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.
In some places, it's already affecting patients.
The 24-bed Northern Cochise Community Hospital in Willcox, Ariz., lost its surgeons five years ago. Now, emergency cases are flown by helicopter to Tucson, 82 miles away. Each flight costs $14,000; there are about 10 a month.
The problem is that weather in the mountains sometimes makes flying dangerous. In early November, a flight carrying a man with severe stab wounds to the neck and arm had to turn back after 15 minutes. The patient was returned to the emergency room, restabilized and driven by ambulance.
"Now, that's an ordeal," said Harley Smith, the hospital's chief executive. "But he survived."
Surgeons help hospitals remain viable in less obvious ways, too.
South Sunflower County Hospital in the Mississippi Delta town of Indianola serves one of the poorest and most medically needy populations in the United States. More than 80 percent of the women who give birth there are on Medicaid.
The 49-bed hospital has four family practitioners who deliver babies and perform Caesarean sections. Two full-time nurse anesthetists provided the anesthesia for the C-section patients and the patients of the hospital's sole surgeon. When he left two years ago, however, the hospital couldn't afford to keep the anesthetists unless it could find more work for them. And without anesthesia services, the obstetrics service would have to close.
Jimmy Blessitt, the hospital administrator, scrambled and finally persuaded a surgeon at a hospital 40 miles away to come in two days a week.
"We would like to have a full-time person in general surgery," Blessitt said. "But it is getting more and more difficult."Trained in a Vast Field
John Phillips, the Iowa surgeon, is compact and trim, a fisherman, woodworker and quasi-computer geek. In conversation, he tends to be taciturn and unadorned. He has worked in Burlington, a city in southeast Iowa on the Mississippi River, since July 1978, the month he finished his five-year general surgery residency in Chicago.
Like internal medicine physicians, general surgeons are trained in a vast field. Many then specialize. Others, like Phillips, don't.
Phillips performs operations for gallbladders, colon cancer, breast cancer, hernias. He does some easier forms of vascular surgery. He doesn't do chest surgery, but one of his partners does. Burlington also supports a few orthopedic surgeons, but their skills are not interchangeable with those of general surgeons.
When Phillips started out, there were four general surgeons here. Now there are three -- he and two younger partners. Every third weekend, it's his responsibility to see, treat or ship every general surgery case in Great River Medical Center's catchment area -- 50,000 people in a region stretching east across the Mississippi into Illinois and south into Missouri.
People like fifth-grader Luis Rascon Jr.
In an adult, draining a skin abscess wouldn't require general anesthesia. But in a muscular preadolescent boy who might kick and scream, it does. It takes Phillips less than 15 minutes. He cleans the infected tissue of blood and pus, packs the unsutured wound with gauze, and covers it with a bandage.
The boy's parents, brother and one set of grandparents are the only people in the waiting room. His father is a high school wrestling coach, his mother a respiratory therapist. She is spooked by how quickly her son's infection developed.
On Tuesday, it was "a little pimple," says Jennifer Rascon. On Wednesday, the pediatrician gave her cream for it. On Thursday, the child "could barely walk when he came home from school." By Friday night, he was in the hospital.
It turns out it's an MRSA infection -- "methicillin-resistant Staphylococcus aureus" -- a once-rare hospital-acquired bug that's now in "the community" nationwide.
Phillips, in blue scrubs, steps out and tells the Rascon family that all is well. The boy will have to stay in the hospital a couple of days until the redness on his skin goes away. Repacking the wound will hurt.
"He'll do fine, though," the doctor says, adding he will see them in the morning, if not before.'Critical Access'
By mid-afternoon, Phillips is done with rounds and an emergency colonoscopy. He heads home to do yardwork while his wife paints the garage. It's a sunny day, and his partner, Michael Niehaus, 52, offers to fly a reporter halfway across Iowa to see a surgeon friend who is even more overworked than they are.
Like Phillips, Bob Kuhl has spent his career in one place -- in his case, where he grew up and where his father practiced general surgery for 32 years.
Kuhl is short and wiry, with a military-trim mustache. As he drives his visitors to the hospital, he explains that Creston is named for the highest point (1,312 feet) between the Mississippi and Missouri rivers on the Burlington Route. It is a working-class town. Most of the jobs are on the railroad, in farming-related businesses and in a few small factories, including ones that make Gummi Bears and coffeepots.
Iowa has 117 hospitals. All but nine of its 99 counties have one. The vast majority have fewer than 25 beds and are what the federal Medicare program designates "critical access" institutions. Nevertheless, in many towns such as Creston the hospital is in good financial shape, the result of civic commitment and six decades of growth in health-care spending.
The incongruously named Greater Regional Medical Center -- it has 25 beds -- has a $12 million addition that includes a new emergency room, cancer center and radiation therapy suite. Out back is a new $1.6 million hospice. Responsible for one-third of the hospital's revenue is the surgery department -- Kuhl and one other surgeon.
"A hospital like this would fold quickly without surgery," he says matter-of-factly.
He had another partner for 22 years, but that man left 18 months ago. His new, younger partner has a smaller repertoire of operations that doesn't include orthopedics, which means Kuhl is summoned for those cases even when he's off duty. The new man didn't perform C-sections either until Kuhl taught him, scrubbing in to supervise the first dozen. Kuhl still does 67 percent of Creston's surgeries.
Things aren't as bad as they were in the 1980s, when Kuhl was the only surgeon in Creston for 2 1/2 years. Nevertheless, at 57 he is on call every other night -- a frequency not allowed for young surgeons in training -- which he says "gets tiresome."
Sitting at the empty nursing station in the intensive-care unit -- no critically ill patients are in the hospital at the moment -- he talks about a less obvious burden.
Much research has revealed that volume and quality often go hand-in-hand in medicine. Doctors who perform a procedure often tend to have fewer complications than doctors who do it rarely. But rural general surgeons are necessarily "low-volume" practitioners of many operations they're expected to perform. Knowing which patients to keep -- and which to refer elsewhere -- requires that a surgeon continually reassess his own skill and experience.
For example, Kuhl no longer operates on the pancreas (which many surgeons liken to disarming a land mine). He acknowledges that if he had a patient with "a nasty gastric cancer, I don't know if I'd do it now." Those patients go to Des Moines, Omaha or Iowa City -- 80, 100 and 190 miles away.
He has been sued for malpractice only twice, neither time successfully.
He also has filled the Marcus Welby, M.D., role willingly, with a civic life that included coaching his sons' sports teams and 18 years on the school board. But many younger surgeons are not interested in this kind of life -- and when they are, their spouses often aren't. It takes a lot to lure them to places such as Creston.
When the hospital hired Kuhl's younger partner, it guaranteed him a salary greater than the $185,000 the older man had been making. Kuhl threatened to quit; arrangements were made to assure him a higher income, too.
Kuhl wants to retire in about five years. He has all kinds of plans. But he won't rule out doing orthopedic cases part time. Without him, he knows, patients like the 94-year-old widow would have to go 80 miles to have their hip fractures treated.
"Lots of old farm folk around here," Kuhl says in the dim light of the empty ICU. "They're the most loyal people. Some of these people would literally rather die than go to Des Moines."