World J Surg DOI 10.1007/s00268-014-2890-7
ORIGINAL SCIENTIFIC REPORT
‘‘Is General Surgery Still Relevant to the Subspecialised Trainee?’’ A 10 Year Comparison of General Versus Specialty Surgical Practice C. A. Fleming • Z. Khan • E. J. Andrews • G. J. Fulton • H. P. Redmond • M. A. Corrigan
Ó Socie´te´ Internationale de Chirurgie 2014
Abstract Background The splintering of general surgery into subspecialties in the past decade has brought into question the relevance of a continued emphasis on traditional general surgical training. With the majority of trainees now expressing a preference to subspecialise early, this study sought to identify if the requirement for proficiency in managing general surgical conditions has reduced over the past decade through comparison of general and specialty surgical admissions at a tertiary referral center. Methods A cross-sectional review of all surgical admissions at Cork University Hospital was performed at three individual time points: 2002, 2007 & 2012. Basic demographic details of both elective & emergency admissions were tabulated & analysed. Categorisation of admissions into specialty relevant or general surgery was made using International guidelines. Results 11,288 surgical admissions were recorded (2002:2773, 2007:3498 & 2012:5017), showing an increase of 81 % over the 10-year period. While growth in overall service provision was seen, the practice of general versus specialty relevant emergency surgery showed no statistically significant change in practice from 2002 to 2012 (p = 0.87). General surgery was mostly practiced in the emergency setting (84 % of all emergency admissions in 2012) with only 28 % elective admissions for general surgery. A reduction in length of stay was seen in both elective (3.62–2.58 bed days, p = 0.342) & emergency admissions (7.36–5.65, p = 0.026). Conclusions General surgical emergency work continues to constitute a major part of the specialists practice. These results emphasize the importance of general surgical training even for those trainees committed to sub-specialisation.
Introduction The splintering of general surgery into subspecialties in the past decade has questioned the relevance of a continued emphasis on traditional general surgical training [1]. Debate is ongoing regarding the requirement of trainees to undergo general training prior to specialisation. Since 2009, dramatic changes have gradually been implemented C. A. Fleming (&) Z. Khan E. J. Andrews G. J. Fulton H. P. Redmond M. A. Corrigan Department of General Surgery, Cork University Hospital, Cork, Ireland e-mail: [email protected]; [email protected]
to Irish Surgical Training, culminating in 2013 with the introduction of a new shorter, specialty-focused programme for general surgical trainees [2]. It is well established that sub-specialisation improves patient outcomes, but the practice of general surgery is still important due to service demand even in specialist tertiary referral centres [3–6]. In The United States, trainers have looked at ‘‘specialising’’ general emergency surgery into its own entity to maintain quality of service and meet service demands [7]. With the majority of higher surgical trainees now expressing an early preference to subspecialise, this study sought to question the current role of the general surgeon in providing general surgery compared to specialty service,
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and question if this role has changed over the past 10 years with practice trends towards specialisation.
Materials and methods Patient selection, study setting and data collection A cross-sectional review of surgical admissions at Cork University Hospital was performed of three individual time points during the evolution of centralisation: 2002, 2007 and 2012. Overall number of surgical admissions and hospital length of stay (LOS) were used as measurement tools. Twenty-four hour emergency surgery cover is provided at our institute covering a catchment area of approximately 500,000 [8]. It is the largest University teaching hospital and the only Level 1 Trauma center in the Republic of Ireland. It is also a Regional Cancer Referral Centre. The Hospital Inpatient Enquiry (HIPE) database in our hospital was used to identify all surgical admissions during the above years. This database is a prospectively maintained medical record in operation in 61 Irish hospitals and is used by the Department of Health and Children to identify hospital case-mix and plan resource allocation and is supported as a data source for research purposes [9]. Disease conditions are coded in keeping with the ICD-10 guidelines, 2008, Version 8. Training of new coders and refresher courses for existing coders is conducted in-house initially and by the Economic and Social Research Institute (ESRI) on a monthly basis [9]. Training is held in the form of practical workshops; the aim of which is to support high quality and accurate data input. The database records admissions as elective or emergency. Emergency admissions are defined as all those admitted acutely through the emergency department. The HIPE database previously demonstrated to achieve significant fidelity in the capture of hospital admissions to approximately 86 % [10]. A variety of variables are recorded and for the purpose of this study the following were obtained: age, gender, date of admission and date of discharge, LOS, the admitting and discharging consultant, primary diagnosis (including other diagnoses recorded up to a maximum of four) and the primary procedure performed (including other procedures recorded up to a maximum of four).
