By Jon C. White, MD
The 1992 Clinton campaign headquarters had a poster on the wall stating, “It’s the economy, stupid.” This mantra, chanted by his staff for that entire campaign season, is thought to have been the strategy that convinced the U.S. electorate to choose a virtually unknown governor of a small, southern state over a popular, sitting president. The belief that the economy is all-important is shared by health care discussants who point to the increasing difficulties we have in financing our large and complicated industry. Most health care programs, such as Obamacare and Romneycare, or health care strategies, such as fee for service, socialized medicine, managed care and medical savings accounts are just different ways of financing the same industry. I was one of those who had been seduced by the notion that our system would be fine as long as we figured out how to pay for it. The more I study the health care industry, however, the more I see that I was wrong and the industry is not fine. It has problems that are more serious than its high price tag. I am now convinced that the major issue facing us is not how we are going to finance our industry, but how we are going to fundamentally change it so that we can continue to provide high-quality health care for our citizens.
In my January editorial (General Surgery News 2013;40:1), I discussed the dual problems of the U.S. population growing in both number and age. The U.S. Census Bureau predicts that from the years 2010 to 2050, our population will grow from 310 million to 440 million, and those over the age of 65 years will grow from 40 million to 89 million. Older people have more chronic illnesses than younger people, and their medical problems are not only expensive but are very resource-dependent. Taken together, these statistics present challenges to our profession that will require a change in the way we do business.
Much has been written about the impending shortage of health care providers. Despite the fact that health care providers in the United States are comparatively well compensated, we have only 24 physicians per 10,000 people, which ranks us as 53rd of the world’s 200 nations! A study by the Association of American Medical Colleges (AAMC) estimates that there will be a nationwide shortage of 100,000 physicians in the next decade, 46,000 of which will be surgeons. Some observers, such as those of the Dartmouth Atlas Project, suggest that there is a maldistribution of physicians both geographically and by specialty. If you follow their argument for general surgeons, however, redistribution might lessen our current needs but will not even come close to meeting future demand. Although surgical residency training programs have been accepting more foreign medical graduates and foreign-trained surgeons are being encouraged to practice in the United States, almost 700 of our 3,000 counties have no surgeon at all. Meanwhile, the training period is longer, and issues such as the contentious malpractice atmosphere are encouraging earlier retirement.
The numbers for nurse shortages are more alarming, but difficult to calculate because there is an estimated 2.7 million nurses in the country working in environments ranging from private-duty practices to large hospitals. Most calculations demonstrate that there are both regional and global shortages; there is increasing job burnout; and the nurse workforce is aging. The American Association of Colleges of Nursing projects a shortage of 260,000 registered nurses by 2025. Currently, we are filling our ranks by importing nurses from countries such as the Philippines—a practice that is siphoning off a vital resource from underserved countries.
The concept that every physician should be a polymath—knowledgeable in all aspects of medicine, published in the scientific literature, schooled in all subspecialties—and still be an expert in one field, is a romantic but completely impractical notion. Although some of our rural surgeons still have, and use, an amazing repertoire of knowledge and skills, most of us were schooled and trained in a broad range of disciplines only to spend most of our professional lives concentrating on a subspecialty such as cardiac surgery, breast surgery, colorectal surgery, and so on. To master any one of these narrow disciplines, technically and intellectually, should not require years of unfocused exposure to everything. Our training should be shorter and should emphasize depth rather than breadth. I am hearing more reports of surgeons being unsure of their abilities even after completing seven or eight years of postgraduate training. They feel that it is necessary to apprentice themselves to older surgeons for a few years after residency and fellowship.
If we had unlimited financial and human resources, we could continue this liberal arts education approach to surgical training, but unfortunately we don’t. I work with physician assistants who, with far less but more focused training than surgeons, function at extraordinarily high levels. I am also reminded that Vivien Thomas, the surgical assistant with no formal training, is credited with designing surgeon Alfred Blalock’s blue baby operation in the lab. He then assisted in the operating room when the operation was first performed on a human subject. Most surgery does not require a lot of formal schooling as much as it does intensive practical training. When we concentrate on didactics and de-emphasize training, which seems to be the current trend, we are not producing, in my estimation, the most competent surgeons. We really do have to revisit our concept of medical education and postgraduate training. We can no longer afford to spend an entire decade training someone to function in a narrowly circumscribed field.
I have always loved my job, as well as my broad training and wide exposure to lots of interesting subspecialties. I have cherished memories of participating in pediatric patent ductus arteriosus closures, open prostatectomies, aortic aneurysm resections, and so on. I have never, and will never, perform any of these procedures in my post-training career. Although this wide exposure may give me some perspective on my own specialty, I don’t think that we have the manpower or womanpower to continue this long and leisurely road to professional competence. And it is not just a fiscal issue. Surgeons should spend more of their careers being surgeons and less of their careers being trained. If our country continues to grow in size and age, the demands on our workforce will be so great that we could import all of the graduates and all of the nurses of foreign medical schools and we would still come up short. We have to rethink the way our industry works and reevaluate the training and the roles of its participants, including its most important participant—the patient.
The Role of Patients
The computing industry started 60 years ago when computers were the size of buildings and required a fleet of programmers and operators. If we had predicted back then the amount of computing that we do today, we would have assumed that one out of every 10 buildings of the future would be devoted to computers and one of every 10 professionals would be a programmer. That obviously has not happened because the advances in technology have led to a progression of computers, from mainframe to desktop to laptop to iPad to iPhone, which has revolutionized computing. A fifth grader with an iPad can now do what were once functions of unimaginable complexity.
By the same token, checkout cashiers, elevator operators, airline counter assistants, gasoline station attendants and bank tellers are being replaced by automation. Technology and automation allow people to do more for themselves and this has fundamentally changed many industries, so why not ours? I am not going to suggest that automation will allow people to do open heart surgery in their garages, but automation could lead to more independent testing such as assaying blood values, measuring vital signs or taking simple radiographic images. Information technology could play an important role insofar as data can be transmitted over distances to be interpreted remotely by a person with very focused training. I am not suggesting either that we will no longer need physicians, but I do think that physicians of the future will be more specifically trained and will serve different roles. They may be supervising a large group of physician extenders or counseling patients on what diagnostics or therapeutics they can perform for themselves. They may be reviewing data collected locally and transmitted centrally. As physician numbers decrease relative to the general population, their role will become more complex and more challenging.
If Not the Economy…?
Although “it’s the economy, stupid” may be an appropriate incantation for politicians and economists trying to finance our current medical system, we, as the stewards of our profession, have to be thinking outside the box. We have to take the long view and imagine new ways to train physicians, create innovative ways to use physician extenders and develop strategies that will allow patients to take a more active role in their own health care. We have to change the way we practice medicine and, in our health care reform headquarters, we should have a poster on the wall stating, “it’s not the economy, it’s the industry, stupid.”
Dr. White is chief of surgical services at the Veterans Affairs Medical Center and professor of surgery at George Washington University, both in Washington, D.C.