Monthly Archives: January 2014

Residents and Fellowships the Saga Continues

Residents and Fellowships

General Surgery News¬†had an article in the January edition about how residents are pursuing fellowships despite the job market not requiring fellowship training. The article can be found here.¬†Clearly there appears to be a multitude of problems when 70% of surgery residents are entering fellowship and only 1/3rd of the job postings require a fellowship. While a lot has changed in general surgery, general surgery training, and the culture of the medical field resulting in residents wanting to specialize, I don’t think that analysis of job postings is the right way to look at it. Here are my thoughts:

  1. Fellowship trained physicians enter a much smaller community where job postings may not need to be as frequently utilized. Job postings are likely to be for more difficult to fill positions.
  2. Likely the organizations care less about your fellowship and more about how you fit into the call pool, and they want you in the general surgery call pool.
  3. Surgery has been in a specialization phase to keep up with the rapid advancement of minimally invasive techniques. This created a over-inflated demand for the young specialist who could do these procedures. Supply will overturn demand eventually.
  4. The real study should be surveying graduated fellows how completion of the training program affected their job, with a follow up survey at 3 years about the utility of their fellowship in their daily practice.
  5. The societies of the specialties should be the ones monitoring the utility of their fellowship and figuring out how to create maximum benefit to the graduates even if this means winding down lower tier fellowships ultimately reducing the number of members of their society. They have a duty to maintain the integrity of the specialty.

Ultimately with the proper training, good bedside manner, and excellent interactions with referring physicians you can find your niche and practice your specialty but it may become increasingly difficult to keep yourself in a specialist only practice and call pool and to fend off the wave of incoming newly minted specialists.

Inpatient vs. Outpatient Treatment of Diverticulitis

Great strides have been made in moving treatments into the less expensive outpatient setting. Diverticulitis is one disease process that we have become more and more aggressive in our outpatient management and a newly published randomized controlled trial shines high level evidence on this trend.

Article in Annals of Surgery, should be a free PDF too.

In a multicenter randomized controlled trial, researchers randomized uncomplicated diverticulitis patients in to two groups. Group 1 was hospitalized for minimum of 36h and given IV antibiotics and then discharged on PO antibiotics, Group 2 was given IV antibiotics in the ER and sent home on PO antibiotics.

While there were many worthwhile exclusion criteria included one, in particular bothered me “absence of symptom relief (maintenance of tenderness, fever, or/and persistence or worsening of acute pain after analgesic and first doses of antibiotics)” as this seems to subjectively select for the milder forms of diverticulitis. Which also plays out in the analysis of the patient populations as the mean WBC count was 11.1 for the two groups.

Ultimately their analysis demonstrated no difference between the inpatient and outpatient groups. So what does this mean… Unfortunately the most that I can take away from this evidence is that mild diverticulitis should be treated as an outpatient. Most physicians know this and their practice patterns reflect this.

I would have liked to have seen the study without the above mentioned exclusion criteria, to see whether or not the more severe diverticulitis patient’s benefited from hospitalization.

Learning Point:

Diverticulitis is bad mmmmkay