We are heading for a train wreck of too few residency positions in the next decade. - Thomas Nasca, MD, executive director, Accreditation Council for Graduate Medical Education, in his keynote address to the Association of Program Directors in Surgery at their annual meeting in Salt Lake City, Utah, April 30, 2009
General surgery is the “primary care” of surgery. General surgeons provide broad-based clinical service, including areas such as trauma surgery, emergency care for many of the most common surgical emergencies (such as acute appendicitis), and critical care services, in hospitals throughout the country. In rural areas generally not served by surgical specialists, general surgeons often provide basic surgical care in disciplines such as orthopedics, urology, and gynecology. The “primary care” role for general surgeons in such rural areas is even more critical.1
Current manpower analyses predict a worsening shortage of general surgeons in the next 10 to 20 years.2 However, the output of the Accreditation Council for Graduate Medical Education (ACGME)-accredited residency programs in general surgery has remained constant at slightly more than 1,000 chief residents per year since the early 1980s, despite a population increase of more than 33% since 1980 (Frank R. Lewis, Jr, MD, executive director, American Board of Surgery, personal communication, March 2009). In addition, the ACGME duty hours standards and the stricter duty hours reductions for which the Institute of Medicine (IOM) recently advocated have posed special compliance problems for general surgery residency programs.3,4 This challenge is especially relevant for those residency programs centered in major teaching and safety net hospitals faced with an increasing volume and complexity of surgical caseloads and limited ability to hire the midlevel practitioners and staff physicians necessary to meet those clinical challenges. We believe that the barriers to the expansion of general surgery residency programs can and should be overcome and that thoughtful expansion of general surgery residency programs should be pursued.
The Current and Projected Shortage of General Surgeons
Projection of future physician manpower needs has been a risky business, and during the past 35 years, we have seen the pendulum swing from projected surplus to projected shortage. For example, the 1975 Study on Surgical Services for the United States projected a surgeon surplus, and the 1980 Graduate Medical Education National Advisory Committee study projected an overall physician surplus by 2000.5,6 The Third Report of the Council on Graduate Medical Education (COGME)1 focused on the imbalance between primary and specialty physicians and proposed to cap Medicare-funded first-year GME positions at 110% of U.S. medical school graduates. However, the report noted that there were important exceptions to the projected national surplus of specialty physicians, noting general surgery among those exceptions. The rationale for COGME's proposal for an expansion of surgery training positions included the aging of the population, the growing need for trauma care services, and the decreasing percentage of general surgery residency graduates who become general surgeons and practice in rural areas. In 2001, Cooper et al7 forecasted an impending national physician shortage on the basis of economic and historical trends. Most recently, the Association of American Medical Colleges (AAMC) has identified a significant overall physician shortage and has advocated a 30% increase across 10 years in student enrollment at Liaison Committee on Medical Education-accredited medical schools.8 During a congressional briefing in April 2009, representatives of the AAMC identified general surgery as an area of specific need.9
A recent population analysis by Williams and Ellison2 projected a national general surgeon shortage of 1,300 by 2010, 1,875 by 2020, and 6,000 by 2050. Williams and Ellison describe three algorithms to predict the future supply of physicians: (1) an economic, or trend, model, (2) a population model, and (3) estimating physicians needed by workforce studies. However, their calculations do not account for the regional distribution of general surgeons, which may make current and projected surgeon shortages in areas such as the Southeast even more acute.
The Overall Growth in Graduate Medical Education Training
Foreign-trained general surgeons who obtain medical licensure in the United States can help to address some of the workforce shortages. However, the primary “spigot” regulating the entrance into clinical practice of new general surgeons is the number of chief residents completing ACGME-approved residency programs in general surgery each year. The number of such positions must be judged in the context of historical trends in the overall number of residents in ACGME-accredited programs (all disciplines) and in the number of U.S. medical school graduates (both MDs and DOs, as osteopathic graduates are eligible to participate in ACGME-accredited general surgery programs as well).