Table 1 Guideline criteria for classification of procedures as specialty relevant Specialty
Guideline
Colorectal
ACGME minimum cases for Colon and Rectal Surgery [11]
Vascular
ABS SCORE Core Curriculum for Vascular Surgery Residents [12]
Breast
ISCP Surgical Curriculum Programme, p.26 [13]
Professorial unit Breast
ISCP Surgical Curriculum Programme, p.26 [13]
Endocrine
Cleveland clinic–Endocrine surgery [14]
Surgical oncology
Memorial Sloan Kettering, Guidelines on Surgical Oncology Fellowship Programme [15]
ACGME Accreditation Council for Graduate Medical Education ABS The American Board of Surgery ISCP Intercollegiate Surgical Curriculum Programme
categories created: colorectal, vascular, breast and professorial unit. The Professorial Unit of our Department provides a large Surgical Oncology Service which covers a wide spectrum of conditions such as breast disease, sarcoma, melanoma, endocrine disease as well as elective and emergency general surgery. It does not cover hepatobiliary surgery. Table 1 shows the guideline criteria used to classify admissions into specialty groups for each of the four subspecialties [11–15]. If a condition or procedure did not meet the above criteria then it was categorised as general surgery. Statistical analysis and ethical approval All data were tabulated and analysed using the statistical package IBM SPSS Version 22.0, August 2013. Descriptive analysis in the form of mean and confidence intervals (95 %) was performed on demographic information. Differences between general and specialty admissions were assessed using the student t test for continuous variables and the v2 test for categorical variables. Statistical significance was accepted as p \ 0.05. Ethical approval to perform this study was obtained from the Clinical Research and Ethics Committee (CREC) of the Cork Teaching Hospitals.
Definition of specialty-related procedure
Results
Based on data collected, classification into a general surgery or specialty relevant admission was carried out. There are five specialties practiced at our institute under the combined umbrella of general surgery including colorectal, vascular, breast and endocrine surgery and complex surgical oncology. For analysis, there were four specialty
Surgical admissions
123
In total, there were 11,288 surgical admissions in the study periods observed (2,773 in 2002, 3,498 in 2007 and 5,017 in 2012). This showed an increase of 26 and 43 % from 2002–2007 to 2007–2012, respectively, and an increase of
World J Surg Table 2 Overall admissions (including elective and emergency breakdown) and number of Consultant surgeons practicing in the general surgery department over the 10-year study period 2002
2007
2012
Growth
Total admissions
2773
3498
5017
81 %
Elective
1804
2170
2764
53.2 %
969 3
1328 5
2253 8
132.5 %* 166.7 %
Emergency Consultants
Fig. 2 Number of surgical admissions which were general surgical admissions overall, elective and emergency
Fig. 1 Comparison of general and specialty admissions as per all admissions to the general surgery department over the 10-year study period
81 % of total surgical admissions over the total 10-year period. The Central Statistics Office in Ireland reported a steady 7.6–7.8 % rate of population growth in the catchment area during this study period [16] and the number of consultants employed in the department increased from three in 2002 to five in 2007 to eight in 2012. Table 2, shows an outline of changing demographics in the surgical department and growth of service provision over the 10-year study period. General/specialty breakdown Figure 1 shows a breakdown of general and specialty surgery during each study period. General surgery comprised 57.6 % of admissions in 2002, 55.6 % in 2007 and 53.1 % in 2012. Thus, while service provision increased dramatically overall and sub-specialisation expanded, no statistically significant difference was seen in general surgery compared to specialty relevant admissions over the 10-year period (p = 0.967). Trends differed in elective and emergency general surgery admissions (Fig. 2). Emergency general surgery increased overall by 6.9 % but did not achieve statistical significance (p = 0.871). Expressed as a factor of overall admissions, as a representation of overall
departmental workload, general emergency admissions represented 37.7 % of workload in 2012, an increase of 10.7 % over the 10 years (27 % in 2002, 30.8 % in 2007). Conversely, elective surgical admissions decreased significantly by 19 % over the 10-year study period (p = 0.046). This may be explained by establishment of the Regional Cancer Referral Centre and expansion of specialised Vascular and Endovascular practice at our institute. It should also be noted that all cholecystectomies were classified as a general surgery procedure as the hepatobiliary service for our catchment area is provided at a different hospital. Length of stay Overall LOS for all patients admitted to the general surgical department reduced over the 10-year period, most notably over the past 5 years. Elective admission length of stay reduced from 3.62 bed nights in 2002 to 2.58 in 2012 (p = 0.342). Emergency LOS reduced also from 7.36 bed nights in 2002 to 5.65 in 2012 (p = 0.026) as seen in Table 3. Total bed days for specialty and general admissions were tabulated for the 3 years showing that 37.7 % of all hospital bed days were for general surgical admissions 2012, a figure that has increased (27 % in 2002 and 30.8 % in 2007). Specialty and procedural breakdown Table 3 highlights trends in general and specialty admissions within each general surgery subspecialty practiced at our institute. Notably, while overall general surgery admissions slightly reduced per subspecialty when interdepartmental breakdown is performed, it increased by 5.3 % over the 10-year period in the department of Vascular surgery, a technically sub-specialised department
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World J Surg Table 3 Hospital LOS in days, comparison of trends over 10-year study period 2002
2007
2012
p Value
Overall
4.93
4.84
3.96
p = 0.126
(Range)
(1–170)
(1–271)
(1–196)
95 % CI
3.23–6.63
2.60–7.08
2.42–5.50
Emergency
7.36
7.11
5.65
(Range)
(1–170)
(1–271)
(1–196)
95 % CI
6.60–8.13
6.23–7.98
5.24–6.06
Elective (Range)
3.62 (1–83)
3.46 (1–95)
2.58 (1–79)
95 % CI
3.37–3.87
3.20–3.72
2.40–2.76
p = 0.026
p = 0.342
CI confidence interval
whom in many hospitals no longer participate in general emergency surgery rotas. Table 4 profiles procedures performed during surgical admission. Interestingly, as many as one fifth of all patients were managed non-operatively. As expected the number of angiograms performed increased significantly over the past 10 years from 1.4 % in 2002 to 2.6 % in 2012. Surprisingly, the number of specialty performed scopes greater than doubled over the 10-year study period (22.9–51.7 %). We can see from Table 5 the high incidence of general surgical procedures performed by each specialty. A list of the five most commonly performed procedures with specialty breakdown can also be seen in Table 5 (all procedures performed not just procedures relevant to each specialty). The ratio of general:specialty performed operations is largely unchanged from a 1:1 ratio over the past 10 years also, further supporting the clinical importance for proficiency in general surgery.
