- Email: [email protected]
General surgery: Should you do it or not?
ARTICLE IN PRESS Seminars in Colon and Rectal Surgery 000 (2019) 100716
Contents lists available at ScienceDirect
Seminars in Colon and Rectal Surgery journal homepage: www.elsevier.com/locate/yscrs
General surgery: Should you do it or not? Chitra N. Sambasivana, Sharon L. Steinb,* a
Colorectal Surgeon, Presbyterian Healthcare Services, PMG Colorectal Surgery at Presbyterian Kaseman Hospital Physician Office Building, 8300 Constitution Ave NE, Albuquerque, NM 87110, United States b Colorectal Surgery, University Hospitals Research in Surgical Outcomes and Effectiveness, University Hospitals Cleveland Medical Center, Case Western University School of Medicine, 11100 Euclid Ave LKS 5047, Cleveland, OH 44106, United States
A R T I C L E
I N F O
Keywords: Colorectal surgery General surgery Surgical practice Subspecialty surgery
A B S T R A C T
Colon and rectal surgery is a well-established surgical subspecialty which was at the forefront of the development of specialization. One of the considerations of such a specialty surgeon is if the incorporation of continued general surgery work should be a component of their practice. Does this diminish their distinction as an expert in their field? Is their day to day experience broad enough to allow for continued coverage of a field that they trained in, but are not being consistently exposed to? The viewpoints on this topic can be divergent. This forum considers this multifaceted issue from these varied perspectives while providing historical context. It is important to realize that, when considering entering into a position, a physician must decide what their professional goals are and what they are looking for in a job while taking into account this very important topic. © 2019 Elsevier Inc. All rights reserved.
Introduction As the graduating Colon and Rectal Surgery Resident begins to evaluate staff positions, the question of whether or not to do general surgery as part of one’s practice is often broached. There are complex and varying opinions on whether a fellowship trained specialist should continue to do general surgery. This discussion focuses on the historical roots of specialization, the role of mastery in ones’ practice, and market pressures. The historic roots of specialization Historically, the motivation for certification and creation of medical boards was to protect the integrity of the medical profession. In order to ensure quality of care, physicians created standards for training and practice. Defining standards for physicians grouped doctors by practice patterns and these groups became specialties. The field of colon and rectal surgery, or proctology as it was first defined, has always been at the leading edge of this movement, both in terms of certification and creation of standards. The field of surgery was originated from barbers who slowly began to perform surgical procedures.1 Initially, there was no standardization of training required and it was not until the 18700 s and 18800 s that hospitals began to set up departments of surgery including ophthalmology, *Corresponding author. E-mail address: [email protected] (S.L. Stein). https://doi.org/10.1016/j.scrs.2019.100716 1043-1489/© 2019 Elsevier Inc. All rights reserved.
dermatology and proctology. Joseph Matthews, often considered the father of modern proctology, set up a department of proctology at the Kentucky School of Medicine in 1883.2 Standardization and specialization of practice followed and in the 18900 s, specialty societies began to emerge.3,4 Dr. Matthews, despite being elected president of the American Medical Association in 1898, practiced only colon and rectal surgery. The first meeting of the American Society of Proctologists occurred in Columbus Ohio in 18992 when 13 proctologists met and declared their mission to be “the cultivation and dissemination of knowledge in whatever related to diseases of the colon and rectum”.5 The next step in standardization and specialization was creation of training programs. William Halsted’s revolutionary ideas would form the basis for modern surgical residency. He believed that the resident required intense repetitive opportunities to care for a patient under the supervision of a skilled surgical teacher, that the resident would need an understanding of the scientific basis of surgical disease, and that the resident needed to acquire skills in patient management and technical operations during the course of their training.6 These were new ideas, that a certain skill level should be achieved prior to calling oneself, “surgeon”. By 1933, the National Board of Medical Societies was created, truly advocating for practice standards. The American Board of Proctology was founded in 1935, predating the American Board of Surgery by two years. In 1961, it would change its name to the American Board of Colon and Rectal Surgery.2 Specialization was present, even early in the years of standardization.
