Future Trends in General Surgery Training: Challenges and Solutions

1. Training General Surgeons for Tomorrow Thomas V Whalen, MD

2. Predictions are Difficult… • “The future ain’t what it used to be.”

3. New and Old Technologies • Ulcer Surgery • Bariatrics • Breast conservation • Hernia Watch and Wait • NOTES • Interventional Radiology • Telerobotics

4. 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

5. Lifestyle Issues • Only 46.5% of US Medical graduates plan to engage in full time practice • Impact of the female Physician Workforce

6. 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

7. Current Workforce

8. AAMC Projections to 2025

9. AAMC Projection: Most Plausible

10. AAMC Projection: Worst Case

11. By Specialty

12. 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”

13. 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 %).

14. 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

15. Production • Programs: 249 • Graduates: 1050 • Specialization: 79% • Some continue as General Surgeons • Number of Surgeons Certified: • 1980: 945 • 2008: 972

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

17. Willcox, AZ

22. Retirement • Was decreasing… • The Economy

23. 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

24. Surgical Workforce • Number of General Surgery Training Programs Flat (249) • Production of those Programs Flat (1000)

25. Dartmouth Atlas: 1996 to 2006 • Number of General Surgeons declined 16.3%

26. Bureau of Health Professions • From 2005 to 2020: • Surgeons overall will increase 3% • General Surgery will decrease 7%

27. AAMC Center for Workforce • General Surgeons < 55 YO: 42% • FP: 37% and Internal Med: 32%

28. Rural General Surgery • Over 50 Million of our US Citizenry • Greater on call demands • Lower reimbursement

29. US Medical Graduates • Five specialties have more applicants than positions: • Plastic Surgery • General Surgery • Dermatology • Orthopedic Surgery • Radiation Oncology

30. 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.”

31. IMGs • Constitute 25% of the nation’s 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

32. 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

33. 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

34. Ohio State Study – Comments • Hiram Polk: “The pundits on the East and West Coasts don’t have a clue…” • Polk: “…we ought to open (a) thousand slots” at good programs • Resident comment on remuneration and lifestyle

35. The RRC • The ACGME • Nominating Organizations • ABS • ACS • AMA-CME

36. 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)

37. What the RRC Does NOT Do • Set Production Quotas • Certify Individuals

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

39. 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

40. The ACGME and the RRC • New Leadership • New model of the CRCC and the ACGME Board

41. 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

42. 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

43. Questions??