Education and debate

Are generalists still needed in a specialised world?

The renaissance of general surgery

Survival of the general physician

Are generalists still needed in a specialised world?

As specialism in medicine progresses to subspecialism and superspecialism, it might seem that the general physician or surgeon is a relic of a bygone era. Here a surgeon and a physician argue that generalists are needed as much today as ever, particularly in emergency medicine and away from large hospitals in major conurbations

The renaissance of general surgery

I J P Loefler, surgeon. 

Nairobi Hospital, PO Box 47964, Nairobi, Kenya

loefler{at}swiftkenya.com

Although the merits of specialisation within surgery are said to be self evident and in the interests of the patients, neither assertion has been proved. That the breadth of the field means that no one can be competent in all areas and that competence presupposes experience may be obvious. According to Sarmeinto, "One could argue that a structured exposure to subspecialties is imperative because of the explosion of knowledge and technology.... The body of knowledge ... is not necessarily greater. Instead new knowledge has replaced old knowledge. Other professions and traders have clearly demonstrated that point."¹ Taylor states succinctly that "the predominant argument in favour of superspecialization relates to the perception that high volume in surgery equates with better outcome."² That outcome is related to experience, teaching, training, and practice is true for all professions and crafts, but there is no proof that repeating a procedure hundreds of times and limiting the repertoire to a few procedures benefits the client.³ One thorough overview of the topic concludes: "Data from the literature do not support the idea that centralization of treatment of patients with solid cancers per se leads to improved results."⁴

The relation between volume and healthcare outcomes was examined in an effectiveness bulletin in the December 1996 issue of Effective Health Care. After analysing around 200 studies, the bulletin concludes: "The best research suggests that there is no general relationship between volume and quality. However, in some specialties there appear to be quality gains associated with increased hospital or clinician volume."⁵ According to the bulletin, the extent to which positive associations between quality and volume are due to the experience of the surgeon rather than that of the theatre staff or the nurses is unclear. With regard to common surgical conditions, even where a quality gain related to the operating surgeon can be shown, this is modest. For instance, surgeons who treat 29 cases of breast cancer a year have a better outcome than those who treat a smaller number, but they do just as well as surgeons who treat more than 50 cases a year. With regard to colectomy, there was no difference in outcome between surgeons who performed 44 procedures and those who undertook 110 colectomies a year. There was no statistically significant relation between volume and outcome in prostatectomies, gastric surgery, cholecystectomy, or stomach operations for cancer. In the case of cataract surgery, the relation was inversesurgeons operating on more than 200 eyes a year had a higher rate of complications. Nevertheless some patients, particularly those requiring complex treatment, do benefit from the specialist organisation of surgery that prevails in teaching centres in the Western world.

Diseconomies of scale

As surgery becomes more and more specialised it becomes more and more expensive, a phenomenon that is associated with the belief that highly trained practitioners are needed for every aspect of surgery, diagnostic as well as therapeutic, in all areas. Large, specialist centres like to claim that they save costs by being more efficient. However, there is no evidence for this assertion. According to the bulletin quoted above, large hospitals show diseconomies of scale. For acute hospitals the best size seems to be around 200 beds.⁵ It would be difficult to accommodate all specialties and subspecialties in hospitals of 200 beds and maintain quality if this were related to volume. One possibility would be a network of specialised hospitals of this size, but as many patients have several medical problems, not least postoperative complications, the cost and difficulty of bringing in specialists from other units would need to be taken into account.

Whether highly specialised units are more efficient and cost effective because of greater diagnostic accuracy remains to be shown. Experience indicates that the number of investigations and their complexity increases with specialisationwitness the long lists of mandatory investigations detailed in publications and textbooks. Furthermore, as the barriers between subspecialties rise higher, the system becomes ever more inflexible. For all these reasons access to the appropriate subspecialty, and hence to surgery itself, is reduced. Problems of access have implications in terms of costs as well as quality of care. The costs of access are often borne by the patients themselves, who may have to travel long distances to see the specialist.

(Credit: LIANE PAYNE)

Questions of competence

Specialisation is a necessity imposed by limitations in capability, be they knowledge or skill. The problem of deteriorating access to an adequate standard of care arises not from the concept of specialisation within surgery as such but from the fact that "general surgery" is not identified as surgery of the common surgical conditions and emergencies. Instead, general surgery is looked upon as something outdateda leftover. In the most prestigious medical institutions of the Western world general surgery is defunct.

