Tuesday, November 20, 2007

The Future of Surgery XII......
From the November 14th edition of The Journal of the American Medical Association comes an article penned by Dr. Josef Fischer titled The Impending Disappearance of the General Surgeon. To begin:
In the United States, approximately 1000 general surgeons complete their residency training each year. These surgeons have completed 4 years of medical school and 5 clinical years of residency, and during residency many also have spent 1 or 2 years in a research laboratory. Thus, these physicians enter the workforce between the ages of 33 and 35 and usually have $150 000 to $250 000 in educational debt. The training of surgeons has been stable since the early 1970s, and the number of general surgery residency training programs will not likely increase. Even if new medical schools were established the number of surgeons trained would not likely increase much, because many medical students have lost interest in pursuing a career in surgery.

When I entered the life of a workaday surgeon I was slightly younger and my debt was toward the low end of the range above. But even now, before the mass retirements of the baby boomer surgeons begin, the squeeze is on:
In small urban or rural hospitals, which care for approximately 54 million patients,2 general surgeons care for emergencies and trauma and perform a variety of operations. They are essential to the provision of adequate health care and often are the most well-rounded surgical clinicians in the area. Therefore, training only 1000 general surgeons per year will not meet demands. Specialization also affects the general surgical workforce. Presently, approximately 70% of graduating surgical residents pursue specialized surgery training, and this percentage may be increasing. Thus, only about 300 to 400 of the 1000 general surgeons completing residency each year will choose general surgery practice.
The numbers of surgeons undergoing certification and re-certification (required every ten years) has remained relatively static according to the American Board of Surgery. Dr. Fischer brings up the usual reasons for this being so:
There are several reasons for surgeons to specialize. To be thoroughly competent in the face of a knowledge base that is increasing in all areas, many surgeons choose to limit the number and types of surgical procedures they perform. Additionally, it may be easier to develop expertise in some subspecialties, and more refined expertise often leads to economic rewards. In some large urban environments, subspecialists bill at higher fees than general surgeons performing the same procedures.

A career as a specialist caters to the lifestyle preference of medical school graduates, who have little desire to work 80 to 100 hours per week with little time for families. They are less focused on being entrepreneurial and accept being employed by large group practices if it means they need not worry about the economics of practice and if they can have less demanding on-call schedules, which enable them to spend more time with their families.

Furthermore, current surgical residents are being trained in the environment of an 80-hour work week. These individuals have come to understand that even if they have a sick patient who has not been totally stabilized, they must hand over the care of the patient to someone else. Residents are forced to be content with this system, in which they are instructed about number of work hours.

While limited work hours and a lifestyle conducive to family priorities are desirable, the nature of surgical problems remains unchanged or may be more intense because of an aging patient population. For example, the situation of a patient with a perforated colon who will die in 12 to 24 hours if peritonitis is not controlled does not change so a surgeon can go home at a decent hour.

Residents who are "less focused on being entrepreneurial" because of the rise of managed care. In the day you could hang your shingle as a solo practice surgeon and share call (or not). The need to negotiate with multiple insurance companies has forced the formation of large groups. This also speaks of the poor job that residency programs do in teaching the financial aspects of surgical practice. The decline in reimbursment is then discussed, with a short history of the RBRVS:
The American College of Surgeons' General Surgery Coding and Reimbursement Committee has addressed the methods of reimbursement, primarily for Medicare, and most insurers use Medicare as a means of determining reimbursement. Beginning in 1992, relative value units (RVUs)—a basis for reimbursement—were never intended to be used for reimbursement but rather as a research tool. The Resource-Based Relative Value Scale became the basis on which reimbursement was determined. General surgery did not participate in the study or in the research and negotiation process initially, whereas some surgical specialties, such as orthopedics and ophthalmology, did participate.

The reimbursement process has had its flaws. For example, operative times—a key driver of reimbursement—were deliberately underestimated by some surgeons. Nonetheless, when Medicare began the process, it paid "usual and customary reimbursement" and then instituted the Resource-Based Relative Value Scale payment system over the next several years. Surgeons experienced increasing pressure on surgical fees as it became clear that there was not enough money in the system to supply their historical fees as well as new increases in other nonsurgical encounters. A list of procedures "overvalued" in Medicare included the procedures most commonly performed by general surgeons: cholecystectomy, inguinal herniorrhaphy, and colectomy or small bowel resection.

