Increasing the number of trainees in general surgery residencies: is there capacity?

Examining the Growing Demand for Surgical Care in Rural Communities and Novel Approaches to Achieving a Sustainable Surgical Workforce: A Narrative Review

Surgery continues to be an increasingly vital component of public health and aspect of patient care in rural communities. An anticipated shortage of surgeons within the next decade in the United States prompts a growing concern for increasing the delivery of essential surgical care to these populations. When considering the existing barriers to surgical healthcare in rural communities, there is a sense of urgency to identify innovative approaches that will promote a sustainable surgeon workforce. A narrative review was conducted to investigate the current state of access to essential surgical care in rural communities. Qualitative and quantitative data were collected to better understand the key issues in rural healthcare and to provide statistical data related to the status of the surgical workforce. With the anticipated shortage of surgeons in both rural and urban areas, this review highlights the importance of enacting immediate measures to address the concern. This review has accomplished the initial objectives of gaining a better understanding of the current state of access to surgical care in rural communities and utilizing this knowledge to provide recommendations to readily attain a sustainable number of rural surgeons. With each approach addressing ways to address the contributory issues to the surgeon shortage, this review reveals a new avenue of integrating valuable aspects from each approach, rather than relying on a single approach. In particular, enhancing the overall pipeline of medical training to attending status may prove to be more beneficial for achieving this goal. Ultimately, this may be accomplished by introducing additional rural surgical mentorship opportunities for medical students, developing a rural surgery fellowship, and incorporating a market-based response that will correspond to attractive incentives that help to retain a sustainable number of surgeons working in rural areas.

Effectiveness of an Orthopaedic Trauma Research Fellowship to Produce Successfully Matching Residents

OBJECTIVE

Orthopaedics is becoming increasingly competitive. Approximately 25% of applicants to orthopaedic surgery go unmatched each year. The mean US Medical Licensing Examination step scores and average publication numbers have increased markedly in recent years. Reapplicants have a match rate of <60%. This study describes the results of an orthopaedic trauma research fellowship and its effectiveness in obtaining a successful orthopaedic match.

METHODS

A 1 to 2-year research fellowship was established at a level 1 academic trauma center. Prefellowship and fellowship metrics of 11 fellows were recorded, including undergraduate and medical schools; step-1 + step-2 scores; Alpha Omega Alpha appointment; and publication, podium, poster, and chapter accomplishments.

RESULTS

The average step-1 score of the fellows was 218 (range, 192 to 252) and 232 (range, 212 to 254) for step-2. Seven of 11 fellows were reapplicants. Prefellowship, the average number of journal publications was 1, one podium, two posters, and zero textbook chapters. During fellowship, the average publications was 5, five podiums, six posters, and 1.5 textbook chapters. Ten of 11 fellows successfully matched into an orthopaedic residency, with six of seven being reapplicants.

CONCLUSIONS

Six of 7 reapplying fellows (86%) successfully matched highlighting the effectiveness of this fellowship. Research fellowships should be considered as an excellent choice for applicants who may be less than ideal candidates or reapplicants.

Regional Population-Based Workforce Shortages in General Surgery by Practicing Surgeon and Resident Trainee

BACKGROUND

The physician shortage in the United States (US) continues to become more apparent. We aimed to evaluate the relationship between the US physician distribution from 2012-2019 by specialty at the state/regional level relative to the corresponding population growth.

METHODS

US matched residents and practicing physicians from 2012-2019 were extracted from the National Resident Matching Program and Association of American Medical College databases, respectively. Residents and practicing physicians were divided by geographic regions (West, Midwest, South, Northeast), states, and specialties (anesthesiology, emergency medicine, family medicine, general surgery (GS), internal medicine, obstetrics/gynecology and pediatrics).

RESULTS

Entering residents and physicians increased across 7 specialties from 2012-2019 with the exception of GS, which showed .2% decrease in practicing physicians. GS experienced decreases in entering residents in all US regions except the South. All specialties showed a decrease in the people-per-physician (PPP) except GS and pediatrics, which had a 4.1% and 71.3% increase, respectively. EM showed the largest growth overall, both in entering residents and overall workforce.

CONCLUSION

GS experienced slow growth of residents, decreases in practicing physicians and workforce overall, and an increase in PPP from 2012-2019. Our findings suggest that current population growth rate is exceeding the rate of physicians entering the field of GS and highlights the need for interventions to promote the recruitment of GS residents and retainment of attending physicians, particularly for rural areas. Future research to measure surgeon distribution in relation to patient outcomes and the efficacy of recent policy to address shortages can help define additional interventions to address physician shortages moving forward.

