Access to Care and the Surgeon Shortage: American Surgical Association Forum

Sheldon, George F. MD, FACS

Disclosures

Annals of Surgery. 2010;252(4):582-590. 

In This Article

Response to Shortage of Doctors

It is generally acknowledged that we have a shortage of doctors, nurses, and other health care providers. As the Affordable Care Act (ACA) includes no provision to increase the number of doctors, it becomes incumbent on surgical leadership to adapt the existing resources to the realities of our current system. It seems unlikely that provision for the training of more physicians than is currently occurring will take place, as it is limited by GME funding.

Workforce shortages exist in all surgical fields. An immediate national shortage of 1300 general surgeons was predicted by Williams and Chris.[6] A Grover study suggests that the need for cardiothoracic surgeons will increase by 46% whereas availability decreases by 21%.[7] HRSA projects a 15% decrease in the number of cardiothoracic surgeons.[8] Etzioni estimates the amount of surgical work will increase from 14% to 47%.[9]

General surgery, the largest specialty, is under duress (Fig. 1). Described in a recent Journal of the American Medical Association article as a "unique universe," it is the backbone of all other specialties, especially in rural communities. Of the 3107 rural counties, 30% (925) have no surgeons (Fig. 2).[10]

Figure 1.

Figure 2.

Merritt Hawkins provides analysis of revenues that specialties bring to a hospital. Hospitals value full time surgeons with neurosurgeons leading the group, bringing in average revenues of $2,815,650, followed by orthopedists with $2,117,764 and general surgeons with $2,112,492. General surgeons play a unique role in trauma. In rural America their presence is essential for the viability of the small-town hospital. Moreover, the rural hospital is often the largest employer in the town (Fig. 3).

Figure 3.

General surgeons generated more revenue in 2010 than in 2007, which could be attributable to the growing shortage of this specialty. General surgery, considered by many doctors to be the "primary care of surgery" is allegedly declining in popularity among medical students because of income disparities with other surgical fields, but it still recruits a full complement of US Medical Graduates each year. A shortage of general surgeons is increasing per physician caseloads at hospitals and driving up physician generated revenue.[11]

Trends in the shortage of general surgeons, as in other specialties, have been exacerbated by specialization. Specialization historically occurred during the evolution of a career. More recently, it occurs as 2 years or more of a Fellowship after certification in general surgery. With more non-American Board of Medical Specialties (ABMS) fellowships offered, progressive specialization occurs in approximately 78% of all general surgery diplomates. In recent years, specialties that historically required general surgery before specialty fellowship (Cardiothoracic, Plastics, and Vascular) have discontinued the general surgery requirement. So the number of general surgery certificates has diminished accordingly. The estimates, courtesy of Dr. Frank Lewis, Executive Director of the American Board of Surgery (ABS), show that the annual number of certificates in general surgery will be 900. As it is unlikely that the growth of physician numbers will parallel current population growth, maximizing their services is best accomplished by concentrating them regionally as appropriate.

Most current discussion of systems is based on the role of primary care practitioners and a system similar to an HMO. The primary care physician and nurse practitioner can provide care with Medical Home models and the like. Primary care physicians are at 77/100,000 which is within Council On Graduate Medical Education (COGME) workforce recommendations.[12] Primary care physicians are best deployed for complex chronic illness, and their care is especially useful in geriatric populations where a physician is challenged by coordinating care among a number of age-related illnesses. Thus, it seems logical for nonphysician providers to treat minor illness and give preventative care. The elderly make more clinic visits, are often undercared for, have 3 to 5 conditions, and require direct coordinated care by a primary care team.

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