Opportunities to Create New General Surgery Residency Programs to Alleviate the Shortage of General Surgeons.

PURPOSE: To estimate the capacity for supporting new general surgery residency programs among U.S. hospitals that currently do not have such programs. METHOD: The authors compiled 2011 American Hospital Association data regarding the characteristics of hospitals with and without a general surgery residency program and 2012 Accreditation Council for Graduate Medical Education data regarding existing general surgery residencies. They performed an ordinary least squares regression to model the number of residents who could be trained at existing programs on the basis of residency program-level variables. They identified candidate hospitals on the basis of a priori defined criteria for new general surgery residency programs and an out-of-sample prediction of resident capacity among the candidate hospitals. RESULTS: The authors found that 153 hospitals in 39 states could support a general surgery residency program. The characteristics of these hospitals closely resembled the characteristics of hospitals with existing programs. They identified 435 new residency positions: 40 hospitals could support 2 residents per year, 99 hospitals could support 3 residents, 12 hospitals could support 4 residents, and 2 hospitals could support 5 residents. Accounting for progressive specialization, new residency programs could add 287 additional general surgeons to the workforce annually (after an initial five- to seven-year lead time). CONCLUSIONS: By creating new general surgery residency programs, hospitals could increase the number of general surgeons entering the workforce each year by 25%. A challenge to achieving this growth remains finding new funding mechanisms within and outside Medicare. Such changes are needed to mitigate projected workforce shortages.

Embrace the challenge: advice for current and prospective department chairs.

In this issue, Kastor discusses the challenges and responsibilities of a contemporary chair of medicine as described in interviews of 44 chairs. As a chair of surgery at the University of North Carolina at Chapel Hill for 17 years, the author of this commentary uses his own experiences to reflect on how the insights presented in Kastor's commentary can apply to department chairs in other specialties. Elements from Kastor's commentary, as well as additional observations from the author's tenure, may be sources of advice to future chairs of any department. The author concludes that, despite a changing health care environment and other significant leadership challenges, being a department chair is a rewarding job with many opportunities to pursue worthwhile objectives.

The employed surgeon: a changing professional paradigm.

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.

Projecting surgeon supply using a dynamic model.

OBJECTIVE: To develop a projection model to forecast the head count and full-time equivalent supply of surgeons by age, sex, and specialty in the United States from 2009 to 2028. SUMMARY BACKGROUND DATA: The search for the optimal number and specialty mix of surgeons to care for the United States population has taken on increased urgency under health care reform. Expanded insurance coverage and an aging population will increase demand for surgical and other medical services. Accurate forecasts of surgical service capacity are crucial to inform the federal government, training institutions, professional associations, and others charged with improving access to health care. METHODS: The study uses a dynamic stock and flow model that simulates future changes in numbers and specialty type by factoring in changes in surgeon demographics and policy factors. RESULTS: : Forecasts show that overall surgeon supply will decrease 18% during the period form 2009 to 2028 with declines in all specialties except colorectal, pediatric, neurological surgery, and vascular surgery. Model simulations suggest that none of the proposed changes to increase graduate medical education currently under consideration will be sufficient to offset declines. CONCLUSIONS: The length of time it takes to train surgeons, the anticipated decrease in hours worked by surgeons in younger generations, and the potential decreases in graduate medical education funding suggest that there may be an insufficient surgeon workforce to meet population needs. Existing maldistribution patterns are likely to be exacerbated, leading to delayed or lost access to time-sensitive surgical procedures, particularly in rural areas.

Get on your boots: preparing fourth-year medical students for a career in surgery, using a focused curriculum to teach the competency of professionalism.

