The Bull Ensign had just been promoted to the exalted rank of Lieutenant, Junior Grade, and had liberty to get off the ship on Friday night and celebrate at the Guantanamo Bay Officer’s Club. Sometime past the zenith of the wetting-down party, he started walking along the top of the retaining wall that overlooked the bay and separated the club’s patio from a steep embankment. His mates were either in the bar or too many sheets to the wind to notice that the Lt., J.G. had disappeared. They went back to the ship after they’d had their fill.

Shortly after daybreak, the young officer was awakened by the sound of shouting from the nearby tennis courts where the base orthopedic surgeon was engaged in a match with the base oral surgeon. The lieutenant picked himself up and crawled up the embankment back toward the O-club, nursing a very sore neck and a hangover. He got to the officer’s landing and caught a launch back to his ship. He negotiated a maze of ladders and hatches to get to the sick bay. The ship’s corpsman did an exam and sent him to the hospital for x-rays of the neck.

After another bumpy ride in the launch and an even bumpier one on the base bus, the hungover celebrant got to the hospital’s ER and got his x-ray. Fortunately, he was neurologically intact on arrival; unfortunately, the x-ray showed an unstable cervical fracture.

By now, my buddy, Eddie McDevitt, the orthopedic surgeon, had finished his tennis match, showered, puttered around the house and had had lunch with his family. As the only bone doctor, he was called to the ER to care for the patient. He confirmed the diagnosis and told the patient that the fracture would have to be surgically stabilized before Eddie would feel comfortable medevacing him back to the States.

Before agreeing to the operation, the lieutenant asked that his sister, a registered nurse, be called. Nice guy that he was (and is), Eddie made the call from one of the two overseas lines in the hospital. On hearing of her brother’s serious injury, the nurse first requested immediate transfer to a major hospital. That was a dead end—there was no possibility of sending little brother to Real Cuba, and Eddie wouldn’t ship out anyone who was likely to get pithed on transfer, especially since he had been trained to do back and neck surgery and was capable of stabilizing the patient’s C-spine.

In spite of this, the sister requested that the neurosurgeon do the case. Eddie said we didn’t have one. Then she made a reasonable request to know what anesthesiologist would be sleeping her brother. Eddie said we didn’t have an anesthesiologist, only a nurse anesthetist. Finally, the frustrated sister wanted to know if the “other” orthopedic surgeon would be assisting. Eddie replied that one Hal Kent, the base general surgeon, would be the second pair of hands at the table. The sister had to acquiesce to reality after she heard that. We successfully stabilized the officer’s C-spine and eventually shipped him out, neurologically intact. I was grateful the J.G. hadn’t fallen on his head and gotten a subdural—I would have been on the phone with a neurosurgeon on the other end and a drill in my hand trying to remember how to turn a skull flap.

The point of this story is that we didn’t have a neurosurgeon in GTMO 21 years ago because we didn’t really need one. We could temporize with a general surgeon who was forced to rotate on neurosurgery for a couple of months to learn about back and skull surgery and an orthopedic surgeon who could actually do some back surgery. As a matter of fact, that year was the first time in many years that the U.S. Navy sent an orthopedic surgeon to Cuba full-time; they figured out that having a bone doc down there was cheaper than having the general surgeon wash out fractures and then medevac everyone back to Norfolk, Va.

The real reason that the base rated a general surgeon had to do with the Marine Defense Force maintaining a very large, active, anti-personnel minefield. The general surgeon was aboard just in case one of the maintenance team members stepped on a mine. Doing the appendectomies and vasectomies without the expense of shipping them back to the States was just financial gravy for the navy.

Back in the civilian world, it appears that general surgeons are on the decline, what with articles like “The Impending Disappearance of the General Surgeon” (JAMA 2007;298:2191-2193), the crush of general surgery program graduates applying for fellowships, and the restructuring of residencies to allow subspecialty tracks early on instead of requiring completion of a general surgery residency as the initial ticket punch to enter fellowship. No, I will not talk about reimbursements, although that is the underlying reason for the reasons behind the decline. Any discussion of touchy-feely attendings and 80-hour workweeks will be avoided as well. It’s time for a solution to the problem here.

The solution has been right in front of us all along, and it has become obvious to me that the specialty of general surgery needs to go on gently into that good night of things past and things outmoded. This really won’t take much work, just a little tuning up around the edges of all of the things that are happening now and have happened up to this point. My proposal is this: Abolish the specialty of general surgery and general surgery residencies—we just don’t need them anymore. It’s time for a little tough love, folks.

