Will there be a good general surgeon when you need one? (Part II) Solutions and taking back general surgery

Examining the Growing Demand for Surgical Care in Rural Communities and Novel Approaches to Achieving a Sustainable Surgical Workforce: A Narrative Review

Surgery continues to be an increasingly vital component of public health and aspect of patient care in rural communities. An anticipated shortage of surgeons within the next decade in the United States prompts a growing concern for increasing the delivery of essential surgical care to these populations. When considering the existing barriers to surgical healthcare in rural communities, there is a sense of urgency to identify innovative approaches that will promote a sustainable surgeon workforce. A narrative review was conducted to investigate the current state of access to essential surgical care in rural communities. Qualitative and quantitative data were collected to better understand the key issues in rural healthcare and to provide statistical data related to the status of the surgical workforce. With the anticipated shortage of surgeons in both rural and urban areas, this review highlights the importance of enacting immediate measures to address the concern. This review has accomplished the initial objectives of gaining a better understanding of the current state of access to surgical care in rural communities and utilizing this knowledge to provide recommendations to readily attain a sustainable number of rural surgeons. With each approach addressing ways to address the contributory issues to the surgeon shortage, this review reveals a new avenue of integrating valuable aspects from each approach, rather than relying on a single approach. In particular, enhancing the overall pipeline of medical training to attending status may prove to be more beneficial for achieving this goal. Ultimately, this may be accomplished by introducing additional rural surgical mentorship opportunities for medical students, developing a rural surgery fellowship, and incorporating a market-based response that will correspond to attractive incentives that help to retain a sustainable number of surgeons working in rural areas.

A contemporary reassessment of the US surgical workforce through 2050 predicts continued shortages and increased productivity demands

BACKGROUND

We aimed to predict practicing surgeon workforce size across ten specialties to provide an up-to-date, national perspective on future surgical workforce shortages or surpluses.

METHODS

Twenty-one years of AMA Masterfile data (1997-2017) were used to predict surgeons practicing from 2030 to 2050. Published ratios of surgeons/100,000 population were used to estimate the number of surgeons needed. MGMA median wRVU/surgeon by specialty (2017) was used to determine wRVU demand and capacity based on projected and needed number of surgeons.

RESULTS

By 2030, surgeon shortages across nine specialties: Cardiothoracic, Otolaryngology, General Surgery, Obstetrics-Gynecology, Ophthalmology, Orthopedics, Plastics, Urology, and Vascular, are estimated to increase clinical workload by 10-50% additional wRVU. By 2050, shortages in eight specialties are estimated to increase clinical workload by 7-61% additional wRVU.

CONCLUSIONS

If historical trends continue, a majority of surgical specialties are estimated to experience workforce deficits, increasing clinical demands substantially.

Supervisor, Colleague, or Assistant: General Surgery Resident Perceptions of Advanced Practitioners

Integration of advanced practitioners (APs) into academic medical centers can improve processes of care and decrease physician workload but may adversely impact general surgery residency training. The aim of the present study was to characterize general surgery resident perceptions of APs and their impact on resident training. We conducted an institutional review board–approved survey covering five topic areas: knowledge of AP training, interaction with APs, scope-of-practice of APs, role of APs in the health-care team, and impact of APs on physician training. The survey was administered to general surgery residents at six large academic medical centers. One hundred eighteen general surgery residents completed the survey. The majority (43.6%) of respondents were junior residents. All respondents had interactions with APs with 90.7 per cent having worked directly with an AP in the last month. Residents reported minimal formal educational involvement by APs with 6.8 per cent reporting participation in didactics and 22.2 per cent teaching operative techniques. Almost half (44.1%) of the respondents reported that APs played an important role in their education, and 42.4 per cent of respondents disagreed or strongly disagreed that the role of the AP is well defined in their hospital. Today's general surgery residents work closely with APs who seem to positively impact resident education. Although residents perceive significant benefit with integration of APs, well-defined roles are lacking.

For Love, Not Money: The Financial Implications of Surgical Fellowship Training

Surgical residents cite “increased income potential” as a motivation for pursuing fellowship training, despite little evidence supporting this perception. Thus, our goal is to quantify the financial impact of surgical fellowship training on financial career value. By using Medical Group Management Association and Association of American Medical Colleges physician income data, and accounting for resident salary, student debt, a progressive tax structure, and forgone wages associated with prolonged training, we generated a net present value (NPV) for both generalist and subspecialist surgeons. By comparing generalist and subspecialist career values, we determined that cardiovascular (ANPV = $698,931), pediatric ($430,964), thoracic ($239,189), bariatric ($166,493), vascular ($96,071), and transplant ($46,669) fellowships improve career value. Alternatively, trauma (-$11,374), colorectal (-$44,622), surgical oncology (-$203,021), and breast surgery (-$326,465) fellowships all reduce career value. In orthopedic surgery, spine ($505,198), trauma ($123,250), hip and joint ($60,372), and sport medicine ($56,167) fellowships improve career value, whereas shoulder and elbow (-$4,539), foot and ankle (-$173,766), hand (-$366,300), and pediatric (-$489,683) fellowships reduce career NPV. In obstetrics and gynecology, reproductive endocrinology ($352,854), and maternal and fetal medicine ($322,511) fellowships improve career value, whereas gynecology oncology (-$28,101) and urogynecology (-$206,171) fellowships reduce career value. These data indicate that the financial return of fellowship is highly variable.

Are self-identified "disadvantaged" students less likely to enter surgical residencies? A single-institution study

BACKGROUND

Given more emphasis on training primary care physicians for underserved areas, we hypothesized that students self-identifying as "disadvantaged" would be less likely to pursue surgical training.

METHODS

We retrospectively reviewed medical school data on students graduating 2005-2014. Students were stratified into "disadvantaged" and "nondisadvantaged". Data were recorded on age, grade point average, Medical College Admission Test (MCAT), gender, surgery grade, United States Medical Licensing Examination step 1 score, and residency match into a surgical field. A comparison of the proportion of students matching into a surgical field was assessed with chi-square test. Multivariate logistic regression was performed to assess the factors that predict the choice of general surgery versus another surgical field.

RESULTS

Of the 1140 students who graduated during the study period, 219 (19.2%) students self-identified as "disadvantaged". Of all students, 158 (13.9%) chose a surgical field. The disadvantaged group was older at entry and had lower grade point average and total MCAT scores. Twenty-seven (12.3%) disadvantaged students chose a surgical residency versus 130 (14.1%) nondisadvantaged students (P = 0.56). On multivariate logistic regression, female gender (odds ratio [OR] = 3.9; 95% confidence interval = [1.9-8.3], P < 0.01), disadvantaged status (OR = 2.8 [1.1-7.1], P = 0.03), and United States Medical Licensing Examination step 1 score ≥ 227 (OR = 0.43 [0.21-0.88], P = 0.02) were significantly associated with matching into general surgery versus another surgical specialty.

DISCUSSION

Although the disadvantaged cohort was older and had lower undergraduate GPAs and MCAT scores, the proportion of disadvantaged students matching into a surgical residency was not statistically different. To address the future shortage of general surgeons in underserved areas, increasing enrollment of "disadvantaged" students may alleviate the "surgical desert".