The Future of Surgery???

[Guitarzan the Jungle Man]

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Well, I've thrown my hat into the surgery ring, and I am wondering what the future holds for us general surgeons to be. My thoughts are...
The "general" surgeon practice will undergo a windfall due to lack of applicants for residency physicians. With the growing number of elderly people, surgery will be in increased demand, but will have fewer providers (decreased supply.) This will force 3rd party payer to increase reimbursment for various procedures or risk multiple hospitalizations and long term drug therapy for patients with gallstones and no one to take out the gallbladder.

Maybe this is rather simple thinking but I had an economics proffesor who routinly stated that..."all the equations in the world come back to the simple principle of supply and demand."

What do you guys think??

 

[bigfrank]

Your logic is somewhat accurate if this were a macroeconomic paradigm. However, as things usually are, your logic is incorrectly directed.

ALL of the surgery spots will eventually fill with DOs, non-matched MDs, IMGs, etc.

There will not be a shortage of surgeons, per se.

 

[Winged Scapula]

The current downward trend in popularity of General Surgery is simply a trend - one that changes every 5-7 years. The spots will be filled and eventually the field will become more competitive again.

The elderly population argument doesn't really work for me - most general surgery patients aren't really old, especially if you are focusing on belly procedures (ie, hernias, appys, choles, etc. - mostly younger patients). The real elderly do get partial and complete bowel obstructions and of course, often need some surgical SUBspecialty intervention (ie, CABG, urologic procedures such as TURPs) for other problems, but by and large the general surgery population isn't much older than 50s-60s and often quite a bit younger, IMHO.

 

[godfather]

things really aren't looking that good for surgery and in particular general surgery. the only hope i see for the field is a shortage perhaps helping the market out, but as the previous poster pointed out, there really won't be shortage as long as fmgs are willing to take spots(and they always will take a spot if it means being able to train here.) The fact is that the trend is always going to towards less invasive management and this means less surgeries will happen. however the place where gen surgery really hurt itself was in giving up so many well paying procedures to other fields. A couple that come to mind right away are the various gI scoping procedures which are completely lost to gi and bronchs which at the hospitols i've been at are entirely done by the pulmonologist. Alot of other procedures have been lost to interventional radiology (eg quinton cathers, which are done by nephrology or radiology) and i can even see anaesthesia moving in on both some of the procedures and running the icu's(which in some hospitols are run by them. Couple this with the fact that gen surgery depends on other specialties for their patients (ie they don't have their own patient base) and you can see why things look really bleak. I know a couple of the surgeons that are graduating this year and one is actually going to start of at 50 dollars an hour at a level 2 trauma center. another attending who's only two years out of residency was started off at 90k !!!(granted he is at an academic setting, but still this after a grueling 5 year residency). on top of all this this guy is in the hospitol so much that the running joke amongst the residents is that he is the intern of the year. And you can see the affects of all of this on what so many of the surgery residents are planning to do. I'd say more than half of the upper level residents are planning on doing some type of fellowship(plastics is the most popular) and of the earlier residents alot are bailing into anaesthsia. Surgery will always have my respect, i don't think there is another group of residents that endure so much so needlessly. I use to always bitch about the scutwork we had to do in all my rotations but after doing 3months of trauma surgery and taking Q3 call, and holding retractors for inhumanely long hours, i have never complained at any of my rotations again since and even working as an intern, is going to be like two steps down from how q3 call kicked my ass. I mean nothing beat gen surgery out of my system like q3 call.

 

[misfit]

Does anyone think this trend will force residencies towards a non-malignant and more resident/family-friendly model?

I have been in interested in surgery as a discipline for a while, but from what I've seen personally, it's far too abusive for me to spend five years of my life enduring it. I hope that changes, though.

 

[droliver]

Godfather,

I think your interpretation is off the mark re. the future of surgery. There is a huge demand for graduating residents, we get headhunters & phone calls all the time from people/towns desperately looking for associates. The large # of baby boomers portends an increase in the number of procedures that will be required and we get into an crisis-level issue of will there be enough surgeons to serve this population, especially outside of some of the most attractive locales.

Endoscopy (upper & lower) is a field done by many surgeons as part of their practices, but may vary by referral patterns. Lower endoscopy itself is also staring @ the new technologies which could drastically reduce their demand for screening purposes by all providers (see CT "virtual colonoscopies" & those mini pill-sized endoscopes that you swallow & take 100's of images as their transit).

