T he practice of general surgery is constantly evolving. Numerous factors such as advances in surgi- cal knowledge, techniques, and tech- nology, as well as patient and physician preferences, have driven an increasing numbers of surgeons to specialization. More general surgery (GS) graduates are specializing; in fact, more than 80 percent of graduates of general sur- gery programs are pursuing additional training beyond the ive-year surgical residency. 1 To accommodate these trends, a number of early-specialization train- ing models have emerged.  Models vary with respect to time of entry, board cer- ti ication process, and length of train- ing. The most well-established approach is the fully integrated model, which is used in plastic, vascular, and car- Early surgical subspecialization: A new paradigm? Aif N. Kulaylat, MD; Feibi Zheng, MD; SreyRam Kuy, MD, MHS; and James G. Bittner IV, MD HIGHLIGHTS • Describes various pathways to specialization, including the traditional integrated model, the American Board of Surgery- approved Early Specialization Program, the flexibility in surgical training programs, and transition to practice models • Leading surgical educators and training program directors offer their views on issues related to early specialization, including the challenges associated with implementation and the possible effects on the future of surgical training Part II: Interviews with leaders in surgical education AUG 2013 BULLETIN American College of Surgeons | 43 RAS-ACS: EVOLVING DEMANDS OF RESIDENT TRAINING