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The Case Against Superspecialization in Surgery
NEWS AND VIEWS
The Case Against Superspecialization in Surgery Sreekumar Subramanian, MD, and Friedrich W. Mohr, MD, PhD If the splintering and fragmentation of surgery continues to the end that an established surgeon, whether in the academic arena or in community surgery, addresses himself to the acquisition of mastership of a few operations, certainly he will do these operations better than the wide ranging surgical generalist . . . If the surgical specialist is to dominate the scene completely, the future advance of surgery in my opinion will be retarded. Owen Wangensteen (American surgical pioneer), 1972 Almost 40 years ago, Dr. Charles Eckert,1 in a presidential address of the Central Surgical Association, discussed the phenomenon of specialization and superspecialization in surgery. At that time, the certificate for pediatric surgery was almost approved, and a similar certificate was being sought for peripheral vascular surgery. Eckert surmised that proliferation of subspecialty training programs would detract from the quality of general surgical training and produce general surgeons incapable of caring for the broad spectrum of surgical pathology. He further cautioned that the frontiers of surgery, having historically been advanced by the “efforts of men with unrestricted vision [general surgeons],” would be hindered by the creation of surgical subspecialists, echoing the sentiments of Wangensteen. In the ensuing 40 years, the development of multiple subspecialties within general surgery has resulted in a wide array of surgical training opportunities for those wishing to work in more rural areas to those who plan to enter academics. A brief look at a recent cardiothoracic surgery job advertisement sheds light on the issue of superspecialization in cardiothoracic surgery. “The ideal candidate possesses skills and experience in heart and lung transplantation, assist devices, percutaneous and minimally invasive valve
Department of Cardiac Surgery, Heart Center Leipzig, Leipzig, Germany. Address reprint requests to Friedrich W. Mohr, MD, PhD, Department of Cardiac Surgery, Heart Center Leipzig, Strümpellstraße 39, 04289 Leipzig, Germany. E-mail: mohrf@ medizin.uni-leipzig.de
1043-0679/$-see front matter © 2011 Elsevier Inc. All rights reserved. doi:10.1053/j.semtcvs.2011.10.004
surgery, VATS [video-assisted thoracic surgery] lobectomy, robotics, off-pump coronary and endovascular surgery.”2 Although the advertisement is amusing to the graduating chief resident, it also illustrates the need for superspecialization as science advances, because none of these subspecialty areas had been developed at the time Eckert addressed the Central Surgical Association. Superspecialization in surgery is, therefore, a necessary aspect of surgical evolution. What then is the case against superspecialization in surgery? Inversely postulated, is there still a need for a basic general surgical education? If one considers the increasingly complex nature of cardiothoracic surgery, it is quite clear that a solid surgical foundation is still a necessary prerequisite. Learning how to hold the scalpel, tie knots, achieve meticulous hemostasis, and other basic surgical skills are best acquired during simpler operations, not first during the course of a complex cardiothoracic operation. Similarly, preoperative and postoperative patient management, including how to do an abdominal examination to rule out surgical pathology, as well as understanding fluid shifts, diagnosis and management of common perioperative surgical complications (including acute extremity ischemia, deep venous thrombosis, atrial fibrillation), can be mastered on a general surgical service. These skills are important to the classic as well as the contemporary practice of cardiothoracic surgery and argue against a straight-track cardiothoracic training without general surgical exposure. Although many cardiothoracic surgeons in the United States favor a complete division of the specialty into cardiac and thoracic components, similar to the paradigm in Europe and South America, this fragmentation might also have undesirable consequences. Because cardiothoracic surgical care is more often provided by generalists than by superspecialists, it is conceivable that there will be communities with a cardiac, but no thoracic, surgeon, and vice versa. Patients would then have to travel longer distances to undergo a lung resection or a coronary artery bypass, which is quite difficult for older patients with multiple comorbidities. This validates one of Eckert’s1 postulates, namely that the quality of health care would decline by widespread 171
