Wednesday, April 08, 2009

Physician Thunderdome..
In this post Kevin throws down the gauntlet:
Make no mistake, specialist organizations are ready to throw primary care under the bus, with the opening salvo of implying that generalist doctors can be easily replaced by mid-level providers telegraphing their intentions.

Let's hope that the ACP is aggressive in countering these tactics. It's becoming clear that a conciliatory approach with specialist organizations may not be feasible, and more contentious, potentially confrontational, methods may be needed to be heard above the din.
Two enter, one leaves indeed.

Kevin links again to Bob Doherty'sblog where the American College of Surgeons is taken to task over their Operation Patient Access website and advocacy program:
The American College of Surgeons, joined by other surgical specialty societies, has created Operation Patient Access (OPA), a campaign to "bring into focus the urgent issues facing access to quality surgical care in the United States ... and to call attention to urgently needed policy changes to address gaps in the availability of quality surgical patient." According to the OPA website (which is pretty nicely done, by the way), 400 surgeons - sporting "Will a surgeon be a there when you need one?" buttons - descended on Capitol Hill last week to urge lawmakers to "consider a wide range of solutions, such as providing more funding for graduate surgical education, reducing liability costs, expanding the National Health Service Corps, and implementing alternative payment methods for health care. If we fail to act now, these shortages will undermine attempts to expand access to health care and will further endanger the lives of all our citizens."

If this sounds familiar, it is because the surgeons' diagnosis and policy prescriptions are virtually identical to the case that ACP has been making on the primary care physician shortage.

Which is a problem, because it blurs the urgent need to rebuild the primary care physician workforce in the United States by suggesting that the crisis in surgery is of greater concern. The tools to increase the numbers and proportions of primary care physicians in the United States - payment reform, scholarships and loan forgiveness in exchange for service obligations, and graduate medical education funding - will be ineffective if the limited funding for such programs are broadly diverted to increase the numbers of surgeons, including some surgical specialties where there is scant evidence of a shortage. The OPA website speaks broadly of shortage of surgeons, when the evidence that I've seen - including the evidence on the OPA website - suggests that the shortage is principally in general surgery and a few of the surgical subspecialties and in certain parts of the country, particularly rural areas.
While there is a distribution problem with subspecialist surgeons there is a growing shortage of general surgeons. This is primarily due to the static number of residency slots, it is further worsened by the twenty-five percent of graduating chief residents that stay within general surgery. Some of the websites claims can be chalked up to advances in technology and declines in revenue: ("There aren't enough applicants to fill needed training spots in cardiothoracic surgery"), lifestyle and liability concerns: ("75% of U.S. hospitals report inadequate on-call surgical coverage in their Emergency Departments", "Emergency Departments have a shortage of neuro, orthopedic, general and plastic surgeons"), or demographics: (1/3 of rural hospitals have a surgeon leaving in the next two years). Given the income that surgeons bring in to those rural hospitals, a great many of them may close.

Demographics not only in the patient population, but within the specialty itself, will have a large impact. According to the AAMC's Center for Workforce Data's 2008 Physician Specialty Data general surgery had a higher percentage of its' workforce over 55 years of age (42.4%) than IM (32.3%), FP (36.7%), pediatrics (33.6%), or all specialties (37.6%). Even more interesting, while from 1996 to 2006 the numbers of family practitioners increased by 20.2 percent, internists by 30.2 percent, and pediatricians by 31.7 percent the number of general surgeons fell by 2.3 percent over that time. While the number of physicians of all specialties increased, on average, 28.6 percent, the number of general surgeons declined. All during Dr. Parker's post-medical school career.

If the number of primary care physicians grew by 21 percent over the past 10 years , and they are perceived to be in crisis, what of the specialty that not only shrunk, but grew older during that time period?

In fairness to Bob Doherty, he does give the ACS credit for a well-designed site. Here is a link found on the site to a Good Morning America interview with one of the best speakers I have ever heard, Dr. L.D. Britt.

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