Book Review: Advanced Surgical Practice
Authors: David C Britton
Journal: Journal of the Royal Society of Medicine (2003)

It was in the days of the biplane and the steam railway engine that Moynihan of Leeds sought to broadcast general surgical knowledge by founding the Association of Surgeons. A cordial invitation from the Association's current president reveals that this year's meeting will be held in conjunction with the Association of Breast Surgeons at BASO (the cancer surgeons' society), the Association of Coloproctology of Great Britain & Ireland, the Association of Endoscopic Surgeons of Great Britain & Ireland, the Association of Upper Gastrointestinal Surgeons, the British Association of Endocrine Surgeons, the British Transplantation Society, and the Vascular Surgical Society of Great Britain and Ireland. The cohesion of these groups in timing their symposia to coincide with the meeting of Moynihan's association is praiseworthy, but the tortured syntax of their titles reflects realpolitik. British (and Irish) surgeons believe that the day of the general surgeon is drawing to an end.

The Department of Health, however, is aware that common things occur commonly. Knowledge of the management of phaeochromocytoma is not a prerequisite for management of a hernia. Modernization of the National Health Service is intended to ensure that a new generation of British surgeons will be 'fit for purpose'. This purpose seems to be the staffing of the district general hospitals by consultants licensed, after a foreshortened training, to perform a limited repertoire of surgical techniques. Personal and professional advancement from a timetable of night-time appendicectomies and day-time herniorrhaphies will be possible, but only with the approval of management, and only for the chosen. The 'few' could be the only new members of the specialist societies, and may work only in specialist regional resection centres. General surgery may persist in the UK long after its demise in most other countries. The name for these Jacks of all trades might be 'junior surgical specialist' or 'senior registrar'. An exit examination in general surgery seems set to continue therefore, although whether under the control of the (four) Royal Colleges of Surgeons in these islands or of the Government's Postgraduate Medical Education and Training Board is not resolved. Currently there are two postgraduate examinations in surgery, both designed in committee with collegiate self-interest. The MRCS is taken by senior house officers and is designed to be the entrance examination into higher surgical training. In all four surgical colleges (an independent examination being currently held in each college), an attempt has been made to combine an appraisal in the basic medical sciences (anatomy, physiology and pathology) with a repeat of undergraduate surgical finals, more or less to honours level. Many examiners feel that the standard of the examination in the basic medical sciences could be more robust. Return of the old primary examination in these basic medical sciences, perhaps taken in specialist modules, seems overdue. The FRCS is the exit examination. It combines an examination in general surgery with a viva and clinical in a specialty if the candidate elects to be examined as a specialist. Specialty examiners, and the specialist societies listed above, feel that this appraisal, the last hurdle before independent consultant practice, could also be more robust.

Professor Majid of Kuala Lumpur, Malaysia, and Professor Kingsnorth of Plymouth, UK, have edited Advanced Surgical Practice as a comprehensive text for those preparing for all aspects of the exit FRCS in general surgery. It has more than 80 contributors, of whom some are acknowledged experts and some are still in training. The book weighs in at 3.4 kg and is not constructed for reading in an easy chair; a two-volume version might be considered when it comes to a second edition. Eight sections represent the specialties referred to previously. In addition there is a section on paediatric surgery, although this has a separate exit examination in the UK. There is an epilogue on clinical governance. Some of the subjects covered would probably not be considered part of the current practice of a British general surgeon—oral cavity malignancy, for example, and spinal dysraphism. At the end of each chapter there is a section on operative surgery. This is refreshing, but some of the operations described are outdated and many of the operative descriptions are not detailed enough for use as preoperative texts. The use of 85 contributors has produced obvious variations in style, although this is not intrusive. The line drawings and tables are clear and helpful. The colour photographs, attractive to me where they depict old friends in action, do not always add to the reader's understanding; the orientation, particularly in the endocrine and vascular sections, is sometimes unclear.

A large volume that contains information on subjects as disparate as rhabdomyosarcoma, colonoscopy, liver transplantation, aldosterone levels, advanced breast cancer, anal tumours, radiation enteritis, and cancer of the tongue, is inevitably better in some parts than in others. The fault here lies not with the book but with the extensive syllabus of the current examination in general surgery. Trainees seeking to sit the exit FRCS in general surgery will find this volume comprehensive enough for their requirements. Candidates for the same examination with the specialist tag might find the relevant chapters too succinct. I particularly enjoyed the section on the breast and the chapter on the salivary glands. Overall, the authors are to be congratulated on producing a book that is instructive and pleasant to read. The sheer bulk of it, however, signals the eventual demise of general surgery even in the UK. Informed consumer power will demand it. Meanwhile, Majid and Kingsnorth's weighty codex will meet the needs of those who confront the existing examination.