Thursday, October 07, 2004

The Future of Surgery III.....
The final commentary on the Annals of Surgery piece.Surgical Education in the United States: Portents for Change. As an aside, I apologize for the lack of a free link. Since there is no abstract in this paper Medline only has the citation. This post analyzes the paper's statements concerning general and specialist surgeons.
It was suggested as recently as 1998 that most leading surgeons in the country still believe that broad surgical training is superior and should be maintained. It is not surprising that a group (79%) of surgeons older than 50 years would support the regimen that molded them!

The general surgeon, the hallowed product of surgical training in this country, is a vanishing breed. More than 70% of surgeons completing general surgical residency opt for subspecialty training immediately after residency, and an even greater majority self-differentiate by the time of first recertification.
I was not aware that the number of surgeons who specialize was that high. There are multiple fellowships that surgical residency graduates can pursue ranging anywhere from 1 to 4 years. Specialization offers the potential of higher pay, better hours, and the ability to engage in an area of practice which one really enjoys. As noted above, even more surgeons "self-differentiate" as they stay in practice. While some may obtain new skills and concentrate their efforts there, more often it is by eliminating areas of their practice as time goes by. Many stop covering trauma, performing cancer procedures, or otherwise shrink their "sphere of influence". The reasons are many: fear of liability, group dynamics (you have fellowship trained associates that concentrate their practice), community dynamics (other fellowship trained surgeons in town), geography (proximity to an academic medical center), and facilities (does your hospital have the staff and physical plant capable of handling things?).
Those surgeons who remain as classic general surgeons have a practice that barely resembles what they were trained to do. A recent analysis of the workforce patterns of rural surgeons in West Virginia suggested that more than half were so discouraged that they would not encourage a young person to pursue a career in medicine. More than one third of these surgeons practiced some general medicine daily, and the surgical caseload varied by community size. In communities of fewer than 10,000, they listed obstetrics and gynecologic (9%), urological (5%), otolaryngology (9%), and orthopaedic (4%) procedures as part of the regular caseload. Endoscopic procedures comprised 17% to 24% of total procedures regardless of community size, which is clearly not a focus of the current general residency education program.
One must remember that during the time this survey was taken West Virginia was embroiled in a liability insurance controversy which could explain the 50 percent dissatisfaction described above. In smaller communities there are often not ant gynecologists, otolaryngologists, urologists, or other orthopedic specialties. Endoscopy is attractive to surgeons because it is quick, easy, and can lead to other procedures. There is a large body of research that shows, quite frankly, there are some procedures that the community general surgeon has no business performing:
Other general surgeons believe that they should be trained and encouraged in all surgical practices, particularly gastrointestinal surgery. Academic reports and societal demands, however, emphasize that the casual operator has morbidity and mortality rates unacceptable for major procedures such as esophagectomy, pancreatectomy, and liver resection. High-volume surgeon and institutional experience improves operative mortality, morbidity, and long-term survival. That 25% of patients undergoing pancreatectomy are operated on by surgeons who perform less than 1 procedure a year, and that 96% of surgeons who performed a pancreatectomy in the State of New York between the years 1983 and 1991 performed 1 or fewer annually, is hardly desirable patient care.

Is it possible or even appropriate to train generalists to do such procedures when so few exist in the majority of residency training programs in this country? The converse argument is that while we wish that complex procedures be performed in high-volume centers, it will just not happen; eg, in a study of Medicare patients undergoing pancreaticoduodenectomy 28% of patients had their procedure performed at an institution that did less than 1 a year and 80% had an operation in an institution that did less than 5 a year. However, because it is so does not mean it is the desired aim. Ask the patient! It is becoming clear that when patients have information and the possibility to choose, they will choose centers with better outcomes. Analyzing this issue from the pure perspective of where the operation has been performed is flawed, because it incorrectly assumes that patients had both information and the possibility to choose.
This raises again the issue I brought up in this post, that patients with the motivation and means to find themselves a "center of excellence" will receive better care.
The generalist is in part damned because he or she is judged against the outcome results of the specialist.
(emphasis mine)
However community general surgeons as a group seem to realize this themselves:
The general surgeon, even in the absence of any fellowship training, self-differentiates. Of surgeons presenting at 10 years for recertification, the average number of hepatic and pancreatic procedures per year was less than 1, 86% did no liver procedures, and 79% had not performed a pancreatectomy. Procedures for which the median annual experience was zero included esophagus, liver, any transplant, splenectomy, and any complex vascular procedure. Even if we believe that the generalist should do it all, the general surgeon and the patient have decided otherwise.
But the desire for patients to all go to a "center of excellence" for a particular procedure, gets splashed in the face with the ice water of reality:
It is clear that we cannot mandate where common operations be performed. It is estimated that if colectomy was limited to hospitals doing a minimum of 15 procedures in 5 years, 1400 patients (5% of the total) would be redirected and 263 hospitals (45%) would discontinue the procedure, and the operative mortality would fall from 4.59% to 4.44%.
As I pointed out here this study cited a false-negative rate of appendectomy in children of 4.8 percent in high volume centers, compared to 8.4 percent overall. The 4.8% was reached only in 13 out of 2521 hospitals that contributed data, and those hospitals accounted for only 5.6 percent of the procedures analyzed. Hope you like to travel. There are also implications for training future surgeons in those types of procedures:
More frightening is the question of where might these procedures be performed in sufficient volume to train anyone? In a previous study, only 27 hospitals in the nation did more than 16 pancreatic resections a year, which strongly argues for using these uncommon cases to train only those who will fully embrace this type of practice.
So what do I do all day?
What are the recertifying general surgeons doing? In part, it depends on the population, but in the main, it is endoscopy, breast, cholecystectomy, hernias, and appendectomy.

