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American Surgical Association Forum Discussion on Reassessment of the Medical Work Force: Impact on Surgical Manpower in the 21st Century

doi: 10.1097/SLA.0b013e3181575d79
Forum on the State of the Health Workforce

Moderator: President Jay L. Grosfeld, MD

Dr. Richard J. Shemin (Los Angeles, California): I speak as a cardiothoracic surgeon. I have had the privilege of being the chair of our Practice and Access Work Force, which is a combined committee between the Society of Thoracic Surgeons and the American Association for Thoracic Surgery. Since 1975, we completed probably 10 surveys. Since 1995, we have done three, every 5 years.

Recently, because of the data that Dr. Sheldon alluded to, 150 GME first-year slots are available a year, with the applicant pool falling under 100, and this year it may be as low as 50. We are extremely concerned about our future work force given the influx of baby boomers and cardiovascular disease still remaining the number one problem in the country.

So the bottom line is that we went ahead and employed the AAMC to help make sure that our work force studies are correct, because volunteer work force surveys by a specialty society may have significant error. However, we did corroborate the information that Dr. Cooper spoke about, which is similar to the large work force study among physicians over the age of 50. Low physician satisfaction and early retirement is a problem. This reduces the enthusiasm of medical students and general surgical residents to pursue a career in what many of us still think is a very vibrant and exciting specialty. The bottom line is that we are looking at major shortages in our specialty, and I have 2 questions.

First, should we consider performance-based education both in medical school and in GME instead of time-based education because the length of training has been alluded to as a major issue?

Second, we heard a lot of information this morning that clearly identifies the magnitude of the problem, and I would like to hear a little bit of discussion on how we will fund all of this education when we still have to provide the care.

Dr. Darrell G. Kirch: I think we are finally moving towards performance-based assessment as an aspect of acknowledging the continuum and streamlining and individualizing it. Our prior mode of episodic cognitive-based testing just is not getting the job done.

There are people in this room who probably know more about the process than I do. Tom Russell may be one of them. A group convened over 4 summits to talk about physician competence and performance and how you assess it, and how we could develop an integrated approach to it that could then be adapted to different specialties and different situations. What is extraordinary is that the specialty societies, the AMA and the AAMC, are all coming to the table saying it is time to work on this.

With regard to the funding issue, I think it is a national problem. We have gotten ourselves deeply into a national attitude of letting market forces fix a problem. And I believe that there are certain larger social issues that market forces cannot be solely trusted to fix. I think our collective national psyche needs to break out of the mold we have been in. I do not believe markets can adequately take care of health care and health care work force issues, and the government needs to intervene. That may mean governmental support.

Dr. Richard A. Cooper: Just a brief comment. Jonathan Kozol wrote a book in the early ’90s, originally for children, about the homeless. He said early in the book, “I’ll tell you a lot about the homeless and various aspects of what their life is like and a variety of social and cultural issues. But do not lose sight of the fundamental issue: The reason there are homeless is there are not enough homes.”

I had the same reaction to the question, which is an important question, and to the issue overall. There are many aspects of this that are interesting and are worthy of discussion and examination. But the fundamental problem is we are not training enough doctors.

There is no point in dealing with the subsidiary issues if you do not deal with the primary issue. Without training more doctors, the rest does not matter. It is worse than “it does not matter”; it diverts the energy of people away from the real issue.

The issue is, we must train more doctors. We must have more residency programs, and I am not going to let anybody I talk to exit from that awareness.

Dr. L.D. Britt (Norfolk, Virginia): President Grosfeld, I hope you will allow me to turn up the temperature a little bit in the room. I want to direct this question to Dr. Kirch. Is it not time for us to give up the ruse and declare what we already know, that the most wasted year in medical education is the fourth year of medical school? Right now most of the medical students in the fourth year are probably in Cancun.

So my question to you is, is it time for the AAMC to overhaul undergraduate medical education and maybe modify or even get rid of the fourth year? That certainly would help the loan debt burden and it would make medical school more attractive?

