Surgical Specialties Stemming from General Surgery
General surgery serves as the parent specialty from which multiple surgical subspecialties have historically evolved and separated, including vascular surgery, plastic surgery, thoracic surgery, cardiothoracic surgery, pediatric surgery, and others that traditionally required completion of general surgery training before subspecialization. 1, 2
Historical Evolution and Current Structure
General surgery has been progressively redefined through the identification and separation of subspecialties over the past century, with specialization becoming a major trend following World War I 1, 3. The specialty has evolved into both a parent discipline and a subspecialty in its own right—maintaining responsibility for general disease states (trauma, critical care, nutrition, transplantation, oncology) while focusing specifically on gastrointestinal surgery 1, 4.
Traditional Subspecialties Derived from General Surgery
The following specialties historically required five years of general surgery training before subspecialization 2:
Vascular surgery - Now recognized as a separate specialty with its own integrated training pathway, though exposure to vascular surgery during general surgery training remains important for managing emergency vascular cases 5, 2
Plastic surgery - Developed as an integrated program separate from the traditional general surgery pathway 2, 6
Thoracic surgery and cardiothoracic surgery - Board-certified cardiothoracic surgeons who practice primarily thoracic surgery represent a distinct specialty, with approximately 25% of pulmonary resections in the US performed by these specialists versus 30% by general surgeons 5
Pediatric surgery - Requires completion of 5 years of general surgery residency plus 2 years of pediatric surgery fellowship, with certification by the American Board of Surgery 7
Current Training Paradigm Shifts
Three significant phenomena are reshaping the relationship between general surgery and its subspecialties 2:
- Proliferation of fellowships in subspecialties of general surgery
- Increasing desire of subspecialties for recognition as independent specialties rather than derivatives of general surgery
- Pressure to reduce or eliminate the traditional five-year general surgery requirement before subspecialization
Integrated Programs
Integrated programs now exist that bypass traditional general surgery training entirely, including plastic surgery and vascular surgery 6. These programs have become increasingly competitive, with integrated programs (weighted rank score 1.17) and surgical subspecialties like orthopedic surgery, neurosurgery, and otolaryngology (1.92) attracting more competitive applicants than general surgery (2.85) based on USMLE scores, research experience, and Alpha Omega Alpha membership 6.
UK Training Structure
In the UK system, there are ten recognized surgical specialties that trainees can enter after Core Surgical Training 5. The Shape of Training review addressed run-through training pathways across all ten surgical specialties, with successful implementation in neurosurgery and ongoing pilots in cardiothoracics and oral and maxillofacial surgery 5.
Core Competencies of General Surgery
Modern general surgery maintains broad responsibility for 4:
- Comprehensive care of the surgical patient including diagnosis, preoperative, operative, and postoperative management
- Special expertise in alimentary tract, abdomen, endocrines, vascular, and head and neck surgery
- Comprehensive trauma and critical care management
- Leadership in undergraduate surgical education and basic training for all surgical specialties
Clinical Implications
A critical pitfall is the emerging shortage of surgeons capable of handling a broad caseload of emergency general surgery and trauma due to fewer trainees selecting general surgery as a career and increasing subspecialization 2. This has led to concerns about maintaining adequate coverage for emergency surgical services, particularly as subspecialties like vascular surgery separate entirely from general surgery training 5.
The future general surgeon requires broad-based training with knowledge in basic sciences while maintaining special interest and expertise in a subspecialty area, balancing the demands of comprehensive patient care with the realities of modern surgical practice 4.