Discussion The practice of general surgery still comprises a large component of surgical workload in sub-specialized general surgery departments (53.1 % of all admissions in 2012 and 37.7 % of all bed days). Overall, as expected, growth in service provision was substantial in our institute over the 10-year study period due to centralization of emergency surgical services and establishment of the Cancer Regional Referral Center but this did not create a significant reduction in the practice of general surgery. Quantifying the practice of general surgery compared to specialty service provision has not been directly performed in previous studies, some have looked at the practice of general surgery as a specialty in the emergency setting alone in large specialist hospitals and the practice of specialist procedures in rural community hospitals in the US [7, 17]. Acknowledging service demands for general surgery provision, Intercollegiate general surgical curriculum guidelines in the UK state that all general surgeons with sub-specialised training still need proficiency in an array of general emergency procedures at the end of their training and prior to appointment to a Consultant post [13]. However, many trainees doubt their general surgery proficiency in the era of early sub-specialisation. With the American College of Surgeons undertaking changes to overall surgical training and encouraging early sub-specialisation, in 2012 as many as 38 % of general surgery residents in the US when questioned expressed a lack of confidence in their general surgical skills following a 5-year basic training program [18]. With implementation of the European Working Time Directive (EWTD), shorter working hours
Table 4 Trends in procedures performed over the 10-year study period, elective/emergency and general/specialty surgery breakdown (percentage of procedure performed as general or specialty) Overall
Elective
Emergency
Specialty
General
1704
1265
439
882 (51.8 %)
822 (48.2 %)
424
348
76
97 (22.9 %)
327 (77.1 %)
2002 Surgery Scope Angio Non-operative
39
35
4
39 (100 %)
0
605
155
450
156 (25.8 %)
449 (74.2 %)
2171 539
1583 434
588 105
1225 (56.4 %) 151 (28.0 %)
946 (43.6 %) 388 (72.0 %)
2007 Surgery Scope Angio Non-operative
72
45
27
72 (100 %)
0
714
107
607
109 (15.3 %)
606 (84.7 %)
2885
1944
941
1657 (57.4 %)
1228 (42.6 %)
2012 Surgery Scope
806
652
154
417 (51.7 %)
389 (48.3 %)
Angio
134
100
34
134 (100 %)
0
1169
64
1105
144 (12.3 %)
1025 (87.7 %)
Non-operative
123
Diagnostic laparoscopy
IGTN removal
Inguinal hernia repair
Incisional hernia repair
3
4
IGTN removal Pilonidal sinus excision
4 5
Inguinal hernia repair
Cholecystectomy
IGTN removal
Paraumbilical hernia repair
2
3
4
5
I&D perianal abscess
Strangulated hernia repair
I&D Abscess
Cholecystectomy
Appendicectomy
Diagnostic laparoscopy Cholecystectomy
I&D perianal abscess
Laparotomy–small bowel
Appendicectomy
Laparotomy–small bowel
Open AAA repair
Excisional biopsy
Arterial bypass
Endarterectomy
SFJ ligation carotid
Arterial bypass Carotid endarterectomy
Appendicectomy
Angiogram ± plasty
SFJ ligation
Angiogram ± plasty
Carotid endarterectomy
Arterial Bypass
Appendicectomy
SFJ Ligation
Vascular surgery
Seton/fissure repair
EUA rectum
Inguinal hernia repair
Cholecystectomy
Appendicectomy
EUA rectum Anterior resection
Inguinal hernia repair
Laparoscopic cholecystectomy
Appendicectomy
Anterior resection
EUA rectum
Appendicectomy
Inguinal hernia repair
Laparoscopic cholecystectomy
Colorectal surgery
a
Excisional biopsy of skin/superficial lesion
IGTN ingrown toenail, I&D incision and drainage, SFJ saphenofemoral junction, SLNBx sentinel lymph node biopsy
Excisional biopsya
1
2012
Laparoscopic cholecystectomy
Inguinal hernia repair
2
3
Excisional biopsya
1
2007
5
Laparotomy–large bowel
Cholecystectomy
2
I&D abscess
Excisional biopsya Appendicectomy
General surgery (emergency)
1
2002
General surgery (elective)
Regional node clearance
Mastectomy
Thyroidectomy Appendicectomy
Excisional biopsya
Breast WLE & SLNBx
Excisional biopsya
Mastectomy Parathyroidectomy
Thyroidectomy
Breast WLE & SLNBx
Excisional biopsya
Inguinal hernia repair
Mastectomy
Appendicectomy
Breast WLE
Excisional biopsya
Professorial unit
Mastectomy
Appendicectomy
Breast WLE & SLNBx
Component of professorial unit
Component of professorial unit
Breast surgery
Table 5 List of most commonly performed procedures in order of frequency with breakdown into each specialty (all procedures performed not just those relevant to specialty) and general surgery procedures with breakdown into elective and emergency
