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American College of Emergency Physicians
Trauma Surgery
General Surgery Article in WSJ
Finance
Stress
News
ACS Views on Legislative, Regulatory, and Other Issues
Workforce Issues in Health Care Reform: Assessing the Present and Preparing for the Future
American College of Surgeons Federal Testimony
| A Modest Proposal |
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| by Dr. Kent. Click picture. |
The Ethics of Surgical Practice: Cases, Dilemmas, and Resolutions
Rural Surgery
November 15, 2010 — Surgery and night duty cause stress
on surgeons, and the current shortage of surgeons has increased this stress load, according to the results of a study reported
online November 15 in the Archives of Surgery.
"The number of young doctors who want to be surgeons has
decreased recently, with the rate in 2000 declining to 80% of that in the 1980s," write Koji Yamaguchi, MD, PhD, from the
University of Occupational and Environmental Health in Kitakyushu, Japan, and colleagues from the Kitakyushu Surgical Study
Group. "One of the reasons is the unfavourable working conditions experienced by surgeons, which has led to a decrease in
the number of surgeons and, in turn, has caused even greater increases in the surgeons' workload and risk of errors.... This
study subjectively and objectively examined the stress experienced by surgeons in response to surgery and night duty."
At 1 university hospital and 15 community/public hospitals
in Kitakyushu City, Japan, 66 Japanese surgeons completed subjective questionnaires and gave urine samples for objective analysis.
The primary study endpoints were scores on two different surveys — the NASA Task Load Index and the Stress Arousal Checklist
(SACL) — as well as measurement of urine biopyrin levels. As the authors explain, serum bilirubin acts as a scavenger
of oxidative stress, which is metabolized and excreted in urine as a biopyrin metabolite. Urine biopyrin levels, therefore,
reflect levels of oxidative stress. Surveys were completed the morning before surgery and after an operation performed during
the day, and at the start of the evening of nighttime duty and again the following evening (ie, when the surgeon was going
off duty). Timing of urine samples was similar: before and after an operation and before and after nighttime duty.
The Task Load Index, or TLX, assesses mental workload on
five 7-point scales that address mental, physical, and temporal workloads; performance; effort; and frustration. The SACL
uses 4-point scales for 30 adjectives relating to perceptions of arousal and stress.
Determined by Pearson-χ2 test, the TLX total
demand score significantly increased in association with the duration of surgery (P < .001) and the amount of
surgical blood loss (P = .001). There was no association between either TLX or SACL scores and the number of operations
performed each day. SACL scores suggested that arousal diminished with length of surgical operations, and stress increased
with degree of blood loss.
Mean operating time was 210 minutes, which was then used
as a cutoff point. Urine biopyrin levels were significantly higher following a surgery that was 210 minutes or longer compared
with operations that took 209 minutes or less. Urine biopyrin levels were also significantly increased after an operation
with blood loss of 200 g or more.
Sleep time was significantly decreased by night duty, and
urine biopyrin levels were significantly increased. On the morning after night duty and the evening after the end of the following
day shift, SACL arousal scores were significantly decreased.
"Surgeons' surgical stress increased in association with
the duration of surgery and the amount of surgical blood loss. Night duty significantly decreased the sleep time of surgeons
and decreased arousal the morning after night duty and the evening following the day shift," the study authors write.
Limitations of this study include the failure to examine
the details of night duty and the day shift.
"The problem of chronic sleep deprivation and overwork of
surgical residents has become an important issue in the world, including Japan. In Japan, surgeons usually work after night
duty in most hospitals," the study authors conclude. "The present study demonstrated the stress of night duty on surgeons
subjectively and objectively. Surgeons' working conditions, including night duty, should be improved to enhance the quality
of life for surgeons, resulting in fewer errors in operations and medical treatment and better medical services for patients."
From Medscape.
In practice over 25 years, increasingly concerned re lack of new surgeons in area. A few have come and
given up.
Seems to me that it is no longer viable to simply start practice and earn living from surgical fees.
$60-70K/Year malpractice
$60-70K/ year for rent, secretary,and general expenses.