Training costs

The consequences of general surgery's moribund state for training, undergraduate and postgraduate, are immense in terms of administrative problems, cost, andinescapablyquality. "Educational institutions recruited faculty who limited their practices to smaller and smaller areas of the body. As the faculty had to be accommodated with the residents, rotations through the various sections became shorter and shorter."¹ The economics of education and training are not customarily included in healthcare costs. Subspecialist training, as it is conducted in metropolitan teaching hospitals today, is expensive, and the introduction of every new subspecialty necessarily adds to the cost. The irony of the modern, specialised surgical career is that the training is unnecessarily broad yet the cost of training is cited to justify the practitioner's income.

Effect on services in remote areas

Although general surgery's demise is often bemoaned in a nostalgic, sometimes Luddite, manner, the loss is a valid one.⁶ The disastrous effects were foreseen in developing countries, where the quality of surgery in the rural areassurgery that includes gynaecology, obstetrics, and dentistrydeteriorated in step with subspecialisation. ^{7 8} Despite the warnings, the pace of specialisation accelerated, even in developing countries, where the status and income of the superspecialist grew in inverse proportion to the disintegration of health care. Subspecialisation or superspecialisation is essentially part of the structure of large medical centres, and by attracting young surgeons these institutions have contributed to the disappearance of surgical services in remote areas. People are disadvantaged if they live in places where complete specialist surgical services cannot be provided or reached by means of transport. This group includes most patients, particularly in poor countries.

No training in general surgery

Surgical subspecialists working in metropolitan centres, while maintaining that their organisational structure is appropriate to their circumstances, particularly in areas of high population density, do concede that the rest of the world may need general surgeons, a circumstance which they relate to backwardness in these places. Unfortunately, for the past 40 years the surgical establishment of the West has urged surgeons in developing countries to follow its pattern and has refused to accept the argument that the hospital of the Western metropolis is the exception and should not be made the rule. Nowadays, surgical training throughout the world is oriented to subspecialties.

Admonishments coming from developing countries were not heeded. Maurice King's Primary Surgery was written in Africa.⁹ In the preface Hugh Dudley states: "At a time when surgery seems to be splitting into even more arcane fragments, this is an attempt to synthesize, to unify the discipline and to cross specialist boundaries in a way which badly needs doing."¹⁰ The book became the Bible of surgery in the bush. It remains ignored by the establishment.¹¹

Reversing the trend?

Eventually, the observation that the pendulum has swung too far had to come from a metropolitan surgical centre with the courage to declare that pursuing the dual concepts of high volume and exclusiveness is detrimental in several respects: boredom, poor undergraduate teaching, high surgeon to patient ratio, high cost, and insufficient cover for emergencies may result.²

The provision of emergency cover is a growing problem and an unavoidable consequence of specialisation. In many hospitals, the trainees currently provide the emergency cover. According to the confidential inquiry into postoperative deaths, "Many operations were undertaken by surgeons too junior and too inexperienced for the job ... there seems to be little excuse for large hospitals with large consultant surgical staff not being able to exercise complete consultant supervision at all times. This lack of supervision in many cases has led our assessors to recommend that no patient should undergo a surgical operation without prior consultation being obtained by the operating surgeons with the consultant on duty or his senior registrar."¹²

A solution to this problem would be to require all specialists to remain on duty; currently they tend to do this in the private sector only. On the other hand, a new specialty called emergency surgery could be introduced. Emergency medicine already exists. Emergency surgery would need to transcend the present specialty boundaries and would therefore mock the system. Indeed the pendulum has swung too far, to the detriment of many and for reasons that are related to the organisation of the industrial society (except that in the case of surgery mass production has not curbed costs).¹³

Prerequisites for regeneration

Will general surgery regenerate or will it need to be reborn? General surgery is still practised in some hospitals and in remote places, and sometimes to a high standard. Could these surgeons be identified and recruited into teaching? Opportunities for regeneration also exist in the Western setting, in the trauma centres, where emergency surgery is already practised without being recognised as a specialty on its own. This is what American surgeons in a level I trauma centre have to say: "We believe that trauma surgeons should be general surgeons."³ Despite the existence of these "islands" of general surgery in the bush and in cities, general surgery will thrive only if it is taught systematically and with enthusiasm. For this it will need to be recognised as a prestigious branch of surgery and its practitioners respected and paid accordingly, reflecting the fact that general surgery of the required kind pre-supposes a long training period whereas training for many subspecialties does not.

The time has come for the surgical establishment to change attitudes. General surgery has to be reinvented, structured, taught, examined, and honoured. The redefinition of general surgery will benefit multitudes of patients, yet it will happen only when surgeons recognise that the new direction is also beneficial to them. We will have to overcome the excessive specialisation and industrialisation of surgery by matching resources and service with epidemiology. The word "general" must recapture its original meaning: common, widespread, frequent, and not so very special. Only then, will the renaissance occur.

