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General surgery has become increasingly fragmented into subspecialties and diseases previously treated by general surgeons are now managed by "specialists". The Resident Education Committee of the Society for Surgery of the Alimentary Tract (SSAT) has reviewed the history of surgical training and factors that have contributed to this evolution to subsepcialization. As it is unlikely that this paradigm shift is reversible, a clear understanding of the contributing factors is essential. Herein, we present a timeline and taxonomy of forces in this evolution to subspecialization.

Objective: To identify trends and characteristics of surgeon employment in the United States. Surgeons are increasingly choosing hospital or large group employment as their practice environment. DESIGN American Medical Association Physician Masterfile data were analyzed for the years 2001 to 2009., Setting: Surgeons identified within the American Medical Association Masterfile., Participants: Surgeons were defined using definitions from the American Medical Association specialty data and the American Board of Medical Specialties certification data and included active, nonfederal, and nonresident physicians younger than 80 years of age., Main Outcome Measures: Employment status and trends., Results: The number of surgeons who reported having their own self-employed practice decreased from 48% to 33% between 2001 and 2009, and this decrease corresponded with an increase in the number of employed surgeons. Sixty-eight percent of surgeons in the United States now self-identify their practice environment as employed. Between 2006 and 2011, there was a 32% increase in the number of surgeon in a full-time hospital employment arrangement. Younger surgeons and female surgeons increasingly favor employment in large group practices. Employment trends were similar for both urban and rural practices., Conclusions: General surgeons and surgical subspecialists are choosing hospital employment instead of independent practice. The trend is especially notable among younger surgeons and among female surgeons. The trend denotes a professional paradigm shift of major importance.

Objectives: To explore trends in the clinical activity of hospital specialists in English National Health Service (NHS) hospitals, and test the effect of contract reform., Design: Retrospective secondary analysis of hospital episode statistics, describing trends and testing for a contract effect using multilevel interrupted time series analysis., Setting: Ten surgical and medical specialties in English NHS hospitals from 1999 to 2009. Participants Hospital consultants on full time or maximum part-time English NHS hospitals., Intervention: A new contract offered to NHS consultants in October 2003, with higher pay alongside job planning and appraisal., Main Outcome Measures: Inpatient finished consultant episodes (FCEs) per consultant per month, with and without accounting for case-mix differences., Results: In most specialties there was a statistically significant downward trend in FCEs per consultant per month. On average in the surgical specialties, FCEs reduced by 0.14 per month (95% CI -0.16 to -0.11) and in medicine there was a smaller reduction of 0.08 FCEs per month (95% CI -0.1 to -0.06). NHS patients symptoms have increased in severity over time, and the downward trend is reduced after case-mix-adjustment, and reversed in general and geriatric medicine. The effect of the contract on clinical activity was minimal. In five specialties there was no statistically significant effect, but in five specialties there was a statistically significant negative effect., Conclusions: Consultant clinical activity, as measured by FCEs per month, has shown a general downward trend from 1999 to 2009. The consultant contract was not associated with an increase in consultant clinical activity rates.

Purpose: It is difficult to compare match outcomes across specialties because they may change over time and data are not reported in uniform formats., Method: Recent U.S. student match outcomes were analyzed for 16 specialties., Results: On the basis of student match rates, three specialties were consistently competitive, eight were consistently noncompetitive, and five were in flux. Unfilled position rates increased for five specialties and remained stable or decreased for 11., Conclusions: Many specialties, both competitive and noncompetitive, recently have become increasingly desirable to match participants, whereas primary care specialties have become less desirable to both U.S. students and other match participants.

Context: Trends in career choice among specialties have varied greatly. Most notable is the recent decrease in the percentage of US medical student graduates choosing a primary care career, which has important implications for the US physician workforce., Objective: To review temporal trends in career choice by graduates of allopathic US medical schools, focusing on US medical doctors entering residencies since 1987., Data Sources: Three databases, the Association of American Medical Colleges Graduation Questionnaire (AAMC GQ), the National Resident Matching Program, and the national Graduate Medical Education census, were used to review temporal trends in the number of US medical doctors entering residencies in primary care, general or subspecialty surgical, and non-primary care and nonsurgical specialties from 1987 to 2002., Data Synthesis: In 1987, 49.2% of all medical school graduates matched to one of the generalist residencies (internal medicine, pediatrics, or family medicine). The percentage of students matching to primary care specialties declined in the early 1990s, peaked at 53.2% in 1998, and declined to 44.2% in 2002. Concurrent with the latter decline, AAMC GQ data showed a decrease in medical student interest in primary care careers (35.6% in 1999 to 21.5% in 2002). The total percentage of US medical doctors matching to general or subspecialty surgical residencies remained stable at 11% to 12% from 1987 to 2002. During this same period, emergency medicine and plastic surgery increased as a match choice, while anesthesiology, pathology, and psychiatry were more variable over time., Conclusions: Distribution of medical students' career choices among specialties varied considerably from 1987 to 2002. The debate will continue regarding the appropriate specialty mix within the physician workforce.

