The last 'True' general surgeons

[cbass1350]

I was having a discussion with a few residents today about general surgery. My question was whether there were any 'true' general surgeons out there anymore. Most believe that gen surg has been marginalized by rapid sprouting of surgical sub-specialties. And except in small communities that are hurting for sub-specialized docs, most general surgeons are pretty limited in the types of procedures that they can do.

Whatever the reasons are for this shifting trends (HMOs, individual income, etc...), it seems that general surgeons simply do not have the jurisdiction and authority that they once did. They are mostly limited to abdominal procedures, which in itself has also been subdivided by other subspecialized surgeons (hepatobiliary, colorectal, etc...). As a general surgeon, I would hate to see some CT surgeon taking my Ivor Lewis procedure 🙁.

Perhaps the last 'true' general surgeons are those in the field of critical care/trauma or ones that work in smaller communities? Any thoughts?

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[Winged Scapula]

As a general surgeon, I would hate to see some CT surgeon taking my Ivor Lewis procedure 🙁.

As a patient, I hope the CT or Surg Onc guy wrestles you to the ground for my esophagectomy.

There is plenty of evidence that these type of technically challenging procedures are done much better in the hands of people who do them often. As a general surgeon, you really aren't going to get that many people who need Whipples or ILEs.

It is true that subspecialization is and has been, encroaching on the field of general surgery. I got plenty of disdain from general surgeons while job hunting because as a fellowship trained breast surgeon I will be taking a fair bit of their bread and butter.

But I also know general surgeons that make a good living and do a variety of things...general surgeons have always been Kings of the Abdomen so to deride the field as becoming that is to turn around and look at what the field has been the last 100 years. That hasn't changed. General surgeons, can and do do endocrine, colorectal and lots of skin and soft tissue. It really is up to whatever the hospital grants you privileges for. I'm not sure you have to be in a one horse town to practice this way...there are plenty of general surgeons in Harrisburg, the state capital of Pennsylvania (ok, its not Philly or NY, but its hardly tiny), who are thriving and enjoying the practice.

Whether general surgeons have the opportunity to do more specialized procedures depends on the medical community and the hospital; some general surgery groups are so powerful as to be able to have a say as to which specialists are given admitting privileges at their hospital.

 

[-Goose-]

As a patient, I hope the CT or Surg Onc guy wrestles you to the ground for my esophagectomy.

There is plenty of evidence that these type of technically challenging procedures are done much better in the hands of people who do them often. As a general surgeon, you really aren't going to get that many people who need Whipples or ILEs.

It is true that subspecialization is and has been, encroaching on the field of general surgery. I got plenty of disdain from general surgeons while job hunting because as a fellowship trained breast surgeon I will be taking a fair bit of their bread and butter.

But I also know general surgeons that make a good living and do a variety of things...general surgeons have always been Kings of the Abdomen so to deride the field as becoming that is to turn around and look at what the field has been the last 100 years. That hasn't changed. General surgeons, can and do do endocrine, colorectal and lots of skin and soft tissue. It really is up to whatever the hospital grants you privileges for. I'm not sure you have to be in a one horse town to practice this way...there are plenty of general surgeons in Harrisburg, the state capital of Pennsylvania (ok, its not Philly or NY, but its hardly tiny), who are thriving and enjoying the practice.

Whether general surgeons have the opportunity to do more specialized procedures depends on the medical community and the hospital; some general surgery groups are so powerful as to be able to have a say as to which specialists are given admitting privileges at their hospital.

I was told that the last true general surgeon was the peds surgeon.

Same deal for neurosurgery. Peds neurosurgeons do it all: spine, tumor, shunts, epilepsy, etc.

Just only on the little people.

 

[SLUser11]

Whether general surgeons have the opportunity to do more specialized procedures depends on the medical community and the hospital; some general surgery groups are so powerful as to be able to have a say as to which specialists are given admitting privileges at their hospital.

Biggest surgical group in the nation.

 

[Winged Scapula]

Good point goose...pediatric surgeons are really general surgeons and specialists (given that many of the procedures they do are not done by genearl surgeons) all rolled into one.

