The term ‘general surgeon’ is somewhat misleading in todays age of sub-specialisation. In years gone by the same surgeon performing the Whipple’s may well have been doing a thyroidectomy the following day, and though somewhat admirable, this jack-of-all-trades mentality may not always lend itself to achieving the best results for patients.
Polytrauma usually pays no regard to anatomical boundaries and sub-specialties; therefore, the skills of a true generalist are coveted in time-critical scenarios. In an ideal world the trauma surgeon must be equally as comfortable and competent in the neck, limbs and chest as they are the in abdomen. Improvements in prehospital management mean that more patients are surviving to hospital with major injuries. We expect these patients to survive and get the best treatment possible
The need for true generalist skills means that trauma surgeons have benefited from the somewhat leisurely and convoluted training pathways of years gone by. A general surgeon’s formative years may well have included rotations through cardiothoracics, neurosurgery, ENT and even orthopaedics. This breadth of experience all adding to one’s inventory, providing the trauma surgeon with various hacks, surgical exposure tricks and anatomical pearls of wisdom to see them through the most demanding of cases. But the streamlined training pathways of the modern era leave little opportunity for the slow osmotic absorption of information, with residents encouraged to sub-specialise early and become experts in their own little field, all while spending fewer hours in the hospital. The Resident Education Committee of the Society for Surgery of the Alimentary Tract (SSAT) offered up a comprehensive review of the paradigm shift towards sub-specialisation and some of the key drivers that include residents’ perceptions of increased marketability, compensation and better work-life balances.
In the UK, vascular surgery used to be an integral part of general surgical training. A few years ago, vascular surgery became its own entirely separate residency programme, with vascular trainees more heavily focused on evolving endovascular skills and only needing to do a year of general surgery. Conversely, general surgery residents are only required to do 6 months of vascular surgery in an entire 6-year program. As a result, the future cadre of general and vascular surgeons will have significantly reduced skills in the alternate specialty, leaving those set on a career as trauma surgeons with a lot of catching up to do in the form of post-residency fellowships and extra experience sought overseas.
In the US there are movements afoot triggered by this modern push to sub-specialise early. Rural surgery fellowships are growing in popularity, aiming to teach enough of everything to see a surgeon through a career of working in relatively remote or austere environments, including basic obstetrics and urology skills. This will help to address the anticipated shortfall in non-urban general surgery trainees coming through the system. Additionally, there is the regionalisation of acute care surgery much in the same way that trauma care has long been regionalised. Whether or not patient outcomes will benefit from the regionalisation of emergency surgery to specialist centres in the same way that trauma patient outcomes have benefited remains to be seen.
It is not uncommon nowadays to see new trauma attendings being mentored and baby-sat in theatre by more senior colleagues. Whilst there may now be an expectation that technical skills will need to be continually honed through the early attending years, the emphasis on the non-operative skills of surgery such as leadership, decision-making skills and communication continues to grow. The question is, who makes a better and safer ‘day one’ attending trauma surgeon? The surgeon who knows their limits, knows who to call for help early and maintains strategic oversight of the patient journey? Or the surgeons who thinks they can handle everything and does just about an ok (but not great) job on the operating table? And are having excellent operative and non-operative skills or excellent general and subspecialty surgical skills mutually exclusive? As high-fidelity surgical models and augmented reality technologies continue to develop, will there be an even greater place for simulation in bringing new surgeons fresh out of residency up to speed with all of the skills required of a generalist trauma surgeon?
As with so much in medicine, little if any evidence backs the current direction of travel. As the generation of truly old school general surgeons continues to edge closer to retirement, who will be left to teach us the old ways should we decide that being a benign proctologist isn’t cutting it when it comes to saving the life of a man hosing out from the neck?
Obi Nnajiuba is a British surgical resident with a specialist interest in trauma, acute care, prehospital care, triage, mass casualty events and trauma systems. His postgraduate qualifications include an MSc in Trauma Sciences and membership of the Royal College of Surgeons of England. He is also a registered Motorsport UK physician, providing trackside advanced trauma care to competitors at world famous motor-racing circuits such as Brands Hatch, Goodwood and Silverstone.
