General Surgeons: More Are Needed

Patricia Rebbeck, MB, ChB, FRCSC

General surgeons: More are needed

The glitter of surgical subspecialties has been luring students away from general surgery—a critical specialty if we are to provide the care our society needs and expects.

ABSTRACT: The specialty of general s a senior general surgeon now. Gradually, more and more sub- surgery has had difficulty attracting I have watched over the specialties were carved off general residents for training and most stu- years as surgery has been surgery and soon we, the general sur- dents who begin general surgery A dissected into smaller and geons working in big cities, lost many residency go on to subspecialties. smaller subspecialties. When I was in of the skills that we had been taught This has led to a shortage of gener- training, there were only 9 main sur- because we were increasingly being al surgeons, particularly in rural gical divisions; now there are 19, and bypassedwith the proliferation of new areas, where they are most needed. there would be more if the Royal Col- subspecialties. Thesubspecialties stop- The answer may be to provide some lege had not declared a moratorium on ped training general surgery residents training in community hospitals creating new subspecialties. while general surgery became the rather than in academic centres. In my day, the object was to pro- training ground in basic skills for duce a surgeon who could cope with a those about to enter a residency in a variety of emergencies and urgent different field. General surgery began cases. We general surgery residents to suffer an identity crisis. There was learned the basic procedures of the talk of the need for a name change. other surgical specialties and were “Oh, you areageneral surgeon. Ithought expected to perform them when those you were a specialist.” specialists were unavailable—which As fewer residents opted for gener- at that time was in most parts of the al surgery and the scarcity increased, country. We could perform a cesarean the question arose: Do we still need section, a hysterectomy, a D and C, general surgeons? Today half the gen- anddeal with an ectopic pregnancy. We eral surgeons in Canada are over 55 could do burr holes, crack a chest, or years of age andwill soon retire, which clear a cloggedartery; our scope ranged will leave the 20% of Canadians liv- from the top of the head to the toe- ing outside major cities, many in rural nails. We could plate a fracture, nibble and northern towns, without an essen- 1,2 a prostate, and wire a broken jaw. We tial service. It is impractical for this were able to operate on babies and the Dr Rebbeck is secretary to the Non-Hospi- very old and all ages in between. The tal Medical/Surgical Facility Committee of result was that we were versatile sur- the College of Physicians and Surgeons of geons who could work almost any- British Columbia. She is also a clinical pro- where and fix almost anything. This fessor emerita of surgery of the University was precisely the sort of surgeon that of British Columbia. smaller centres needed and still need

