› General Surgery
An Acute Issue A LACK OF GENERAL SURGERY SPECIALISTS IS AT THE ROOT OF A POTENTIAL CRISIS IN THE ON-CALL SYSTEM FOR ACUTE SURGICAL CARE. PROFESSOR PAUL RIDGWAY FRCSI EXPLAINS HOW ASAUs ARE PART OF THE SOLUTION
The trend in Ireland and Europe towards sub-specialism means that most surgeons now identify themselves by their sub-specialty interest rather than as General Surgeons. But the reality is that General Surgery accounts for the majority of acute surgical admissions across Ireland every day, with most patients operated on by surgical on-call teams doing emergency work on top of their elective work, a system that leads to delays and inefficiencies in emergency care and has a knock-on impact on elective procedures. “As surgery pathways have become more complex,” explains Professor Paul Ridgway FRCSI, National Clinical Advisor in General Surgery to the National Clinical Programme for Surgery (NCPS), “surgeons have learned more, yet with a smaller focus. As this referral base has become narrower and narrower, it has led to a lack of generalists. For most of us, the only time we are true General Surgeons is when we are on call for emergencies. In pure numbers terms, most of us see more acute patients than we do elective as these represent the majority of patients under General Surgical Care. We have to balance those two pulls. As General Surgery is a large specialty, accounting for such a large proportion of acute surgical admissions, we need to encourage more surgical trainees to take up General Surgery as their specialty.” 22
Professor Ridgway believes that the current national on-call system for acute surgical care will soon come under even more negative workforce pressures than currently exist, thanks to a perfect storm currently brewing. “There is an ageing workforce doing significant night-time emergency work, and there are sub-specialty (e.g. Breast and Paediatric Surgery) trainees who won’t have the elective volume of abdominal surgery to allow them to be emergency-safe on-call when they reach consultancy. The reality is that a new breast surgeon may feel very uncomfortable with the generality of the work required when on call. And finally there is the increasing importance of work/ life balance which limits the attractiveness of consultant posts involving smaller on-call rotas. The desire for better balance is undoubtedly reasonable, but does add to the recruitment challenge.” Professor Ridgway advocates a two-pronged approach to solving the problem before it becomes a crisis. The first is to make on-call rotas bigger. “A one in twelve rota is very manageable,” he says, “but in a lot of Model 3 hospitals currently it might be one in three or four, which is very onerous. We have to build bigger rotas to accommodate bigger numbers. We know that Trainees are not coming home from fellowships from abroad, or only coming back to specific jobs because many of the open jobs are not attractive to them.
