Does the General Surgery Specialty needs splitting?

[Faebinder]

I have had this discussion with several people but seem to get the typical "no it's all good together". What do you guys really think? Should general surgery break into Trauma/Critical-Care/Burn separate from Upper-GI/Colorectal/Bariatrics and separate from Cardiothoracic/Vascular?

I am commenting from watching surgeons in practice. I always see them restricting themselves to 15 operations (give or take) but you go through so much in general surgery residency.

Comments?

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[Winged Scapula]

It is not the 15 operations that matter, but rather the skill set that is learned through a wide-ranging surgical residency. Without having done all the time, seen the wide variety of surgical presentations, approaches and possible complications, you would be rather limited in your scope, regardless of how many operations you do regularly.

Without the breadth of training, you might as well be a PA trained to do the procedure, without a real understanding of what to do when complications arise, when patients have abberant anatomy or other complicating features.

So my answer is, "no, are you crazy?" especially for Trauma surgery which really does encompass the broad range of general surgery (even trauma patients in the ICU need an open chole or ventral hernia repair from time to time).

 

[Faebinder]

It is not the 15 operations that matter, but rather the skill set that is learned through a wide-ranging surgical residency. Without having done all the time, seen the wide variety of surgical presentations, approaches and possible complications, you would be rather limited in your scope, regardless of how many operations you do regularly.

Without the breadth of training, you might as well be a PA trained to do the procedure, without a real understanding of what to do when complications arise, when patients have abberant anatomy or other complicating features.

So my answer is, "no, are you crazy?" especially for Trauma surgery which really does encompass the broad range of general surgery (even trauma patients in the ICU need an open chole or ventral hernia repair from time to time).

Another reason I bring this up, it's cause I got a couple of new publications (solid numbers) that show that surgeons who do more of a one operation (such as Whipples) have lower mortality and lower length of hospital stay.

E.g. Surgeon A does 20 whipples a year vs surgeon B does 40 whipples a year. Surgeon A will have less mortality and lower length of hospital stay.

Basically, if you do something a lot, you will become very good at it which is good for the patient and good for the hospital. Wouldn't it be wiser to start specializing the field more?

 

[Winged Scapula]

Another reason I bring this up, it's cause I got a couple of new publications (solid numbers) that show that surgeons who do more of a one operation (such as Whipples) have lower mortality and lower length of hospital stay.

E.g. Surgeon A does 20 whipples a year vs surgeon B does 40 whipples a year. Surgeon A will have less mortality and lower length of hospital stay.

Basically, if you do something a lot, you will become very good at it which is good for the patient and good for the hospital. Wouldn't it be wiser to start specializing the field more?

And I have no reason to doubt those studies...matter of fact, if I needed my gallbladder out I"d be more likely to go to our local community hospital (where those surgeons do it much more frequently than the academic ones) but if I needed a Whipple I sure as heck wouldn't go there. A friend and I used to compare our surgical experience as residents in the same town, different residencies. He had done dozens x more appys and gallbladders than I, and I, by my 3rd year, could tell him how to do the Whipple when he was a Chief and had never done one.

At any rate, there is nothing wrong with specialization and getting good at a procedure by doing it over and over again. However, I still stand by my ascertation that the goal of a surgical residency is not to make you the best "x" surgeon out there but to expose you to a broad range of techniques, complications, anatomy, etc. Without those years of general surgery teaching you just the basics, you cannot master the more complicated stuff. Besides, there is a lot more to being a surgeon that just operating. A good surgical residency also teaches you about the peri-operative care of the patient, including medical managment of chronic diseases and some acute presentations in surgical patients. In a superspecialized residency, focusing on trauma, vascular, CT, etc. there isn't time for that as well as learning good general surgical practice.

Just my two cents...I'm sure there are plenty of others here (especially some of those interested in Vascular and CT) who will disagree. njbmd needs to weigh in here...he has some strong opinions on the subject.

 

[Surgeon24]

Hi,

I share the same opinion as Kimberli.

