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Yale J Biol Med. 2008 December; 81(4): 187–191.
Published online 2008 December.
PMCID: PMC2605312
Surgery Issue

Early Specialization in Surgery: The New Frontier

Over the past 40 years, the scope and spectrum of surgical training has changed dramatically. Advances in technology, the spectrum and complexity of disease, the environment of less independence and, more recently, duty hour work restrictions [1,2] all have affected the “final product” of the general surgery graduate. This along with changing healthcare economics, the public demand of specialization, and various initiatives in reporting of quality have affected the fate of the general surgeon. Progressive specialization [3] has evolved due to the complex environment of change in both medical education and the healthcare system. The purpose of specialization training after completion of a general surgery residency is to provide a focused, intensive educational experience in a recognized subspecialty area that may result in increased reimbursement from improved market share, improved lifestyle, ability to obtain hospital credentialing, and job security [3,4]. Fellowship training is also likely to result in improved clinical and economic outcomes. In certain subspecialties such as cardiothoracic, plastic, and pediatric surgery, formal fellowship training is mandated to meet credentialing criteria. Furthermore, many graduating general surgical residents do not feel “comfortable and competent” performing select general surgery cases such as esophagectomy, parathyroidectomy, hepatectomy, pancreatectomy, rectal resection, advanced minimally invasive procedures, and complex vascular procedures without additional training in either accredited or non-accredited fellowships. Specialization training is here to stay and now is becoming even more evident with the advent of early specialization or “tracked” training immediately in general thoracic and vascular surgery following medical school graduation [5,6].

Motivations to select specific subspecialty fellowship also remain poorly defined. The intellectual appeal of a certain field, having an influential mentor, and one’s perceived clinical opportunities all weigh in when selecting a field of specialization [4]. However, it cannot be underestimated that reimbursement, the ability to matriculate into that fellowship, and lifestyle issues are also influential, the latter irrespective of gender [7]. The choice of an academic career or private practice also has undergone various changes and trends. Historically, the percentage of graduating residents or fellows has trended toward private practice for a variety of reasons, such as improved financial compensation, the struggles of university bureaucracy, concerns about rank and tenure, and “being one’s own boss.” However, this trend appears to have been reversed as the differential between full-time and private practice salaries has been altered. Also, there may be a perceived improvement in lifestyle in academic practice coupled with intellectual and educational rewards. Accordingly, more graduating residents and fellows now seek full-time academic positions. We have become aware of the continually changing environment of surgery, and our current training program has evolved to prepare residents to meet these demands. Over the past 20 years, our general surgery training has incorporated opportunities for focused scholarly activity, welcomed increased diversity among the residents, struggled with the challenges of both resident and faculty attrition, addressed lifestyle issues, and encouraged graduating residents to pursue fellowship specialization.

The concept of early specialization in surgery has evolved from a number of factors, including decreasing the duration of training, rising medical school debt, and, more importantly, the fact that most residents who embark on fellowship training will limit the scope of their practice. In order to find out if indeed this is the case, we sought to determine the fate of the graduating general surgery resident: who went on to become a general surgeon without any additional fellowship training, the number of residents pursuing fellowship training, and practice patterns with regard to type of practice.