ARTICLE IN PRESS 2
C.N. Sambasivan, S.L. Stein / Seminars in Colon and Rectal Surgery 00 (2019) 100716
The Flexner report,7 published in 1933, made a strong call for educational reform and research based education. Immediately following the report, a number of articles appeared in prestigious journals of medicine, crediting specialization as an “ingenious way for the profession to control the dangers for untrained physicians”. There was significant concern that unqualified practitioners would claim to be physicians, or specialists, and advertise their skills to the uneducated public.8,9 The benefits of specialized and advanced training were seen early on. During both World War I and II, those with specialty training were given greater responsibility in war, higher rank and better pay.10 The American Board of Colon and Rectal Surgery (ABCRS) requires that all diplomats have attained board certification in general surgery (having passed both the written qualifying and oral certifying exam) before they are eligible for certification as a colorectal surgeon. Candidates must have passed the qualifying (written) exam of the American Board of Surgery (ABS) before sitting for the ABCRS written, and similarly must have passed the qualifying (oral) ABS exam before taking the ABCRS qualifying (oral) exam to be fully certified (More information can be found at: http://www.abcrs.org/qualifications/). This distinction differs from other specialties (for example Vascular surgery) which does not require ABS certification prior to becoming a board certified Vascular surgeon. The ABCRS has prided itself on this distinction. While ABS certification has been required for initial ABCRS certification, it has not been required for the traditional10year re-certification. As maintenance of certification transitions to continuous certification platforms, it remains uncertain how this will impact requirements from the board. Mastery of the profession The idea of specialization centers around the idea that the surgeon who more narrowly defines the scope of practice is more likely to become a master within that field. Data on mastery is well documented. Ericsson and colleagues11 were amongst the first to report that it takes a certain amount of time to become an expert. Research found that becoming an “expert” in most cases required 10,000 h of deliberate practice.11 Some surgical literature has argued that even this number may underestimate the time that is required to become an expert surgeon and perhaps as many as 15 20,000 h are necessary.12 Current general surgery training programs provide surgical residents 19,600 h over an 80 h, 49 week, 5 year work schedule.13 However, much of that time is not spent in actual surgical practice or technical tasks. It is estimated that the average general surgical resident spends only 2753 h as a “surgeon” and 272 h as first assistant.14 In addition, the quality of that time matters. Data from after the 80 h work week was established shows that the average number of cases done by a chief resident has decreased by 10% and that the number of opportunities for residents to truly “do the case” has diminished during that time.13 If one believes that performing the same surgery is important in gaining expertise, the data for repetition in residency is concerning: the average graduating general surgery resident performs only 9 operations more than 20 times, only 20 operations more than 10 times, and only 40 operations more than 5 times during the five years of training.15 However, at the end of general surgical residency, graduates are expected to have a comprehensive understanding of the perioperative management and technique of 88 “essential common” operations and 70 “essential-uncommon” operations regardless of individual experience.13,15,16 It is not surprising that at the end of general surgical training many surgeons and program directors have concern about graduates’ ability to operate independently. A 2013 article demonstrated that 23% of graduating chief residents answered that they did not agree or were unsure of whether “a 5-year general surgery residency fully prepares you to practice general surgery”17 and 43% of surveyed
