Untitled Page



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
William Fitzgerald

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.

  • 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.


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

Skip Navigation Links