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General Surgeon Shortage

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kurethmu

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Hello, I have been reading about this coming shortage of General Surgeons. I am interested in finding out what actual doctors think should be done in order to address this. Is the problem in the excessive hours required during residency or is it with too many hours after that? I have heard that Surgeons have to be on call all the time and that doctors in general cannot decide exactly what to do because insurance companies try to control them or keep them under their thumbs however they can. Would a reduction of hours and a boost in pay fix this problem? Thank you for your time.
 

pntgrd

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Hello, I have been reading about this coming shortage of General Surgeons. I am interested in finding out what actual doctors think should be done in order to address this. Is the problem in the excessive hours required during residency or is it with too many hours after that? I have heard that Surgeons have to be on call all the time and that doctors in general cannot decide exactly what to do because insurance companies try to control them or keep them under their thumbs however they can. Would a reduction of hours and a boost in pay fix this problem? Thank you for your time.

They'd need to boost the low reimbursements for surgeons, reduce long length of the difficult training, and fix the perception (which holds a lot of truth) fact that surgery will become a less common part of medicine as drugs and percutaneous operations done by non-surgeons improve.
 

JackADeli

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...been reading about this coming shortage of General Surgeons. I am interested in finding out what actual doctors think should be done in order to address this. Is the problem in the excessive hours required during residency or is it with too many hours after that? I have heard that Surgeons have to be on call all the time and that doctors in general cannot decide exactly what to do because insurance companies try to control them or keep them under their thumbs however they can. Would a reduction of hours and a boost in pay fix this problem? Thank you for your time.
...reduce long length of the difficult training, and fix the perception (which holds a lot of truth) fact that surgery will become a less common part of medicine as drugs and percutaneous operations done by non-surgeons improve.
I am going to try and address both posts.

I do think alteration in reimbursement would help. Surgeons do NOT get paid 30-50K for cutting off a leg. Medical students are less and less likely to extend training years and put off actually living a life if their future holds longer hours, higher risk, and effectively less pay then a PCP. A surgeon is at risk for injury during cases (either exposures or ergonomic/ortho/spine). A surgeon potentially exposes family and loved ones to their exposure. Surgeon, may try, but rarely has a 9-5/no weekends job setting. A surgeon gets a "global" payment for a procedure and this will cover any number of post-op visits during the "global period". The list goes on...... The current system (political & sometimes medical school) demonizes surgeons/surgical subspecialists and during the demonization a message is sent loud and clear..... Your future is uncertain!!! I remember the IM lecturer in medical school saying, "You look at a surgeon and you know why they are surgeons.... they deal best with patients that are onconscious".

As for the comments on reducing training..... the truth IMHO/IMPO is that 5 years focused and structured training is necessary. Reduction will cut performance. The ABS has made efforts to assure effective/modern teaching techniques and simulation components to enhance education. Surgical problems have NOT gotten easier or less. On the contrary, they have become more complex requiring greater skill. I do not see shortening training as a viable or reasonable option.

As for the " holds a lot of truth " perception that medicine is replacing the need for surgery.... I disagree. Medications are NOT replacing hernia repair, cancer resections (skin/breast/colon/gastric/pancrease/esoph/thyroid/etc....), wound surgery, diverticular colon disease, pancreatitis, gall bladder resection, majority of appendectomy, hemorrhoids, etc.... GSurgeons do soooo much and that is why their training requires 5 yrs. There is very little in GSurgery if anything that someone can point to and say no longer surgery just take a pill (only one I know of is gastric ulcer care).

As for on-call, it goes back to reimbursement and malpractice and other items. The volume of work a GSurgeon needs to do to maintain a reasonable compensation is large. This means less surgeons in a given area. Have you looked at hospitals advertising for surgeons???? The hospitals don't want subspecialists. They want a GSurgeon that will be Jack-of-All. i.e. "looking for GSurgeon willing do vascular, thoracic and take Q3 call.... competitive salary 220K...". One may look at that and say, "220K, that's great, it's better then FP at 120k..." Reality is for the RVUs and work for your 220k, you are not doing 5 days a week7:30/8am to 5/6pm with most weekends off. You are rounding early on post-ops, doing cases through the day, seeing consults between or after cases, rounding, getting home to be paged back about 7 days a week. The Q3 call usually means for "new" patients. Most practices I know, surgeon, even in a group, is on-call everyday for their own patients.