fellowship directors disagreed that fellows arrived capable of independently performing 30 min of a major operation.18 It is not surprising that 80% of general surgical residents plan to do fellowships.17 A colon and rectal surgery resident spends significantly more time performing colon and rectal surgery than a general surgery resident. Colon and rectal residents are required to do a minimum of 120 abdominal, 60 anorectal and 185 endoscopic procedures.19 On average, in 2017 2018, a graduating resident did 717 colon and rectal procedures. This included 83 segmental colectomies, 41 low anterior resections and over 100 laparoscopic colon surgeries. The benefits of this focused practice may be that surgeons who are specialists may be better at performing certain surgeries. A Cochrane database systemic review found that patients with colon and rectal cancer had significantly higher 5 year survival and lower mortality when surgery was done by high volume surgeons and colorectal specialists.20 Further data found that after emergency colectomies done by colon and rectal surgeons, patients were likely to have lower morbidity, mortality, and return to the operating room, as well as a 4.4 day shorter length of stay.21 Market forces at work A Survey study sent to the American Society of Colon and Rectal Surgeons (ASCRS) in 2007 demonstrated that 78% respondents also performed general surgery.22 Fellows of ASCRS were less likely to perform general surgery than ASCRS members or candidates, with an average of 25% of practice being general surgery. Herniorrhaphy, cholecystectomy and appendectomy were the most common procedures performed. The most common reason for general surgery practice listed were practice requirement of emergency room coverage. This trend may be changing. More recent data demonstrated that only 36% of graduating colon and rectal surgeons reported taking a job that included general surgery.23 There may be pressure for colon and rectal surgeons to take a job that includes general surgery. Overall, there is a decline in the number of general surgeons. It is estimated that by 2020 there will be a shortage of 1875 surgeons in the US and this number will grow to a shortage of 6000 surgeons by 2050.24 The number of certifications issued by the American Board of Surgery declined by 11% between 2002 and 2011.1,25,26 The shortage of general surgeons is most dramatic in non-urban locations. In 2009, 30% of 1300 critical access hospitals did not have a surgeon living in the county,27 which can lead to increased mortality in emergency situations.28 This overall shortage of general surgeons can lead to pressure on fellowship trained surgeons to take general surgery call, cover general surgery, or include general surgery as part of their practice. The pressure to do general surgery may be more common in hospitalbased positions, private practice and multispecialty groups than in academic or large single-specialty practices. Surgeons early in their careers may find that continuing to practice general surgery may seem to be a practical means of building clinical volume. There are several limitations to taking general surgery call as a specialist. The first is maintenance of one’s skills. Colon and rectal surgeons who practice general surgery have an obligation to ensure that they are doing adequate volume of each general surgical case to maintain their general surgical skills. Just as outcomes are better for colon and rectal surgeons doing colon and rectal surgery, the converse is true as well. The question of skill for a part time generalist is an appropriate question. Evidence is mounting to show that higher surgeon volumes of specific cases lead to lower morbidity and mortality as well as shorter length of stay in multiple specialties.29 34 Even “simple procedures” such as cholecystectomy may be affected in the same way; New York state data demonstrated lower surgeon volumes were associated with increased readmissions and prolonged duration of stay after cholecystectomy.35 Colon and rectal surgeons practicing general surgery are responsible for the same 88 “essential
ARTICLE IN PRESS C.N. Sambasivan, S.L. Stein / Seminars in Colon and Rectal Surgery 00 (2019) 100716
