First and foremost, I will start by saying that America trains the best surgeons in the world and there’s no better place in the world to have surgery. The richest and most influential people in the world come here for care. There will always be room for improvement, and I cannot say that every person has access to the best level of care, still it must be acknowledged, America sets the bar for surgical care.
In order to be the best, and stay the best, you must always look forward. Stay ahead of risks, overcome obstacles and meet your goals.
According to Healthaffairs.org, we face a shortage of 40,000 to 124,000 doctors by 2034. Facs.org lists a shortage of 15,800 to 30,200 surgeons by the same year. While this is more a reality than a risk, there doesn’t seem to be adequate action to address this major national crisis. These numbers are so large it almost seems like a fantasy problem. A city of 100,000 people may have anywhere from 6-20 general surgeons. A city of 50,000 people or less is lucky to have 1-2 general surgeons within 10-30 miles. Do the math on how many cities will lose surgical care by 2034. One surgeon may support 17 or so jobs. So the economic impact of this problems is also large.
So what are our goals as a nation when it comes to training surgeons? Meet population demand, yes. Ensure high quality care, absolutely. Maintain a healthy level of resources to provide care, for sure. Then you might think there is good collaboration between hospitals, medical schools and residencies, health departments and the government guiding all of this, right?
Well not quite.
There are in place some great leaders in surgery ensuring high quality care. The American College of Surgeons (ACS) is the largest and most effective organization leading surgical quality and many of the post-training education programs that make America such a great place to receive surgical care. The American Board of Surgery (ABS)maintains high standards in certifying surgeons for practice (the author does work for both organizations and these opinions and comments are that of the author alone and in no way represent the positions of ACS, ABS or any other organization). The Association of Program Directors in Surgery (APDS) (author is a member) is a group of surgeon educators who have brought educational curriculums to a new level.
But that’s where the good news stops. These organizations all have their niche and they collaborate rather well, but they are not in charge of many of the important decisions needed to provide population level care. The Accreditation Council for Graduate Medical Education (ACGME) is the body in charge of approving and accrediting training programs. They collaborate with the above organizations, while also overseeing residency training programs for most all other specialties.
As a recap, in America to become a practicing doctor one has to typically complete an undergraduate degree over 4 years, an additional 4 years of medical school and then anywhere from 3-6 years in residency for most specialities (then more time for subspecialty training). Ten to 14 years of accumulating debt, working very hard and putting off other life goals like starting a family or saving for the future. Burnout is high and job satisfaction is low. Unlike other countries, here the training doctors take on the debt of all this education. While earning potential in America is higher than in other nations, debt, malpractice liability, practice expenses and hours worked all cut into this profitability. Typical debt for most surgical graduates is now exceeding $200,000 dollars.
The federal government does provide funding for residency training. Most people may not be aware that hospitals receive funding from the government for approved positions (tax payor dollars, your dollars). The problem is the federal government capped the number of funded spots years ago. So any further growth is done at the hospital’s expense. Many hospitals may have hundreds of residents caring for patients. Each one carries a salary and benefits that creep into 6 figure ranges. Much like the Chinese one-child policy has created years of downstream challenges for China, our delay in raising this funding cap is producing the results we see.
Even if we wanted to, we can’t turn the dial quickly enough to produce more doctors. There has been a push to increase medical schools and positions, and this is very much needed. Unfortunately, the federal government has not been able to find a successful path to funding more positions in residency training which would allow hospitals to add to their educational programs. Hospitals are already hemorrhaging cash in the post-Covid/Great Resignation/inflationary world. Houston, we have a problem.
It may take the financial collapse of hospitals and destruction of access to care across many states for legislators to address this problem, but it doesn’t have to.
Money is not the only matter, although it probably remains the biggest challenge.
The other elephant in the room is the fact that the ACGME is not designed to be specialty specific. While a surgeon and a psychologist both treat patients to achieve health, they are very different. Much like baseball and football are both sports, they are very different. We would not want the same commissioner overseeing MLB and NFL. The skills needed to succeed in each field are very different. Yet we have the ACGME dictating the structure of training for fields that have very different demands.