JAD

PS: yes, I am exagerating to the worst case scenarios in on-call example. You may not have to come in everytime your called. The problem is, you are called, you must make clinical decisions, and this means even out of the hospital/clinical you are actively on duty.....
 
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kurethmu

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So if understand correctly, you may make 200k a year, but you HAVE to work a whole lot of hours to get it instead of being paid alot per hour? That does seem like it would quickly wear a person down. But I have read about something called a Surgeon Hospitalist or something to that effect that works more of a set schedule. Does anyone know about that because the hours seem to be much less, which should result in less stress, or is there some catch that I haven't yet seen?
 

JackADeli

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So if understand correctly, you may make 200k a year, but you HAVE to work a whole lot of hours to get it instead of being paid alot per hour?....
That about sums it up....
...I have read about something called a Surgeon Hospitalist or something to that effect that works more of a set schedule...
You would be employed by the hospital. A few different models of this exist. The general idea is you get a set salary... plus/minus production bonus. You are expected to produce a set "RVU" volume to cover your salary. You generally do not worry about the negotiations with insurance companies/etc... But, you still take call, you are an employee, etc.... There are pros & cons to being employed vs private practice. However, you are still a surgeon and thus your hours will NOT be 9-5.

Keep in mind, it is a far different thing to sign out to your partner patients with hypertension/COPD/DM/etc.. then to sign out a patient status post colectomy for perforated diverticulitis or ex-lap for perf gastric ulcer or whipple or etc.... Thus, most are on-call for their individual patients even if not on-call for new/un-assigned patients.

JAD
 

Celiac Plexus

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Hello, I have been reading about this coming shortage of General Surgeons. I am interested in finding out what actual doctors think should be done in order to address this. Is the problem in the excessive hours required during residency or is it with too many hours after that? I have heard that Surgeons have to be on call all the time and that doctors in general cannot decide exactly what to do because insurance companies try to control them or keep them under their thumbs however they can. Would a reduction of hours and a boost in pay fix this problem? Thank you for your time.

General surgery is very stressful. General surgeons generally have the sickest surgical patients. They handle more life and death surgical emergencies than any other surgical specialty. They are often the first surgeon called for any possible surgical issue. The complications from many of the operations they perform are life-threatening.

The liability is atrocious. Malpractice for general surgeons is among the highest.

The reimbursement is the lowest of any surgical subspecialty. General surgeons get paid poorly for what they do. Can anyone explain why urology, ortho, ENT, and plastics pays so much more than general surgery?

The prestige of general surgery has eroded over the years.

The best reimbursed operations, with the best out-patient potential, have been poached away by other specialties.

Lifestyle minded medical students of today are not drawn to such demanding fields.

Most general surgery residents do 1-3 more years of training after general surgery just to be competent, and/or marketable in their area of interest.

These are all reasons why general surgery has seen its popularity dip.

It's hard to recommend general surgery to any med student today. There's just so many other attractive, stimulating, better compensated, and less stressful options.
 
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Blitz2006

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General surgery is very stressful. General surgeons generally have the sickest surgical patients. They handle more life and death surgical emergencies than any other surgical specialty. They are often the first surgeon called for any possible surgical issue. The complications from many of the operations they perform are life-threatening.

The liability is atrocious. Malpractice for general surgeons is among the highest.

The reimbursement is the lowest of any surgical subspecialty. General surgeons get paid poorly for what they do. Can anyone explain why urology, ortho, ENT, and plastics pays so much more than general surgery?

The prestige of general surgery has eroded over the years.

The best reimbursed operations, with the best out-patient potential, have been poached away by other specialties.

Lifestyle minded medical students of today are not drawn to such demanding fields.

Most general surgery residents do 1-3 more years of training after general surgery just to be competent, and/or marketable in their area of interest.

These are all reasons why general surgery has seen its popularity dip.

It's hard to recommend general surgery to any med student today. There's just so many other attractive, stimulating, better compensated, and less stressful options.

Interesting.

