As the American College of Surgeons celebrates its 100-year anniversary, we find ourselves confronted with challenges that threaten the quality and delivery of surgical care in this country. Two of the more pressing issues that imperil the future of our art are perceived deficiencies in surgical training and the lack of clarity and consensus regarding future surgical manpower needs. These two issues are linked and will require a reasoned and active resolution if we are going to provide competent surgeons in a more balanced manner by both geography and specialty to our ever-changing American demographic.
There is now a general agreement among many members of the surgery profession that the current training paradigms are inadequate and in need of immediate reform. Examples include the increasing Board exam failure rates, escalation of subspecialization, increasing need for postresidency mentoring and finishing fellowships, reports of perceived undertraining by our newly minted residents and fellows, uneven competence in the performance of basic surgical procedures noted in the first year of fellowship, and reported difficulties in independent functioning in the early years of surgical practice.
Many forces have aligned to diminish the quality of training including work-hour restrictions, therapeutic trends that have markedly reduced the need for open surgery, the laparoscopic revolution, and the expansion of competing nonsurgical interventional specialties. Other factors include shifts in graduate medical funding with the resultant RVU (Relative Value Unit) pressures on the surgical faculty, generational shifts that emphasize work/life balance, and restrictive training regulations that have led to a reduction in the resident autonomous operative experience.
Despite these developments, many of which are truly intractable, we cannot accept de facto a lower standard of excellence in training for surgeons in this country. We bear a historic responsibility to the talented and dedicated young men and women who depend on us to adequately train them for the rigors of surgical practice. Therefore, we must gain the collective resolve to work among ourselves and within the system to reach out to all members of the house of surgery as well as the involved regulatory agencies. We must dedicate ourselves to an intense study of the problem and ultimately reach a consensus on implementable practical reforms that will result in the needed sea change in surgical training. Preliminary suggestions include providing more autonomy at the senior resident level; limiting the numbers of subspecialties, particularly as they compete with resident training; increasing the efficiencies of training, particularly at the junior levels; and embracing training technologies such as simulators. In addition, surgical faculty should be drawn less from RVU-driven groups and more from a cadre of educators who are remunerated for their educational time and expertise. We should also be looking to the development of specific, nationally required resident performance benchmarks. This is but the beginning of the national dialogue, but with the right resolve, I am confidant we will create the needed corrective recipe.
Currently American surgical delivery is suffering from a maldistribution of surgical talent by both geography and specialty. Futuristic medical manpower studies have been limited by historic biases, poorly designed metrics, and entrenched interests resulting in inaccuracy. The old head-count method of trying to match medical school class size with projected population demographics is overly simplistic and a recipe for failure. To borrow an idea from military planners, we in the surgical profession are always preparing for the last war. To paraphrase a frequently made statement by Dr. Tom Russell, FACS, the essential consideration of any successful manpower study should begin with the question: "What will the future work be and where will it be done and by whom?" The evolution of medical therapeutics, pharmacology, and genomics; improvement and expansion of public health services; the explosion of new technologies; continuing public demand for more minimally invasive as well as nonoperative therapies; and the expansion of competing invasive non-surgical specialties are all trends that will shape future surgical manpower needs. Proliferation and acceptance of physician extenders and nurse practitioners as well as the continued investment in clinical effectiveness studies and clinical guidelines will markedly transform the type and volume of surgical work done in this country.
In addition to understanding the effects of the above forces, it is going to be equally important to consider possible shifts in demographics. A recent and insightful look into possible future scenarios is presented in the book "The Next Hundred Million: America in 2050," by Joel Kotkin (New York: Penguin, 2010). In this futuristic study of American demographics, the author predicts an outmigration from urban America, a resurgence of rural America, and a revitalization of many of America’s so called "fly-over zones." This transformation would be driven by telecommunications, decentralization of American commerce, the recent energy revolution, and the search for lifestyle quality heretofore not realized in urban America. Such an evolution would have tremendous implications for the future of rural surgery and the consequent need for well-trained general surgeons, and would call into question the overcentralization of surgical care.