Surgeon shortage will hit as early as next year — Are you ready?

Researchers predict that by as early as 2010, there could be a shortage of 1,300 general surgeons.1 That number could grow to 1,875 in 2020, and 6,000 in 2050, says the co-author of the research, Thomas E. Williams Jr., MD, PhD, physician scholar at the Department of Surgery at Ohio State University, Columbus, and retired cardiac surgeon.

"According to simple population calculations, if the number of surgical trainees is not increased and the care model remains constant, there will not be a sufficient number of allopathic-trained general surgeons to care for the American people," researchers said.1 Williams has co-authored a book titled The Coming Surgeon Shortage: Who Will Fix our Hearts, your Hip, and Deliver our Grandchildren? The book is expected to be released late this year.

The number of general surgeons per capita has declined 25% over the past 25 years, according to the American College of Surgeons. Almost 75% of surgeons-in-training are choosing subspecialties that are more lucrative and offer better hours than general surgery, the college says. However, shortages also are developing in orthopedic surgery, urology, obstetrics-gynecology, cardiothoracic surgery, and neurosurgery. Another factor is decreased reimbursement.

The American College of Surgeons is taking notice. The college and others groups have formed a group titled Operation Patient Access: Quality Surgical Care for All, which will focus on the urgent issues facing surgical care. "Operation Patient Access is designed to help policy-makers understand that patient access to quality surgical care is at risk and that we want to work with them to craft workable solutions that address access problems while preserving and improving high-quality surgical care," according to a released statement from the college.2

The college's Health Policy Institute issued a new unpublished report that indicates the shortage of general surgeons has raised concerns about access to care for underserved and aging populations in pockets of rural and urban U.S. areas. The study, "Migration of Surgeons," found that surgeons are moving to areas with already established medical communities, which could lead to local shortages, particularly in the Northeastern and Midwestern United States.3

David A. Etzioni, MD, MSHS, assistant professor in the Department of Colorectal Surgery, Keck School of Medicine of USC in Los Angeles, says, "The impact of a surgeon shortage on outpatient surgery will depend on a wide range of factors, but it is a given that more outpatient surgical procedures will be performed."

Among the solutions being discussed by Operation Patient Access participants are increasing the number of residency programs, expanding the National Health Services Corps, establishing student loan forgiveness programs, providing more funding for graduate surgical education, reducing liability cost, and implementing alternative payment methods for health care.

The government must take proactive steps to increase the funding for surgery trainees to prevent the shortage and maintain access to high-quality care, Williams said in his study.1 In the meantime, there are strategies outpatient surgery managers can take now:

Change recruiting strategies.

Hospitals are more likely to employ surgeons in the future, Williams predicts. There will be forgiveness of medical school debt and signing bonuses, he says.

"Business models will be changing over the next 25 years," he says.

Freestanding centers can play up their lack of emergencies, which allows surgeons to live a more scheduled lifestyle, Williams says. Also, surgery centers have no emergency department call/coverage, sources point out.

Make sure physicians are happy.

Are you sure your physicians are happy? Ask them, Etzioni advises.

Medical directors should make sure physicians have what they need for their practice, Williams says. Physicians particularly are drawn to efficient surgery programs, he emphasizes.

In Columbus, OH, some orthopedic surgeons have started performing cases at a specialty hospital, Williams says. One told him that in the same amount of time it takes to do two cases at a local hospital, he can get three cases done at the specialty hospital, "because it's a more efficient delivery system," Williams says.

Do more with less.

Find ways to help surgeons streamline their work, Etzioni advises.

"This may include increasing ancillary staff support, allowing surgeons to go back and forth between rooms, shorter room turnover times, etc.," he says.

These recommendations assume that the surgeon already is busy, Etzioni says. "At the national level, I believe that surgeons are going to become increasingly busy," he says.

References

  1. Williams TE, Ellison EC. Population analysis predicts a future critical shortage of general surgeons. Surgery 2008; 144:548-556. Doi:10.1016/j.surg.2008.05.019.
  2. American College of Surgeons. Surgical groups form "operation patient access: quality surgical care for all" to call attention to escalating workforce shortage. March 24, 2009. Accessed at www.facs.org/news/opa.html.
  3. American College of Surgeons. New trend data shows access to surgical care at risk in rural and urban areas of the United States, American College of Surgeons Health Policy Institute issues advance findings of study on migration of surgeons. March 24, 2009. Accessed at www.facs.org/news/accessatrisk.html.

Temp surgeons creating concerns for managers

General surgeons have become scarcer in hospitals across the country, many of them beaten down by diminishing payments and grueling work hours, and some lured away by specialized surgery niches that offer more money and a better lifestyle.

Hospitals are left with no other choice but to rely more heavily on locum tenens surgeons who are called in as needed, often arriving within hours of the surgery and leaving just as quickly when it is done.

The shorter stays are another part of the trend that concern managers. Previously, locum tenens physicians stayed longer, and the same doctor might visit on a regular basis. Now the statistics show that locum tenens surgeons are more often visiting for just a week or a few days, and then they're gone.

