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Where Have All the Surgeons Gone?

The New Physician September 2001
The typical general surgeon’s lifestyle is turning medical students away from the field, dwindling its numbers and threatening patient care. Can anything be done before it’s to late?


Nobody wants Dr. Kirby Bland’s job, it seems. And that’s surprising because he’s having fun at work, and who wouldn’t want that? Bland is the chairman of the department of surgery at the University of Alabama School of Medicine at Birmingham (UAB), and he spends his days (well, the majority of them anyway) doing what he loves most: operating on people. He finds the work endlessly fascinating, and his excitement is obvious to even a casual observer.


Arriving at the hospital early, 6 a.m. or so, Bland is bright-eyed and eager. He doesn’t shuffle around the nurses’ station hovering over a cup of coffee; instead he strides confidently down the halls, ready to begin his day. And even after 34 years of working as a general surgeon, he remains interested and focused. When he speaks with a patient before surgery, he listens carefully, bending near to be sure he hears her faint words. Later, when standing over the same patient removing a tumor—a procedure he has done many, many times—he points out details to colleagues, students and observers in the room, poses theoretical questions and comments on the procedure as he goes. He rushes from case to case with the zeal of a little leaguer between games of a double-header. When he talks about his work, one gets a sense of the deep satisfaction it brings. “Surgery is the most rewarding profession on the planet,” he says.


But fewer and fewer medical students seem to agree. Recent years have brought a disturbing decline in the number of future physicians choosing to go into general surgery. The number of applicants to general surgery residency programs has decreased by 30 percent in the past decade. In the March 2002 Archives of Surgery, published just before this year’s Match numbers were released, Bland and his colleagues estimated that by 2005, only 76.6 percent of the available positions in general surgery would be filled by graduating U.S. seniors. This was slightly optimistic; turns out only 75 percent of the available positions were filled by U.S. medical school graduates in the 2002 Match. And although foreign medical graduates filled many, but not all, of the remaining slots, analysts do not see this as a solution to the shortage. Visa restrictions and complications limit the number of foreign medical graduates, and analysts don’t expect the situation to improve soon.


For the profession, the shortage means too much work and an even more stressful environment for those who do work in this field. For society, the consequences may be even worse. With 20 percent of the U.S. population projected to be over 65 years old by 2030, the need for surgeons will only increase. The care general surgeons give is rarely the kind a patient can wait for until a surgeon becomes available. For many people, a shortage of general surgeons could be a matter of life and death.


GET A LIFE


If, according to Bland, surgery is fun and rewarding, then why are students turning away from it? Many theories have been proposed, from regulatory hassles to money. (General surgeons often make far less than their counterparts in surgical specialties; according to a survey by Physicians Search, the average annual salary for a general surgeon in practice for more than three years is $261,276. Cardiovascular surgeons in practice for more than three years average $558,719.) Almost everyone who has seriously studied the issue, however, agrees these are relatively minor concerns. The real problem is, as one resident puts it, “lifestyle, lifestyle, lifestyle.”


Surgical residencies are notoriously brutal; they are also long. A typical residency in general surgery can last from five to eight years. To most surgical residents, Bland’s 14-hour days of dashing from case to case and meeting to meeting sound like a week at the beach. Surgical residents typically work in excess of 100 hours a week, and these are difficult, exhausting hours. According to Dr. Howard Wilson*, a fourth-year surgical resident at a West Coast medical center, “It’s harder than most people think. One hundred hours is a good week; 135 is not uncommon.” That’s a grueling schedule even in a profession filled with overachievers and dominated by a hypertrophied work ethic. Wilson also says the work environment, while stimulating and challenging, can be overwhelming, thanks to the intense stress and the “high level of immediacy” in most surgical procedures.


In June, the Accreditation Council for Graduate Medical Education (ACGME) revised its standards to reduce the number of hours residents are allowed to work. Under the new regulations, residents cannot be required to work more than 80 hours a week, cannot be on call more than every third night, and must have at least 10 hours of rest between work shifts. Though this may come as a relief to exhausted residents who no longer see the irony in the phrase “36-hour day,” surgical residents are not holding their breath. The guidelines include a clause, a loophole if you will, allowing programs to request an exemption to these rules by presenting their cases to the ACGME Program Requirements Committee and to its board of directors. Many surgical residents say the reality of their residencies is not likely to change.


