General Surgery as Education, Not Specialization

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.

CHALLENGING TIMES FOR GENERAL SURGEONS

Recently, Organ² solicited opinions from the presidents of major regional American surgical societies on the role of general surgery during the past 10 years. They were requested to answer the following 5 questions. (1) Do our nonsurgical colleagues, patients, medical students, or general surgeons believe we are specialists? Answer: There was a recurrent element of denial: 80% of our nonsurgical colleagues considered general surgery a specialty, 70% of patients considered general surgeons as specialists, and only 85% of medical students and general surgeons themselves believed they were specialists. (2) List some reasons for the declining image of general surgery. Answer: Among the suggestions given, the following responses were chosen: a declining involvement in the medical school curriculum; the image as being a noncognitive discipline; the specialty as too diffuse and not clearly defined; and the term general made the specialty a dumping ground. (3) Why do general surgeons lack pride in their specialty? Answer: Increased referrals to other specialties; often, poor training; a feeling that they were not specialists. (4) List ways in which the image/pride of the general surgeon can be improved. Answer: Among other suggestions, here are some examples: expand the scope of practice; improve training; change the name; do not change the name; doubt that it could be improved. (5) If you believe a name change is needed, please list your suggestions. Answer: The name is fine; add a specific area of concentration behind general surgery, and so forth. Why are general surgeons dissatisfied with what they were doing? There was no single explanation for this feeling; rather, several were expressed: the specialty is just too broad and not sufficiently defined, rising unreasonable expectation of perfection, loss of income, loss of freedom to practice surgery in the way they wish, long hours, and worsening conditions in which to provide high-quality care. Another reason for discontent was that general surgery has become fragmented to the point that the discipline has lost some of its binding values and common identity.

More than 20 years ago, a renowned American surgeon, James Hardy,¹⁰ wrote the provocative editorial “Will the General Surgeon Become Extinct?” He concluded that “surgery and surgical practice are constantly changing, and one may predict with confidence the long term survival of the general surgeon.” Hardy's prediction may have held true during the 20th century, but I feel that it is fading away in the 21st century. In a Presidential Address of our Association, Harder¹¹ stated that “the process of becoming a general surgeon and the practice of general surgery within the actual environment, show signs of weakness or even debility.”

I believe that the discussion on the survival of general surgery should be addressed in terms of what constitutes, on the one hand, a discipline, and on the other hand, a specialty. In 1978, the American Board of Surgery issued a broad definition of general surgery as “a discipline having a central core of knowledge embracing anatomy, physiology, metabolism, immunology, nutrition, pathology, healing, shock and resuscitation, intensive care and neoplasm.” These points are common knowledge that is required for all surgical specialties. This broad definition is more suitable to a basic discipline that is responsible for surgical educational programs.

How do you identify a general surgeon? The general surgeon is a person who is broadly educated in and exposed to all the essential content areas of general surgery, including the alimentary tract; the abdomen and its contents; breast, skin, and soft tissue; the endocrine system; head and neck surgery; pediatric surgery; surgical critical care; surgical oncology; transplantation surgery; trauma/burns; and vascular surgery. During the period of education, these people are expected to have a broad cognitive knowledge of and a wide practical experience with each of these areas. This also includes diagnosis, preoperative evaluation, intraoperative technical familiarity, and postoperative care, including the management of complications. As a result, the practice of general surgery is so heterogeneous that it has raised doubts whether surgical trainees can even acquire the necessary experience to achieve competence in the practice of general surgery. Ritchie¹² critically examined the general surgery certificate. In his words, “that certificate is currently under siege.” Ritchie¹² summarized the criticisms of his respected colleagues on this issue in this way: “Among other things, it has been charged that the broadly trained and relatively versatile surgeon, which the certificate purports to identify, is a fiction; that, in any case, there is no role for such individuals in today's surgical world; that it takes too long to create these generalists to the detriment of specialists and specialist care, and that as a consequence of all of this, the basic certificate has minimal currency today and that its most appropriate fate is to be cannibalized.” Despite all these criticisms, Ritchie¹² still believed that the broadly educated basic general surgeon possesses great value, both real and potential. He believed that “when trained in this way, such an individual can provide total patient care for great many diseases that may require surgically intervention; is capable of providing that care on a continuous basis; is the ‘Captain of the ship’ because he or she expected to and accepts the ultimate patient care responsibility; is probably cost-effective; is more capable and can better adapt to changing patterns of practice than, perhaps, one whose training has been more narrowly focused.” Most of this may be true, but today, in the practice of medicine, including surgery, this type of person, who is so undifferentiated or widely versatile or capable of a broad range of independent practice, may not be needed any more.