But then how come it is still so difficult for IMGs like myself to match into Gen Surg? (Compared to medical specialities like Neurology, IM and Peds).
 

JackADeli

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what types of operations are you referring to?
I think it is as the saying goes.... in the eye of the beholder.... But, some argue doing thyroids/parathyroids & adrenals is sweet (now enter fellowship trained GSurge or ENT). Others like the uncomplicated first time fem-pop and/or carotids.... Then, you have the "fellowship trained" MIS individuals that start to receive higher volumes of the elective lap choles & hernias..... Colorectal trained surgeon doing most of the bowel resections....
Interesting.

But then how come it is still so difficult for IMGs like myself to match into Gen Surg? (Compared to medical specialities like Neurology, IM and Peds).
So, I am going to pose an answer with some generalizations and hypothetical numbers.....

First, I do not think most GSurgery training programs are expanding/increasing class size.
Second, I believe there is still upwards of 20% drop/quit rate.
Third, not every trained GSurge resident practices GSurgery

So, let's look at it this way....
a) popularity may be diminishing. If in past years, we have 5 applicants to 1 training position. Now, maybe we have 2 applicants to one position (made up numbers).
b) population is growing, thus the need for GSurgeons is growing. ...but, amount of trained and practicing GSurgeons is not growing at equal rate....
c) Plenty of "senior" GSurgeons are retiring. Senior GSurgeons of old may have actually straddled 3+ subspecialties in some communities while at the same time accepting Q1 call.....

So, what's this mean.... likely a shortage. Think about it. Someone completes GSurge residency.... then does breast surgical oncology fellowship. He/she does not proceed to replace the retiring/dying GSurgeons. Someone completes GSurge residency.... then does vascular fellowship. Often, he/she does not proceed to replace the retiring/dying GSurgeons (some may do some GSurge). Someone completes GSurge residency.... then does cardiothoracic fellowship. He/she does not proceed to replace the retiring/dying GSurgeons. Someone completes GSurge residency.... then does plastic surgery fellowship. He/she does not proceed to replace the retiring/dying GSurgeons. The list goes on..... numerous folks don't want to do general/trauma/hemorrhoids/GI/woundcare/etc... components of surgery. Most want to focus on their subspecialty.

Back to IMG..... the shortage does not equate an absolute shortage of GSurge spots to applicants. The lack of popularity of this specialty does NOT equate increased popularity and interest in training IMGs. IMGs still in numerous cases fall into a secondary preference position.... Thus, it is still difficult for IMGs.

JAD
 
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Blitz2006

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Hey,

Thanks for that response. I guess you do have a point.

Like I've said in my other posts, GSurg is a dream for me. And I specifically want to do Trauma I think.

But again, after looking at IMG stats, only about 10% of GSurgeons are IMGs, and I'm sure most of those match into J1 Visas (I want H1b).

Sucks how legal issues can be a barrier.

You and Winged Scapula have been really helpful with your responses though.
Would you know of any GSurg programs in the States that are IMG friendly?

I've done tons of searches, and the only ones that seem to even offer H1B visa for Gen Surg are:

Emory
Albert Einstein at Yeshiva
Long Island Jewish
SUNY Downstate Brooklyn

Thats all I could come up with. Thats why I'm now deciding to drop the GSurg dream and do Internal Meds, where there are over 20-30 programs that offer IMGs H1b.

However, I plan on e-mailing a few GSurg program directors this week.

Thx again,

So, I am going to pose an answer with some generalizations and hypothetical numbers.....

First, I do not think most GSurgery training programs are expanding/increasing class size.
Second, I believe there is still upwards of 20% drop/quit rate.
Third, not every trained GSurge resident practices GSurgery

So, let's look at it this way....
a) popularity may be diminishing. If in past years, we have 5 applicants to 1 training position. Now, maybe we have 2 applicants to one position (made up numbers).
b) population is growing, thus the need for GSurgeons is growing. ...but, amount of trained and practicing GSurgeons is not growing at equal rate....
c) Plenty of "senior" GSurgeons are retiring. Senior GSurgeons of old may have actually straddled 3+ subspecialties in some communities while at the same time accepting Q1 call.....

