January 10, 2024
For 2023, RAS members weighed in on the benefits and drawbacks of early specialization and debated the potential impact on trainees, training programs, and surgical patients.
The three winning essays were presented during the RAS Symposium at Clinical Congress 2023 in Boston, Massachusetts. The session is available, to registrants, in the Clinical Congress online platform.
Two honorable mention essays, for and against early specialization, follow.
Dr. David Blitzer
David Blitzer, MD
Once upon a time, all surgeons were also barbers. Surgical training was, by definition, nonexistent. Barber surgeons were not medically trained nor were they considered medical professionals; the procedures they performed consisted of bloodletting, abscess lancing, and amputations on top of their usual responsibilities of cutting hair and nails. We should not forget this when we consider the fantasy of the general surgeon, which is actually a relatively recent construct in the medical professions.
William S. Halstead, MD, FACS, is widely considered the father of American surgery; he helped establish the residency model that we continue to use to this day. He even promoted the concept of specialization, with some of his trainees going on to become forerunners in their own surgical subspecialties, including neurosurgery and urology. With this historical framework, it becomes more evident that the trend toward increasing and earlier specialization among surgeons and surgical trainees is not a new phenomenon but rather the continuation of an ongoing process that has been underway since the dawn of surgical practice.
In the standard flow of academic presentations, this is the point at which a presenter would declare their conflicts of interest. Therefore, for the sake of full disclosure, I will state that I am currently a trainee in an integrated cardiothoracic surgery program. My opinion on this issue is largely influenced by my own positive experiences as a trainee.
The advantages of integrated programs are well-known. A training pathway that offers a targeted clinical experience is the first such advantage. In a world where procedures have become increasingly complex, the idea of gaining comfort within a diverse specialty such as cardiothoracic or vascular surgery after a traditional 2-year fellowship seems increasingly fantastical in itself.
Changes in the practice of general surgery also make the experience in general surgery training less applicable to other surgical subspecialties. While there is certainly some overlap, the widespread adoption of minimally invasive techniques in general surgery means that the training in a general surgery program offers diminishing relevance to the budding cardiothoracic or vascular surgeon.
On top of the increased exposure to a specific desired field, integrated pathways offer the opportunity to reduce training time overall. This is an important consideration for trainees navigating an increasingly complex healthcare system and doing so in the prime years of their lives in terms of starting both careers and families.
Widespread adoption of integrated training pathways also could play a role in mitigating a surgical workforce shortage. Not only could the number of graduates from surgical training programs increase, but the number of applicants to such programs would likely increase, as has been the case with the rapid expansion of integrated cardiothoracic surgery programs.
A reduction in total training time could serve as a major pipeline for increasing the surgical workforce and possibly even help reduce gender and racial disparity in the surgical workforce at the same time. Furthermore, an accelerated training timeline also offers an earlier path toward independent practice, which could play a major role in mitigating the pandemic of burnout afflicting the surgical workforce.
What, then, are the potential disadvantages of the widespread adoption of integrated programs? Clearly, general surgeons are still a necessary part of the surgical workforce, and some would argue that increasing specialization will lead to a decrease in access to general surgeons, particularly in the rural setting.
Frankly, this argument seems to put the cart before the horse.
Smaller and more rural hospitals are closing because of market forces and the corporatization of healthcare. There is no question that this is an incredibly important issue, but there isn’t a number of qualified general surgeons that will mitigate it. This issue needs to be resolved in the halls of the state and federal capitols.
Next, it would clearly be unreasonable to expect every medical student with an interest in surgery narrow their focus so early in their training. Quality general surgery training programs will always be needed to train anyone looking to pursue a career in general surgery without any further specialization. Furthermore, while general surgery experience is not always transferable to other surgical specialties, there are certainly a number of specialties where general surgery experience is critical.
The proliferation of integrated pathways may actually improve the training for many of these individuals. With fewer trainees in general surgery programs, those remaining could benefit from a more concentrated experience, which also minimizes the need for many of the nonaccredited fellowship pathways that are now so prevalent.
For others, greater adoption of hybrid pathways, such as the 4+3 programs in cardiothoracic surgery may be relevant. In this pathway, trainees do 4 years of general surgery training and then progress into a 3-year cardiothoracic training program. Such a hybrid process readily could be applied to other surgical specialties and offer some of the advantages of both the integrated and traditional training pathways.
Ultimately, we know that the arc of the surgical universe bends toward specialization and that integrated training pathways are more likely to proliferate than not. I firmly believe that this process is ultimately to the benefit of surgical trainees and to the field of surgery as a whole, and I hope this brief argument has convinced you, dear reader, to think likewise.
Dr. David Blitzer is a cardiothoracic surgery resident at NewYork-Presbyterian/Columbia University Irving Medical Center in New York.
Dr. Madhuri Nagaraj
Madhuri Nagaraj, MD, MS
Distinguishable by their scrub caps, confident demeanors, and dexterity with tools, the species known as “general surgeons” are critically endangered today. Threats of early specialization and integrated training accelerate habitat destruction of this beloved creature.
