Graduate education in general surgery and its related specialties and subspecialties in the United States

Each year, approximately 1,000 graduating medical students enter training in general surgery and its related specialties and subspecialties in the United States. Traditionally, residents who want to practice vascular surgery, plastic surgery, thoracic surgery, and other specialties and subspecialties derived from general surgery have been required to complete five years of training in general surgery before embarking on further training. However, three phenomena have recently emerged that are changing the picture of surgical training: (1) proliferation of fellowships in subspecialties of general surgery, (2) increasing desire of subspecialties of general surgery for recognition as specialties in their own right, and (3) pressure to reduce or eliminate the traditional general surgery training required before specialization or subspecialization. In the meantime, and perhaps as a consequence of these changes, traditional general surgery has become less attractive as a specialty and there has been significant concern about the quality of training in general surgery. As a result of fewer trainees electing general surgery as a career, there is now increasing evidence of a shortage of surgeons who are able to handle a reasonably broad caseload of emergency care in general surgery and trauma. Many of these issues are currently being addressed by the profession. Among the initiatives underway are developing a standardized curriculum in general surgery, appropriately apportioning operative experience between residency and fellowship, considering alternative pathways for training in subspecialties, and developing a system for oversight of advanced surgical training fellowships. The system for governance of graduate surgical education in the United States is less centralized than in other countries. One initiative that has been undertaken to improve coordination of efforts between educational and regulatory bodies is the formation of the Surgical Council on Resident Education (SCORE), a voluntary consortium of six organizations with the mission of defining a national curriculum for general surgery residency and with the goal of facilitating collaboration on educational issues involving general surgery and its related specialties and subspecialties.