All the group in Wichita needs are some Orthopods, Uro, Gyn and ENT and they'd never have to refer a patient out!

 

[Amgen1]

Most staff surgeons at your county and VA hospital will cover a wide range of cases; even in large cities. Often times for the indigent the plethora of subspecialists are not always available or willing to do the cases

 

[maxheadroom]

I'll second KC's opinion on esophagectomies. If anyone is coming near me or my family to do something like an esophagus, Whipple, or other relatively rare procedure, you'd better believe that it's going to be a high-volume specialist and not just Joe Surgeon who does a couple a year. No way. If you wouldn't recommend that to your mother, why would you recommend that to your patient?

 

[jubb]

I know a general surgeon at a smaller community hospital who does some thoracic work such as wedges, lobectomies, and pleurodesis as well as some vascular work such as carotids. Is this pretty common or is all this stuff expected to be referred to a "center" now?

 

[Pilot Doc]

I know a general surgeon at a smaller community hospital who does some thoracic work such as wedges, lobectomies, and pleurodesis as well as some vascular work such as carotids. Is this pretty common or is all this stuff expected to be referred to a "center" now?

There's an important distinction to be made between what practicing surgeons, particularly older ones, do now and what graduating surgeons can expect to do over their careers. Vascular surgery and to a lesser extent general thoracic were historically well within the scope of general surgery. By historically, I mean when a large number of practicing general surgeons completed residency. These people still perform those operations in many places.

With 2/3-3/4 of GS grads today completing a fellowship and increasing specialization, it would be unusual in an area without a provider shortage for a general surgeon to perform lung work or carotids.

That having been said, there are still lots of areas with surgeon shortages. And neither wedge resections nor carotids (nor especially pleurodeses) are as complicated or disaster prone as esophagectomies or whipples.

Patient preference is another big, big factor. Sophisticated urban patients may well want a fellowship trained, high volume surgeon and have the smarts to seek one out. Other patients may be much more comfortable with a general surgeon (and anesthesiologist and nurse and orderly) who goes to church with them, coaches little league and chews rather than the stuffy tertiary care surgeon 3 hours away. Some won't have the ability to seek other options; others will purposely choose a "higher risk" provider in trade for a more comfortable environment.

 

[Blade28]

As a general surgeon, I would hate to see some CT surgeon taking my Ivor Lewis procedure 🙁.

What? How many esophagectomies do you think the average General Surgery does every year, versus someone from Thoracic or Surg Onc?

 

[cbass1350]

What? How many esophagectomies do you think the average General Surgery does every year, versus someone from Thoracic or Surg Onc?

That's a good point. But let's say a relatively inexperienced general surgeon wanted to become more competent in advanced procedures as such, he/she would not be able to do so (simply because they're taken by the sub-specialized doctors). In a way, it's a catch 22. You need the experience to get better, but you can't get the procedure because you lack the experience.

This was not always the case. There was a time that general surgeons could freely 'branch out' and gain more competency and recognition in doing advanced procedures of their choosing. Just using Ivor Lewis as a quick example. He was not a CT surgeon (although he is recognized as one now). He was a general surgeon with a variety of interests including hernia repair, hepatectomies, and even repair of femoral neck fractures. Granted, this was around the early 50's, but things have clearly gone downhill for general surgeons since then.

 

[Blade28]

That's a good point. But let's say a relatively inexperienced general surgeon wanted to become more competent in advanced procedures as such, he/she would not be able to do so (simply because they're taken by the sub-specialized doctors). In a way, it's a catch 22. You need the experience to get better, but you can't get the procedure because you lack the experience.

This was not always the case. There was a time that general surgeons could freely 'branch out' and gain more competency and recognition in doing advanced procedures of their choosing. Just using Ivor Lewis as a quick example. He was not a CT surgeon (although he is recognized as one now). He was a general surgeon with a variety of interests including hernia repair, hepatectomies, and even repair of femoral neck fractures. Granted, this was around the early 50's, but things have clearly gone downhill for general surgeons since then.