Geographic reasons in industrialized countries and lack resources in developing countries have been claimed as important factors in maintaining the role of surgical generalists. In those settings, the mode of practice as a general surgeon, for whatever intervention may be needed, is absolutely justified: “I (general surgeon) could not have done any more; I was the only one able to provide the care that was needed; and so forth.” Even one of the present leaders of modern surgery, Murray Brennan,¹³ in a recent editorial, was sympathetic to the generalist when referring to the delivery of surgical care to a wide spectrum of relatively uncomplicated diseases in smaller, less concentrated populations. In Brennan's¹³ words, “One can imagine, however, the development of a generalist as a true specialist, as has been done in others parts of the world with the development of what is called ‘rural surgery’ for want of a better name.” I have doubts that generalists would accept being called this name for what they devote to their practice. I do not believe that the generalist's broad practice is tenable any more. In modern medicine, no single person can administer the total health care needed. The management of any disease requires a broad range of expertise for health care to be delivered effectively, efficiently, and safely. Therefore, in the context of surgeons working anywhere, with clear limitations in the infrastructure and/or nonurban areas, surgical specialization should be promoted to provide the best care to patients. The formation of subspecialized surgical clinics calls for parallel development in a number of medical specialties and subspecialties (ie, radiology, pathology, oncology, and so forth). In this environment, educational initiatives may play an important role in ensuring that current surgical approaches are available to all patients.

TRAINING IN GENERAL SURGERY

From a practical standpoint, after the completion of the residency program in general surgery, residents should limit their practice to the area in which they were trained. Looking at the current data from the Residency Review Committee in the United States,¹⁴ of the 880 residents who graduated in 1999, it was observed that, on average, chief residents had performed 948 operations as surgeons. Among them, they had performed 74 breast operations, 104 biliary tract operations, 88 herniorrhaphies, 31 appendectomies, and 43 colectomies. On average, the numbers of complex surgeries performed were 1 total esophagectomy, 1 gastrectomy, 3 liver resections, and 3 pancreatico-duodenectomies. For other areas, such as endocrine surgery,¹⁵ the average number of thyroidectomies by chief residents during the residency program who finished their training between 1987 and 1994 ranged from 10.8 to 12.7. The average number of parathyroidectomies performed by the same residents ranged from 4.1 to 5.1. Other data¹⁶ revealed that an average chief resident barely performed even 1 adrenalectomy and rarely, if ever, had performed a pancreatic endocrine procedure (0.15 case/resident) or a major nonthyroid, nonparathyroid endocrine procedure (0.14 case/resident). These figures are not much different from those of general surgery residency programs found in much of Europe. This analysis suggests that, in a broad discipline such as general surgery that covers many common and uncommon problems, a number of procedures (of the 9 essential primary component areas of general surgery) are infrequently, if ever, performed by most of the surgery residents. With this kind of limited surgical experience, how can the operating surgeon be expected to be knowledgeable in all the diagnostic techniques used to determine the correct preoperative diagnosis, the medical management of the underlying pathologic condition, and the correct postoperative management? Many residency programs in general surgery contradict the basic educational goal: to prepare the resident to function as a qualified practitioner of surgery at the high level of performance expected of a certified specialist. Therefore, at present, general surgery residents do not fulfill the full competency level in general surgery. Competence has been defined as the state of being sufficiently capable, and properly qualified, to do something at a level that is acceptable. Patients expect that surgeons have attained a high standard of competence and expertise to deliver the care needed for their disease. It is well known that the competence of a surgeon is a recognized prognostic factor for surgical outcome.¹⁷ Therefore, a broad practice and competence can be said to be in conflict with each other.