World J Surg
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World J Surg
and a reduction in clinical surgical practice and proficiency in surgery are further threatened [19]. Striking a balance in acquisition of surgical proficiency and regulation of working hours is a complex problem in the practice of modern surgery. Study limitations While great efforts were made in creating an acceptable study design, there were certain challenges that could not be overcome. Inter-departmental and National training and re-training is practiced to maintain high quality data input record as part of the HIPE data collection system, however, human error can occur. As this study was performed in a retrospective cross-sectional manner, the risk of this error is slightly increased. However, the high number of patients included and use of accepted International criteria for classification of general and specialty relevant cases lend to robust results. Certain super-specialised procedures did not have an identified HIPE code and were, therefore, coded as ‘‘miscellaneous’’. This difficulty was overcome in most relevant cases as the admission diagnosis was listed and guidelines not only outline specialty relevant procedures but also specialty relevant conditions. Full years were analysed in preference to monthly or quarterly assessments to remove seasonal bias. In conclusion, General surgical emergency work continues to constitute a major part of the specialists practice in a tertiary referral centre and is increasing. Therefore, general surgery is still relevant to the sub-specialised trainee. Will trends proceed like this or change with further sub-specialisation? In the words of Neils Bohr ‘‘it’s hard to make predictions, especially about the future’’. The results of this study clearly emphasize the current importance of general surgical training even for those trainees committed to sub-specialisation in current practice. Acknowledgments I would like to extend an acknowledgement to all staff in the HIPE department at Cork University Hospital for their time and contribution towards data sourcing for this study. I would also like to thank all the surgical staff at Cork University Hospital.
References 1. Longo WE, Sumpio B, Duffy A, Seashore J, Udelsman R (2008) Early specialisation in surgery: the new frontier. Yale J Biol Med 81:187–191 2. Irish Medical News, Article 11/2/13. Available at: http://www. rcsi.ie/index.jsp?a=2524&n=1220&p=1204. Accessed 08 Sept 2013
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3. Allgood PC, Bachmann MO (2006) Effects of specialisation on treatment and outcomes in screen-detected breast cancers in Wales: cohort study. Br J Cancer 94(1):36–42 4. Archampong D, Borowski D, Wille-Jorgensen P, Iversen LH (2012) Workload and surgeon’s specialty for outcome after colorectal cancer surgery. Cochrane Database Syst Rev 3: CD005391 5. Parks RW, Bettschart V, Frame S, Stockton DL, Brewster DH, Garden OJ (2004) Benefits of specialisation in the management of pancreatic cancer: results of a Scottish population-based study. Br J Cancer 91(3):459–465 6. Nambiar RM (1995) General surgery in an era of superspecialisation—what is the future? Ann Acad Med Singap 24(1):180–187 7. Ahmed HM, Gale SC, Tinti MS, Shiroff AM, Macias AC, Rhodes SC et al (2012) Creation of an emergency surgery service concentrates resident training in general surgical procedures. J Trauma Acute Care Surg 73(3):599–604 8. Health Services Executive, Republic of Ireland. Available at: http://www.cuh.hse.ie/About_CUH/. Accessed 08 Sept 2013 9. Wiley MM (2005) Using HIPE data as a research and planning tool: limitations and opportunities: a response. Ir J Med Sci 174:52–57 10. McHugh SM, Loh KP, Corrigan MA, Sheikh A, Lehane E, Hill AD (2012) PatientsmateÓ: the implementation and evaluation of an online prospective audit system. J Eval Clin Pract 18(2): 365–368 11. Accreditation Council for Graduate Medical Education (ACGME), minimum case list for Colon and Rectal Surgery. Available at: https://www.acgme.org/acgmeweb/Portals/0/PFAssets/Program Resources/060_CRS_Minimum_Case_Numbers.pdf. Accessed 22 Oct 2013 12. The American Board of Surgery. SCORE Core Curriculum for Vascular Surgery Residents. Available at: http://www.absurgery. org/default.jsp?certvsqe_primarycert. Accessed 22 Oct 2013 13. Intercollegiate Surgical Curriculum Programme (ISCP), Competency in Breast Surgery Section, page 26. Available at: https:// www.iscp.ac.uk/static/syllabus2013/gs_curric_2013.pdf. Accessed 