So, what's this mean.... likely a shortage. Think about it. Someone completes GSurge residency.... then does breast surgical oncology fellowship. He/she does not proceed to replace the retiring/dying GSurgeons. Someone completes GSurge residency.... then does vascular fellowship. Often, he/she does not proceed to replace the retiring/dying GSurgeons (some may do some GSurge). Someone completes GSurge residency.... then does cardiothoracic fellowship. He/she does not proceed to replace the retiring/dying GSurgeons. Someone completes GSurge residency.... then does plastic surgery fellowship. He/she does not proceed to replace the retiring/dying GSurgeons. The list goes on..... numerous folks don't want to do general/trauma/hemorrhoids/GI/woundcare/etc... components of surgery. Most want to focus on their subspecialty.

Back to IMG..... the shortage does not equate an absolute shortage of GSurge spots to applicants. The lack of popularity of this specialty does NOT equate increased popularity and interest in training IMGs. IMGs still in numerous cases fall into a secondary preference position.... Thus, it is still difficult for IMGs.

JAD
 

JackADeli

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...Would you know of any GSurg programs in the States that are IMG friendly?...
I can not speak to what Visas they accept. However, you may try looking to North East, I think a program in Ct. accepts IMGs. The best thing you could do is sit down, open Frieda, look up programs in a region, then check ALL their websites to see what comprises their current resident classes. You can on numerous programs identify IMGs on the current class listing as most list the medical school from which they graduated. It shouldn't take you too long to get a general idea.

JAD
 

Blitz2006

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I can not speak to what Visas they accept. However, you may try looking to North East, I think a program in Ct. accepts IMGs. The best thing you could do is sit down, open Frieda, look up programs in a region, then check ALL their websites to see what comprises their current resident classes. You can on numerous programs identify IMGs on the current class listing as most list the medical school from which they graduated. It shouldn't take you too long to get a general idea.

JAD

Cheers,

One other quick question. Obviously and ideally, I want to match into a categorical spot. But lets say I match into Prelim Surg for PGY1.

Now after Prelim PGY1 Surg, lets say I can't swing into Categorical PGY2. What do most people do? Just switch into PGY1 of a non-surgical field like IM?

Thx,

PS. Sorry to the OP for Thread-Jacking.
 

kurethmu

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So General Surgery is the worst surgical specialty to go into as far as hours worked, responsibility, compensation, etc?
 

JackADeli

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...lets say I match into Prelim Surg for PGY1.

Now after Prelim PGY1 Surg, lets say I can't swing into Categorical PGY2. What do most people do? ...
PS. Sorry to the OP for Thread-Jacking.
At this point, I refer you to the search option on this forum. The topics of matching, not-matching, pre-lim and/or pre-lim to categorical positions, and IMGs has been discussed at length. Please do a search and post your question in such a thread. This will bring said thread back up on the list. Thus, you can contribute there and also bring past discussions to forefront for others to see that may share your interests/concerns.... saving them the time of the search.

JAD

PS: if you have trouble using search, you can look under individuals i.e. WS and others and look at their prior posts.... this may also find you previous discussions and advice by others without requiring duplication and reposting and/or "Thread-Jacking"
 

SLUser11

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So General Surgery is the worst surgical specialty to go into as far as hours worked, responsibility, compensation, etc?

Not really. General surgeons still get paid way more than an average non-proceduralist, and many of the low salaries are based on people wanting to practice where a saturation of surgeons exist. Go to small town Iowa and I bet you could make a fortune.

Hours worked is relative, and many of the people going into general surgery are workaholics......not everyone is forced to work 80 hours a week in practice. That being said, most practicing surgeons work around 60 hours a week....according to polls.

The threat of actually getting sued is dependent on your patient population, so once again subspecialty and geography factor in.




I would opine that general surgery is one of the best specialties because it gives you the tools to be one of the last true men-of-all-seasons in the hospital. You learn critical care, medical management, radiology interpretation (compared to most other specialties), and of course, a wide range of surgical skills. How much of this you want to use, or can use, in practice is once again dependent on location, etc.


JAD always cringes when I bust out the dreamy, self-righteous "hero work" surgeon identity......but you can't deny that general surgical training in a good residency program provides a larger skillset than most others.
 

