Training General Surgeons for Tomorrow

Thomas V Whalen, MDThomas V Whalen, MD

Predictions are Difficult…Predictions are Difficult…

““The future ain’t what it used to The future ain’t what it used to be.”be.”

New and Old New and Old TechnologiesTechnologies

Ulcer SurgeryUlcer Surgery BariatricsBariatrics Breast conservationBreast conservation Hernia Watch and WaitHernia Watch and Wait NOTESNOTES Interventional RadiologyInterventional Radiology TeleroboticsTelerobotics

AAMC Workforce Policy: AAMC Workforce Policy: 20062006

Twelve point policyTwelve point policy Called for a 30% Increase in US Called for a 30% Increase in US

Allopathic GraduatesAllopathic Graduates BBA of 1997 and the GME capBBA of 1997 and the GME cap

Medicare GME funding and service Medicare GME funding and service versus educationversus education

Lifestyle IssuesLifestyle Issues

Only 46.5% of US Medical Only 46.5% of US Medical graduates plan to engage in full graduates plan to engage in full time practicetime practice

Impact of the female Physician Impact of the female Physician WorkforceWorkforce

Regionalized Acute Care Regionalized Acute Care SurgerySurgery

On call crisis in urban areasOn call crisis in urban areas Need for a multi-talented specialist Need for a multi-talented specialist

who is available at all timeswho is available at all times Possible synergies with Rural SurgeryPossible synergies with Rural Surgery

Current WorkforceCurrent Workforce

AAMC Projections to AAMC Projections to 20252025

AAMC Projection: Most AAMC Projection: Most PlausiblePlausible

AAMC Projection: Worst AAMC Projection: Worst CaseCase

By SpecialtyBy Specialty

Nurse PractitionersNurse Practitioners

All new NPs as of 2015 must be All new NPs as of 2015 must be DNPsDNPs

CACC: Council for the Advancement of Comprehensive Care

NBME: “the NBME: “the exam will utilize test items previously used in the USMLE Step 3 examination””

SolutionsSolutions

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

Definition of General Definition of General SurgerySurgery

In ManhattanIn Manhattan In Willcox, ArizonaIn Willcox, Arizona In Iraq and AfghanistanIn Iraq and Afghanistan And as cited by Claude Organ,And as cited by Claude Organ,

Friday night at midnight and Friday night at midnight and Monday at NoonMonday at Noon

ProductionProduction

Programs: 249Programs: 249 Graduates: 1050Graduates: 1050 Specialization: 79%Specialization: 79%

Some continue as General Some continue as General SurgeonsSurgeons

Number of Surgeons Certified:Number of Surgeons Certified: 1980: 9451980: 945 2008: 9722008: 972

DemandDemand

7.53 per 100,000 population7.53 per 100,000 population Maryland, Statewide: 5.2Maryland, Statewide: 5.2 Far fewer in remote areas where Far fewer in remote areas where

they are most neededthey are most needed

Willcox, AZWillcox, AZ

RetirementRetirement

Was decreasing…Was decreasing… The EconomyThe Economy

Surgical WorkforceSurgical Workforce

GMENAC Study (1971): All of GMENAC Study (1971): All of Surgery except Otolaryngology Surgery except Otolaryngology deemed in surplusdeemed in surplus

SOSSUS (1975): Concluded that the SOSSUS (1975): Concluded that the existing number of surgeons was existing number of surgeons was sufficient to provide needed servicessufficient to provide needed services Did highlight maldistributionDid highlight maldistribution

AMA CLRPD (1989): General Surgical AMA CLRPD (1989): General Surgical Shortage by 2000 predictedShortage by 2000 predicted

Surgical WorkforceSurgical Workforce

Number of General Surgery Number of General Surgery Training Programs Flat (249)Training Programs Flat (249)

Production of those Programs Production of those Programs Flat (1000)Flat (1000)

Dartmouth Atlas: 1996 to Dartmouth Atlas: 1996 to 20062006

Number of General Surgeons Number of General Surgeons declined 16.3%declined 16.3%

Bureau of Health Bureau of Health ProfessionsProfessions

From 2005 to 2020:From 2005 to 2020: Surgeons overall will increase 3%Surgeons overall will increase 3% General Surgery will decrease 7%General Surgery will decrease 7%

AAMC Center for AAMC Center for WorkforceWorkforce

General Surgeons < 55 YO: 42%General Surgeons < 55 YO: 42% FP: 37% and Internal Med: 32%FP: 37% and Internal Med: 32%

Rural General SurgeryRural General Surgery

Over 50 Million of our US Over 50 Million of our US CitizenryCitizenry

Greater on call demandsGreater on call demands Lower reimbursementLower reimbursement

US Medical GraduatesUS Medical Graduates

Five specialties have more Five specialties have more applicants than positions:applicants than positions: Plastic SurgeryPlastic Surgery General SurgeryGeneral Surgery DermatologyDermatology Orthopedic SurgeryOrthopedic Surgery Radiation OncologyRadiation Oncology

Resident AttritionResident Attrition

Approaching 30%Approaching 30% The Best and the Brightest: The Best and the Brightest:

“Academically highly qualified “Academically highly qualified graduates and graduates who graduates and graduates who chose training in general surgery chose training in general surgery or in a 5-year surgical specialty or in a 5-year surgical specialty were at increased risk of attrition were at increased risk of attrition during GME.”during GME.”

