The Future of General Surgery

Faye Begeti, University of Cambridge School of Clinical Medicine, Addenbrooke's Hospital, Hills Road, Cambridge, CB2 0SP

"General surgeons are not what they used to be many years ago."

This is a phrase I have heard multiple times emanating from nostalgic retired surgeons leading anatomy demonstrations in Cambridge University, always followed by stories of the heroic diversity of operations they performed and how time has changed this; and, albeit anecdotal, it is a perfect illustration of how general surgery has changed over the course of a few generations.

Although superficially it seems that general surgery is thriving, with general surgeons making up 31% of UK surgical workforce [1] (one of the largest specialities), when one looks past the surface, this specialty is vanishing. Despite retaining the title “general”, the procedures performed by surgeons in this field are becoming less general and more specialised.

The reasons behind the demise of general surgery are multi-factorial. In the world of modern surgery there is the clear notion that the best results can be achieved by specialisation with studies showing better outcomes, fewer peri-operative complications and shorter hospital stay [2,3,4]. General surgeons are thought to lack an identity, being jacks of all trades and masters of none. Consequently patients want to be operated upon by a specialist and this is strongly encouraged by the litigation system [5].

However, the downfall of general surgery is not something new. There has been a strong downward drift in medical student interest since the 1980s [6,7]. In 2001 the amount of US general surgical posts exceeded the number of applicants [7]. Some suggested reasons for this are lifestyle factors and inadequate training programmes [8] that do not sufficiently cover the ground of this very broad discipline. It seems unlikely that general surgery will regain the ground that it has lost to other specialties considering that large number of trainees are being trained competitively to become experts in their fields whilst general surgery trainees are choosing to leave this field in order to pursue other specialties [9].

The only setting in which general surgery will continue to be applicable is in the developing world where resources are limited and doctors are spread thinly; an environment that needs breadth in preference to depth. In developed countries, where no single person can provide all the care required and trends are moving towards multidisciplinary teams, general surgery is being rendered obsolete. Consequently, in order to survive in this world of specialisation, the general surgeons have had to evolve by developing “special interests” and restricting their activity to a particular sub-specialty. It is not long before these sub-specialties (breast, colorectal, upper GI, transplant and vascular) step out of the general surgery umbrella and training programmes are adjusted so that trainees spend more time specialising and less time learning a variety of procedures [10].

What will be the impact of the dismemberment of general surgery? Given the expected radical change in population demographics, the downfall of this branch of surgery is unlikely to go unnoticed. As surgeons progressively specialise, they narrow or even completely change the spectrum of services that they provide. Greater numbers of specialists will be required to achieve the same results as generalists [3], making workforce planning much more difficult.

As the 78 million baby boomers grow old – the largest number of people within a narrow age range ever to occupy the Earth – the health care system will be faced with the full impact of the aging population. This pressure will be exacerbated by progressive surgical specialisation, which necessitates the training of additional surgeons to provide stability of services. Furthermore, although specialisation has hithero had a positive outcome, excessive demarcation between specialties may have deleterious effects as the human body is not always compatible with sub-specialisation; and pathological processes are not, by any means, invariably restricted by the arbitrary lines that segregate these specialties.

General surgery has given birth to all of the surgical specialties. However, in the 21st century, the development of these specialties has left no room for the mother of all surgeries and, if its slow decline continues, it will soon become extinct. The question now is whether we should be making efforts to prevent its demise or to remember it fondly as a significant era in the history of modern surgery.

References: 

1. The Royal College of Surgeons of England. The surgical workforce: 2009 update. http://www.rcseng.ac.uk/surgeons/working/docs/workload/The%20surgical%20...

2. Di Carlo A, Andtbacka RH, Shrier I, Belliveau P, Trudel JL, Stein BL. The value of specialization—is there an outcome difference in the management of fistulas complicating diverticulitis. Diseases of the Colon & Rectum. 2001; 44(10):1456-1463. http://dx.doi.org/10.1007/BF02234597

3. Anwar S, Fraser S, Hill J. Surgical specialization and training - its relation to clinical outcome for colorectal cancer surgery. Journal of Evaluation in Clinical Practice. 2010. http://dx.doi.org/10.1111/j.1365-2753.2010.01525.x

4. Bachmann MO, Alderson D, Peters TJ, Bedford C, Edwards D, Wotton S, et al. Influence of specialization on the management and outcome of patients with pancreatic cancer. The British Journal of Surgery. 2003; 90(2):171-7. http://dx.doi.org/10.1002/bjs.4028

5. Goodwin H. Litigation and surgical practice in the UK. The British Journal of Surgery. 2000; 87(8):977-9. http://dx.doi.org/10.1046/j.1365-2168.2000.01562.x

6. Bland KI, Isaacs G. Contemporary trends in student selection of medical specialties: the potential impact on general surgery. Archives of Surgery. 2002; 137(3):259-67. http://dx.doi.org/10.1001/archsurg.137.3.259

7. Barshes NR, Vavra AK, Miller A, Brunicardi FC, Goss JA, Sweeney JF. General surgery as a career: a contemporary review of factors central to medical student specialty choice. Journal of the American College of Surgeons. 2004; 199(5):792-9. http://dx.doi.org/10.1016/j.jamcollsurg.2004.05.281

8. Fernandez-Cruz L. General Surgery as Education, Not Specialization. Annals of Surgery. 2004; 240(6):932-938. http://dx.doi.org/10.1097/01.sla.0000145966.00037.87

9. Dodson TF, Webb AL. Why do residents leave general surgery? The hidden problem in today's programs. Current Surgery. 2005; 62(1):128-31. http://dx.doi.org/10.1016/j.cursur.2004.07.009

10. Skillman J. The future of breast surgery: a new subspecialty of oncoplastic breast surgeons? Breast. 2003; 12(3):161-162. http://www.sciencedirect.com/science/article/pii/S0960977603000237

11. Rainsbury RM. Training and skills for breast surgeons in the new millennium. ANZ Journal of Surgery. 2003; 73(7):511-6. http://dx.doi.org/10.1046/j.1445-1433.2003.02673.x