Rural Areas Facing Dangerous Shortage of General Surgeons

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By David Brown
Washington Post Staff Writer
Thursday, January 1, 2009

BURLINGTON, Iowa -- It's not yet 9 a.m., and as most of his 27,000 neighbors are getting ready for Saturday chores, John Phillips has a familiar one in front of him.

Anesthetized and draped in blue is a 10-year-old boy with a red-hot abscess on his belly. An overhead lamp shines on a patch of iodine-scrubbed skin the size of a playing card. Phillips asks for a scalpel and bisects the glowing rectangle with a single cut.

About 200 miles to the west, Robert Kuhl has started his chores, too. The first is fixing the broken hip of a 94-year-old widow who fell the night before. Like so many of the 7,500 people in Creston, she would rather have the operation where she lives than in a big city miles away.

Through an incision in her thigh, Kuhl will saw off the broken end of the femur and replace it with a metal one that fits the joint socket. The procedure is called a hemiarthroplasty. Kuhl is the only person in an 80-mile radius who can do it. It will take him about 90 minutes.

Phillips, who is 61, and Kuhl, who is 57, are general surgeons. People like them are the backbone of rural medicine, and all across the country they are starting to disappear.

For the one-quarter of Americans who live outside metropolitan areas, general surgeons are the essential ingredient that keeps full-service medical care within reach. Without general surgeons as backup, family practitioners can't deliver babies, emergency rooms can't take trauma cases, and most internists won't do complicated procedures such as colonoscopies. But various forces -- educational, medical and sociological -- are making them an endangered species.

Many young physicians are opting for non-surgical specialties, such as radiology or cardiology, in which they can earn as much money as a surgeon with less grueling and unpredictable hours. Many young surgeons, in turn, choose to concentrate in fields such as transplant surgery or plastic surgery, in which they can make more money and don't have to face (usually alone) the wide range of problems a generalist faces.

"The shortage of general surgeons is at crisis dimensions," said George F. Sheldon, director of the American College of Surgery's Health Policy Institute. If the trend continues, he said, "the quality of health care will suffer, as the services of a surgeon are unique."

In 1980, 945 newly trained general surgeons were certified in the United States. In 2008, the number was essentially the same -- 972 -- even though the population has increased by 79 million. In 1994, there were 7.1 general surgeons per 100,000 people. Today there are five per 100,000.

The problem is not limited to wide-open spaces such as the Iowa countryside. In Maryland the statewide average is 5.2 per 100,000, but in Southern Maryland it is only three per 100,000. A year ago, there were 758 openings for general surgeons in 47 states. Thirty were in Virginia.

Nevertheless, it's in rural America -- where some places have only half as many surgeons per capita as cities -- that the problem is most acute. And it's likely to get worse. More than half of rural general surgeons are older than 50, and a wave of retirements is expected in the coming decade.

The federal government, through the Health Resources and Services Administration, offers various incentives to get primary-care physicians and dentists to work in places with "unserved, underserved, vulnerable, and disadvantaged populations." But general surgeons aren't part of the program. The American College of Surgery's chief tactic to date has been to try to let people know the problem exists.


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© 2009 The Washington Post Company

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