Michel Makaroun, MD, has been hard-pressed finding vascular surgeons. As chief of the division of vascular surgery at the University of Pittsburgh Medical Center (UMPC) Department of Surgery, he helps hire these much-needed specialists. But despite a generous compensation package, five vascular surgeon positions at UPMC hospitals remain unfilled.
Meanwhile, a hospital 120 miles away has lacked a vascular surgeon for several years, getting by with a cardiac surgeon and interventional radiologist. UMPC sends one of its vascular surgeons to the hospital each week, which means a four-hour drive round trip for the specialist.
“It’s always an issue of supply and demand, and currently there is a huge demand for vascular services but unfortunately not as much supply,” says Makaroun, president of the Society for Vascular Surgery.
Vascular surgeons are not the only surgeons in short supply. An April 2019 report prepared for the AAMC by the health care consulting firm IHS Markit Ltd., titled The Complexities of Physician Supply and Demand, estimates a shortage of 14,300 to 23,400 surgical specialists by 2032. And a 2016 Department of Health and Human Services workforce analysis projected shortages in nine out of 10 surgical specialties by 2025, with the greatest shortages in ophthalmology, orthopedic surgery, urology, and general surgery.
“It’s always an issue of supply and demand, and currently there is a huge demand for vascular services but unfortunately not as much supply.”
Michel Makaroun, MD
President of the Society for Vascular Surgery
Those figures are especially alarming considering the growing, aging population in the United States. The number of people 65 and older is expected to reach 83.7 million in 2050, almost twice the 2012 level of 43.1 million, according to the U.S. Census. In addition, many surgeons are edging closer to retirement or contemplating cutting back.
“Fewer surgeons mean greater access issues for patients and delays in care, leading to morbidity and mortality,” says Janis Orlowski, MD, AAMC chief health care officer. “Academic medicine leaders are concerned about this growing problem and are exploring various solutions to ensure that America's health care needs are met.”
Communities in need of surgeons
Cardiothoracic surgeon J. Michael DiMaio, MD, practices in the Dallas-Fort Worth metropolitan area of Texas, a hub of distinguished heart surgery facilities. As is often the case for surgical specialties, complicated cardiothoracic procedures require the support of well-resourced hospitals, notes DiMaio. But those institutions tend to be clustered in metropolitan regions.
“It’s certainly harder in a small market and sometimes in a medium market to have the sufficient support you may need,” says DiMaio, who is also chief of staff and medical director for publications and postgraduate cardiovascular education at the Baylor Scott and White Research Institute and program director for thoracic residency and surgical services at Baylor Scott and White Health.
“Rural surgical practices have been struggling, with under-resourced hospitals unable to provide more complex surgical procedures.”
Janis Orlowski, MD
That’s worrisome in light of the projected growth in the need for cardiothoracic procedures. For example, heart surgery cases will likely increase by 54% and lung cancer cases by 70% in less than two decades, according to a 2016 report.
According to the American Urological Association’s (AUA) 2017 workforce report, nearly 90% of urologists work in metropolitan areas. Urology is one surgical specialty being stretched thin. “We are relatively a small group, maybe less than 1% of all doctors in the United States, but the disease burden is enormous,” says Christopher Gonzalez, MD, public policy council chair at the AUA. He notes that three of the six most common cancers in men — bladder, kidney, and prostate — are all urologic.
Another shortage hitting rural areas hard is general surgery. Many routine surgeries performed in emergency departments, from abscess removals to appendectomies, are often handled by general surgeons, says Patrick Bailey, MD, medical director for the American College of Surgeons (ACS). And in rural hospitals — many of which have closed in recent years — general surgeons are vital.
“They are what’s in the name — they are generalists,” says Bailey. “And for those folks who are in smaller communities, they have a very broad practice so that they’re able to serve their patient population.”
