Keywords
surgery - general surgery - comprehensive surgery - surgical super specialties - rational
organization - surgical services
Introduction
Over the past few decades, we have witnessed vast expansion of knowledge and emergence
of technologies in medical science. It has resulted in widening the scope of surgical
management of complicated cases and undertaking complex procedures. Dedicated departments
are established to provide services and for training purposes. The super specialty
services achieve better outcomes in complex cases and are here to stay. A number of
disciplines have emerged and recognized as surgical super specialty for some disciplines.
There is justifiable increasing demand for similar status for more disciplines.
In the back drop of glamour of super specialties, status accorded to the discipline
of general surgery does not commensurate with the responsibility bestowed on it. Quite
often, opinions are articulated that there is no place for general surgery in the
era of specialization and the discipline is dead.[1] On the contrary, it has been opined that the general surgeons have to play much
more important and complex role.[2] Occasionally, these disciplines are referred to as subspecialties. The nomenclature
whether super or sub is not relevant. Important issue is relative positioning of different
disciplines in the overall organization of surgical services with optimal utilization
of trained manpower.
The aim of organizing care services for surgical diseases is a challenging task and
is dependent on utilization pattern of trained surgical work force. It is contended
that assignment of activities/responsibilities between different disciplines is the
major issue.
Current Scenario
The department of general surgery is the parent department for conducting training
programs for basic certification in surgery for both undergraduate and post graduate
studies. The clinical functions are organized to meet the teaching requirements. Teaching/learning
activities are carried out as part of patient care, thus ensuring adequate exposure
and hands-on-experience. Separate staff for teaching only is not provided. With emergence
of multiple surgical super specialties, though not clearly defined, surgical disciplines
are assigned to general surgery or superspecialties based on the level of competence
expected of the trainees at the end of training. Influenced by this vertical arrangement,
there is a trend of reflex referral of patients to superspecialty services without
any attempt at initial evaluation or basic investigations. By and large, superspecialty
departments do not restrict intake to only referred patients. Usually, there is no
facility for prehospital screening. Also, there is no effective linkage between primary
care providers and hospitals.
General surgery as a discipline includes knowledge of and management of diseases of
organs of wide spectrum of systems. The universities/teaching institutions and the
examining bodies follow proportionate representation of different disciplines in their
curricular planning. The aim of general surgery training is to address the issue of
surgical manpower to best serve the public good.[3] Breadth of training in general surgery is essential for all branches of surgical
practice.[4] System of rotation to other disciplines is practiced wherever needed for comprehensive
coverage of learning objectives. There are variations in disciplines for and duration
of rotation across institutions. Appropriate educational technology is utilized in
all disciplines.
There are diverse motivating factors for opting for superspecialties. The prime mover
is desire of individuals in accepting challenges of undertaking difficult and complex
procedures. Aspirants are willing to devote extra time and finances for further higher
training. However, apart from the legitimate reason, there are other important considerations
for opting for super-specialties arising from lifestyle and financial issues, and
the number of residents opting for careers in general surgery are getting reduced.[5]
[6]
Shortcomings
The widely practiced current system classifies surgical disciplines as a “whole” comprising
care of both complex procedures and those of routine nature. Such a scheme of vertical
arrangement of surgical disciplines has certain limitations. A surgeon who has undertaken
special training to acquire essential advanced skills in superspecialty discipline
is likely to be involved, rightly so, in the care of patients with complicated diseases
and complex procedures to the point of exclusion of patients requiring procedures
of routine nature, for which no additional training is required but which is involving
an organ of superspecialty discipline. In contrast, involvement with routine and simple
cases may overwhelm the superspecialist, which may not permit adequate time and attention
to complicated cases and challenging problems, for which the superspecialty department
is established in the first place. General surgeons may be handicapped in care of
such patients with diseases of routine and simple nature belonging to the superspecialty
discipline, even though they have the requisite competence and confidence for the
management on account of privileging, professional liability concerns, fear of allegations
of negligence and litigation. .
Thus, paradoxically, patients with simple diseases of routine nature are likely to
be neglected. Overwhelming trend for superspecialization resulting in the shortage
of manpower in general surgery has serious implications for the health care delivery.[7]
[8]
[9]
Is there an alternative? Yes. There is.
