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General Surgery in Peril?

Richard Reznick
Richard Reznick
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.

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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