General Surgery and Family Medicine are in the same boat

In its 21^st Report, Improving Value in GraduateMedical Education (1), the Council on Graduate Medical Education made an important recommendation. COGME looked at all of the data regarding the physician workforce and predictions of student specialty choice. Their Recommendation 2 states that “GME funding should be prioritized to accelerate physician workforce alignment with population and health delivery needs.” And even more specifically, that “increases in GME funding should be directed toward the following high priority specialties: Family medicine, Geriatrics, General internal medicine, General surgery, High priority pediatric subspecialties, Psychiatry. I have written a lot about family medicine and primary care, but why is general surgery on this list?

General surgery has been facing many of the same pressures that have afflicted family medicine over the past twenty years.(2) Between 1987 and 2002, the percentage of US allopathic seniors choosing general surgery declined from 7.8% to 5.8%. This occurred while the percentage of students choosing surgical fields remained fairly constant around 12%. This coupled with a 20% attrition from surgical residency programs is leading to a shortage of general surgeons.(3) And compounding the problem is that up to 80% of general surgery residents plan on completing a specialty fellowship after residency.(4) 

Why is this happening? When I was in medical school, the General Surgeons were to gods of the wards. They were terrible to behold—striking fear in medical students, residents, nurses, and staff alike. Their position was lofty. When we needed something important done, we could always count on the surgeons.  So, what happened?

In some ways, it is similar to what has happened to primary care. You could call them the primary care surgeons. (I would not want to offend them with this, but I mean it as a compliment). Those surgeons were true generalists. A good general surgeon could operate in the abdomen, the thorax, the breast, the extremities, even in the gynecologic organs. But then general surgery was picked apart. Graduating residents wanted to confine their practice to a particular area. Maybe they did not like doing breast biopsies and mastectomies, so they limited themselves to the abdomen. Maybe, their friend was the gynecologist in town and did not like them doing hysterectomies because it took away some of their business. Maybe, they did not do enough vascular surgeries to remain competent. Over time, all of these factors, and others (reimbursement, hospital privileging, and local politics) led to general surgeons who were more limited in their scope of practice.

The interesting thing about academic medicine is that residents tend to practice like their teachers. So, when academic general surgery started to fragment, residents and students started to see that as the norm. If you look at a Department of Surgery in a major academic medical center, there are surgeons who operate only on the colon, who only do transplants, who only operate on the liver, and who only do trauma. If you step back a bit, there are now Departments of Urology, Orthopedics, Neurosurgery, etc.  In the past, those were all part of the Department of Surgery. Dean’s offices at medical schools around the nation are happy with things this way. Each time they created a new department, the dean had another department and chair to tax for more money for the Dean’s office. Recruitment is easier too. It is getting pretty hard to find the surgeons that want to do everything.

I used to joke that someday we would have Left Pinky Finger Doctors, but now I am worried that may really happen. It has already happened in other specialties. More than 80% of graduates of Internal Medicine residencies choose to complete further specialty fellowship training, in endocrinology, nephrology, infectious diseases, and others. Most of those doctors only practice in their sub-specialty area without any general medicine. Pediatrics, has seen this also in a smaller way (only 40-50% of graduates sub-specialize). And now, General Surgery is going the same way.

I think it is a great loss to our profession! When all of those “old” guys have died out, we will have lost something important.

References

(1)  The Council on Graduate Medical Education. 2008. 21^st Report, Improving Value in Graduate Medical Education. http://www.hrsa.gov/advisorycommittees/bhpradvisory/cogme/Reports/twentyfirstreport.pdf

(2)  http://usatoday30.usatoday.com/news/health/2008-02-26-doctor-shortage_N.htm

(3)  Newton D, Grayson M. Trends in Career Choice by US Medical School Graduates. JAMA. 2003; 290(9): 1179-1182.

(4)  Fischer J. How to rescue general surgery. Am J Surgery. 2012; 204(4): 541–542.]