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?


The Happy Hospitalist said...

I heard a PA telling a nursing student the other day that she was she was trained so well that she was "like a second surgeon". Almost, but not quite."

That's interesting. I thought only a surgeon could be a surgeon.

whmaloney said...

I have been waiting for the House of Medicine "food fight" to begin. It is ironic that the plight of the classically trained "general surgeon" is very similar to the General Internist, having more and more of your knowledge base be subsumed into mmore specialized services, primarily centered around a procedure or complex processes.
The ACP should be very agressive in responding to the Surgeons. We have a different concern that will require different solutions to their concern. I would be leary of holding out an olive branch, unless they agreed that a shortage of primary care is pre-eminent to the purported surgical shortage.
In the end, Congresional Pay Go Rules has led to the disintegration of physician cohesion in the assault on our professionalism

anuj said...

I think it is irrelevant to talk about shortage of a certain type of physician or surgeon without talking about the needs that exist and who is trained to fill them. General medicine and other primary care specialties have run themselves into the situation that we are in because we have been handing off our work to subspecialists gladly. I see this everyday in my own practice environment. For simple things like a cellulitis, or atril fibrillation without the need for cardioversion, or elevated liver function tests, we consult specialists in the hospital. Why- because of the culture in medicine today, habitual behavior, to prevent malpractice concerns, or we simply dont know what we are doing. Generalists have long been paid simply to see patients and then call a consultant to do the real work. End result - what many of our colleagues do today can be done by non physicians. And that gives other organizations the opportunity to make comments like the one made by the surgical association that you cite.
There has to be a defined reason to consult someone. There have to be limits on when a consult is appropriate. And generalist training has to be improved to the point that they feel confident dealing with most problems that do not require procedures.
The fight over money will happen. Cost control in unavoidable. No physician should make half a million dollars or other outrageous amounts unless they spend all their time working. There has to be a reduction in the pay for specialists and surgeons, the work has to shift to generalists and generalist pay has to increase. That is the way to ensure a system that is not as fragmented as our current system. And, that system will also be cheaper because one physician will have to be paid instead of a slew of physicians for every patient, as is currently happening. For too long, specialists have enjoyed high salaries not justified by their additional time in training. I mean, a cardiologist only has three more years of training and makes about two times as much as a generalist. In terms of value, a cardiologist can only take care of the heart and not of the entire patient. Some of them try to, and end up doing a non evidence based job of it.