General Surgery as Education, Not Specialization

Abstract

The topic I have chosen for the Presidential Address is controversial. I will present my point of view on the subject, which does not necessarily reflect the opinions of the other members of the Association. General surgery in crisis has been an increasingly repeated topic of discussion, but not many solutions to this discussion has been offered. There is no doubt, however, that general surgery should continue to be used as an effective coordinator of undergraduate surgical teaching, not withstanding departmental fragmentation. Over the years, general surgery has been providing core surgical training for many specialties’ residents. Snow1 has outlined this by saying, “The specialties of surgery, other than general surgery, continue to depend upon the discipline and specialty of general surgery for education, research and clinical practice.” Therefore, the discipline of general surgery has remained as the unifying force in surgery. Along this same line, Organ2 defined general surgery as the “gatekeepers” for surgical education, research, and patient care. Despite these eloquent declarations, general surgery has been losing its appeal as a career choice for students and residents alike, and moreover, it has been scrutinized by its nonsurgical colleagues and the public in general. In the United States, general surgery had its peak level of interest in 1981, when 12.1% of senior medical students selected general surgery as the first choice of specialty.3 In 1989, the interest level dropped to 10%, then down to 8% the following year, and to a low of 6.1% in the 2001 match program. Questionnaires were handed out to the students asking them to make a list of factors that were influential in their decision-making process.3 In the 1990s, students ranked the “type of patient problems encountered” as having the greatest influence in their decision of the specialty they wished to pursue. The second most influential factor was “clerkship” in the area, intellectual content of the specialty, or “challenging diagnostic problems.” The third most influential factor was “example of a physician to the specialty,” which was interpreted to be the “role model” that the student identified to. In the data extracted from the 1978 to 2001 medical student graduate questionnaire, all medical schools reported a large percentage of students (38.8%–57.8%) who were initially attracted to the specialty of general surgery and later changed their minds because of the following lifestyle issues4: unpredictable work hours, demands on time and effort, amount of stress, type of patient problems encountered, and the length of the residency program. In an analysis of contemporary trends in student selection of medical specialties by Bland and Isaacs,5 it was confirmed that perceived threats to lifestyle remained an important factor influencing the career choice of medical students. These issues may be among the most important because half of the medical students today are women, and lifestyle in a surgical program has been viewed as “especially difficult to combine with family life.” Program directors must address these issues in an attempt to attract top students. The surgery clerkship experience is also a major factor for students when deciding on a specialty. Polk6 has observed a 30% decrease in required clerkship experience in medical schools and students’ exposure to surgical sciences because of the shortening of requisite surgical rotations. In a recent Presidential Address, “Surgery, a Noble Profession in a Changing World,” Debas7 concluded that unless these trends are reversed (not only the declining number of students applying for surgical training but also the declining quality of training for those who do apply), “general surgery as specialty is threatened, and a future shortage of general surgeons is inevitable.” In addition, in America, the results of the 2001 general surgery national residency match program revealed an entirely unprecedented 7% unfilled first-year general surgery training positions.8 In an analysis9 of the data from the Canadian Residency Matching Service, the number of applicants listing general surgery as their first choice was 5.68% in 1996 and dropped to 4.25% by 2001. There are no official figures in Europe, but there is a consensus that general surgery is now becoming one of the least competitive surgical specialties. Another crucial deterrent in the pursuit of a career in general surgery may be the length of training period (residency programs of 5 or 6 years). Furthermore, quite often there maybe subsequent extensions to their training programs. It could be said that, in light of the current situation, general surgery has probably lost its personality as a specialty.