Between 1967 and 2007, 182 residents completed general surgery residency training at Yale University. Upon completion of all training, 80/182 general surgery residents (44 percent) took an academic position, 100/182 (55 percent) initially worked in private practice, and 2/182 (1 percent) initially worked in a military (non-VA) hospital. Among the 130/182 who did fellowship training, 76/182 (59 percent) took an initial academic position. Five out of 52 (10 percent) took an academic position without fellowship training. Looking at the specific fellowship and those whose initial faculty position was academic surgery, a full-time academic practice occurred in cardiothoracic 19/38 (50 percent), plastic surgery 6/20 (30 percent), pediatric surgery 8/14 (57 percent), colorectal surgery 6/14 (15 percent), surgical oncology 10/12 (83 percent), vascular surgery 7/11 (64 percent), endoscopy/laparoscopy 6/8 (75 percent), trauma/critical care 6/7 (86 percent), transplantation 4/5 (80 percent), and endocrine surgery 1/1 (100 percent). Graduating residents were classified as either practicing general surgery, combining general surgery with a subspecialty, or practice limited to the subspecialty. Currently, 35/182 (19 percent) have limited their elective practice to general surgery, 52/182 (29 percent) limit their practice to general surgery and the subspecialty (i.e., general surgery and vascular surgery), and 95/182 (52 percent) limit their elective practice to the subspecialty (i.e., plastics, colorectal, etc.). Among the 78 graduating residents who eventually took an academic position as their first practice position, 11/78 (14 percent) have left academic surgery and are now in private practice. One in 100 (1 percent) went from the private sector to academia. Among all 182 residents, 114/182 (63 percent) currently are in private practice. Among 94 graduating residents in the past two decades, 53/94 (57 percent) are working in an academic setting.

In medicine, there has been an explosion of knowledge and advancement of science. The public is increasingly better informed about healthcare needs and safety, and, thus, there is increased demand by the public for advanced and specialized care. Surgical care is improving from discipline-based to disease-based. Surgeons will increasingly practice with a team of experts. As a surgical “expert,” restricted clinical focus will be realized in postgraduate advanced training programs. Early specialization is evolving from progressive specialization. The goals are similar: a more focused and “shorter” training period with less extraneous experience. Early specialization will begin right from medical school, where tracking and integrated programs will ensue. There are many arguments for early specialization. These include the need to match training as best as possible to eventual practice, eliminate irrelevant and redundant training experiences, and attract prospective trainees to meet workforce demands.

The majority of residents who have graduated our general surgery training program have pursued additional surgical training after being eligible for the certifying examination by the American Board of Surgery. More specifically, over the past 20 years, > 90 percent of graduating residents obtained fellowships. In this study, fellowship training in cardiothoracic surgery, plastic surgery, and pediatric surgery were most common. Over the past 10 years, fellowship training in colorectal and minimally invasive surgery has gained popularity. Sixty percent of residents who took fellowship training had their first attending position in a university academic setting. It is likely that graduating residents will continue to pursue fellowship training; however, factors related to choice remain uncertain.

It is the goal of general surgery residency training to produce competent surgeons who will be able to meet the challenges of innovation, new technology, difficult pathology, and, above all, to be safe, compassionate doctors. The explosion of new knowledge, continuously emerging technology, and, perhaps, restricted independence has produced ambivalent feelings about the resident’s capability to function as an independent surgeon. This is coupled with the fact that most surgical residents today are trained by specialists, not generalists who may compel residents to embark on additional training [8,9]. It appears that at least in selected cases residents apply to fellowship for reasons such as prestige, lifestyle, ability to capture market share, and the fear of being “just a general surgeon.”

Fellowship training occurs in response to patient demands, rapid growth of medical knowledge, desire to increase market share, and personal factors [10]. Graduating residents, with or without subspecialty training, have the opportunity to pursue either private practice or academic careers. Factors such as potential salary, debt repayment, geography of the practice, lifestyle, and spousal needs all contribute to this decision [11]. Academic surgery involves patient care; teaching students, residents, and fellows; administration; participating in research; and often leadership roles within the hospital or university [12,13]. However, embarking on an academic career poses challenges such as rank and promotion issues and usually requires demonstration of a focus in a specific area of research in basic science, clinical outcomes, or education. In many programs, including ours, residents perform focused research during their junior years and this appears to increase the probability of pursuing an academic career. It has been suggested that fellowship training increases the probability of a resident selecting an academic career [14]. The choice between academic and private practice is often a defining decision in a surgical resident’s career. It appears that current positions in academic surgery require a significant area of clinical specialization and area of research interest. During a standard five-year surgical residency, it often is difficult to achieve a significant clinical niche and research focus. Having a focused research effort during residency potentially may allow this focus to be brought into an academic practice after or during fellowship training [15]. Clearly a resident’s academic history and personal qualifications significantly will affect their performance in residency and subsequent practice choice [16,17].

