will there be a good general surgeon when you need one? (part ii) solutions and taking back general...

ORIGINAL ARTICLE

Will There Be a Good General Surgeon When You Need One?(Part II) Solutions and Taking Back General Surgery

Richard Smith & Steven C. Stain & David W. McFadden & Samuel R. G. Finlayson &

Daniel B. Jones & The Public Policy & Advocacy Committee of the SSAT &

KMarie Reid-Lombardo

Received: 19 March 2014 /Accepted: 31 March 2014 /Published online: 19 April 2014# 2014 The Society for Surgery of the Alimentary Tract

AbstractIntroduction Multiple reports have cited the looming shortage of physicians over the next decades related to increasing demand,an aging of the population, and a stagnant level in the production of new physicians. General surgery shares in this problem, andthe specialty is “stressed” by a declining workforce related to increasing specialization that leaves gaps in emergency, trauma, andrural surgical care.Summary The Society of Surgery of the Alimentary Tract (SSAT) Public Policy and Advocacy Committee sponsored paneldiscussions regarding the general surgery workforce shortage at the Digestive Disease Week 2012 and 2013 meetings. The 2012panel focused on defining the problem. This is the summation of the series with the solutions to the general surgery workforceshortage as offered by the 2013 panel.

Keywords SurgeonShortage .Healthcarepolicy .Affordablehealth care act . Advocacy .Workforce . SSAT

Introduction

The title, “Taking Back General Surgery”, is a reference to Dr.Courtney Townsend’s comment at a meeting to address thegeneral surgery workforce and access to surgical care, spon-sored by the American Surgical Association (ASA), at whichhe said, “no one stole general surgery; we gave it away.”1 Inthe spirit of that comment, we present solutions for “TakingBack General Surgery.” Our panel was comprised of StevenC. Stain, MD, Surgery Chair at Albany Medical College, andformer Chair of the American Board of Surgery (ABS), whospoke about early tracking as a solution for increasing outputof surgeons; Samuel R. G. Finlayson, MD, MPH, Center forSurgery and Public Health at Brigham andWomen’s Hospital,spoke on the responsibilities of society and the government fordealing with the general surgery workforce shortage; andDavid W. McFadden MD, MBA, Professor and Chair, De-partment of Surgery at the University of Connecticut andformer president of the SSATspoke on the changing paradigmof urban and rural surgery.

General surgery is a threatened specialty as we have definedin our previous publication.2 This problem is very apparent ifone examines the current surgical workforce demographics.There is a steep decline in the availability of general surgeons

Presented at the 54th Annual Meeting of the Society for Surgery of theAlimentary Tract on May 18, 2013, Orlando, FL

R. SmithTripler Army Medical Center, Honolulu, HI, USA

S. C. StainDepartment of Surgery, Albany Medical College, Albany, NY, USA

D. W. McFaddenDepartment of Surgery, University of Connecticut, Farmington, CT,USA

S. R. G. Finlayson :D. B. JonesDepartment of Surgery, Beth Israel Deaconess Medical Center,Boston, MA, USA

The Public Policy & Advocacy Committee of the SSATSociety for Surgery of the Alimentary Tract, Beverly, MA, USA

K. Reid-Lombardo (*)Department of Surgery, Mayo Clinic, 200 First Street SW, Rochester,MN 55905, USAe-mail: [email protected]

J Gastrointest Surg (2014) 18:1334–1342DOI 10.1007/s11605-014-2522-4

likely due to the fact that most surgical residents are increas-ingly choosing subspecialty training. Lynge et al. found a 25%decrease in the number of general surgeons per capita from1981 to 2005.3 Williams et al. predicted a shortage of generalsurgeons of 1,875 by 2020.4 The decreasing number of surgi-cal residents choosing general surgery combined with theincreasing size and graying of the US population creates asituation that demands immediate attention.

Early Tracking: A Solution to the Impending Shortageof General Surgeons

Surgical residents are still choosing subspecialty training de-spite the obvious need for more general surgeons. An imbal-ance exists between subspecialists and general surgeons. Thisimbalance evolved as a result of complex changes in thehealthcare system and training.5 Surgical internships havechanged from broad exposure that included otolaryngology,cardiac, urology, and orthopedic exposure to limited specialtyrotations. Responsibility for patient care has moved from oneof graduated responsibility producing senior residents capableof coverage of all encountered problems to a decreased pres-ence of residents on the wards and more attending and physi-cian extender coverage. A system of continuity of care forinpatients has changed to a float system of coverage.6 Oper-ative experience of a chief resident has changed from a sig-nificant teaching assistant role to a minimal teaching role. Allof this translates into a loss of resident autonomy. This loss ofautonomy may result in more residents choosing additionaltraining through subspecialty training.1,6–9

