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PubMed1995

What the future may hold for general surgery. A position paper of the American Board of Surgery.

Developments in the specialty of general surgery have never been more important, nor have the opportunities for general surgeons been more exciting, than at the present. Technologic advances and the expansion of basic knowledge of surgical diseases have contributed to this renaissance of the field. It is of utmost importance that general surgeons seize the opportunity to participate in the education of medical students at all levels in the undergraduate years, seek to improve the surgical clerkships, and strive for the optimal learning environment for surgical residents. Through these means, the best and the brightest students will be attracted to general surgery as a career and will be retained in the practice of general surgery upon completion of residency training. Education of the student preparing for a nonsurgical career in the fundamental concepts underlying surgical therapy must be kept at the forefront of an undergraduate surgical curriculum. Integration and coordination of graduate surgical education in all of the general surgery-based specialties is an important obligation for the future, as knowledge expands in each specialty and the need for more specialty-specific education becomes apparent.

Education, Medical↗
PubMed1999

Incidence of small-bowel obstruction and adhesiolysis after open colorectal and general surgery.

PURPOSE: The study contained herein was undertaken to establish the incidence of small-bowel obstruction, adhesiolysis for obstruction, and additional abdominal surgery after open colorectal and general surgery. METHODS: A retrospective cohort study was performed using patient-specific Health Care Financing Administration data to evaluate a random 5 percent sample of all Medicare patients who underwent surgery in 1993. Of these, 18,912 patients had an index abdominal procedure. Two-year follow-up data documented outcomes of hospitalizations with obstruction, adhesiolysis for obstruction, and/or additional open colorectal or general surgery. RESULTS: Within two years of incision, excision, and anastomosis of intestine (International Classification of Dis eases (ICD)-9 code 45), 14.3 percent of patients had obstructions, 2.6 percent required adhesiolysis for obstructions, and 12.9 percent underwent additional open colorectal or general surgery. After other operations of intestine (ICD code 46), 17 percent of patients had obstructions, 3.1 percent required adhesiolysis for obstructions, and 20.2 percent underwent additional open colorectal or general surgery. After operations of rectum, rectosigmoid, and perirectal tissue (ICD code 48), 15.3 percent of patients had obstructions, 5.1 percent required adhesiolysis for obstructions, and 16.4 percent underwent additional open colorectal or general surgery. After other operations on the abdominal region (ICD code 54), 12.4 percent of patients had obstructions, 2.3 percent required adhesiolysis for obstructions, and 8.8 percent underwent additional open colorectal or general surgery. CONCLUSIONS: In this retrospective study of Medicare patients, we learned that bowel obstruction, adhesiolysis for obstructions, and additional abdominal surgery occurred more often after abdominal surgery than was previously published.

Abdomen↗
PubMed1983

Adhesive membrane device (Op-site) for skin closure in general surgery.

Sixty general surgical cases in a district hospital had skin closure accomplished with an adhesive membrance device (Op-site, Smith and Nephew). The technique of application is described. Thirteen cases had minor wound complications. It was found that the device was not applicable to all skin wounds, had some limitations in vertical wound closure, was comparable in price with skin sutures, usually gave good cosmetic results especially in transverse wounds, and as it could be removed by the patient, avoided problems of suture removal after discharge from hospital.

Adolescent↗
PubMed1992

General surgery: is there a future?

General surgery may not survive in an age of superspecialization unless the emphasis of general surgical training shifts from broad competence to defined areas of expertise. The author presents suggestions for restructuring general surgery residency requirements.

Forecasting↗
PubMedDate not supplied

Is there declining interest in general surgery training?

PURPOSE: To monitor and report the quality of categorical first-year surgery residents matched to U.S. general surgery training programs from 1996 to 2001. METHODS: A survey was sent to 258 program directors of accredited general surgery training programs. In this survey, data were requested regarding United States Medical Licensing Exam (USMLE) Step 1 and 2 scores, matched residents' rank list position, Alpha Omega Alpha (AOA) status, number of applications received, and interviews granted pertaining to all National Residency Matching Program (NRMP) residents matched. In addition, the USMLE and NRMP were petitioned for national data regarding Step 1 and 2 scores in all entering surgery residents and first-time USMLE takers. RESULTS: Usable survey data were received on 1241 residents. The number for each year (and percent of total matched PGY-1 residents) was as follows: 1996-196 (20.0), 1997-206 (20.4), 1998-204 (19.9), 1999-212 (21.0), 2000-212 (20.7), and 2001-211 (21.7). The mean Step 1 scores increased over time (p < 0.001), and programs with 5 or more categorical spots had higher scores than those with 4 or less (p < 0.001). The depth required to fill the rank list increased over the study period (p < 0.05). National data received from the NRMP from 1994 to 2001 (mean of 916 residents at each year) showed a similar increase in USMLE Step 1 scores when compared with our survey. The proportion of AOA students matching into general surgery has decreased from 30% in 1996 to 15% in 2001 (p < 0.001). CONCLUSIONS: Over the 6 years of our study, USMLE Step 1 scores increased and the results of our survey are in agreement with the national data. However, the proportion of AOA students declined, implying the top 10% of the medical school class found general surgery training less attractive. Also, programs went deeper into their rank lists to fill, implying a shrinking pool of candidates.