IS GENERAL SURGERY A SPECIALTY, AND ARE GENERAL SURGEONS SPECIALISTS?

One important contribution on this discussion, published 10 years ago by Warshaw,¹⁸ was entitled, “Restoration, Not Preservation, of General Surgery Residency”: “My main concern, however, is that we are not doing the job for today's general surgeons. We are still doing what we have always promised and delivered, training surgeons broadly, perhaps as a jack-of-all-trades and master of none.” Warshaw's¹⁸ perception is not much different from many residents’ point of view: “the need for training beyond general surgery to become a specialist... They sense that a general surgeon gets no respect.” Warshaw¹⁸ concludes by saying, “we cannot simply preserve general surgery...we must restore to general surgery a sense of specialization and must devise the means to make that real.”

Way¹⁹ asked 80 surgeons for their prediction of what they felt would be the major advances in general surgery in the next 25 years. The list is long, but it can be summarized as follows: “the effects of new technology on the practice of general surgery are more technical complexity, decreasing invasiveness, with fewer traditional operations; the consequences for the training of surgeons, the division of responsibilities among specialists, and the organization of surgical care will be substantial.”

General surgery is continuously growing in both sophistication and technology and has become defined in terms of subspecialties: esophageal-gastric surgery; hepato-biliary-pancreatic surgery, including transplantation; colorectal surgery; endocrine surgery; and surgical oncology, including breast cancer. These subspecialties essentially split the contents of general surgery into specific domains. Therefore, the structure of a general surgery residency program should also change. Residents’ cognitive knowledge and practical experience should be redefined and be focused on what is actually being done in their community. This will enable medical colleagues and the public to help identify the particular specialty. Even with the introduction of these changes, the essential content areas of general surgery should remain as part of the basic education training. However, specific priorities in clinical practice must be developed to provide the surgical trainee with appropriate diagnostic and technical skills to achieve the highest level of competence. As discussed, the operations in the abdominal compartment compose the bulk of general surgery practice: noncomplex biliary surgery, esophageal-gastric surgery (reflux esophagitis), colon-rectal surgery, acute abdomen, hernia, and so forth. Why not rename a general surgery graduate an abdominal surgery specialist? This training could create people with true expertise in abdominal surgery. The areas of subspecialties in the abdomen (hepato-biliary-pancreatic surgery, including transplantation, esophageal surgery, complex colon-rectal surgery) should not be exclusionary cartels for a resident in training; on the contrary, they should have a substantive role in the preparation process of people who choose a career in this specific domain. The trainee, broadly educated in general surgery but a specialist in abdominal surgery, may choose further specialization in 1 organ of the abdomen such as the liver, pancreas, colon-rectum, and so forth, or even in some other domain outside the abdomen, such as breast cancer or endocrine surgery. In the latter, despite the relatively uncomplicated patient treatment, the need for further specialization is a result of the high technical complexity of the procedures.

In Sweden, the resident training program lasts for approximately 5 years and is directed exclusively toward clinical and procedural activities that are relevant for any given specialty.²⁰ Limited work hours have enforced subspecialization so that the surgeons have a reasonable number of patients and operations within the area of expertise.²⁰ According to Ihse and Haglund,²⁰ general surgeons are an endangered species. Subspecialization among Swedish surgeons is probably the main reason for the improved quality of surgical care seen during recent years.

GENERAL SURGERY IN THE AGE OF HIGH TECHNOLOGY

In the past 15 years or so, there has been exponential growth of technology in surgery. This new era requires a specialized workforce. In the words of Sheldon,²¹ “it is our challenge to provide a workforce with the expertise to implement the scientific advances.” Patients expect the transition of these technologies to make advances in clinical applications.