While our society needs surgeons with a broad skill set thatincludes skills in emergency and trauma surgery and ruralcoverage, residents are choosing practices that offer subspe-cialty focus with referral of elective cases instead of emergen-cy surgery.8,10

The most cited reasons for residents not choosing to prac-tice general surgery are a demanding call schedule, compara-tively poor reimbursement, broad and irregular skill set re-quirement, and a poor image of the specialty.5,10 The demand-ing call schedule is a function of frequent legitimate emergen-cies in general surgery, and the declining number of generalsurgeons to take call exacerbates the workload. The callschedule leads to irregular work hours, decreased morale,and a difficulty balancing competing needs of an electivepractice and academics. The broad and irregular skill setneeded further drives the desire for additional training.

The American Surgical Association sponsored a conferencein 2010 to develop a proposal for dealing with the workforceissues in general surgery.1 The recommendations were asfollows: (1) increase the number of trainees in surgery andexpand the breadth of training, (2) incorporate flexibility andmore depth in training, (3) minimally invasive surgery must

return to core general surgery training, (4) resume communityrotations for residents, increasing exposure to a broad generalsurgery practices, (5) loan forgiveness, and (6) select residentswith interest in general surgery. Unfortunately, there is notlikely to be additional funding available for graduate medicaleducation (GME) reform to increase the number of trainees.

Specialization is here to stay, advances in technology,increased disease complexity, an environment of decreasedindependence, duty hour restrictions, changing healthcareeconomics, public demand for specialization, and variousinitiatives in reporting of quality leads to an increase in spe-cialization. Recognizing that the trend will not reverse, we as asurgical community need to recognize that early specializationhas the potential to shorten basic surgical training.5 Emanueland Fuchs recommend reducing training time by 30 % basedon decreasing medical school, residencies, and earlyspecialization.11 The basic argument is that we are wastingtime training specialized surgeons, i.e., plastic surgeons, to docore general surgery cases that they will never do in practice.Theoretically, this leaves more core general surgery casesavailable for residents that choose general surgery as a career.Other benefits include eliminating wasted time for some ofsociety’s most highly educated and talented people, anticipat-ing the likely decrease in Medicare budget, funding of GME,and lower debt of students from medical school.11

It may be time to change surgical residency training. Earlytracking could be a solution if certain specialties retain theability to do general surgery. This would entail earlier differ-entiation in training to prepare for a specialty. There is someconcern that early tracking could impact general surgery neg-atively at a time when the workforce is already stressedthrough the loss of interest in general surgery, increased res-idency attrition, and decreased operative experience. The ben-efit of early tracking for general surgery could be seen in lesscompetition for index cases at the chief resident level with anenriched experience for general surgery chief residents.

Early tracking for general surgery could look somethinglike Fig. 1. The first four and a half years would be coregeneral surgery training. During the last 6 months of thepostgraduate year (PGY)-5 year, residents planning on doing

Fig. 1 Example of early tracking in general surgery, fellowship trainingbegins in the postgraduate 5 year instead of after residency graduation

J Gastrointest Surg (2014) 18:1334–1342 1335

general surgery would continue doing core general surgeryprocedures, and residents who will be doing a fellowshipwould concentrate on cases within their subspecialty for thelast 6 months. This model was applied to case logs from the2008ABS qualifying exam (QE) applicants.9 Applicants werequeried into plans for further training and divided into generalsurgery (minimally invasive surgery (MIS), surgical oncolo-gy, advanced gastroenterology (GI), transplant, and criticalcare) and fellowship bound (cardiac, vascular, colorectal,and pediatric). Hypothetically, a subspecialty fellowship-bound (SFB) resident would be doing only cases associatedwith their fellowship for the last 6 months. This would makeabout half of their index cases reported in their case logsavailable to general surgery residents. Table 1 is a presentationof the hypothetical results on case counts divided into ninecore areas. There were similar numbers of cases in the ninecore areas between both groups. By giving half the SFBresidents index cases to the general surgery residents, we geta 20–37 % increase in colon, gastrectomy, anti-reflux, pancre-as, liver, and endocrine cases for general surgery residents.There is potential to increase the operative experience incomplex GI cases for those going into general surgery whilestill allowing those going into fellowship to meet their num-bers for general surgery board certification.