ICU care @ many private hospitals is already a quagmire of multiple consultants, each of whom end up running an organ system. I'm not sure I see anesthesiologists wanting or being able to unilaterally control an ICU (especially as many new applicants go into anesthesia to avoid patient continuity/responsibility outside of the operating room).

As far as dialysis catheters,lines,etc... these are money losers for surgeons & are done out of courtesy in most instances to maintain realtionships with referring physicians. Although many surgeons will now not put central lines in at night as consultants any more b/c of liability and essentially no reimbursement.

For the single-best layed out position on the state of surgery I've ever heard I refer you to this link: <a href="http://archsurg.ama-assn.org/issues/current/rfull/sws1029.html" target="_blank">http://archsurg.ama-assn.org/issues/current/rfull/sws1029.html</a>

by Dr. J. David Richardson, one of my professors & the smartest and most thoughful physician I have ever met

 

[Stormreaver]

•••quote:•••Originally posted by godfather:
• there really won't be shortage as long as fmgs are willing to take spots(and they always will take a spot if it means being able to train here.)•••••This is only relevent if those IMGs have US nationality. A large number of them don't and have to return home after completing their residencies due to visa exigencies.

 

[EidolonSix]

Most of you have missed the issue that the contemporary surgeon no longer has the time to do so many things which his training may have exposed him to. One factor which swayed me from surgery was the growing trend into "niche" surgery, where a surgeon is exclusive to one area of anatomy and only a handful of procedures. Examples could be bariatric surgery, laproscopic surgery, etc...

Just as with nonprocedural specialties, the need for surgeons to see more and more patients for less reimbursement each has made it hard for one to have a diverse practice.

Not to say that this is God's truth or anything and I know the classic surgeons exist out there, but even in academia, you see this trend, where some classical general surgery cases are farmed out.

As for the shortage of surgeons, there really isn't one although surgery's notorious "selectivity" worked against it this year, as many "good" programs did not fill. It is an illusion. In medical school, we see overworked residents and faculty tackling ungodly amounts of patients...but this is not necessarily the case in private practice where young surgeons, yet to develop a rapport with referring docs, often "scrounge" for cases. Most fresh surgeons do not want to duke it out in the trenches of academia for one third the salary and twice the work. So as with all of medicine these days, the shortage is really a maldistribution of physicians.

 

[edmadison]

I agree with Eidolon. The growing subspecialization of Surgery is causing a narrowing of the field. Twenty-Five years ago the General Surgeon did everything: Vascular, Bowel, Breast, GI.... Now they do less and less. You're left with appendectomies, hernias, and choleocystectomies. Also with the movement away from traditional fellowships and into catagorical programs (Plastics, CT surg) what's next. I think it is more than just the usually cycle. I think it is also the changing field

Ed

 

[medstud721]

Our generation of doctors want cash and a good lifestyle. With general surgery you get neither. The day of general surgery is dead.

 

[Guitarzan the Jungle Man]

medstud all you just did was show you are dumb as a stump.

Anyway, I lament the fact that therre are really very few General surgeons around anymore, but this is not a phenomenon that is limited to just gen. Surg. All of medicine is becoming more and more subspeciallized. Even the vaunted Orth surg is beginning to become specialized into specific joints.
I suppose specialization is the wave of the future.

 

[EidolonSix]

True, "super specialization" beginning to run rampant. The sad thing is our patients and the bond that we develop as physicians suffer. Patients with multiple health problems are forced to see so many specialists....making appointments on time can be a full time job for some of them. Ultimately, no one has been able to say without a doubt that overall care is better....

Hey, lets give another round of applause for the lawyers, insurance companies, and news media for making medicine so much more difficult to practice, less rewarding, and more stressful for our patients.....Good show guys...good show...

