Early Specialization in Surgery: The New Frontier

Over the past 40 years, the scope and spectrum of surgical training has changed dramatically. Advances in technology, the spectrum and complexity of disease, the environment of less independence and, more recently, duty hour work restrictions [1,2] all have affected the “final product” of the general surgery graduate. This along with changing healthcare economics, the public demand of specialization, and various initiatives in reporting of quality have affected the fate of the general surgeon. Progressive specialization [3] has evolved due to the complex environment of change in both medical education and the healthcare system. The purpose of specialization training after completion of a general surgery residency is to provide a focused, intensive educational experience in a recognized subspecialty area that may result in increased reimbursement from improved market share, improved lifestyle, ability to obtain hospital credentialing, and job security [3,4]. Fellowship training is also likely to result in improved clinical and economic outcomes. In certain subspecialties such as cardiothoracic, plastic, and pediatric surgery, formal fellowship training is mandated to meet credentialing criteria. Furthermore, many graduating general surgical residents do not feel “comfortable and competent” performing select general surgery cases such as esophagectomy, parathyroidectomy, hepatectomy, pancreatectomy, rectal resection, advanced minimally invasive procedures, and complex vascular procedures without additional training in either accredited or non-accredited fellowships. Specialization training is here to stay and now is becoming even more evident with the advent of early specialization or “tracked” training immediately in general thoracic and vascular surgery following medical school graduation [5,6]. Motivations to select specific subspecialty fellowship also remain poorly defined. The intellectual appeal of a certain field, having an influential mentor, and one’s perceived clinical opportunities all weigh in when selecting a field of specialization [4]. However, it cannot be underestimated that reimbursement, the ability to