Alternative
The system of vertical arrangement of disciplines is based on the premise that there
are some disciplines dealing with complex procedures and others with procedures of
only a simple and routine nature. However, this premise is not correct. Each discipline
is a mix of simple routine as well as of complex nature cases requiring specialized
treatment.
It is therefore incumbent to consider modification of organization of services to
achieve the learning objectives for the purpose providing trained surgical manpower.
Activities/procedures within each discipline may be scrutinized to classify according
to the level of competence expected from trainees. Criteria applied for the classification
of activities are as follows: on completion, the trainee is capable to assume full
responsibility-category 1; has gained sufficient experience-category 2; and is conversant
with broad understanding-category 3. It may be emphasized that there is a shifting
of categorization from “ discipline” to “nature/character of the activities of each
branch as per defined criteria.” Every discipline will have components of category
1, 2, or, 3 in variable proportion.
Activities of simple and routine nature requiring no more than usual training and
equipment of all discipline are put in category 1, those requiring additional advanced
dedicated training, sophisticated equipment, and infrastructure are categorized as
category 3. Those in the middle comprising some difficult cases, which may require
some additional orientation but not requiring heavy inputs in equipment or specialized
training, are categorized as category 2.
Activities of category 1 of all disciplines are part of general surgery and those
of category 3 are in the respective superspecialty. Category 2 activities are assigned
to either general surgery as additional/optional activities or superspecialty depending
on local factors comprising case load, infrastructure, interest of staff, etc.
The clinical services are organized accordingly aimed at meeting educational requirements.
The proposed rational organization is schematically represented in [Fig. 1].
Fig. 1 Horizontal distribution of activities in all disciplines.
Due attention is merited for authorization for clinical functions including operative
work to the staff as per the proposed organization. Privileging is a managerial tool
granting permission to staff of the department basically aimed at quality assurance.
The process of privileging is not a part of certification or examining bodies but
is the responsibility of institutions.[10] A list of privileged specific procedures needs to be reviewed regularly. Addition
of new procedures in privileges list is based on careful objective evaluation of competence.
Maintaining acceptable level of quality of care is a difficult and challenging task
requiring continuing education and organizing workshops, etc. This is true for all
branches of surgery. It is to be appreciated that quality and safety issues addressed
voluntarily are more effective and reduce chances of intrusive actions.[11]
Changing Scenario:
Shift from “ general” to “ comprehensive” discipline
The activities in category 1 across all disciplines are included in general surgery
as primary constituents of general surgery forming “ essential core service,” which
is indispensable for basic certification. The scope of general surgery is thus broadened.
The practice and concept of general surgery are shifted from “residual” to what could
be termed “comprehensive” discipline.
Primary responsibilities of parts from each surgical discipline help achieve harmonious
synthesis of constituents, leading to integrated comprehensive teaching/learning and
training instead of collage of fragments. There may not be necessity for rotation
to superspecialty for orientation to basic aspects of the concerned specialty. This
arrangement will have desirable impact on undergraduate medical and post graduate
studies in surgery, for training of “family physician” and “surgical specialist.”
It may also provide opportunity for making informed decision in choosing superspecialty
training, having been exposed to some aspects of all the disciplines, albeit of simple
nature. It is a common observation that candidates apply for more than one superspecialty
course.
In addition to discharging responsibility to “core essential,” general surgeons may
take interest and participate in some of activities in category 2 included as additional/optional
activities in general surgery. This will be intellectually and professionally satisfying
experience and should be encouraged. However, due caution is needed to ensure that
responsibility of essential core primary constituents is not diluted in any way. It
is possible that same activity may be opted by more than one staff as per individual's
interest. This merits to be accommodated. All staff members may be persuaded to participate
in one or more activities of category 2 so as to have maximal coverage of optional
items. Desirably, the aim should be to attempt to include all category 2 activities
in general surgery in the true spirit of broad-spectrum service.
Planning of infrastructure requirement comprising hospital beds, operation theatres,
OPD facilities, office space, staff, ancillary services, etc. should take into account
additional commitment.