A general surgery residency needs to expose you to a lot of different anatomy, physiology, pathology, surgery techniques, complications. Not everyone wants to practice in a super-specialized academic hospital. Some residency programs here in Canada are known to expect their PGY-1 residents to already choose a sub-speciality in gen. surg (I.e. vascular, CT, pediatrics, etc..), to start doing research in that field and to 'forget' about the rest. That's great if you know already what you want to do and IF you know you will have a job in 6-7 years in that speciality.... but if it isn't so, you might find yourself in a bad situation when you're practicing in a community hospital and you don't know how to do a lap. chole.

I strongly believe a resident in general surgery HAS to be familiar with a lot of different pathologies, techniques and have a strong understanding of anatomy/physiology. Even if you plan to practice in a community hospital, I believe you need to be exposed to whipples, transplants, etc...There will come a time when you recieve a trauma patient and you have to dissect the pancreatic region: if you haven't been exposed to to that anatomy and surgical techniques, you will cry for your mother.

 

[droliver]

Strongly agree with Kimberli, et. al.

There is really something to be said for broad-based training prior to subspecialization. I think it really changes how you look at & approach things.

Much like ortho & neurosurgery, I do feel that Vascular surgery is one though that I feel is quickly becoming so differentiated (due to the endovascular explosion) that it may not be able to be under the same roof of general surgery training despite some of the common components of traditional vascular surgery techniques.

 

[Blade28]

Agree with the previous three posts.

General surgery isn't about perfecting the lap chole, trauma ex-lap, or diverting colostomy - it's about developing your skill set in tackling a wide variety of patients and surgical problems.

Without broad exposure in a variety of settings (e.g. private hospital, university hospital, county hospital, VA, children's hospital, etc.), I really don't think you'll be adequately equipped to be an attending.

E.g. Surgeon A does 20 whipples a year vs surgeon B does 40 whipples a year. Surgeon A will have less mortality and lower length of hospital stay.

BTW, for interesting reading on why perfecting a single operation does NOT necessarily make you an excellent surgeon, read about the Shouldice Hospital in Ontario, Canada.

 

[footcramp]

can you elaborate on the shouldice example? from what i understand they have the lowest hernia complication rates around while also performing the operation in record time.

 

[Apollyon]

njbmd needs to weigh in here...he has some strong opinions on the subject.

I thought "he" was a "she".

 

[Winged Scapula]

I thought "he" was a "she".

Sorry... typo!

 

[Winged Scapula]

can you elaborate on the shouldice example? from what i understand they have the lowest hernia complication rates around while also performing the operation in record time.

The Shouldice clinic has a low hernia complication rate because their patients are very highly selected; ie, there is a bias toward people who are likely to have a good outcome (ie, no morbidly obese, immunosuppressed, diabetics, etc.)

 

[Complications]

The Shouldice clinic has a low hernia complication rate because their patients are very highly selected; ie, there is a bias toward people who are likely to have a good outcome (ie, no morbidly obese, immunosuppressed, diabetics, etc.)

The way I understood it as well was that some were family docs, etc ... trained specifically to do one procedure. Not sure about the seleciton bias.

There is a large amount of data gathering to support much of what is said in the thread. Higher volume surgeons, higher volume hospitals, and surgeon subspecialty does improve mortality for a wide number of procedures. I don't think this really says anything about training ... there are a lot of potential confounders when you talk about training. What about the benefit of a wide range of cases/surgical techniques, etc?

Anyway, places like Michigan, Brigham, etc are doing a lot in the way of research in this area.

 

[Winged Scapula]

The way I understood it as well was that some were family docs, etc ... trained specifically to do one procedure. Not sure about the seleciton bias.

There is a large amount of data gathering to support much of what is said in the thread. Higher volume surgeons, higher volume hospitals, and surgeon subspecialty does improve mortality for a wide number of procedures. I don't think this really says anything about training ... there are a lot of potential confounders when you talk about training. What about the benefit of a wide range of cases/surgical techniques, etc?

Anyway, places like Michigan, Brigham, etc are doing a lot in the way of research in this area.

Certainly it is true that the SHouldice Clinic has low M&M rates because of the training. I wasn't questioning that but wanted others to be aware that ONE of the reasons is also patient selection. I'll have a zero M&M rate if I don't operate either!

Its an interesting topic and as a future breast surgeon, who wants to do only that (which isn't technically difficult), I could argue that I wasted 5 years of learning about general surgery. But again, it trained me in the basics and pre, intra and post op patient care as well sa surgery.