References

1.	Sarmeinto A. Commentary. J Bone Joint Surg Am 1998; 80: 601-603[Free Full Text].
2.	Taylor I. Superspecialization in cancer surgery: how beneficial? Surgery 1997; 15: 5.
3.	Richardson JD, Schwieg R, Boaz P, Spain DA, Wohltmann C, Wilson M, et al. Impact of trauma attending surgeon case volume on outcome: is more better? J Trauma Injury Infect Crit Care 1998; 44: 266-272[CrossRef].
4.	Jarhult Z. The importance of volume for outcome in cancer surgeryan overview. Eur J Surg Oncol 1996; 22: 205-215[Medline].
5.	Ferguson B, Rice N, Sykes D, Aletras V, Eastwood A, Sheldon T, et al. Hospital volume and health care outcomes, costs and patient access. Effective Health Care 1996; 2(8): 1-16.
6.	Whither (or withering) surgery [editorial]. Lancet 1993; 341: 597-598[CrossRef][Medline].
7.	Symposium. Surgery in the district hospital, Nairobi. J R Coll Surg Edin 1976; 23: 151-164.
8.	Symposium. Surgery in East Africa: technology and training. Proc Assoc Surg East Africa 1981; 4: 58-156.
9.	King M, Bewes P, Cairns J, Thronton J. Primary surgery. Oxford: Oxford University Press, 1990.
10.	Dudley H. Preface. In: King M, Bewes P, Cairns J, Thronton J, eds. Primary surgery. , Vol 1 Oxford: Oxford University Press, 1990.
11.	Bookshelf. Med Dig 1990; 16: 51-54.
12.	Buck N, Devlin BR, Lunn J. The report of confidential enquiry into postoperative deaths. London: Nuffield Provincial Hospitals Trust, King's Fund, 1987:38.
13.	Loefler IJP. More on specialization. Surgery 1998; 16: 2[CrossRef],i.

Footnotes

   Competing interests: None declared.

(Accepted 23 September 1999)

Survival of the general physician

Leslie Turnberg, chairman. 

Public Health Laboratory Service, London NW9 5DF

The days when the consultant physician could know everything in medicine have long gone. The exponential increase in knowledge and the extraordinary advances in technology have seen the emergence of specialists, subspecialists, and superspecialists. Specialisation is an irresistible force that has brought considerable advantages in the way we care for patients. The question is not therefore whether specialisation should be resisted but whether there remains any room for the generalist.¹ I believe that there is indeed an important place for the type of care that general physicians provide. I hope to convince readers that this is not simply a nostalgic reactionary's rearguard defence of a bygone era but a highly desirable way of meeting the needs of many patients today.

Emergenciesa major factor

Patients admitted as emergencies occupy over 80% of beds in medical wards, and in many hospitals the proportion is over 90%. It is scarcely surprising, therefore, that how we handle emergency medical admissions dominates discussions about the role of general physicians. Traditionally, trainee doctors cover emergency admissions, but emphasis is being placed increasingly on consultants' involvement with these patients, who, after all, deserve the best immediate care that can be provided. This inevitably means that at least some consultants should be capable of caring for the wide range of diseases seen in acutely ill patients. There are several models of care provision.

(Credit: LIANE PAYNE)

Models of care

Specialised emergency physicians
Physicians who are trained to deal primarily with a full range of acute illnesses and spend their careers as emergency consultant physicians could theoretically meet the requirement for specialised emergency physicians. Consultants in accident and emergency medicine perform some of these roles in the period immediately after arrival at hospital, but the development of specialised emergency physicians who continue care for patients beyond this time calls for a new breed of doctor and a specific training programme. Although this model could be developed, its success would depend on having enough doctors who are sufficiently motivated to take on this type of work.

Teams of specialists
Teams of relevant specialists could care for acutely ill medical patients. This structure requires sufficiently large teams of all the medical specialties to be available 24 hours a day, together with enough beds and other resources. Clearly this can be achieved only in very large hospitals, usually in major cities.

Rota of physicians
However, the model in operation in most British hospitals is one in which a rota of physicians provides careeach team accepting all emergency admissions and later referring patients on to relevant specialists where this seems necessary or appropriate.² This model poses problems. It demands that physicians, who almost always practise a subspecialty, have to maintain their general skills and knowledge. Few consultant physicians practise purely general medicine, but about half of all physicians practise both general medicine and their subspecialty.³

Specialist plus generalist approach
The following arrangement allows some flexibility in the management of patients admitted as an emergency. For patients in whom it is clear what the diagnosis is and which specialist is required, rapid transfer can be arranged. However, where the diagnosis is unclear or the patient seems to have several problems, physicians who maintain a general medical approach may be more appropriate. This system has advantages: it avoids the situation in which the patient is admitted under the "wrong" specialist, makes inappropriate investigations less likely, and may reduce the problem of overloading some specialists with large numbers of patients who do not require their highly specialised skills.