INTRODUCTION: Few educational programs exist for medical students that address professionalism in surgery, even though this core competency is required for graduate medical education and maintenance of board certification. Lapses in professional behavior occur commonly in surgical disciplines, with a negative effect on the operative team and patient care. Therefore, education regarding professionalism should begin early in the surgeon's formative process, to improve behavior. The goal of this project was to enhance the attitudes and knowledge of medical students regarding professionalism, to help them understand the role of professionalism in a surgical practice. METHODS: We implemented a 4-h seminar, spread out as 1-h sessions over the course of their month-long rotation, for 4th-year medical students serving as acting interns (AIs) in General Surgery, a surgical subspecialty, Obstetrics/Gynecology, or Anesthesia. Teaching methods included lecture, small group discussion, case studies, and journal club. Topics included Cognitive/Ethical Basis of Professionalism, Behavioral/Social Components of Professionalism, Managing Yourself, and Leading While You Work. We assessed attitudes about professionalism with a pre-course survey and tracked effect on learning and behavior with a post-course questionnaire. We asked AIs to rate the egregiousness of 30 scenarios involving potential lapses in professionalism. RESULTS: A total of 104 AIs (mean age, 26.5 y; male to female ratio, 1.6:1) participated in our course on professionalism in surgery. Up to 17.8% of the AIs had an alternate career before coming to medical school. Distribution of intended careers was: General Surgery, 27.4%; surgical subspecialties, 46.6%; Obstetrics/Gynecology, 13.7%; and Anesthesia, 12.3%. Acting interns ranked professionalism as the third most important of the six core competencies, after clinical skills and medical knowledge, but only slightly ahead of communication. Most AIs believed that professionalism could be taught and learned, and that the largest obstacle was not enough time in the curriculum. The most effective reported teaching methods were mentoring and modeling; lecture and journal club were the effective. Regarding attitudes toward professionalism, the most egregious examples of misconduct were substance abuse, illegal billing, boundary issues, sexual harassment, and lying about patient data, whereas the least egregious examples were receiving textbooks or honoraria from drug companies, advertising, self-prescribing for family members, and exceeding work-hour restrictions. The most important attributes of the professional were integrity and honesty, whereas the least valued were autonomy and altruism. The AIs reported that the course significantly improved their ability to define professionalism, identify attributes of the professional, understand the importance of professionalism, and integrate these concepts into practice (all P < 0.01). CONCLUSIONS: Although medical students interested in surgery may already have well-formed attitudes and sophisticated knowledge about professionalism, this core competency can still be taught to and learned by trainees pursuing a surgical career.

The evolving surgeon shortage in the health reform era.

The evolving surgeon shortage is occurring at a time of societal change. For one of the first times in history, a scientific revolution is occurring while the organization of health care is also changing. With a demand for a more quality health care and a population that has both aged significantly and grown by ten million citizens each decade, the shortage of health care providers is problematic. For surgery, the shortage is particularly challenging. In 1981, 1047 surgeons were certified by the American Board of Surgery; in 2008, that number had dropped to just 909.

Increasing the number of trainees in general surgery residencies: is there capacity?

PURPOSE: General surgeons have decreased as a proportion of the total U.S. surgical workforce. Given the likelihood of increasing shortages of general surgeons, the authors evaluated available expansion capacity of existing general surgery residency programs. METHOD: In November 2009, the authors e-mailed a Web-based questionnaire to the program directors and coordinators of the 246 U.S. general surgery residency programs that were then certified by the Accreditation Council for Graduate Medical Education. RESULTS: Of the 246 programs the authors contacted, 123 (50%) completed the survey. Community hospital programs and academic programs had similar response rates (52% and 50%, respectively). Of the 115 program directors who responded to the relevant question, 92 (80%) reported sufficient existing case volume capacity to accommodate additional surgery residents. Both community and academic program directors reported modest expansion capacity: an average of 1.7 and 2.0 additional residents per year, respectively. Across all programs, the average additional capacity reported was 1.9 additional residents per year. An expansion of this size would increase the number of general surgery residency positions from 1,137 to 1,515 annually. After accounting for subspecialization, this increase of 378 residents would result in approximately 249 additional general surgeons entering the workforce per year after five years. CONCLUSIONS: Expansion capacity within existing approved general surgery residency programs is insufficient to meet the expected demand for general surgeons in the United States. Strategies to alleviate shortages include developing new training programs, cultivating new medical education funding streams, and changing the surgical training paradigm.

Characteristics of practice among rural and urban general surgeons in North Carolina.

