Shortage of general surgeons is straining some facilities

The number of general surgeons per 100,000 people fell 26% during the past 25 years, according to an April Archives of Surgery study.

Some hospitals are finding it difficult to locate general surgeons to repair hernias or abdominal traumas on an emergency basis, said Dana Christian Lynge, MD, lead study author.

"We know the system is somewhat strained in areas like urban emergency call and in some rural areas," said Dr. Lynge, associate professor of surgery at the University of Washington School of Medicine in Seattle.

One or two general surgeons can make or break a rural hospital, he said, because it relies on revenue from routine and emergency surgical procedures. Mortality and morbidity from trauma increases if there isn't a general surgeon available, he added.

Dr. Lynge and his co-authors found that the number of general surgeons dropped in both rural and urban areas. Overall, the number of general surgeons per 100,000 people fell to 5.69 in 2005 from 7.68 per 100,000 in 1981 in the U.S. The urban ratio of general surgeons per 100,000 fell to 5.85 from 8.04 during the same time, and the rural ratio sank to 5.02 from 6.36.

One reason for the decline is that many general surgical trainees choose to subspecialize, he said, referring to recent research that found 70% of general surgery residents pursued fellowships.

And while the U.S. population has grown, the amount of general surgical residency positions has stayed nearly unchanged, according to the study.

Lifestyle and reimbursement have had an impact on the willingness of general surgeons to take night call, Dr. Lynge said. Some are reluctant because of the demands, low compensation and high liability risk, the study said. Others have subspecialized to a point where they no longer feel qualified to handle the range of injuries in emergency departments.

As a result, some hospitals and large physician practices have started to hire general surgeon hospitalists to cover surgical emergencies and consults at the hospital, Dr. Lynge said. These surgeons typically only work hospital call and do not see patients in private practice.

George F. Sheldon, MD, surgery professor at the University of North Carolina School of Medicine in Chapel Hill, wrote an accompanying article on the general surgery study. He supported the study's recommendations, which include lifting the federal cap on residency funding imposed by the Balanced Budget Act of 1997 to pay for more general surgery residency positions.

Dr. Sheldon would like to see more general surgery residencies offer rural rotations in order to encourage young physicians to practice in such settings. Surgical subspecialists may be able to fill the gap in urban areas, he said, but access in rural areas is starting to be compromised. In North Carolina, for example, since 1972 there has been a sharp increase in the number of counties without a general surgeon, he said.

The American College of Surgeons has policy stating that access to surgical care is eroding and that the problem is most evident in rural areas, trauma centers and emergency departments.

Robert W. Sewell, MD, president of the American Society of General Surgeons, said demand for general surgeons will continue to exceed supply unless there is significant change in the payment system, starting with the Centers for Medicare & Medicaid Services.

"The rewards are no longer worth the sacrifice," Dr. Sewell said. "I know a surgeon, doing elective procedures for sweaty palms, who makes more money on that than on coronary bypass. There's something terribly wrong with that system."