First and foremost, I will start by saying the United States trains the best surgeons in the world, and there’s no better place in the world to have surgery. The richest and most influential people in the world come here for care. There will always be room for improvement, and I cannot say every person has access to the best level of care, but still it must be acknowledged, America sets the bar for surgical care. But in order to be the best, and stay the best, you must always look forward—stay ahead of risks, overcome obstacles and meet your goals.
According to healthaffairs.org, we face a shortage of 40,000 to 124,000 doctors by 2034. The American College of Surgeons (ACS) predicts a shortage of 15,800 to 30,200 surgeons by the same year (www.facs.org/advocacy/ federal-legislation/ surgical-workforce/ ). While this is more a reality than a risk, there doesn’t seem to be adequate action to address this major national crisis. These numbers are so large it almost seems like a fantasy problem. A city of 100,000 people may have anywhere from six to 20 general surgeons. A city of 50,000 people or less is lucky to have one or two general surgeons within 10 to 30 miles. Do the math on how many cities will lose surgical care by 2034. One surgeon may support 17 or so jobs. So, the economic impact of this problem is also large.
What are our goals as a nation when it comes to training surgeons? Meet population demand? Yes. Ensure high-quality care? Absolutely. Maintain a healthy level of resources to provide care? For sure. Then you might think there is good collaboration between hospitals, medical schools and residencies, health departments, and the government guiding all of this. Right?
Well, not quite.
There are some great leaders in surgery ensuring high-quality care. The ACS is the largest and most effective organization leading surgical quality and many of the post-training education programs that make America such a great place to receive surgical care. The American Board of Surgery (ABS) maintains high standards in certifying surgeons for practice. (Disclosure: I work for both organizations, and these opinions and comments are my own, and in no way represent the positions of the ACS, ABS or any other organization.) The Association of Program Directors in Surgery (APDS), of which I am also a member, is a group of surgeon educators who have brought educational curriculums to a new level.
But that’s where the good news stops. These organizations all have their niche, and they collaborate rather well, but they are not in charge of many of the important decisions needed to provide population-level care. The Accreditation Council for Graduate Medical Education (ACGME) is the body in charge of approving and accrediting training programs. They collaborate with the above organizations, while also overseeing residency training programs for most all other specialties.
As a recap, to become a practicing doctor in the United States, one has to typically complete an undergraduate degree of four years, then complete an additional four years of medical school and then spend anywhere from three to six years in residency for most specialties—and even more time for subspecialty training. That is 10 to 14 years of accumulating debt, working very hard and putting off other life goals like starting a family or saving for the future. Burnout is high and job satisfaction is low. Unlike other countries, the training doctors here take on the debt of all this education. While earning potential in the United States is higher than in other nations, debt, malpractice liability, practice expenses and hours worked all cut into this profitability. Typical debt for most surgical graduates now exceeds $200,000.
The federal government provides funding for residency training. Most people may not be aware that hospitals receive funding from the government for approved positions (taxpayer dollars, your dollars). The problem is the federal government capped the number of funded spots years ago. As a result, any further growth is done at the hospital’s expense. Many hospitals may have hundreds of residents caring for patients. Each one carries a salary and benefits that creep into six-figure ranges. Much like the Chinese one-child policy has created years of downstream challenges for China, our delay in raising this funding cap is producing the results we see.
Even if we wanted to, we can’t turn the dial quickly enough to produce more doctors. There has been a push to increase medical schools and positions, and this is very much needed. Unfortunately, the federal government has not been able to find a successful path to funding more positions in residency training, which would allow hospitals to add to their educational programs. Hospitals are already hemorrhaging cash in the post–COVID-19/Great Resignation/inflationary world. “Houston, we have a problem.”
It may take the financial collapse of hospitals and destruction of access to care across many states for legislators to address this problem, but it doesn’t have to. Money is not the only matter, although it probably remains the biggest challenge.
The other elephant in the room is the fact that the ACGME is not designed to be specialty specific. While a surgeon and psychologist both treat patients to achieve health, they are very different. Much like baseball and football are both sports, they are very different. We would not want the same commissioner overseeing Major League Baseball and the National Football League. The skills needed to succeed in each field are very different. Yet we have the ACGME dictating the structure of training for fields that have very different demands.
The ACGME has done many great things for doctors and patients. Restrictions on work hours were needed. Fatigued doctors do not provide optimal care. At the same time, the evolution of the ACGME policies fail to appreciate the importance of selecting individuals who can perform well under stress and lead others under very challenging daily situations. These traits actually are suppressed unintentionally at times. It isn’t until the new physician is in practice that these traits might be exposed or refined. The graduates are by and large capable, so this is not about placing blame on a very talented young generation of surgeons.