Currently, the ABS offers early specialization training(ESP) in cardiothoracic and vascular surgery. The ABS intro-duced Flexibility in General Surgery Residency Specialty-Specific Guidelines in 2011 to allow greater flexibility in thestructure of general surgery residency training. The policyallows up to 12 months of flexible rotations to tailor trainingto a resident’s future career interests. The flexibility in surgicaltraining (FIST) pilot study will evaluate the impact of enactingthe ABS’s new guidelines. The pilot began at ten institutionsin 2013 including Brigham and Women’s Hospital, CornellUniversity, Johns Hopkins, Massachusetts General Hospital,Northwestern University, Oregon Health and Science Univer-sity, University of Oklahoma, University of Southern Califor-nia, and Washington University in Saint Louis, the generalsurgery residency program of the Emory University School of

Medicine. Residents will be monitored and followed fromtraining through certification in their intended specialty. Out-comes measured will include case numbers, operative perfor-mance rating systems, milestones, annual ABS In-TrainingExamination (ABSITE®; ABS, Philadelphia, PA) results,completion of specified core and specialty specific SCORE®(ABS, Philadelphia, PA)modules, and several other measures.The pilot is expected to last a minimum of 5 years. The intentis to ensure that nonparticipating residents will not be adverse-ly affected, and the hope is that residents going into generalsurgery may have their experience enhanced by FIST. If theflexibility programs can be shown to be effective, the eventualgoal could be an early specialization tract for all residents thatwould look like Fig. 2. This would reduce the time of trainingby 1 year for subspecialties and has the potential to improvethe training of all residents by matching their training to theirultimate practice.

In summary, the majority residents are going to do fellow-ships. Trying to reverse that trend has not been successful todate and is not likely in the future. Early tracking has thepotential to decrease total training time for subspecialties andimprove the operative experience of residents going into gen-eral surgery. A more realistic training in general surgery couldalso offer a better opportunity for residents to see the positivesin a career in general surgery. It is also important to expand thedefinition of general surgeon to include subspecialties with aGI focus and ensure continued board certification in generalsurgery for those subspecialties. This will require makingcertain they have the necessary skills to practice general sur-gery (acute care surgery/trauma, colorectal, hepatobiliary andpancreas (HPB), foregut, bariatric, and surgical oncology).

Surgical Workforce: Responsibility of Societyand Government

The Association of American Medical Colleges (AAMC)estimates that there will be a shortage of physicians of124,000 by 2025.12 They recommend that increasing the

Table 1 Hypothetical cases that can be directed to general surgery if early tracking is instituted

5 years total cases GS 5 years total cases FB GS chief cases 1/2 FB chief cases Projected GS total

Mastectomy 21.7 20.0 2.7 1.4 23.1 (6.5 %)

Colon resection 63.0 68.5 28.7 14.3 77.3 (22.8 %)

Gastrectomy 9.4 8.1 4.5 2.2 11.6 (23.4 %)

Antireflux procedures 7.7 8.1 3.7 1.8 9.5 (23.4 %)

Pancreatic resection 9.1 9.6 6.9 3.4 12.5 (37.4 %)

Liver resection 8.2 8.5 4.6 2.4 10.6 (29.3 %)

Endocrine procedures 35.2 35.7 13.7 6.9 42.1 (19.6 %)

Trauma operations 33.7 35.1 8.8 4.5 38.2 (13.3 %)

GI endoscopy 66.0 65.0 8.6 4.3 71.3 (6.5 %)

1336 J Gastrointest Surg (2014) 18:1334–1342

number of medical school positions by 30 % can potentiallyavert such a shortage.13 The current workforce crisis in gen-eral surgery is viewed as a reflection of this overall shortage ofphysicians, as there has been a 25 % decline in the generalsurgeon to population ratio over the last 25 years.3 The declinein general surgeons and the anticipated increase in demandhave led calls to increase the production of surgery residents.1

The reasons for this decline in general surgery numbers,however, are complex and need to be more closely examinedin order to identify a truly workable solution. We need toconsider our next steps cautiously and go beyond simplyanswering the calls to increase the production of surgeryresidents to supply this anticipated increase in demand. Otherfactors, such as surgical specialization and geographic distri-bution, may play larger roles in the decline in general sur-geons. If this is the case, then simply increasing the number of

general surgery residents will not improve the situation andcould possibly even worsen it.

The change in distribution and specialization of surgeonsbetween 2006 and 2011 is shown in Fig. 3.14 The map showsthe change in total number of surgeons (general surgeons andall subspecialties) per capita.14We see that only 17 states had adecrease in total surgeons per capita14 If we compare that to anidentical map (Fig. 4) looking only at general surgeons, almostthe entire map shows a decrease in number of surgeons percapita.15 We are currently producing more surgeons per capitaoverall than ever before, unfortunately because of the increasein specialization, too few general surgeons.

