With the modern tendency towards early sub-specialisation in surgical training, there is something warm and nostalgic in reminiscing back to the old days when a general surgeon was a general surgeon in the truest sense of the word. A few weeks back I was on a weekend round with one of my senior attendings who told me that a regular elective operating list for him as a resident would consist of a thyroidectomy followed by a couple of hernia repairs and finishing with something juicy like an open aortic aneurysm repair. His attending at the time wouldn’t show his face in the OR until my boss had started the AAA repair and dissected down to the aorta. No doubt this style of training tightened sphincters, steeled nerves and with time honed the skills of would-be master surgeons. The old mantra of “feel free to cope” is now often said in jest by my seniors who would once have had it said to them in all seriousness.
However, the significant harm likely caused to patients cannot be discounted. Furthermore the consequences of such forays were more easily swept under the carpet in the more deferential and less litigious world that our seniors grew up in. The advantages of subspecialisation are obvious and can be extrapolated to the broader centralisation of services such as cardiac surgery to specialist tertiary centers. High volumes and repetition translate to fewer complications, a fact that applies to everything from hernia repairs at the Shouldice Hospital to adrenal surgery across the United States.
Yet there still remains a place for the true generalist. Perhaps not in heavily-populated and well-resourced metropolitan areas, but more so in the sparsely-populated rural areas, especially in poorer parts of the world given that around 92% of the Earth’s rural population located in developing countries. The bulk of emergency surgery in the developing world is required for the treatment of traumatic injury. This further emphasises the importance of being a true generalist when it comes to trauma surgery. In a previous article I touched on the idea of subspecialist training being at odds with the reality of the skillset required of a trauma surgeon, where anatomical boundaries often go out of the window.
For many surgeons in training, it’s rite of passage to have spent some time in a high-volume trauma centre in a developing country in Africa or Latin America dealing with the results of violence driven by endemic socioeconomic deprivation. Whilst it may be an exhilarating and worthwhile experience providing stories and anecdotes for years to come, it’s also worth considering the ethics of such practices. Are people in poor countries ok to be the surgical guinea pigs of trainees from rich countries carrying out procedures they may not be trusted to do in their own countrie Surgical training programmes do recognise this desire for a more generalised ‘jack-of-all-trades’ style training. The UK curriculum for General Surgery training sets out an extensive list of competencies expected of those wishing to pursue a specialist interest in Remote and Rural Surgery. These include the kind of crossover surgical skills you’d expect such as Caesarean sections, common gynaecological emergencies and early pregnancy complications. But it also lists emergency craniotomy, maxillofacial fracture manipulation, ureteric stenting and hand surgery among other things. Rural surgery will appeal to many not least because the remunerations for rural physicians are often higher [HN5] to act as an incentive to draw doctors away from the excitement and bright lights of the city. That along with generous relocation packages, lower living costs and more professional freedoms could make being a rural ‘Jack-of-all trades’ surgeon an appealing prospect.
Outside of a dedicated training programme it can be difficult gaining the additional skills and experience required to operate outside of one’s subspecialty. I make a habit of joining my obstetric colleagues from time to time for elective caesarean lists, my rationale being as a trauma/emergency surgeon I never know when I’ll have to perform an emergency c-section on a patient. This desire was born of witnessing my own trauma attending do a c-section on a pregnant woman who had been shot be jealous ex-partner with a crossbow. My current bosses would much rather I spent the extra time in endoscopy or operating as a general surgeon, however we all have the right to exercise a degree of autonomy over what we learn along the way
I used to have dreams of getting some anaesthetic training and spending some time flying out with London’s Air Ambulance Service (European air ambulances tend to fly with doctors and operate quite differently to American services, as detailed previously in this blog). The realities of a fast-paced and competitive training treadmill with boxes to tick and set numbers of procedures to be signed off on means there is little opportunity for me and many others to branch out. Add to that a long-suffering wife steadily losing patience with the lifestyle and shift patterns of a resident
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.