Monday, May 11, 2009

Where have the surgeons gone?

Addressing the surgeon shortage

Dr. Andrew Warshaw

This spring, 400 surgeons from American College of Surgeons (ACS) convened in Washington D.C. to speak with lawmakers about a shortage in their workforce that could negatively impact patient care. Both rural and urban areas of the United States are facing a critical shortage in access to surgical care with the potential to overwhelm trauma centers and emergency rooms.

The problem is most prominent among general surgeons, who are specifically trained to provide comprehensive surgical care for a wide range of medical conditions and emergency cases. Despite their importance in the health care system, analysis of data shows a sharp decline in their numbers during the past 20 years. In fact, the number of general surgeons as a proportion of the population has declined by 25 percent since 1981, according to a study in the Archives of Surgery.

“In contrast, the numbers of primary care physicians has been growing, yet that issue gets much more political attention,” says Andrew L. Warshaw, MD, Massachusetts General Hospital surgeon-in-chief, who was among the surgeons working to bring light to this issue in Washington D.C.

The ACS argues that the number of general surgery training positions does not reflect the level of need among the population. There are 1,000 general surgery residency spots per year as set by the Balanced Budget Act of 1996, but a greater majority of graduates from these programs now go on to subspecialize and do not practice general surgery. In 1992 only half of all general surgery residents entered a training fellowship; now that number is 70 percent, according to the ACS.

The ACS is lobbying for legislation to increase the number of residency spots and to help establish new residency training programs. By providing a greater number of programs in previously underserved areas, the surgeon shortage could be reduced in many states, according to the ACS.

However, there are several factors contributing to the shortage, said Warshaw. General surgeons are retiring earlier and the training to replace them is extensive. In addition, the lifestyle of a general surgeon is more complicated than their counterparts in surgical specialties.

“General surgeons are often at the beck and call of the hospital. Many have to take emergency calls and trauma rotations, all contributing to a more hectic and disorderly lifestyle,” said Dr. Warshaw. “These and other stressors are combining to create the bottom line – there are not enough general surgeons.”

Surgical critical care

Building on the existing model of certified trauma centers, which must staff a trained trauma surgeon 24-hours per day, many hospitals are establishing fellowships to train surgeons in emergency general surgery to operate under the same principles.

Mass General established a Surgical Critical Care/Acute Care Surgery Fellowship within the Division of Trauma, Emergency Surgery and Surgical Critical Care in 2007. The first year of the fellowship develops advanced skills in treating critically ill patients, followed by a year of trauma and emergency general surgery training.

“First and foremost is when a patient comes into a hospital with an acute, life-threatening surgical condition, no matter what time of day or night, there will be a qualified surgeon who is comfortable and well-equipped to take care of them,” said Hasan Alam, MD, program director for the a Surgical Critical Care/Acute Care Surgery Fellowship. “We need to prepare a new breed of well-trained people who are comfortable taking care of these high-risk cases.”

Alam says there is a trend toward this type of training with several such programs established nationwide. There is also an effort to formalize the training. American Association for the Surgery of Trauma (AAST) is in the process of certifying acute care surgery fellowships that meet its standards.

“The reality is that the patient population is aging, resulting in more medical and surgical issues, and left unaddressed the shortage in surgeons will get worse over time,” said Alam. “Time will tell if these fellowship program will help eliminate the problem, but it’s certainly a step in the right direction toward providing the best surgical coverage and care for hospitals and patients.”

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