Surgery Today Jpn. J. Surg. (1992) 22:293-296 @ SURGERYTODAY

© Springer-Verlag 1992

Review Articles

What Is General Surgery: Definition, Education and Practice

LLOYD M. NYHUS

The Department of Surgery, University of Illinois College of Medicine, Box 6998, Chicago, I160680, USA

This report is a condensed version of a paper read by Dr. L. M. Nyhus at the 91st Annual Meeting of the Japan Surgical Society, Kyoto, Japan, 1991

Introduction

It is a pleasure, indeed honor, to be with you again on the occasion of your annual meeting. My first visit was 26 years ago when my maestro, the late Professor Henry N. Harkins and I joined the 1965 meeting with Professor Minoru Oi in the Chair of President. I was privileged to attend the 77th meeting in 1977 under the leadership of President Tadashige Murakami. It is almost unbelievable that we find ourselves again here at the 91st meeting in the beautiful setting of Kyoto to renew old friendships with President Takayoshi Tobe and many others of your membership.

I shall spend these few moments with you attempting to place the medical specialty of General Surgery in its proper perspective, at least as it is envisioned in the United States today.

A Definition of General Surgery

The Booklet of Information (1991) of the American Board of Surgery interprets the term "General Surgery" in a comprehensive but specific manner, as a discipline having a central core of knowledge embrac- ing anatomy, physiology, metabolism, immunology, nutrition, pathology, wound healing, shock and resusci-

Dr. Nyhus is an Honorary Member of the Japan Surgical Society Reprint requests to: L.M. Nyhus (Received for publication on Apr. 8, 1991; accepted on May 1, 1992)

tation, intensive care and neoplasia, which are common to all surgical specialities.

The General Surgeon is one who has specialized knowledge and skill relating to the diagnosis, pre- operative, operative, and postoperative management in the following areas of primary responsibility: alimentary tract, abdomen and its contents, breast, skin and soft tissue, head and neck, including trauma; vascular, endocrine, congenital and oncologic disorders - - particularly tumors of the skin, salivary glands, thyroid, parathyroid, and the oral cavity, vascular sys- tem, excluding the intracrainial vessels, the heart and those vessels intrinsic and immediately adjacent thereto, and the endocrine system.

Surgical oncology, including coordinated multi- modality management of the cancer patient by screen- ing, surveillance, surgical adjunctive therapy, rehabilitation, and follow-up, comprehensive man- agement of trauma, including musculo-skeletal, hand and head injuries. The responsibility for all phases of care of the iniured patient is an essential component of general surgery, and complete care of critically ill patients with underlying surgical conditions, in the Emergency Room, Intensive Care Unit and Trauma/ Burn Units; all are primary responsibilities.

Additionally, the General Surgeon is expected to have significant preoperative, operative and post- operative experience in pediatric, plastic and gen- eral thoracic surgery. Also, the surgeon must have understanding of the management of the more com- mon problems in cardiac, gynecologic, neurologic, orthopedic, transplant, and urologic surgery, and of the administration of anesthetic agents.

The General Surgeon must be capable of employing endoscopic techniques, particularly proctosig- moidoscopy and operative choledochoscopy, and must have experience with a variety of other endoscopic techniques such as laryngoscopy, bronchoscopy, esophagogastroduodenoscopy, colonoscopy and peri-

294 L.M. Nyhus: General Surgery

toneoscopy. It is desirable that the General Surgeon have opportunity, whenever possible, to gain some knowledge and experience of evolving technological methods, e.g., laser applications, lithotripsy, and endoscopic operations.

This definition of the specialty of general surgery may seem overly broad or all inclusive. However, note the several levels of the information base necessary, that is, a detailed knowledge and experience in the commonly understood areas and an understanding of the principles and experience in the common problems of the specialties of surgery. The introduction of the fiberoptic endoscopic instruments into the diagnostic and therapeutic arena of patient care and other evolv- ing technological methods such as laser applications, lithotripsy and endoscopic operations has necessitated the addition of these instrumental techniques into our specialty.

A Method of Surgical Training

After primary education (grade school, ages 6-13), secondary education (high school, ages 14-18), under- graduate education (university, ages 18-21), graduate education (medical school, ages 22-26), a period of postgraduate education begins (the surgical residency, ages 26-31).