The decrease in the number of general surgeons is notevenly distributed across the US. The decreases in the numberof general surgeons have beenmuchmore pronounced in ruralareas when compared to urban areas (Fig. 5). Almost twice asmany rural counties (380) had a decrease as urban counties(189). In addition, 4 times as many rural (155) counties lost allof their surgeons when compared to urban (38) from 2006 to2011. Finally, 583 rural counties had no surgeons at all duringthe time period.16

Recognizing the impact that surgical specialization and thegeographic distribution of general surgeons have on the short-age of general surgeons will help guide us toward possiblesolutions. As such, our discussion must move beyond simplyincreasing supply to meet the increasing demand. Anotherpoint to consider is that the medical community has beenhistorically very poor at workforce projections. The Commis-sion on Graduate Education (COGME), after predicting a large

Fig. 2 Future surgical training core module plus subspecialty training

Fig. 3 Change in workforce across all surgical specialties, 2006–2011 (reprinted with permission from the ACS Health Policy Research Institute)


surplus of physicians a decade earlier, issued a report in 2005estimating an actual 85,000 shortage by 2020. Furthermore,focusing on increasing total numbers of surgical residents spe-cifically and total physicians more generally may distract fromcritical policy issues. This could ultimately lead to actions withunintended harms. We need to recognize that health care and,specifically, surgical care is changing. The workforce issuesmust be addressed in consideration of new models of care.

The University of Dartmouth has developed a five-pointargument to the AAMC’s and COGME’s call for significantlyincreasing the number of physicians produced annually.17 Thekey point is geographic distribution. The physician workforceis highly variable across regions of the US and the variation inthe supply of physicians does not correlate with the concen-tration or severity of illness of a population. The geographicdistribution is based more on where physicians want to liveand practice. The regional supply of physicians varies bymorethan 50 %, and this variation dwarfs the 10 % shortfall inphysician supply the COGME fears.17

Second, higher per capita physician numbers does nottranslate into better care. Physicians practicing in higher sup-ply areas are more likely to report problems with continuity ofcare, communication, and providing good quality care.18

There is no evidence that outcomes are better in high supplyregions.17,19–21 The only certainty is that regions with thehighest supplies of physicians will have the highest spendingon healthcare.20,21

Third, the growth in physician supply is likely to exacer-bate regional disparities. Between 1979 and 1999, physician

supply increased by 45 % in primary care, 118 % in medicalspecialties, and 21 % in surgical specialties.22 Despite theseacross the board increases, four out of five graduating resi-dents settled in regions where supply was already high.22

Fourth, the expansion of the physician workforce couldmake the health care system functionmore poorly. The currentreimbursement system favors specialization. This would fur-ther undermine primary care in favor of a fragmented,specialist-oriented health care system.17 The goal should bestrengthening primary care not specialized care.

Fifth, healthcare spending at current levels is unsustainableand will be worsened by indiscriminate growth in physiciannumbers. The process of creating more physicians is veryexpensive with an estimated cost of $5–10 billion per yearto increase physician workforce by 30 %.17 Focusing onincreasing physician workforce numbers diverts money andpolicy attention from other important healthcare issues. In theend, increasing the physician workforce indiscriminately fur-ther entrenches cost-inefficient healthcare.

The question for general surgery is, can we extrapolate theDartmouth argument to the surgeon workforce? If we were torewrite the five points, they would be as follows: (1) there isregional variation in surgeon workforce; (2) more surgeonsdoes not lead to better care; (3) training more surgeons couldlead to more regional disparities; (4) more surgeons worsensthe trend toward more fragmented, specialty-oriented acre;and (5) producing more surgeons is costly.

Regarding the first point of regional variation, in the US,14% of the population has 1.5–2 times the national average of

Fig. 4 Change in workforce in general surgery, 2006–2011 (reprinted with permission from the ACS Health Policy Research Institute)


supply, and 12 % has either no surgeon or only half thenational average of surgeons per capita15 (Fig. 5). The secondpoint is the relationship between the number of surgeons andquality of care. We must first acknowledge that this is notwell-studied. One such study examined the rate of perforatedappendix in relation to surgeon supply.23 We would expectthat perforation rates would be higher in areas with a lownumber of surgeons per capita due to a delay in care. Thehealth services area (HSA) is a single county or cluster ofcontiguous counties, which are relatively self-contained withrespect to hospital care. The highest perforation rates are seenin HSAs with twice the national average of surgeons percapita. The increased perforation rate may be a marker for apoorly integrated and coordinated system that occurs when theworkforce is in oversupply.

