The end of the General Surgeon? Noel Lynch Vascular SHO 11/10/2010

Who is a General Surgeon? RCSI released a document entitled The Responsibilities of General Surgeons outwith their Specialty in General Hospitals In a number of General hospitals, the remit of General Surgeons has to be wider than in larger hospitals, particularly when other specialties are not represented General Surgeons should therefore be in a position to carry out the initial management and triaging across a wide spectrum of surgery where necessary surgery, where necessary.

Competencies are listed as those deemed necessary to achieve a Certificate of Completion of Training (CCT) in General Surgery

CCT candidates should be able to accept responsibility and make appropriate referrals to other specialists for the following conditions:

Assessment of the acute abdomen Biliary tract emergencies Acute pancreatitis Swallowed foreign bodies Gastrointestinal bleeding Appendicitis and right iliac fossa pain Abdominal pain in children Peritonitis Acute intestinal obstruction Intestinal pseudo-obstruction Strangulated hernia Intestinal ischaemia Toxic megacolon Superficial sepsis and abscesses Acute ano-rectal sepsis Rectal injuries Ruptured abdominal aortic aneurysm Acutely ischaemic upper and lower limb Chronic critical limb ischaemia Diabetic foot Gas gangrene Venous gangrene Iliofemoral DVT Acute compartment syndrome of upper and lower limb Acute presentations of urological disease Acute presentations of gynaecological disease Scrotal emergencies in all age groups Assessment of the multiple injured patient including children Closed abdominal injuries, especially splenic, hepatic and pancreatic injuries Closed chest injuries Stab and gunshot wounds Arterial and venous injuries Injuries of the urinary tract

CCT Candidates should be able to perform or supervise the following required emergency procedures (procedures listed in italics are within the practice of a consultant general surgeon but competence is not a pre-requisite for a CCT):

Tracheostomy Emergency thoracotomy Diagnostic laparoscopy Closure of perforated peptic ulcer Endoscopy for upper GI bleeding Operations for GI bleeding Emergency cholecystectomy Splenectomy for trauma General Surgery Specialty Specific Guidance Page 12 of 13 Emergency hernia repair Laparotomy for small bowel obstruction Emergency hernia repair Laparotomy for small bowel obstruction Small bowel resection Laparotomy for large bowel obstruction Laparotomy for perforated colon Stoma formation Appendicectomy Drainage of ano-rectal sepsis Laparotomy for abdominal injury Laparotomy for postoperative complications Bladder drainage Suprapubic cystostomy Exploration of scrotum Reduction of paraphimosis Balloon thrombo-embolectomy Fasciotomy

CCT Candidates should be able to provide an elective general surgical service in the following areas:

Excision of skin tumours Split and full thickness skin grafting Node biopsy Block dissection of axilla and groin Thyroidectomy Fine needle aspiration cytology and core biopsy Excision of breast lump and wide excision of breast tumours Mastectomy Diagnostic upper GI endoscopy Laparoscopic cholecystectomy Conversion to open cholecystectomy Exploration of common bile duct Biliary bypass Partial gastrectomy Splenectomy Laparoscopic appendicectomy Laparoscopic suturing and knotting Surgery for all herniae of the abdominal wall, with appropriate techniques including laparoscopic Repair of abdominal wall herniae in children Orchidopexy Circumcision in children Flexible sigmoidoscopy Colonoscopy, diagnostic and therapeutic Haemorrhoidectomy Procedures for fistula in ano Right hemicolectomy Left hemicolectomy Sub-total colectomy General Surgery Specialty Specific Guidance Page 13 of 13 Resections for rectal cancer, restorative and excisional Panproctocolectomy Reversal of Hartmann’s procedure Operations for common scrotal conditions Adult circumcision Vasectomy Vascular suture and anastomosis Approach to and control of major vessels Femoral artery dissection and exposure Standard amputations of the lower limb Abdominal aortic aneurysm repair, elective and ruptured Primary operation for varicose veins

Progressive specialisation within General surgery is a reality Abdominal surgery oft considered the realm of a general surgeon is now sub divided into upper GI surgery, Hepatobiliary surgery and colorectal surgery These trends in the surgical landscape suggest a danger that general surgeons might disappear over the next few years

The benefits of centralised units, especially in the filed of oncological surgery, with specialised practitioners with high volume practice providing the service is well documented 1

However I think there are a number of compelling arguments for the need of general trained surgeons more than ever

In the United States, approximately 1000 general surgeons complete their residency training each year 2 Presently, approximately 70% of graduating surgical residents pursue specialized surgery training, and this percentage may be increasing. 3 3 Thus, only about 300 to 400 of the 1000 general surgeons completing residency each year will choose general surgery practice.

Hospitals need general surgeons to perform various types of surgical procedures, and also to be available to respond to surgical emergencies and trauma. Specialization has greatly decreased the number of such surgeons available to provide this coverage

In small urban or rural hospitals, which care for approximately 54 million patients, general surgeons care for emergencies and trauma and perform a variety of operations 4 In rural South Australia surgical services are provided by a combination of GPs and General Surgeons 5

Humanitarian Surgery The poor availability of surgery in developing countries is a long-neglected problem that has recently gained attention Surgical services are now recognized as cost-effective public health interventions that aim to prevent death and disability; up to 15% of the world's disability-adjusted life-years are amenable to surgery The inverse care law, which dictates that the availability of medical care is inversely proportional to need, is starkly apparent in surgery, with the poorest third of the world estimated to benefit from only 3.5% of surgical procedures 6

Surgeons make an invaluable contribution to humanitarian assistance programs, providing essential services to victims of armed conflict, urban violence, and natural disasters However Organisations such as Médecins Sans Frontières (MSF) have found it more difficult to find broadly trained general surgeons to fill their posts

I acknowledge the huge advances in Surgery over the last decades including robotic surgery, laparoscopic surgery, transplantation surgery The contribution that surgery can make to reducing mortality and morbidity in humanitarian crises is diminishing with increasing subspecialisation and fewer general surgeons

The General Surgeon Surgery is gradually being recognised as a real solution to public health issues in 3 rd world countries Broadly Trained General surgeon traditionally fitted the bill to provide care Rural services What would happen without them?

Thanks ladies and Gentlemen

References 1)Hospital and Physician Volume or Specialization and Outcomes in Cancer Treatment: Importance in Quality of Cancer Care Bruce E. Hillner, Thomas J. Smith, Christopher E. Desch Journal of Clinical Oncology, Vol 18, Issue 11 (June), 2000: )The impending disappearence of the general surgeon J. Fischer JAMA. 2007;298(18): )Progressive specialization within general surgery: adding to the complexity of workforce planning. Stitzenberg KB, Sheldon GF.J Am Coll Surg. 2005;201(6): ) General surgery programs in small rural New York state hospitals: a pilot survey of hospital administrators. Zuckerman R, Doty B, Gold M, et al. J Rural Health. 2006;22(4): )The provision of general surgical services in rural south Australia: A new model for rural surgery. H. Bruening, G. J. Maddern Australian and New Zealand Journal of Surgery Volume 68, Issue 11, pages 764–768, November 1998 Volume 68, Issue 11, 6) An estimation of the global volume of surgery: a modelling strategy based on available data. Weiser TG, Regenbogen SE, Thompson KD; et al. Lancet. 2008;372(9633):