IMGsIMGs

Constitute 25% of the nation’s Constitute 25% of the nation’s PhysiciansPhysicians

Many from other countries are Many from other countries are the “best and the brightest”the “best and the brightest”

Twenty percent of Categorical Twenty percent of Categorical General Surgery Residents are General Surgery Residents are IMGsIMGs

A transgression of Distributive A transgression of Distributive Justice in the WorldJustice in the World

Ohio State StudyOhio State Study

Assumes that 85% of certified Assumes that 85% of certified surgeons will practice general surgeons will practice general surgery and 705 will annually surgery and 705 will annually retireretire

Restricts analysis to allopathic Restricts analysis to allopathic productionproduction

Static Assumptions as to disease Static Assumptions as to disease demanddemand

Ohio State StudyOhio State Study

Projects shortage of 1300 in Projects shortage of 1300 in 20102010

Grows to 6000 in 2050Grows to 6000 in 2050 Proportionate to population, Proportionate to population,

General Surgeons decreased General Surgeons decreased 25% from 1981 to 200525% from 1981 to 2005

Ohio State Study – Ohio State Study – CommentsComments

Hiram Polk: “The pundits on the Hiram Polk: “The pundits on the East and West Coasts don’t have East and West Coasts don’t have a clue…”a clue…”

Polk: “…we ought to open (a) Polk: “…we ought to open (a) thousand slots” at good thousand slots” at good programsprograms

Resident comment on Resident comment on remuneration and lifestyleremuneration and lifestyle

The RRCThe RRC

The ACGMEThe ACGME Nominating OrganizationsNominating Organizations

ABSABS ACSACS AMA-CMEAMA-CME

What the RRC DoesWhat the RRC Does

Program Review and AccreditationProgram Review and Accreditation CitationsCitations Cycle LengthCycle Length

Requirements for TrainingRequirements for Training Additional Rural Surgery elements??Additional Rural Surgery elements??

Coordination with the ABSCoordination with the ABS General, Pediatric, Vascular, General, Pediatric, Vascular,

Surgical Critical Care (Hand)Surgical Critical Care (Hand)

What the RRC Does NOT What the RRC Does NOT DoDo

Set Production QuotasSet Production Quotas Certify IndividualsCertify Individuals

Current RRC IssuesCurrent RRC Issues

MilestonesMilestones Duty HoursDuty Hours

Accelerated VisitsAccelerated Visits Preliminary ResidentsPreliminary Residents Essential Content Area ExperienceEssential Content Area Experience International RotationsInternational Rotations Seventh CompetencySeventh Competency Fellowship Minimum Pass RatesFellowship Minimum Pass Rates

International RotationsInternational Rotations

Non-Chief rotation up to six monthsNon-Chief rotation up to six months Faculty members from the parent Faculty members from the parent

program or equivalently-trained program or equivalently-trained host facultyhost faculty

Clearly state educational rationaleClearly state educational rationale Appropriate educational Appropriate educational

environmentenvironment Appropriate supervisionAppropriate supervision Educational resourcesEducational resources

The ACGME and the RRCThe ACGME and the RRC

New LeadershipNew Leadership New model of the CRCC and the New model of the CRCC and the

ACGME BoardACGME Board

What Else Can Be Done?What Else Can Be Done?

GME FundingGME Funding General Surgery as Surgical Primary General Surgery as Surgical Primary

CareCare Title VII Health Professions ProgramTitle VII Health Professions Program

Alleviate Medical School Debt Alleviate Medical School Debt BurdenBurden Extend Loan Deferment Extend Loan Deferment

ConclusionConclusion

There is little question that there is a There is little question that there is a shortage of general surgeonsshortage of general surgeons

The shortage will worsenThe shortage will worsen The dynamic environment makes The dynamic environment makes

planning difficultplanning difficult The pipeline is longThe pipeline is long General Surgeons have job securityGeneral Surgeons have job security The RRC stands ready to approve The RRC stands ready to approve

appropriateappropriate additional positions and additional positions and programsprograms

Questions??Questions??