Rise in Specialists Puts General Surgery in a Bind
Fewer residents choose general surgery, forcing hospitals to scramble to fill spots
The number of general surgeons, a linchpin for rural and small suburban hospitals for both patient care and revenue streams, is declining.
“General surgeons are jacks-of-all-trades,” says Josef Fischer, M.D., a general surgeon and chair of the surgery department at Beth Israel Deaconess Medical Center in Boston. These are the doctors that remove a troublesome gallbladder or appendix and perform gastrointestinal surgery in markets that can’t sustain a specialist practice. They also stabilize and evacuate trauma patients, and care for the sickest patients in rural ICUs, he notes.
The problem: of the 1,000 residents in the United States who finish their general surgery training each year, 70 percent choose a subspecialty, according to data from the Association of American Medical Colleges. No one is more aware of this than Fischer, who is also a professor at Harvard Medical School.
“For the past three years, I’ve had no one [out of nine surgery residents] decline a fellowship to specialize,” he says.
Statistics from American Medical Association data bear this out. General surgeons per 100,000 people dropped from 14.7 in 1980 to 12.8 in 2005. During that same time period, the percentage of general surgeons of all doctors in the United States fell from 6.9 percent to 4.2 percent.
The falling numbers are causing an age disparity, with 35 percent of general surgeons over age 55 and only 21 percent under 35. “You don’t need to be a rocket scientist to figure out what is going to happen,” Fischer says. “There are a lot of 65- and 70-year-old surgeons that would like to retire, but can’t.”
Take Gerald Bechamps, M.D., 70, part of a seven-surgeon practice in Winchester, Va. “In the next five years, I want to retire,” he says. “I could have retired four or five years ago, but I saw how it would increase the workload for my partners.”
Fischer says reimbursement and lifestyle are two main drawbacks to entering the field. Medicare payments have dropped for many of the procedures performed by general surgeons. Bechamps’ hernia repair pay decreased by 37 percent from 1989 to 2007 accounting for inflation, while the cost for practice employees and office space has continued to climb, he says.
In terms of lifestyle, general surgeons are often on-call for emergency departments and that will only get worse as their numbers dwindle. Bechamps’ practice has been unsuccessfully searching for new general surgeons for several years, says Winchester Medical Center President and CEO Reese Jackson; the medical center has been assisting in the search.
“We have lost recruits to hospitals that have an employment model, and those that can offer better salaries or have better call schedules,” he says.
Jackson is considering an employment model and working with general surgeons on a way to better share emergency call.
The graying of the field is also a problem. “We may be replacing 75-year-old general surgeons with 65-year-olds,” says Allen Dye, a vice president of marketing at Merritt Hawkins & Associates, Irving, Texas. Over the past two years, Merritt Hawkins has placed four surgeons that were 50 or older at hospitals in the Northwest.
Merritt Hawkins’ data show that a general surgeon adds, on average, $2 million to a hospital’s bottom line annually. More than that, loss of a general surgeon can cripple a hospital, closing its operating suites or emergency department. “If you don’t have ED coverage with a general surgeon, ambulances will pass you by,” Dye says.
One doctor bucking the trend is Jacob Breeding, M.D., 33, is the sole general surgeon at Pratt (Kan.) Regional Medical Center. He has only two weekends a month off from call, and hopes the hospital can recruit a second surgeon. “I like the depth and breadth of the things I get to do,” he says. To beef up the general surgeon counts, he suggests exposing medical students to surgery—and rural practice—-earlier in their training.
Even if reimbursements and lifestyle improve, and younger surgeons enter the field, there’s a lag time for those things to take effect. “It’s going to get worse before it gets better,” Bechamps says, “and it will only get better if things change.”
General surgeon Decline
Physicians per 100,000 population
| Internal medicine | Family medicine/ general practitioner |
General surgery | |
| 1990 | 39.0% | 27.9% | 15.2% |
| 2005 | 52.0% | 31.3% | 12.8% |
Source: Physician Characteristics and Distribution in the U.S., 2007 edition, American Medical Association