Dear Fellow of the American College of Surgeons: 

As you may be aware, for the past number of years those of us who have been involved in the socio-political activities of the College in Washington, DC, in interactions with Medicare program officials, and in discussions with some of the health insurance companies and other organizations have attempted to point out that the number of general surgeons is decreasing precipitously and that this trend will result in a crisis of access for surgical patients in this country. We have also indicated in these various interactions that this trend is one that is beginning to affect other surgical specialties as well. 

The response we have received from individuals at the Centers for Medicare & Medicaid Services (CMS) over the past several years is that there is no crisis of access. CMS officials point to the ongoing increase in the number of surgical E&M codes that are used for Medicare patients as evidence that these patients are being seen by the surgical community.

Over the course of the past two or three years, it has become clear that there is, in fact, a crisis of access developing in an important component of our health care system?the 54 million patients who depend on small urban or rural critical access hospitals for their care. This crisis has finally been recognized, although perhaps too late.

This issue was addressed in The Impending Disappearance of the General Surgeon, which appeared in the November 14, 2007, issue of the Journal of the American Medical Association(JAMA). The copyright for the article, of course, is held by the American Medical Association. The Editor-in-Chief, Dr. Catherine DeAngelis, indicated that it would be inappropriate to distribute the entire article to members of the College given current copyright laws. However, she agreed that a brief synopsis of the article could be used for that purpose. Although all of you have access to the online version of JAMA either at your library or through someone you know who is a subscriber, following is that synopsis for your information.

1. The number of general surgeons trained in the American allopathic residency programs has remained constant at 1,000 over the past three decades. These finished general surgeons enter the workforce between the ages of 33 and 35, generally married and often with several children, and with educational debt between $150,000 and $250,000.
   
2. The number of finishing general surgeons who pursue fellowships is at least 70%. Thus, the net production of generalist general surgeons is 400, or more likely, 300.
   
3. There are a number of reasons for surgeons to specialize, including a desire to develop enhanced expertise in a more constricted knowledge base and to limit the types of surgical procedures they perform (with decreased exposure to professional liability claims). Also, a career as a general surgery sub-specialist caters to the lifestyle preference of current medical school graduates who prefer to have a more adequate division of their time between their family and their surgical practice.
   
4. Fifty-four million Americans depend on critical access, small urban, or rural hospitals for their care. In these hospitals, the general surgeon provides care for emergency patients and victims of trauma. Upwards of 40% of the margin of critical access hospitals is produced by the general surgeon.
   
5. Other factors also contribute to the lack of desirability of general surgery as a career, including
   
   • Repeated and decreasing reimbursement for general surgeons
   • The commoditization of medicine, resulting in armies of technicians and nurses whose sole purpose it seems is to deny post-care payment for services already performed
   • Managed care with its ever-changing rules
   • Professional liability insurance premiums and ongoing exposure to unjustified and unwarranted claims
     
     A reiteration of decreases in reimbursement for general surgeons has been detailed.
     
6. In 1993 Congress declared a redistribution of funds from proceduralists to primary care physicians. In the most recent Medicare five-year review, CMS wanted to concentrate on patients with one or two chronic conditions on which 96% of the Medicare dollar is spent. The 37 % increase in the work values assigned to the most common E&M code 99213 resulted in a transfer of an estimated $4 billion annually from proceduralists to individuals whose practice consists largely of evaluation and management services.
   
7. The number of general surgeons has decreased from approximately 9 or 10% of specialties to approximately 5%. The workforce is aging. Thirty-two percent of general surgeons are older than 55 and 20 percent are younger than 35. Surgeons are delaying retirement, particularly in critical access hospitals, because once the general surgeon retires, it takes an average of 14 ? 16 months to recruit a replacement. As Randy Zuckerman has shown, if a general surgeon is not recruited, the hospital closes. And for the first time, a Medicare advisory commission has found that Medicare beneficiaries have more trouble accessing specialists than doprivate pay patients.
   
8. The article concludes that while most health policy experts have concentrated on primary care and the need to improve reimbursement for those caring for patients with chronic disease, there is another important component of physician workforce that is rapidly disappearing–the generalist general surgeon. This trend is resulting in a crisis of access in a population of 54 million people who depend on small urban and rural hospitals for their care.
   
9. Unless efforts are made to reverse the current problems leading surgeons to abandon general surgery at a fearsome rate, there will be a significant crisis of access that will occur in this country in the very near future.
   
10. While the article did not deal with surgical specialties, a similar situation exists for them as well.

Sincerely, 

Josef E. Fischer, MD, FACS 
Chair, Board of Regents 
American College of Surgeons