The concept of temporary surgeons is nothing new, and the medical community has long recognized that they can pose some risk to patient safety. But the growing dependence on surgeons-for-hire means that whatever risk has always existed is now growing too, says Leilani Kicklighter, RN, ARM, MBA, CPHRM, LHRM, a patient safety and risk management consultant with The Kicklighter Group in Tamarac, FL, and a past president of the American Society for Healthcare Risk Management (ASHRM). What once may have seemed an unfortunate but tolerable risk is now becoming more worrisome, she says.

"I think the trend is going to continue to get worse, and we will see more and more problems," she predicts. "We may be seeing the tip of the iceberg now."

The risks are easy for a manager to spot. For starters, the locum tenens surgeon arrives with scant knowledge about the patient and little time to study the case. And then after the surgery, the temporary surgeon leaves the patient in someone else's hands for follow-up care. The whole concept of continuity of care is thrown out the window.

The American College of Surgeons has a Statement of Principles that clearly outlines the responsibility of the operating surgeon:1 "That is to see the patient preoperatively, intraoperatively, and postoperatively," says Paul Collicott, MD, FACS, director of the college's division of member services.

David A. Etzioni, MD, MSHS, assistant professor in the Department of Colorectal Surgery, Keck School of Medicine of USC in Los Angeles, says, "We generally assume that if a surgeon provides a surgical service to a patient, that there is a contract of sorts between the patient and physician." The contract implies that the surgeon will be available to care for the patient on a long-term basis, he says. "What if there is a complication that arises that requires ongoing treatment?" he asks. "From a reimbursement point of view, each major surgical procedure has a 'global period,' but in terms of the actual physician-patient relationship, this contract is permanent."

If the locum tenens surgeon is unable to provide postoperative care, then that care should be turned over to the surgeon who was temporarily replaced or a surgeon who can render surgical care equivalent to that provided by the locum tenens surgeon, say experts interviewed by Same-Day Surgery." An orthopedist shouldn't be following up with a cholecystectomy," Collicott says.

Other caveats: The college advises surgeons who do specialized work in urban hospitals not to work in small, rural facilities where the needs are more general. Also, inform patients that the regular surgeon is not doing the operation, Collicott advises.

Another concern for managers is that the locum tenens surgeon is not part of the facility's culture and community. The surgeon does not know the staff he or she will work with in the OR, and neither is he nor she familiar with the equipment to be used in surgery. That can be important in a crisis, when familiarity with the surroundings and equipment will facilitate a quick response with fewer mistakes.

Perhaps one of the most vexing problems for managers is that the locum tenens surgeon is not party to all of the policies and procedures, inservices, and other education that the manager has deemed so important for everyone else. The traveling surgeon might be required to sign off on certain requirements, and the agency providing the surgeon might certify that he or she meets certain standards, but that is not the same as knowing that the physician has been part of your own facility's learning process, Kicklighter says.

It can be hard enough to have physicians to comply with all your expectations even when they are local, operate at your facility regularly, and are part of the facility's community, she points out. The manager faces a real challenge when the surgeon just flew in, is tired, and the patient needs surgery in a hurry. For example, sources say, how will you ensure that these surgeons know how to handle a fire emergency and are familiar with the procedures to evacuate patients? Do those surgeons even know where the exits are?

"In the world of risk management, the first requirement is adhering to your own policies and procedures. If they don't know what you require, how can you expect them to comply?" Kicklighter says. "These aren't just a few simple rules, after all. We're talking about a whole slew of specific things that are not going to be the same from one [facility] to another."

The risks posed by itinerant surgeons can be mitigated by carefully choosing the agencies and the individual surgeons, she says.

There are other risk exposures to consider also, Kicklighter says. If the facility provides accommodations for locum tenens surgeons, such as a nearby apartment, there can be potential general liability issues there. Similarly, local transportation for the surgeon and security if the facility is in an unsafe area can bring liability. Workers' compensation also is a concern. "If they get stuck [by a needle] in your hospital and don't tell you about it, you aren't able to get a baseline on them or do any follow-up. But then they may come down with something, and years later you're brought in to a lawsuit," Kicklighter says.

Kicklighter also is concerned about how a manager could do a timely and effective investigation after an adverse event when the surgeon has left the community and has little obligation to participate. Also, she questions the ability to conduct a proper disclosure after an adverse event. If the surgeon is gone several days later, once you've investigated, is it right to disclose details to the patient without the surgeon participating in person?

Claims related to the surgery also could be problematic, Kicklighter says. "If a claim is filed several years later, what kind of guarantee do you have that you'll be able to track this doctor down? What kind of leverage do you have to ensure the doctor will be cooperative?" she asks. "I also expect a lot of claims in which there is disagreement about whether the fault lies with the surgeon or the doctor who was left to follow up with the patient after the surgeon leaves town."