Cross-Sectional Analysis of Global Surgery Opportunities Among General Surgery Residency Programs

BACKGROUND

Global surgery is a rising field within academic surgery. With the publication of recent landmark papers highlighting the need for increased global efforts to combat surgical disease, many general surgery residents seek opportunities to gain clinical, research, and educational experience related to global surgery during residency. This study aims to quantify the global surgery opportunities that are publicly available to residents training in Accreditation Council for Graduate Medical Education (ACGME)-accredited general surgery programs.

METHODS

The websites of all ACGME-accredited general surgery residency programs were surveyed for mention of global surgery training opportunities. Each opportunity was recorded in a database and categorized based on type. Recorded categories include international clinical rotations, international surgical research opportunities, and formal tracks or training pathways for global surgery.

RESULTS

Of the 299 ACGME-accredited general surgery training programs, 52 (17%) mention some form of international surgical opportunity on their website. Among these programs, 11 (21%) note both clinical and research opportunities, 28 (54%) mention only clinical opportunities, and 13 (25%) list only research opportunities. The large majority of global surgery opportunities were based in training programs at academic medical centers (n = 50, 96%). There was no significant difference in the percentage of global surgery programs when evaluated by program region (p = 0.154) CONCLUSIONS: Few general surgery residency programs mention international training opportunities on their program websites. For those programs that do offer global surgery opportunities, these are typically international rotations offered as electives for upper-level residents. Expanding access to global surgery opportunities may be beneficial to meet the desires of residents wishing to pursue academic global surgery.

Ten Year Projections for US Residency Positions: Will There be Enough Positions to Accommodate the Growing Number of U.S. Medical School Graduates?

OBJECTIVE

Recently, a multitude of new U.S. medical schools have been established and existing medical schools have expanded their enrollments. The National Residency Match Program (NRMP) reports that in 2016 there were 23,339 categorical residency positions offered in the match and 26,836 overall applicants with 17,789 (66.29%) of the total candidates being U.S. allopathic graduates. In view of the rapid growth of medical school graduates, the aim of this study is to determine if current trends suggest a shortage of residency positions within the next ten years.

DESIGN

The total number of graduates from U.S. medical schools was obtained from the Association of American Medical Colleges (AAMC) for 2005-2014 academic years and was trended linearly for a 10-year prediction for the number of graduates. The yearly number of categorical positions filled by U.S. graduates for calendar years 2006-2015 was obtained from the NRMP and was trended longitudinally 10 years into the future. Analysis of subspecialty data focused on the comparison of differences in growth rates and potential foreseeable deficits in available categorical positions in U.S. residency programs.

RESULTS

According to trended data from AAMC, the total number of graduates from U.S. medical schools has increased 1.52 percent annually (15,927 in 2005 to 18,705 in 2014); with a forecast of 22,280 U.S. medical school graduates in 2026. The growth rate of all categorical positions available in U.S. residency programs was 2.55 percent annually, predicting 29,880 positions available in 2026. In view of these results, an analysis of specific residencies was done to determine potential shortages in specific residencies. With 17.4 percent of all U.S. graduates matching into internal medicine and a 3.17 percent growth rate in residency positions, in 2026 the number of internal medicine residency positions will be 9,026 with 3,874 U.S. graduates predicted to match into these positions. In general surgery, residency positions note a growth rate of 1.55 percent. Of all U.S. graduates, 5.6 percent match into general surgery. Overall this projects 1,445 general surgery residency positions in 2026 with 1,257 U.S. graduates matching. In orthopedics with a growth rate of 1.35 percent and a match rate of 3.75 percent, there are projected to be 827 positions available with 836 U.S. graduates projected to match.

CONCLUSIONS

Despite the increasing number of medical school graduates, our model suggests the rate of growth of residency positions continues to be higher than the rate of growth of U.S. medical school graduates. While there is no apparent shortage of categorical positions overall, highly competitive subspecialties like orthopedics may develop a shortage within the next ten years.

Opportunities to Create New General Surgery Residency Programs to Alleviate the Shortage of General Surgeons

PURPOSE

To estimate the capacity for supporting new general surgery residency programs among U.S. hospitals that currently do not have such programs.

METHOD

The authors compiled 2011 American Hospital Association data regarding the characteristics of hospitals with and without a general surgery residency program and 2012 Accreditation Council for Graduate Medical Education data regarding existing general surgery residencies. They performed an ordinary least squares regression to model the number of residents who could be trained at existing programs on the basis of residency program-level variables. They identified candidate hospitals on the basis of a priori defined criteria for new general surgery residency programs and an out-of-sample prediction of resident capacity among the candidate hospitals.