The third and fourth points are that training more surgeonscould contribute to regional disparities and worsen the trendtoward a more fragmented, specialty-oriented healthcare sys-tem. In Goodman’s paper showing that four of five newphysicians settled in regions where supply was already highalso looked specifically at several surgical specialties.22 Foralmost all surgical specialties, there was an increase in sur-geons per capita with the exception of general surgery.22 Thisdecreasing trend in general surgeons was already occurringfrom 1979 to 1999.More recently, the changes in surgeons percapita were examined for the period 1996–2005 for urbanversus rural location. The HSAswere divided into urban, largerural, small rural, and isolated based on a classification systemdeveloped by the University of Washington.24 The AmericanMedical Association (AMA) PhysicianMasterfile was used toclassify surgeons as general surgeons, specialized surgeonsthat could do some general surgery (trauma, endocrine, colo-rectal, etc.), or superspecialized surgeons that trained in gen-eral surgery but would not be expected to be doing any generalsurgery (cardiac, transplant).25We now have an increase in thetotal number of surgeons per capita in urban areas, and the

disparity between urban and rural areas has increased as thespecialty surgeons preferentially settle in the urban areas.Finally, if we include superspecialized surgeons, we furtherincrease the number of surgeons per capita in urban areas andfurther widen the gap between urban and rural surgeons percapita (Fig. 5).

If we are looking at ways to solve the problem of maldis-tribution, we must recognize that there exists equilibriumbetween surgeons settling in rural areas and urban areas. Thatdistribution favors a higher per capita surgeon supply in urbanareas. Given this equilibrium, if you add more surgeons, themajority will settle in urban areas and some small trickle willdistribute to the rural areas. Therefore, we need to adjust theforces contributing to the current equilibrium. The forcescontributing to this equilibrium are compensation and attrac-tiveness of the profession. The workforce crisis can also beaddressed by decreasing the workload at a practice level.

There are several potential policy levers involving com-pensation that could be used to better distribute the surgicalworkforce. Tax relief could be offered for providing uncom-pensated care. This could encourage practice in areas with abad insurance case mix. The current Medicare sustainablegrowth rate (SGR) could be replaced with a variable growthrate cap that favors practice in underserved areas. This couldgradually increase compensation for those practicing in un-derserved areas. Medicare stipends could be established forcall coverage where volumes are low (i.e., rural areas). TitleVII loan programs and loan forgiveness could be extended tocover surgeons who practice in underserved areas.

Several policies could be pursued at the level of the pro-fession to address maldistribution. A surgery specialty couldbe created and made attractive that better reflects the needs ofunderserved areas. There is precedent for this type of solution,as occurred in response to a problem of coverage of emergen-cy care and trauma. The creation of trauma and acute caresurgerymodels has solved the call coverage problems in urban

Fig. 5 Change in surgeonworkplace (general, specialized,and superspecialized) per capitabetween urban and rural areas,1996–2005 (reprinted withpermission from WoltersKluwer Health)


hospitals and allowed general surgeons to focus on theirelective practices.

The shortage of general surgeons can also be addressed atthe practice level by recognizing the fact that we have beenapproaching the problem using a paradigm in which demandwill only increase.26 The Balanced Budget Act of 1997capped the supply of physicians but demand continues toincrease. This ever increasing demand is an extrapolation ofthe post-World War II era where demand for healthcareparalleled the rise in gross domestic product (GDP). Theeffective supply of physicians is even lower based on newerphysicians demanding a better lifestyle with decreased hoursworsening the problem. Although some increased demand isto be expected with an aging population, if this graph isfollowed out far enough, the ratio of physician to the popula-tion becomes 1:1. Looking at the need to increase supply tomeet increasing demand is the wrong approach. Efficient,high-quality, cost-effective healthcare should not require moresurgeons per capita over time.

We need to look at how we can bend the demand curve notincrease supply to meet demand. Focusing on higher qualitycare increases the delivery of care to more patients by reduc-ing time dealing with complications. Better coordinated carewith more efficient processes so that a larger part of thephysician’s time is spent taking care of patients and better taskallocation so that physicians can “work at the top of theirlicenses.” Currently, in many systems, a large part of time isspent doing things that nonsurgeons could do, such as admin-istrative tasks. Areas with a high surgeon per capita may be amarker for where this is not being done well.

In summary, there is a crisis in the surgical workforcerelated to distribution and specialization. Policies need tofocus on these issues and in particular, geographic distribu-tion. Simply expanding the overall surgeon workforce is not agood policy solution and would likely lead to unintendedharms (oversupply and higher costs). Policy should focus ondistribution, specialty mix, and creating better systems of care.

