General Surgery in Peril?
Richard Reznick
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General surgeons, broadly
educated and capable of performing
a wide spectrum of
surgical procedures, have long
been the backbone of hospitals
and the surgical community.
Unfortunately, a number
of trends have emerged in recent
years which suggest that general
surgery may be in serious
decline. This may be truer in the United States than in
Canada, but notwithstanding the major differences in
our health care systems, we often see changes that first
occur in the U.S. echo in Canada a decade later. In that
regard, we should be aware and concerned about some of
the current threats to general surgery that are occurring
south of the border.
A January 2009 Wall Street Journal article, entitled
"Surgeon Shortage Pushes Hospitals to Hire Temps" (1)
highlighted the growing practice of hiring locum tenens
through temporary staffing agencies to address general surgeon
shortages in U.S. hospitals. Instead of local surgeons,
many hospitals in the U.S. now have to staff their on-call
roster by procuring "temporary" surgeons at a high cost.
The WSJ article tells the story of Dr. Peppers, a
42-year-old general surgeon who has "hit the road".
Her typical month might now include a weekend in
Springfield, Oregon, followed by two weeks at a rural
Kentucky or New Hampshire hospital. Though she
misses her husband, she earns double her old salary and
has paid off a big chunk of her medical school debt. "I'd
much prefer to be in my hospital in my little town," says
Dr. Peppers, who is now licensed in five states. "But I
don't see how that's possible."
This shift from the traditional practice paradigm to
a modus operandi that requires general surgeons to shut
down their practices in favour of more lucrative transitory
assignments is symptomatic of many deep-seated
issues that are plaguing this specialty. The Wall Street
Journal article noted numerous causes to explain the
waning popularity of the traditional general surgery
practice, such as steep overhead expenses, reductions in
surgical fees, punishing schedules, and the lure of more
financially rewarding surgical specialities and subspecialties.
In Canada, we are beginning to see some parallels,
with the majority of our graduates in general surgery
seeking further training and pursuing careers in a subspecialty
of general surgery.
It is not beyond our imagination to see a five-person
surgical group faced with the following scenario when a
patient with a massively bleeding ulcer comes to the ER.
The colorectal surgeon is away at a national meeting.
The HPB has exceeded his mandated work hours for the
past 24 hours and is home. The breast surgeon doesn't
do emergency laparotomies. The minimally invasive
surgeon did only two open ulcer operations during her
residency training. And the surgical oncologist restricts
his practice to melanoma and sarcoma.
To quantify this issue, the WSJ article cited a study
published last year in the Archives of Surgery, which
found that the number of general surgeons per capita has
decreased by more than 25% since 1981 - a far more
precipitous decline than was evident in other surgical
specialties. (2) Not only has there been relative decline in
this specialty, but the absolute number of general surgeons
in the United States is decreasing. To compound matters,
this issue is manifesting itself at a time when the health
care system can ill afford to cope with a manpower issue of
this magnitude, given the increased burden posed by the
aging population. The situation is also exacerbated by the
advancing age of the average general surgeon.
As bad as this problem is, it doesn't seem likely that
it will be resolved any time soon. The specialty is losing
popularity with medical students and residents, which
does not bode well for the future. In the United States,
there is an increased number of unfilled general surgery
residency spots, more positions are given to lower ranked
students, and there is a substantial residency attrition
rate. Similarly, in Canada, analysis of the CARMS database
has revealed that the number of applicants selecting
general surgery as their first choice is in decline. (3)
Fortunately, this trend has not affected our own residency
program in General Surgery at U of T.
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Students are increasingly being attracted to more lucrative
specialties with more predictable schedules. For instance, it
has been found that there is a perception among many
female medical students that a career in general surgery is
incompatible with having a well-balanced family life. This
is a major issue in a time when around 50% of medical
students are female. (4) There are also generational issues
that will further reduce the ranks of general surgeons in
the future. Young medical students, both male and female,
are increasingly seeking to work reduced hours and opting
to apply to "controllable lifestyle specialties", which have
lighter workloads, predictable hours, and greater flexibility.
Of the students who do opt for general surgery careers,
more and more of them are choosing to narrow their
scope of practice and subspecialize. Currently, over 70%
of graduating general surgery residents pursue fellowship
training, compared with only 55% a decade ago. (5)
Moreover, with general surgery becoming increasingly
more sophisticated as a result of medical and technological
advancements, a specialized workforce will be in greater
demand, prompting more graduates to seek advanced
training. At the same time, the increasing sophistication of
the field means that it is less and less likely that a "general"
general surgeon will be able to master all the competencies
required to provide such a broad range of care.
While surgeon shortages haven't yet spawned a booming
temporary medical recruitment industry in Canada,
many trends playing out south of the border, such as
the shift to reduced hours, are being mirrored in the
Canadian health care system. In fact, it may not be long
before our hospitals will have to adopt similar measures
to address workforce shortages. The time has come for
us to consider ways to address the systemic problems
that threaten this specialty by tackling issues surrounding
training, lifestyle, workload, and compensation. If
current trends prevail, we will be faced with a deepening
shortage of general surgeons, and the specialty of general
surgery will continue to be under threat.
The Chair would like to thank Maggie Jugenberg for
her research and assistance with this column.
Richard K. Reznick
R. S. McLaughlin Professor and Chair
(1) Fuhrmans, V. Surgeon shortage pushes hospitals to hire
temps. The Wall Street Journal. January 13, 2009.
(2) Lynge CD, et al. A longitudinal analysis of the general
surgery workforce in the Unites States, 1981-2005. Arch
Surgery; 143:345-350, 2008.
(3) Marschall, JG. Karimuddin, AA. Decline in popularity
of general surgery as a career choice in North America: review
of postgraduate residency training selection in Canada, 1996-
2001. World J of Surg; 32(6), June 2008.
(4) Scott, IM. Matejcek, A. Gowans M, Diet, MN. Wright,
BJ. Brenneis, FR. Choosing a career in surgery: factors that
influence Canadian medical students' interest in pursuing a
surgical career. Can J Surg, Vol. 51(5), October 2008.
(5) Stitzenberg, K. Sheldon, GF. Progressive specialization
within general surgery: adding to the complexity of workforce
planning. J Am Coll Surg. Vol. 201, No.6, December 2005.
Two interesting approaches to this problem are discussed in "What is an Acute Care Surgeon and why do we need them?" (Spotlight Fall 2008) and the Editor's Column (Spotlight Fall 2007). Ed.
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