Since 1980, there has been significant growth in the overall number of resident positions, while the number of general surgery resident positions has remained stagnant (See Table 1). Following passage of the Balanced Budget Act (BBA) of 1997, which established a cap on Medicare spending for GME positions, there was a temporary halt to the number of physicians, which persisted through 2002.3 Medicare currently funds the costs of training for about 93,200 residents.3 Thereafter, steady growth in the number of resident positions has resumed, even though these additional positions do not receive Medicare funding. Many of these new positions are filled by international medical school graduates. Among the reasons for these overall increases may be the implementation of the ACGME duty hours requirements in 2003.3 Salsberg et al3 speculate, “It is possible that some hospitals concluded that adding residents was the most cost-effective way of covering services that might not otherwise be covered because of the limit on the number of hours a resident could work under the new work rules.”
Hospitals can only add resident positions with the permission of the ACGME and its review committees (RCs). However, by any calculation, and even without Medicare subsidy of resident salaries, residents are more cost-effective than midlevel practitioners or staff physicians/faculty in meeting the challenge of serving an increasing patient population. Growth in overall GME positions, with a relatively constant resident-to-population ratio, is thus not surprising. In contrast, the stasis in general surgery positions, specifically chief resident positions, is surprising.
The ACGME Duty Hours Requirements
The 2003 ACGME duty hours requirements, which capped weekly work hours at 80 hours, on average, has significantly reduced the effective time of training of U.S. surgical residents. Remarkably, current data suggest that the total case experience of graduating chief residents in general surgery has not decreased, and, similarly, American Board of Surgery In-Training Examination scores have not deteriorated.10,11 Yet nationally, general surgery and other surgical subspecialties are among the disciplines that have had the greatest difficulty remaining in compliance with the ACGME duty hours requirements. Should the latest duty hours recommendations of the IOM be adopted, there will be further workload compression for general surgery residents.4 The IOM has calculated the cost of implementation of its proposed duty hours standards, including additional midlevel providers, staff physicians, and residents, as in excess of $1.5B.4 General surgery will certainly bear a disproportionate share of this cost unless the number of surgical trainees and residency graduates is allowed to expand.
Impediments to Surgery Residency Growth
Demand for surgery residency training positions
Since 2003, there has been continued growth in the number of U.S. MD and DO graduates applying to general surgery residency programs.12 Between 1997 and 2007, the percentage of female residents in general surgery residency programs has grown from 20.5% to 30.7%.13,14 At this time, essentially all categorical positions in general surgery are filled through the National Resident Match Program.15 The “demand” for general surgery positions has grown, and there is currently no “excess capacity” of categorical residency positions to accommodate the upcoming increase in U.S. MD and DO medical school graduates. With no increase in capacity, these new graduates will simply displace IMG general surgery residents, who currently constitute about 20% of residents in U.S. general surgery residency program.16 IMGs presently make up 20% of the surgical workforce and are the safety net for U.S. surgical health care.12
Inadequate educational resources to expand surgery residency positions
Whereas the procedural requirements for general surgery residency training have recently increased in endoscopy, there is no indication that the number of surgical procedures, including so-called “index” cases, in teaching hospitals currently represents a significant constraint on residency expansion. Nationally, the number of surgical procedures is growing, despite short-term decreases in the volume of economically sensitive procedures, such as cosmetic surgery.17,18 In many teaching hospitals, surgical procedures of significant educational value are presently not covered by residents because of a shortage of residents.
Inadequate financial resources to expand surgery residency positions
The BBA of 1997 temporarily halted the historical trend of GME program growth since 1980 (See Table 1). However, the overall number of residency and fellowship positions has grown each year since 2002, in the absence of additional Centers for Medicare and Medicaid Services (CMS) funding to teaching hospitals for these new positions.3 At least one possible explanation is that, in the face of the ACGME duty hours requirements (and the resultant functional reduction in resident availability to provide direct patient care in teaching hospitals) and increasing patient-service demands, such as the increasing number and medical complexity of patients, many teaching hospitals have supported residency expansion instead of hiring additional midlevel practitioners or attending physicians as the most cost-effective means to meet these needs, even without additional CMS funding support.3 However, teaching hospitals can only add resident positions with the permission of the ACGME and its RCs.