common” operations and 70 “essential-uncommon” operations as any general surgeon.15 Taking general surgery call may also ultimately hinder recognition of the provider as a colon and rectal surgeon. It may be easier to become known as an expert in colorectal disease if this is established from the outset as a distinction from the local general surgeons. If a colorectal surgeon does general surgery, what is the differentiation between the two fields? Why send the colorectal cases to the colorectal surgeon, rather than to another general surgeon? This diminishes the benefits of the specialty training and dilutes the mastery of the field. There is then no distinction from the general surgeons who do colon and rectal surgery. Many have found that a surgeon who develops a reputation for being an excellent general surgeon who also does colorectal surgery, may find it more challenging to focus their practice in colorectal surgery in the future. There are a few final considerations. One is malpractice premiums, which may be higher for someone who does emergency general surgery procedures (including cholecystectomy) in addition to colorectal surgery procedures. Another is hospital credentialing committees often require board certification in a medical specialty to obtain privileges. If one allows ABS certification to lapse, this may affect his or her ability to perform general surgery procedures. Finally, there are certain medicare and third party payer issues, whereby quality credits, preferential network participation rates and other cost/quality implications may play a role in reimbursement and other factors for physicians that are or are not certified. Conclusion Ultimately, the decision of whether to include general surgery as a component of a colon and rectal surgery practice will be a personal decision. Factors to consider include: abilities and training, professional goals such as prospects for recognition, teaching and/or research opportunities, lifestyle with regards to family or personal needs, geographic location, and financial compensation.36 38 References 1. Bruns SD, Davis BR, Demirjian AN, et al. The subspecialization of surgery: a paradigm shift. J Gastrointest Surg. 2014;18(8):1523–1531. https://doi.org/10.1007/ s11605-014-2514-4. 2. Schoetz DJ. The American board of colon and rectal surgery: past, present and future. Clin Colon Rect Surg. 2012;25:166–170. 3. Burd DA. Super-specialization leads to higher surgical standards? Br J Plastic Surg. 1990;43:112–115. 4. King LS. Medical practice: specialization. JAMA. 1984;251(10):1333–1338. 5. ASCRS website. https://www.fascrs.org/about-us. Accessed 3/21/19. 6. Imber G. Genius on the edge: the bizarre double life of Dr. William Stewart Halsted. New York: Kaplan Publishing; 2010. 7. Flexner A. Medical education in the united states and canada: a report to the carnegie foundation for the advancement of teaching. bulletin no. 4. New York: Carnegie foundation for the advancement of teaching, 1910. (Editor) the certification of specialists. N Engl J Med. 1936;215:468–469. 8. Fitz R. The rise of the practice of internal medicine as a specialty. N Engl J Med. 1950;242:569–574. 9. Cassel CK, Rueben DB. Specialization, subspecialization and subsubspecialization in internal medicine. N Engl J Med. 2011;364(12):1169.
3
10. Ludmerer KM. Time to heal: American medical education from the turn of the century to the era of managed care. New York: Oxford University Press; 1999. 11. Ericsson KA, Krampe RT, Tesch-Romer C. The role of deliberate practice in the acquisition of expert performance. Psychol Rev. 1993;100(3):363–406. 12. Purcell Jackson G, Tarpley JL. How long does it take to train a surgeon? BMJ. 2009;339:b4260. 13. Sorensen M. Surgical subspecialization: escape route for surgeons or added benefit for patients. J Grad Med Ed 2014215. 14. Chung RS. How much time do surgical residents need to learn operative surgery? Am J Surg. 2005;190(3):351–353. 15. Malangoni MA, Biester TW, Jones AT, et al. Operative experience of surgery residents: trends and challenges. J Surg Educ. 2013;70(6):783–788. 16. SCORE: Curriculum Outline. http://www.surgicalcore.org/public/curriculum. Accessed February 13, 2014. 17. Coleman JJ, Esposito TJ, Rozycki FS, et al. Early subspecialization and perceived competence in surgical training: are residents ready? J Am Coll Surg. 2013;216: 764–771. 18. Mattar SG, Alseidi AA, Jones DB, et al. General surgery residency inadequately prepares trainees for fellowship: results of a survey of fellowship program directors. Ann Surg. 2013;258(3):440–449. 19. https://apps.acgme.org/ads/Program/CaselogReport/CaselogReportDownload? reportId=90958. Accessed 3/21/19. 20. Archampong D, Borowski D, Willie-Jorgensen P, et al. Work load and surgeon’s specialty for outcome after colorectal cancer surgery. Cochrane Databse Sys Rev. 2012;14(3) CD005391. 21. Kulaylat AS, Pappou E, Philp MM, et al. Emergent colon resections: does surgeon specialization influence outcomes? Dis Colon Rectum. 