In 1995, the American Board of Plastic Surgery first recognized a 6-year integrated plastic surgery training model.1 Vascular surgery followed suit in 2006, with the “certificate in vascular surgery” from the American Board of Surgery.2 And cardiothoracic surgery in 2013, recognized the first integrated 6-year (I-6) graduates.3
These hard-fought battles for recognition aimed to prove the benefits of early and focused subspecialty training, reduce training time, and accelerate the supply of surgeons. However, in this essay, I aim to prove that these rationales oversell the benefits of integrated training models. Rather, the negative implications of making early specialization the default training model scale local to global—with the lack of training structure and oversight, the trainee selection bias, and the death of the general surgeon as we know it.
As opposed to independent trainees who present with experience and maturity, trainees who join an integrated surgical model are just out of medical school. This raw potential requires both appropriate mentorship and curricular structure to thrive. And yet despite having existed for nearly 2 decades with an emphasis on “focused” training, a major disadvantage of integrated training programs remains the lack of curriculum structure and faculty preparation.3
Despite residents finding critical care training the most helpful, integrated cardiothoracic surgery residents spend a variable amount of time (ranging 0–42 weeks) with this experience.4 This variability carries over to exposure of general surgery subspecialties, adjunct fields of importance (i.e., cardiology, catheterization, perfusion), and dedicated research time. The dramatic lack of standardization was reflected in an analysis of plastic surgery curricula, as well as by concerns expressed by 58% of integrated vascular surgery program directors.5,6 Given the diminishing exposure to open principles in vascular surgery training, these inconsistencies in training can produce highly variable products.7
A more alarming aspect is the lack of faculty preparedness “to teach junior residents” as demonstrated by cardiothoracic surgery trainee perceptions.8 This lack of faculty buy-in is bolstered by 45% of cardiothoracic faculty after 10 years of exposure to the integrated model still preferring the traditional pathway.9,10
As of recent National Resident Matching Program data, integrated fellowships such as plastics, cardiothoracic, and vascular rank as some of the most competitive fields. Smood and colleagues recommend that those interested in applying for cardiothoracic integrated programs have US Medical Licensing Examination Step scores greater than 230, have nine work and volunteer experiences, and 10.5 publications, with ambitious research goals.11
Those who argue that integrated positions decrease training time do not recognize that 59% of medical students going into competitive specialties took research time, of whom, 32% intended it to increase their application competitiveness.12 This competitiveness, however, allows for selection bias and the development of a cookie-cutter resident.
Data from 2015 demonstrate that, with time, the proportion of White integrated trainees has increased; conversely those of women, Black, and Hispanic trainees remain disproportionately lower than the medical school demographic.13-16 Furthermore, 2023 data show that despite all integrated residencies increasing the number of offered positions, the MD match rate grossly outbalanced the DO match rate (43%–82% vs. 0%–23.5%, respectively).17
Many medical schools lack these highly specialized departments, thus inadvertently limiting the early access and exposure to research and mentors required of an integrated applicant.1 These systems clearly select against many diverse and potentially brilliant trainees and should not represent the sole opportunity of the future.18
Finally, it is well established that there is a critical shortage of general surgeons that continues to widen as the population ages.19 Nearly half of the most frequently performed operations nationally fall under the purview of general surgeons, including herniorrhaphies, appendectomies, cholecystectomies, breast biopsies, wound debridement, endoscopies, hemorrhoidectomies, and skin procedures.
It is well known that the first years of practice comprise building clientele and taking the “bread-and-butter” cases. Indeed, a study of community vascular surgeons found that 10% reported covering general surgery in their practice, 17% felt that covering general surgery was important for a potential hire, and a significantly higher proportion felt independent graduates were more mature and technically capable.20 And yet, the early introduction of specialty training necessitates a loss of training in general surgery.
Data demonstrate that integrated residents are far more likely to pursue academic medicine careers and thereby concentrate themselves in urban settings.19 This not only directly widens the urban-rural divide in access to specialty care but also indirectly widens the gap in general surgery care. In the US, general surgeons perform 50% of thoracic surgery procedures.21 It is simple mathematics that specialty cases logged by integrated residents necessitates a subtraction in the order of hundreds for the training general surgeon.22
I went into general surgery for one main reason. When I was enjoying the breadth of medicine too much that I could not decide a residency, a surgeon mentor said to me “a good surgeon is a good doctor with an extra skillset.” There is no default surgeon; therefore, we should not create a default training paradigm.
It is important to provide all trainees, regardless of background, access, and education, with every opportunity to maximize their potential. And while early specialization and integrated pathways have their place, making these pathways the default of training will cause ramifications that will affect the survival of surgeons and their patients for generations to come.
Dr. Madhuri Nagaraj is a general surgery resident at The University of Texas Southwestern Medical Center in Dallas.