Addressing the Current and Projected Shortage of General Surgeons
There is a national shortage of general surgeons that, for many reasons, is worsening over time. The number of graduates of U.S. general surgery residency programs has not kept pace with the population growth. The demand for categorical general surgery residency slots is currently robust, and there is no excess capacity to absorb the projected increases in the number of U.S. MD and DO medical school graduates as a result of the creation of new medical schools and the increase in class sizes at existing medical schools. In his recent presidential address to the Southeastern Surgical Congress, Kirby Bland16 has called for a multipronged effort to increase our annual output of general surgeons, including a repeal of the 1997 BBA caps on the resident training pool, prospective linkage of the ACGME-approved RC surgery positions to the population census, and structured recruitment of IMGs through incentive programs for VA service or service to underserved populations in return for visa waivers.
A collateral benefit of such program expansion would be to help many general surgery programs better address current ACGME accreditation challenges, such as the duty hours requirements and the balance of service to education. Although increased federal funding support from CMS to teaching hospitals, through the elimination of the BBA caps, would certainly facilitate the expansion of general surgery residencies, the authors believe that many teaching institutions, if granted ACGME approval, would choose to expand their residency programs even without additional funding support. By any calculation, this plan is the most cost-effective means to support the increasing volume and intensity of surgical services, especially in safety net institutions.
1Council on Graduate Medical Education. Improving Access to Health Care Through Physician Workforce Reform: Directions for the 21st Century. Third Report. Rockville, MD: U.S. Department of Health and Human Services; 1992.
2Williams TE Jr, Ellison EC. Population analysis predicts a future critical shortage of general surgeons. Surgery. 2008;144:548–556.
3Salsberg E, Rockey PH, Rivers KI, Brotherton SE, Jackson GR. U.S. residency training before and after the 1997 Balanced Budget Act. JAMA. 2008;200:1174–1180.
4Ulmer C, Miller Wolman D, Johns MME, eds. Resident Duty Hours: Enhancing Sleep, Supervision, and Safety. Washington, DC: National Academies Press; 2008.
5Moore FD. Manpower goals in American surgery. Implications for residency training. Future surgical manpower in the framework of total United States physicians. Ann Surg. 1976;184:125–144.
6Graduate Medical Education National Advisory Committee. Report of the Graduate Medical Education National Advisory Committee to the Secretary, Department of Health and Human Services. Washington, DC: U.S. Department of Health and Human Services; 1981.
7Cooper RA, Getzen TE, McKee HJ, Laud P. Economic and demographic trends signal an impending physician shortage. Health Aff (Millwood). 2002;21:140–154.
10Spencer AU, Teitelbaum DH. Impact of work-hour restrictions on residents'operative volume on a subspecialty surgical service. J Am Coll Surg. 2005;200:670–676.
11Hutter MM, Kellogg KC, Ferguson CM, et al. The impact of the 80-hour workweek on surgical residents and attending surgeons. Ann Surg. 2006;243:864–871.
12Association of American Medical Colleges. Table 40: Residency applicants of U.S. medical school graduates by specialty, 2003–2009. Electronic Residency Application Services (ERAS) Data. Available at: http://www.aamc.org/data/facts/erasmdphd/start.htm
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13Dunn MR, Miller RS, Richter TH. Graduate medical education, 1997–1998. Appendix II. JAMA. 1998;280:809–812, 836–845.
14Brotherton SE, Etzel SI. Graduate medical education, 2007–2008. JAMA. 2008;300:1228–1243.
15NRMP Data. Washington, DC: National Resident Matching Program; April 2009.
16Bland KI. In defense of general surgery: Rewards, threats, and challenges. Am Surg. 2009;75:443–457.