Well it also depends on where you're practicing. In many smaller, rural towns, a General Surgeon will be handling a lot of the Trauma, Surg Onc, Thoracic, Vascular, even some OB! Obviously things are very different in academics, where super-specialization and finding the ever-elusive "niche" are commonplace.

 

[johnny_blaze]

Good point goose...pediatric surgeons are really general surgeons and specialists

This is arguable. I’m on paed surgery now at a very large academic centre and all the paed surgeons here are sub specialised (Upper GI, Lower GI, Oncology, Urology).

 

[Winged Scapula]

This is arguable. I'm on paed surgery now at a very large academic centre and all the paed surgeons here are sub specialised (Upper GI, Lower GI, Oncology, Urology).

Really? Except for Peds Ortho, CT, and Neurosurg I haven't seen that much superspecialization here in the states. Anybody else?

Upper GI/Lower GI... That's getting a little too specialized for me!

Our peds surgeons basically did it all except neurosurg and ortho. I did some cloacal anomalies, Kasai procedures, pectuses (pecti?), CDH, cardiac, gastroschisis, etc. along with the usual pedi stuff.

 

[-Goose-]

I hate to hijack this thread, but...

Do peds CT surgeons have to do a peds CT fellowship?

The guy I'm going to shadow only did a general CT fellowship, but he solely does peds CT cases.

Is this the exception to the rule?

 

[Winged Scapula]

I hate to hijack this thread, but...

Do peds CT surgeons have to do a peds CT fellowship?

The guy I'm going to shadow only did a general CT fellowship, but he solely does peds CT cases.

Is this the exception to the rule?

Have to and choose to are two separate possibilities.

There are Pediatric CTS fellowships and one might imagine that if you got little experience in some of the pediatric procedures during your gen surg and CTS training programs, you would want to pursue additional training as it may be required for credentialing.

Then again, if you are the only game in town and can show that you have some experience doing these cases, a hospital may credential you without the fellowship. The guy you know may be old enough to predate the existence of pediatric CTS fellowships.

 

[Blade28]

Really? Except for Peds Ortho, CT, and Neurosurg I haven't seen that much superspecialization here in the states. Anybody else?

Upper GI/Lower GI... That's getting a little too specialized for me!

I've heard of Peds GU as well.

Seems like everything else - Vascular, Trauma, Surg Onc, etc. - is handled by the General Peds Surg folks.

 

[-Goose-]

Have to and choose to are two separate possibilities.

There are Pediatric CTS fellowships and one might imagine that if you got little experience in some of the pediatric procedures during your gen surg and CTS training programs, you would want to pursue additional training as it may be required for credentialing.

Then again, if you are the only game in town and can show that you have some experience doing these cases, a hospital may credential you without the fellowship. The guy you know may be old enough to predate the existence of pediatric CTS fellowships.

Thanks!

 

[johnny_blaze]

Really? Except for Peds Ortho, CT, and Neurosurg I haven't seen that much superspecialization here in the states. Anybody else?

Upper GI/Lower GI... That's getting a little too specialized for me!

Our peds surgeons basically did it all except neurosurg and ortho. I did some cloacal anomalies, Kasai procedures, pectuses (pecti?), CDH, cardiac, gastroschisis, etc. along with the usual pedi stuff.

Well there are about 10 paediatric surgeons where I work and most of them have their own subspecialised elective list. Generally these guys can do everything in an emergency but tend to keep their elective work subspecialised (i.e. the bum guys don’t touch the stomach unless they have to). Oncology is always done by the surg oncologists and urology by the urologists. Trauma is a given... who ever is on-call and whatever they can do. Based on what I’ve seen the future looks dim for the true general surgeon.

 

[Winged Scapula]

Well there are about 10 paediatric surgeons where I work and most of them have their own subspecialised elective list. Generally these guys can do everything in an emergency but tend to keep their elective work subspecialised (i.e. the bum guys don’t touch the stomach unless they have to). Oncology is always done by the surg oncologists and urology by the urologists. Trauma is a given... who ever is on-call and whatever they can do. Based on what I’ve seen the future looks dim for the true general surgeon.

Interesting. The peds guys I've worked with do a bit of everything (although admittedly have an interest in the pediatric chest).