Dr. Kirch: I was actually in a discussion yesterday with the National Student Affairs Group and the Minority Affairs Section. They had a joint meeting, and this very issue came up. I have a hard time finding anybody other than a fourth-year medical student sitting on a beach somewhere who thinks the fourth year is a great component of the education. That makes it even more mysterious about why we haven’t fixed it.

I think there is a readiness to fix it. What I think is important, though, is that it is not as simple as fixing that single piece of it. How do we create a sequence and flexibility in sequence? Several specialties had the ability in past years, for example, to essentially use the fourth year as the equivalent of a year of training and merge them together, and then backed off of this. It seems to me that what we need to do is to return to those kinds of innovations.

I also wonder about the front end. There are students who come to medical school so highly qualified that much of the first 2 years is repetitious for them.

I would like to see us look at all the dimensions of this issue, to compress it. And in fact that was a key point in a report on medical education that came out 2 years ago from the Deans Group at the AAMC. So there is a lot of support for what you say.

Dr. George F. Sheldon: Well, the G-PEP report, Professional Education of Physicians, that was funded by the Johnson Foundation and a few others, and administered by the AAMC, in 1984 recommended that they call the fourth year a revolving cafeteria of specialty choices and recommended that it be fixed. Primary care and family medicine actually tried to have the fourth year count as the first year of residency. But as Darrell mentioned, somehow it was abandoned; I think family medicine had some other problems at the time. So I am not sure that model should not be tried maybe in surgery or someplace else.

Dr. Kirch: I just want to underscore how important it is, though, that we do not focus on only one piece of it. Some of the most interesting discussion now is about the USMLE and the STEPS. There are a lot of people who feel that STEP 1, the basic science test, has become an obstacle that slows the process down and the distortion in some of the decisions you make in resident selection and training. So there is a lot of foment out there about those issues.

Dr. Karen R. Borman (Jackson, Mississippi): I have the opportunity to sit on the Medicare Payment Advisory Commission, and we recently decided to delve into the issue of manpower. As you know, much of the funding for GME comes through the Medicare program, and I need to share with you questions for which I need answers to take back as I sit at the Commission.

Data have been presented, very nicely done economic analyses and trending costs, that the current IME payment is roughly double what is necessary and that, in fact, if you care to go forward, we can train twice as many graduate trainees because we are getting twice as much money as we should get. And while no one in the room probably accepts that, just saying that we do not believe that is not going to work.

I would ask our panelists to empower me with information about how the money that is out there in GME can fund more slots. The corollary to this is that in the whole debate, no one could come forward with believable data about what it costs to train a resident today.

I would suggest to everybody in this room that the cost of training a surgeon is different when you start to think about the cost of simulation centers, when you dial the potential cost of PAs and midlevel providers that we must employ to make up for the shorter resident work hours. We really need a way to project what the cost of graduate medical education per resident is now. I would ask if the panelists have any good source of information for me to take back to the Med PAC.

Then I have a final comment about an issue that does not relate to the Med PAC that the panelists have brought up is the issue of lifestyle. Lifestyle is 2 things. It is effort in and reward out. And reward out comes in 2 fashions: time and money.

The issue of reimbursement, as everybody in this room knows, subtly affects this equation of lifestyle of students and management as well. They do not want to work as hard as we do, particularly for the outcomes that we get or the outputs that we get. So anything we can suggest about how to make that better is certainly going to advance our cause.

Dr. Cooper: That is very important. With respect to the first comment that you made, it is exactly that discussion that has to happen.

The historic linkage between residencies and IME payments is peculiar. It was an axiom of history. It is not medical education; it is not resident education, but something else. So we now must rationalize how what we are currently doing is being paid for if we are going to extrapolate that into the future.

That requires a willingness to hold the very conversation of the sort that is happening right now. It means a willingness to talk about GME. And the reason you want to talk about it is because you want to do something about it.

Well, the minute you start talking about it, a lot of people feel threatened because there will be winners and losers. It may be a waste here, but one person’s waste is another person’s profit and so forth.

So I would say that if this organization and others can come together and say, look, we do not know how it will turn out, we have to answer the kinds of questions that were just asked. They are critical. We have to express a willingness to answer them. Because when we know the answers, we can do what we need to. And that is to build larger and maybe different GME programs. But it is the willingness to do this that is so critical to making it ultimately happen.

