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How to rescue general surgery
The American Journal of Surgery (2012) 204, 541–542
Editorial Opinion
How to rescue general surgery The alarms concerning general surgery and its imminent demise are well known. Eighty percent of the finishing general surgeons take fellowships when they enter general surgical programs. This in itself should be cause for concern because it indicates that most would-be general surgeons entering as interns believe that they need to pursue further training after general surgical programs. Those programs that do produce general surgeons seem to be smaller, more rural programs that do not have specialists but have a number of excellent general surgeons who do most of the surgery and serve as role models for the residents. The shortage in general surgeons is perhaps worse in rural areas and has consequences far beyond just a surgeon retiring. The lack of surgeons to take call and cover trauma is resulting in patients dying because of the lack of surgical coverage. Indeed, the shortage of general surgeons has been highlighted by front-page articles in USA Today, a January 1, 2009, front-page article in the Washington Post and 2 weeks later in the Wall Street Journal. In addition, one of the major networks is pursuing a story concerning the general surgeon shortage. Senator Charles Grassley, the ranking Republican member of the Senate Finance Committee, in a recent hearing noted with some concern a 26% decrease in general surgeons. This is probably low according to American Medical Association data. However, not all individuals who take fellowships are lost to general surgery. A number (probably somewhat less than 10%) use their fellowship to enhance their practice of general surgery. Nonetheless, there is a crisis, and the duration of training and the length of the pipeline indicate that once the pipeline is broken it will be extraordinarily difficult to fix in less than 10 to 15 years. Furthermore, the margin that a general surgeon produces in a hospital (margin, not income) is 45%, and if the general surgeon retires or leaves, the hospital closes. Excellent data from the University of North Carolina has shown that once a hospital closes no business will move into a county in North Carolina (a growth state) for at least 5 years, making this disaster not only a health disaster but * Corresponding author. Tel.: ⫹1-617-754-9242; fax: ⫹1-617-7549230. E-mail address: [email protected] Manuscript received April 9, 2009
0002-9610/$ - see front matter © 2012 Elsevier Inc. All rights reserved. doi:10.1016/j.amjsurg.2010.01.035
also a business disaster. Good data from the Sheps Center showed that of the 47 counties in which a rural hospital closed, even a small hospital of 15 beds, no business would move into that county for at least the next 5 years. Finally, in families that have produced general surgeons where previously the grandfather was a general surgeon and the father was a general surgeon, the third generation is not a general surgeon. A few may persist, but this is considerably less frequent and is the loss of a valuable tradition. General surgery is the “mother church” as it were of all of surgery, and the loss of general surgery as a specialty will diminish all of surgery. General surgery deserves our support. Let me outline several steps that we, the general surgeons, and general surgeons who have become specialized as surgical specialists can take to preserve the specialty of general surgery. 1. The statement needs to be made that despite all of these discouraging trends and problems, general surgery is a great, very satisfying profession. 2. One thing overlooked when we speak of general surgery is the gratitude of patients that few other professions experience. 3. It is our obligation as general surgeons to ensure continued and even increased supply of general surgeons for the country and for the continued growth of the economy. What must we do? 1. Stop trashing the practice of general surgery. 2. Get together and support general surgery as the “mother church” from which all other surgery springs. 3. Emphasize the good thing about the practice of general surgery. How can we help make general surgery a viable specialty? 1. Vigorous socioeconomic representation at both a federal and a state level: this can come from increasing the value of CPT codes for general surgery. 2. Emergency cases, especially those in the middle of the night, should be valued higher.
542 3. Because general surgeons have become generalists, they need to be paid for the coordination of care. This is especially true, now, as most internists, especially in the urban setting, have stopped coming to the hospital and turn their patients over to hospitalists. The hospitalists care only about the patient while they are in the hospital, and the internist or family practice physician does not know what went on in the hospital except on a piece of paper or electronically but has not personally viewed the patient’s course within the hospital. Philosophically, the fact that primary care practitioners do not come to the hospitals at the time of the patient’s greatest need is very disappointing to me and constitutes abandonment of the patient. 4. Therefore, general surgeons must be paid for the coordination of care in the following settings: trauma and some complex patients. Remember that under these circumstances the general surgeon is the only one who has been present within the hospital and knows what exactly is going on throughout the hospital course and follow-up. 5. Prepare for surgeons a legal template to negotiate with hospitals over call, pay for call and limitations on call. Hospitals do not want to negotiate with groups of general surgeons saying that they will sue them for antitrust; however, there are legal ways, which are relatively straightforward, which general surgeons can use to negotiate as a group and be free of antitrust. The mechanism is for them to share risk. It does not need to be sharing total risk but parts of risk. In addition, it is our responsibility to prepare a legal template so that surgeons can easily follow this with the aid of an attorney so that they can negotiate with the hospital on the previously discussed issues. 6. If surgeons are to cover the Emergency Medical Treatment and Active Labor Act (EMTALA) and indigent patients for which they are not paid, that portion of malpractice insurance that they are required to cover should be paid for by the hospital. Again, a legal template for negotiation needs to be prepared by the leadership of general surgery to enable these surgeons to negotiate with the hospital without the risk of being sued for antitrust. 7. The leadership of general surgery must provide guidelines for the duration of on-call hours similar to what anesthesia has done. This is not “whimping out.” General surgeons deserve a life, and the patient deserves a general surgeon who is not exhausted.