THE CASE AGAINST SUPERSPECIALIZATION IN SURGERY superspecialization. Just as we continue to need general surgeons, we still need “general” cardiothoracic surgeons, who might be called on to help or take care of a ruptured abdominal aortic aneurysm, either because there is no vascular surgeon available, or the recently trained vascular surgeon has extensive experience with endovascular stenting and has never done an open ruptured abdominal aortic aneurysm. Another negative aspect of specialization is the potential loss of mentorship from surgeons in various disciplines. In a broad general surgical curriculum, the cross-fertilization of ideas, the broad exposure to cutting-edge research, and/or clinical advancements in different areas of surgery expose trainees to an array of mentors who are able to make varied contributions to a trainee’s education. It might be a renal transplant surgeon, a colorectal surgeon, or a neurosurgeon who stimulates the surgical resident to read more and do research, show him/her how to balance a career and family, and/or establish
1. Eckert C: Specialization and superspecialization in surgery. Arch Surg 109:139-142, 1974
172
a successful private practice. This creates diversity in surgical education that is lost during straight-track training. Innovation, it could be argued, comes from being able to connect ideas from diverse sources into a coherent stream of thought. The lack of exposure to mentors within different surgical disciplines removes an element of diversity and might adversely impact innovation. In summary, although a necessary evolutionary step in cardiothoracic surgery, superspecialization cannot be viewed as uniformly positive. A foundation on basic surgical principles, the need for cardiothoracic generalists to maintain health care delivery, and the benefits of multidisciplinary mentorship represent the case against superspecialization. Those who have witnessed and/or studied the last 40 years of evolution in (cardiothoracic) surgery can appreciate the wisdom in Wangensteen’s words, while those who are committed to shaping its future will take action.
2. Adapted from Job Advertisement from CTSNet Career Center (http://www.ctsnet.org). Accessed June 2011
Seminars in Thoracic and Cardiovascular Surgery ● Volume 23, Number 3
The Case Against Superspecialization in Surgery Sreekumar Subramanian, MD, and Friedrich W. Mohr, MD, PhD If the splintering and fragmentation of surgery continues to the end that an established surgeon, whether in the academic arena or in community surgery, addresses himself to the acquisition of mastership of a few operations, certainly he will do these operations better than the wide ranging surgical generalist . . . If the surgical specialist is to dominate the scene completely, the future advance of surgery in my opinion will be retarded. Owen Wangensteen (American surgical pioneer), 1972 Almost 40 years ago, Dr. Charles Eckert,1 in a presidential address of the Central Surgical Association, discussed the phenomenon of specialization and superspecialization in surgery. At that time, the certificate for pediatric surgery was almost approved, and a similar certificate was being sought for peripheral vascular surgery. Eckert surmised that proliferation of subspecialty training programs would detract from the quality of general surgical training and produce general surgeons incapable of caring for the broad spectrum of surgical pathology. He further cautioned that the frontiers of surgery, having historically been advanced by the “efforts of men with unrestricted vision [general surgeons],” would be hindered by the creation of surgical subspecialists, echoing the sentiments of Wangensteen. In the ensuing 40 years, the development of multiple subspecialties within general surgery has resulted in a wide array of surgical training opportunities for those wishing to work in more rural areas to those who plan to enter academics. A brief look at a recent cardiothoracic surgery job advertisement sheds light on the issue of superspecialization in cardiothoracic surgery. “The ideal candidate possesses skills and experience in heart and lung transplantation, assist devices, percutaneous and minimally invasive valve
Department of Cardiac Surgery, Heart Center Leipzig, Leipzig, Germany. Address reprint requests to Friedrich W. Mohr, MD, PhD, Department of Cardiac Surgery, Heart Center Leipzig, Strümpellstraße 39, 04289 Leipzig, Germany. E-mail: mohrf@ medizin.uni-leipzig.de
1043-0679/$-see front matter © 2011 Elsevier Inc. All rights reserved. doi:10.1053/j.semtcvs.2011.10.004
