As part of a global trend, shortage in the surgical workforce in the US is imminent, with a projected deficit of more than 40,000 surgeons expected by 2020.1 One direct consequence of this shortage is exacerbating the number of surgically underserved areas in the US over the next decade. Recruiting surgeons to practice full time in these areas, through incentives such as loan repayment or visa requirement waivers, has been the primary approach to meet their surgical needs. However, this mechanism does not seem to suffice the impending and growing need. With the general surgeons workforce affected the most by these shortages (the number of general surgeons decreased in 44 states between 2006 and 2011), many hospitals in surgically underserved areas are already unable to recruit a general surgeon and are therefore facing closure, further reducing patients’ access to surgical care in these areas.
Increasing the number of residency slots by 3000 is the main proposal to address this shortage. With a heavy trend toward specialization beyond residency,2 this proposal, estimated to cost one billion dollars, will, however, not guarantee that the additional surgeons will practice general surgery and/or in the surgically underserved areas. Referral to regional high-volume centers (also known as regionalization of care) is another mechanism that potentially solves this challenge; yet, a regional center is not always available and in some cases may be hundreds of miles away. The high costs of seeking care regionally to patients and their families, especially to disadvantaged populations, may sway patients away from or delay seeking surgical care in such cases, which oftentimes adversely affects patient outcomes.3 In underserved areas absent of a proximal regional center, and when recruitment of a full time surgeon is not possible, additional venues for providing surgical care to these areas are needed.
Encouraging more surgeon volunteerism in the US may address some of the unmet needs in surgically underserved areas. Volunteerism is undeniable among established surgeons, and surgical societies highly encourage and praise these humanitarian activities.4 The emerging field of global surgery also signals a strong commitment to volunteering in underserved areas among young surgeons. A number of surgeon volunteerism efforts currently exist in the US. Most notable is the American College of Surgeons’ “Operation Giving Back” initiative, an online resource for surgical volunteerism that includes a database of facilities in underserved areas in the US that are in need for volunteer surgeons. However, most efforts to date continue to be directed towards international volunteerism, not only because international volunteerism has an element of adventure in a foreign land, but also because of the challenges that currently face surgeons considering volunteering in the US.
In this viewpoint, I highlight these challenges. I draw on international volunteering experience and make recommendations that can potentially overcome these challenges, and redirect some of the international surgical volunteerism to locally underserved areas. Surgeons are discouraged from volunteering in the US, as opposed to overseas, mainly because they perceive that it may result in suboptimal outcomes because of the unfamiliar practice setting,5 and thus make them more susceptible to malpractice lawsuits. Surgical outcomes are generally highly dependent on 2 main factors: competence of the surgical team, and effectiveness of postoperative care. These factors may be challenging to manage effectively, given the brief nature of volunteer episodes. In addition, malpractice insurance is not always provided by hospitals when mistakes do happen.
International experiences in surgical volunteerism provide insights into how to alleviate the challenges aforementioned and encourage more surgeons to consider volunteering in the US. A number of care approaches have been applied in international settings, and these suggest that the nature of the procedure and the availability of resources in the underserved area hospital play a critical role in the ability of the volunteering effort to meet the needs of this area. These approaches range from the brigade approach, on one hand, to the minimalist approach, on the other hand.6 In the brigade approach, a surgical team volunteers with all their equipment and supplies. This approach is suitable in areas with little infrastructure and high need for a procedure, which requires significant coordination during surgery. In the minimalist approach, the volunteering surgeon tries to fit into the underserved area hospital using its own supplies and equipment. This approach is more suitable in areas with some infrastructure and low demand for particular procedures, and these procedures require low levels of technical coordination during surgery. A minimalist approach involves generally longer durations of time compared with the brigade approach, during which teaching activities also occur in the receiving hospital. In addition, models of improving patients preoperative and provide postsurgical care have also emerged. For example, “Operation Smile,” one of the largest American volunteering organizations that mainly focuses on international volunteerism for cleft lip and palate surgery in over 80 countries, coordinates with local entities in these countries for screening and follow-up care.7 They send a team to screen for surgical candidates and leave behind a postsurgical care team, when it is not locally available.
These international efforts suggest that institutionalization of surgeon volunteerism is critical to encourage more surgeons to volunteer in the US in areas of unmet needs. I therefore propose establishing a national coordinating center whose main objective is to screen the unmet needs and the available resources in a particular area, and determine the volunteering approach most likely to fit the needs for this area. For this to happen, hospitals needing volunteer surgeons should provide the coordinating center with information regarding available operating room staff and resources, as well as availability of local staff for preoperative screening and postoperative care. The coordinating center should also have clinical information on patients’ severity and their surgical needs to determine the scope of work. The center will then use these 2 pieces of information to identify the best volunteering approach and recruit volunteering surgeons accordingly. The coordinating center may collaborate with volunteering physician organizations to cover preoperative screening and postoperative care, as well as with volunteer physician assistants and surgical nurse organizations to staff surgical brigades.
Given that surgeons who volunteer do so out of their own altruism and not to make additional income,4 nonfinancial incentives are needed. The coordinating center should alleviate current challenges. To do so, it should first provide malpractice insurance coverage for volunteering surgeons, since not all states require hospitals to have malpractice insurance. The Affordable Care Act has provided provisions for malpractice coverage of physicians providing care in free clinics serving the underserved.8 Similar provisions may be needed to cover surgeons volunteering through the center. The center should also work with state agencies to obtain a restricted license for surgeons volunteering outside their state boarders. Volunteering will likely bring surgeons from areas that have a surplus to those that suffer from a shortage. Finally, the center should negotiate with participating hospitals accommodations for volunteering surgeons to facilitate their stay and maximize their volunteering time. To engage surgeons, the coordinating center should raise national awareness, and within the surgical community, of the benefit that the surgeon brings by volunteering. For example, surgeons may be more motivated to volunteer if they knew how many lives are impacted if they volunteer to keep the sole rural hospital in a particular area open.9,10 Whereas this value-added is taken as a given in international settings, it needs to be demonstrated in the US. Additionally, the coordinating center may consider partnering with professional surgical societies to recognize national humanitarian efforts that convey a strong message of service to one's own country. Most of these awards currently recognize humanitarian efforts in general, and still have a connotation of addressing international efforts.
In summary, creating a national coordinating center has the potential to overcome existing challenges that discourage surgeons from volunteering in the US and thus should result in redirecting some of the international volunteering efforts locally. These efforts, if properly facilitated, complement current proposals in fulfilling the needs of patients and hospitals in surgically underserved areas. US surgeons have made an impeccable difference in underserved areas around the world. If provided with a supportive environment, they will make an even greater difference here at home.
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8. US Department of Health and Human Services HRaSA, Macrae J. Requirements for Medical Malpractice Coverage for Free Clinic Board Members, Officers, Employees and Individual Contractors Under the Affordable Care Act Amendment to 42 U.S.C. 233. 2010.
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