JackADeli

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So General Surgery is the worst surgical specialty to go into as far as hours worked, responsibility, compensation, etc?
I wouldn't necessarily agree with it being put that way....
...JAD always cringes when I bust out the dreamy, self-righteous "hero work" surgeon identity......but you can't deny that general surgical training in a good residency program provides a larger skillset than most others.
:poke:
 

Playmakur42

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Go to small town Iowa and I bet you could make a fortune. GS learns...a wide range of surgical skills. How much of this you want to use, or can use, in practice is once again dependent on location, etc

The threat of actually getting sued is dependent on your patient population, so once again subspecialty and geography factor in.

From reading this forum, I've picked up on 2 different outlooks re: GS
1.) Other sub-specialties infringing on their procedure breadth &
2.) Still alot of opportunity for GS in small to mid-sized towns

I know none of us has a crystal ball, but was looking for some opinions:
Should a general surgeon planning to practice in a small to mid-sized town expect a viable practice with a wide variety of procedures, or will (s)he always be worried about a fellowship trained surgeon comng into the picture and siphoning off some of their procedures?

I was also curious as to which patients/locations were most litigious.
Thanks.
 

JackADeli

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...Should a general surgeon planning to practice in a small to mid-sized town expect a viable practice with a wide variety of procedures, or will (s)he always be worried about a fellowship trained surgeon comng into the picture and siphoning off some of their procedures?...
I can't speak to where/how much as far as litiginous...

Currently, it would appear there are numerous small town/rural areas specifically looking for GSurgeons willing to be the everything proceduralist. I would say some CEOs are specifically looking for it that way.... they can pay less then a subspecialist with a hope to "keep the business from going to the university". I have found some hospitals looking for GSurgeon willing to do as much as.... even C-sections.

What will the future hold? I don't know. I posted a thread question in reference to subspecialty practicing.
http://forums.studentdoctor.net/showthread.php?t=676286
I think patients may very well push a great deal of this and lawyers may also push a great deal. I remember enjoying greatly doing carotids and other procedures during GSurgery residency. As a surgeon, I have to consider if I am doing the best by my patients if I hang a shingle and offer to do their carotids, etc... dabble in a dozen a year as opposed to my patients traveling 50-100+ miles and get it done by a vascular surgeon that does over 100 per year.
http://forums.studentdoctor.net/showthread.php?t=676286

JAD
 

Playmakur42

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As a surgeon, I have to consider if I am doing the best by my patients if I hang a shingle and offer to do their carotids, etc... dabble in a dozen a year as opposed to my patients traveling 50-100+ miles and get it done by a vascular surgeon that does over 100 per year.

I did a quick search of various studies, and the results are varied. Some say high volume centers have better outcomes, and others say that's not the case.
Are there any "minimums" that have been recommended to remain skilled in different procedures? How does a surgeon "know" if (s)he is doing enough of a specific procedure to be doing the best for their patient by operating rather than sending them somewhere else?
 

JackADeli

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...Some say high volume centers have better outcomes, and others say that's not the case.
Are there any "minimums" that have been recommended to remain skilled in different procedures?...
I don't know all the details, but I think there is some "leap frog" statements on numbers. The numbers include things such as pancrease surgery, cardiac, esophagus, etc.... I don't know the numbers. i haven't searched the leapfrog statements yet. i also don't necessarily proclaim leapfrog to be the bible. it does however, set some baseline markers that folks look at as to if one should be practicing certain things...
i.e.:
https://leapfrog.medstat.com/pdf/final.pdf
http://www.ncbi.nlm.nih.gov/pubmed/15179361
http://www.aetna.com/provider/data/AIOQBariatricSurgeryFacilitiesCriteria.pdf

JAD
 
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umean2tellme

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Just a question that's been on my mind a while. What do you all think about training in gen surg in a more rural area vs a more metropolitan area like Miami? I would imagine in practice in a smaller area a G surg would be expected to perform a wider range of procedures b/c of the lack of specialists in the area, but as far as training would you get the same amount of exposure to such cases and if so would you learn them as well without the specialists to train you to do them? thanks.
 
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