In Norway, as in most Western countries, doctors' choice of specialty has been strongly gendered. Female physicians have tended both to specialise to a lesser degree and to enter other specialties than male colleagues. In spite of the increase of women in medicine, previous studies have not managed to show any changes in this pattern. Comparing data from two cohorts of Norwegian doctors, authorised in 1970-73 and 1980-83 respectively, this article demonstrates that changes are in fact taking place. The changes are, however, not unequivocal. Firstly, women in these cohorts specialise to a very high degree and just as much as their male colleagues. Secondly, women doctors of the 1980s cohort spread their choice of specialisation over more fields than their predecessors did. They have, for example, started to enter surgery, although still not as often as men. Thirdly, proportionally more doctors of the 1980s cohort than the 1970s cohort have chosen general practice as their main specialty, and this applies to both women and men. Fourthly, there are tendencies towards an increasing concentration of women in some disciplines such as obstetrics and gynaecology, as well as paediatrics. These changes in doctors' pattern of specialisation are discussed as consequences of socially shaped individual preferences, structural aspects of the Norwegian health system and the existence of gendered closure mechanisms within specific medical fields. Although the medical profession still appears as a gender differentiated community, the article gives a more dynamic and in some respects a more optimistic picture than earlier studies.

Objectives: The Manitoba Centre for Health Policy and Evaluation worked in support of a provincial Physician Resource Committee to address questions pertinent to assessing Manitoba's supply of specialist physicians., Research Design: Because there was no direct method of determining whether the province's supply of specialists was adequate, three types of evidence were reviewed: the supply of specialists relative to recommended population/physician ratios; the supply of specialists relative to other Canadian provinces; and the level of care delivered by specialists in Manitoba relative to other provinces. Four additional questions were addressed: is a problem developing from the aging of Manitoba's specialist physicians? and will the supply of specialists be sufficient to keep up with the aging of the population? How well do specialists serve as a provincial resource? and how well do specialists serve high-need populations?

Subspecialization is currently fashionable, but with present hospital organization, the need to cover emergencies and the lack of convincing evidence for its superiority, the tide is on the ebb and the place of the general surgeon is secure.

From 1980 to 1994, 283,024 certificates were issued by the 23 specialty boards. Of these certificates, 137,852 (48.7%) were issued in primary care specialties, 84,993 (30.0%) were certificates in the other medical specialties, and 60,179 (21.2%) were certificates in the surgical specialties. The figure on page 26 illustrates the changes that have occurred in the pool of board-certified physicians from 1980 to 1994. Since 1980, the number of certificates issued in the primary care specialties and the number of certificates issued in the other medical specialties has consistently exceeded those issued in the surgical specialties. In 1977, Mr. James Haug, Director, ACS Socioeconomic Affairs Department, correctly predicted that the pool of board-certified surgeons as a percentage of the total pool of board-certified physicians would decline. In 1980, the total number of certificates issued by the 23 specialty boards was 16,034. Surgical specialty certificates accounted for 23.8 percent of the total number of certificates issued by the 23 specialty boards in 1980. In 1994, the total number of certificates issued by the 23 specialty boards was 22,090. Surgical specialty certificates accounted for 19.8 percent of the total number of certificates issued by the 23 specialty boards in 1994. In 1980, 1984, 1986, and 1989 primary care specialty certificates accounted for greater than 50.0 percent of the total number of certificates issued by the 23 specialty boards in those years. Given the substantial growth in the number of certificates in the primary care and other medical specialties depicted in the figure, certificates in the surgical specialties as a percentage of the total number of certificates has remained stable.

Medicine is entering an unprecedented era of provider abundance, including both physician and nonphysician providers. Over the next several decades, the projected number of primary care physicians will be more than adequate to meet national needs, although there is no assurance that any number of physicians will create an equitable distribution. At the same time, a growing surplus of specialists is projected. A balanced abundance in both primary care and specialty medicine will continue if approximately 33% of first-year residents ultimately practice primary care and 67% become specialists. In contrast, a shift to 50:50, as has been proposed by the Committee on Graduate Medical Education and others, will lead to a superabundance in primary care and a potential deficiency in specialty medicine later in the 21st century. Under either scenario, maintaining balance will be aided by those physicians with sufficient generalist skills to enable them to practice at the interface of primary care and specialty medicine, the domain of "middle care." The nation will be well served by educational policy that imparts such generalist expertise to medical students and that creates a workforce of highly skilled physicians capable of caring for patients in the technologically advanced clinical environment of the future.