Training General Surgeons for Tomorrow

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Training General Surgeons for Tomorrow

• Thomas V Whalen, MD

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Predictions are Difficult

• The future aint what it used to be.

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New and Old Technologies

• Ulcer Surgery
• Bariatrics
• Breast conservation
• Hernia Watch and Wait
• NOTES
• Interventional Radiology
• Telerobotics

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AAMC Workforce Policy 2006

• Twelve point policy
• Called for a 30 Increase in US Allopathic
  Graduates
• BBA of 1997 and the GME cap
• Medicare GME funding and service versus education

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Lifestyle Issues

• Only 46.5 of US Medical graduates plan to engage
  in full time practice
• Impact of the female Physician Workforce

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Regionalized Acute Care Surgery

• On call crisis in urban areas
• Need for a multi-talented specialist who is
  available at all times
• Possible synergies with Rural Surgery

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Current Workforce
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AAMC Projections to 2025
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AAMC Projection Most Plausible
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AAMC Projection Worst Case
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By Specialty
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Nurse Practitioners

• All new NPs as of 2015 must be DNPs
• CACC Council for the Advancement of
  Comprehensive Care
• NBME the exam will utilize test items
  previously used in the USMLE Step 3 examination

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Solutions

• Even a robust expansion of GME capacity (from
  25,000 new entrants per year to 32,000) would
  only reduce the projected shortage in 2025 by
  54,000 physicians (43 ).

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Definition of General Surgery

• In Manhattan
• In Willcox, Arizona
• In Iraq and Afghanistan
• And as cited by Claude Organ,
• Friday night at midnight and Monday at Noon

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Production

• Programs 249
• Graduates 1050
• Specialization 79
• Some continue as General Surgeons
• Number of Surgeons Certified
• 1980 945
• 2008 972

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Demand

• 7.53 per 100,000 population
• Maryland, Statewide 5.2
• Far fewer in remote areas where they are most
  needed

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Willcox, AZ
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Retirement

• Was decreasing
• The Economy

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Surgical Workforce

• GMENAC Study (1971) All of Surgery except
  Otolaryngology deemed in surplus
• SOSSUS (1975) Concluded that the existing number
  of surgeons was sufficient to provide needed
  services
• Did highlight maldistribution
• AMA CLRPD (1989) General Surgical Shortage by
  2000 predicted

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Surgical Workforce

• Number of General Surgery Training Programs Flat
  (249)
• Production of those Programs Flat (1000)

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Dartmouth Atlas 1996 to 2006

• Number of General Surgeons declined 16.3

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Bureau of Health Professions

• From 2005 to 2020
• Surgeons overall will increase 3
• General Surgery will decrease 7

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AAMC Center for Workforce

• General Surgeons lt 55 YO 42
• FP 37 and Internal Med 32

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Rural General Surgery

• Over 50 Million of our US Citizenry
• Greater on call demands
• Lower reimbursement

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US Medical Graduates

• Five specialties have more applicants than
  positions
• Plastic Surgery
• General Surgery
• Dermatology
• Orthopedic Surgery
• Radiation Oncology

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Resident Attrition

• Approaching 30
• The Best and the Brightest Academically highly
  qualified graduates and graduates who chose
  training in general surgery or in a 5-year
  surgical specialty were at increased risk of
  attrition during GME.

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IMGs

• Constitute 25 of the nations Physicians
• Many from other countries are the best and the
  brightest
• Twenty percent of Categorical General Surgery
  Residents are IMGs
• A transgression of Distributive Justice in the
  World

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Ohio State Study

• Assumes that 85 of certified surgeons will
  practice general surgery and 705 will annually
  retire
• Restricts analysis to allopathic production
• Static Assumptions as to disease demand

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Ohio State Study

• Projects shortage of 1300 in 2010
• Grows to 6000 in 2050
• Proportionate to population, General Surgeons
  decreased 25 from 1981 to 2005

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Ohio State Study Comments

• Hiram Polk The pundits on the East and West
  Coasts dont have a clue
• Polk we ought to open (a) thousand slots at
  good programs
• Resident comment on remuneration and lifestyle

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The RRC

• The ACGME
• Nominating Organizations
• ABS
• ACS
• AMA-CME

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What the RRC Does

• Program Review and Accreditation
• Citations
• Cycle Length
• Requirements for Training
• Additional Rural Surgery elements??
• Coordination with the ABS
• General, Pediatric, Vascular, Surgical Critical
  Care (Hand)

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What the RRC Does NOT Do

• Set Production Quotas
• Certify Individuals

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Current RRC Issues

• Milestones
• Duty Hours
• Accelerated Visits
• Preliminary Residents
• Essential Content Area Experience
• International Rotations
• Seventh Competency
• Fellowship Minimum Pass Rates

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International Rotations

• Non-Chief rotation up to six months
• Faculty members from the parent program or
  equivalently-trained host faculty
• Clearly state educational rationale
• Appropriate educational environment
• Appropriate supervision
• Educational resources

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The ACGME and the RRC

• New Leadership
• New model of the CRCC and the ACGME Board

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What Else Can Be Done?

• GME Funding
• General Surgery as Surgical Primary Care
• Title VII Health Professions Program
• Alleviate Medical School Debt Burden
• Extend Loan Deferment

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Conclusion

• There is little question that there is a shortage
  of general surgeons
• The shortage will worsen
• The dynamic environment makes planning difficult
• The pipeline is long
• General Surgeons have job security
• The RRC stands ready to approve appropriate
  additional positions and programs

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Questions??