Analysis of Variance↗
PubMed2006

Economic impact of bariatrics on a general surgery practice.

Bariatric surgery is currently a rapidly growing subsection of general surgery, with exponential expansion over the past decade. Many residency programs lacked sufficient experience in bariatrics, necessitating established surgeons to consider re-training and re-vamping of their practice to enter the field. The addition of bariatric surgery to a general surgery practice can present economic consequences, which are both positive and negative. Positive consequences include a potential new revenue source with a large population base. Negative consequences include increased employees, required paper-work and office resources, increased malpractice premiums, difficulties with appropriate reimbursement, and limitations on access to appointment time for non-bariatric cases. This paper reviews the potential economic impact of bariatric surgery on a general surgery practice and possible alternatives to manage these efficiently.

Appointments and Schedules↗
PubMed2005

Endovascular procedures, carotid endarterectomies, and aortic surgery should preferentially be done by a vascular trainee rather than a general surgery resident.

This article is the result of a debate. The motion proposed was that "endovascular procedures, carotid endarterectomies, and aortic surgery should be done preferentially by a vascular trainee rather than a general surgery resident.'' Arguments in favor of the motion were that with the development of endovascular surgery, there are now less open vascular procedures to perform and hence, vascular trainees needed to hone their skills on these limited cases rather than waste that experience on a general surgery resident. This focused training experience would allow vascular fellows to be become more highly skilled vascular surgeons. Additionally, endovascular procedures are an important component of modern vascular surgery, and it is important for the vascular fellow to develop significant experience with and acquire the appropriate numbers of endovascular cases to get the necessary credentials when going into a vascular practice. Arguments against the motion were that exposure to vascular cases will make a better general surgeon, one who will also be well equipped to deal with trauma cases and situations where the control of bleeding might be life saving. Additionally, the issue of exposure of general surgery residents to vascular cases might be a positive recruitment strategy for future vascular fellows. The motion was carried by a small majority vote.

Aorta↗
PubMed1987

Presidential address, 1986. The future of general surgery.

The future of general surgery is assured provided the discipline remains flexible, adaptable and innovative. A strong and continuing emphasis on education and continuing emphasis on education and research at all levels is essential to maintain these qualities.

Canada↗
PubMed1998

[Colorectal surgery--an integral part of general surgery!].

The controversy, whether colorectal surgery should be performed by the general surgeon or the specialist colorectal surgeon, is gaining increasing importance in Europe. The short and long term results in colorectal surgery as well as in other subspecialties are largely determined by the annual case load and the surgical training in colorectal surgery. If both conditions are met, colorectal surgery can be just as safely and successfully performed in a district hospital by a general surgeon. The following advantages support the treatment of colorectal lesions by a general surgeon: the capacity to cope with unforeseen intraoperative problems thanks to the broad surgical experience of the general surgeon, the ability and authorisation to perform multivisceral resections and the ability through the daily training in abdominal surgery to perform emergency interventions since about 30% of all colorectal operations are performed in an emergency setting. Against colorectal specialisation can be argued: increased costs through the need of specialised colorectal surgeons, the establishment of independent units for colorectal surgery, impairment of surgical training and sometimes loss of enthusiasm through the daily routine of the highly specialised surgeon. The common colorectal surgery should remain an integral part of general surgery, given the conditions of an sufficient annual case load of at least 30 colorectal resections and of an adequate surgical training in colorectal surgery.

Clinical Competence↗
PubMed2002

Surgical endoscopy training is integral to general surgery residency and should be integrated into residency and fellowships abandoned.

It is a basic premise that laparoscopic procedures are an integral part of the practice of general surgery. Currently, general surgery training programs as a whole are failing to provide residents with significant surgical experience in advanced laparoscopic procedures. The teaching of advanced laparoscopic procedures can and should be incorporated into the 5-year surgical residency. The challenge for Program Directors is that it is time to restructure general surgery training so that additional fellowship training is not required to provide an adequate experience in this fundamental part of general surgery.

Fellowships and Scholarships↗
PubMed2006

Early perioperative outcomes and pancreaticoduodenectomy in a general surgery residency training program.

Current trends in national health care are triggering a reassessment of training in general surgery. Currently, 75% of general surgery residents seek postgraduate fellowship training, and significant debate has occurred regarding the best manner for surgeons to acquire competency in performing complex operations. Pancreaticoduodenectomy (PD) is a complex procedure performed infrequently by most surgical graduates. From 1990 through 1997, the average number of PD operations performed per general surgery graduate ranged from 1.5 to 2.5. We examine the surgical outcomes following PD performed by surgical resident staff in a university-based general surgery training program. Between January 2001 and October 2004, 164 patients underwent PD for periampullary disease. Data were prospectively entered into a computerized database, including resident participation. We analyzed 30-day mortality and morbidity rates. Perioperative outcomes were 30-day mortality (2.2%), pancreatic fistula (6.1%), reoperation (2.2%), average length of hospital stay (13.5 days), mean operating time (489 minutes), and median estimated blood loss (1274 ml per case). PD can be performed with an acceptable morbidity and mortality within the teaching structure of a general surgery training program. These outcomes are likely related to the performance of PD at a high-volume, tertiary center by a single surgeon and compare favorably to best-practice benchmark outcomes.