RESULTS

The authors found that 153 hospitals in 39 states could support a general surgery residency program. The characteristics of these hospitals closely resembled the characteristics of hospitals with existing programs. They identified 435 new residency positions: 40 hospitals could support 2 residents per year, 99 hospitals could support 3 residents, 12 hospitals could support 4 residents, and 2 hospitals could support 5 residents. Accounting for progressive specialization, new residency programs could add 287 additional general surgeons to the workforce annually (after an initial five- to seven-year lead time).

CONCLUSIONS

By creating new general surgery residency programs, hospitals could increase the number of general surgeons entering the workforce each year by 25%. A challenge to achieving this growth remains finding new funding mechanisms within and outside Medicare. Such changes are needed to mitigate projected workforce shortages.

National Survey of Burnout among US General Surgery Residents

BACKGROUND

Burnout is a complex syndrome of emotional distress that can disproportionately affect individuals who work in health care professions.

STUDY DESIGN

For a national survey of burnout in US general surgery residents, we asked all ACGME-accredited general surgery program directors to email their general surgery residents an invitation to complete an anonymous, online survey. Burnout was assessed with the Maslach Burnout Inventory; total scores for Emotional Exhaustion (EE), Depersonalization (DP), and Personal Accomplishment (PA) subscales were calculated. Burnout was defined as having a score in the highest tertile for EE or DP or lowest tertile for PA. Chi-square tests and one-way ANOVA were used to test associations between burnout tertiles for each subscale and various resident and training-program characteristics as appropriate.

RESULTS

From April to December 2014, six hundred and sixty-five residents actively engaged in clinical training had data for analysis; 69% met the criterion for burnout on at least one subscale. Higher burnout on each subscale was reported by residents planning private practice careers compared with academic careers. A greater proportion of women than men reported burnout on EE and PA. Higher burnout on EE and DP was associated with greater work hours per week. Having a structured mentoring program was associated with lower burnout on each subscale.

CONCLUSIONS

The high rates of burnout among general surgery residents are concerning, given the potential impact of burnout on the quality of patient care. Efforts to identify at-risk populations and to design targeted interventions to mitigate burnout in surgical trainees are warranted.

Workforce shortage for general surgeons: results from the Society for Surgery of the Alimentary Track (SSAT) surgeon shortage survey

BACKGROUND

Population shifts among surgeons and the general populous will contribute to a predicted general surgeon shortage by 2020. The Public Policy and Advocacy Committee of the Society for Surgery of the Alimentary Tract designed and conducted a survey to assess perceptions and possible solutions from important stakeholders: practicing surgeons of the society, general surgery residents, and medical students.

RESULTS

Responses from 1,208 participants: 658 practicing surgeons, 183 general surgery residents, and 367 medical students, were analyzed. There was a strong perception of a current and future surgeon shortage. The majority of surgeons (59.3 %) and residents (64.5 %) perceived a current general surgeon shortage, while 28.6 % of medical students responded the same. When asked of a perceived general surgery shortage in 20 years, 82.4, 81.4, and 51 % said "yes", respectively. There were generational differences in responses to contributors and solutions for the impending shortage. Surgeons placed a high value on improving reimbursement, tort reform, and surgeon burnout, while residents held a strong interest in a national loan forgiveness program and improving lifestyle barriers.

CONCLUSION

Our survey offers insight into possible solutions to ward off a surgeon shortage that should be addressed with programmatic changes in residency training and by reform of the national health care system.

Will there be a good general surgeon when you need one?

The Public Policy & Advocacy Committee sponsored the panel on the topic of "Will There Be a General Surgeon When You Need One?" at the 2012 Annual Meeting of the SSAT. The panel of experts was convened to formulate recommendations to help general surgeons adapt to the changing landscape which will undoubtedly affect the practice of surgery in the future. The invited speakers were Drs. David Hoyt, Carlos Pellegrini, Kaye M. Reid-Lombardo, and David Rattner. The session was moderated by Drs. Ross Goldberg and Tara Kent. The invited presentations and audience commentary are the basis of this manuscript.

Military and academic programs outperform community programs on the American Board of Surgery Examinations

BACKGROUND

There is a paucity of American Board of Surgery (ABS) Qualifying Examination (QE) and Certifying Examination (CE) outcomes comparing residency programs by academic, community, or military affiliation. We hypothesize that the larger academic programs will outperform the smaller community programs.