$100,000 salary for you
Average Surgeon does (at Medicare rates)
30 gb/ year @675
20 hernias@ 500
10 colectomies a@ 975
15 ports a@ 325
throw in "consults" 100 @75
100 other procedures averaging@ 750(very optimistic)
suffice it to say that the numbers do not add up, nor will they add up, nor will the expenses go down.The
present economic model of a surgeon supporting himself from fees is quickly dying.
In the future no surgeon will start unless he is supported financially- A salary PLUS fees.
"You will be hired and fired by a hospital or organization. Work rule hours will be enforced. European model
of a position PLUS fees will be the norm.
Am I off base or does anyone else see this coming or have ideas on what will be the model for the future"?
From Sermo or Medscape
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Internal Medicine
Fewer Medical Students Choosing General Internal Medicine Careers
The Worst-Paying Jobs for Doctors
Does Preventive Care Save Money? Health Economics and the Presidential Candidates
Cash Only
Emergency Medicine News
Neurology
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PRIVATE NEUROLOGY
Obstetrics / Gynecology
OB-Gyn: Cost/Benefit
Why a doctor chose OB over family practice
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Pediatrics
Psychiatry
Psychiatry: Cost/Benefit
Psychiatric Times
Developing Unbiased Diagnostic and Treatment Guidelines in Psychiatry
Will Gitmo Shrinks Lose Their Credentials?
Radiology
No one ever said being a doctor was easy. School and training
go on seemingly forever, and once graduation arrives, doctors work long hours and are faced with life-and-death decisions
daily.
There were once rewards. For decades, doctors earned hefty paychecks, had autonomy and respect. Those benefits
are fading, and as a result, so is the number of doctors. Within the next 15 years, the United States will experience a shortage
of between 90,000 to 200,000 physicians, according to the recently published Will the Last Physician in America Please Turn
Off the Lights: A Look at America's Looming Doctor Shortage.
The American Medical Association recognizes there are
shortages in certain geographic areas and in certain specialties. Part of that is due to the aging population and a stagnant
number of medical school applicants.
See the galleries: Reasons Not To Become A Doctor
bigger reasons not to
become a doctor
There are, however, other significant reasons not to become a doctor. They include the increasing costs
of medical malpractice coverage, higher practice costs, lower insurance reimbursement rates and insurance-company restrictions
resulting in less autonomy over how patients are cared for.
This is not just a question of career choice -- consumers
will be affected greatly by this shortage. If you think there's a long wait for an appointment now, it could be nothing compared
with 15 years down the road. The three coauthors of Will the Last Physician in America Please Turn Off the Lights, all from
the physician-staffing firm Merritt, Hawkins and Associates, say the wait will jump to three to four months or more to see
a doctor for a non-emergency, and a routine doctor's visit will cost two to three times what it does now -- whether you are
insured or not, they say.
insurance cutting into salary
Insurance has become a loaded word. One-third of the country
is insured by Medicare, and over the next nine years, the government program plans to cut payments to physicians by about
40%, while practice costs are projected to increase 20%, according to the American Medical Association. The first of those
cuts will take place in July,
when the reimbursement rate to doctors will drop by 10.6%. The next cut of 5% will occur in January.
It's expected to have a trickle-down effect. "If Medicare
makes a change to their reimbursement, other insurance companies follow their lead, since Medicare drives the marketplace,"
says Lawrence Smarr, president of the Physician Insurers Association of America, a trade association for medical malpractice
insurance companies.
As costs continue to rise, many doctors say they need to see more patients in order to maintain
their salaries and cover basic practice costs.
"We used to have a lot of respect for doctors, but now they seem like
easy targets," says Phillip Miller, an author of Will the Last Physician in America Please Turn off the Lights. "There's a
perception among patients that, 'I went to a doctor's appointment and he was 45 minutes late. He's probably on the golf course
or driving his Mercedes.' The truth is, they're probably busy with patients."
medical school enrollment is down
The
Association of American Medical Colleges projects that America needs a 30% annual increase in medical-school enrollment in
order to keep up with need for doctors. In 2012, compared with 2002, medical-school enrollment will be up 21%.