Dr. Thomas R. Russell (Chicago, Illinois): My question deals with what the work will be in 20 years? It is a little hard to figure out the work force unless you know what the work is going to be.

I think there are forces out there now that will affect the work, things like a movement for wellness and prevention and safety, doing things more around evidence-based disease management, all of technology, which is going to be the driving forces. I visited Pfizer. The drugs they have in the pipeline are not only for obesity but to stop atherosclerosis. Also the expectations of the public will have to change as we go forward and, of course, the electronic medical record will come into play.

So my question is, with all these forces, what is the work going to be in 20 years? It has often been said the only thing worse than a shortage of physicians is too many doctors. And does this factor in, Buz, in your thinking in addition to the gross domestic product?

Dr. Cooper: First, I am not sure that too many is bad versus a shortage. The dilemma as a forecaster is that you cannot forecast what people are going to do.

So you have to say medicine has been changing since 1920. It has always been changing. What can we learn about the way it changes and the underlying dynamics? At this time, for sure, we have no idea.

Whoever knew about a CAT scan, let alone an MRI or minimally invasive surgery or any of these advances? We did not know about it. I did not learn about it in medical school. The words did not exist. A stent did not exist in anyone’s vocabulary.

Therefore, if you say we cannot define the future work force until we know what they are going to do, then let’s figure that out. We know the 2 alternatives: either we cannot do it, or we are sure to do it wrong.

You can only say there will be a need for doctors because within the spectrum of health care there will be some highly skilled individuals needed. And they are doctors. We do not know what skills or what they will really do, but within this panoply of activity there will be highly skilled people, medium skilled people, and low skilled people. How many relative to each other? Not too many highly skilled people, more in the middle, and a lot at the bottom. It is a pyramid. How big will the pyramid be? It will be about as big as the country can afford, because there are so many things that are eventually possible, and they will take some resources. But beyond that you cannot look at specifics. On the other hand, you can have a great deal of confidence within a range that the pyramid will be big if the economy is big, and that the top of the pyramid will have to be occupied. We do not have to occupy it; other professions can be invented. That is what happens. That is the system of professions. If a profession does not respond to its clientele, others will rise to fill important needs. I am quoting Andrea Abbott’s profound book on the professions.

So it is not doctors that necessarily have to occupy the highly skilled portion of the pyramid. We have already said we will not, because we are not training enough of us. We said to the world we are not going to do it. The nurse practitioners are going to doctoral level programs. They will attempt to move into that top part of the pyramid. But there will be a top part.

I feel passionately that physicians should occupy that triangle. I feel passionate about medical education. I feel that we have the culture and the approach that is most important. But if we do not do it, I promise you, somebody else will.

Dr. Sheldon: There was a 1989 study done by the Committee on Long-Term Planning of the American Medical Association. It is about the only study done in that period that predicted a shortage of general surgeons. It projected a 16% to 19% need by the year 2000 over what was available in 1989. They based that on the aging of the population and what general surgeons do.

In this particular projection they were taking out gallbladders, which were all being done open at that time. Eighty-five percent of them are now done laparoscopically. So the method of treatment has changed, but the disease is still being taken care of by general surgeons. Hernias are being done differently, but are still done. And lastly, there is exploratory laparotomy. We do not do many of those for trauma anymore because we do CAT scans, but we still take care of the patients.

Dr. R. Scott Jones (Charlottesville, Virginia): Medicare, for all intents and purposes, funds graduate education. For political as well as economic reasons, we can anticipate draconian cuts in Medicare funding. And now I would remind the panel that the health insurance industry, the pharmaceutical industry, and the producers of equipment and devices have been and are currently experiencing unprecedented profits.

One of the speakers mentioned that some residency or fellowship programs are currently being funded from industrial sources. So my question is what do you think of the prospects and possibilities of continuing to increase the funding or narrowing this gap with funding from industry as opposed to the government?

Dr. Kirch: I think we have also all observed the public questions raised about the conflict of interest inherent in industry-medicine relationships. I hear these discussions, and it seems like this is one more case where we have become polarized.

