Tuesday, April 22, 2008
An article in today's paper incites a post, where none had been forthcoming. It's not news, really, in the sense that it's been well-known to many: us general surgeons are a dying breed. But it threatens to become very serious. There are many reasons, the mentioning of some of which could cause ire. The usual: doctors complaining about money and work. Sex, too.
It was just before I started training that California adopted a system for comparing one operation to another, payment-wise. Called the California Relative Value System (CRVS), and used or copied nationally, it purported to consider degree of difficulty, post-operative care, and, as I recall, a few other factors, in order to compare, say, a colon resection to a hernia repair; and, more interestingly, to a prostatectomy or hip replacement. Rumor had it that the general surgeon on the panel that came up with the scale was so busy he missed a lot of meetings. As a consequence, general surgery got screwed. The work of a colon resection was very unfavorably compared to that prostatectomy and pretty much everything else. The CRVS assigned "units:" if a hernia got, say, 11 units, (making that up; I don't recall the specifics and don't feel like looking it up), a colon resection got, say, 24. It was up to insurers, and medicaid, and medicare to assign dollars to units. Depending on who was paying, a unit might differ from institution to institution by many dollars; but the relative values were the same. The lowness (which translates to lowliness) of general surgical operations always annoyed me. The systems are different now, but the comparison remains: there are some quick outpatient eye operations, for example, that pay more than a Whipple procedure, which takes several hours, a boatload more skill, and requires many days of inpatient, and weeks of outpatient, care. Alas, poor me.
Add to the above the fact that emergency call for general surgeons can actually involve emergencies. This is, of course, true for other surgical specialties -- particularly orthopedics -- but in most communities there are fewer general surgeons than orthopods, so the frequency of call is greater. And the orthopedist fixes the bone and bolts (as it were); the general surgeon is left holding the bags. It's disruptive, it's hard, it's onerous. So it's not surprising that surgeons looking ahead, while looking back at the debt that trails them out of training, see options that are more remunerative and less demanding, and find the choice pretty clear. General surgery has its special attractions. No other field is as broad and deep. The variety of what we do is both rewarding and challenging; and the opportunity to have on-going relations with patients and families -- to be their "family surgeon" -- is something I cherished in my own practice. But there are limits... So, as we see in the initially-referenced article, the relative and actual numbers of general surgeons is heading down, dramatically. And there's another factor, not mentioned in the paper: girls.
I wrote recently about a trip I took back to UCSF, my training grounds, for a dinner honoring an old prof. Among the speakers was the chairperson of the surgery department, a very impressive and very talented woman. (Also, it was clear, a hell-raiser, in the best sense of the term.) With pride, she mentioned that for the first time the entire incoming group of surgery interns was female. The guest of honor, Senator Feinstein, seemed pleased. "Uh oh," was what I thought.
It's reality: women doctors are more likely to shorten careers for raising a family; or to seek opportunities for job-sharing; or to choose specialties which allow more flexibilty. One of my partners was a woman, and she quit entirely, and young, to be with her kids. The one hired after I left took several lengthy times off for maternity excursions. It's not that I object. I don't see any qualitative differences between boy surgeons and girl surgeons. It's just that it represents another -- and not-much-talked-about -- hole in the sinking ship of surgery. It will add to the shortage. Is all I'm saying.
You can't force people to become general surgeons (oh, I suppose you can, but I doubt it'd work out.) Solutions, if there are any, will be multi-faceted. Reimbursement inequities will need addressing. So will work hours. As I've said recently, the trend toward hospitalists might be a major boon; in fact, I don't see a solution that doesn't involve it. Meanwhile, look both ways when crossing the street, eat plenty of fiber, exercise, and don't swallow cherry pits.