The American College of Surgeons is dedicated to improving the care of the surgical patient and to safeguarding standards of care in an optimal and ethical practice environment.

Oct. 11, 2009
Oct. 13, 2009
Oct. 15, 2009

Contents:
• Evolution of trauma care in the U.S. should focus on inclusive systems
• Surgeon shortage one area that health care reform should address
• National Safety Council Surgeons’ Award for Service to Safety
• Distinguished Philanthropist Award
• Award-winning geneticist to participate in Surgical Forum
• Young Fellows Association debuts
• Bernard Fisher, MD, FACS, is recipient of 2009 Jacobson Innovation Award
• No easy answers to medical industry support for CME
• Commission on Cancer Paper Competition winners announced
• ACS-Emerson Scholar-in-Residence in Medical Ethics established

Surgeon shortage one area that health care reform should address

The burgeoning shortage of surgeons and its relationship to ongoing health care reform efforts was the focus of the Excelsior Surgical Society Edward D. Churchill Lecture, which George F. Sheldon, MD, FACS, presented Tuesday morning. More specifically, Dr. Sheldon, Director of the American College of Surgeons Health Policy Research Institute, outlined the evolution of the current health care reform debate in Congress and explained how physician workforce shortfalls affect access to appropriate care.

Dr. Sheldon, Zack D. Owens Distinguished Professor of Surgery at the University of North Carolina-Chapel Hill, said that some misconceptions have been perpetuated in the health care debate. For example, he explained that new evidence shows that prevention—often hailed as an effective method of reducing unwarranted spending—will not actually avert the evolution of disease of lower costs. He also noted that questions about the number of uninsured Americans continue to arise and underscored the point that “uninsured is not uncared for.” Furthermore, Dr. Sheldon said policymakers need to disabuse themselves of the notion that physicians are “interchangeable.”

“You’ve heard it said that a larger share of primary care physicians results in lower mortality rates,” Dr. Sheldon said. However, there is no evidence of such a correlation. Actually, “mortality is where surgeons aren’t.” Preventable mortality rates are also high in areas that lack proper trauma support systems. To date, 38 percent of the states don’t have emergency medical systems in place.

In addition, Dr. Sheldon asserted that too few surgeons are being produced to keep pace with the growing population. He noted that in the 1980s, health policy experts were predicting a surplus of physicians. Consequently, in 1993 the Council on Graduate Medical Education called for limiting the number of residency slots, and the Association of American Medical Colleges suggested that half of all U.S. medical school graduates should enter “generalist” professions, such as primary care and family medicine. Next, the Balanced Budget Act of 1997 limited funding for graduate medical education (GME). By 2003, however, it had become clear that the earlier estimated physician-patient ratios were incorrect and that, in fact, the nation was on the brink of a medical workforce shortage, he said.

Indeed, general surgery is now experiencing deficit growth. The areas of the nation that are experiencing the largest depletion of general surgeons are urban centers and rural areas, Dr. Sheldon noted.

A major contributing factor in the reduction of the general surgery workforce is the continued movement toward subspecialization. More physicians are entering the subspecialties and voluntarily narrowing their scope of practice due to increased patient demand, advances in medical knowledge and technology, and lifestyle issues, Dr. Sheldon said.

Furthermore, general surgeons and other physicians are experiencing encroachment from non-physician clinicians, including nurse practitioners, physician assistants, and so on. These individuals are now granted licenses that allow them to provide a broader range of services, to write more prescriptions, and to function more autonomously. “Almost everyone is practicing medicine these days,” Dr. Sheldon observed.

Other trends in health care that Dr. Sheldon spoke about include the migration from solo to large group practices and the increasing number of well-trained international medical school graduates. “Right now, almost half of all individuals applying for residencies have trained outside of the U.S.,” he said.

“We’ve got a lot of problems to fix,” Dr. Sheldon said. Suggested repairs include lifting the GME funding freeze. With respect to health system reform, he called for tighter insurance industry regulation, medical liability tort reform, increased efforts aimed at improving quality of care, and universal access to health insurance coverage.

Dr. Sheldon further suggested that there should be some clarification of the differences in scope of practice for physicians and nonphysicians. For example, physicians should be responsible for providing high-tech and acute care, managing complex chronic diseases, and so on, while nonphysicians should be responsible for symptom control and other types of routine care.

The ACS Health Policy Research Institute will continue to study the issues affecting health system reform, including the workforce shortage, and to offer solutions to the problems. “This institute is really a unique experiment that the College is doing,” Dr. Sheldon said, adding that the program should prove to be a good investment for the ACS and in the future of surgery.