How Acute Care Strengthens General Surgery

Najma Ahmed with her daughter Izzi

The University of Toronto General Surgery Program is a flagship program, characterized by clinical excellence, breadth of training opportunities and an outstanding level of scholarship. Najma Ahmed became the Program Director in 2008, taking over from Lorne Rotstein. She is working on strengthening individual attention to residents’ experience, creating specific competency - based evaluation, and defining milestones that will assist in promotion of residents. She has also been working with Shady Ashamalla, Teodor Grantcharov and Samir Grover to integrate level - appropriate simulation training in endoscopy and laparoscopy into the formal curricula. She finds working with and teaching the future leaders of surgery very gratifying. “Some of the best ideas for curricular innovation and residency design come from the residents.” She feels that she has “the best faculty and the most engaged residents in the largest surgery training program in North America”.

Najma has the advantage of interacting with other program directors through the Royal College of Surgeons twice a year and the Specialty Committee twice a year. She also sits on the Examination Board of the Royal College, which offers “excellent interactions with peers and an amazing CME opportunity”. She speaks highly of the ICRE (the International Congress on Residency Education) which is a Canadian born, but now international organization. It is considered among the best conferences worldwide to disseminate and discuss new ideas and innovation in postgraduate medical education. The ICRE grew out of the Royal College, first as a committee, then as a meeting, and now as an international congress http://www.royalcollege.ca/portal/page/portal/rc/ events/icre.The American College of Surgeons meetings also have excellent sessions and scholarly work related to undergraduate and postgraduate education.

Najma is involved in the on-going advances related to duty hours for residents. She is the Chair of the Working Group for procedural disciplines, of the National Steering Committee on Resident Duty Hours at the Royal College. Among the topics under discussion is the distinction between continuous wakefulness and continuous duty hours - these are not identical experiences. She will keep us informed as this issue evolves.

Najma spearheaded the effort to have Trauma Surgery recognized as an area of focused competence by the Royal College. Trauma Surgery is now a nationally recognized diploma - bearing fellowship program. There has been a tendency to move away from more formal “fellowships” as these tend to cause greater fragmentation within the specialty of General Surgery. However, there is a need to recognize advanced training and competence and this is why the Areas of Focused Competence Programs were developed at the Royal College. Trauma Surgery is the first diploma program in Surgery. The diplomas have standards for experience, training and will help to develop academic leaders in their respective fields. The Trauma Surgery diploma program will not, for the moment, have Royal College certification examinations, but rather have oversight for completion of requirements by the Trauma Association of Canada. Candidates will have to complete oral examinations, keep a portfolio of cases and provide evidence of scholarship during their trauma surgery training.

Acute Care Surgery and Trauma can in some cases be considered parallel disciplines that share many similarities. However, Acute Care Surgery is not a diploma program. Elective surgery is becoming progressively more specialized, especially in academic centres and this phenomenon has perhaps opened the door for a new breed of surgeons in academic centres: trauma and acute care surgery specialists. Some surgeons in this type of clinical practice combine it with critical care.

Najma loves acute care, “its diagnostic uncertainty, clinical and technical challenges, tempo, and that its practice allows for clear separation of clinical work from academic work. During TACS (Trauma and Acute Care Surgery) weeks, I have no elective clinical activity (ORs, clinics, meetings), I take all the admissions to General Surgery, do lots of emergency cases, and manage, with a house staff team, about 30 patients on a ward and 6-8 patients in the ICU. I can give immediate attention to urgent problems and I am completely immersed in the clinical and learning environment with the medical students, residents and fellows - free from other obligations. All patients are cohorted onto one ward, which allows the nurses and other paraprofessionals to develop an area of expertise, and for the clinical teams to learn about best practices in this unique patient population. Another advantage is that chief residents can focus on their elective cases without interruptions during the day.

“Surgical emergencies used to disrupt elective surgical life and were considered a nuisance. With this model in place, the emergency patient is the central focus of the team’s attention. This has been a very patient focused development. I think that this started in US trauma centers as the trauma volumes decreased (see Avery Nathens’ article http://www.surgicalspotlight.ca/Article.aspx?ver =Fall_2012&f=SunnybrookTrauma). As the crack and gun epidemic died down, and as we have developed safer cars and seatbelt and helmet laws, operations for trauma have also decreased. This model of trauma and acute care surgery is well underway at Sunnybrook and St. Michael’s.

“When I leave TACS, I follow a few patients with interest, especially the ones with more complex operations, but otherwise I am free to focus on academic and administrative life and my small elective practice. I am on TACS for approximately 10 weeks per year. During those weeks I am on call every other night. In addition, I am an intensivist and do several weeks in the ICU. The elective surgery component of my practice is usually reconstruction of trauma patients and benign general surgery.

“In some sense, acute care surgery has been a very positive development for General Surgery – it was becoming too specialized without a generalist practice. It is somewhat like being on call for one night, but it is consolidated into one week. Community surgeons might be able to implement a similar model, however it would require some re-organization of their clinical practice patterns. For instance hospitals that are in proximity might consider a collaborative model in order to create a cohort of interested surgeons.”

Najma travels with her daughter Izza, who is a grade 3 student at Branksome Hall. She most recently read a novel called Beautiful Ruins by Jess Walter. She travels to Mexico each winter and in the summer, she and her family often rent a cottage near Muskoka. She is an active gardener at her home at the Southern end of Leaside in the Governor’s Bridge community.

M.M.