Adenocarcinoma↗
PubMedDate not supplied

Nosocomial infections in general surgery: surveillance report from a German university clinic.

At the general surgery clinics, University of Giessen, we developed our own system for surveillance of nosocomial infections according to the guidelines of the Centers of Disease Control. Atlanta, USA, and according to the results of the SENIC Project. We wanted to receive information about the overall infection rate, the procedure specific infection rate, site specific infection rate, distribution of nosocomial infections by pathogen and resistance pattern of antibiotics at the general surgery clinics. The overall infection rate of operations, classified as clean, clean--contaminated, and contaminated and dirty, was 13%. The surgical wound infection rate of 3% after clean operations was mainly caused by an elevated infection rate of 13% after clean operations of a prolonged duration and hyperthermic perfusion of the extremities in patients with melanoma. There is also a difference in nosocomial infection rates at the general surgery ward (11%) and at the intensive care unit (29%). At the intensive care unit candida and coagulase negative staphylococci are mainly isolated whereas Escherichia coli, Staphylococcus aureus and Enterococcus faecalis dominated the general surgery ward. Different operations show different distributions of isolates; operations on the pancreas are prone to have infections with coagulase negative staphylococci, candida and Pseudomonas aeruginosa. The antibiotic susceptibility tests for the most commonly used antibiotics revealed no resistance problems for E. coli, E. faecalis, and Staphylococcus aureus, common pathogens at the general surgery ward, but did for coagulase-negative staphylococci where we can consider only a few antibiotics like amikacin in obvious infections at the intensive care unit.

Cross Infection↗
PubMed2002

The state of general surgery residency in the United States: program director perspectives, 2001.

HYPOTHESIS: Current demographic patterns and lifestyle factors of general surgery residents may contribute to recent changes in recruitment patterns. DESIGN: Survey addressing the characteristics of general surgery residency, including demographic data, 3-year recruitment and retention trends, and working conditions of general surgery residents. PARTICIPANTS: A convenience sample of all residency program directors in attendance at the 2001 Surgical Education Week was given the opportunity to voluntarily complete the survey. RESULTS: A total of 109 program directors responded to the survey. Women constitute 25% of all current general surgery residents: 66% of the program directors perceived a decline in the number of applicants for general surgery residency. Recruitment patterns differ significantly between small (< or =4 categorical residents per year) and large (>4 categorical residents per year) residency programs. Residents at large programs averaged a 95-hour workweek, whereas those at small programs averaged an 88-hour workweek (P =.01). The mean 1-year attrition rate for general surgery residents was 20.2% in 2000, and attrition showed no relationship to program size, gender composition, or working conditions. CONCLUSIONS: Women remain underrepresented in general surgery residency. Recruitment and match statistics show some variation, but the relevance of a shrinking applicant pool to these changes is unclear. Resident working conditions remain a difficult issue, and attrition rates continue to be significant. A substantial research agenda remains in graduate surgical education.

Attitude of Health Personnel↗
PubMed1998

Is a mandatory general surgery rotation necessary in the surgical clerkship?

BACKGROUND: Changes in the spectrum of general surgery and the delivery of surgical care have placed the requirement for a mandatory general surgery rotation in the surgical clerkship in question. METHODS: We tested the hypothesis that equal mastery of surgical clerkship objectives can be obtained in a clerkship with and without general surgery. Students chose any two surgical rotations and were assessed by written examination, objective structured clinical examination (OSCE), ward evaluations, self-assessment objectives questionnaire, and satisfaction survey. RESULTS: Data for 54 students showed no differences in scores between groups on any parameter. No specific concerns related to the absence of general surgery were identified. CONCLUSIONS: Effective undergraduate surgical education can be offered in many specialty settings. Removal of the requirement for general surgery in clerkship may lead to a more effective use of all educational opportunities. A careful analysis of local programs and facilities is necessary before suggesting this change to other institutions.

Attitude↗
PubMed1991

The future of general surgery.

The origin of the term "general surgery" is uncertain, but it is known that it has been in the lexicon of surgical parlance for more than a century. Although specialization began at least 150 years ago, it became a major trend at the end of World War I. The potential fragmentation of the specialty is the most significant problem currently faced by general surgeons. Other areas affecting the future of general surgery are discussed, including residency requirements, manpower analyses, and physician reimbursement. Because of rapid technologic changes and the aging of the population, surgeons need to incorporate those features that will improve patient care into their practices to meet the needs of the future.

Fees, Medical↗