LETTERS FROM OUR READERS
GENERAL SURGERY IN PERIL? OR THE FAILURE OF OUR PROFESSIONALISM?
Dear Richard,
Your
Chair's Column: General Surgery in Peril? (Surgical Spotlight, Winter 2008-2009)
catalogues a litany of ills increasingly affecting the provision of general surgical services.
You correctly call for action to address systemic problems
in the areas of training, lifestyle, workload and
compensation.
Seventy percent (70%) of current trainees go on to fellowship.
Many plan to subspecialize or to develop a special
interest which will allow them to limit their scope of practice.
Why so? I am convinced this is because subspecialty
practice is the only mode of practice to which they are
exposed in our major teaching centres. The generalist surgeon
may be encountered during brief rural electives but
certainly is not held up as a role model. Yet the generalist
surgeon is admirably suited to interface with students and
residents, the future of our specialty, especially in their formative
years. The generalist surgeon is also well positioned
to relate to community surgeons on issues of clinical care,
teaching and research, thereby promoting distributed learning
in a university truly without walls.
Pursuing fellowship training defers entry into independent
practice which suggests to me that many trainees
lack self confidence. That this should be the case after
6 years of residency might reasonably lead the taxpayer
to ask Why so?
Climate change, geopolitical uncertainties and our
current financial woes combine to make today's world
a troubling, uncertain place. Every thinking Canadian
must be concerned about our country's security and
self sufficiency. I suspect we may see an increase in the
rural population of this country as citizens increasingly
seek safe surroundings, locally produced foods, combat
climate change and develop environmentally sound and
secure sources of energy. These citizens will require generalist
surgical care.
Canadians will continue to be called upon in their
roles as peacekeepers/peacemakers and in the provision
of humanitarian relief. All such initiatives require the
support of well and broadly trained generalist surgeons.
William Fitzgerald
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We Canadians can not expect
to enjoy a high standard of living
and the fruits of "peace, order and
good government" in a pluralist,
liberal democracy if much of the
rest of the world has no hope of
the same. Accordingly it is a matter
of enlightened self interest that we
extend the helping hand of friendship
as part of coordinated foreign
policy initiatives designed to dispel distrust and ignorance.
Generalist surgeons are essential to such initiatives.
Lifestyle, workload and compensation are intimately
interrelated. The Canadian Association of General
Surgeons' Practice Guidelines suggest a 1 in 5 call
schedule is supportable. Such demands would be seen as
excessive to many academics yet an unattainable dream
to many community surgeons. Feminization (I prefer to
think humanization) of the profession and retirement of
the Boomer generation combine to force us to develop
imaginative ways to collaborate in the provision of care
without compromising quality of care.
Positive, proactive colleagues working together and
enthusiastically celebrating their collective successes in
improving the health of Canadians are far more likely to
attract students to the discipline than impotent whinging
complainers in staff lounges railing against politicians
and bureaucrats while bemoaning the passage of
the good old days.
General Surgeons are the engines that drive community
and rural hospitals. Though often overshadowed by
more glamorous subspecialty services in larger teaching
institutions no subspecialty can function without general
surgical backup.
Through the social contract society invests heavily in
health care, including the training and remuneration
of general surgeons. This contract accords surgeons self
governing professional status and the exclusive right to
practice the art and science of surgery. If as a profession
we are unable to provide in a timely manner the services
society has a right to reasonably expect then we have
failed in our professional obligations under this contract.
As a proud graduate of the University of Toronto's
Gallie Surgical Training Program I believe I can in
this forum assert, without fear of contradiction, that I
consider myself an alumnus of the finest training programme
in the country!
That being the case I call upon you as Professor and
Chairman of the country's premiere Surgical Department
to lead the way in tackling the important issues you raise
and to consider the following suggestions:
- Establish a division of generalist general surgery
intended to legitimize those who are broadly trained
in all aspects of general surgery as currently understood.
This service should be mandated to adopt a
proactive CAN DO philosophy. General surgical care
certainly requires subspecialty back up but can never
be replaced by the same. Practitioners on the unit
would be prepared to deal with abdominal emergencies
of every variety, trauma, surgical infection and
participate in the Surgical ICU. In multiple trauma
and other complex cases trainees should have the
opportunity to collaborate with consultants in other
disciplines (neuro, ortho, plastics, thoracic, vascular
etc.) in case management. Opportunities equally
should exist for formal rotations on services such as
the above. Elective cases representing the spectrum of
general surgery should form the foundation of such
a service. Continuity of care should be central to its
organization.
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- As appropriate encourage colleagues to participate in
general call such that skills, judgement and confidence
do not diminish with time.
- Foster mentoring relationships intended to accompany
the trainee into practice.
- Develop imaginative, equitable, alternate funding
plans that recognize case volume, clinical teaching
and research, length of service, continuity of care and
include provision for sabbatical leave.
- Seek to increase exposure of residents in senior years
to the challenges and rewards of community, rural and
remote practice.
- Explore with The Canadian Association of General
Surgeons, The Royal College of Physicians and
Surgeons of Canada and the College of Family
Practice of Canada a surgical training programme
designed specifically for Family Physicians. Support
the practice of graduates of such a programme.
- Explore with other stakeholders (Gov't., CPSO,
CAGS, RCPSC) a competency based training &
assessment programe for IMGs.
- Actively promote collaborative outreach projects with
rotations of staff and residents in developing countries.
General surgeons, broadly educated and capable �
are exactly what the public deserve and have every right
to expect. Anything less is the result of the failure of our
professionalism.
Respectfully submitted,
G. William N. Fitzgerald, CM, MD, FRCSC
General Surgeon
The writer is President of the Royal College of Physicians
and Surgeons of Canada.
GENERAL SURGERY IS A SPECIALTY
Dr. Reznick,
I read with interest your thoughts in the most recent
issue of the surgical spotlight. I think you made some
very salient points.
I always felt that general surgery really was a subspecialty.
During residency I often used the line "Don't be fooled
by the word general, general surgeons are specialists
too". An individual who doesn't do multiple fellowships
should be considered a master of surgery of the alimentary
tract at minimum.
Another massive advantage of being a general surgeon is
Volume. There is a staggering amount of general surgery
that a community requires. No hospital larger than a cottage
could survive without at least one general surgeon.
There are likely to be quite a few general surgeons in
a hospital... That means call, although busy, should be
less frequent. In addition, if things are insanely busy,
arrangements can be made so an individual is ON
CALL ONLY (no clinic no OR). Over the last year
that is exactly what the general surgeons at Sunnybrook
have done. It's called the access team and so far it's been
working pretty well. Staff surgeons get a chance to clear
the schedules and concentrate their call, which helps to
manage their practice and their lives.
I liked your scenario with the bleeding ulcer patient
with 5 general surgeons either away or uncomfortable
with the procedure. That will never go away completely
(and to perhaps to a lesser degree has been with us for
a long time) but there are creative solutions to enhance
lifestyle while maintaining income. Hopefully we can
demonstrate some of these strategies to our residents and
medical students.
Andrew Dueck
Assistant Professor, University of Toronto
Division of Cardiac and Vascular Surgery
Sunnybrook Health Sciences Centre
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