In surgery, we are living in a period of history called the Information Age.²² Laparoscopic surgery is an example of halfway technology: half from the Industrial Age, in which hand-held mechanical instruments were used, and half from the Information Age, in which digital imaging (video monitoring) is used to allow surgeons to view the inner cavities and perform surgery through tiny incisions. Minimal access surgery has revolutionized surgical care. However, even after the introduction of laparoscopic cholecystectomy, most intra-abdominal operations are still performed using 19th century instruments and techniques.

There is strong evidence that surgeons must be able and willing to keep up with the advance in technology. However, it takes time to dominate the new technology with confidence. As an example, before the introduction of laparoscopic cholecystectomy, the standard of care of patients with gallstones and choledocholithiasis was common bile duct clearance at the time of cholecystectomy (clearance rates of more than 90%). Interestingly, however, in the laparoscopic era, most surgeons have sent the patients to endoscopists for endoscopic retrograde cholangiography with or without sphincterotomy and stone removal before or after laparoscopic cholecystectomy. The addition of endoscopic retrograde cholangiography has been associated with morbidly rates as high as 15% and mortality rates of 1%; furthermore, it has seen an increase in the cost of the treatment of these patients. Laparoscopic choledocholithotomy techniques, both transcystic and transductal access methods, have been described since 1991. Since that time, high-resolution portable fluoroscopy imaging machines have been available in addition to laparoscopic ultrasonography and choledochoscope for ductal evaluation. Laparoscopic common bile duct exploration requires advanced technical skills in management of balloon-tipped catheters and baskets, laparoscopic suturing, and knotting.²³ There is no real justification for not making an effort to become proficient in these techniques. Along this same line, in both open and laparoscopic surgery, in their daily practice, many “experts” in hepato-biliary-pancreatic surgery prefer to rely on the opinion of the radiologist (expert in ultrasonography) for the intraoperative decision-making rather than learn to interpret the imaging for diagnosis and appropriate treatment on their own.

Technology can help us to become better surgeons and give us the potential to upgrade our skills and improve our outcomes. Then why have we surgeons failed to learn the clinical applications of new technologies, despite the obvious advantages for our patients? The introduction of a new technique is fraught with risk for the patient. Sometimes these risks pay off, and sometimes they do not. To balance, there is a probable benefit, although without formal testing in clinical trials, it is hard to know. This new culture requires complete transparency. In Way's¹⁹ opinion, “General Surgery has displayed ambivalence about new technology, and this may represent a specific cultural myopia that is responsible for some of our problems.” In modern medicine, surgeons should be experts in disease management, not just operators. The role of the surgeon should expand to encompass the total treatment of the patient without undermining the surgeon as true technical expert.

How well are general surgery residency programs doing in offering technical training to their residents? In Europe, the results of a Belgian survey in trainees on laparoscopic training showed that 62% estimate the laparoscopic theoretical teaching and 66% estimate the practical teaching of laparoscopy are inadequate, independent their year of learning.²⁴ Most (72%) senior trainees (5th and 6th years) performed fewer than 50 laparoscopic cholecystectomies or appendectomies as first surgeon. Very few of them had the opportunity to perform advanced procedures (fundoplication or colon resection). In the majority of surgical centers, the trainee has few opportunities to perform supervised laparoscopic surgery because of the limited experience of the surgical staff, the learning curve of tutors, and the limited number of laparoscopic operations in some centers. In a recent study from Canada,²⁵ graduating general surgery residents were asked 2 questions: was their training in basic and advanced laparoscopic surgery sufficient, and did their surgical faculty have the necessary skills to train them in advanced laparoscopic surgery? Fewer than 18% believed they were qualified to perform advanced laparoscopic procedures after their residency, and only 25% believed there were people on their faculty sufficiently qualified to teach them these procedures. Chung et al²⁶ analyzed the laparoscopic experiences of all American surgical residents graduating between 1994 and 2001. They reported that laparoscopic surgery constituted only 5.7% of a trainee's total surgical experience in 1994, but constituted 13% by 2001, with 68% cholecystectomies. In 2001, the numbers of other laparoscopic operations per trainee were appendectomy, 10.4; hernia, 5.1; and partial colectomy, 2.2. This analysis demonstrated the growth of laparoscopic surgery in training programs; however, the number of laparoscopic operations is still far from what could be acceptable to become proficient in advanced laparoscopic procedures. The term advanced laparoscopy has been used to refer to the newer operations, implying that these are to be learned after acquiring skill in the basic or more commonly performed procedures. The authors concluded, “since competence depends on exposure, residency training alone may not provide depth to allow recent graduate to perform newer operations independently.” The need for training beyond the postgraduate fifth-year (58% of the respondents) was reported by Rattner et al²⁷ in a recent survey. The need of a fellowship to achieve competence seems obvious.^28,29

