Schwartz lecture raises issues over national shortage of surgeons
Even though there is an increasing shortage of surgeons in several key specialties across the United States, the need for general surgeons in urban and rural areas has reached crisis levels, according to Dr. David Richardson, Vice Chair of the Department of Surgery at the University of Louisville and a past president of the American College of Surgeons (ACS). Richardson delivered this news as the special guest lecturer at the fourth annual Richard W. Schwartz, MD Memorial Lecture and Surgical Symposium on Thursday afternoon, November 16th.
Organizers of the symposium,Drs. Andrew Bernard and David Sloan, faculty members with the University of Kentucky Division of General Surgery, and Janet Schwartz Evans, streamlined the event’s format to feature just two guest presentations before the Schwartz Memorial Lecture. A good portion of the afternoon was given over to two sessions of resident case presentations. The addition of case presentations was appropriate for an event established in memory of Dr. Richard Schwartz, said Dr. Sloan during the event’s opening remarks.
The late Dr. Schwartz was a noted gastrointestinal surgeon and a respected member of the UK College of Medicine faculty. Surgical education and the development of new physician leaders was his passion, one that garnered him national recognition and led his wife, Janet Schwartz, and his colleagues to establish the annual symposium and lecture series in his memory.
“It was not unusual to see a half-dozen residents hanging out in Dr. Schwartz’ office talking about cases and getting his feedback,” said Dr. Sloan.
Science symposium presenters included Dr. Matthew Shane, an alum of the UK general surgery residency program, who is currently in private practice with the Lexington Surgeons. The other presenter was Dr. Joseph Iocono, chief of pediatric surgery at UK and a co-director of the UK Department of Surgery Education program.
Dr. Shane’s presentation, Is Private Practice General Surgery Dead?, addressed the viability of surgeons entering private practice in the coming decade. Dr. Iocono’s presentation, Is There Any Time Left to Teach? – Teaching Surgery in the Era of Competency, touched on the challenges faculty experience in contemporary surgical education when trying to teach and document residents’ development toward autonomy and manage their own professional practice.
While both presentations touched on key issues with regard to resident training and surgical practice, it was Dr. Richardson’s lecture, “Are We Training a Surgical Workforce to Meet America’s Needs?” that introduced alarming information about the lack of access Americans have to general surgeons.
During his term as president of the American College of Surgeons (ACS), the organization commissioned the Sheps Center for Health Services Research at the University of North Carolina to conduct a study correlating the US population with the availability of surgeons. Included with the published results of that study was a map of the United States which Richardson displayed as part iof his slide presentation. The map identified large geographic areas that researchers termed “surgical deserts” where there was little to no surgery coverage within a 50-mile radius. Particularly hard hit were areas of the Midwest and South, Richardson said.
"Much has been written and reported on the shortage of surgeons serving rural areas of the country, but access is becoming increasingly difficult in even some major American cities," he said. Louisville, for instance, has a general surgery shortage. In New York City, there are many sections that lack enough general surgeons to meet the population. Richardson shared a personal story from a colleague in Crockett, Texas. When the local hospital closed in that community, access to the nearest available surgeon of any type, general or specialty, was a one and half hour drive in any direction, he said.
Adding further complications to the scenario is that the average age of urban and rural surgeons is also rising. Practitioners are retiring faster than residency programs can fill gaps. Studies indicate that the United States has suffered an annual net loss of active surgeons for the past 20 years.
“It is reasonable to say that we’re in crisis mode [in terms of access to available surgeons] in many parts of rural and urban America,” Richardson said.
There have been ongoing efforts to increase the number of practicing surgeons in the country. But few ideas have worked. Ideas that have not worked, he said, include expanding the number of general surgery residency programs, relying on the influence of free market forces, and appealing to the better nature of young surgeons.
“I used to think increasing the number of programs in the country was an answer, but I was wrong… I ask residents from time to time what they’d like to do professionally and some respond, ‘I’d like to provide international health.’ And that’s good…the next question I ask then is ‘Would you go to Whitesburg or a rural place like that to practice?’ and they look at me like I'm crazy. It’s good to want to provide help in shortage areas, but surgeons are not making the choice to provide services in these areas where shortages are most acute. I find that fundamentally troubling,” Richardson commented.
There are very few ideas being floated about at the federal level about dealing with this shortage. There has been ideas floated to return some basic surgery back over to primary care providers, "but I think that's dangerous." One of the more prominent discussions at the Centers for Medicare and Medicaid Services (CMS) have been about linking Graduate Medical Education (GME) funding directly to a resident and holding institutions accountable for the types of providers they produce.
If shortages persist, there is a potential danger for practicing surgeons going forward, he said. Changing payer models that favpr keeping patients out of the hospital have the potential of turning surgery departments from profit centers to cost centers for institutions. “We [surgeons] have got to make a case that we’re doing what’s right for America. I don’t think we can fully make that case yet, I really don’t,” Richardson said.
What may work? Richardson admitted that the answer is unclear.
In a free society where professionals can choose where they want to practice medicine, it’s difficult to imagine an equitable geographic distribution of general surgeons across the country. But to the extent that there is talk in Washington, DC about their constituents’ access to physicians, the talk is centered on primary care and general surgery. Things have, surprisingly, not got to the point were a political solution is mandated, but if circumstances get worse - something will happen and surgeon may not get a voice in the solution, he warned.
“We simply have to do a better job than we are doing in providing access and producing what the country needs,” he concluded.
Video of Dr. Richardson’s full presentation can be heard on the Schwartz Memorial Lecture and Symposium page on the UK Department of Surgery website.
Click here for photos from the event and the Boone Center reception.