12 Oct 2013 14. Endocrine Surgery, Cleveland Clinic, North America. Available at: http://my.clevelandclinic.org/endocrinology-metabolism/departments-centers/endocrine-surgery.aspx. Accessed 22 Oct 2013 15. Michelassi Fabrizio (2011) American board of surgery certificate in general complex surgical oncology. Ann Surg Oncol 18:2405–2406 16. Central Statistics Office, Ireland. Available at: http://www.cso.ie/ en/statistics/healthandsocialconditions/publiclyfundedacute hospitalsstatistics2009/. Accessed 08 Sept 2013 17. Gillman LM, Vergis A (2013) General surgery graduates may be ill prepared to enter rural or community surgical practice. Am J Surg 205(6):752–757 18. Coleman JJ, Esposito TJ, Rozycki GS, Feliciano DV (2013) Early subspecialisation and perceived competence in surgical training: are residents ready? J Am Coll Surg 216(4):764–771 19. Breen KJ, Hogan AM, Mealy K (2013) The detrimental impact of the implementation of the European working time directive (EWTD) on surgical senior house officer (SHO) operative experience. Ir J Med Sci 182(3):383–387
ORIGINAL SCIENTIFIC REPORT
‘‘Is General Surgery Still Relevant to the Subspecialised Trainee?’’ A 10 Year Comparison of General Versus Specialty Surgical Practice C. A. Fleming • Z. Khan • E. J. Andrews • G. J. Fulton • H. P. Redmond • M. A. Corrigan
Ó Socie´te´ Internationale de Chirurgie 2014
Abstract Background The splintering of general surgery into subspecialties in the past decade has brought into question the relevance of a continued emphasis on traditional general surgical training. With the majority of trainees now expressing a preference to subspecialise early, this study sought to identify if the requirement for proficiency in managing general surgical conditions has reduced over the past decade through comparison of general and specialty surgical admissions at a tertiary referral center. Methods A cross-sectional review of all surgical admissions at Cork University Hospital was performed at three individual time points: 2002, 2007 & 2012. Basic demographic details of both elective & emergency admissions were tabulated & analysed. Categorisation of admissions into specialty relevant or general surgery was made using International guidelines. Results 11,288 surgical admissions were recorded (2002:2773, 2007:3498 & 2012:5017), showing an increase of 81 % over the 10-year period. While growth in overall service provision was seen, the practice of general versus specialty relevant emergency surgery showed no statistically significant change in practice from 2002 to 2012 (p = 0.87). General surgery was mostly practiced in the emergency setting (84 % of all emergency admissions in 2012) with only 28 % elective admissions for general surgery. A reduction in length of stay was seen in both elective (3.62–2.58 bed days, p = 0.342) & emergency admissions (7.36–5.65, p = 0.026). Conclusions General surgical emergency work continues to constitute a major part of the specialists practice. These results emphasize the importance of general surgical training even for those trainees committed to sub-specialisation.
Introduction The splintering of general surgery into subspecialties in the past decade has questioned the relevance of a continued emphasis on traditional general surgical training [1]. Debate is ongoing regarding the requirement of trainees to undergo general training prior to specialisation. Since 2009, dramatic changes have gradually been implemented C. A. Fleming (&) Z. Khan E. J. Andrews G. J. Fulton H. P. Redmond M. A. Corrigan Department of General Surgery, Cork University Hospital, Cork, Ireland e-mail: [email protected]; [email protected]
to Irish Surgical Training, culminating in 2013 with the introduction of a new shorter, specialty-focused programme for general surgical trainees [2]. It is well established that sub-specialisation improves patient outcomes, but the practice of general surgery is still important due to service demand even in specialist tertiary referral centres [3–6]. In The United States, trainers have looked at ‘‘specialising’’ general emergency surgery into its own entity to maintain quality of service and meet service demands [7]. With the majority of higher surgical trainees now expressing an early preference to subspecialise, this study sought to question the current role of the general surgeon in providing general surgery compared to specialty service,
123
World J Surg
and question if this role has changed over the past 10 years with practice trends towards specialisation.
