Friday, January 2, 2009
A nice article from the Washington Post (via KevinMD) last week about the impending general surgeon shortage in rural America. Here are some choice tidbits:
*In 1980, 980 general surgeons were trained in the the USA. In 2008, the number has reamined constant despite an increase in population by 79 million.
*Today there are only 5 general surgeons per 100,000 people
*Most rural general surgeons are over the age of 50
So this a good thing if you're a young general surgeon, right? There's going to be a huge demand to replace the retiring generation of surgeons and hospitals will need to reconstitute its forces. Because let's face it, surgeons are vital to a rural hospital's bottom line. The lucrative procedures that a local general surgeon can bring in often makes the difference between profitability and a hospital closing. Check out this power point presentation from the AAMC on rural surgery. Surgical services can potentially provide up to 30% of hospital revenue in the rural setting. Every time Podunk Hospital has to ship out an appendectomy or a hip fracture or a colon cancer because of surgeon unavailability, that's money lost.
But before we lose ourselves (we being young general surgeons) in rapturous expectations, there are some cold hard facts to digest. Namely, that in order to be a rural general surgeon, this means that you have to convince your spouse that it would be a great idea to move to Otsego, New York or Platteville, WI. You actually have to live in these towns. This isn't necessarily a bad thing, but you better be damn sure living the small town American life is what you really want. Secondly, rural surgery requires that one is comfortable performing certain procedures that most residents in training these days are not exposed to, i.e. setting minor fractures, hysterectomies, and ceasarean sections. Finally, although the hospital benefits enormously from successfully recruiting a general surgeon and will pay handsomely up front to do so, it can be difficult to maintain a suitably busy practice if you live in a town of 10,000. What happens is, the hospital will entice you to their sleepy hamlet with a seemingly exorbitant guaranteed contract (most general surgeons receive a steady deluge of junk emails from headhunters promising $350,000 a year or more guaranteed for the first three years, maybe with a large signing bonus on top of that). But when the guarantee runs out, you're on your own. And if you live in a town with, say, three primary care practices, it's going to be hard to maintain the sort of volume that will sustain your previous income level. You may find you are only doing 5 or 6 cases a week without a reasonable expectation of growth (given the population) and your income falls by 50% or more. It happens. And the hospitals don't care because they're still racking in the procedural profits from the cases you do book.
So be careful. Be wary of those glossy post cards that come in the mail with a picture of a moose and some mountains and a burbling stream in the background promising half a million bucks to start if only you come to this "quaint little midwestern bedroom community" that is only "a short drive to a major metropolitan area" (i.e. 3 hours to Dayton, OH) and is perfect for the "hunting and fishing enthusiast."
I think the answer to the problem is two-fold:
1. Loan forgiveness for surgical residents willing to commit to the backwoods of America (much like I propose loan forgiveness as a way to increase the number of medical students who opt for a career in primary care).
2. The creation of a dedicated specialty of "rural surgery" where more attention is given to the learning of OB/Gyn, endoscopy, and orthopedics. We have fellowships for "advanced laparoscopy" that didn't exist five years ago. The field of "trauma surgery' has become so non-operative that now trauma surgeons are looking to cherry pick late night emergency cases. Surgical training is constantly in flux. Rural surgery is the obvious next field for potential growth....