The Role and Rewards of a General Surgeon in Current Surgical Practice

General surgeons are doctors who specialise in surgical procedures.^[1] General surgeons have a broad knowledge of many varied diseases and conditions and so perform operations for a wide range of common ailments.^[2] The general surgeon is also looked upon as the leader of the surgical teams in a hospital. However, with the very rapid progress in science and medical technology, every body part has evolved into complex and more specific solutions for that organ-related pathology. A general surgeon is not able to keep up with all such changes. Into this fit now comes the ‘super-specialist,’ who has spent time and got the needed training for expertise in that specific field.

A common topic of conversation in surgical circles is the ever-rapidly declining role of the ‘general surgeon’ and the practice of ‘general surgery.’ The rapid rise of specialisation has removed many surgical conditions from the domain of general surgeons. Organ-specific and age-specific surgical specialization (like neurosurgery, cardiothoracic surgery, plastic surgery, urology, and paediatric surgery) did not affect the general surgeon. But it is subspecialising within the scope of general surgery that has severely restricted the range of their work. The rise of the head and neck surgeons, GI surgeons (further subdivided into upper GI specialists, hepato-biliary pancreatic specialists, and colorectal specialists), urologists, and surgical oncologists has taken away much of what was mostly the routine work of the general surgeon just a few decades ago. But all is not lost for the general surgeon. They still have the scope and range to be a very successful and much-needed cog within the healthcare systems. Listed below and briefly described are the roles the general surgeon has to fulfill in the present-day context.

1. The ‘first stop’ Surgeon. With subspecialisation, while one acquires in-depth knowledge and skill on ‘less and less,’ there grows a fence around that specialisation, and the overall big picture of the patient is lost. It is here that the general surgeon steps in. They are much better equipped to see the patient as a whole and offer treatment for a variety of conditions. They also pick leads that may warrant the referral to the specialist surgeon. When such a referral pattern is established, it not only gives the general surgeon a vital role in health care but also reduces the burden of the specialist having to see every case that comes their way. It is thanks to the information technology explosion that everyone feels informed and decides to go directly to the specialist and take away their vital time with ‘minor issues’ that could have been covered by the general surgeon. So, all is not lost for the general surgeon. He/she continues to be the tree from which all branches of surgery take their origin. Also, general surgeons are the first encounter for all those who opt for surgical work as a career. And there are many pointers to the very strong and significant role that general surgery still occupies in the world of surgery.

2. The ‘Benign’ Surgeon: There still exists an ocean of benign surgical conditions which need removal/correction. Such surgical interventions return quality of life, and the patients live long and are always grateful for this. This brings huge accolades of success as the years pass by. Timely intervention for the acute abdomen, relief from gallstone disease, proper and safe repair of abdominal and groin hernias, along external genital pathology in the male all form a large group of patients that will keep the general surgeon busy. Today, updated skills in minimally invasive surgery are an absolute sine qua non in the armamentarium of every general surgeon. So too, the graduation into robotic surgery is easily accomplished by the general surgeon.

3. The ‘Surface’ Surgeon: Visible lumps and bumps abound all over the body and need surgical attention. Cutaneous presentation of sepsis-like carbuncles, perianal abscesses, and necrotising fasciitis needs early and correct drainage, with or without debridement. Wound care and subsequent skin cover by split skin grafts can be done. The general surgeon also does surgery for salivary gland tumours, thyroid nodules, and benign breast disease. Fistulas, fissures in ano, and haemorrhoids form over 30% of patients in clinical distress, needing early surgical assessment and intervention. Into this group come many surgical conditions of the limbs, like varicose veins, and the need for limb conservation or amputation for conditions of dead, deadly, and deformed peripheral tissues.

4. The ‘Trauma’ Surgeon: The general surgeon is the first surgical help at the emergency stations across health care. Proper triage and assessment are paramount to restricting the casualties of accidents or natural disasters that arrive at emergency services. Fundamentals of trauma interventions (aside neurosurgical) give the general surgeon and his team the responsibility of life-saving interventions, like the intercostal chest drain, focused abdominal ultrasound for trauma (FAST), control of peripheral haemorrhage, and the abbreviated laparotomy. The stabilised patient now goes through the secondary survey, cross-sectional imaging as indicated, and then appropriate referral to surgical specialists.