Progressive specialization of optional category 2 activities within the constituents
of general surgery is feasible and will provide breadth of services expected of general
surgery.[12]
[13] Shortened integrated training strategy has been recommended, which may require logistic
and financial considerations.[14]
Distribution of activities among disciplines is dependent on many factors such as
case load, infrastructure, and training opportunities. Each institution is expected
to formulate the list of “core essential” and “advanced/additional” topics. Professional
associations/regulatory bodies may provide guidelines. A list of suggestion of some
activities/topics is included as example in the proposed curriculum for postgraduate
training in surgery submitted to the Medical Council of India.[15]
Advantages
There are distinct advantages of such horizontally placed activities. The superspecialty
departments may be able to devote more attention and time to complex procedures, for
which the superspecialty was established in the first place. Patients needing attention
of routine nature are taken care of by trained surgeons, and unnecessary referrals
are avoided. The suggested system is useful for providing satisfactory service as
well as training commitments. The discipline of general surgery is expected to play
an important role in the health care delivery system,[16] and proposed organization of surgical service will facilitate this role.
Collateral Issues
Under the proposed organization, the general surgical practitioners in whatever setting,
teaching, community, charity, corporate hospital, or private clinics, are likely to
deal with more variety of cases. One direct result is the number of patients in any
one condition is small and consequently of reduced experience in every item. This
limited experience in a particular procedure may have some apprehension about the
competence of the surgeon. This apprehension, however, is unfounded as basic surgical
skills are same across all disciplines.
Also, the possibility of large personal/institutional series is reduced, which may
be perceived as a negative feature. It actually is a positive feature for satisfactory
comprehensive patient care and clinical research. Under the proposed scheme, the research
is undertaken by multi-institutional collaborative data collection, and the patient
care follows practice guidelines/protocols developed for decision making in the management
instead of personal anecdotal observations. It is increasingly being recognized to
develop and follow clinical pathways and practice guidelines for efficient and cost-effective
patient care.[17]
Advancement within the primary constituents of general surgery will provide breadth
of services expected of general surgery requiring complex manpower planning.[12] Shortened integrated training may need logistic and financial support. It must be
ensured that “essential core” topics are not compromised while paying attention to
acquiring additional skills for optional items.
The aim of surgical research is to encourage curiosity and critical appraisal and
helps achieving open and interdisciplinary problem solving approach in improving patient
care.[18]
[19] Research activities by trainees enhance chances for career progression. Properly
supervised research reinforces education of future surgeons.[20] Modified organization of surgical services as “comprehensive surgery” departments
will have opportunities to engage in relevant research activities to address a wider
range of surgical issues prevalent in the society.
Advanced Trauma Life Support (ATLS) course initially designed for rural practitioners
is recommended to be included as part of training objectives of general surgery.[21] It is desirable to extend the application of ATLS protocols to all emergency surgical
cases or may even be to all patients attending casualty/emergency department pertaining
to all departments. It may be worthwhile to modify the term “ATLS'-“Advanced Trauma
Life Support” to “ALS”–“Advanced Life Support.”
Though trauma is not on focus in this presentation, it may briefly be mentioned that
establishing separate “standalone” trauma centers, which are being advocated widely,
are of doubtful value in the context of serving all trauma victims in a given community,
notwithstanding improved outcomes in the institutional statistics of “Trauma Centre,”
which may as well be due to better infrastructure and availability of equipment. It
may briefly be mentioned that care of trauma victims in the community is likely to
be improved more by establishing multi-specialty hospitals not trauma centers, network
of peripheral centers for stabilizing, and well-equipped ambulance service. Trauma
victims need to be treated as any other emergency patients. Surgeons with broad-spectrum
training are better placed in dealing with such situations.
It may briefly be mentioned that establishing specialty of “Traumatology,” “Emergency
Medicine/Surgery,” etc., independent of main discipline does not appear logical. Trauma
victims are likely to have involvement of multiple organs and are best attended to
by a broadly trained surgical team. Experience in elective cold routine cases is useful
in emergency situations. Referral to other departments are made selectively for specific
problems and advanced interventions to the respective superspecialty service.