Potential
physicians face a future of looming medical-school debt, which is higher than ever. Students who graduate from a public medical
school have a median debt of $100,000 and private-school students graduate with a median debt of $135,000, according to a
2003 study by the Association of American Medical Colleges. Compare that with 1984, when median debt for public-school graduates
was $22,000 and private-school students was $27,000.
Monthly payment on a debt of $150,000 at the end of residency
at an interest rate of 2.8% is $1,761, according to the study.
The amount of time it takes to pay off debt depends
on the specialty. The average physician's net income, adjusted for inflation, declined 7% between 1995 and 2003, according
to the Center for Studying Health System Change. In order to enter the most lucrative specialties, like radiology, ophthalmology,
anesthesiology, and dermatology, doctors must continue with their training into their 30s. That means they can't start chipping
away at their debt -- let alone make money -- until a time by which their counterparts in law or business are usually prospering.
doctors
and malpractice
Meanwhile, getting sued by a patient is a major concern. Of course, doctors who make fatal mistakes and
who are unqualified should be held responsible, but there's evidence that the bulk of lawsuits brought are frivolous. Of all
malpractice lawsuits brought to jury trial in 2004, the defendant won 91% of the time. Only 6% of all lawsuits go to trial;
those that aren't thrown out are settled. Only 27% of all claims made against doctors result in money awarded to the plaintiff,
according to Smarr, president of the trade association for medical malpractice companies.
Regardless, doctors need
to defend themselves against the possibility of damages -- and that's an extremely expensive proposition. It takes about four-and-a-half
years from the start of a lawsuit to the end, and the average cost to the defense in legal fees was $94,284 in 2004, according
to the American Medical Association.
Many states are trying to establish laws to protect doctors from baseless suits.
Texas went from the state with the most lawsuits filed to the only state that wrote tort reform into its constitution after
its citizens voted it into law. Since tort reform was enacted in 2004, the yearly premium doctors pay in Texas for malpractice
insurance has dropped by 40%. Now, the most plaintiffs can recoup for emotional damages is $250,000 from doctors and $500,000
from hospitals. Most interestingly, the number of claims filed against doctors has dropped by about half.
"The lawyers
know the huge damages they were [previously] able to get are [now] limited," says Smarr.
Miami-Dade County, in South
Florida, is now the most precarious place for doctors to practice when it comes to lawsuits. In 2007, OB/GYNs paid on average
$275,466 annually for malpractice insurance. That number is a slight drop from 2006, when the average cost was $299,000, according
to Mike Matray, editor of the newsletter Medical Liability Monitor.
the future of medicine
Doctors have to practice
defensive medicine, and their insurance rates are so high," says Matray. "But rates are leveling off and coming down right
now. However, if history repeats itself, they will go up in a few years. A lot of doctors right now are not encouraging their
kids to be doctors."
To support that assertion, a 2007 survey by Merritt, Hawkins indicated that 57% of 1,175 doctors
questioned would not recommend the field to their children.
The solutions are widespread. Nine new medical schools
are under development or discussion, according to the Liaison Committee on Medical Education, which accredits medical schools.
The AAMC estimates that almost 800 first-year students will attend these new schools in the academic year 2012-2013, based
on future enrollment figures.
Hospitals and medical practices are trying to entice doctors by addressing the work-life
balance issue. Many hospitals now use "hospitalists," physicians who do shift work in order to relieve the physician shortage
in many hospitals and practices. They chose only to work in hospitals and don't have outside practices. For instance, if a
physician needs to admit a patient to the hospital, that patient might be seen by their primary doctor's hospitalist so the
physician can continue to see scheduled patients. Laborists serve the same function in the OB/GYN field.
"That allows
physicians to free up some of their time and makes them more efficient in their clinics," says Cindy Bagwell, vice president
of professional staffing at Geisinger Medical Center in Dannville, Pennsylvania, a practice that uses hospitalists and laborists
frequently.
On the flip side, many hospitalists and laborists enjoy knowing they have a set schedule and will never
be woken up in the middle of the night by an emergency at the hospital. Many of these changes have to do with doctors wanting
more free time and female physicians' desire to work and raise a family.
"It's hard to argue with people wanting to
take great care of their children, so we try to make it work," says Bagwell. "As long as we can keep patient care at the forefront,
we're willing to try things."
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