surgery, VATS [video-assisted thoracic surgery] lobectomy, robotics, off-pump coronary and endovascular surgery.”2 Although the advertisement is amusing to the graduating chief resident, it also illustrates the need for superspecialization as science advances, because none of these subspecialty areas had been developed at the time Eckert addressed the Central Surgical Association. Superspecialization in surgery is, therefore, a necessary aspect of surgical evolution. What then is the case against superspecialization in surgery? Inversely postulated, is there still a need for a basic general surgical education? If one considers the increasingly complex nature of cardiothoracic surgery, it is quite clear that a solid surgical foundation is still a necessary prerequisite. Learning how to hold the scalpel, tie knots, achieve meticulous hemostasis, and other basic surgical skills are best acquired during simpler operations, not first during the course of a complex cardiothoracic operation. Similarly, preoperative and postoperative patient management, including how to do an abdominal examination to rule out surgical pathology, as well as understanding fluid shifts, diagnosis and management of common perioperative surgical complications (including acute extremity ischemia, deep venous thrombosis, atrial fibrillation), can be mastered on a general surgical service. These skills are important to the classic as well as the contemporary practice of cardiothoracic surgery and argue against a straight-track cardiothoracic training without general surgical exposure. Although many cardiothoracic surgeons in the United States favor a complete division of the specialty into cardiac and thoracic components, similar to the paradigm in Europe and South America, this fragmentation might also have undesirable consequences. Because cardiothoracic surgical care is more often provided by generalists than by superspecialists, it is conceivable that there will be communities with a cardiac, but no thoracic, surgeon, and vice versa. Patients would then have to travel longer distances to undergo a lung resection or a coronary artery bypass, which is quite difficult for older patients with multiple comorbidities. This validates one of Eckert’s1 postulates, namely that the quality of health care would decline by widespread 171
THE CASE AGAINST SUPERSPECIALIZATION IN SURGERY superspecialization. Just as we continue to need general surgeons, we still need “general” cardiothoracic surgeons, who might be called on to help or take care of a ruptured abdominal aortic aneurysm, either because there is no vascular surgeon available, or the recently trained vascular surgeon has extensive experience with endovascular stenting and has never done an open ruptured abdominal aortic aneurysm. Another negative aspect of specialization is the potential loss of mentorship from surgeons in various disciplines. In a broad general surgical curriculum, the cross-fertilization of ideas, the broad exposure to cutting-edge research, and/or clinical advancements in different areas of surgery expose trainees to an array of mentors who are able to make varied contributions to a trainee’s education. It might be a renal transplant surgeon, a colorectal surgeon, or a neurosurgeon who stimulates the surgical resident to read more and do research, show him/her how to balance a career and family, and/or establish
1. Eckert C: Specialization and superspecialization in surgery. Arch Surg 109:139-142, 1974
172
a successful private practice. This creates diversity in surgical education that is lost during straight-track training. Innovation, it could be argued, comes from being able to connect ideas from diverse sources into a coherent stream of thought. The lack of exposure to mentors within different surgical disciplines removes an element of diversity and might adversely impact innovation. In summary, although a necessary evolutionary step in cardiothoracic surgery, superspecialization cannot be viewed as uniformly positive. A foundation on basic surgical principles, the need for cardiothoracic generalists to maintain health care delivery, and the benefits of multidisciplinary mentorship represent the case against superspecialization. Those who have witnessed and/or studied the last 40 years of evolution in (cardiothoracic) surgery can appreciate the wisdom in Wangensteen’s words, while those who are committed to shaping its future will take action.
2. Adapted from Job Advertisement from CTSNet Career Center (http://www.ctsnet.org). Accessed June 2011
Seminars in Thoracic and Cardiovascular Surgery ● Volume 23, Number 3