Standards of care

It has been suggested that acutely ill patients are best treated by a doctor who specialises in their condition, but the evidence for this statement is not clear cut. It is true of patients with asthma⁴ or with gastrointestinal haemorrhage, who do best under the relevant specialist, but is more difficult to show for other disorders. In any event, clear protocols that have been developed by relevant specialists and include an indication of the circumstances under which referral to a subspecialist is necessary can provide a hospital-wide standard.

Problems of smaller hospitals

There are therefore reasons of logistics, economics, and standards of care supporting the role in acute services of physicians with general medical skills. Furthermore, providing round the clock specialist management for all patients admitted acutely (presuming the diagnosis is known) would be logistically and economically justifiable and possible only in large hospitals with enough consultants in a full range of specialties. This service structure is less feasible in small centres, where the need is for locally accessible emergency care.

Uncertainty and complex disease

Even leaving these reasons aside, a general physician's approach to meeting the needs of patients with diseases of uncertain diagnosis and minimising the fragmentation of care for patients with several or complex diseases provides added clinical value. For patients with non-urgent and chronic conditions in whom the diagnosis (or the system) is reasonably well defined, appropriate specialist care seems the best option. However, many patients do not fit neatly into such a category. The diagnosis may not be immediately obvious in patients who present with vague systems such as anorexia, fatigue, or weight loss, and it may not be clear which specialist should most appropriately investigate and treat them. Patients may have diseases that affect many systemssuch as diabetics with complications, collagen diseases, or AIDSor a combination of different diseases may afflict the same person. Here the potential for fragmenting care between a number of specialists is high. The prospect of a patient being investigated in series is not unknown; it can certainly result in him or her undergoing several expensive, sometimes inappropriate, investigations. All of this supports the need for the skills and knowledge of physicians who have retained a general approach and are not limited by their subspecialty.

Maintaining general skills

Though the case for the maintaining general medical skills is well founded, it is not quite so obvious how this can be achieved. For acute care, the development of emergency physicians is one possibility. This would have to be an attractive proposition for sufficient numbers of doctors and although it is worth exploring further, this solution may not fulfil all the service needs. Nor does it seem likely that enough physicians would be willing to practise "pure" general medicine without developing a subspecialty interest.

It follows that for the immediate future at least we will continue to require some specialists to practise general medicine to meet patients' needs. However, the pressures placed on specialists to practise in their area of expertise are high, and as subspecialties evolve they become more complex and time consuming. This inevitably means that not only will we have to provide enough physicians to deliver all the specialist and generalist care that is required, but we will also have to accept the need for training and continuing education to enable some physicians to maintain their general knowledge and skills. Somewhat surprisingly, this is quite an attractive proposition for many, providing of course that they do not feel that they are being left to carry too heavy a workload.

Still an interest

Fortunately, there is still considerable interest in general internal medicine among trainees. The Royal College of Physicians surveyed senior house officers about their career aspirations and found that the largest group wished to continue training in general internal medicine.⁵ Dual training in general internal medicine plus a specialty is the most common option taken by specialist trainees in medicine.

We have, therefore, by happy coincidence, doctors who wish to practise general internal medicine at a time when patients continue to require the particular attributes that a general physician brings to an increasingly specialist world. There is a strong case for the general physician to work with specialists, and it is probable that most will practise a specialty as well as their general medicine. However, this desirable form of practice depends critically on the availability of more doctors than the currently very hard pressed numbers practising general medicine.

References

1.	Thomson GE. General internists and sub-specialists. Ann Intern Med 1993; 119: 165-166[Free Full Text].
2.	Worth R, Young G. Consultant physician of the week: a solution to the bed crisis. J R Coll Physicians 1996; 30: 211-212.
3.	Royal College of Physicians. Future patterns of care by general and specialist physicians. London: RCP, 1996.
4.	Osman J, Ormerod P, Stableforth D. Management of acute asthma: a survey of hospital practice and comparison between thoracic and general physicians in Birmingham and Manchester. Br J Dis Chest 1987; 31: 232-242.
5.	Leach D, Turnberg LA. Career intentions of senior house officers in medicine. London: Royal College of Physicians, 1997. (Occasional paper.)

Footnotes

   Competing interests: None declared.