LEARNING AND MASTERY OF GENERAL SURGERY

REYNALDO O. JOSON, MD, DPBS

To learn and master general surgery, one should first know

what general surgery is all about. So, what is general surgery?

Historically, general surgery is surgery in general. It

encompasses all types of surgical procedures and all the surgical

subspecialties that are presently in existence. These include

obstetrics and gynecology, ophthalmology, otorhinolaryngology,

and orthopedic surgery.

This definition of general surgery is, however, already a

definition of the past. In this present stage of

subspecialization, general surgery nowadays is what is left of

general surgery of yesteryears after the secession and

declaration of independence of various surgical subspecialties.

Obstetrics and gynecology, anesthesia, ophthalmology,

otorhinolaryngology, and orthopedics, which were formerly part of

general surgery, are now distinct, independent departments that

stand side by side with the department of surgery. Neurosurgery,

urology, pediatric surgery, plastic and reconstructive surgery,

and thoracic and cardiovascular surgery, which were formerly part

of general surgery, are now distinct subspecialties that stand

side by side with general surgery.

Nowadays, what are left of general surgery are head and neck

surgery, breast surgery, abdominal surgery, and skin and soft

tissue surgery. Despite the secession of so many subspecialties,

general surgery has unrealistically maintained its name of

"general surgery."

The present general surgery residency training program

consists primarily of training in head and neck surgery, breast

surgery, abdominal surgery, and skin and soft tissue surgery with

exposure to cardiovascular and thoracic surgery; neurosurgery;

plastic and reconstructive surgery; pediatric surgery; urologic

surgery; and orthopedic surgery. This program is good because it

promotes a well-rounded surgeon. However, it is important to

emphasize that after graduation, a general surgeon who is a

graduate of a general surgery program, is usually limited to the

practice of head and neck, breast, abdominal, and skin and soft

tissue surgery. He may perform other types of surgery that were

part of his training. However, he can only do so if there are no

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subspecialists in his area of practice to perform such

operations. Thus, a general surgeon, although he is a graduate

of a general surgery program, is not anymore a general surgeon in

the strictest sense of the phrase who can perform all sorts of

surgical procedures.

To be certified by the Philippine Board of Surgery, a

graduate of a general surgery residency program has to pass the

examinations given by the Board. The content of the examinations

consists of head and neck surgery; breast surgery; abdominal

surgery; skin and soft tissue surgery; neurosurgery; urologic

surgery; pediatric surgery; thoracic and cardiovascular surgery;

plastic and reconstructive surgery; and orthopedic surgery.

Again, even after passing the examinations and after being

certified by the Philippine Board of Surgery, a full-pledged

general surgeon is still limited to the practice of head and neck

surgery, breast surgery, abdominal surgery, and skin and soft

tissue surgery.

That, in essence, is the realistic picture of what general

surgery of today is all about, in terms of scope of training,

examination, and practice after graduation.

Knowing these realistic situations, a general surgeon to be

may now decide what to learn and to master and what to put

emphasis on. Knowing what to study and what one wants to study

constitute the first step in the learning and mastery of general

surgery.

The second step is to have a commitment and a resolve to

learn and master general surgery. It is important to emphasize

here that learning and mastering general surgery is a long,

continuous, and even a lifetime process, and not just an

overnight thing.

The third step is to know the various ways of learning and

mastering general surgery and to appreciate their importance.

The last step is to start the learning and mastering process

and once started, to keep it up and maintain it until death or

unwanted disability forces one to stop.

There are so many ways in the learning and mastery of

general surgery that it is impossible to put up a complete list.

The usual ways that every student of medicine is familiar with,

however, are listed below:

1. Reading

2. Classroom learning

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3. Wet clinics

4. Hands-on learning

5. Presenting in medical conferences

6. Research and paper writing

7. Teaching

The first four ways are easy to understand and need no

further explanation. Presenting in medical conferences and

teaching entail reading, writing, and lots of preparations. In

so doing, the presentor and the teacher learn and master the

subject matter of their presentation. Doing research and writing

also promote learning and mastery of general surgery. In fact,

they are the most extensive and intensive ways of learning and

mastering general surgery.

Whatever the method of learning employed, the ultimate goal

should be the attainment of both evaluation and operative skills.

Evaluation and operative skills are the most important and most

fundamental skills that every surgeon must possess. Without the

two of them, no physician can rightfully be called a surgeon,

more so a competent surgeon.

Evaluation skills include skills in evaluating situations

for a diagnosis, for selection of treatment, and for a plan of

action. Evaluation skills are needed for surgical decision-

making. The basic requirements for evaluation skills are

knowledge, data, interpretation of data, and experience.

Knowledge includes general medical knowledge with special

emphasis on anatomy, pathophysiology, and surgery. Data means

gathering of complete and accurate data for logical and accurate

interpretation. Experience is likewise needed as part of the

training for evaluation skills.

Operative skills include knowledge of all possible operative

procedures that may be performed, their indications, their actual

performance, and their possible complications. Operative

procedures must be done skillfully to avoid postoperative

complications.

Below are some other tips and advices in the learning and

mastery of general surgery:

1. Consider every patient that one encounters as a

learning case or experience. Study the patient

from admission to discharge and if possible, even

after discharge from the hospital. Study the

chart. Study the operative procedure, the

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preoperative and postoperative course. Analyze

each case thoroughly and in detail.

2. Keep a record of all cases seen and experienced. If

possible, make a diary of these cases. If possible

also, keep a photographic record of all interesting

cases.

3. To learn operative skills, start off by mastering

the elemental skills of an operation. Read on the

techniques of a particular operative procedure

beforehand. Watch the actual performance of the

said operative procedure. Learn and master the

procedure, first mentally then with actual

performance.

4. When assisting, do not just watch what the surgeon

is doing. Do more than assisting and watching.

Analyze every move of the surgeon, its indication,

its quality of performance, and its result.

Maximize the learning experience in every case

assisted in the operating room.

5. To learn decision-making, start off by analyzing

all cases seen but handled by somebody else. Make

a critique of the decision-making aspect of the

case. After managing a case, make an introspection

or a self-audit of the decision-making done. Learn

from the experience.

6. Read and review whenever possible and whenever

necessary. Read and review anatomy and technique

of a surgical procedure before operating or before

assisting in an operation. Read to look for

answers to any questions, such as those encountered

in a patient and in preparation for a medical

conference.

7. Be inquisitive, be analytical, and be critical.

Ask, consult, and discuss.

8. Strive to be a master of general surgery through

whatever learning methods.

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