Parenthetically, there is a marked variation relative to the exposure to the discipline of surgery received by medical students. In the four year curriculum, approximately 12 weeks will be served by the medical students on the surgical wards of our hospitals, in many instances working with the iunior house officer in direct care of the surgical patient. In addition, the medical student often will elect to serve another 8 or 12 weeks upon one or more surgical sub-speciality hospital wards during his or her final year of medical school.

It is upon this base that the surgical trainee begins the postgraduate program in general surgery. The program at the University of Illinois, which includes four major hospitals (University of Illinois, Cook County, West Side Veterans Administration and Michael Reese), will be used as an example of program structure. The goal of this program is to provide the opportunity for our graduate students to acquire a broad understanding of human biology as it relates to disorders of a surgical nature and the technical knowledge and skills appro- priate to be applied as a surgeon. This goal is best obtained by a progressively graded curriculum of study and clinical experience under guidance and supervision of our senior surgeons. The experience provides for a progression through succeeding stages of responsibility for patient care up to the final one of complete manage- ment. Maior operative experience at the final stage

of the program is an essential component of surgical education. The length of time involved in training may vary, although in our setting, it has evolved that a minimum of five years of progressive education in surgery following graduation from medical school is required for attainment of an acceptable level of competency.

The University of Illinois Program

The integrated five year program at the University of Illinois is designed to meet the aforementioned goals and objectives. The program is structured to permit trainees interested in academic surgery to spend one or more additional years in research pursuits separate from the clinical rotation.

During the five years of clinical training, the resident will have a balanced experience in the four Medical Center hospitals. Surgical residents are recruited each year through the National Resident Matching Program and are carried through the postgraduate I and II years. As previously mentioned, selected residents are given the opportunity to participate in basic research on a full-time basis for a minimum of 12 months in the postgraduate IlI year. The remaining residents will continue in the clinical program for a total of five years of training. (Table 1). Each resident is expected to perform a large volume of major surgical procedures under the supervision of the attending staff. The trainee also is involved directly in didactic and clin- ical teaching experiences with fellow residents and medical students. Regularly scheduled conferences are key to this didactic portion of the program. Divis- ional conferences are scheduled in general surgery and the sul~specialty services. The general surgery weekly scheduled conferences include a tumor board, a conference which reviews complications and death (morbidity and mortality conference), vascular con- ferences and surgical grand rounds wherein visiting professors lecture or panel discussions are presented. A journal club meets on a monthly basis, alternating weeks with a trauma, oncology or surgical pathology conference.

The Evaluation Process

Residents receive a written evaluation after each clin- ical rotation by the chief surgeon of that unit. During each year of training the resident is required to take an examination delivered and administered by the American Board of Surgery. After satisfactory com- pletion of training the resident is eligible to take the

L.M. Nyhus: General Surgery 295

Table 1. The University of Illinois training program rotations

First PG year: junior resident 1. General surgery 2. Surgical oncology 3. Cardiothoracic surgery 4. Pediatric surgery 5. Transplantation surgery 6. Colon-rectal surgery 7. Vascular surgery 8. Urology

Second PG year: junior resident 1. Trauma unit 2. Burn unit 3. Emergency room 4. Selected specihlties: (including those in first PG year)

a. Orthopedi~zs b. Plastic surgery c. Neurosurgery d. Surgical pathology e. AnesthesiOlogy

I

Third-fifth PG years (optional: 1, 2, or 3 years o f full-time research)

Third PG year: intermediate resident 1. General surgely 2. Surgical intengive care 3. Selected specialties

Fourth PG year: #enior resident 1. Private rotation 2. Transplantatiqn surgery 3. Pediatric surgery 4. Cardiothoraci¢ surgery 5. Trauma unit 6. Surgical endoslcopy

Fifth PG year: ch+'ef resident 1. General surgery 2. Vascular surgery 3. Surgical oncolggy 4. Colon-rectal surgery

PG , Postgraduate

two examinations of the American Board of Surgery, namely, the Qualifying Examination - - a written exam- ination given l~te in the year immediately following completion of the residency - - and a Certifying Exam- ination, which is an oral examination given subsequent to successful completion of the Qualifying Examination.