2019;62(1):79–87. https:// doi.org/10.1097/DCR.0000000000001230. 22. Chu KM, Schoetz DJ. What impact might general surgery practice patterns of colon and rectal surgeons have on future training. Dis Colon Rect. 2007;50(7):1–5. 23. Sherman KL, Steinhagen E, Brady JT, et al. Landing your first colorectal surgery job: how to find it and what to expect. Dis Colon Rectum. 2019;62(5):529–536. https:// doi.org/10.1097/DCR.0000000000001341. 24. Williams TE, Ellison EC. Population analysis predicts a future critical shortage of general surgeons. Surgery. 2008;144:548–556. 25. Sheldon GF. The evolving surgeon shortage in the health reform era. J Gastrointest Surg. 2011;15:1104–1111. 26. AMBS 2012 Certification Statistics. Available at: www.abmsdirectory.com. 27. Sheldon GF. The surgeon shortage: constructive participation during health reform. J Am Coll Surg. 2010;210(6):887–894. 28. Richardson JD. General surgeon shortage in the united states: fact or fiction, causes, and consequences. Soc Work Public Health. 2011;26:513–523. 29. Ali MR, Tichansky DS, Kothari SN, et al. Validation that a 1-year fellowship in minimally invasive and bariatric surgery can eliminate the learning curve for laparoscopic gastric bypass. Surg Endosc. 2010;24(1):138–144. 30. Barker II FG, Amin-Hanjani S, Butler WE, et al. In-hospital mortality and morbidity after surgical treatment of unruptured intracranial aneurysms in the united states, 1996-2000: the effect of hospital and surgeon volume. Neurosurgery. 2003;52 (5):995–1007. discussion 1007-1009. 31. Kulkarni GS, Urbach DR, Austin PC, et al. Higher surgeon and hospital volume improves long-term survival after radical cystectomy. Cancer. 2013;119 (19):3546–3554. 32. Lau RL, Perruccio AV, Gandhi R, et al. The role of surgeon volume on patient outcome in total knee arthroplasty: a systematic review of the literature. BMC Musculoskelet Disord. 2012;13:250. 33. Schneider EB, Hyder O, Wolfgang CL, et al. Provider versus patient factors impacting hospital length of stay after pancreaticoduodenectomy. Surgery. 2013;154 (2):152–161. 34. Kandil E, Noureldine SI, Abbas A, et al. The impact of surgical volume on patient outcomes following thyroid surgery. Surgery. 2013;154(6):1346–1352. discussion 1352-1353. 35. Abelson JS, Spiegel JD, Afaneh C, et al. Evaluating cumulative and annual surgeon volume in laparoscopic cholecystectomy. Surgery. 2017;161(3):611–617. 36. Alavi K, Madoff RD, Rothenberger DA. Career options in colon and rectal surgery. Clin Colon Rectal Surg. 2006;19(3):114–118. 37. Vargas HD. Private practice for the colon and rectal surgeon. Clin Colon Rectal Surg. 2006;19(3):119–128. 38. Interview with Dr. Scott Steele: http://medicalschoolhq.net/ss-36-what-does-aca demic-colorectal-surgery-look-like/.
Contents lists available at ScienceDirect
Seminars in Colon and Rectal Surgery journal homepage: www.elsevier.com/locate/yscrs
General surgery: Should you do it or not? Chitra N. Sambasivana, Sharon L. Steinb,* a
Colorectal Surgeon, Presbyterian Healthcare Services, PMG Colorectal Surgery at Presbyterian Kaseman Hospital Physician Office Building, 8300 Constitution Ave NE, Albuquerque, NM 87110, United States b Colorectal Surgery, University Hospitals Research in Surgical Outcomes and Effectiveness, University Hospitals Cleveland Medical Center, Case Western University School of Medicine, 11100 Euclid Ave LKS 5047, Cleveland, OH 44106, United States
A R T I C L E
I N F O
Keywords: Colorectal surgery General surgery Surgical practice Subspecialty surgery
A B S T R A C T
Colon and rectal surgery is a well-established surgical subspecialty which was at the forefront of the development of specialization. One of the considerations of such a specialty surgeon is if the incorporation of continued general surgery work should be a component of their practice. Does this diminish their distinction as an expert in their field? Is their day to day experience broad enough to allow for continued coverage of a field that they trained in, but are not being consistently exposed to? The viewpoints on this topic can be divergent. This forum considers this multifaceted issue from these varied perspectives while providing historical context. It is important to realize that, when considering entering into a position, a physician must decide what their professional goals are and what they are looking for in a job while taking into account this very important topic. © 2019 Elsevier Inc. All rights reserved.
