A Chance to Cut is a Chance to Cure

Friday, October 01, 2004

The Future of Surgery...
I had been working on a post titled "The Incredible Shrinking Surgeon" about the various forces that have caused the scope of general surgery practice to contract, and how that would affect the field in the future. That is until I read this paper in the latest Annals of Surgery: Surgical Education in the United States: Portents for Change($$). This article provides a great deal of background information so I will combine my commentary with the post I had planned earlier. The paper identifies several "constituencies being served" by surgical education. They are: patients, medical students, surgical residents, general and specialist surgeons, third-party payors, and academia. Since this topic is too large to cover in one post and still have you awake at the end, I will split it up. This post will deal with the patients and payors.

The crucial issue for the patient may well be: Will there be a doctor to care for me?

It is now strongly suggested that by the year 2020, there will be a large shortage in the physician workforce, none more obvious than in the discipline of surgery. If one accepts the postulations based on gross domestic product increases, then by the year 2020, there will be an approximately 200,000 physician shortage in the United States. Although some of this shortfall can be made up by nonphysician clinicians, a serious shortfall in physicians, particularly specialist physicians, is projected.

A recent survey of 70 medical schools in 35 states reported shortages in surgeons that approximate 20%. A survey by the Massachusetts Medical Society suggests a physician shortage in general surgery of 32%, with orthopaedics, neurosurgery, and urology having even greater shortages.

According to the data presented, the answer to the question may be "maybe not". There are multiple factors which have caused the impending physician shortage. The increasing numbers of the elderly, and their increasing utilization of healthcare and the diminishing popularity of medicine are the most prominent. Continuing along:

Society's and the patient's perception of what he or she wants has changed. Given a choice between a specialist and a generalist, the patient chooses a specialist. This is compounded by ready access to available information from the Internet, much of it uncensored, colored, and often tainted with institutional, if not personal, claims of supremacy in the delivery of care. The media is vociferous in defining what the public should expect from their surgeons and voracious in its pursuit of perceived inappropriate care. How can we cope with the suggestion that sleep deprivation of residents equates to inebriation?

Patients accept much of what they see on the internet and in the lay press as gospel. The amount of information out there is immense and the surgeon has to know about a fair deal about many conditions but patients can spend days researching their own condition and be offended when you can't cite the latest Scandinavian study.

Some patients look only for a competent generalist. This may be by personal choice of time and access, of distance, or because of a lack of access to a specialist caused by societal, ethnic, financial, or language barriers. Patients roundly rejected the attempt of the managed care industry to create primary care physician gatekeepers for their care. The American public, often well informed about quality of health care, has decided it prefers to be treated within specialties.

So what could arise is the patients with the means to travel, regardless of insurance status, will have access to the best care.

Increasingly, patients and employees are asking to see the results of interventions before they select their doctors or hospitals. Clinical care is becoming patient-centered and outcome-based, and it is likely that both referral patterns and reimbursement rates will depend on demonstrated good clinical outcome Increasingly, patients will have more and more say in their own treatment. As they do, they will no longer accept to be treated by physicians-in-training and will demand that their care be provided by experienced practitioners. This raises the important issue of training by methods that do not involve direct patient care. How, if at all, is our training system prepared to deliver on these important issues?

Here is where the rubber meets the road, patients are insisting on minimal resident involvement. Learning to operate is a exercise in repetition. That is why a surgical residency is five years. Everyone is put together differently, and sometimes things don't go as planned. Such a strategy is great now, but just wait 15-20 years to see how well that will really work.

Now on to the payors...

State registries can identify and characterize the practice patterns of individual surgeons, the mortality, morbidity, length of stay, and other characteristics that track or evaluate some degree of competency of care. Increasingly, data is available for surgeon, by operation, for the cost and charges initiated by that provider. This is compounded by cost analysis and increasing demands to lower the cost of medical care when the demand for expensive technology is simultaneously increasing. Demand for technologically advanced clinical care is increasing as societal exposure and media promises escalate. The nexus of ever-increasing technology with ever-increasing demands by society for its use creates the impossible prospect of limitless expenditure, which is a prospect incompatible with the trends in the national economy. Why are we so unwilling to add cost-effectiveness to the evaluation of the clinical efficacy of each newly introduced technology?

Ah yes, everybody wants the latest whiz-bang technology, but no one wants to pay for it. Here is where such organizations as theLeapfrog Group will play a larger role in the future. Probably a more prominent role than the AMA, American Board of Surgery, or the American College of Surgeons will play. Because the one with the gold makes the rules.
The next post will deal with medical students, residents, and academia.Cross-posted at Galen's Log

Labels: Future of Surgery