How to Become a Surgeons, All Other

Where Surgeons, All Others have the most money left over after rent

Median pay minus estimated federal + state + FICA taxes, minus 12 months of rent at HUD's 2-bedroom Fair Market Rent. Darker green means more money left over each year. Hover any state for the breakdown.

Education and training

General surgery is five years of residency after four years of medical school after four years of undergrad. That's 13 years minimum from high school graduation before you're a real surgeon. If you add a fellowship (which most people do now), it's 14-15 years. Understand that before you commit.

Undergrad requirements are the standard pre-med package. Surgery-bound applicants benefit from research, but clinical experience matters more for surgery than for academic-heavy fields. Volunteering in an OR as an undergrad, even in a limited capacity, tells you things about yourself that no amount of reading will. Some people discover they love the environment. Others discover they hate it. Better to find out at 20 than at 28.

Medical school: four years. Your surgery shelf exam matters. Your sub-internship in surgery matters a lot, both for your application and for your own certainty about the specialty. Step 1 scores for surgery match are in the 240+ range for most programs, competitive programs want higher. General surgery is competitive but not dermatology-competitive; a solid student who genuinely wants to operate and communicates that well in their application and interviews matches successfully.

General surgery residency is five years, categorized as PGY1 through PGY5. PGY1 is still broadly called internship and is characterized by floor work, endless scut, and learning to function on inadequate sleep. The operative experience builds through residency. PGY3 and PGY4 are often the most educationally intensive years. PGY5 is the chief year, when you're running the OR service and doing the complex cases.

Fellowship after general surgery has become essentially required for subspecialty practice. Colorectal, minimally invasive/bariatric, hepatopancreatobiliary (HPB), surgical oncology, trauma/critical care, endocrine, and thoracic are the major tracks. Fellowship is one to two years. Many programs also offer integrated five or six-year residencies in thoracic and vascular surgery that don't require a separate general surgery residency. Board certification from the American Board of Surgery requires passing both written and oral examinations after residency completion.

Licensing and certification

State medical licensing after passing USMLE Steps 1, 2, and 3 is required. Surgeons taking their first job should apply for licensure early in their final residency year because credentialing at the hospital where you'll operate also takes two to four months and you can't work until both are complete.

Hospital credentialing for surgeons is more complex than for physicians who don't do procedures. You'll need to demonstrate procedural competency, submit operative logs showing case volume and type, and have your training verified. Every hospital where you want operative privileges requires a separate credentialing application. If you're in a health system operating at multiple sites, expect to credential at each one.

DEA registration is required for prescribing controlled substances in the perioperative setting. Most surgeons carry a DEA number routinely.

ABS board certification (American Board of Surgery) requires completing written boards and oral boards after residency. Written boards have a 70-75% pass rate on first attempt. Oral boards are more variable and test your judgment in complex clinical scenarios; they're genuinely difficult and failing them is more common than in some other specialties. MOC after initial certification requires ongoing CME and periodic recertification. Fellowship-trained surgeons seeking subspecialty certification may pursue additional boards, such as the American Board of Colon and Rectal Surgery for colorectal specialists.

What the day-to-day looks like

The general surgeon's day starts before most people are awake. Pre-operative rounds at 5:30 or 6 AM to see post-op patients from the previous day, check drains, review labs, write notes. OR cases start at 7:30 AM and run until they run until. A scheduled day might include a cholecystectomy, a hernia repair, a bowel resection, and an appendectomy, but the emergency add-ons don't care about your schedule.

Clinic happens on non-operative days, running new patient consultations and follow-ups. Surgeons who do a lot of elective work have fairly predictable clinic-OR alternating schedules. Trauma surgeons and acute care surgeons have a more chaotic rhythm dictated by what comes through the ER.

Call is the defining lifestyle feature of general surgery. Trauma call, acute care call, and general surgical emergencies mean that being on call as a general surgeon is genuinely unpredictable. Mid-level attendings in community hospitals who are covering acute care and trauma can be up all night and then expected back in the OR the next morning. The 80-hour workweek rule applies to residents; there's no such rule for attendings.