"What do you have when you send 10000 lawyers to the bottom of the sea....
...
...
...a good start"

 

[droliver]

•••quote:•••Originally posted by EidolonSix:
•
As for the shortage of surgeons, there really isn't one although surgery's notorious "selectivity" worked against it this year, as many "good" programs did not fill. It is an illusion. In medical school, we see overworked residents and faculty tackling ungodly amounts of patients...but this is not necessarily the case in private practice where young surgeons, yet to develop a rapport with referring docs, often "scrounge" for cases.•••••This perception really shows a lack of understanding about how serious the workforce issues are in surgery right now. If you live in Georgetown, Manhattan, Paolo Alto, or Charleston you may not have a problem finding a surgeon willing to take care of you if you have insurance & your problem is elective. If you're uninsured or have complex problems or get sick @ night or on the weekend, you might have a hard time getting timely care even in the larger cities. Outside the major metropolitan areas or boutique smaller areas, there are whole counties and large areas of every state where there are no surgeons available despite desperate & lucrative recruiting efforts by headhunters. The problem reflects both a distribution AND numerical problem.

 

[halothane]

Well the way things look now.....the only way a surgeon can feel $$ worthwhile going into surgery is to specialise. With the advent of more and more non invasive procedures there is only bound to be less stuff for a surgeon to do...( this means trouble for us anesthesia folks too...compounded by the CRNA issue, luckily we cater to a wide variety of surgeons and interventionalists, more than demand and supply our task right now would be to break the attack of the CRNAs, this done our bread and butter and the future of the speciality will be intact). Still a smart way for surgeons to save the profession would be to keep a keen eye on the market forces and accord adjustments to output. It is really not a pretty picture for a person to grope around for a job after 5 years of back breaking work.

 

[EidolonSix]

•••quote:•••Originally posted by droliver:
•

Originally posted by EidolonSix:
[qb]
Outside the major metropolitan areas or boutique smaller areas, there are whole counties and large areas of every state where there are no surgeons available despite desperate & lucrative recruiting efforts by headhunters. The problem reflects both a distribution AND numerical problem.•••••I agree with you droliver, but I would have to say maldistribution is probably the largest component. There still is no reason to get nasty about it though...

Speaking from experience, having spent time in underserved counties in Texas....many of the surgeons that do serve these areas are those who can't find work in the urban areas which they live...so they travel from town to town seeking referrals and cases. You may be correct in identifying a numerical problem and my opinion does not represent "a lack of understanding." However, the system has historically been built on the idea that a surgeon will maintain a certain case load, which is not maintainable in many rural counties with populations ranging from 5000 to 25000 people. The evolution of 3rd party payers precludes many people who need surgery from being served by their local surgeon, if indeed they are uninsured...therefore requiring them to be sent to public institutions with missions to provide care to the underserved.

So the present system is overtaxing our public health resources with 40% of the total American population without insurance.....leading to both a maldistribution and numerical shortage of doctors in these arenas...

Also of note is that it is the ACS itself that dictates the number of surgical residents per annum....which, given the present crises in public health care would benefit from reforms in surgical education...namely through provision of adequate residents per population served, and work hour reforms (which would probably be possible with the former). I certainly don't think the system would be hurt by having more surgeons...but reality is that surgeons require resources i.e hospitals, surgical suites, trained personnel, to perform their work.....and these components are becoming harder to come by in many places outside of our urban strongholds. However I would say, that if you took all the surgeons in the country and spread them out evenly, per populations served, you would have at least adequate surgical coverage.

 

[droliver]

EidolonSix,

I didn't mean to infer any nastiness by implying that you misunderstand the situation. But indeed there is both anecdotal & real data to sound the alarm about workforce issues in both urban and rural areas. I for instance,train in a metropolitan area of over 1 million people & if not for some of our attendings taking disproportionate amts. of ER call for general surgery at several of the private hospitals, you would have a hard time finding a surgeon to see you at inconvenient times.

 

[EidolonSix]

Thanks droliver....sorry to take things the wrong way. The hard and fast numbers are hard to come by and the reality is that much of our health care crisis has nothing to do with the docs, which for the most part are still working the same grueling hours as in the past, but with less and less patient contact. As with surgery, one could ask why the geniuses in the American College of Cardiology felt that cutting back on the number of fellows 10 years ago was a good idea....despite the impending aging of the baby boomer generation.

I suppose my family heritage (I'm a third generation doc) lends me to believe that taking call and being available for your patients, despite its many inconveniences, is a duty required of the title...but then again most of my peers don't see it that way and choose to believe that the initials M.D. are all that make you a physician. I suppose I have missed the golden age of the Osler/Halsted mentality of medicine...but so be it.