In agreement with Satava and Wolf,³⁰ recent technologic innovation points to a disruptive change in the practice of surgery. The traditional skills will continue to form the basis of surgical education; however, more and more training will be needed in bioinformatics, bioengineering, and systems integration. These emerging technologies will be available perhaps within a decade. In the meantime, we should prepare our students and residents for this knowledge. Residency program directors should be thinking about how to rearrange the surgical education program for practicing and executing this technology innovation. Today, robotic surgery has a place in clinical practice, retaining all the advantages of minimally invasive surgery while mitigating the shortcomings of laparoscopy.³¹ The worldwide application will depend on the cost, but after adequate robotics training, surgeons can be expected to exceed their laparoscopic performance. Telepresence and telementoring are the next steps in the evolution of robotic surgery.³² Telepresence surgery offers a technologic solution to surgical manpower shortages in remote and underserved areas. As an example, J. Marescaux, sitting at a Zeus console in New York City, performed a telerobotic cholecystectomy on a patient in Strasbourg, France. The surgeon's console was connected directly to Zeus's robotic arms by a transatlantic fiberoptic cable. Telementoring permits an expert surgeon to instruct a novice surgeon in a remote location on how to perform a new operation or use a new surgical technology. All these technologic applications are very costly but worth the investment if it can ultimately help the patient.

The demands for technical perfection will be imperative with the future development of preemptive surgery, or prophylactic operations for genetically predestined malignant diseases. This surgery requires high-level performance. According to Brennan,¹³ preemptive surgery will result in more disease-based rather than discipline-based surgery, but he cautions, “The surgeon can either be assigned the role of a pure technician in an area controlled by a knowledgeable disease-based specialist, or can take up the challenge and become that disease-based leader so desperately needed.”

NEED FOR GENERAL SURGERY REPOSITIONING IN DELIVERING HEALTH CARE

The 20th century was truly the age of surgeons; however, the 21st century will be the age of multidisciplinary patient care. One good example is the treatment of cancer patients.³³ In the past, the general surgery department was the entry point for patient into the care system. The surgeon possessed broad diagnostic abilities, was familiar with a wide range of treatment options, and was able to coordinate or deliver many of them. Today, multimodality cancer treatment is the standard for a large number of patients. However, in this multidisciplinary approach, there is no room for generalists. In his Presidential Address for our Association, Ihse³⁴ stated, “Even if the skill of the individual surgeon is important, it seems to be even more crucial that the multidisciplinary treatment team develops substantial experience in the management of the patients. It is becoming more and more difficult for the general surgeons to defend their preserves and to persist in undertaking cancer procedures once in a while.” At present, general surgeons with additional subspecialty training (liver surgery, pancreatic surgery, esophageal-gastric surgery, and so forth) work in partnership with their medical colleagues in the tasks of surveillance, adjunctive therapy, rehabilitation, and follow-up. This group defines the standard of care for an individual patient, curative or palliative, and incorporates surgical quality control criteria. In this way, reproducible surgical results can be obtained. Who will coordinate the care of the patients with cancer? Anyone, surgeons or medical specialists, can take this responsibility as long as the decisions are made within the team of oncology specialist. Surgical specialists maintain the dual responsibly of being role models and consultants in both surgical care and oncologic care. In this way, surgeons are in a position to shape the treatment of cancer patients through clinical trials. A good example is the recent European multicenter prospective randomized study of adjuvant therapy in patients with pancreatic cancer. This investigation, led by a scientific surgeon, J. Neoptolemos,³⁵ is the largest trial (541 patients) ever conducted in the literature in pancreatic cancer. This trial exemplifies that European multicentric clinical trials are possible when highly specialized surgeons with common interests come together and work for the benefit of the patients.

