HYPOTHETICAL FUTURE WITHOUT GENERAL SURGEONS

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Dropping reimbursement for general surgical procedures and increased everyday expenses. These issues combined to make the viability of a general surgery practice a more difficult proposition. What if this disturbing trend continues? Could medicine really withstand the loss of a general surgeon altogether?

You are listening to ReachMD, The Channel for Medical Professionals. Welcome to the Clinician’s Roundtable. I am your host, Dr. Mark Dolan Hill, Professor of Surgery and practicing general surgeon. Our guest is Dr. Dana Christian Lynge, Associate Professor of Surgery at the University of Washington School of Medicine and practicing general surgeon. Dr. Lynge is the lead author of research published by the Archives of Surgery and the National Shortage of General Surgeons.

DR. MARK DOLAN HILL:

Welcome Dr. Lynge.

DR. DANA CHRISTIAN LYNGE:

Thank you for having me.

DR. MARK DOLAN HILL:

We are discussing hypothetical future without general surgeons. Dr. Lynge, is this possible?

DR. LYNGE:

Of course, if general surgeons we like to think not, but history shows that things change. I had an interesting conversation recently with a friend of mine, who spent early part of his career as a family practitioner in remote area and now hold the position of high medical administration and research responsibility and we were talking about a joint research project and he asked about this paper on General Surgery Work, which I had published, which documented a 25% decline in number of general surgeons of 100,000 population, and we are talking little bit about the future of general surgery, and he said you know are Medical School Department for years has made great efforts to hype and promote family practice and emphasized its importance, but he said it is hard to attract medical students in many cases to go under the family practice because the hours are long and the remuneration is significantly less than others in medical endeavor. If you look at a lot of more remote areas of this country, many even not so remote, primary care physicians are being replaced by nurse practitioners and PAs. He said may be the same thing will happen with general surgeons, may be they will be replaced by physician extenders or ancillary personnel. I mentioned that somewhat in our paper because that’s what other people suggested, I don’t think that’s possible. There is no PA or nurse practitioner, who can offer the full range of general surgical services. The training is in no way equivalent. So, what will happen in rural areas? I don’t think presently, there is any substitute for a well-trained general surgeon, who provides most of the surgical trauma, critical care services in those areas and often by the way contributes to good deal of making the hospital financially viable because there is good literature to support the fact that provision of surgical services is profitable and often once they lose their surgeons, the small hospitals go under and that’s not only a crisis for the community in terms of provision of healthcare, but it often removes a large employer, but on the other hand for the demographic reasons, which I said in our paper and because of the perceived poor lifestyle of the real general surgeon would being on-call very frequently when having difficulty getting coverage for practice to go on vacation or go to meetings. It is very hard for a lot of real general surgeon to recruit partners. The question is will they be replaced and what happens if there are more and more communities without a general surgeon. I don’t think unless there is a sudden liberalization of loss in American Board of Surgery rules to let a lot of foreign trained surgeons into this country that there is a real substitute for a general surgeon that means that more and more communities are going to have to be flying or driving patients with acute surgical care problems out to urban centers for their care much like happens in say countries like Australia where you have a vast territory and people living in isolated circumstances. You know that is not only expensive, but probably not ideal and we already know that in terms of trauma that living at a rural location, which you had increased chance of mortality and particularly if you don’t have a well-trained general surgeon nearby. As far as urban areas go, a lot of what was the traditional turf of general surgeons has been <_____> up and you have people who do minimally invasive surgery and people, who do breast surgery, people, who do colorectal surgery, people who do endocrine or hepatic surgery. Will that really spell that death knell of the general surgeon hard to say, but still be the necessity for provision of emergency general surgical services such as the person, who rules in with perforated diverticulitis, perforated ulcer, appendicitis, necrotizing fasciitis, abscesses in the middle of night, who is going to take that if not the general surgeon? Perhaps the surgical hospitalist growing phenomena with somebody, who is trained in general surgery, who covers a shift and takes care of all the acute surgical emergencies, may be they will be the only last “general surgeon available in urban areas.” It's hard to say how things will unfold.