The need for general surgical leadership in clinical practice is very real. It is clear that the general surgeon, whether practicing in small communities or large, remains an important bastion in emergency management of inflammatory conditions such as acute cholecystitis or acute diverticulitis and in initial management of the burned or otherwise injured patient. All of these areas progressively demand the resources of specialized centers and specialized surgeons so that patient outcome can be maximized.
In an ironic twist to all this, many trauma attendings in university settings are acting like community surgeons and handling general surgical emergencies while on call in an attempt to maintain skills. Of course there will now be a cry for an "emergency surgery" fellowship.
Speaking of the specialist surgeon:
Seventy percent of male surgeons and 50% of female surgeons completing a surgical residency go on to subspecialty training. Many argue that the general surgical experience provides little beyond a basic understanding of surgical principles that prepares them for a subsequent career in a focused discipline. Urology, orthopedics, and neurosurgery take a 1-year internship and then move directly to their own discipline. Would it not be better if we served the needs of all potential surgical faculty with a structured introductory surgical component and then allowed early differentiation?
Are urologists, orthopedists, and the like included in that seventy percent? I doubt it.
The demand for greater cultural training in communication and humanistic as well as technical skills is increasing, but does the dedicated cardiothoracic surgeon need to do one pancreatic resection or total gastrectomy to prepare him or her for a career in which he or she will rarely, if ever, see the organ, let alone operate on it? Many surgical residents who go on to specialty training see at least 2 of the 5 years spent in general surgical training as a waste of the most productive years of their lives, which could be dedicated to their specialty or to research within that specialty. Plastic surgery has experimented with 1, 3, or 5 years of a general surgical program before moving on to a dedicated 2- to 3-year course in plastic and reconstructive surgery. An analysis of the participants in each of these pathways would provide great insight into the merits of each approach.
So we are taking operations that are rare (pancreatic resection and gastrectomy) and have a direct outcome-volume relationship, and "forcing" residents that have little or no interest in performing them outside of training to do them while they (the residents) could better spend that time with other endeavors. Some surgical specialties are moving beyond the traditional "blade and suture" approach, while also trying to maintain traditional general surgical skills:
Advances in science and technology are forcing the melding of specialist practices. The training required in vascular surgery needs to be meshed with that of interventional radiology, and combination residencies have been promulgated. A similar dilemma will exist in other image-guided therapies. Conversely, if one wishes to practice general surgery in addition to the specialty field, as has been suggested by one third of current vascular surgeons, how do we address the need for the vascular surgeon to be appropriately and adequately trained for the general surgery practice that he or she desires to pursue?
There are also serious implications for re-certification:
The demands for analysis of competency, whether in training, generalist, or specialist practice, will add further burdens to the limits to which comprehensive all things to all people training can be maintained. How appropriate is it to demand of a vascular surgeon that he or she be recertified in general surgery, or that a general surgeon be recertified to include the elements of vascular surgery that he or she no longer practices? What of the person who has dedicated his or her life to the management of breast disease, who is asked to be recertified in the broad discipline that he or she initially embarked upon? Testing surgeons in areas in which they do not practice defeats the goal of recertification or continuing education. How much does recertification in a comprehensive generalist sense, when personal focus is highly specialized, deter re-evaluation and assessment of competency?
In addition to this there are calls for increasing the requirements for recertification, such as submitting charts, CE "modules" and videotapes of operations. When does the desire to insure competency become an onerous burden? It will take years to work these issues out, and I see stormy weather ahead.
Cross-posted at Galen's Log


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