Calling all surgeons – Shoals faces critical shortage of general surgeons

By Michelle Rupe Eubanks
http://www.timesdaily.com

Dr. Shelby Bailey was like a lot of his peers when he began his private practice: burdened with student loan debt but determined to solve the medical problems of his patients.

“Everyone has their own reasons for becoming a doctor, and I chose it for a variety of reasons,” he said. “I liked being able to identify an acute type of problem, be able to repair or remove the problem and have the patient go on and fully recover.”

His reasons are what make being a general surgeon worthwhile, even with the long hours, weekends spent on-call and less time with his wife and children, Bailey said.

Fewer and fewer medical school graduates, however, share Bailey’s love for the job. Recent data compiled by Dr. Dana Lynge and his colleagues at the University of Washington, Seattle, revealed that the number of general surgeons per 100,000 Americans has declined by more than 25 percent in the past 25 years. The study appeared in the April issue of the journal Archives of Surgery.

“General surgeons play a pivotal role in the health-care system of the United States,” Lynge said. “There is some question as to whether there will be an adequate number of general surgeons to care for an increasingly elderly population, with its attendant increased demand for surgical care.”

Rural general surgeons provide backup to primary care physicians and help keep small rural hospitals financially viable, while general surgeons in urban areas provide important surgical services, including emergency and trauma care that some surgical subspecialists may not offer. It’s the general surgeon, for instance, who will perform the appendectomy, the gall bladder removal or the emergency Caesarean section.

The Shoals is unique among the nation in that the area appears to be well staffed with general surgeons. In Colbert and Lauderdale counties combined, there are 10 general surgeons to treat a population of around 143,000, well ahead of the seven general surgeons per 100,000 on average in the U.S.

Where the disparity is evident is in how these surgeons are divided. Six, including Bailey, who shares his practice with William Collignon, are in Colbert County and treat a population of around 55,000 at Helen Keller Hospital in Sheffield and Shoals Hospital in Muscle Shoals. Lauderdale County, however, is served by four general surgeons, yet census figures show more than 88,000 residents, making it underserved for the size of the market.

Area hospitals typically don’t recruit general surgeons to the Shoals; it’s something often left to physicians in private practice who see a need. Even if they could, it might be an uphill battle, according to Dr. Hughes Evans, senior associate dean for medical education at the University of Alabama at Birmingham.

“It boils down to economics,” she said. “The trend is toward areas of medicine that are more flexible, and the average student (at UAB) has $100,000 in student loans, and it’s hard to pick a practice that will allow them to raise a family, have a house and pay back all those loans. So students are more savvy about that, and they’re choosing specialties that allow them more flexibility. Surgery has tended not to be that flexible.”

Bailey contends it’s a bit of bad marketing going so far as to say the name “general surgeon” is a misnomer “because we’re really specialists in everything, and our training takes several years, and that’s on top of the years we spend in medical school.”

Although UAB has seen a slight increase in the number of general surgery graduates in the past few years, there is no guarantee those individuals will choose to practice in rural areas, which stand to lose the most with the shortage of general surgeons.

Dr. Thomas Foley, a general surgeon in Marshalltown, Iowa, said 40 percent of rural hospitals in the U.S. may be without a general surgeon in as little as two years. With one other surgeon sharing on-call responsibilities in his market, he said he understands the reasons someone would rather practice in an urban, rather than rural, area.

But he points much of the blame for this problem on reimbursements from insurance companies, specifically the Centers for Medicare and Medicaid Services.

“Rates have been declining, especially for surgeons who face the added financial burdens of longer training requirements,” Foley said. “Reimbursement rates are generally lower in Iowa relative to the rest of the United States, and still lower in rural Iowa.”

It’s true in the Shoals, too.

Reimbursement rates vary widely in the state, with some physicians, including those in Huntsville, receiving much more than those in the Shoals for the same procedure. Further, it’s not the rate of inflation, cost of living or even the surgeons performing the procedures that determines these rates. Reimbursements are set by insurance companies, chief among them Medicare as the largest insurer in the country.

It’s a problem further compounded by an aging population. According to census data, more than 16 percent of the population in Colbert and Lauderdale counties is over 65, well above the state and national averages for that group.

One glimmer of hope is in medical schools that have upcapped admissions and expect to graduate 17,800 this spring, up from 16,000 in 2007. Additionally, several state accrediting agencies are allowing for more four-year universities to get into the business of training future doctors.

Florida State won approval from the state Legislature to become the nation’s 126th medical school by emphasizing family practice and other specialties needed in rural areas and inner cities, where the doctor shortage is already acute.

Arizona, Nevada and California are looking at their options for opening medical schools, and several other states are considering expanding theirs.

Study author Lynge said there are other options.

“These might include increased funding of residency positions and exploring and addressing the issues surrounding training, remuneration and lifestyle that seem to have made general surgery less attractive than other specialties to medical students, especially women,” he said.

Bailey, however, remains unconvinced that there is a viable way to solve the shortage.

“It’s going to have to be a multi-faceted approach on a variety of levels to see a reversal,” he said. “And it may be that society is trending away from a solution.” But, because reimbursements haven’t been shown to change, liability continues to be an issue and governmental red tape is only getting worse. “I’m afraid the trend is not reversible.”

Michelle Rupe Eubanks can be reached at 740-5745 or michelle.eubanks@timesdaily.com.

USAToday contributed to this report.

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