 

[Faebinder]

Certainly it is true that the SHouldice Clinic has low M&M rates because of the training. I wasn't questioning that but wanted others to be aware that ONE of the reasons is also patient selection. I'll have a zero M&M rate if I don't operate either!

Its an interesting topic and as a future breast surgeon, who wants to do only that (which isn't technically difficult), I could argue that I wasted 5 years of learning about general surgery. But again, it trained me in the basics and pre, intra and post op patient care as well sa surgery.

So doing something like 1 year surgery internship and 3 years breast surgery is not enough you think to make a breast surgeon? Similar to ophtho. After all, you are dealing with one organ just like them...

 

[zambo]

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[TigerLily46]

I think general surgery should remain as it is and that Kimberli's comments are well taken. I would also like to add that there may not be many medical students who come out of fourth year knowing they want to be a specific type of surgeon. I did a lot of general surgery in med school, but there was no way to cram in rotations in peds surgery, transplant, vascular, or CT. I tried to do some internal medicine as a 4th year so that I would know things like how to manage diabetes well and to have some insight into nephrology. I also did radiology and anesthesiology. I think these are good things to do as a 4th year, and I'm glad that I will have a lot of options for fellowship when I'm done with residency. Plus, you don't always know where your personal life will be at the end of residency. I'm interested in transplant, but that doesn't have the best lifestyle. Maybe I'll decide that I would like to fix boobs and noses for a living so that I can have more time with my family. Who knows? I thought I wanted to be a neurologist when I started med school. It's good to be able to change your mind and find the right fit.

 

[anxietypeaker]

regardless, isnt general surgery being more and more broken up...
ABTS is gonna fast track CT surgery. Moreover, theyre gonna split cardiac from thoracic in the future. Vascular already got the go ahead to do a fast track. Plastics already has it (yes, its impossible to do but its there).

 

[njbmd]

And I have no reason to doubt those studies...matter of fact, if I needed my gallbladder out I"d be more likely to go to our local community hospital (where those surgeons do it much more frequently than the academic ones) but if I needed a Whipple I sure as heck wouldn't go there. A friend and I used to compare our surgical experience as residents in the same town, different residencies. He had done dozens x more appys and gallbladders than I, and I, by my 3rd year, could tell him how to do the Whipple when he was a Chief and had never done one.

At any rate, there is nothing wrong with specialization and getting good at a procedure by doing it over and over again. However, I still stand by my ascertation that the goal of a surgical residency is not to make you the best "x" surgeon out there but to expose you to a broad range of techniques, complications, anatomy, etc. Without those years of general surgery teaching you just the basics, you cannot master the more complicated stuff. Besides, there is a lot more to being a surgeon that just operating. A good surgical residency also teaches you about the peri-operative care of the patient, including medical managment of chronic diseases and some acute presentations in surgical patients. In a superspecialized residency, focusing on trauma, vascular, CT, etc. there isn't time for that as well as learning good general surgical practice.

Just my two cents...I'm sure there are plenty of others here (especially some of those interested in Vascular and CT) who will disagree. njbmd needs to weigh in here...he has some strong opinions on the subject.

Hey there,
Fresh from a sex change here! I would agree that the General Surgery residency needs to give broad exposure to a variety of anatomy. Even going into a surgical subspecialty, you need to have that wide exposure.

The other problem is the manner in which the surgical residency is constructed. Most residents spend most of their first and second years learning patient care and patient evaluation. By the time they get to mid-level, they start to exponentially pick up and hone surgical skills but the forth and fifth year is where they really learn to perform various cases.

As a future vascular surgeon, I would be terrible if I headed off to vascular after my third year with little substantial experience in the abdominal cavity. I promise you that while working on the SMA and abdomial aorta, one can find themselves in a whole heap of "doo-doo" both literally and figuratively if you are not throughly familiar with all of the pitfalls in here. This is the worst case if you are trying to put in graft. Perhaps the chest folks might be able to get away with not having so much abdominal work but the vascular folks cannot. Not everyone is a candidate for endovascular repair of a AAA.

I cannot argue with the positions of Dr. Cox and Dr. Blade.

njbmd