The Changing Paradigm of Urban and Rural Surgery

First, let us frame the situation: we are facing a medicalprofessional shortage, not just in general surgery. There arealmost 1 million physicians across the US, a ratio of 320doctors per 100,000 Americans. The AAMC estimates thatthe current shortage is nearly 14,000 physicians, and the “toofew” are maldistributed. The GME cap on residency slots hasnot been changed since 1997; the Accountable Care Act doesnot lift the cap but redistributes 65 % of unused slots toprimary care, as an estimated 7,200 additional primary carephysicians will be needed. There is a need for 7 generalsurgeons per 100,000 population; nationally, we are at 5.8/100,000, a drop of 26 % in the last 25 years.27 Rurally, this

ratio is only about 5/100,000 and only 4.3/100,000 for smallnonadjacent rural counties. The 7 % of general surgeons inrural practices serve 60 million people, or 24 % of the popu-lation. Nearly 1,000 counties in the US do not have a generalsurgeon. As for the current work force, the majority of ruralgeneral surgeons are approaching retirement age with anaverage age of 58.28 Women make up a larger proportion ofthe rural general surgery workforce; their proportion rose from1.0 % in 1981 to 8.9 % in 2005; unfortunately, ABS datareveal that women general surgeons perform 25% fewer casesper year than their male counterparts.3

One frequent solution offered is to increase the number ofresidents being trained. If all accredited programs increasetheir resident complements to the maximum, another 1,500surgeons would graduate, starting 5 years from theinception.27 The cost, however, would be in the billions ofdollars, and there is no guarantee that any more than thecurrent minority of current finishing residents would go intorural or urban general surgery. The result would be an expen-sive increase in the current maldistribution.

Rural general surgeons are perhaps the only surgeons whopractice the full breadth of their specialty. Indispensable totheir hospitals and communities, they provide general surgicalcare as well as trauma and critical care, endoscopy, and often,obstetrical backup. Without a committed general surgeon,many rural hospitals would have to close or limit services.Primary care providers are also unwilling to practice in alocation without surgical backup.28,29 In the absence of surgi-cal services, small hospitals often fail, which reduces commu-nity employment, jeopardizes local health care, and discour-ages business development. Research from the National Cen-ter for Rural Health Works indicates 10–15 % of the jobs inmany rural counties are in the health care sector, with hospitalsthe second largest employer trailing only local schoolsystems.29 The potential loss of a general surgeon in a ruralhospital represents a substantive economic risk. Patients whogo elsewhere for general surgery are more likely to bypassother local services. In addition, the loss of general surgery-linked emergency department volume can affect not onlyrevenues, but also community views of local quality. A gen-eral surgeon generates $1.4 million dollars for the hospitalfrom patient activity.29 Using the multiplier effect, the eco-nomic importance of a general surgeon to a hospital and acommunity is approximately $2.7 million in revenue, $1.4million in payroll, and 26 jobs created.29

In a large survey of hospital administrators, 83 % said theirgeneral surgery programs were essential to the overall finan-cial stability of their hospitals. Another 12 % thought theywould have to close if they could no longer offer generalsurgery programs.29 One third of hospital administrators saidthey are actively recruiting a surgeon and reported that theyhadmore problems recruiting a general surgeon than a primarycare physician, taking a median of 12 months to fill a vacancy.


Research shows that the scope of urban and rural generalsurgical procedures is often markedly different. It is difficult toidentify a single definition that would describe every ruralgeneral surgeon or the routine procedures that they perform.Experience, personal preference, and/or subspecialty trainingwill affect the types of procedures that general surgeons willperform on a routine basis. Nevertheless, there is a distinctneed for more broadly based general surgeons in both urbanand rural areas.30,31

Several strategies should be considered. The ACS regent,James Elsey, lists the potential reasons restricting the influx ofcommunity general surgeons as follows: medical technologyinfrastructure, lower reimbursement, professional isolation,shallow medical/consultative/tertiary care back-up, fewer“general surgeons” in the market, and the lack of neededcompetencies in graduating residents.32 Thomas Cogbill re-ports that the residency review committee (RRC) and ABSmake it problematic for residents to get enough electives inrural surgery.30 Also, fewer surgery residency graduates todayappear to be willing to take on a rural general surgery practicewith its professional isolation, heavy call burden, and lack ofsubspecialty support. Both experts suggest that authoritiesmust design a curriculum specifically for rural practice withenough flexibility to allow extra training in endoscopy andsurgical subspecialties. Currently, just over 36 % of surgeryprograms have reported what they consider to be a ruralcurriculum.

Other specific strategies listed in Cogbill’s salient articlesare as follows: consideration should be made for admission ofmedical students likely to choose rural careers, such as thosefrom rural locations; focusing medical school expansion ef-forts upon the shortage of rural physicians, legislation, andtuition and/or loan remission. Others policy considerationsinclude lifting the current cap on graduate medical educationtraining positions for residency programs that produce ruralphysicians that include experience in endoscopy, obstetricsand gynecology, orthopedics, and otolaryngology, and in-creasing reimbursement for general surgeons, especially thosein rural and underserved settings.30,31

Finally, two lessons learned from the field of economics arethat (1) incentives motivate behavior and (2) when supplydecreases as demand increases, only an increase in price(reimbursement) and/or governmental action can recreateequilibrium. With all of the negative incentives, includingprice (reimbursement), discussed above, we must look to ourpolitical leaders to align with initiatives that benefit our pa-tients and practice in order to emerge from the crisis.