If you were designing an ideal NFL training camp, you would repeatedly try to simulate game day environments. In surgery training, the trainees find themselves under greater protections than practicing surgeons, while being frequently pulled out of real-time situations to participate in simulation and didactics. These are indeed important, but the balance is at risk for tilting. Trainees need more time on the field.
We cannot afford to extend training to meet ACGME programmatic requirements. We need to ensure efficient pathways to practice while maintaining high standards. Of the eight categories for which the ACGME holds training programs accountable, only one of these citation categories, board exam rates, addresses an outcome that can be linked to surgeon quality (www.acgme.org). The others are related to program structure and process: environment, program director responsibilities, feedback, service to education, faculty responsibilities, education and institutional resources. While the intentions have been great, we have lost sight of the goal. A program that trains great surgeons but has poor structure may get many citations and be on probation, and therefore will be unable to expand training spots. A program that looks good on paper, but trains underprepared surgeons can go on unrecognized. While it would be great to think the ABS could catch all of this, the technical aspect of what surgeons do makes it more important that training programs have the freedom to focus on honing the skills of the trainees they know and not be handcuffed focusing on process.
The icing on the cake that really brings this all to a grind, even if we all agreed that the ACGME has the right plan, is that there simply are not enough surgeon educators in our country who have the time to implement increasing education demands while also meeting the demands of their practice and the population. Hospitals, which now employ such a large portion of doctors, have increased demands on doctors, largely as a consequence of government policies passed over the last couple of decades that created a greater burden of documentation and process. We can’t squeeze more work out of a workforce that is already burned out. As long as it takes to produce one surgeon, it takes even longer to produce a surgeon educator of adequate caliber.
We can debate solutions a great deal. Any solution must address the need to serve a population with an appropriate level of quality. We don’t want to lower our standards and put out inferior surgeons.
How do we do it?
For one, it may be best to reduce the time students spend in college and medical school. Integrated five- to six-year programs would cut down the time to practice and easily save $50,000 to $100,000 in debt (before interest). In addition, I think a strong argument could be made to modify the M4 final year of medical school. Too much time is spent interviewing for residency, which is also very costly, and then waiting to start residency. The residency application process can be trimmed through tiered approaches and consolidated to a two- or three-month period instead of the six to eight months it consumes now. The latter half of M4 could be modified to a specialty-specific period to complete some basic accreditation and simulation needed to help succeed in the first year of residency. Most schools are moving in this direction, but a bigger push is needed.
Most importantly, the federal government needs to increase funding for residency programs (all specialties), and it needs to do so ASAP. It takes several years to ramp up training spots. The race to 2034 is not looking good for us. The government also needs to continue looking at solutions to the debt burden of education. We mustn’t think doctors are immune to this problem. At a state level, more work needs to be done in tort reform to protect doctors from escalating litigation risks. This discourages young talented people from entering and/or staying in medicine. We need fewer hurdles from insurance companies, and honestly, we need to stop the middle men from taking such a huge chunk of the healthcare dollar.
Finally, within the field of surgery, we need to consider bold moves to redirect the focus of residency programs to the actual functional quality of graduating surgeons and less so on the process. We have lost sight of the forest for the trees. Whether this means abandoning the ACGME in favor of an ACS-/ABS-/APDS-led effort, or a serious adjustment of ACGME authority, can be debated. The ACS is well positioned with its relationships in Washington, D.C., to help direct traffic on how many surgeons we need and how we train them. What is not open for debate is that we are not going to be able to meet the challenges we face with the current solutions in place.
Dr. Tsoraides is the chair of surgery, Springfield Clinic Peoria, in Illinois. He has served as the program director for the University of Illinois surgical residency, and is an examiner for the American Board of Surgery.
This article is from the November 2023 print issue.
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We could also have current surgeons continue to practice which would fill the gap immediately. The reason many are retiring and retiring early is because the paltry reimbursements make private practice for surgeons unaffordable unless they are part of large groups, hospital owned, or private equity funded.
As long as the financial metrics continue on its downward trend the amount of RVUs/procedures/patient encounters need to increase to maintain past earnings. This leads to burnout and early retirement.
Instead of trying to speed up the process by creating woefully inadequate or prepared physicians, lets incentivize current physicians to continue practicing long into the future.
But alas, this will fall on death's ears and we will wake up in the next decade with a crisis and too late to bring physicians back. I guess NPs and PAs will be able to perform appendectomies by then
A balanced, well-informed piece that avoids “the sky is falling” panic, but makes the point quite well. Hopefully, those that can make changes are listening.
I think it is a time to abolish the undergrade part of the mandatory requirement. This will give more intense training needed for surgeon. This will cut down on debt and dropout, stress and waste of premium time in life.
As long as corporations employ(own) doctors, the situation will not improve. Bless their little hearts, the only thing that motivates a corporation is money. Quality is of no real concern except to embellish in hopes of improving the bottom line.