Chattanooga: Turning away from 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.

The trend is raising concern among health care officials nationwide who see a declining number of general surgeons. Surgeons are leaving the field because of declining reimbursement, increasing malpractice premiums and exhausting schedules that require on-call duty. They often migrate to subspecialty fields that offer better pay and hours.

“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.”

PRESSURES OF FIELD

The scope of a general surgeon’s practice is broad, covering almost every area of the body and usually including comprehensive management of a patient’s pre- and post-operative care, according to the Association of American Medical Colleges.

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?”

Today’s medical residents also are watching general surgeons who must take on a greater share of on-call shifts and larger caseloads, said Dr. Michael Roe, associate professor of surgery at the UT College of Medicine in Chattanooga.

“Those left behind doing (general surgery) are hit even harder having to carry more responsibility” to be on call or work emergency room shifts, Dr. Roe said.

“People who are doing it are overwhelmed, and that once again discourages people from wanting to take on that much,” he said. “It’s a vicious cycle.”

The changing make-up of the surgeon work force will have a major impact on access in the coming years, particularly as the population continues to age. Shortages already are constraining rural hospitals, doctors here said.

“I think we’re facing a physician shortage in some areas currently right now, and I think this is only going to get worse in the next 10 years,” said Dr. David Seaberg, dean of the UT College of Medicine in Chattanooga.

TOUGH DECISIONS

A rising number of surgical residents are choosing to go into subspecialties such as plastic surgery, vascular surgery or breast surgery, or are opting for “lifestyle” specialties such as anesthesiology or radiology, according to the Journal of the American College of Surgeons.

The proportion of general surgical residents who go on to pursue fellowship training in a subspecialty has grown from 55 percent to more than 70 percent since 1992, according to a 2005 study.

Market demand is fueling the increases in doctors pursuing subspecialties.

“The consumer, especially the insured paying consumer, wants to have somebody who specializes in their case,” Dr. Seaberg said. “Because of the medical legal environment, we’re moving toward specialization.”

After completing his general surgery residency at Erlanger this year, Dr. Kye Higdon will go to a plastic and reconstructive surgery fellowship, though he emphasized that lifestyle or finances were not the reason his subspecialty decision. He predicted that new restrictions on the number of hours medical residents can work may increase the number of young doctors leaving general surgery for lifestyle reasons in the coming years.

RURAL HEALTH STRUGGLES

Recruitment of surgeons is a challenge in rural areas, where general surgeons more often are on call and have large caseloads, the Archives of Surgery study said. The overall ratio of general surgeons per 100,000 population in rural areas dropped by 21 percent in the study period. Urban areas experienced decreases of more than 27 percent.

At Rhea Medical Center, Chief Financial Office Harv Sanders said the hospital took four years to hire a general surgeon after a needs assessment showed the center was understaffed, with just one general surgeon working part time.

The assessment showed that for the 30,000 people in its service area, 1.6 to 3 surgeons are recommended, he said.

“One person can’t be on call 24 hours a day, 7 days a week, so we don’t have surgery coverage all the time,” he said.

Patients who come to the emergency room even with a simple surgery may have to be sent to Chattanooga for treatment if the surgeon is unavailable, he said.

“It’s added costs, and it’s a delay in treatment,” he said.