Documentation also can be an issue with locum tenens surgeons, she says. With the move toward electronic medical records (EMR), physicians must know how to use the hospital's system. "How are we going to orient the surgeon to this particular hospital's EMR? It's one more thing to teach them when they arrive, and there's no time for it all," she says. "I'm concerned that we might see a lot of incomplete records."

Arun Ravi, a health care consultant with Frost & Sullivan, a consulting firm in New York City, says there is growing concern about whether traveling surgeons are adequately rested. "We're always concerned about surgeons working long hours and irregular hours, then being asked to perform a complex procedure," he says. "That is a concern, even with local surgeons, and then it becomes a much bigger concern when you have someone flying in from out of town, plus you have no idea what sort of experience they have had in the previous day or two."

Ravi notes, however, that the increasing use of locum tenens surgeons is not all bad. Though it is a solution that comes with its own batch of potential problems, using locum tenens surgeons addresses the shortage of surgeons by allowing hospitals to maintain their surgical revenue. The practice also helps patients avoid traveling to distant locations for surgery.

"This seems to be a pattern of practice that has taken hold in the medical community, for better or worse, so it is up to [facilities] to come up with policies and procedures that address some of the inherent risks," he says. "The most important thing right now is to understand that the use of temporary surgeons is not going to be just an aberration."

Reference

  1. American College of Surgeons. Statement of Principles. Revised Sept. 18, 2008. Accessed at www.facs.org

Overview: Locum Tenens

  • Locum tenens surgeons typically work 10-20 days, but temporary providers can work anywhere from three days up to a full year.
  • At least 1 in 20 general surgeons works on a temporary basis at least some of the time.
  • They can earn $250,000 or more due partly to the fact that they have no overhead.
  • A temporary surgeon can cost about $1,500 a day, which includes the staffing agency fee. Additionally, the facility pays for travel and lodging expenses. Sometimes these costs can be passed on during contract negotiations with insurers.
  • Providers have to balance the cost against the lost revenue and patient dissatisfaction from a surgeon shortage. Additionally, physician recruitment efforts can take four to six months.

Sources: Fuhrmans V. Surgeon Shortage Pushes Hospitals to Hire Temps. Wall St Journal, Jan. 13, 2009. Accessed at online.wsj.com/article/SB123179145452274561.html.


Consider modifying bylaws to reduce locum tenens risk

Extending temporary privileges to a traveling surgeon can be risky business, says Leilani Kicklighter, RN, ARM, MBA, CPHRM, LHRM, a patient safety and risk management consultant with The Kicklighter Group in Tamarac, FL, and a past president of the American Society for Healthcare Risk Management (ASHRM) in Chicago.

Even if you use due diligence in selecting the agency providing the surgeon, the very nature of locum tenens surgery might mean that you have to cut corners in some of your typical process for privileging surgeons. The shortcut may be unavoidable, but it could come back to haunt you. For instance, if your facility typically requires that surgeons be credentialed individually and proctored before you grant privileges, a plaintiff's attorney could ask why you saw fit to allow this locum tenens surgeon to operate without proctoring.

"You can make the argument at that point that you had no time for proctoring and had to save the patient's life, but if something goes wrong with that patient, the issue will come up when you're sued," she says.

To avoid inconsistency, which can be used against you later in court, Kicklighter says it might be necessary to modify your medical bylaws to create a special category for the locum tenens doctor. She suggests raising the idea with physician leaders to determine how the bylaws can better accommodate what is becoming a common practice rather than the exception.

"The special category approved by the physician leadership will show that you have considered the need for locum tenens and established under what conditions it is acceptable," she says. "You have that consistency, rather than just making an exception for locum tenens."

An orientation checklist could be useful and could be signed by your locum tenens surgeon, sources suggest. Arun Ravi, a health care consultant with Frost & Sullivan, a consulting firm in New York City, offers these other suggestions for mitigating the risk of such surgeons:

  • Put most of your effort into choosing the right locum tenens agency. Ensure that the agency's standards and credentialing are good enough to satisfy your needs, so that you don't have to start from scratch.
  • Draw up an agreement that each locum tenens surgeon must sign before operating. This agreement, which is in addition to the standard contracts and documents that bring the doctor to your facility, can address any particular concerns you have about policies and procedures unique to your hospital. This agreement can alert the surgeon to any protocols you expect him or her to follow.
  • Require the surgeon to arrive at least 12 hours before the first scheduled procedure, or preferably 24 hours. This time period will be enough for an orientation and rest.
  • Provide an orientation tour of the facility, with particular attention to the surgical area and the types of equipment that will be used for the procedure.

Sources

For more information on risks posed by locum tenens surgeons, contact:

  • Leilani Kicklighter, RN, ARM, MBA, CPHRM, LHRM, Patient Safety and Risk Management Consultant, The Kicklighter Group, Tamarac, FL. Telephone: (954) 294-8821. E-mail: imlani@comcast.net.
  • Arun Ravi, Health Care Consultant, Frost & Sullivan, New York City. Telephone: (877) 463-7678.