Introduction As the graduating Colon and Rectal Surgery Resident begins to evaluate staff positions, the question of whether or not to do general surgery as part of one’s practice is often broached. There are complex and varying opinions on whether a fellowship trained specialist should continue to do general surgery. This discussion focuses on the historical roots of specialization, the role of mastery in ones’ practice, and market pressures. The historic roots of specialization Historically, the motivation for certification and creation of medical boards was to protect the integrity of the medical profession. In order to ensure quality of care, physicians created standards for training and practice. Defining standards for physicians grouped doctors by practice patterns and these groups became specialties. The field of colon and rectal surgery, or proctology as it was first defined, has always been at the leading edge of this movement, both in terms of certification and creation of standards. The field of surgery was originated from barbers who slowly began to perform surgical procedures.1 Initially, there was no standardization of training required and it was not until the 18700 s and 18800 s that hospitals began to set up departments of surgery including ophthalmology, *Corresponding author. E-mail address: [email protected] (S.L. Stein). https://doi.org/10.1016/j.scrs.2019.100716 1043-1489/© 2019 Elsevier Inc. All rights reserved.
dermatology and proctology. Joseph Matthews, often considered the father of modern proctology, set up a department of proctology at the Kentucky School of Medicine in 1883.2 Standardization and specialization of practice followed and in the 18900 s, specialty societies began to emerge.3,4 Dr. Matthews, despite being elected president of the American Medical Association in 1898, practiced only colon and rectal surgery. The first meeting of the American Society of Proctologists occurred in Columbus Ohio in 18992 when 13 proctologists met and declared their mission to be “the cultivation and dissemination of knowledge in whatever related to diseases of the colon and rectum”.5 The next step in standardization and specialization was creation of training programs. William Halsted’s revolutionary ideas would form the basis for modern surgical residency. He believed that the resident required intense repetitive opportunities to care for a patient under the supervision of a skilled surgical teacher, that the resident would need an understanding of the scientific basis of surgical disease, and that the resident needed to acquire skills in patient management and technical operations during the course of their training.6 These were new ideas, that a certain skill level should be achieved prior to calling oneself, “surgeon”. By 1933, the National Board of Medical Societies was created, truly advocating for practice standards. The American Board of Proctology was founded in 1935, predating the American Board of Surgery by two years. In 1961, it would change its name to the American Board of Colon and Rectal Surgery.2 Specialization was present, even early in the years of standardization.
ARTICLE IN PRESS 2
C.N. Sambasivan, S.L. Stein / Seminars in Colon and Rectal Surgery 00 (2019) 100716
The Flexner report,7 published in 1933, made a strong call for educational reform and research based education. Immediately following the report, a number of articles appeared in prestigious journals of medicine, crediting specialization as an “ingenious way for the profession to control the dangers for untrained physicians”. There was significant concern that unqualified practitioners would claim to be physicians, or specialists, and advertise their skills to the uneducated public.8,9 The benefits of specialized and advanced training were seen early on. During both World War I and II, those with specialty training were given greater responsibility in war, higher rank and better pay.10 The American Board of Colon and Rectal Surgery (ABCRS) requires that all diplomats have attained board certification in general surgery (having passed both the written qualifying and oral certifying exam) before they are eligible for certification as a colorectal surgeon. Candidates must have passed the qualifying (written) exam of the American Board of Surgery (ABS) before sitting for the ABCRS written, and similarly must have passed the qualifying (oral) ABS exam before taking the ABCRS qualifying (oral) exam to be fully certified (More information can be found at: http://www.abcrs.org/qualifications/). This distinction differs from other specialties (for example Vascular surgery) which does not require ABS certification prior to becoming a board certified Vascular surgeon. The ABCRS has prided itself on this distinction. While ABS certification has been required for initial ABCRS certification, it has not been required for the traditional10year re-certification. As maintenance of certification transitions to continuous