Reimbursement was devalued precipitously. Budget neutrality followed; there would be no additional reimbursement for unusually complex procedures—an increase in one area would be followed by a decrease in reimbursement elsewhere. In the current system, operating on a patient with a gastrointestinal tract cutaneous fistula, a difficult procedure that often requires 6 to 8 hours, is reimbursed exactly the same whether performed by a new surgeon or one with many years of experience.....
.....In addition, the 90-day global period means that no additional payments will be made for any physician services that can be associated with the initial procedure, regardless of how much work the follow-up entails. Other physicians can see patients daily for the same illness or situation and can bill and collect each time.
No other profession or situation apart from medicine experiences denial of payment for services already performed. At times, it seems that health insurance companies employ staff whose only goal appears to be to deny payment for services already performed.

These sequential decreases in reimbursement provide a substantial disincentive to enter these branches of surgery and may have profound future consequences. The self-designated specialties of internal medicine, medicine, and pediatrics have substantially increased members since 1985, while general surgery membership has remained level.

Professional liability and malpractice also contribute to an unfavorable, perhaps even hostile, work environment. Malpractice affects physicians in large measure equally, but the dangers of the professional liability problem are more difficult for proceduralists, such as surgeons.

Insurance companies take great delight in denials. Managment of problems unrelated to the procedure, even when documented and coded appropriately, are often denied. So there is little incintive for the surgeon to obey the dictum that a surgeon is an "internist who operates". Dr. Fischer sees clouds ahead for the rural and suburban hospitals:
Whatever the current and future difficulties of surgery, the implications for hospitals and the patient population are significant. Can rural and small hospitals survive with the current general surgeon workforce? The economics of hospitals and surgeons are closely linked. Hospitals need general surgeons to perform various types of surgical procedures, and also to be available to respond to surgical emergencies and trauma. Specialization has greatly decreased the number of such surgeons available to provide this coverage. This is not because specialty surgeons are unwilling to treat patients with surgical emergencies or trauma, but because they no longer feel secure in their skills in these areas. These trends in the surgical landscape suggest a danger that general surgeons might disappear over the next few years, especially from rural and smaller suburban hospitals. This could lead to difficulties in ready access to care, because when these hospitals lose their general surgeons they may be forced to close.

The population of general surgeons is decreasing . Fewer residents are choosing general surgery and existing general surgeons are aging, and as a result 32% of general surgeons are older than 55 years and 20% are younger than 35 years. Emergency department visits have increased 26% since 1993, and 75% of hospitals report inadequate on-call surgeon coverage. For the first time ever, the Medicare Payment Advisory Commission found that their beneficiaries have more trouble accessing specialists than do private-pay patients.....

...Efforts probably will be made to reverse the tendency of subspecialization and to engage more surgical residents in general surgery to staff the small suburban and rural hospitals. However, the pipeline for general surgeons is now broken, and it will take 7 to 15 years to fix because of the length of time from college graduation to completion of general surgical training.....

....While most attention of health policy experts has focused on the care of the chronically ill, changes have occurred in an important component of the workforce—general surgeons. Their numbers have been decreasing precipitously. Causes of this shortage include an unfavorable work environment, reimbursement issues, professional liability, and, probably most important, the change in the nature of the workforce of individuals who are entering medicine.

The implications of the general surgeon shortage include the inability of patients to access surgical care and a lack of surgeons willing to take call for emergencies and trauma, as well as the threatened survival of small and rural hospitals, since more than 40% of the margin of such hospitals depends on cases performed by general surgeons. Unless remedied, this shortage will affect the ability of patients to seek care; in certain areas of the country, it limits the ability of patients to obtain adequate emergency care in close proximity to their homes.

Will a general surgeon be available when you need one? If the current situation remains, the answer will be no.

Here is a chart illustrating the decline of general surgery as a percentage of all medical specialists. Other surgical subspecialties have remained constant.


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