Following the completion of surgical training in the UK, a new consultant is expected to be emergency-safe and competent in dealing with a given specialty’s standard, day-to-day workload. They will then, in many cases, undertake fellowship training in a sub-specialist area.
It is logical that if a surgeon focuses on a given sub-specialist area and deals with a higher volume of certain cases, they will perform better and achieve better outcomes. Indeed, there is ample evidence to support this assertion. As a consequence, across all surgical specialties, there is a justifiable trend towards sub-specialisation. Rarer pathologies are being funnelled towards a smaller number of centres, expertise is being centralised, and often outcomes are demonstrably improving. Being able to show evidence of a satisfactory annual case volume for a given operation is already necessary in certain fields. In an ever more litigious world, this is likely to become ubiquitous.
But how far should this go? Whilst there is an undeniable benefit for the sub-specialist service, broader knowledge and skills inevitably attenuate. In large cities with large, well-resourced hospitals that employ many surgeons and allied health professionals, there is capacity to run high volume and high-quality sub-specialist rotas in parallel. But the world is not made up only of large metropolises. One might argue that sub-specialisation could have a detrimental effect in more remote and rural areas, where having a broader knowledge and skills base is essential. Indeed, the broad skillset required for remote and rural surgery is resulting in this becoming a sub-specialty in itself.
It is encouraging to see the Royal College of Surgeons of Edinburgh proposing a novel model to optimise care in both contexts. With careers lengthening, there is growing demand amongst some of the most experienced surgeons to seek more flexible ways of working. The Scottish Clinical Collaborative recognises this and aims to set up a network of experienced clinicians (initially surgeons) who take on short-term work supporting rural general hospitals. This appears an excellent way to exchange knowledge, enhance care, and maintain enthusiasm amongst the workforce.
Clinical Lecturer in Neurosurgery, University of Edinburgh