Many rural hospitals are receiving notices or are anticipating retirement plans from their general surgeon(s). This has been expected, yet has been overshadowed by the struggle to recruit and keep primary care providers. All areas of the United States will suffer a shortage of general surgeons now and in the future, yet rural areas will bear the brunt of the shortage. There are many reasons for the problem but most focus on supply, demand, overspecialization of the specialty, and lifestyle factors. We must also consider the fact that in rural locales, other surgical specialties are not typically available to help meet demand. As an example, an urban-based physician may primarily practice as an ENT, yet be able to fill in the work schedule with other surgical options that cross over into what is typically general surgery domain in rural areas.
What has changed?
The supply of general surgeons has been nearly the same for 25 years! Each year residency programs produce about 1,000 general surgeons. Seventy-three percent of the 2011 General Surgery residents chose to pursue “additional training” in a fellowship. This additional training often “over-specializes” the surgeon, he/she them less likely to be interested in a rural location. Of the 166 residents that chose to practice general surgery after residency, only 4.2% chose to go to underserved rural or urban locations. That is only about seven surgeons of the class of 1,000.
The practicing surgeons are retiring at a rapid pace. One third of the general surgeons today are over the age of 55. According to several studies, general surgeons practicing in rural areas are older “on average” than general surgeons in urban areas. Retirements will happen sooner in rural areas. According to the 2008 HRSA Workforce Study, there will be a three percent reduction in the number of general surgeons “in practice” between 2010 and 2020. This estimate excludes subspecialty surgeons. There will be over 1,000 fewer general surgeons in practice in 2020 than today. This means general surgeons will begin to retire far faster than we can replace them. Even family medicine, in the HRSA study, experiences growth in supply between 2010 and 2020, although the growth is inadequate to meet the anticipated demand and population growth. To adequately serve the population, the general surgery supply should be approximately seven general surgeons per 100,000 people. Currently, the supply ratio in the US is 5.8 surgeons per 100,000 people. That supply ratio has decreased 26 percent in the last 25 years.
In the last 25 years, demand has increased significantly. The population is aging, creating demand for life extending procedures that were not available even 20 years ago, and the population is increasing. Medical schools and graduate medical programs have not planned adequately for the increased need for surgeons. “Over the next two decades, more surgical procedures will be performed than ever. At the same time, doctors have invented many new types of procedures, such as bariatric and cardiovascular stent surgery. Given the expansion in the use of new technology, and increasing numbers of older patients, there just aren’t going to be enough surgeons,” says Dr. Richard Cooper, professor of medicine at the Leonard Davis Institute of Health Economics at the University of Pennsylvania in Philadelphia. Rural areas will experience a need for general surgeons sooner than our counterparts in city due to rural general surgeon’s being older on average and the demand for surgeries in rural’ s aging populations.
With fewer general surgeons in practice, the number of residents in general surgery training stable, and the demand for surgical procedures increasing, it is safe to say everyone will be recruiting general surgeons. Urban areas will attract more surgeons for the same reasons other specialists choose to practice there. Most young physicians now choose their practice based on lifestyle factors; geography, call coverage, access to academic environments and colleagues, and community amenities all play significant roles in practice choices. These are all areas of difficulty for rural locations. Frequently primary care physicians choose rural locations due to the availability of federal and state loan repayment and/or J-1 visa needs. However, general surgery is not part of the current state or federal loan repayment programs. In addition, the Illinois Conrad 30 J-1 waiver program reserves the majority of the programs waivers for primary care and psychiatry in the first and second quarters. Only twelve waivers are set aside for specialties other than primary care. Historically, the Conrad 30 J-1 waivers are exhausted by the end of the first quarter. The Delta Regional Authority (DRA) J-1 waiver program typically only accepts applicants who are to practice primary care or psychiatry. However, the DRA does note exceptions might be made if certain conditions are met.
So, we know recruitment will be hard, what do we do? Planning and collaboration will be very important to your ability to recruit new professionals in the future. Maintain contact with your local general surgeon and try to anticipate and understand his/her plans. If you decide to recruit a general surgeon, try to begin recruitment as soon as possible. As usual, you must offer the most competitive recruitment package you can afford. Competitive does not mean comparable to your urban neighbor. Median MGMA compensation for a general surgeon in the Midwest is about $383,000. Upon reviewing the costs associated with anesthesia coverage, call relief, and the salary and benefit expenses for a full time general surgeon, you may realize that recruitment of a general surgeon may not be the best option or even possible. This is when collaboration with similar providers can be an important option.
Many thought leaders suggest that rural areas will benefit from sharing “networks” of general surgeons. You likely are already doing this to some degree by way of visiting specialists. However, to provide reasonable surgery coverage, these collaborations may need to extend to call coverage. You will benefit from considering the option of a collaborative venture with neighboring rural hospital. It may be worthwhile to begin planning how such a collaboration might meet your needs as well as those of other partners, protecting all of you in the event of unexpected departure of your general surgeon(s).
About the Author:
Carrie Galbraith is the Director of Recruitment for ICAHN (Illinois Critical Access Hospital Network). Carrie understands rural life, and was born, raised, and lives in rural Illinois. She has ten years of rural physician recruitment experience.