The ACP Advocate Blog
by Bob Doherty
Tuesday, March 31, 2009
Are the surgeons misdiagnosing the physician workforce crisis?
The American College of Surgeons, joined by other surgical specialty societies, has created Operation Patient Access (OPA), a campaign to "bring into focus the urgent issues facing access to quality surgical care in the United States ... and to call attention to urgently needed policy changes to address gaps in the availability of quality surgical patient." According to the OPA website (which is pretty nicely done, by the way), 400 surgeons - sporting "Will a surgeon be a there when you need one?" buttons - descended on Capitol Hill last week to urge lawmakers to "consider a wide range of solutions, such as providing more funding for graduate surgical education, reducing liability costs, expanding the National Health Service Corps, and implementing alternative payment methods for health care. If we fail to act now, these shortages will undermine attempts to expand access to health care and will further endanger the lives of all our citizens."
If this sounds familiar, it is because the surgeons' diagnosis and policy prescriptions are virtually identical to the case that ACP has been making on the primary care physician shortage.
Which is a problem, because it blurs the urgent need to rebuild the primary care physician workforce in the United States by suggesting that the crisis in surgery is of greater concern. The tools to increase the numbers and proportions of primary care physicians in the United States - payment reform, scholarships and loan forgiveness in exchange for service obligations, and graduate medical education funding - will be ineffective if the limited funding for such programs are broadly diverted to increase the numbers of surgeons, including some surgical specialties where there is scant evidence of a shortage. The OPA website speaks broadly of shortage of surgeons, when the evidence that I've seen - including the evidence on the OPA website - suggests that the shortage is principally in general surgery and a few of the surgical subspecialties and in certain parts of the country, particularly rural areas.
On payment reform, there is very strong evidence that the disparities in payment between primary care and other more highly compensated specialties is a principal reason why so many young physicians are choosing the higher paid specialties over general internal medicine, family practice and pediatrics. Yet the OPA website suggests that "reimbursement policies" are one of the contributors to the surgical workforce shortage. The OPA, not surprisingly, makes it clear that it will oppose any effort to increase payment for primary care physicians at the expense of surgeons.
Perhaps the most troubling aspect of the OPA campaign is that it diminishes the crisis in primary care physician workforce, by arguing that the surgical workforce "crisis" is "different" because non-physicians can substitute for primary care physicians but not for surgeons. This is what surgeon George Sheldon, MD, FACS, writes in the OPA blog:
"Regions around the country are facing shortages of nurses, primary care physicians, other health care workers and certain specialists. We certainly understand the concern and urgent need to fill these positions. But, you may be wondering, what's different for surgeons? What's different is that there is no substitute for a surgeon. While internal medicine and family practice physicians and advanced practice nurses often overlap in their roles, surgical specialties do not overlap with other health providers or with each other. An urologist cannot fill in for a neurosurgeon. A cardiothoracic surgeon cannot fill in for an orthopedic surgeon. And only a trained surgeon can perform an operation."
To be clear, I believe that the United States needs a national workforce policy to determine the appropriate mix and distribution of all physician specialties including primary care and general surgery. I am sympathetic to the concerns about the shortage of general surgeons as well as shortages in some other surgical and medical subspecialty areas - these too should be addressed in workforce planning and polices.
But the evidence is overwhelming that primary care in the United States is heading toward collapse, that urgent action is required to reverse the primary care shortage, and that the quality of care will be lower, and the cost higher, without enough primary care physicians. (For a good review of the evidence, see the testimony that ACP President Jeff Harris, MD, FACP, presented last week to the House Energy and Commerce Committee, complete with over 51 scholarly references).
The answer to the crisis in primary care is not to substitute non-physicians for primary care doctors. Or to blur the lines so that the public policy tools available to increase the numbers and proportion of primary care physicians are diverted to other specialties.
Today's question: What is your reaction to the surgeons' Operation Patient Access campaign?
About the Author
Bob Doherty is Senior Vice President, American College of Physicians Government Affairs and Public Policy; Author of the ACP Advocate Blog
Email Bob Doherty: TheACPAdvocateblog@acponline.org.Follow @BobDohertyACP
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