Residency Review Committee

Residency programs in surgery in the United States are reviewed and approved by the Residency Review Committee. Final accreditation of each program is by another overview body, named the Accredita- tion Council for Graduate Medical Education. The members of the Residency Review Committee are appointed by three bodies - - The American College of Surgeons, the American Board of Surgery and the American Medical Association. Surgical training pro- grams are reviewed on a regular, on site basis. After a site visit, a program may be given a full approval for one to three years or, because of deficiencies, be placed on probation. The reasons for probation are shared with the program director, and a period of one to two years is allowed to remedy the deficiencies. Re-review can eventuate full approval or, if the deficiencies have not been corrected, disapproval of the program.

The American Board of Surgery

The American Board of Surgery (ABS) was formally charted in July of 1937. The formation, functions and organization of the Board had been previously con- sidered by a committee formed upon the initiative of the American Surgical Association and composed of representatives from certain national and sectional surgical societies. The findings and recommendations of the committee were approved by the cooperating societies with the understanding that the Board when organized would have the power to make such changes in the proposed plan as might be found appropriate. This Board was created in accordance with the action of the Advisory Board for Medical Specialties, which names certain specialty fields as being suitable for such Boards. These Boards have the purposes of certifying those found to be qualified after meeting reasonable requirements, and of improving existing opportunities for the graduate education of specialists within the field concerned. The action was taken for the protec- tion of the public and for the good of the specialty.

Organization of the Board

Quality Control of Surgical Education

A system of review has evolved which constantly monitors both the training programs and the individ- ual graduates. Programs and graduates are evaluated by the Residency Review Committee in surgery and the American Board of Surgery, respectively.

The American Board of Surgery is composed of members elected from among nominees provided by national and regional surgical and specialty societies and organizations. The normal term of a member is six years.

The Board's policies, requirements, procedures and evaluative processes are developed through the

296 L.M. Nyhus: General Surgery

medium of committees. The Committees report their findings and recommendations to the Directors, who in turn are responsible to the Active Membership.

Purposes of the Board

The American Board of Surgery is a private, voluntary, non-profit, autonomous organization founded for the following purposes:

A. To conduct examinations of acceptable candidates who seek Certification or Recertification by the Board

B. To issue Certificates of Qualification to all can- didates meeting the Board's requirements and who satisfactorily complete its prescribed examinations

C. To improve and broaden the opportunities for the graduate education and training of surgeons

The Board limits its responsibilities to fulfilling the purposes stated above. It is not concerned with the attainment of special privileges or recognition for its Diplomates in the practice of surgery. It is neither the intent nor the purpose of the Board to define the requirements for membership on the staff of hospitals or institutions involved in the practice or teaching of surgery. Its principal objective is to pass judgment on the education, training and knowledge of broadly com- petent and responsible surgeons and not to designate who shall or shall not perform surgical operations or any category thereof. The Board specifically disclaims interest in or recognition of differential emoluments that may be based upon Certification.

The Connection

What is the meaning of all this to those of us assembled here today. Your general surgery graduates are pro- ducts of your own definitions and methods of quality

Table 2. Research fellows from Japan at the University of Illinois, 1967-1991

1971 Rikiya Abe Fukushima Medical College 1972 Koji Kusakari St. Marianna University School of

Medicine 1977 Nobuji Kono Wakayama University 1978 Masahiro Sano Kyoto Teishin Hospital 1982 Toshio Miura Nagasaki University, 1st

Department of Surgery 1982 Junro Takeda Kurume University School of

Medicine 1983 Hiroshi Akimoto Jikei University School of

Medicine • 1984 Junji Machi Medical College of Pennsylvania,

Fukuoka 1985 Atsunobu Kumamoto University School of

Misumi Medicine 1988 Junichi Yoshida Kyushu University 1990 Atsushi Sugitani Kyushu University 1991 Keisei Anan Kyushu University

control in surgical education. I am somewhat familiar with your system and students of surgery, since we have had the pleasure of having many students from Japan in our research laboratories (Table 2) during the past 24 years. Each has been a credit to your country and to your basic educational system. You should be proud of these colleagues, who have competed so successfully in the academic environment of our North American institution; an environment of surgical education as described herein. In addition, our own teaching pro- gram has been enhanced by visits of varying lengths of time by many of your surgical scholars who have given demonstrations in the operative theatre and many dis- tinguished lectures.

The discipline of general surgery is the keystone of surgical disciplines. We must dedicate ourselves to assure that the education of the general surgeon pro- vides the very best product in terms of day-to-day excellent care of our patients.