DR. MARK DOLAN HILL:

If you have just joined us, you are listening to the Clinician’s Roundtable on ReachMD. I am your host, Dr. Mark Dolan Hill and our guest is Dr. Dana Christian Lynge, Associate Professor of Surgery at the University of Washington School of Medicine and a practicing general surgeon. We are discussing a hypothetical future without general surgeons.

Dr. Lynge, when I was in medical school during the first few days all of the faculty asked the students what you are going to do when you finish medical school and there were of variety of answers and some said, well we are going to stay in the city and some said well I am going to go back to the small town I came from and help out there and when we finished medical school, they had the same discussion and they asked us the same question, and it was remarkable the percentage of graduates, who said well, we really want to stay in the city and we really want to be in the urban areas. When we talked about a shortage of general surgeons are we talking a real number shortage absolutely or is it just a mal-distribution from the city compared to the rural?

DR. DANA CHRISTIANLYNGE:

Well again, our paper documents 25% decline in the number of general surgeons relative to 100,000 population. It does not document inadequacy or shortfall in General Surgical Services, but again there’s a lot of reports in literature about problems with provision of at least emergency general surgery services in urban emergency rooms because of people being less willing to cover general surgical call either because they feel that they want to restrict their area of practice or they don’t feel qualified or they don’t feel that they are being paid for or they don’t like to perceive litigation exposure. So, there are many reasons. As far as provision of General Surgical Services in rural areas, the number of general surgeons in rural areas per 100,000 people is much less in general around 4 per 100,000 and sometimes as low as 2 per 100,000 as the average in rural areas, which varies between 5 and 7 per 100,000 and then especially in the American West, you have issues of geography, so might be 100s of miles to reach the next general surgeon. So, there is fewer on the ground out there and it is harder for those general surgeons in rural areas, who are as our paper showed tend to be older closer to retirement, tend to be predominantly male and nearer where half of medical students are female and increasing proportion of general surgeons are female. It’s harder for those surgeons out there to recruit replacements because of perceived poor lifestyle, more frequent call, harder to get away for vacations, harder to get away for continuing education and in some cases poor reimbursement. One thing I would like to say about your question though is that I think it does show something because most general surgery training takes place in urban highly sub-specialized settings. It makes it less likely that people can all of sudden choose to go to more rural areas. I think, it would help rural areas if some effort was made to include some training opportunities in rural settings and program such as Oregon Health Sciences, Cooperstown in New York, and others have rotations and/or fellowships or tracks where people interested in rural surgery do lot of their training in that setting and learn what it's about and what it takes to be successful and if it is attracted to them.

DR. MARK DOLAN HILL:

Now being in the city myself, a big city, the hospital that I am on staff at, there is a plethora of general surgeons. I mean there is no question that if every general surgeon said that they would be happy to take general surgery or trauma call, they would have more than they needed, but you look at the rural situation out in the country and the small hospitals where they really need surgeons. What are those hospitals going to do? What’s the viability of those hospitals, if they just can’t get general surgeons? I want you to look into your crystal ball and tell me what you think you will see for general surgeons, lets say 5-10 years down the line?

DR. DANA CHRISTIAN LYNGE:

I think in rural areas, you are going to see more and more of an effort for programs to train and prepare people for rural surgery by giving them rotations out or rural track or rural fellowship to prepare them to do that breadth surgery to give him the business trained around the small business. I think hospitals will have to make and perhaps if they want to keep people in those areas, will have to make more financial concessions to provide guaranteed locum tenens so that those surgeons can get time away from their practice for recreation and continuing medical education. In urban areas, I think that you will see more and more hospitalist, we are going to see more surgical hospitalist probably to cover emergency room call and/or hospitals remunerating general surgeons in order to get them to cover emergency room call, and I think probably general surgery training will morph into being more of a GI surgeon.

DR. MARK DOLAN HILL:

I want to thank our guest, Dr. Dana Christian Lynge. We have been discussing a hypothetical future without general surgeons. I am Dr. Mark Dolan Hill and you have been listening to the Clinician’s Roundtable on ReachMD XM157, The Channel for Medical Professionals. Be sure to visit our website at reachmd.com featuring on demand podcasts of our entire library and thank you for listening.