Wednesday, January 21, 2009

The Dying of General Surgery

Chief surgical resident Aaron Kendrick, who wanted to be a surgeon since middle school, has spent almost six years in a grueling general surgery training program at Erlanger hospital.
But this summer he’s switching gears to begin a three-year residency in anesthesiology, a field with better pay and a more relaxed schedule that will allow Dr. Kendrick to spend time with his wife and new baby, due in December.


“Mainly for me it’s the predictability of schedule,” he said. “General anesthesiologists work shift work, and when your shift is done, you go home.”

The number of general surgery residents here who practice as general surgeons is falling, said Dr. Phillip Burns, chairman of the department of surgery at the University of Tennessee College of Medicine’s campus in Chattanooga.

“Whereas 15 years ago 75 percent of our (general surgery residency) graduates here would be going into general surgery practice, it’s now down to about 25 percent,” Dr. Burns said.

...

“We have a shortage of surgeons, and physicians in general, that is coming on like a freight train in this country,” Dr. Burns said. “If we don’t do something to increase the numbers of surgeons that are graduating and available to go into spots, we’re going to have huge problems. In 10 years we’re going to have catastrophic problems.”


...

It’s a field in which pay is declining, with falling reimbursements from private insurers and government programs such as Medicare. Doctors also point to increasing medical liability insurance costs as a deterrent to entering the field.

For many young doctors entering practice with sometimes $150,000 in debt, general surgery may not make sense as a career choice, said Dr. Charles Portera, a surgical oncologist, a subspecialty that still incorporates general surgery.

“It’s kind of a sad state of affairs,” he said. “You’ve got to work harder to make the same amount of money that you did a few years ago. ... Why should these young kids go into it when there’s easier ways to make a living out there and still have a family and quality free time?”

[Full Article]


As a guy who's been interested in surgery since early childhood, it was quite the smack in the face to find that I have yet to encounter even one person involved in the medical field who would recommend going into general surgery. And I've spoken to plenty. The training is long, you work like a dog, and the compensation is small (and shrinking - thanks Medicare!) compared to the time put in and opportunity costs - and especially compared to the careers of other specialties.

General Surgery is a dying field in America through the shrinking compensations of government programs, endless hassles of hospital administrative red tape, which make for an unpleasant working environment and which exist only secondary to the perverse litigiousness of American society. This artificially intense liability of a surgeon simply working his trade also manages to add insult to injury by requiring ever larger chunks of one's salary be handed directly to malpractice insurance. As surgeons need to take on larger and larger loads just to stay afloat it saps them of leisure time, basic family interaction and those periodic iconic personal events that make up a person's private life.

Why would anyone want to be a general surgeon?

Heck, in twenty years where are you even going to find a general surgeon when your kid has emergent appendicitis at 3am? Is America ever going to wake up?

20 comments:

Manya Shochet said...

There is currently an even greater shortage of anesthesiologists, although the malpractice insurance isn't any lower.

Nice Jewish Guy said...

It's a big problem. And unless something is done to make it more attractive for someone to go into General Surgery, it's not going to get any better. What will happen-- and what is already happening-- is that the field will become comprised almost exclusively of foreign medical graduates. Not to say that FMGs are any less skilled or knowledgable, but they are still making more in the US in their fields here than their countries of origin.

Orthoprax said...

Manya,

"There is currently an even greater shortage of anesthesiologists, although the malpractice insurance isn't any lower."

Yeah, but that shortage is due more to an increased national demand, not a reducing supply. Anesthesiology is currently one of the more competitive residencies to get into and the compensation plus lifestyle is widely appealing (it's on the ROAD). I suspect that shortage will be self-correcting within a few years.


NJG,

Seems to me that this country is going enthusiastically headlong into the idea that it's good for society to give away the labor of doctors to the lowest bidder. The idea that because the work is so important it ought to be free for everyone is perverse. Doctors are willing to work hard for their patients but they're not going to put up with being slaves to the system or a cog in an administrator's care plan.

Lots of important fields are suffering in America because the incentives for practice are so backwards.