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population to depend on a plethora of university encourages this approach, for general surgery is not as attractive 3 faraway subspecialty surgeons. Apart since kudos, andin part income, depend as the schedule for surgical subspe- from emergency surgical work, which on research and publications, and sur- cialties in larger centres. must be done immediately, a wide gical subspecialties as opposedto gen- If we need general surgeons, where range of less emergent andelective sur- eral surgery are more likely to provide best to train them? The life and scope gical procedures are well within the them. In short, the medical schools of a general surgeon in the tertiary care capabilities of a properly trained gen- have little incentive to encourage gen- teaching hospital is rather different eral surgeon. Also, if these surgeons eral surgery. In addition, medical stu- from that of a general surgeon in the did not exist, many patients would dents inclined to a surgical career may community, andalthough many excel- lent mentors are available in these teaching hospitals, it would perhaps be better if the general surgery residents had much of their training in the community, in rural or northern set- tings. It is well known that students and residents receiving training in an We were versatile surgeons who could work area often remain when the training is complete, and this could be an added almost anywhere and fix almost anything. benefit for our neglected regions. This was precisely the sort of surgeon that A few sites still exist with enough general surgeons to develop training smaller centres needed and still need now. and mentoring programs, and it is important that these surgeons be en- gaged to reverse the downward trend in general surgery. The University of Northern British Columbia, in part- nership with UBC, already trains general surgery residents andshould, along with other sites, be given every incentive to continue and expand its pro- have to be transferred to a major cen- get the impression that a generalist grams. The university medical school tre at considerable cost to the system path is somehow of lesser merit once must understand that training surgical 4 and inconvenience to the patients. It they are exposed to the glitter of the residents, depending on their seniority, would set two standards of health care surgical subspecialties. will require more operating room time for Canadians, which we would right- Then there is lifestyle—an increas- and may reduce the teaching surgeon’s ly reject. Clearly this cannot be ingly important consideration for young output by up to 15%; this will of 6 allowed to happen. surgeons, and rightly so. Because course increase waiting lists for elec- Why are so few students consider- there is a shortage of general surgeons, tive cases and erode the income of the 5 ing a career in general surgery? There the call schedule, particularly in under- mentoring surgeons, both with obvi- are several reasons. First, although the serviced rural and northern areas, is ous financial implications that cannot fact of this scarcity is generally known, more onerous than that of a subspe- be ignored. our medical schools have not grasped cialist in a large centre. This problem On a hopeful note, there is some the severity of the situation and do not is self-perpetuating—the fewer gener- evidence that more would-be surgeons appear to have any concrete plans to al surgeons we train, the worse the are considering general surgery. Many deal with it; the heads of surgical de- shortage becomes, and the more on- of the subspecialty surgical areas are partments are seldom if ever general call coverage will be needed for gener- filling up and it is increasingly hard surgeons and they naturally promote al surgeons, making future students for new trainees to find jobs exactly the subspecialties that might bring even less inclined to consider general where they would like to work. It will national and international renown to surgery as a career option. This is not be some time before this happens in their departments. Furthermore, the helped by the fact that the fee schedule general surgery, andprovidedthat this

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trend continues we may look forward to community, rural, and northern positions being filled with enough The future of general surgery, a critical specialty general surgeons not only to provide a if we are to provide the care our society needs vital and professionally rewarding service but to allow a satisfactory and expects, depends on the medical schools 7,8 lifestyle. and their surgical departments making it crystal The future of general surgery, a critical specialty if we are to provide clear to students that school officials and the care our society needs and expects, department heads consider general surgery depends on the medical schools and their surgical departments making it every bit as prestigious and as important to crystal clear to students that school society as any of the surgical subspecialties. officials and department heads consider general surgery every bit as prestigious and as important to society as any of the surgical subspecialties. At References 6. Bland KI. Contemporary trends in stu- the same time, they must ensure there 1. Canadian Medical Association. Statistical dent selection of medical specialties:The are sufficient funds to support the men- information on Canadian physicians. Feb- potential impact on general surgery.Arch toring programs in those communi- 9 ruary 2005. www.cma.ca/multimedia/ Surg 2001;137:259-267. ties able to provide training. CMA/content (accessed 25 April 2005). 7. Schroen AT,Brownstein MR, Sheldon GF, It might be added that many young 2. College of Family Physicians of Canada. et al. Comparison of private versus acad- graduates areinterestedin offering their National Physician Survey. Retirement emic practice for general surgeons: A services to countries less fortunate figures. www.cfpc.ca/nps (accessed 25 guide for medical students and residents. than ours, either before settling in a April 2005). J Am Coll Surg 2003;197:1000-1011. practice or from time to time while in 3. Pollett WG, Harris KA. The future of rural 8. Barshes NR,VavraAK, MillerA, et al. Gen- practice. General surgery skills are surgical care in Canada: A time for action. eral surgery as a career: A contemporary more portable than many and in this Can J Surg 2002;45:88-89. review of factors central to medical stu- regard the world is the general sur- 4. Iglesias S, Jones LC. Rural surgical pro- dent specialty choice. J Am Coll Surg geon’s oyster—another attraction to grams in Western Canada. Can J Rural 2004;199:792-799. considering this career option. Med 2002;7:103-107. 9. Cochran A, Paukert JL, Scales EM, et al. Competing interests 5. Ko CY, Escarce JJ, Baker LL, et al. Pre- How medical students define surgical None declared. dictors for medical students entering a mentors. Am J Surg 2004;187:698-701. general surgery residency. Surgery 2004;136:567-572.

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