title: Sub-specialization in general surgery: the problem of providing a safe emergency general surgical service.
abstract: BACKGROUND
  The increasing subspecialization of general surgeons in their elective work may result in deskilling and create problems in providing expert care for emergency cases. To evaluate the size of the problem this study determined how often complex emergency surgical cases are treated by general surgeons working outside their own elective subspecialty.
  
  
  METHODS
  In a district general hospital in the south of the UK serving a population of 550 000 where there is almost complete subspecialization within general surgery, 1554 patients having emergency general surgical operations were studied in a one-year review. The time an operation occurred, the seniority of the operating surgeon, the subspecialty interest of the consultant responsible for the case compared with the specialist nature of the operation was determined.
  
  
  RESULTS
  Of 1554 patients having emergency general surgical operations, 23% (352/1554) were of a high category of complexity. Ninety were vascular procedures and were dealt with by specialist vascular surgeons on a separate rota. Of the remaining 262 operations, 78 (30%) did not match the subspecialty of the consultant surgeon responsible for their care; 56 (72%) of these occurred out of hours of which 14 (18%) had a consultant surgeon present and scrubbed in the theatre; one per month of the study. Seventy-three percent (57/78) of these were complex colorectal operations.
  
  
  CONCLUSIONS
  The mismatch between the subspecialist elective interests of the consultant general surgeon and out of hours specialist major surgery needing consultant involvement occurred infrequently, and was mainly due to major lower gastrointestinal cases managed by upper gastrointestinal and breast surgeons. This has important implications for the future training of general surgeons and the provision of an emergency nonvascular general surgical service.
authors.affiliation: Department of Surgery, Queen Alexandra Hospital, Portsmouth, UK.
authors.forename: J P
authors.initials: JP
authors.lastname: Garner
authors.forename: D
authors.initials: D
authors.lastname: Prytherch
authors.forename: A
authors.initials: A
authors.lastname: Senapati
authors.forename: D
authors.initials: D
authors.lastname: O'Leary
authors.forename: M R
authors.initials: MR
authors.lastname: Thompson
mesh_terms: D004636:Emergency Service, Hospital / Q000706:statistics & numerical data*; D006767:Hospitals, District; D006769:Hospitals, General; D006801:Humans; D012017:Referral and Consultation / Q000706:statistics & numerical data; D012189:Retrospective Studies; D013043:Specialties, Surgical / Q000706:statistics & numerical data*; D013514:Surgical Procedures, Operative / Q000706:statistics & numerical data*; D006113:United Kingdom; D016526:Workload / Q000706:statistics & numerical data