patients who are athletes and individuals suffering from athletic injuries.
  • Trauma orthopedics is a growing field. Patients are individuals with critical or multiple injuries to the musculoskeletal system.
• Pediatric surgery – disorders for individuals still considered children, including teenagers. There are multiple subspecialties within this area.
  • Neonatal – newborn care.
  • Prenatal – fetal care.
  • Trauma – Because children take lots of risks and end up hurting themselves, pediatric surgeons frequently face situations involving traumatic injuries sustained by children.
  • Oncology – malignant tumors and benign growths.
• Plastic and maxillofacial surgery– cosmetic procedures and the repair of body parts after the loss of tissue such as an ear. Thorough knowledge of the musculoskeletal system is critical.
• Thoracic surgery – anything in the chest area, but primarily the heart and lungs.
• Urology – manages benign and malignant medical and surgical disorders of the adrenal gland and the genitourinary system for both males and females.
• Vascular surgery – treats diseases impacting the arteries and veins throughout the body. Hardening of the arteries may be the most common problem that vascular surgeons treat.

Types of Surgery

Once you become a surgeon, you may be called upon to perform one or all of the following types of procedures.

• Open surgery is when a surgeon makes an incision with a scalpel, inserts instruments into the opening and performs surgery. An example of open surgery is a surgeon making an incision with a steel scalpel in the abdominal skin to perform a gastric operation.
• Aspiration is a type of biopsy procedure where fluid and diseased tissue are removed by a needle for laboratory examination. An example of this is a breast biopsy where the tissue removed is sent to a lab to determine if it is cancerous.
• Cryosurgery is a minimally invasive treatment where diseased tissue is destroyed by freezing it. Skin tumors, skin tags, and even freckles can be removed by this method of surgery.
• Electrosurgery uses electrical instruments operating on high-frequency electric currents. Electric currents can harden tissue, or destroy it. In essence, a surgeon “burns” away diseased tissue, or growths, or make surgical incisions while the electric current seals off blood vessels at the same time, thus minimizing bleeding.
• Laser surgery utilizes a laser beam to make bloodless cuts in tissue or to remove surface lesions. Lasers can be used for eye surgery, removal of skin marks and small tumors.
• Scope surgery is minimally invasive since it does not involve slitting open the body as a surgeon does in open surgery. Some common scope surgeries include laparoscopy, endoscopy, and colonoscopy.
• Shockwaves is a noninvasive surgical technique where soundwaves are used to break apart kidney stones. However, the sound, or shockwaves come from outside the body. Currently it is considered the surgery of choice to break apart large kidney stones.
• Ultrasonic scalpels use soundwaves to make surgical incisions that minimize This type of surgery is used when extreme precision is needed to remove small and delicate tissues, but can also be used for large tissue removal.

Post-surgical Discomforts and Complications

No matter how minor the surgery, almost all patients experience a period of discomfort during the healing process. Although every patient heals differently, most discomfort improves daily and ultimately disappears. Some of the most common discomforts include:

• Constipation and gas (flatulence).
• Nausea and vomiting from general anesthesia.
• Restlessness and sleeplessness.
• Soreness, pain, and swelling around the incision site.
• Sore throat (caused by the tube placed in the windpipe for breathing during surgery).
• Thirst.

No operation is routine. All surgeries carry with them some inherent risk because most surgeries invade the body. Risk can result in complications. Complications common to all surgeries are excessive bleeding during or after an operation and infection of surgical wounds. Others are:

• Delayed healing and non-healing wounds. An example of this is a broken bone taking a very long time to heal, or perhaps it will not grow together at all.
• A hemorrhage occurs when there is rapid blood loss from the site of surgery. This may lead to shock, so it must be treated quickly.
• Loss of function. Sometimes a patient will be unable to perform one or more tasks or activities after the operation that were possible before the surgery.
• Lung (pulmonary) complications. This complication is monitored for the first 48 hours after surgery. Sometimes deep breathing and coughing exercises are mandated for the patient to minimize the risk. The most common symptoms include wheezing, chest pain, fever, and cough.
• Neurological complications.These may manifest as the loss of individual senses such as vision, feeling in a specific area, or control of a voluntary muscle.
• Reaction to anesthesia. Although rare, patients can experience mild to severe allergic reactions to anesthetics.
• Rejection. An example of this is the rejection of a transplanted organ such as a kidney.
• Shock. Shock is created by excessive bleeding, wound infection, brain injury or metabolic problem. Immediate treatment is required.
• Sinuses and fistulas. These are small canals and holes which can result from surgery.
• Urinary retention. Temporary urine retention, or the inability to empty the bladder, may occur after surgery due to anesthesia.
• Wound infection. When bacteria enter the site of surgery, an infection can result that delays healing. In some cases, wound infections can spread to nearby organs or tissue, or to distant areas through the bloodstream.