The long-term outcome of performing a postdoctoral research fellowship during general surgery residency is of interest. A large number of surgical trainees who perform a research fellowship become funded investigators [18]. More interesting is that residents who perform research in a specialty laboratory are likely to pursue fellowship training and often in that field [19]. Over the 25 years of our study, we found that 60 percent who pursued training following completion of general surgery training spent time in the laboratory during residency. In many subspecialty fellowships, the ability to match in a competitive fellowship is evidence of scholarly activity within that specialty.

Fellowships offer additional rewards beyond the ability to pursue an academic career. Fellowship training can compensate for inadequate operative caseload in specialty during residency, correct inadequate didactic teaching in a specialty during residency, and enhance private practice opportunities [5]. Potential goals of additional surgical training after residency are to increase knowledge and management of specific disease types, focus academic pursuits, and improve patient care. There have been arguments against fellowship training and early specialization in general surgery [20]. First, more training requires more time, more debt, and the potential of delaying one’s mastery of their craft (which often takes five to 10 years of practice). Secondly, not all programs have deficiencies in complex operations. For example, in our program, residents routinely graduate with 25 to 30 complex hepatobiliary and more than 100 endocrine procedures. Some have gone as far as saying that super specialization detracts from good basic surgical care and focuses only on the problem at hand. The specialist becomes disease centered rather than patient centered [5,8,20].

The discipline of surgery is in a state of accelerated evolution of patient management strategies, surgical technology, and targeted therapies. The body of knowledge is vast. Surgical trainees can absorb only so much knowledge and skills in the limited time. Therapeutic strategies often change so rapidly it is difficult to maintain state of the art skills for a broad-based general surgical practice. Training in the primary components of surgery often is only the minimum before an intensive fellowship experience ensues [21]. Tracking suggests that training in certain essential areas of surgery may not require the same comprehensive training in general surgery once considered mandatory. There is the potential benefit of making surgical training more efficient, balancing the workforce, and allowing complex cases to be performed by surgeons who incorporate these procedures into their practices. It is obvious that surgical specialization is here to stay and tracking of training may be more efficient for the educator and trainee. Nonetheless, there must be a place for the general surgery track that focuses on emergency surgery, trauma, and critical care [6,21].

Duty hour restrictions are likely to be a reality for practicing surgeons. If not mandated, residents who trained during the 80-hour work week are likely to extend this concept into their practice. Thus, surgeons who operate on a specific organ system or type of pathology will be pressing to focus their training, maintenance of certification, and continuing education on issues relevant to their practice [22,23]. Exposure to patients in a training environment would serve to make the residents that much stronger as they transition to attending level practioners. The benefits of alternative training pathways must be weighed against the potential adverse consequences of these changes to our traditional model of resident training [8,20]. A program of tracked training also raises logistical problems for residents in training. The requirement to select a particular track of surgery will be temporally accelerated before many residents have had sufficient exposure to the various areas of general surgery [6,21]. This could lead to attrition if one’s initial choice becomes unpopular, it could put holes in the tracked program, and it may cause the previously tracked resident to scramble or begin in a new track [6].

General surgery training is now in a stage of progressive specialization in the form of fellowship training. In the past 10 years, 55 of 58 of our graduating residents took additional training following completion of general surgery. We also have noted that a percentage of our residents increasingly are pursuing academic careers following their fellowship training. Issues such as further reduction in resident duty hours, work hour restrictions for faculty, tracking of surgical training lines, diminished resources for research, and potentially less reimbursement will all affect career choices for graduating general surgery residents.


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