Materials and methods Patient selection, study setting and data collection A cross-sectional review of surgical admissions at Cork University Hospital was performed of three individual time points during the evolution of centralisation: 2002, 2007 and 2012. Overall number of surgical admissions and hospital length of stay (LOS) were used as measurement tools. Twenty-four hour emergency surgery cover is provided at our institute covering a catchment area of approximately 500,000 [8]. It is the largest University teaching hospital and the only Level 1 Trauma center in the Republic of Ireland. It is also a Regional Cancer Referral Centre. The Hospital Inpatient Enquiry (HIPE) database in our hospital was used to identify all surgical admissions during the above years. This database is a prospectively maintained medical record in operation in 61 Irish hospitals and is used by the Department of Health and Children to identify hospital case-mix and plan resource allocation and is supported as a data source for research purposes [9]. Disease conditions are coded in keeping with the ICD-10 guidelines, 2008, Version 8. Training of new coders and refresher courses for existing coders is conducted in-house initially and by the Economic and Social Research Institute (ESRI) on a monthly basis [9]. Training is held in the form of practical workshops; the aim of which is to support high quality and accurate data input. The database records admissions as elective or emergency. Emergency admissions are defined as all those admitted acutely through the emergency department. The HIPE database previously demonstrated to achieve significant fidelity in the capture of hospital admissions to approximately 86 % [10]. A variety of variables are recorded and for the purpose of this study the following were obtained: age, gender, date of admission and date of discharge, LOS, the admitting and discharging consultant, primary diagnosis (including other diagnoses recorded up to a maximum of four) and the primary procedure performed (including other procedures recorded up to a maximum of four).
Table 1 Guideline criteria for classification of procedures as specialty relevant Specialty
Guideline
Colorectal
ACGME minimum cases for Colon and Rectal Surgery [11]
Vascular
ABS SCORE Core Curriculum for Vascular Surgery Residents [12]
Breast
ISCP Surgical Curriculum Programme, p.26 [13]
Professorial unit Breast
ISCP Surgical Curriculum Programme, p.26 [13]
Endocrine
Cleveland clinic–Endocrine surgery [14]
Surgical oncology
Memorial Sloan Kettering, Guidelines on Surgical Oncology Fellowship Programme [15]
ACGME Accreditation Council for Graduate Medical Education ABS The American Board of Surgery ISCP Intercollegiate Surgical Curriculum Programme
categories created: colorectal, vascular, breast and professorial unit. The Professorial Unit of our Department provides a large Surgical Oncology Service which covers a wide spectrum of conditions such as breast disease, sarcoma, melanoma, endocrine disease as well as elective and emergency general surgery. It does not cover hepatobiliary surgery. Table 1 shows the guideline criteria used to classify admissions into specialty groups for each of the four subspecialties [11–15]. If a condition or procedure did not meet the above criteria then it was categorised as general surgery. Statistical analysis and ethical approval All data were tabulated and analysed using the statistical package IBM SPSS Version 22.0, August 2013. Descriptive analysis in the form of mean and confidence intervals (95 %) was performed on demographic information. Differences between general and specialty admissions were assessed using the student t test for continuous variables and the v2 test for categorical variables. Statistical significance was accepted as p \ 0.05. Ethical approval to perform this study was obtained from the Clinical Research and Ethics Committee (CREC) of the Cork Teaching Hospitals.
Definition of specialty-related procedure
Results
Based on data collected, classification into a general surgery or specialty relevant admission was carried out. There are five specialties practiced at our institute under the combined umbrella of general surgery including colorectal, vascular, breast and endocrine surgery and complex surgical oncology. For analysis, there were four specialty
Surgical admissions
123
In total, there were 11,288 surgical admissions in the study periods observed (2,773 in 2002, 3,498 in 2007 and 5,017 in 2012). This showed an increase of 26 and 43 % from 2002–2007 to 2007–2012, respectively, and an increase of
World J Surg Table 2 Overall admissions (including elective and emergency breakdown) and number of Consultant surgeons practicing in the general surgery department over the 10-year study period 2002
2007
2012
Growth
Total admissions
2773
3498
5017
81 %
Elective
1804
2170
2764
53.2 %
969 3
1328 5
2253 8
132.5 %* 166.7 %
Emergency Consultants
Fig. 2 Number of surgical admissions which were general surgical admissions overall, elective and emergency
Fig. 1 Comparison of general and specialty admissions as per all admissions to the general surgery department over the 10-year study period