5. The ‘Emergency’ Surgeon: This is actually a role that encompasses all three aspects described above. It is being used as an additional description to fulfil the role of being available on-call 24/7 on a fixed rota basis. It involves the time and effort spent outside the regular working hours and often across the whole night, saving lives with timely and specific surgical procedures.

6. The ‘Versatile’ Surgeon: A general surgeon’s work involves a broad range of conditions affecting various areas of the body. It’s an incredibly versatile speciality that offers training in many conditions and types of procedures, including endoscopic procedures and video-assisted surgery. For many young doctors, general surgery is a stepping stone to numerous different surgical career paths.

7. The ‘Fundamental’ Surgeon: The general surgeon qualifies to occupy positions in the National Health Services as being that of the basic level of entry into the system of organised health care delivery. This could be the ‘Uniformed’ surgeon, who is a general surgeon that can pursue a military-related career through different branches of the uniformed services—the Air Force, the Navy, or the Army—as a commission in the military service. The other big opening is in the governmental institutions and medical colleges, where there is a big pool of patient flow to cater to, besides the added advantage of teaching and the potential for research and scientific study. The benefits of both these general surgical career options include an assured patient load without having to incur the cost of infrastructure, equipment, and supplies and, importantly, in today’s world, malpractice insurance premiums.

8. The Teaching (Academic) Surgeon: To the young medico with a surgical interest, the general surgeon is his/her first direct surgical interaction and involvement. This is akin to the nursery school teacher, who initiates the young ones into the path of learning and the acquisition of life skills. In much of the similar vein, the general surgeon has a role at the start of every surgical career. Basic surgical skills and basic minimally invasive principles and practice are taught by the general surgeon. Becoming a surgeon is not just about surgical skills and surgical anatomy but also needs a very good understanding of surgical physiology and surgical pathology. All these are learnt under the tutelage of the general surgeon. The emphasis on surgical aseptic routines and operation theatre discipline is also acquired from the general surgeon. The importance of clinical surgical examination and the use/interpretations of laboratory and imaging information, to arrive at the clinical diagnosis is built into the routine of the young general surgeon by his general surgical mentor. The clinical ‘rounds’ of all inpatients are the bed of surgical wealth, for it is what happens on these rounds that helps the growth of young surgeons. The challenge of the complicated case, the management of surgical complications, and the handling of the abusive patient or relatives by the general surgeon are stepping stones into the future of surgical life. The soft skills meant to make the surgeon acceptable to his patients, like communication skills, empathy, and surgical integrity, are honed at this juncture of the young surgical career. If the general surgeon is made redundant by specialization, we are removing the very foundation of the surgical career, resulting in what society will view the future specialized surgeons as ‘surgeons of poor competence.’ After all, surgical excellence is not just technical competence but is a combination of technical ability and properly acquired life skills. It is all about treating every patient as a ‘whole’ and not just an organ/system-specific disorder. Finally, the general surgeon is the person to instill the ‘reading habit’ into the younger colleagues. All medical and surgical fields are swept by frequent change and enhancement. One must keep abreast of times and so one needs that daily input of self-learning from standard journals and literature reviews. Finally, the qualities of leadership are first experienced by the general surgeon, who is in charge of the surgical team that includes an anesthesiologist, nurses, and surgical technicians. The buck stops with the lead general surgeon, and all surgical decisions will be on their shoulders.

A common misconception appears to be that a general surgeon is a ‘lesser surgeon’ than a ‘specialist surgeon.’ This is not correct. A general surgeon has training in a broad range of surgical procedures, while a specialist surgeon has the necessary training and expertise in a very specific area of surgery. The increasing trend towards post-residency surgical subspecialisation has been blamed for ‘intensifying the shortage of general surgeons’ and is projected to ‘lead to further shortfall in general surgical services.’^[3]

Having now described the very useful and vital role of the general surgeon, what are the reasons for the specialist surgeon’s discomfort? This is very simply explained by there being a large ‘grey area’ of what should be their total domain and what could be the degree to which the general surgeon can offer service. It is here that the administrators and senior leaders need to develop guidelines to ensure a fair distribution of surgical work between the specialists and the general surgeon.

General surgeons deliver robust surgical care electively and in emergencies. This is in the true spirit of ‘Vayam Sevaamahe – We are for service,’ the motto of the Association of Surgeons of India.^[4]