Conclusion

The general surgeon shortage is due to a complex interactionof a changing healthcare system, increased drive to select

subspecialization, societal norms, reimbursement, changingpractice, and surgeon lifestyle desires. The problem has mostfrequently been considered in an environment of increasingdemand and answered with calls for increasing supply. Theproblem is more accurately defined as too many specialistsand a geographic maldistribution of the available workforce.The demand aspect does not have to be viewed as everincreasing. Improvement in quality and efficiency could actu-ally decrease demand for surgical services. The specializationand maldistribution affects rural areas most directly but alsoeffects urban areas in terms of cost, efficiency, and systemquality. The specialization problem is not going to change inthe current environment. The early tracking of residents couldultimately save a year of training for surgical residents andenrich the training of residents going into general surgery.Increasing exposure to broad-based practices in general sur-gery and concentrating complex GI cases for residents prac-ticing general surgery will address some of the forces favoringspecialization. Developing rural-focused training programsand increasing trainees from rural backgrounds will havesome impact in maldistribution. On their own, these measureswill not solve the problem. For that, we need to change theincentives that control the equilibrium between specializationand broad-based general surgery and the equilibrium betweenurban and rural practice. The strongest force driving special-ization and maldistribution is money, and changing reim-bursement models that drive these trends is needed.

Disclaimer The views expressed in this article are those of the authorsalone and do not reflect the official policy of the Department of the Army,Department of Defense, or the United States Government.

References

1. Polk HC, Jr., Bland KI, Ellison EC, Grosfeld J, Trunkey DD, StainSC, and Townsend CM. A proposal for enhancing the general surgi-cal workforce and access to surgical care. Ann Surg, 2012.255(4): p. 611–617.

2. Goldberg R, Reid-Lombardo K, Hoyt D, Pellegrini C, Rattner D,Kent T, Jones D, and SSAT PPACot. Will There Be A Good GeneralSurgeon When You Need One? Journal of Gastrointestinal Surgery,2013 [Epub ahead of print].

3. Lynge DC, Larson EH, ThompsonMJ, Rosenblatt RA, and Hart LG.A longitudinal analysis of the general surgery workforce in theUnited States, 1981–2005. Arch Surg, 2008. 143(4): p. 345–350;discussion 351.

4. Williams TE, Jr. and Ellison EC. Population analysis predicts a futurecritical shortage of general surgeons. Surgery, 2008. 144(4): p. 548–554; discussion 554–546.

5. Longo WE, Sumpio B, Duffy A, Seashore J, and Udelsman R. Earlyspecialization in surgery: the new frontier. Yale J Biol Med, 2008.81(4): p. 187–191.

6. Lewis FR. Comment of the American Board of Surgery on therecommendations of the Institute of Medicine Report, “Resident


Duty Hours: enhancing sleep, supervision, and safety”. Surgery,2009. 146(3): p. 410–419.

7. Bucholz EM, Sue GR, Yeo H, Roman SA, Bell RH, Jr., and Sosa JA.Our trainees’ confidence: results from a national survey of 4136 USgeneral surgery residents. Arch Surg, 2011. 146(8): p. 907–914.

8. Coleman JJ, Esposito TJ, Rozycki GS, and Feliciano DV. Earlysubspecialization and perceived competence in surgical training: areresidents ready? J Am Coll Surg, 2013. 216(4): p. 764–771; discus-sion 771–763.

9. Stain SC, Biester TW, Hanks JB, Ashley SW, Valentine RJ, Bass BL,and Buyske J. Early tracking would improve the operative experienceof general surgery residents. Ann Surg, 2010. 252(3): p. 445–449;discussion 449–451.

10. Hudkins JR, Helmer SD, and Smith RS. General surgery residentpractice plans: a workforce for the future? Am J Surg, 2009. 198(6):p. 798–803.

11. Emanuel EJ and Fuchs VR. Shortening medical training by 30 %.Jama, 2012. 307(11): p. 1143–1144.

12. Dill M and Salsberg E. The Complexities of Physician Supply andDemand: Projections through 2025, 2008, Association of AmericanMedical Colleges: Center forWorkforce Studies: Washington D.C. p.1–94.

13. Association of American Medical Colleges. Statement on thePhysician Workforce, 2006, Association of American MedicalColleges: Washington D.C. p. 1–9.