81 % of total surgical admissions over the total 10-year period. The Central Statistics Office in Ireland reported a steady 7.6–7.8 % rate of population growth in the catchment area during this study period [16] and the number of consultants employed in the department increased from three in 2002 to five in 2007 to eight in 2012. Table 2, shows an outline of changing demographics in the surgical department and growth of service provision over the 10-year study period. General/specialty breakdown Figure 1 shows a breakdown of general and specialty surgery during each study period. General surgery comprised 57.6 % of admissions in 2002, 55.6 % in 2007 and 53.1 % in 2012. Thus, while service provision increased dramatically overall and sub-specialisation expanded, no statistically significant difference was seen in general surgery compared to specialty relevant admissions over the 10-year period (p = 0.967). Trends differed in elective and emergency general surgery admissions (Fig. 2). Emergency general surgery increased overall by 6.9 % but did not achieve statistical significance (p = 0.871). Expressed as a factor of overall admissions, as a representation of overall
departmental workload, general emergency admissions represented 37.7 % of workload in 2012, an increase of 10.7 % over the 10 years (27 % in 2002, 30.8 % in 2007). Conversely, elective surgical admissions decreased significantly by 19 % over the 10-year study period (p = 0.046). This may be explained by establishment of the Regional Cancer Referral Centre and expansion of specialised Vascular and Endovascular practice at our institute. It should also be noted that all cholecystectomies were classified as a general surgery procedure as the hepatobiliary service for our catchment area is provided at a different hospital. Length of stay Overall LOS for all patients admitted to the general surgical department reduced over the 10-year period, most notably over the past 5 years. Elective admission length of stay reduced from 3.62 bed nights in 2002 to 2.58 in 2012 (p = 0.342). Emergency LOS reduced also from 7.36 bed nights in 2002 to 5.65 in 2012 (p = 0.026) as seen in Table 3. Total bed days for specialty and general admissions were tabulated for the 3 years showing that 37.7 % of all hospital bed days were for general surgical admissions 2012, a figure that has increased (27 % in 2002 and 30.8 % in 2007). Specialty and procedural breakdown Table 3 highlights trends in general and specialty admissions within each general surgery subspecialty practiced at our institute. Notably, while overall general surgery admissions slightly reduced per subspecialty when interdepartmental breakdown is performed, it increased by 5.3 % over the 10-year period in the department of Vascular surgery, a technically sub-specialised department
123
World J Surg Table 3 Hospital LOS in days, comparison of trends over 10-year study period 2002
2007
2012
p Value
Overall
4.93
4.84
3.96
p = 0.126
(Range)
(1–170)
(1–271)
(1–196)
95 % CI
3.23–6.63
2.60–7.08
2.42–5.50
Emergency
7.36
7.11
5.65
(Range)
(1–170)
(1–271)
(1–196)
95 % CI
6.60–8.13
6.23–7.98
5.24–6.06
Elective (Range)
3.62 (1–83)
3.46 (1–95)
2.58 (1–79)
95 % CI
3.37–3.87
3.20–3.72
2.40–2.76
p = 0.026
p = 0.342
CI confidence interval
whom in many hospitals no longer participate in general emergency surgery rotas. Table 4 profiles procedures performed during surgical admission. Interestingly, as many as one fifth of all patients were managed non-operatively. As expected the number of angiograms performed increased significantly over the past 10 years from 1.4 % in 2002 to 2.6 % in 2012. Surprisingly, the number of specialty performed scopes greater than doubled over the 10-year study period (22.9–51.7 %). We can see from Table 5 the high incidence of general surgical procedures performed by each specialty. A list of the five most commonly performed procedures with specialty breakdown can also be seen in Table 5 (all procedures performed not just procedures relevant to each specialty). The ratio of general:specialty performed operations is largely unchanged from a 1:1 ratio over the past 10 years also, further supporting the clinical importance for proficiency in general surgery.
Discussion The practice of general surgery still comprises a large component of surgical workload in sub-specialized general surgery departments (53.1 % of all admissions in 2012 and 37.7 % of all bed days). Overall, as expected, growth in service provision was substantial in our institute over the 10-year study period due to centralization of emergency surgical services and establishment of the Cancer Regional Referral Center but this did not create a significant reduction in the practice of general surgery. Quantifying the practice of general surgery compared to specialty service provision has not been directly performed in previous studies, some have looked at the practice of general surgery as a specialty in the emergency setting alone in large specialist hospitals and the practice of specialist procedures in rural community hospitals in the US [7, 17]. Acknowledging service demands for general surgery provision, Intercollegiate general surgical curriculum guidelines in the UK state that all general surgeons with sub-specialised training still need proficiency in an array of general emergency procedures at the end of their training and prior to appointment to a Consultant post [13]. However, many trainees doubt their general surgery proficiency in the era of early sub-specialisation. With the American College of Surgeons undertaking changes to overall surgical training and encouraging early sub-specialisation, in 2012 as many as 38 % of general surgery residents in the US when questioned expressed a lack of confidence in their general surgical skills following a 5-year basic training program [18]. With implementation of the European Working Time Directive (EWTD), shorter working hours
