For some, it no longer pays to be a surgeon

By LISA GREENE, Times Staff Writer
http://www.sptimes.com

TAMPA – Dr. Jack Brock still wears blue surgical scrubs each day, even though he no longer needs them.

That’s because Brock, once the respected director of cardiac surgery at Tampa General Hospital, no longer spends his days stitching arteries and removing lung tumors. Instead, he has joined an office practicing “anti-aging medicine,” where he’ll offer weight-loss plans and sell supplements.

Once, Brock saved lives at their most fragile.

“That’s what I … love doing,” he said. “But I can’t make a living doing it, to be honest with you.”

Across the country, doctors in Brock’s specialty, thoracic surgery, are leaving the field. Medicare payments for bypass surgeries have dropped 54 percent since 1989. The number of bypass surgeries performed has also dropped, replaced by less-invasive angioplasties and stents.

Brock, 55, said his take-home pay had fallen from $380,000 in the early 1980s to about $80,000. His malpractice insurance cost $70,000 a year, while he was being paid only $1,500 per bypass operation.

Brock says that he’s excited about his new work and that he ultimately may save more lives preventing heart disease than he did fixing the damage.

But many doctors in Tampa Bay see Brock’s defection in symbolic terms. Brock, after all, was supposed to be at the top of the medical heap. He was performing complex surgeries including heart transplants at a major trauma hospital. He even trained with Dr. Michael E. DeBakey, one of the world’s best-known heart surgeons. If Brock is bested by rising malpractice costs and shrinking payments, what hope is there for the rest of medicine?

“He was trained by God,” protested Dr. Daniel Greenwald, a Tampa plastic surgeon.

Dr. Neil Alan Fenske, chair of dermatology and cutaneous surgery at the University of South Florida, worries about a shortage of surgeons.

“You can make more money selling vitamins in your office than you can doing cardiovascular surgery. It’s insanity,” Fenske said. “These are good docs who we desperately need in the system.”

“When I was in Pennsylvania, there were cardiothoracic surgeons selling Amway,” said Dr. Stephen Klasko, dean of the USF medical school.

Exciting and romantic

Brock and other surgeons are the first to say that even with lower income, these doctors still make plenty of money, though Brock has also started to sell real estate. None of them expect pity. The question is whether their departure will hurt patient care.

In the short run, Brock said, everything’s fine. Tampa General has a new cardiac chief and no shortage of heart surgeons. Brock is on call for trauma cases one week each month.

But a few years from now?

“That might be a little dicey,” Brock said.

As Brock and other surgeons leave, nobody is replacing them. This year, a third of the nation’s 130 fellowship slots to train cardiothoracic surgeons went unfilled.

Instead, bright young medical students are searching for jobs with higher pay and more regular hours. USF has 500 applicants for three dermatology residency slots.

“When Jack trained, the creme de la creme went into cardiac surgery,” said Dr. Keith Naunheim, chair of the health policy council for the Society of Thoracic Surgeons. “Heart surgery was not just interesting and exciting, it was romantic. It was the thing to do.”

But soon, the shortage of heart surgeons is going to be a problem, Naunheim and other surgeons say.

“The whole Baby Boom population is coming down the pike,” Naunheim said. “They’re going to need heart valves replaced, lung cancers removed, bypasses. … The number of people needing to be treated is going to rise dramatically at the same time the number of heart surgeons is going to fall dramatically.”

Not everyone believes this. Part of the reason cardiothoracic surgeons make less is because they have less to do. Interventional cardiologists who perform angioplasties – reopening clogged arteries with a balloon – have taken part of their job.

Thoracic surgery is “a dying specialty,” Klasko said, and if that’s because a less invasive procedure has replaced a more dangerous one, that’s a good thing.

“Tomorrow there could be a pill to cure heart disease, and cardiologists will be in the same situation,” said Klasko, also vice president of USF Health.

‘Is is really worth it?’

Brock himself has moved on.

“Surgery was a great thing to do for 100 years,” he said. “But surgery is a pretty gross approach to treatment of disease. We’re becoming a lot more sophisticated now. Maybe surgery has run its course.”

Brock sat in his office last week, scribbling chemical diagrams on exam table paper, showing how fat affects testosterone. He has always liked knowing how things worked. Growing up in Tampa as the son of a road builder, Brock once built a crude kidney dialysis machine for a high school project, using a laundry tub and outdated blood cajoled from a blood bank.

Now, Brock’s focus is on preventing the diseases of aging, especially for middle-aged men, a group that often neglects preventive care.

Brock will help patients lose weight, analyze their blood chemistry and say whether their blood sugar, triglycerides or cholesterol is too high. For some he may prescribe statins; to others, he will sell vitamins and other supplements. He also will treat varicose veins, usually those bad enough to cause medical problems. Zapping harmless spider veins is the only cosmetic work he does.

“Maybe the money is just an excuse,” he said. “It’s time for me to move on, do something more preventive. I’m going to make my patients live longer.”

It’s hard to argue with better preventive medicine. But what about the people whose hearts are already damaged, or who have lung cancer, or are hit by a car? For them, a good surgeon can be hard to find.

The number of general surgeons has dropped so fast that last month, a leading medical journal published an article about their “impending disappearance.” Finding surgical specialists to staff emergency rooms has become a national crisis. This summer, the American College of Surgeons warned that federal action is needed to address the surgical shortage.

One New York pediatric surgeon told the national surgeon’s group he had quit to drive a cab. Naunheim knows a thoracic surgeon who’s now treating varicose veins and injecting Botox. In St. Petersburg, vascular surgeon William M. Blackshear Jr. used to spend most of his time doing hospital-based surgeries, from putting in stents to taking out plaque.

Now he spends more time in his office, doing everything from laser vein treatments to weight loss management to injecting Botox. He keeps caring for his longtime patients, but had to make a change to cope with declining insurance payments and rising malpractice costs.

“You get to a point where you say, ‘Is this really worth it for the time and work and sweat you put in?'” he said. “The answer for a lot of physicians is no.”

Without some changes, these doctors say, the United States is going to find itself with plenty of doctors in certain well-paying specialties, but not enough to do the basic primary care or the critical care for specialties such as Brock’s.

“We are going to have the best skin of any country in the world,” Naunheim said. “But we’re going to end up dying of lung cancer.”
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