Some people want us to build a firewall and cut off all relationships with industry and others say to let entrepreneurial forces work. I believe that we must have relationships with industry, but we need to manage them better than we have. They create a public trust problem for us.

With regard to the other sources of funding of GME, I have been struck in a number of discussions I have had with people in Congress recently. They said to me—and I will pose the question to you—“We are willing to continue Medicare funding of GME, and maybe even increase it. Are you willing, as a high earner, to give up your own Medicare benefits to have means testing for Medicare?”

I will not tell you what my answer is, but you can think about your answer, because I do believe that that is what it is all going to reduce to for us. If we are going to fix some of these problems, we will have to decide on what our pain-sharing formula will be.

Dr. Keith Lillemoe (Indianapolis, IN): With great trepidation, I would like to add just a note of skepticism to this. I am confused and perhaps the experts can explain it to me. We have the highest ratio of physicians per capita in the entire world. We spend more money per capita than the entire world. And yet we have mediocre outcomes.

It seems to me the emphasis in our health care crisis ought to be on improving the health care system in the United States: regionalized health care, reducing bureaucracy, controlling tort reform, reducing pharmacy benefits, etc.

Dr. Cooper: So the question is why should we have more physicians?

Dr. Lillemoe: Well, let me offer the alternative hypothesis. I would offer the hypothesis that one of the reasons that our health care system is in crisis in the United States is because we have an overabundance of physicians and we have an inefficient health care system. We need to revamp the health care system, not drive it with more physicians. Then we will end up like Europe, where, as you know, the physicians are flocking to other countries because there is an oversupply of physicians.

Dr. Cooper: There are a lot of complicated interactions here. Physicians are flocking from Eastern Europe to Western Europe because there is an oversupply. There is an oversupply in the non-English-speaking countries because Uganda, Italy, Germany, and other countries have always trained a lot of physicians, and now Eastern Europe is training a lot.

But you have to really take a deep breath and say, do we need more physicians to do what the public wants? Is the public getting the range of services that it needs and will need? Part of the public gets it very inefficiently, especially the poorest part of the public. Regionally there are a lot of inefficiencies, and even physicians work inefficiently because of the nature of the administrative structure. So if we were in fact going to insure all the uninsured and bring everybody in this country up to a level of access to care that you have yourself, how many physicians will we need? How big a health care system do we need? The answer is so vast that we cannot afford it.

That is why we have this national debate about equity. The national debate about equitable health care can never be resolved, because we cannot afford equitable health care. Equitable health care means health care for everybody at the level that you personally experience. The nation cannot afford it anymore than Uganda can.

So inevitably, we have these arguments. That is why we have the argument about defined benefit versus defined contribution health care, or the matter of the Medicare issue that Darrell talked about a moment ago, because we cannot afford it.

We will always spend to the level we can afford. And my belief is, as long as the economy grows we can in fact afford more as a nation. That will consume more health care workers, physicians among them. I do not see a future where the nation levels off with what we have now and we use, therefore, fewer physicians for more mediocre access to care.

Dr. Kirch: We should make a correction. We are the highest spenders per capita in the world, there is no question about that, but we do not have the highest number of physicians per capita.

Dr. Cooper: You are correct. In fact, the most interesting work in this area is Jerry Anderson’s work from Johns Hopkins. If you look at the size of the health care labor force in all developed countries, the number of health care laborers (us among them), per capita, it corresponds very closely to per capita income, and we are right on the line.

We are off the line because of price. Dr. Anderson published a paper in Health Affairs: “It’s the Price, Stupid.” It is because everything costs more. Drugs cost more. Construction is more. Physicians make more. Nurses make more. Everybody makes more.

But in terms of units of service, the number of units of service per citizen relates very closely to per capita income, and we are right on the line. In terms of physicians per capita, we are kind of in the middle of the developed countries.

Dr. Sheldon: I think there is an article everybody ought to read by Cutler that was in The New England Journal about 6 months ago. Our baseline costs and charges are higher than most other people. Our rate of growth is about the same; it is about average.