Other complications are more external. They may not impair function, present life-threatening situations or interfere with activities of daily living. But they can lower self-esteem and self-confidence because they can be obvious and mar external aesthetics. For a patient these conditions can be all-consuming and surgeons must be prepared to manage the emotional implications. External complications include:

• Over exuberant healing
  • Keloid – a growth-like scar of a surgical wound.
  • Scarring – usually harder than the adjacent tissue and often cosmetically not pleasing.
• Pigmentation and loss of normal pigmentation – discoloration or loss of normal coloring to the area.

Frontiers of Surgery

Medical science is always evolving. Doctors and researchers are continually looking for ways to minimize risk, pain, infection and healing time to patients. There are two types of surgery on the leading edge of medicine.

• Robotic surgery. With the use of a camera and mechanical arms with surgical instruments attached to them, a surgeon can operate by sitting at a computer console. The console provides the surgeon with a magnified, three-dimensional view of the surgical site from which she or he controls the movement of the mechanical arms. The advantages of this technology include fewer complications, quicker recovery and smaller, perhaps less visible scars. As robotic surgery is refined, it’s possible that surgery can be performed on a patient who is a long distance away, including operations on astronauts in space or soldiers in the battlefield.

Healthcare Informatics, formerly known as The Institute for Health Technology Transformation (iHT2) commissioned a video featuring Intuitive Surgical’s da Vinci Arm device. Dr. David Samadi of Mount Sinai School of Medicine explains the arm and gives his thoughts on the future of robotic surgery.

• Tissue engineering/regenerative medicine. Although regenerative medicine does not yet play a significant role in treatment, it has the potential of transforming how surgery is approached. According to the National Institute of Biomedical Imaging and Bioengineering, the goal of tissue engineering is to develop,“biological substitutes that restore, maintain, or improve tissue function.” [2]. They developed a two-minute video on tissue engineering which you can see here:

Medical scientists can already grow specific types of tissue from the patient’s own cells, thereby avoiding the risk of rejection. The FDA has approved the use of artificial skin and cartilage, although their use in patients is still limited. The growing of an organ, such as a kidney from the patient’s own cells, appears to be just around the corner.

The History of Surgery

The Egyptians practiced surgery as early as 1600 B.C. Papyrus scrolls vividly describe the splinting of fractures, the care of wounds, the drainage of abscesses, etc.

Hippocrates (400 B.C.), commonly described as “the father of medicine,” wrote books on surgery, including the treatment of head injuries. TheHippocratic Oath is a pledge some medical students make when they become doctors and is commonly believed to include the phrase, “first, do no harm.”

As surprising as it sounds, during the Middle Ages, surgery was mainly performed by barbers as part of their duties. They aided monks, who, at that time were considered the primary practitioners of medicine. But a Papal decree forbade monks to spill blood on themselves, so surgery was performed by the barbers instead. Over time surgery was claimed by scientific medicine in the 16th to 18th centuries.

John Hunter, a Scottish surgeon (1728-1793), applied experimental methods in surgery. He taught his students that a surgical operation was the last resort and an admission that other methods had failed.

Two seemingly impossible situations presented stumbling blocks in the field of surgery. One was the excruciating pain associated with surgical interventions. The other was the almost inevitable wound infections occurring after surgery, especially surgery to the abdomen, chest, and skull. Most of these were fatal.

In the 1840’s, English surgeon Joseph Lister overcame the problem of intense pain through the use of anesthesia. In the 1860s, he introduced principles of surgery which significantly reduced infection.

The 20th century saw a rapid expansion and refinement in anesthetic technique, anesthetic agents and machines, sterility and asepsis, and the discovery of antibiotics. Each advancement allowed surgery to expand into many sub-surgical disciplines. With them came new, safer and less invasive surgical techniques which have become the standard surgical practices and procedures of today.

The development of the heart-lung machine made safe surgery to the heart possible – culminating in the first successful human heart transplant in 1967 by Professor Christiaan Barnard, a South African heart surgeon.

Since 1967, there have been many additional contributions in surgical history, particularly ones that lead to its newest frontiers.

References:

[1] A Guide to Surgical Specialists, American College of Surgeons,https://www.facs.org/education/patient-education/patient-resources/specialists.

[2] Tissue Engineering and Regenerative Medicine, National Institute of Biomedical Imagining and Bioengineering,https://www.nibib.nih.gov/science-education/science-topics/tissue-engineering-and-regenerative-medicine.

Featured Image Credit: Qoolingblog

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