Sometime before the first general surgery boards, general surgeons did stuff that got chiseled off bit by bit and became another specialty. After that, what we recognize as our specialty encompassed things that none of us do anymore. Even when I was a real general surgeon, I didn’t pin hips and I didn’t do hysterectomies. Some of that is political, since I’d rather have the OB/GYN docs send me their patients with gallstones than compete with them for hysterectomies. My endoscopy cases went away as we increased the number of gastroenterologists in town. I’d rather do one colon resection than the dozens of colonoscopies it takes to find a single cancer. There are plenty of other specialties that are chipping away at our turf, but just the good stuff, really. It’s time to hand off the bad and the ugly with the good. That means the night call, the emergency call and all of the overlapping pieces.

Back at the ivory tower and in the shadow it casts, there will be plenty of overlapping of specialties so that all together, they will add up to a general surgeon equivalent. We won’t have to worry about the big cities, either. Add up the vascular surgeons, trauma surgeons, pediatric surgeons, colon and rectal surgeons, the minimalista fellowship-trained surgeons, thoracic surgeons, hernia surgeons, breast surgeons, endocrine surgeons, endoscopists, laparoscopists, liver surgeons, pancreaticobiliary surgeons, oncology surgeons, gynecologic surgeons, plastic surgeons, orthopedic surgeons, intensivists, hospitalists and urologists—and anyone else I’ve left out. Once you do that, there won’t be a need for a general surgeon anywhere in that environment. There will only be a need for one specialist from each category to be on call or available every day and every night, just in case there’s something that has to be done in an OR right now. Everything else can wait.

At this point, the only places to worry about are those that are somewhat distant and remote from an urban amalgamation of specialists that collectively can replace a general surgeon. Places that are extremely distant have no expectation of general surgery coverage close at hand. We’ve all been to those places and hoped we wouldn’t get sick. It’s just not possible to plunk down a general surgeon everywhere there’s a filling station or a fast food drive-through. That leaves us with the places in between where there might be an occasional need for a general surgeon on an emergent basis.

Facts are stubborn things and unpleasant to face. Elective general surgery can be sent out of town without any problem. Most of us are painfully aware of this every time a local with a routine case of cholelithiasis opts to go to the medical Mecca instead of getting his cholecystectomy done at Hometown General Hospital. The fact is that we’re not really needed for any elective surgery. We’re only needed for the case where the local civilian or visitor has stepped on the pathologic equivalent of an anti-personnel mine. Trauma cases probably head this list. The list of usual suspects that we’d call “surgical emergencies,” including acute inflammations of the appendix, gallbladder and colon can get shipped out without much harm to the patient. Just do what they used to do in the British navy—stick in an I.V., a nose hose, and pump in some antibiotics so you have more time to transfer to a safe harbor with appropriate surgical expertise. Other emergencies are a bit hit-or-miss. Ruptured aneurysms can select out survivors pretty quickly, so those patients will either die or survive long enough to get to a vascular surgeon. There are a lot of minor things that many specialists can do—lance boils, evacuate thrombosed hemorrhoids, suture lacerations, and suspect intra-abdominal conditions of surgical import—just like surgeons.

So, what should we be teaching these other specialists? Back in the navy, there were family practice docs who had done appendectomies when they wintered over in Antarctica. Stranger things than that have happened back in the old Canoe Club—more than I can describe. With the general surgeon shortage, we might train some other specialists to do damage-control laparotomy. My attendings were even able to train me to get in and out of the abdomen safely in a fairly short period of time. It’s not rocket science. Stapling shut holes in bowel and cramming in a half bale of cotton in the form of lap sponges and covering the whole thing with a sterile dressing and abdominal binder—or approximating the midline wound with towel clips—isn’t much of a technical challenge. That’s what we can do. We won’t even need general surgeons in most places.

I’ve been thinking about this for a while now and I’ve been adding to my thoughts for a couple of months. I know I can’t cover all of the bases; that’s for wiser heads than mine. Only 1,600 words into this exercise, I actually thought I was writing mostly tongue-in-cheek. It’s only a modest proposal: We can do without general surgeons for the most part. It’s fodder for discussion and angry letters back to the editor. Except for what I just read in the November 2008 Surgery News from the American College of Surgeons (page 1): There’s a proposal that maybe sending emergency surgery cases to trauma centers would be a good thing for local hospitals and trauma centers alike. The proposal would leave the elective operations at the local hospitals, even though those cases could migrate safely to another hemisphere without harm to the patients. Meanwhile the trauma centers would get some money for doing all emergency surgery. Now my proposal isn’t so modest anymore. I guess I’m just behind the power curve on getting my thoughts out there.

We’re autocannibalizing to feed ourselves. We’ve cut out our own hearts. Our hands will be the last to go. We operate, therefore we exist ...

Not for long.

—Dr. Kent is a bariatric and general sugeon in Brunswick, Ga.