And lifestyle is extremely important to today’s generation of medical graduates—much more so than it was to previous generations. In fact, for many in the medical profession, the all-work-and-no-play (or rest) lifestyle is a respected tradition. The older generation of surgeons often considers this type of training something of an initiation, a rite of passage. But like many traditions, this one may have outlived its usefulness, for modern medical students represent a new breed of physicians.


In a recent Archives of Surgery article, Dr. Stephen Evans examines this issue. Evans, who works in the department of surgery at George Washington University Medical Center in Washington, D.C., notes that looks can be deceiving. For although the new surgeons are still, for the most part, a white male club, they have other goals, values and what Evans calls “lifestyle demands.” According to him, today’s physician-in-training “does not subscribe to the regimented, hierarchical thinking that marks surgical training” nearly so much as his predecessors did.


Bland agrees with this assessment. “Today’s medical student demands more time for family and leisure. A career in surgery simply offers less time for either,” he says, and future physicians echo his comment.


Bill Hudson, a third-year medical student at UAB, says he enjoyed his surgical rotation but has “pretty much ruled out surgery.” As of now, he plans to specialize in Ob-Gyn, where the lifestyle is better, but not by much. Hudson prefers Ob-Gyn, however, because he likes the continuity of care. “You get more good outcomes in Ob-Gyn,” he says. For Hudson, the issue is not just time, but quality of life.


Even Dr. Jennifer Boll, a second-year UAB surgical resident, looks to an eventual escape from the profession. “I chose surgery because I like the problem-solving aspect of surgery and I like working with my hands…. [But] I may go into plastics because I want a family. I want more control of my life.”


Lifestyle issues are important, but for some, the challenges and satisfactions of the job are worth the sacrifices. Of course, some physicians just manage it better than others do, thanks to tremendous support networks. Dr. Atul Gawande has survived seven years of an eight-year surgical residency while being a husband, fathering three children and writing a book about medicine called Complications: A Surgeon’s Notes on an Imperfect Science. When asked how he manages it all, he gives much of the credit to his wife, who stays at home and takes care of the children and household affairs while he’s working. She also makes sure he gets a few hours writing time on the weekends. “Family support really helps a lot,” he says.


SO WHO DOES GO INTO SURGERY?


There is a common perception, among the general public at least, that surgeons fit a typical personality profile—a profile that’s not terribly attractive. A surgeon is arrogant, insensitive and definitely not “a people person.” Is it true that it takes a certain kind of person to do this work? If so, is that kind of person becoming as rare as a Siberian tiger?


Gawande thinks the stereotype of a surgeon is just that: a stereotype. However, he does agree that the very nature of the job requires, and perhaps nurtures, certain traits. The old saying about surgeons, “sometimes wrong, never in doubt,” gets to a truth about the nature of the work, he says. To perform a surgery, one needs a “fierce sense of personal responsibility and a tremendous amount of self-confidence.”


Boll agrees. “Self-confidence is absolutely necessary. There’s no time to second-guess. You can’t be wishy-washy or the patient will die,” she says.


Surgeons may occasionally seem overly sure of themselves, but according to people who do this work, that’s a plus, not a negative. “If you have a hard time making decisions, this work is not for you,” Wilson says.


Gawande believes there are other personality traits necessary to being a good surgeon. “The need to make sure that things go right technically can lead you to forget the human aspect of what you are doing, and surgeons can sometimes be coldhearted, but most surgeons I know don’t fit the stereotype,” he says. “A good doctor, no matter what the specialty, must have two things: competence and kindness. And there is no reason, even in surgery, to sacrifice one for the other.”


Wilson concurs. “I’ve seen a little of the prima-donna surgeon behavior, but not much. The ones who are the most likely to fit the stereotype tend to be the worst doctors.” Fortunately, for all of us, the image of petulant surgical geniuses flinging scalpels and shouting at support staff seems to be more a feature of television than of the OR.


“I haven’t been yelled at all this year,” Gawande says cheerfully.


