BOCA RATON, FLA. – General surgeons are working harder than ever, with significantly bigger annual operative case totals than a decade ago, and the overload is expected to worsen, based on findings of a new American Board of Surgery analysis of general surgery workloads and practice patterns during 2007-2009.

"My sense is that there’s a worsening shortage of general surgeons that’s causing them to work harder. There’s more need for them. I don’t know what is the maximum number of operations a general surgeon can do in a year, but I bet it’s pretty close to where we are right now," Dr. R. James Valentine said in presenting the ABS survey findings at the annual meeting of the American Surgical Association.

Nearly 80% of trainees completing general surgery residencies now opt to obtain additional surgical subspecialty fellowship training, which means that the number of general surgeons going directly into practice is decreasing and the number of surgical subspecialists is climbing.

The ABS survey showed that these subspecialist surgeons perform roughly 25% of all core general surgery procedures being done in the United States. But as these subspecialist surgeons narrow their practices over time – which is the norm in response to patient demands and practice referral patterns – the core general surgery procedures that they will no longer be doing will fall squarely on the shoulders of already-overworked general surgeons, explained Dr. Valentine, professor and vice chairman of the department of surgery at the University of Texas Southwestern Medical Center, Dallas.

The ABS study involved analysis of the surgical operative logs of 4,968 surgeons who took the recertification exam in 2007-2009. Some 68% of them were certified only in general surgery, whereas the rest had one or more additional American Board of Medical Specialties certificates.

In all, 88% of all general surgeons seeking recertification were men. They performed an average of 506 operative cases per year, compared with 375 for female general surgeons. These operative caseloads were significantly higher than those reflected in a similar ABS survey conducted a decade earlier. Moreover, in 2007-2009, general surgeons performed more procedures in all areas – abdominal, alimentary, breast, endoscopy, vascular, and laparoscopy – than in 1997-1999.

Among other key study findings were the following:

• Female general surgeons performed far more breast operations and significantly fewer abdominal, alimentary, and laparoscopic operations than did their male counterparts.

• Subspecialist surgeons did 26% of all core general surgery alimentary operations such as appendectomies and cholecystectomies, 10% of all breast operations, 13% of abdominal, 15% of laparoscopic, and 26% of endoscopic procedures.

General surgeons performed 46% of all vascular, 16% of thoracic, 30% of pediatric, and 33% of plastic surgery operations.

• A huge difference in practice patterns between urban and rural general surgeons was identified. Rural general surgeons performed far more endoscopic procedures and significantly fewer abdominal, alimentary, and laparoscopic procedures than did their urban counterparts.

• Within the field of vascular surgery, general surgeons performed 35% of all carotid endarterectomies, 27% of leg bypass procedures, 25% of aneurysm repairs, and 24% of all endovascular procedures.

• U.S. medical school graduates and international medical graduates had similar workloads and distribution of operations.

"We conclude from these data that the reduced general surgery operative experience in residencies with coexisting fellowship programs may negatively impact access to general surgery care. Similarly, narrowing general surgery residency operative experience may impair access to specialty operations," Dr. Valentine said.

Discussant Dr. George F. Sheldon said the message of this and other studies is that there remains a clear need to train general surgeons who are able to care for a wide range of surgical conditions.

"The type of practice and some of the tools may differ, and the setting in which we work may be changing, but I really think the fundamental concept of a broadly trained general surgeon is validated by all of the studies that have been done," said Dr. Sheldon, professor of surgery and social medicine at the University of North Carolina at Chapel Hill.

Dr. E. Christopher Ellison, chair of the ABS, drew attention to the large number of endoscopic procedures being performed by general surgeons, particularly those in rural practice.

"I think with the recent debate about the role of general surgeons in endoscopy, your evidence presents a case that we need to continue a high level of endoscopy training in our general surgery programs. In our rural and less populated areas, the general surgeon provides ready access to endoscopy of the upper and lower GI tract. Certainly, this is a benefit to the patients living in those areas," commented Dr. Ellison, professor and chair of the department of surgery and associate vice president for health sciences at the Ohio State University, Columbus.

Dr. Valentine concurred.

"It certainly looks like general surgeons are doing a lot of endoscopy without the help of our GI colleagues, especially in rural areas. That’s something that we need to remember when we’re challenged by those societies," according to Dr. Valentine.

He said he had no financial conflicts.

ABS Survey Finds Increased Caseloads Among General Surgeons