HPB surgeons, colorectal surgeons, and surgical oncologists in academic centers have a more predictable rhythm because elective subspecialty cases dominate. They still take call, but it's often shared in larger groups. Private practice general surgeons in community settings often carry more acute care burden than their academic subspecialty colleagues.

Career progression

General surgery attending salaries start at $300,000-$450,000 for employed positions. Productivity-based private practice can yield more, but you're building from zero in a new market. Trauma and acute care surgery employment often comes with a guaranteed salary because the hospital needs someone to cover 24/7 and they'll pay for that coverage.

Five years into practice, established general surgeons in private practice or high-productivity employed models earn $400,000-$600,000. Subspecialists in HPB, colorectal, and surgical oncology at major academic centers earn $350,000-$550,000, with the academic pay ceiling being lower than private practice. High-volume minimally invasive and bariatric surgeons in productive private practices can exceed $600,000.

Partnership in private surgical groups requires capital buy-in (for clinic space, equipment, and accounts receivable). This can range from $50,000-$200,000 depending on practice size. The economics of surgeon-owned practices have been under pressure from hospital employment, so the landscape varies significantly by geography.

The income ceiling in general surgery isn't as high as in cardiology or orthopedics because the RVU value of many general surgery procedures has eroded over the decades. You can work very hard and generate very good money, but the path to $800,000+ requires either subspecialization into high-value procedures or ownership of a high-volume practice with ancillary revenue.

Salary progression

Highest paying states

Where the jobs are

Salary negotiation

General surgery contracts are highly variable depending on practice setting. Hospital-employed positions often have a base salary plus productivity bonus structure. Academic positions have salary plus potential administrative or research supplements.

RVU targets for general surgery vary by subspecialty. A general community surgeon seeing a mixed case load should expect targets around 10,000-13,000 wRVUs annually. Subspecialists doing complex oncology cases generate fewer wRVUs per case despite longer operative times because the RVU values don't fully reflect complexity. Know your case mix and what the wRVU yield actually is before agreeing to a target.

Call stipends are negotiable and should be explicit. Trauma call pays $1,000-$3,000 per weekend or per day in markets where call burden is high. If you're being recruited specifically to provide call coverage, that call has a dollar value to the hospital and you should capture some of it.

Tail coverage for surgery runs higher than for non-procedural specialties because malpractice risk is higher. Tail costs of $80,000-$150,000 are not unusual for general surgery. Get the employer to pay tail or get an occurrence-based policy from the start.

Non-competes in surgery can be problematic because your referral network takes years to build. A non-compete that forces you out of your geographic area if you leave destroys that investment. Push for narrow geographic restrictions or defined financial buyouts.

What the data doesn't tell you

Surgery selects for people who can function under stress, who like to fix problems with their hands, and who can make decisions quickly with incomplete information. It also selects, historically, for people who can normalize a genuinely unsustainable workload. The culture has improved from what it was 20 years ago, but if you expect a surgery training program to prioritize your wellness over operative volume, you will be disappointed.

The physical demands are underestimated. Standing for four, six, eight hours. Awkward positions at the laparoscopic tower or at the robot console. Repetitive stress on shoulders and back. Surgeons with musculoskeletal problems that limit their ability to operate are more common than the specialty publicly acknowledges.

Fellowship is essentially required now if you want a non-generalist practice. The general surgeon who does a bit of everything is increasingly rare outside of rural settings where being a generalist is a genuine community service. In urban and suburban markets, patients and referrers expect subspecialization.

The most under-discussed issue in general surgery is the transition from residency to independent practice. Residency trains you to operate with an attending present. The first time you're the most senior person in the room and something unexpected happens, you'll feel the weight of that differently. Find a practice with mentorship structure if you can, particularly for your first one to two years.

Frequently asked questions