METHODS

In this retrospective study from 2002 to 2012, examination performance on the ABS QE and CE were obtained from the ABS for all of the general surgery residency programs. Programs were categorized by academic, community, and military affiliation. Both nonparametric and parametric statistics were used for comparison, using an α = 0.05.

RESULTS

There were 137/235 (58.3%) academic programs, 90/235 (38.3%) community programs, and 8/235 (3.4%) military programs that satisfied inclusion criteria for this study. The Mann-Whitney U tests showed that the military programs outperformed academic and community programs on the ABS QE and the ABS CE, and had a higher proportion of examinees passing both examinations on the first attempt (all p≤0.02). One-tailed Student t-tests showed that academic programs had higher pass rates than community programs on the ABS QE (85.4%±9.5% vs. 81.9%±11.5%), higher pass rates on the ABS CE (83.6%±8.3% vs. 80.6%±11.0%), and a higher proportion of examinees passing both examinations on the first attempt (0.73±0.12 vs. 0.68±0.15) (all p≤0.01). The chi-square and Fisher exact tests showed that examinees performed highest in military programs, followed by academic programs, and lowest in community programs on the ABS QE and ABS CE (all p≤ 0.01).

CONCLUSIONS

Military programs have the highest degrees of success on all of the ABS examinations. Academic programs outperform community programs. These results have the potential to affect application patterns to established general surgery residency programs.

Influence of resident education in correctly diagnosing extremity soft tissue sarcoma

Background. One-third of all extremity soft tissue sarcomas are misdiagnosed and inappropriately excised without proper preoperative diagnosis and planning. This study aimed at examining the clinical judgment of residents in both general and orthopaedic surgery and at determining whether resident education plays a role in appropriately managing unknown soft tissue masses. Methods. A case-based survey was used to assess clinical decisions, practice patterns, and demographics. Aggregate response for all of the clinical cases by each respondent was correlated with the selections made for practice patterns and demographic data. Results. A total of 381 responses were returned. A higher percentage of respondents from the orthopaedic group (84.2%) noted having a dedicated STS rotation as compared to the general surgery group (35.8%) P < 0.001. Depth, size, and location of the mass, rate of growth, and imaging characteristics were considered to be important factors. Each additional year of training resulted in 10% increased odds of selecting the correct clinical decision for both groups. Conclusion. Our study showed that current residents in both orthopaedic surgery and general surgery are able to appropriately identify patients with suspicious masses. Continuing education in sarcoma care should be implemented beyond the years of residency training.

General surgery vs fellowship: the role of the Independent Academic Medical Center

OBJECTIVES

To compare career choices of residency graduates from Independent Academic Medical Center (IAMC) and University Academic Medical Center (UAMC) programs and evaluate program directors' perceptions of residents' motivations for pursuing general surgery or fellowships.

DESIGN

From May to August 2011, an electronic survey collected information on program characteristics, graduates' career pursuits, and career motivations. Fisher's exact tests were calculated to compare responses by program type. Multivariate logistic regression was used to identify independent program characteristics associated with graduates pursuing general surgery.

SETTING

Data were collected on graduates over 3 years (2009-2011).

PARTICIPANTS

Surgery residency program directors.

RESULTS

Seventy-four program directors completed the survey; 42% represented IAMCs. IAMCs reported more graduates choosing general surgery. Over one-quarter of graduates pursued general surgery from 52% of IAMC vs 37% of UAMC programs (p = 0.243). Career choices varied significantly by region: over one-quarter of graduates pursue general surgery from 78% of Western, 60% of Midwestern, 40% of Southern, and 24% of Northeastern programs (p = 0.018). On multivariate analysis, IAMC programs were independently associated with more graduates choosing general surgery (p = 0.017), after adjustment for other program characteristics. Seventy-five percent of UAMC programs reported over three-fourths of graduates receive first choice fellowship, compared with only 52% of IAMC programs (p = 0.067). Fellowships were comparable among IAMC and UAMC programs, most commonly MIS/Bariatric (16%), Critical Care/Trauma (16%), and Vascular (14%). IAMC and UAMC program directors cite similar reasons for graduate career choices.

CONCLUSIONS

Most general surgery residents undergo fellowship training. Graduates from IAMC and UAMC programs pursue similar specialties, but UAMC programs report more first choice acceptance. IAMC programs may graduate proportionately more general surgeons. Further studies directly evaluating surgical residents' career choices are warranted to understand the influence of independent and university programs in shaping these choices and to develop strategies for reducing the general surgeon shortage.