Ben Avuyah said...

I was actually scheduled to go into general surgery at one point, until I heard one attending complaining that on the rare occasions he had time off he really didn't know what to do with it.... all of his relationships outside the hospital had just, sort of, dwindled away.

Surgical subspecialties are still pretty nice ;-)

But I share your concern... health care is going in so many wrong directions at once it's hard to know how to pull out of this nose dive.

Orthoprax said...

Ben,

Ah, for nothing too serious I hope, but I know what he means. Not that my schedule is so terrible yet it's already much more difficult to be as socially active as I was compared to my college years. I just don't have the time to hang out with all the people I once did. The schedule of a GS is that much more overbearing and that much more socially debilitating.

Some surgical specialties are nice, which is why I'm considering maybe doing vascular right now. But we'll see. In any case I'll need to run the gauntlet of at least a tough 5 year surgical residency - where (as I hear) the hours are worse than at any other time of a surgeon's career. But I'm willing to do that if the outcome is something worthwhile - not the (literally) endless night of a GS' lifestyle.

What kind of medicine do you practice? Any advice? ;-)

Ben Avuyah said...

I'll be happy to give you my two cents...I'll email you !

Orthoprax said...

Yes, please do!

Jeff said...

OP,

Somehow I see you as an ID guy. What you've said about surgery is true. It'd be a shame for you to hit rock bottom 8 months into your intern year at 5 in the morning after a 40 hour shift. The next day you'll be switching to ER or anesthesia and glad you don't have to waste another 4 months of your life in hell surrounded by bitter and petty minigods. You have one life to live. Let others make the mistake.

I found PM&R late in my fourth year, ignored ignorant comments by others, and have been tremendously happy doing interventional spine. Don't forget that derm, rads and anesthesia were scoffed upon only 20 years ago!

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Anonymous said...

Very thoughtful article. I love to be a surgeon however I hate to be one in this country mainly because of these hungry, pethetic and inhumane lawyers. These bastards dont want to change anything because they are the ones making rules at the top too.

secure tabs said...

you know that I met Aaron Kendrick when he was a child, and i am so glad to hear about him since it's been many years that I did not know anything about him. I'm also glad that he is working so hard at Erlanger Hospital

Leo Voisey said...

David Summers, a 37 year old MS patient from Murfreesboro, Tennessee was a score of 8.0 on the Expanded Disability Status Scale (EDSS) when he had the Combination Liberation Therapy and Stem Cell Transplantation at CCSVI Clinic in March of 2012. Having been diagnosed in 1996 he had been in a wheelchair for the past decade without any sensation below the waist or use of his legs.
“It was late 2011 and I didn’t have much future to look forward to” says David. “My MS was getting more progressive and ravaging my body. I was diagnosed as an 8.0 on the EDSS scale; 1 being mild symptoms, 10 being death. There were many new lesions on my optic nerves, in my brain and on my spinal cord. My neurologist just told me: ‘be prepared to deteriorate’. I knew that he was telling me I didn’t have much time left, or at least not much with any quality.” David had previously sought out the liberation therapy in 2010 and had it done in a clinic in Duluth Georgia. “The Interventional Radiologist who did it told me that 50% of all MS patients who have the jugular vein-clearing therapy eventually restenose. I didn’t believe that would happen to me if I could get it done. But I have had MS for 16 years and apparently my veins were pretty twisted up”. Within 90 days, David’s veins had narrowed again, and worse, they were now blocked in even more places than before his procedure.
“I was so happy after my original procedure in 2010. I immediately lost all of the typical symptoms of MS. The cog fog disappeared, my speech came back, the vision in my right eye improved, I was able to regulate my body temperature again, and some of the sensation in my hands came back. But as much as I wanted to believe I felt something, there was nothing below the waist. I kind of knew that I wouldn’t get anything back in my legs. There was just way too much nerve damage now”. But any improvements felt by David lasted for just a few months.
After his relapse, David and his family were frustrated but undaunted. They had seen what opening the jugular veins could do to improve him. Because the veins had closed so quickly after his liberation procedure, they considered another clinic that advocated stent implants to keep the veins open, but upon doing their due diligence, they decided it was just too risky. They kept on searching the many CCSVI information sites that were cropping up on the Internet for something that offered more hope. Finding a suitable treatment, especially where there was no known cure for the disease was also a race against time. David was still suffering new attacks and was definitely deteriorating. Then David’s mother Janice began reading some patient blogs about a Clinic that was offering both the liberation therapy and adult autologous stem cell injections in a series of procedures during a hospital stay. “These patients were reporting a ‘full recovery’ of their neurodegenerative deficits” says Janice, “I hadn’t seen anything like that anywhere else”. She contacted CCSVI Clinic in late 2011 and after a succession of calls with the researchers and surgeons they decided in favor of the combination therapies.For more information please visit http://www.ccsviclinic.ca/?p=904