“Rural surgical practices have been struggling, with under-resourced hospitals unable to provide more complex surgical procedures,” says Orlowski. “In addition, because general surgeons in rural areas are older and approaching retirement faster, these ranks need to be filled by younger physicians who care passionately about their field of work and want to bring care to rural areas.”
Looking for solutions
The shortages have set off alarm bells among leaders in surgery and academic medicine, and they have set out to find solutions.
One way the AAMC, the ACS, and others are working to combat the problem is by educating policymakers on the federal government’s critical role in physician training and advocating that Congress should responsibly lift the current caps on federally supported residency slots. “Increasing the resident cap in hospitals would be tremendous in improving all physician shortages, including surgery,” says DiMaio, who has developed graduate medical education policy for the Society of Thoracic Surgeons.
Groups are also exploring ways to address the problem of burnout among surgeons as its prevalence tops 50%, according to a 2016 systematic review. The ACS, for example, leads initiatives aimed at reducing contributors to burnout, including administrative burdens that can curtail physicians’ time with patients.
Despite burnout, surgery can be an incredibly rewarding career, say experts, but students need to experience it up close and early if they are going to develop a passion for it.
“Increasing the resident cap in hospitals would be tremendous in improving all physician shortages, including surgery.”
J. Michael DiMaio, MD
Baylor Scott and White Research Institute
According to the AAMC’s 2018 Medical School Graduation Questionnaire, medical school graduates’ specialty choice was most greatly influenced by whether it “fit with personality, interests, and skills,” with almost 88% indicating a “strong influence.”
“Particularly for those who rotate with medical students who have their first exposure to surgery, that’s really where you want to work on having the love of the field,” says Orlowski. “You need to have people who have a positive focus and a balance to their life. That is what’s attractive to a medical student.”
While working at the Case Western Reserve University School of Medicine, Gonzalez, who is now chair of the department of urology at the Loyola University Chicago Stritch School of Medicine, worked closely with the dean to bring urology to the forefront of education. That process involved him advocating for urology as a required rotation and reaching out to students early and regularly to share the benefits of a career in the field. “A lot of [attracting students to surgery] is going to be boots on the ground in individual medical schools, just getting students excited,” Gonzales notes.
Bringing care to underserved populations
Because residents tend to practice where they trained, medical schools and teaching hospitals are working to educate future physicians in areas hit by shortages. The University of Nevada, Las Vegas School of Medicine (UNLV) is one such institution.
“We would like to create a medical community here that’s on par with some of the other things the city is known for,” says John Fildes, MD, professor and inaugural chair of the UNLV department of surgery. “It’s a world-class destination for entertainment, world-class destination for art and architecture. People move here expecting that there’s going to be world-class medical services, and we intend to build them.”
“General surgery really is the foundation of procedural medicine, and most general surgeons can support the procedural needs of large numbers of patients, and that’s what makes them very valuable.”
John Fildes, MD
University of Nevada, Las Vegas School of Medicine
Established in 2017, the school opts for applicants with ties to Nevada who want to live and work in the state. Increasing the number of general surgeons aligns with that priority. According to a 2018 Nevada physician workforce report, the state ranked 49th in the country for general surgeons per 100,000 people.
“General surgery really is the foundation of procedural medicine, and most general surgeons can support the procedural needs of large numbers of patients, and that’s what makes them very valuable,” says Fildes.
Halfway across the country, in the department of surgery at the University of Wisconsin (UW) School of Medicine and Public Health, the rural general surgery residency track is also helping fill the need for surgeons in underserved parts of the state, giving students the training necessary to serve patients in rural and community practices.
The life of a general surgeon isn’t for everyone, but there is something special about the opportunity to serve an esteemed role in small communities, getting to know patients personally and caring for them throughout their lives, says Jacob Greenberg, MD, EdM, director of the general surgery residency program at the UW School of Medicine and Public Health.
“The more we can focus on this the better,” Greenberg says. “I would use this as a call to arms.”