ACGME has done many great things for doctors and patients Restrictions on work hours were needed. Fatigued doctors do not provide optimal care. At the same time, the evolution of the ACGME policies fail to appreciate the importance of selecting out individuals who can perform well under stress and lead others under very challenging daily situations. These traits are actually suppressed unintentionally at times. It isn’t until practice that these traits might be exposed or refined now. The graduates are by and large capable, so this is not about placing blame on a very talented young generation of surgeons.
If you were designing an ideal NFL training camp, you would repeatedly try to simulate game day environments. In surgery training, the trainees find themselves under greater protections than practicing surgeons while being frequently pulled out of real time situations to participate in simulation and didactics. These are indeed important, but the balance is at risk of being in tilt. Trainees need more time on the field.
We cannot afford to extend training to meet ACGME programatic requirements. We need to ensure efficient pathways to practice while maintaining high standards. Of the 8 categories ACGME holds training programs accountable for (acgme.org), only one of these Citation categories, Board Exam rates, address an outcome that can be linked to surgeon quality. The others are related to program structure and process: environment, program director responsibilities, feedback, service to education, faculty responsibilities, education and institutional resources. While the intentions have been great, we have lost sight of the goal. A program that trains great surgeons, but has poor structure may get many citations and be on probation (and therefore will be unable to expand training spots). A program that looks good on paper but trains less than prepared surgeons can go on unrecognized. While it would be great to think the ABS can catch all of this, the technical aspect of what surgeons do make it more important that training programs have freedom to focus on honing the skills of the trainees they know and not be hand-cuffed focussing on process.
The icing on the cake that really brings this all to a grind, even if we all agreed that the ACGME has the right plan, is that there simply isn’t enough surgeon educators in our country who have the time to implement increasing education demands while also meeting the demands of their practice and the population. Hospitals, who now employ such a large portion of doctors, have increased demands on doctors, largely as a consequence of government policies passed over the last 1-2 decades that created a greater burden of documentation and process. We can’t squeeze more work out of a workforce that is already burned out. As long as it takes to produce one surgeon, it takes even longer to produce a surgeon educator of adequate caliber.
We can debate solutions a great deal. Any solution must address the need to serve a population with an appropriate level of quality. We don’t want to lower our standards and put out inferior surgeons.
How do we do it?
For one, it may be best to reduce the time students spend in college and medical school. Integrated 5-6 year programs would cut down the time to practice and also easily save $50,000 – $100,000 in debt (before interest). In addition, I think a strong argument could be made to modify the M4 final year of medical school. Too much time is spent interviewing for residency, which is also very costly, and then waiting to start residency. The residency application process can be trimmed through tiered approaches and consolidated to a 2-3 month period instead of the 6-8 months it consumes now. The latter half of M4 can be modified to a specialty specific period to complete some basic accreditation and simulation needed to help succeed in the first year of residency. Most schools are moving in this direction, but a bigger push is needed.
Most importantly, the federal government needs to increase funding for residency programs (all specialties) and it needs to do so ASAP. It takes several years to ramp up training spots. The race to 2034 is not looking good for us. The government also needs to continue looking at solutions to the debt burden of education. We mustn’t think doctors are immune to this problem. At a state level, more work needs to be done in tort reform to protect doctors from escalating litigation risks. This discourages young talented people from entering and/or staying in medicine. We need less hurdles from insurance companies and, honestly, we need to stop the middle men from taking such a huge chunk of the health care dollar.
Finally, within the field of surgery, we need to consider bold moves to redirect the focus of residency programs to the actual functional quality of graduating surgeons and less so on the process. We have lost the forest for the trees. Whether this means abandoning the ACGME in favor of an ACS/ABS/APDS led effort, or a serious adjustment of ACGME authority can be debated. The ACS is well positioned with its relationships in Washington D.C. to help direct traffic on how many surgeons we need and how we train them. What is not open for debate is that we are not going to be able to meet the challenges we face with the current solutions in place.