Dr. Robert J. Touloukian (New Haven, Connecticut): I think we ought to spend at least a couple of minutes talking about the other half of the student-teacher equation. And that is maintenance of the faculty for the basic sciences as well as for the clinical faculty in teaching the new students that we hope to attract to our “build it and they will come” medical schools.

As I see it today, we have a crisis in maintaining our own faculty in our surgical departments across the country. I think we need to deal with that issue as well as the number of students that are going to be available for them to teach.

So I would ask the panelists to answer the question, who is going to pay the new faculty that are needed in the basic sciences and in the clinical departments to teach these new students that we hope to recruit to our schools? And, will we be able to maintain the kind of quality that we have always felt has been essential in our medical schools? Finally, will faculty recruitment match student recruitment? In other words, is it de facto that we will have more faculty when we have more students?

Dr. Kirch: Those are very rich questions. I cannot do them justice. The short answer on the satisfaction side is, I am as worried as you are. And the AAMC is actually in the middle of developing a faculty satisfaction tool that could be used nationally and would provide you benchmark data nationally and would help us start to locate and get our arms around the pressure points on faculty satisfaction.

With regard to faculty compensation for teaching, the variance in this is incredible to me. There are many medical schools in this country where tuition and appropriation revenue for teaching is more than enough to cover the teaching cost. And there are many where it falls far short and then you have to cross-subsidize.

The problem is that most institutions do not understand which category they are in because their funds flow is so murky around the school and between the hospital and the school. I personally advocate for getting at this question by first figuring out your revenue flow, your allocation to your missions, then, you will know whether you have enough to pay for teaching and whether you need to find new forms of cross-subsidy.

Dr. Marshall Schwartz (Philadelphia, PA): I want to address a couple things that have been touched on already in the discussion.

One is the fact, and I concur, that we need more medical students, we need more residents. The issue becomes, if we accomplish that with more medical schools and more residency slots, where does the money come from for these educators?

Everybody in this room is here because they are educators as well as surgeons. But Dr. Kirch alluded to the need for affiliations to community hospitals. Dr. Cooper said that not every applicant to medical school is a qualified applicant. Not every practicing physician in clinical and community hospitals is going to be a good teacher. So aside from the dollars needed for educators, how about the quality of the people serving as teachers in these clinical settings?

Dr. Cooper is in Philadelphia; I am also located in Philadelphia. We have seen a lot of out-migration from our university hospitals to community hospitals for tertiary care: heart transplants, liver transplants, etc, are being done in community hospitals, where the quality of the surgery and the care may be good, but that does not mean that these people are educators to the students in residence that will end up rotating to those sites.

The other comment I want to make is that unless we address the broken health care system, it will be hard to totally fix the number of physicians produced. There are apples and oranges, but they are interrelated. If we do not deal with the economics of our broken health care system, then the impact of how many qualified doctors there will be is diminished.

Dr. Kirch: I think those comments are well taken. If most of the people in this room are like me, you learned your craft by “see one, do one, teach one.” We really paid no attention to faculty development. The good news is there is a lot going on for faculty development with full-time faculty. The bad news is we have not started to work on programs to work with community-based faculty as much as we should.

Dr. Cooper: You know, it is worth looking at the osteopathic model of medical education that has developed. They are very different medical schools. They focus specifically on medical education as opposed to an academic health center and research and tertiary care and all those things. The conceptual model puts education at the middle of the decision-making process.

It is one that the new schools are beginning to look at, the schools developing de novo at the moment. Will they be academic health centers or will they be medical schools? What is the business of the enterprise? Is it medical education or is it being a research institute and a tertiary care referral center?

Those are very important questions. So if medical education is the issue on the table, then I believe it has to be dealt with by looking at systems of medical education that might be focused with medical education as the principal product.

Dr. Sheldon: Many schools are now developing an academy of educators with specific pay lines for people participating in that. When I was a department chairman, this was a percentage of the salary that they received every year. If they did not receive good teaching ratings, they did not get that pay. So there are ways you can stimulate people to do things.

President Grosfeld: I want to sincerely thank our panelists for providing an enlightening and stimulating forum discussion. Thank you very much.

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