certification platforms, it remains uncertain how this will impact requirements from the board. Mastery of the profession The idea of specialization centers around the idea that the surgeon who more narrowly defines the scope of practice is more likely to become a master within that field. Data on mastery is well documented. Ericsson and colleagues11 were amongst the first to report that it takes a certain amount of time to become an expert. Research found that becoming an “expert” in most cases required 10,000 h of deliberate practice.11 Some surgical literature has argued that even this number may underestimate the time that is required to become an expert surgeon and perhaps as many as 15 20,000 h are necessary.12 Current general surgery training programs provide surgical residents 19,600 h over an 80 h, 49 week, 5 year work schedule.13 However, much of that time is not spent in actual surgical practice or technical tasks. It is estimated that the average general surgical resident spends only 2753 h as a “surgeon” and 272 h as first assistant.14 In addition, the quality of that time matters. Data from after the 80 h work week was established shows that the average number of cases done by a chief resident has decreased by 10% and that the number of opportunities for residents to truly “do the case” has diminished during that time.13 If one believes that performing the same surgery is important in gaining expertise, the data for repetition in residency is concerning: the average graduating general surgery resident performs only 9 operations more than 20 times, only 20 operations more than 10 times, and only 40 operations more than 5 times during the five years of training.15 However, at the end of general surgical residency, graduates are expected to have a comprehensive understanding of the perioperative management and technique of 88 “essential common” operations and 70 “essential-uncommon” operations regardless of individual experience.13,15,16 It is not surprising that at the end of general surgical training many surgeons and program directors have concern about graduates’ ability to operate independently. A 2013 article demonstrated that 23% of graduating chief residents answered that they did not agree or were unsure of whether “a 5-year general surgery residency fully prepares you to practice general surgery”17 and 43% of surveyed
fellowship directors disagreed that fellows arrived capable of independently performing 30 min of a major operation.18 It is not surprising that 80% of general surgical residents plan to do fellowships.17 A colon and rectal surgery resident spends significantly more time performing colon and rectal surgery than a general surgery resident. Colon and rectal residents are required to do a minimum of 120 abdominal, 60 anorectal and 185 endoscopic procedures.19 On average, in 2017 2018, a graduating resident did 717 colon and rectal procedures. This included 83 segmental colectomies, 41 low anterior resections and over 100 laparoscopic colon surgeries. The benefits of this focused practice may be that surgeons who are specialists may be better at performing certain surgeries. A Cochrane database systemic review found that patients with colon and rectal cancer had significantly higher 5 year survival and lower mortality when surgery was done by high volume surgeons and colorectal specialists.20 Further data found that after emergency colectomies done by colon and rectal surgeons, patients were likely to have lower morbidity, mortality, and return to the operating room, as well as a 4.4 day shorter length of stay.21 Market forces at work A Survey study sent to the American Society of Colon and Rectal Surgeons (ASCRS) in 2007 demonstrated that 78% respondents also performed general surgery.22 Fellows of ASCRS were less likely to perform general surgery than ASCRS members or candidates, with an average of 25% of practice being general surgery. Herniorrhaphy, cholecystectomy and appendectomy were the most common procedures performed. The most common reason for general surgery practice listed were practice requirement of emergency room coverage. This trend may be changing. More recent data demonstrated that only 36% of graduating colon and rectal surgeons reported taking a job that included general surgery.23 There may be pressure for colon and rectal surgeons to take a job that includes general surgery. Overall, there is a decline in the number of general surgeons. It is estimated that by 2020 there will be a shortage of 1875 surgeons in the US and this number will grow to a shortage of 6000 surgeons by 2050.24 The number of certifications issued by the American Board of Surgery declined by 11% between 2002 and 2011.1,25,26 The shortage of general surgeons is most dramatic in non-urban locations. In 2009, 30% of 1300 critical access hospitals did not have a surgeon living in the county,27 which can lead to increased mortality in emergency situations.28 This overall shortage