Departments of surgery in teaching institutions are mandated to train suitable manpower
for future general surgeons, surgical superspecialists, and family physicians. Teaching
program of the department is directed to undergraduate medical students, interns,
postgraduate students and senior residents in surgery, continuing education, incorporating
new procedures, and maintaining learnt skills. Curriculum planning and strategy to
address the wide spectrum of teaching role needs to be planned holistically. The challenging
task for the academic departments is to train manpower in general surgery for mentoring
medical students and residents may require opportunities for acquiring teaching skills
and technologies.[22]
Separate staff for teaching exclusively is not required, and the teaching is carried
out as part of regular clinical responsibility. Proper infrastructure is required
to ensure that both functions are carried out without disturbing each other.[23] Unfortunately, teaching is accorded low priority and the faculty is not rewarded
adequately for the time and effort in teaching. It needs to be emphasized that patient
care is not an addendum to but essential constituent of medical teaching. It has rightly
been pointed out that teaching activities contribute to patient care.[24]
Practice currently in vogue for holding an all India examination aimed at reducing
stress of multiple examinations, with objective-type question system, for uniformity
for admission to MS/MD during internship and to M.Ch/DM during senior residency has
serious implications on training opportunities.[25]
[26] Admission process to these courses for candidates with wide variations in the qualifying
examinations merits to be revisited.
The system of rotation to superspecialties departments currently in vogue for exposure
to diseases in category 3 activities with expected competence of “only broad understanding
of management” is dispensed with. Cognitive aspects of specialized disciplines can
easily be covered by lectures/discussions and other educational tools. The learner
gets more time in the main department and has larger opportunity for observation,
hands-on experience, and participation in the management of wide range of surgical
diseases including from the disciplines of subspecialty sections. Innovations and
application of modern educational technology contribute to improving educational outputs.
There are programs for providing adequate exposure and competence in medical educational
technology in distance learning and institutional formats.[27]
Simulation as a teaching and assessment tool for imparting skill training is being
recognized.[28]
[29] The aim is that the learner acquires minimal level of competence on simulators before
actually performing on human patients. Wide range of skills can be practiced including
basic clinical skills of injections, blood sampling; dressing and splinting, etc.;
essential surgical skills of knotting, suturing, anastomoses etc.; advanced surgical
procedures such as endoscopy and laparoscopy etc. Simulators consisting of models
and mannequins, synthetic material mimicking tissues, animal tissues, training boxes
for laparoscopy, virtual reality, etc. are being increasingly used for skill learning
and assessment for core competencies.[30] Surgical skill laboratory, which may be considered an essential component of teaching
department, is still underutilized.[31]
Training in general surgery is a pre-requisite for recruitment to superspecialty courses.
Approximately less than half of the trainees are estimated to continue in the discipline
of general surgery.[32] Organization of services with inclusion of parts of all disciplines provides opportunity
to prospective candidates for informed decision in identifying area of interest and
choosing courses for further training. It is a common observation that most candidates
apply for more than one course.
Apprehensions and Critiques
Apprehensions and Critiques
The scheme of broadening the scope of general surgery by including some activities
from disciplines recognized as super/subspecialization is feared with apprehensions.
It may be perceived as a retrograde step and is not considered a viable proposition.
It may be alleged that surgical care is being provided by semi-/untrained surgeons,
which may have serious professional liability concerns. Nevertheless, it is emphasized
the scheme is a step in right direction. Broad-based surgical training is effective
in achieving high-quality surgical services without compromising on the overall quality
and containing costs. It is good not only for developing countries such as India but
also has a global appeal.
It is perceived by some that surgical care in the hands of general surgery is not
cost-effective or efficient in quality.[33] These criticisms are unfounded and are based on the consideration of territorial
interests of the “super specialty” departments instead of adopting an appropriate
problem-solving approach; utilizing the talent is in the best interest of care. Perception
that general surgeon is a multiple superspecialist rolled into one is erroneous. As
explained earlier, only some selected items are included in the general surgery, which
do not require special equipment or detailed further training, and the trained general
surgeon is competent to discharge the responsibility. Superspecialists need to be
convinced that “taking off load” is good for the specialty.
Objective of better outcomes and reducing defective service is a reasonable goal;
however, the concern is how to achieve this. Super specialization may appear to be
an obvious simple solution intuitively. However, fragmentation and lack of continuity
are not in the best interest of patient care.[34]
A part of resistance in accepting the concept arises from the use of value-loaded
term “super,” indicating higher status to some disciplines as compared to others in
terms of social hierarchy and financial compensation in both organized service and
self-employed. This distortion needs to be corrected.
Conclusion
Horizontal distribution of activities between general surgery and surgical super specialties
is a rational, logical, and practical strategy for organizing good-quality surgical
services covering full-spectrum of surgical diseases with wide reach out in the community.
