Training General Surgeons for Tomorrow

Thomas V Whalen, MD

Predictions are Difficult…  “The future ain’t what it used to be.”

New and Old Technologies  Ulcer Surgery   Bariatrics Breast conservation   Hernia Watch and Wait NOTES   Interventional Radiology Telerobotics

AAMC Workforce Policy: 2006    Twelve point policy Called for a 30% Increase in US Allopathic Graduates BBA of 1997 and the GME cap  Medicare GME funding and service versus education

Lifestyle Issues   Only 46.5% of US Medical graduates plan to engage in full time practice Impact of the female Physician Workforce

Regionalized Acute Care Surgery    On call crisis in urban areas Need for a multi-talented specialist who is available at all times Possible synergies with Rural Surgery

Current Workforce

AAMC Projections to 2025

AAMC Projection: Most Plausible

AAMC Projection: Worst Case

By Specialty

Nurse Practitioners    All new NPs as of 2015 must be DNPs CACC: Council for the Advancement of Comprehensive Care NBME: “the exam will utilize test items previously used in the USMLE Step 3 examination”

Solutions  Even a robust expansion of GME capacity (from 25,000 new entrants per year to 32,000) would only reduce the projected shortage in 2025 by 54,000 physicians (43 %).

Definition of General Surgery     In Manhattan In Willcox, Arizona In Iraq and Afghanistan And as cited by Claude Organ,  Friday night at midnight and Monday at Noon

Production     Programs: 249 Graduates: 1050 Specialization: 79%  Some continue as General Surgeons Number of Surgeons Certified:   1980: 945 2008: 972

Demand    7.53 per 100,000 population Maryland, Statewide: 5.2

Far fewer in remote areas where they are most needed

Willcox, AZ

Retirement   Was decreasing… The Economy

Surgical Workforce    GMENAC Study (1971): All of Surgery except Otolaryngology deemed in surplus SOSSUS (1975): Concluded that the existing number of surgeons was sufficient to provide needed services  Did highlight maldistribution AMA CLRPD (1989): General Surgical Shortage by 2000 predicted

Surgical Workforce   Number of General Surgery Training Programs Flat (249) Production of those Programs Flat (1000)

Dartmouth Atlas: 1996 to 2006  Number of General Surgeons declined 16.3%

Bureau of Health Professions  From 2005 to 2020:   Surgeons overall will increase 3% General Surgery will decrease 7%

AAMC Center for Workforce   General Surgeons < 55 YO: 42% FP: 37% and Internal Med: 32%

Rural General Surgery    Over 50 Million of our US Citizenry Greater on call demands Lower reimbursement

US Medical Graduates  Five specialties have more applicants than positions:   Plastic Surgery General Surgery   Dermatology Orthopedic Surgery  Radiation Oncology

Resident Attrition   Approaching 30% The Best and the Brightest: “Academically highly qualified graduates and graduates who chose training in general surgery or in a 5 year surgical specialty were at increased risk of attrition during GME.”

IMGs     Constitute 25% of the nation’s Physicians Many from other countries are the “best and the brightest” Twenty percent of Categorical General Surgery Residents are IMGs A transgression of Distributive Justice in the World

Ohio State Study    Assumes that 85% of certified surgeons will practice general surgery and 705 will annually retire Restricts analysis to allopathic production Static Assumptions as to disease demand

Ohio State Study    Projects shortage of 1300 in 2010 Grows to 6000 in 2050 Proportionate to population, General Surgeons decreased 25% from 1981 to 2005

Ohio State Study – Comments    Hiram Polk: “The pundits on the East and West Coasts don’t have a clue…” Polk: “…we ought to open (a) thousand slots” at good programs Resident comment on remuneration and lifestyle

The RRC   The ACGME Nominating Organizations  ABS   ACS AMA-CME

What the RRC Does     Program Review and Accreditation   Citations Cycle Length Requirements for Training  Additional Rural Surgery elements??

Coordination with the ABS General, Pediatric, Vascular, Surgical Critical Care (Hand)

What the RRC Does NOT Do   Set Production Quotas Certify Individuals

Current RRC Issues        Milestones Duty Hours  Accelerated Visits Preliminary Residents Essential Content Area Experience International Rotations Seventh Competency Fellowship Minimum Pass Rates

International Rotations       Non-Chief rotation up to six months Faculty members from the parent program or equivalently-trained host faculty Clearly state educational rationale Appropriate educational environment Appropriate supervision Educational resources

The ACGME and the RRC   New Leadership New model of the CRCC and the ACGME Board

What Else Can Be Done?

  GME Funding   General Surgery as Surgical Primary Care Title VII Health Professions Program Alleviate Medical School Debt Burden  Extend Loan Deferment

Conclusion       There is little question that there is a shortage of general surgeons The shortage will worsen The dynamic environment makes planning difficult The pipeline is long General Surgeons have job security The RRC stands ready to approve appropriate additional positions and programs

Questions??