14. The American College of Surgeons Health Policy Research Institute.Change in Workforce Across All Surgical Specialties, 2006–2011.United States Atlas of the Surgical Workforce 2012 [cited 2013].

15. The American College of Surgeons Health Policy Research Institute.Change in Workforce in General Surgery, 2006–2011. United StatesAtlas of the Surgical Workforce 2012 [cited 2013].

16. American College of Surgeons Health Policy Research Institute. TheSurgicalWorkforce in theUnited States: Profile andRecent Trends, 2009.

17. Goodman DC and Fisher ES. Physician workforce crisis? Wrongdiagnosis, wrong prescription. N Engl J Med, 2008. 358(16): p.1658–1661.

18. Sirovich BE, Gottlieb DJ, Welch HG, and Fisher ES. Regionalvariations in health care intensity and physician perceptions of qual-ity of care. Ann Intern Med, 2006. 144(9): p. 641–649.

19. Fisher E, Wennberg D, Stukel T, Gottlieb D, Lucas F, and Pinder E.The implications of regional variations in Medicare spending. Part 2:Health outcomes and satisfaction with care. [Summary for patients inAnn Intern Med. 2003 FEb 18; 138(4):149; PMID: 12585852]. AnnIntern Med, 2003. 138(4): p. 288–298.

20. Fisher ES, Wennberg DE, Stukel TA, Gottlieb DJ, Lucas FL, andPinder EL. The implications of regional variations in Medicarespending. Part 1: the content, quality, and accessibility of care.[Summary for patients in Ann Intern Med. 2003 Feb 18;138(4):I36;PMID: 12585853]. Ann Intern Med, 2003. 138(4): p. 273–287.

21. Goodman DC, Fisher ES, Little GA, Stukel TA, Chang C-h, andSchoendorf KS. The relation between the availability of neonatalintensive care and neonatal mortality. N Engl J Med, 2002.346(20): p. 1538–1544.

22. Goodman DC. Twenty-year trends in regional variations in the U.S.physician workforce. Health Aff (Millwood), 2004. Suppl Variation:p. VAR90-97.

23. Makuc DM, Haglund B, Ingram DD, Kleinman JC, and Feldman JJ.Health service areas for the United States. Vital Health Stat 2,1991(112): p. 1–102.

24. Hart L, Morrill R, and Cromartie J. Use of RUCAs in healthservices research, in Academy Health Annual Conference2006:Seattle, WA.

25. Association AM. AMA Physician Masterfile, 2014, AmericanMedical Association.

26. Cooper RA. It’s time to address the problem of physician shortages:graduate medical education is the key. Ann Surg, 2007. 246(4): p.527–534.

27. Scalpel S. The shortage of general surgeons demands attention.KevinMD.com 2011 September 17, 2011 [cited September 28,2013].

28. Doescher M, Dana C, Lynge D, and Skillman S. The crisis in ruralgeneral surgery - Policy brief 4, 2009, University of Washington:Seattle.

29. Eilrich F, Sprague J, Whitacre B, Brooks L, Doeksen G, and St. ClairC. The Economic Impact of a Rural General Surgeon and Model forForecasting Need, 2010, National Center for Rural Health Works,Oklahoma State University: Stillwater.

30. Stain SC, Cogbill TH, Ellison EC, Britt LD, Ricotta JJ, Calhoun JH,and BaumgartnerWA. Surgical trainingmodels: a new vision. Broad-based general surgery and rural general surgery training. CurrentProblems in Surgery. 49(10): p. 565–623.

31. Valentine RJ, Jones A, Biester TW, Cogbill TH, Borman KR, andRhodes RS. General surgery workloads and practice patterns in theUnited States, 2007 to 2009: a 10-year update from the AmericanBoard of Surgery. Ann Surg, 2011. 254(3): p. 520–525; discussion525–526.

32. Elsey JK. A regent’s perspective. Bull Am Coll Surg, 2013. 98(4): p.59–62.

The following are members of the SSAT Public Policy Committee:KMarie Reid Lombardo, M.D., M.S., ChairEdward D. Auyang, M.D.David Bentrem, M.D.Clancy J. Clark, M.D.Ross F. Goldberg, M.D.Matthew M. Hutter, MD, M.P.H.Timothy M. Iseri, M.D.Daniel B. Jones, M.D., M.S.Tara S. Kent, M.D., M.S.Kui Hin Liau, M.D., FRCSDavid J. Maron, M.D.Marek Rudnicki, M.D.Shean Satgunam, M.D.Bruce D Schirmer, M.D.Thomas Schnelldorfer, M.D.Richard Smith, M.D.Steven D. Schwaitzberg, M.D.Daniel Tseng, M.D.Randall S. Zuckerman, M.D.


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