Table 4 Trends in procedures performed over the 10-year study period, elective/emergency and general/specialty surgery breakdown (percentage of procedure performed as general or specialty) Overall
Elective
Emergency
Specialty
General
1704
1265
439
882 (51.8 %)
822 (48.2 %)
424
348
76
97 (22.9 %)
327 (77.1 %)
2002 Surgery Scope Angio Non-operative
39
35
4
39 (100 %)
0
605
155
450
156 (25.8 %)
449 (74.2 %)
2171 539
1583 434
588 105
1225 (56.4 %) 151 (28.0 %)
946 (43.6 %) 388 (72.0 %)
2007 Surgery Scope Angio Non-operative
72
45
27
72 (100 %)
0
714
107
607
109 (15.3 %)
606 (84.7 %)
2885
1944
941
1657 (57.4 %)
1228 (42.6 %)
2012 Surgery Scope
806
652
154
417 (51.7 %)
389 (48.3 %)
Angio
134
100
34
134 (100 %)
0
1169
64
1105
144 (12.3 %)
1025 (87.7 %)
Non-operative
123
Diagnostic laparoscopy
IGTN removal
Inguinal hernia repair
Incisional hernia repair
3
4
IGTN removal Pilonidal sinus excision
4 5
Inguinal hernia repair
Cholecystectomy
IGTN removal
Paraumbilical hernia repair
2
3
4
5
I&D perianal abscess
Strangulated hernia repair
I&D Abscess
Cholecystectomy
Appendicectomy
Diagnostic laparoscopy Cholecystectomy
I&D perianal abscess
Laparotomy–small bowel
Appendicectomy
Laparotomy–small bowel
Open AAA repair
Excisional biopsy
Arterial bypass
Endarterectomy
SFJ ligation carotid
Arterial bypass Carotid endarterectomy
Appendicectomy
Angiogram ± plasty
SFJ ligation
Angiogram ± plasty
Carotid endarterectomy
Arterial Bypass
Appendicectomy
SFJ Ligation
Vascular surgery
Seton/fissure repair
EUA rectum
Inguinal hernia repair
Cholecystectomy
Appendicectomy
EUA rectum Anterior resection
Inguinal hernia repair
Laparoscopic cholecystectomy
Appendicectomy
Anterior resection
EUA rectum
Appendicectomy
Inguinal hernia repair
Laparoscopic cholecystectomy
Colorectal surgery
a
Excisional biopsy of skin/superficial lesion
IGTN ingrown toenail, I&D incision and drainage, SFJ saphenofemoral junction, SLNBx sentinel lymph node biopsy
Excisional biopsya
1
2012
Laparoscopic cholecystectomy
Inguinal hernia repair
2
3
Excisional biopsya
1
2007
5
Laparotomy–large bowel
Cholecystectomy
2
I&D abscess
Excisional biopsya Appendicectomy
General surgery (emergency)
1
2002
General surgery (elective)
Regional node clearance
Mastectomy
Thyroidectomy Appendicectomy
Excisional biopsya
Breast WLE & SLNBx
Excisional biopsya
Mastectomy Parathyroidectomy
Thyroidectomy
Breast WLE & SLNBx
Excisional biopsya
Inguinal hernia repair
Mastectomy
Appendicectomy
Breast WLE
Excisional biopsya
Professorial unit
Mastectomy
Appendicectomy
Breast WLE & SLNBx
Component of professorial unit
Component of professorial unit
Breast surgery
Table 5 List of most commonly performed procedures in order of frequency with breakdown into each specialty (all procedures performed not just those relevant to specialty) and general surgery procedures with breakdown into elective and emergency
World J Surg
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World J Surg
and a reduction in clinical surgical practice and proficiency in surgery are further threatened [19]. Striking a balance in acquisition of surgical proficiency and regulation of working hours is a complex problem in the practice of modern surgery. Study limitations While great efforts were made in creating an acceptable study design, there were certain challenges that could not be overcome. Inter-departmental and National training and re-training is practiced to maintain high quality data input record as part of the HIPE data collection system, however, human error can occur. As this study was performed in a retrospective cross-sectional manner, the risk of this error is slightly increased. However, the high number of patients included and use of accepted International criteria for classification of general and specialty relevant cases lend to robust results. Certain super-specialised procedures did not have an identified HIPE code and were, therefore, coded as ‘‘miscellaneous’’. This difficulty was overcome in most relevant cases as the admission diagnosis was listed and guidelines not only outline specialty relevant procedures but also specialty relevant conditions. Full years were analysed in preference to monthly or quarterly assessments to remove seasonal bias. In conclusion, General surgical emergency work continues to constitute a major part of the specialists practice in a tertiary referral centre and is increasing. Therefore, general surgery is still relevant to the sub-specialised trainee. Will trends proceed like this or change with further sub-specialisation? In the words of Neils Bohr ‘‘it’s hard to make predictions, especially about the future’’. The results of this study clearly emphasize the current importance of general surgical training even for those trainees committed to sub-specialisation in current practice. Acknowledgments I would like to extend an acknowledgement to all staff in the HIPE department at Cork University Hospital for their time and contribution towards data sourcing for this study. I would also like to thank all the surgical staff at Cork University Hospital.
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