of general surgeons can lead to pressure on fellowship trained surgeons to take general surgery call, cover general surgery, or include general surgery as part of their practice. The pressure to do general surgery may be more common in hospitalbased positions, private practice and multispecialty groups than in academic or large single-specialty practices. Surgeons early in their careers may find that continuing to practice general surgery may seem to be a practical means of building clinical volume. There are several limitations to taking general surgery call as a specialist. The first is maintenance of one’s skills. Colon and rectal surgeons who practice general surgery have an obligation to ensure that they are doing adequate volume of each general surgical case to maintain their general surgical skills. Just as outcomes are better for colon and rectal surgeons doing colon and rectal surgery, the converse is true as well. The question of skill for a part time generalist is an appropriate question. Evidence is mounting to show that higher surgeon volumes of specific cases lead to lower morbidity and mortality as well as shorter length of stay in multiple specialties.29 34 Even “simple procedures” such as cholecystectomy may be affected in the same way; New York state data demonstrated lower surgeon volumes were associated with increased readmissions and prolonged duration of stay after cholecystectomy.35 Colon and rectal surgeons practicing general surgery are responsible for the same 88 “essential
ARTICLE IN PRESS C.N. Sambasivan, S.L. Stein / Seminars in Colon and Rectal Surgery 00 (2019) 100716
common” operations and 70 “essential-uncommon” operations as any general surgeon.15 Taking general surgery call may also ultimately hinder recognition of the provider as a colon and rectal surgeon. It may be easier to become known as an expert in colorectal disease if this is established from the outset as a distinction from the local general surgeons. If a colorectal surgeon does general surgery, what is the differentiation between the two fields? Why send the colorectal cases to the colorectal surgeon, rather than to another general surgeon? This diminishes the benefits of the specialty training and dilutes the mastery of the field. There is then no distinction from the general surgeons who do colon and rectal surgery. Many have found that a surgeon who develops a reputation for being an excellent general surgeon who also does colorectal surgery, may find it more challenging to focus their practice in colorectal surgery in the future. There are a few final considerations. One is malpractice premiums, which may be higher for someone who does emergency general surgery procedures (including cholecystectomy) in addition to colorectal surgery procedures. Another is hospital credentialing committees often require board certification in a medical specialty to obtain privileges. If one allows ABS certification to lapse, this may affect his or her ability to perform general surgery procedures. Finally, there are certain medicare and third party payer issues, whereby quality credits, preferential network participation rates and other cost/quality implications may play a role in reimbursement and other factors for physicians that are or are not certified. Conclusion Ultimately, the decision of whether to include general surgery as a component of a colon and rectal surgery practice will be a personal decision. Factors to consider include: abilities and training, professional goals such as prospects for recognition, teaching and/or research opportunities, lifestyle with regards to family or personal needs, geographic location, and financial compensation.36 38 References 1. Bruns SD, Davis BR, Demirjian AN, et al. The subspecialization of surgery: a paradigm shift. J Gastrointest Surg. 2014;18(8):1523–1531. https://doi.org/10.1007/ s11605-014-2514-4. 2. Schoetz DJ. The American board of colon and rectal surgery: past, present and future. Clin Colon Rect Surg. 2012;25:166–170. 3. Burd DA. Super-specialization leads to higher surgical standards? Br J Plastic Surg. 1990;43:112–115. 4. King LS. Medical practice: specialization. JAMA. 1984;251(10):1333–1338. 5. ASCRS website. https://www.fascrs.org/about-us. Accessed 3/21/19. 6. Imber G. Genius on the edge: the bizarre double life of Dr. William Stewart Halsted. New York: Kaplan Publishing; 2010. 7. Flexner A. Medical education in the united states and canada: a report to the carnegie foundation for the advancement of teaching. bulletin no. 4. New York: Carnegie foundation for the advancement of teaching, 1910. (Editor) the certification of specialists. N Engl J Med. 1936;215:468–469. 8. Fitz R. The rise of the practice of internal medicine as a specialty. N Engl J Med. 1950;242:569–574. 9. Cassel CK, Rueben DB. Specialization, subspecialization and subsubspecialization in internal medicine. N Engl J Med. 2011;364(12):1169.
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