The American Journal of Surgery, Vol 204, No 4, October 2012 8. A name for general surgeons must be fashioned. When most people hear that I am a general surgeon, the immediate response is “just a general surgeon?” I am not just a general surgeon, and neither are other general surgeons. We must come up with a name so that general surgeons are viewed as specialists. 9. Restore the dignity of general surgeons. Most general surgeons really feel that they are at the bottom of the hill, and everything rolls down on them. The concept “just keep them alive until I get there in the morning” by some specialists is not acceptable. If the general surgeon is to keep the patient alive, the person for whom they must keep the patient alive must be there with them. Otherwise, if there is an isolated injury, such as a fractured leg, the individual should be coming in themselves to take care of the patient. 10. Finally, although one hates to stress the socioeconomic aspects, a specialty cannot exist in which the person who is of that specialty cannot do the following 3 things simultaneously. a. Pay off their educational debt. b. Educate their children. The red line as I have said in the past (and a young surgeon recently reminded me of it) is when the general surgeon cannot afford to educate their children in the same college the surgeon attended. Surgeons are educationally driven. They put in as many as 15 to 18 years after graduation from high school in educational institutions and are very sensitive to educational quality. c. Prepare for retirement. Unless these 3 conditions are met, a specialty is nonviable. As “the mother church” of all surgery, general surgery deserves the support and the political help of other surgical specialties and indeed of all of surgery to survive. If we allow general surgery to fail, all of us will be diminished. Finally, as I follow the job market, it is not surgical oncology or hepatobiliary surgery in which lucrative offers of $380,000 to $450,000 abound. It is general surgery. It is time our trainees and medical students knew about these; they are not all in rural areas. Josef E. Fischer, M.D., F.A.C.S.* Harvard Medical School V. William, Renaissance Building 1135 Tremont Street, Suite 511–512 Boston, MA 02120, USA
Editorial Opinion
How to rescue general surgery The alarms concerning general surgery and its imminent demise are well known. Eighty percent of the finishing general surgeons take fellowships when they enter general surgical programs. This in itself should be cause for concern because it indicates that most would-be general surgeons entering as interns believe that they need to pursue further training after general surgical programs. Those programs that do produce general surgeons seem to be smaller, more rural programs that do not have specialists but have a number of excellent general surgeons who do most of the surgery and serve as role models for the residents. The shortage in general surgeons is perhaps worse in rural areas and has consequences far beyond just a surgeon retiring. The lack of surgeons to take call and cover trauma is resulting in patients dying because of the lack of surgical coverage. Indeed, the shortage of general surgeons has been highlighted by front-page articles in USA Today, a January 1, 2009, front-page article in the Washington Post and 2 weeks later in the Wall Street Journal. In addition, one of the major networks is pursuing a story concerning the general surgeon shortage. Senator Charles Grassley, the ranking Republican member of the Senate Finance Committee, in a recent hearing noted with some concern a 26% decrease in general surgeons. This is probably low according to American Medical Association data. However, not all individuals who take fellowships are lost to general surgery. A number (probably somewhat less than 10%) use their fellowship to enhance their practice of general surgery. Nonetheless, there is a crisis, and the duration of training and the length of the pipeline indicate that once the pipeline is broken it will be extraordinarily difficult to fix in less than 10 to 15 years. Furthermore, the margin that a general surgeon produces in a hospital (margin, not income) is 45%, and if the general surgeon retires or leaves, the hospital closes. Excellent data from the University of North Carolina has shown that once a hospital closes no business will move into a county in North Carolina (a growth state) for at least 5 years, making this disaster not only a health disaster but * Corresponding author. Tel.: ⫹1-617-754-9242; fax: ⫹1-617-7549230. E-mail address: [email protected] Manuscript received April 9, 2009
0002-9610/$ - see front matter © 2012 Elsevier Inc. All rights reserved. doi:10.1016/j.amjsurg.2010.01.035
also a business disaster. Good data from the Sheps Center showed that of the 47 counties in which a rural hospital closed, even a small hospital of 15 beds, no business would move into that county for at least the next 5 years. Finally, in families that have produced general surgeons where previously the grandfather was a general surgeon and the father was a general surgeon, the third generation is not a general surgeon. A few may persist, but this is considerably less frequent and is the loss of a valuable tradition. General surgery is the “mother church” as it were of all of surgery, and the loss of general surgery as a specialty will diminish all of surgery. General surgery deserves our support. Let me outline several steps that we, the general surgeons, and general surgeons who have become specialized as surgical specialists can take to preserve the specialty of general surgery. 1. The statement needs to be made that despite all of these discouraging trends and problems, general surgery is a great, very satisfying profession. 2. One thing overlooked when we speak of general surgery is the gratitude of patients that few other professions experience. 3. It is our obligation as general surgeons to ensure continued and even increased supply of general surgeons for the country and for the continued growth of the economy. What must we do? 1. Stop trashing the practice of general surgery. 2. Get together and support general surgery as the “mother church” from which all other surgery springs. 3. Emphasize the good thing about the practice of general surgery. How can we help make general surgery a viable specialty? 1. Vigorous socioeconomic representation at both a federal and a state level: this can come from increasing the value of CPT codes for general surgery. 2. Emergency cases, especially those in the middle of the night, should be valued higher.