In all aspects of modern medicine, surgeons must learn to be team players. Surgical decisions on relatively simple treatment may require a broad range of expertise to be delivered effectively efficiently and safely. With this mentality, it should be readily accepted that what we used do and did best may not currently be the best after all. Alternative procedures may be more simple, safe, and efficient.³⁰

The surgical profession in this modern age of advanced technology has an opportunity to take a leadership role in the health care system. The components of a better system had been recently outlined: (1) a system that centers on collaborative care—that is, patients receive care from variety of professionals who work as a team; (2) a system that focuses on patient safety and error reduction; and (3) a system that is devoid of waste (misuse of equipment, supplies, ideas, and energy). We surgeons, acting as a professionals, base our surgical advice on scientific evidence rather than experience alone. Advocates of evidence-based medicine wish to provide surgeons with a theoretical and practical foundation for making clinical decisions. The fundamental change between past and present medicine is access to information. Surgeons need to adjust to this highly technical new knowledge and the information power that patients may have thanks to the Internet. Patients want to know the evidence on which the surgeon is basing clinical judgments and decisions, the likely complications, and how successful the surgeon will be at avoiding them. Trust is simply more qualified now and more circumscribed to a specific technical skill. Horton³⁶ has provided a working definition of trust in medicine. Trust requires belief in the person providing care, confidence in the theory or system of medicine being offered by this person, dependence on the competence of those working in that system, and transcendence from feelings of fear created by ignorance.

CONCLUSIONS

The time has come to redefine and to optimize graduate training in general surgery. The specialty seems to be losing popularity, and among the variety of explanations, the most important are lifestyle issues, length of training, and the loss of identity. The residents clearly express that, during the residency period, they do not have the opportunity to gain enough experience necessary to perform reliably in a safe and effective manner. In addition, working hours are being restricted to a degree that has become incompatible with the acquisition of sufficient surgical experience and volume. As a result, more than 60% of general surgery trainees currently go on to further subspecialty training. The need for further specialization is the consequence of the exponential growth in technology. To find solutions to all these problems, imaginative efforts are needed by training program directors. Here are some tentative suggestions. (1) General surgery should continue to be the core of medical education. (2) The resident training program should be structured and organized to provide focused training in abdominal surgery. After 5 or 6 years, the trainees should become abdominal surgery specialists. These abdominal surgery specialists may seek an area of subspecialization to acquire a breadth and depth of clinical experience in organs of the abdomen or outside the abdomen. During this period, the residency program should offer much more complete technical training. This technology-oriented system will be balanced with important educational issues. (a) Residents should base surgical advise on scientific evidence rather than experience alone. (b) Residents should learn to work in a system that centers on collaborative effort care with other professionals (multidisciplinary care). (c) With the advent of telemedicine and other advances in information technology, surgical residents could obtain rapid access to recent development and evidence-based practice related to new technology and innovations in surgical practice. (d) Training should be focused on a disease-based rather than a discipline-based system. (3) Therefore, it is necessary to organize structured surgical fellowships to develop a new body of knowledge in areas (subspecialty surgery) such as hepato-biliary-pancreatic surgery, including transplantation; colon-rectal surgery; esophageal-gastric surgery; endocrine surgery; surgical oncology, especially breast cancer, melanoma, sarcoma, and so forth; and surgical critical care. (4) Shortening the duration of general surgery education and abdominal surgery specialization might be considered to permit earlier entry into subspecialty surgery.

I hope this discussion will help us to define most appropriate training program and health care system that allow residents to assimilate useful knowledge and incorporate it into the clinical practice with competence, always keeping the best interests of the patient in mind.

General surgery, in name, should continue to be an education tool, but as a consequence of the focused training experience, the trainee should be named not a general surgeon but by the specialty or subspecialty in the area of expertise. Specialization not only gives the surgeon an identity but also may be an answer to improve patient outcome.