Intended for healthcare professionals

Careers

The time has come for a surgical medicine subspecialty

BMJ 2014; 349 doi: https://doi.org/10.1136/bmj.g5460 (Published 09 September 2014) Cite this as: BMJ 2014;349:g5460
  1. Daniel Furmedge, NIHR academic clinical fellow in medical education1, specialty registrar, geriatric and general internal medicine 2
  1. 1UCL Medical School, 74 Huntley Street, London, WC1E 6AU
  2. 2Lewisham and Greenwich NHS Trust, London, UK
  1. dfurmedge{at}doctors.org.uk

Abstract

Physician input for surgical patients is becoming increasingly routine, so the time has come for a surgical medicine subspecialty and shared care for all surgical patients, argues Daniel Furmedge

In an enduring but uncomfortable paradox, the fate of surgical patients with medical problems has long been the subject of both humour and concern. The engagement of surgical teams with medical problems is stereotypically—though certainly not universally—poor, and there is increasing interest from medical teams, particularly geriatricians, in surgical patients.

Personal experience does little to allay these stereotypes. Though some surgical teams are engaged and interested in addressing comorbidity, complications, and psychosocial issues, a substantial proportion are not. When I am on call as the medical registrar, surgical trainees and trust doctors frequently tell me that electrocardiogram interpretation, shortness of breath, hyponatraemia, and “social issues” are medical, not surgical, problems. Reflex referrals without basic investigations for simple chest pain and confusion, and meek calls from foundation doctors left with seriously unwell patients, are relatively common. Although stories of such encounters with surgical teams are recounted frequently by my colleagues and we laugh, these stories do highlight a problem that must be addressed.

Should surgical teams be expected to deal with medical problems?

There is almost certainly no difference between common post-surgical complications and medical problems. Delirium, pneumonia, constipation, arrhythmia, thromboembolism, and “social issues” all sound suspiciously like regulars on the general medical intake to me, and surgical teams may not be best placed and trained to manage these problems. The surgical training curriculum beyond core training places little specific input on the management of medical problems and is constructed with broad statements of curriculum outcomes rather than specific objectives.1

Most doctors with experience of regular medical input for surgical patients, such as geriatricians and surgeons, will strongly attest to its benefits and there is increasing evidence that the involvement of physicians has clear value. The proactive care of older people undergoing surgery (POPS) scheme provides multidisciplinary input, including from a consultant geriatrician, for older surgical patients from preoperative assessment to postoperative follow-up. This scheme has demonstrated considerable reductions in postoperative complications and length of stay.2

The presence of geriatricians in hip fracture care has become its own subspecialist area, and it currently sits as a subspecialty interest in the postgraduate curriculum for higher specialist training in geriatric medicine. Orthogeriatrics forms part of a complex intervention with an overarching positive effect on patient care. Routine geriatrician input is a recognised standard in the care of all patients after hip fracture and now also for those undergoing emergency abdominal surgery. But there is still a long way to go, wide variation in access, and a paucity of proactive services that routinely see all eligible patients.345

The case for medical input into all surgical admissions, particularly emergencies, has never been stronger, and services are slowly beginning to reflect this. But such changes will pose challenges. By taking responsibility for the medical management of surgical patients, surgical trainees may become deskilled and contribute to this cycle. It may not be clear which consultant is in charge of a patient’s care. Decisions would have to be made about whether input is limited solely to the frail older patient, and whether we really want a model where surgeons act solely as operative technicians.

Orthogeriatrics and bariatric medicine

Orthogeriatric services may offer a promising model. In some areas, patients with fractured neck of femur are admitted to a dedicated perioperative medicine unit led by a geriatrician with shared care from the surgical team, often retaining surgical junior doctors. These units see hip fracture as one entity and admit all patients regardless of age. Limiting similar services solely to elderly people does not make sense, because, although older patients are typically more frail and at risk of poorer outcomes, many other patients have complex medical problems and issues.

A bariatric medicine subspecialty is also being created specifically to deliver rounded, specialist medical care to this complex group of patients after a need was identified for specialists to provide overarching holistic, rather than fragmented, care to this group.6 Despite this, the importance of system-specialist doctors, such as gastroenterologists, in patients with inflammatory bowel disease should not be overlooked. Likewise, the input of surgeons postoperatively is imperative as only they understand exactly what happened in theatre.

Further directed research into the outcomes of medical input for surgical patients is crucial, and should include a particular focus on acute non-elective admissions and younger patients to augment the growing data on comprehensive medical intervention. That said, regardless of outcome, the increasing momentum and patient centred obligation for medical input for all surgical inpatients cannot be avoided.

All surgical admissions must be reviewed by a physician as a routine to improve care and outcomes. The future must embrace dedicated surgical units led by physicians where surgeons provide advice and shared care and operate. In anticipation of this, and in line with other subspecialty innovations, a certificate of completion of subspecialty training in surgical medicine must be developed now.

Footnotes

  • I have read and understood the BMJ policy on declaration of interests and declare the following interests: None

References