OBJECTIVE: To examine variation in the practice patterns of individual general surgeons and how they differ between rural and urban areas of North Carolina. SUMMARY OF BACKGROUND DATA: Traditional physician supply analyses often rely on "head counts" and do not take into account how physicians' practice patterns differ. Practice characteristics including the volume and the breadth of services that a physician provides may be especially important in understanding the supply and distribution of specialists, such as general surgeons. METHODS: Cross-sectional study using physician licensure data linked with administrative records on all inpatient hospital discharges and all surgeries performed at freestanding ambulatory surgery centers in North Carolina in 2004. RESULTS: Total procedure volumes varied widely (interquartile range: 356-700). The average general surgeon in a rural county performed 54 different procedures at least once during the year, compared to 59 in counties with small urban areas and 62 in metropolitan counties. The 10 procedures that a general surgeon performed most frequently accounted for 72% of that surgeon's total annual procedures in rural counties, 67% in counties with small urban areas, and 66% in metropolitan counties. These rural metropolitan differences were smaller after controlling for secondary specialty and other surgeon characteristics. CONCLUSIONS: There was significant variation in the volume and scope of procedures that North Carolina general surgeons performed in the year. Many general surgeons in metropolitan areas performed an array of procedures that was broader than those in rural areas.

The global health workforce shortage: role of surgeons and other providers.

The debate over the status of the physician workforce seems to be concluded. It now is clear that a shortage of physicians exists and is likely to worsen. In retrospect it seems obvious that a static annual production of physicians, coupled with a population growth of 25 million persons each decade, would result in a progressively lower physician to population ratio. Moreover, Cooper has demonstrated convincingly that the robust economy of the past 50 years correlates with demand for physician services. The aging physician workforce is an additional problem: one third of physicians are over 55 years of age, and the population over the age of 65 years is expected to double by 2030. Signs of a physician and surgeon shortage are becoming apparent. The largest organization of physicians in the world (119,000 members), the American College of Physicians, published a white paper in 2006 titled, "The Impending Collapse of Primary Care Medicine and Its Implications for the State of the Nation's Health Care" [37]. The American College of Surgeons, the largest organization of surgeons, has published an article on access to emergency surgery [38], and the Institute of Medicine of the National Academies of Science has published a book on the future of emergency care (Fig. 10). The reports document diminished involvement and availability of emergency care by general surgeons, neurologic surgeons, orthopedists, hand surgeons, plastic surgeons, and others. The emergency room has become the primary care physician after 5 PM for much of the population. A survey done by the Commonwealth Fund revealed that less than half of primary care practices have an on-call arrangement for after-hours care. Other evidence of evolving shortage are reports of long wait times for appointments, the hospitalist movement, and others. The policies for the future should move beyond dispute over whether or not a shortage exists. The immediate need is for the United States, as a society, to commit to workforce self sufficiency in health care. The reliance on international graduates for more than 25% of the nation's physicians is a transnational problem. Reliance on IMGs, nurses and other health professions for the United States workforce is an issue of international distributive justice. Wealthy, developed countries, such as the United States, should be able to educate sufficient health professionals without relying on a less fortunate country's educated health workers. The 2000 Report of the Chair of the AAMC, the accrediting agency for United States and Canadian medical schools through the LCME, recommended expansion of medical school class sizes and expansion of medical schools [41]. For the past 25 years, the AAMC has supported a no-growth policy and the goal that 50% of USMGs be primary care physicians. In 2003, the AAMC developed a workforce center,-led by Edward Salsberg. The workforce center has provided valuable data and monitoring of the evolving workforce graduating from medical and and osteopathic schools in the United States. The NRMP, also managed by the AAMC, has begun useful studies analyzing the specialty choices of the more than 20,000 participants in the Match each year. The AAMC workforce policy was altered in 2006, and a 12-point policy statement was issued (see http://aamc.workforceposition.pdf). Three of the 12 points reflected significant change from past positions. They are a call for a 30% increase in physicians graduated by United States allopathic medical schools and an increase in residency positions now limited by the BBA of 1997. The recommendation that students make personal specialty choices reversed the prior recommendation that a majority of students enter primary care practice.