542 3. Because general surgeons have become generalists, they need to be paid for the coordination of care. This is especially true, now, as most internists, especially in the urban setting, have stopped coming to the hospital and turn their patients over to hospitalists. The hospitalists care only about the patient while they are in the hospital, and the internist or family practice physician does not know what went on in the hospital except on a piece of paper or electronically but has not personally viewed the patient’s course within the hospital. Philosophically, the fact that primary care practitioners do not come to the hospitals at the time of the patient’s greatest need is very disappointing to me and constitutes abandonment of the patient. 4. Therefore, general surgeons must be paid for the coordination of care in the following settings: trauma and some complex patients. Remember that under these circumstances the general surgeon is the only one who has been present within the hospital and knows what exactly is going on throughout the hospital course and follow-up. 5. Prepare for surgeons a legal template to negotiate with hospitals over call, pay for call and limitations on call. Hospitals do not want to negotiate with groups of general surgeons saying that they will sue them for antitrust; however, there are legal ways, which are relatively straightforward, which general surgeons can use to negotiate as a group and be free of antitrust. The mechanism is for them to share risk. It does not need to be sharing total risk but parts of risk. In addition, it is our responsibility to prepare a legal template so that surgeons can easily follow this with the aid of an attorney so that they can negotiate with the hospital on the previously discussed issues. 6. If surgeons are to cover the Emergency Medical Treatment and Active Labor Act (EMTALA) and indigent patients for which they are not paid, that portion of malpractice insurance that they are required to cover should be paid for by the hospital. Again, a legal template for negotiation needs to be prepared by the leadership of general surgery to enable these surgeons to negotiate with the hospital without the risk of being sued for antitrust. 7. The leadership of general surgery must provide guidelines for the duration of on-call hours similar to what anesthesia has done. This is not “whimping out.” General surgeons deserve a life, and the patient deserves a general surgeon who is not exhausted.
The American Journal of Surgery, Vol 204, No 4, October 2012 8. A name for general surgeons must be fashioned. When most people hear that I am a general surgeon, the immediate response is “just a general surgeon?” I am not just a general surgeon, and neither are other general surgeons. We must come up with a name so that general surgeons are viewed as specialists. 9. Restore the dignity of general surgeons. Most general surgeons really feel that they are at the bottom of the hill, and everything rolls down on them. The concept “just keep them alive until I get there in the morning” by some specialists is not acceptable. If the general surgeon is to keep the patient alive, the person for whom they must keep the patient alive must be there with them. Otherwise, if there is an isolated injury, such as a fractured leg, the individual should be coming in themselves to take care of the patient. 10. Finally, although one hates to stress the socioeconomic aspects, a specialty cannot exist in which the person who is of that specialty cannot do the following 3 things simultaneously. a. Pay off their educational debt. b. Educate their children. The red line as I have said in the past (and a young surgeon recently reminded me of it) is when the general surgeon cannot afford to educate their children in the same college the surgeon attended. Surgeons are educationally driven. They put in as many as 15 to 18 years after graduation from high school in educational institutions and are very sensitive to educational quality. c. Prepare for retirement. Unless these 3 conditions are met, a specialty is nonviable. As “the mother church” of all surgery, general surgery deserves the support and the political help of other surgical specialties and indeed of all of surgery to survive. If we allow general surgery to fail, all of us will be diminished. Finally, as I follow the job market, it is not surgical oncology or hepatobiliary surgery in which lucrative offers of $380,000 to $450,000 abound. It is general surgery. It is time our trainees and medical students knew about these; they are not all in rural areas. Josef E. Fischer, M.D., F.A.C.S.* Harvard Medical School V. William, Renaissance Building 1135 Tremont Street, Suite 511–512 Boston, MA 02120, USA