How Acute Care Strengthens General Surgery
Najma Ahmed with her daughter Izzi
The University of Toronto General Surgery Program is
a flagship program, characterized by clinical excellence,
breadth of training opportunities and an outstanding
level of scholarship. Najma Ahmed became the Program
Director in 2008, taking over from Lorne Rotstein. She
is working on strengthening individual attention to residents’
experience, creating specific competency - based
evaluation, and defining milestones that will assist in
promotion of residents. She has also been working with
Shady Ashamalla, Teodor Grantcharov and Samir Grover
to integrate level - appropriate simulation training in
endoscopy and laparoscopy into the formal curricula.
She finds working with and teaching the future leaders
of surgery very gratifying. “Some of the best ideas for
curricular innovation and residency design come from
the residents.” She feels that she has “the best faculty and
the most engaged residents in the largest surgery training
program in North America”.
Najma has the advantage of interacting with other
program directors through the Royal College of Surgeons
twice a year and the Specialty Committee twice a year.
She also sits on the Examination Board of the Royal
College, which offers “excellent interactions with peers
and an amazing CME opportunity”. She speaks highly
of the ICRE (the International Congress on Residency
Education) which is a Canadian born, but now international
organization. It is considered among the best conferences
worldwide to disseminate and discuss new ideas
and innovation in postgraduate medical education. The
ICRE grew out of the Royal College, first as a committee,
then as a meeting, and now as an international congress
http://www.royalcollege.ca/portal/page/portal/rc/ events/icre.The American College of Surgeons meetings
also have excellent sessions and scholarly work related to
undergraduate and postgraduate education.
Najma is involved in the on-going advances related
to duty hours for residents. She is the Chair of
the Working Group for procedural disciplines, of the
National Steering Committee on Resident Duty Hours
at the Royal College. Among the topics under discussion
is the distinction between continuous wakefulness and
continuous duty hours - these are not identical experiences.
She will keep us informed as this issue evolves.
Najma spearheaded the effort to have Trauma Surgery
recognized as an area of focused competence by the Royal
College. Trauma Surgery is now a nationally recognized
diploma - bearing fellowship program. There has been a
tendency to move away from more formal “fellowships”
as these tend to cause greater fragmentation within the
specialty of General Surgery. However, there is a need
to recognize advanced training and competence and
this is why the Areas of Focused Competence Programs
were developed at the Royal College. Trauma Surgery
is the first diploma program in Surgery. The diplomas
have standards for experience, training and will help
to develop academic leaders in their respective fields.
The Trauma Surgery diploma program will not, for the
moment, have Royal College certification examinations,
but rather have oversight for completion of requirements
by the Trauma Association of Canada. Candidates will
have to complete oral examinations, keep a portfolio of
cases and provide evidence of scholarship during their
trauma surgery training.
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Acute Care Surgery and Trauma can in some cases be
considered parallel disciplines that share many similarities.
However, Acute Care Surgery is not a diploma program.
Elective surgery is becoming progressively more
specialized, especially in academic centres and this phenomenon
has perhaps opened the door for a new breed
of surgeons in academic centres: trauma and acute care
surgery specialists. Some surgeons in this type of clinical
practice combine it with critical care.
Najma loves acute care, “its diagnostic uncertainty,
clinical and technical challenges, tempo, and that its
practice allows for clear separation of clinical work from
academic work. During TACS (Trauma and Acute Care
Surgery) weeks, I have no elective clinical activity (ORs,
clinics, meetings), I take all the admissions to General
Surgery, do lots of emergency cases, and manage, with
a house staff team, about 30 patients on a ward and
6-8 patients in the ICU. I can give immediate attention
to urgent problems and I am completely immersed in
the clinical and learning environment with the medical
students, residents and fellows - free from other obligations.
All patients are cohorted onto one ward, which
allows the nurses and other paraprofessionals to develop
an area of expertise, and for the clinical teams to learn
about best practices in this unique patient population.
Another advantage is that chief residents can focus on
their elective cases without interruptions during the day.
“Surgical emergencies used to disrupt elective surgical
life and were considered a nuisance. With this model in
place, the emergency patient is the central focus of the
team’s attention. This has been a very patient focused
development. I think that this started in US trauma centers
as the trauma volumes decreased (see Avery Nathens’
article http://www.surgicalspotlight.ca/Article.aspx?ver =Fall_2012&f=SunnybrookTrauma). As the crack and
gun epidemic died down, and as we have developed
safer cars and seatbelt and helmet laws, operations for
trauma have also decreased. This model of trauma and
acute care surgery is well underway at Sunnybrook and
St. Michael’s.
“When I leave TACS, I follow a few patients with
interest, especially the ones with more complex operations,
but otherwise I am free to focus on academic and
administrative life and my small elective practice. I am on
TACS for approximately 10 weeks per year. During those
weeks I am on call every other night. In addition, I am an
intensivist and do several weeks in the ICU. The elective
surgery component of my practice is usually reconstruction
of trauma patients and benign general surgery.
“In some sense, acute care surgery has been a very
positive development for General Surgery – it was
becoming too specialized without a generalist practice.
It is somewhat like being on call for one night, but it
is consolidated into one week. Community surgeons
might be able to implement a similar model, however it
would require some re-organization of their clinical practice
patterns. For instance hospitals that are in proximity
might consider a collaborative model in order to create a
cohort of interested surgeons.”
Najma travels with her daughter Izza, who is a grade
3 student at Branksome Hall. She most recently read a
novel called Beautiful Ruins by Jess Walter. She travels to
Mexico each winter and in the summer, she and her family
often rent a cottage near Muskoka. She is an active
gardener at her home at the Southern end of Leaside in
the Governor’s Bridge community.
M.M.
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