Leo Voisey said...

Chronic cerebrospinal venous insufficiency (CCSVI), or the pathological restriction of venous vessel discharge from the CNS has been proposed by Zamboni, et al, as having a correlative relationship to Multiple Sclerosis. From a clinical perspective, it has been demonstrated that the narrowed jugular veins in an MS patient, once widened, do affect the presenting symptoms of MS and the overall health of the patient. It has also been noted that these same veins once treated, restenose after a time in the majority of cases. Why the veins restenose is speculative. One insight, developed through practical observation, suggests that there are gaps in the therapy protocol as it is currently practiced. In general, CCSVI therapy has focused on directly treating the venous system and the stenosed veins. Several other factors that would naturally affect vein recovery have received much less consideration. As to treatment for CCSVI, it should be noted that no meaningful aftercare protocol based on evidence has been considered by the main proponents of the ‘liberation’ therapy (neck venoplasty). In fact, in all of the clinics or hospitals examined for this study, patients weren’t required to stay in the clinical setting any longer than a few hours post-procedure in most cases. Even though it has been observed to be therapeutically useful by some of the main early practitioners of the ‘liberation’ therapy, follow-up, supportive care for recovering patients post-operatively has not seriously been considered to be part of the treatment protocol. To date, follow-up care has primarily centered on when vein re-imaging should be done post-venoplasty. The fact is, by that time, most patients have restenosed (or partially restenosed) and the follow-up Doppler testing is simply detecting restenosis and retrograde flow in veins that are very much deteriorated due to scarring left by the initial procedure. This article discusses a variable approach as to a combination of safe and effective interventional therapies that have been observed to result in enduring venous drainage of the CNS to offset the destructive effects of inflammation and neurodegeneration, and to regenerate disease damaged tissue.
As stated, it has been observed that a number of presenting symptoms of MS almost completely vanish as soon as the jugulars are widened and the flows equalize in most MS patients. Where a small number of MS patients have received no immediate benefit from the ‘liberation’ procedure, flows in subject samples have been shown not to have equalized post-procedure in these patients and therefore even a very small retrograde blood flow back to the CNS can offset the therapeutic benefits. Furthermore once the obstructed veins are further examined for hemodynamic obstruction and widened at the point of occlusion in those patients to allow full drainage, the presenting symptoms of MS retreat. This noted observation along with the large number of MS patients who have CCSVI establish a clear association of vein disease with MS, although it is clearly not the disease ‘trigger’.For more information please visit http://www.ccsviclinic.ca/?p=978

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general surgery said...

Yes, i think that the general surgery includes many other surgeries. For instance, It also is called minimally invasive surgery, bandaid surgery, or keyhole surgery. The Orthopaedic Surgeons only operate a length of usually 0.5–1.5 cm as opposed to the larger incisions needed in laparotomy. Usually, the trauma surgery is one of general surgeries. It is an important component of the invasive treatment of physical injuries, typically in an emergency setting. The trauma surgeon takes on the responsibility for the initial resuscitation and stabilization of the patient, as well as persistent evaluation and management.

General Surgery in India said...

This is all due to the that may people seek more opportunities in General surgery as it includes more other surgeries and huge career scope.