If the personality stereotype doesn’t hold up, there are still certain skills and habits necessary to succeed in this field. According to Bland, a surgeon must be highly organized, extremely punctual and pay relentless attention to detail. Manual dexterity is helpful but can be learned, he says. And these physicians must be willing to study and practice, practice, practice. Therefore, a strong work ethic is required.


Wilson says it also helps to be the type of person who can get by with little sleep. “I do well on less sleep than most people. Those who need sleep at night don’t go into surgery,” he says.


These characteristics may not be the stuff of drama, but they are certainly traits any patient would like her physician to have when she goes under the knife. Still whatever traits the job demands, choosing surgery as a profession is rarely a calculated decision. Surgeons say that medical students just seem to know whether or not it’s for them when they first encounter surgery. “For many people it does seem to be a calling of sorts,” Gawande says.


Watching Bland work, or even listening to him talk about his work, makes one see how this could be true. It’s difficult to imagine him doing anything else. And staying in the field for so long has its perks; now that he’s older and highly placed in administration, Bland operates only three days a week, spends one full day in the clinic, and one day is devoted to academic and administrative duties. But even when he is out of his scrubs and sitting around a conference table (a job he does with the same drive and energy he brings to the OR), his eyes glimmer a bit more when he talks about surgery.


SURGEON, HEAL THY PROGRAM


Even if surgery is a calling, the fact remains that fewer and fewer people are being called to it. The looming crisis can be averted, but doing so may require serious and fundamental changes in a profession not known for its enthusiasm for change. If lifestyle issues are indeed the primary reason for loss of interest in the field, then graduate programs in surgery may be forced to reduce their hours or face even grimmer numbers.


This will not be as easy as it seems. It’s not pure stubbornness that has made general surgery programs among the most resistant to the idea of limiting resident work hours. One of the reasons residencies in general surgery are so long and the hours are so demanding is that it takes time—lots of time—to get the experience necessary to perform the wide variety of procedures that come up in the career of a general surgeon. Learning the pertinent skills and developing the necessary confidence takes plenty of practice. Just as tennis players get good by hitting ball after ball after ball, surgeons get good by cutting incision after incision. The problem is not insurmountable, however. Several suggestions have been made that might help.


New technologies, such as online instruction and computer programs providing “virtual” surgical experience, could take the place of some actual OR time. Hospitals could hire more support staff and rely less on residents for paperwork and other tasks that could just as easily be done by others, freeing residents to spend the time they are at work actually learning and gaining experience. Dr. Janet Compton*, a surgical resident at an Eastern medical school, says she spends a lot of her time completing tasks that don’t really require a medical degree.


“In residents, the American Hospital Association has the best and cheapest labor force in the world,” Bland says. “If we were to pay residents according to the hours they actually put in, that would help tremendously.”


Because half the potential applicants for general surgery positions are female (50 percent of medical graduates are women), some consideration also needs to be given to such issues as maternity and family leave.


Other suggestions include ensuring residencies offer rich learning experiences and that students are introduced to surgery early. Many students get little or no experience with surgery until their third-year surgical rotation. Bland recommends first- and second-year students be offered tours of the OR and other surgical work environments, and have the chance to attend frequent seminars on surgical techniques. By gaining exposure to surgery early in their training, medical students would be more likely to develop a lasting interest in the field, he says.


Evans points out that for most students, exposure to surgeons is spent with residents at the hospital. And even during surgical residencies, physicians-in-training don’t get an accurate view of what the life of a surgeon is like beyond residency. Evans and Bland both recommend students be offered the opportunity to shadow a surgeon, giving them a chance to see not only what goes on in the hospital, but what clinic days are like, and letting them experience the lifestyle of a general surgeon in private practice.


Perhaps most important, teaching hospitals could adopt the suggestion of the American College of Surgeons and ensure that surgical residents work and learn in an environment that is “mutually supportive between attendings and residents” and one in which residents are “treated with respect and dignity.”


If the number of future physicians choosing surgery as a specialty continues to decline, changes must be made. Some of these changes are undoubtedly overdue and will be welcomed by physicians-in-training and attendings alike. Better working conditions and a chance to have a life outside the hospital may be just the incentives necessary to encourage future physicians to seek the pleasures and rewards of a career in general surgery.
Avery Hurt is a freelance writer based in Birmingham, Alabama.