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Now that I’ve reached my mid-50s, I sometimes think about retirement, and to be honest it worries me.
I’m not talking about the typical things you worry about pre-retirement, such as the loss of income or lifestyle changes. I worry about what will happen to my patients.
Why? For the simple reason that it will be hard to replace me. This isn’t my ego talking: there simply aren’t nearly enough new surgeons coming along to replace me – or my other contemporaries, for that matter.
I work in Glasgow, Montana, a town of 3,500 in northeastern Montana that is about as rural as it gets. I serve more than 20,000 patients in an area that runs 100 or more miles in every direction except north past the Canadian border. I’ve been on call essentially every hour of every day since I came to Montana over 20 years ago.
Don’t get me wrong, I’m not complaining, I actually love what I do. I am challenged each day, do interesting work, and I’m not worried about losing my job or becoming obsolete. I have the rewards of working with dedicated people and feeling that my work makes a difference in people’s lives. But the problem is that this life isn’t for everyone. The hours can be long, the on call duty constant, and the environment somewhat isolated. And even students who want to be rural surgeons may feel compelled to choose other specialties or areas to live in order to be able to pay off their staggering medical school debt loads which are easily over $100,000.
But, this is a bigger issue than who will replace me someday in Glasgow. A couple of weeks ago, I was in Washington, D.C. for the first time in 15 years, to be part of an expert panel looking at the shortage of surgeons and its impact on patient access to quality surgical care. The panel was a part of a new campaign, Operation Patient Access , to call attention to this issue. One of my fellow panelists, a surgeon workforce researcher, said that there is an inadequate supply of surgeons in 70 percent of rural areas and 20 percent of urban areas.
Rural areas like mine are particularly hard hit – studies indicate that in the next few years two out of every five rural hospitals won’t have a surgeon on staff and, as a result, may have to cut back services or close down altogether. There are a variety of reasons for the shortage – not enough doctors are in training to become surgeons, there are concerns about lifestyle issues, more uninsured patients, declining reimbursements, liability issues – you name it.
And, the shortage will get worse before it gets better: A third of surgeons are, like me, within a decade of retirement, and there aren’t nearly enough medical students coming up through the pipeline to replace us. Given the long time it takes to train a surgeon, the pipeline won’t be fixed any time soon.
We’re already feeling the effects of the shortage in my region. Twice a month, I pack up my SUV with supplies, and a nurse and I drive to another town 70 miles west. During the second week of the month, we go 50 miles to the East – a stop I had to add several years ago because the hospital there wasn’t able to keep a surgeon on staff.
Most days of the month, my patients take a long, bumpy ride to Glasgow from a hundred or more miles away – and often face long waits before they can see me. When I’m out of town and their need is urgent, my patients are forced to take an air ambulance to another hospital at least 150 miles away, or further.
Are there solutions to these problems? I certainly hope so. But it’s going to take a lot of work and changes in many aspects of training, practice, and support. Hopefully more new students will be attracted to health care as a career, and come to see the rewards of a rural practice as well as the challenges. Meanwhile, our elected officials in Washington can help ease the shortage by passing good health care reform policies, finding ways to attract, train and retain more surgeons (especially in areas where there are shortages), fixing the Medicare system, and putting limits on malpractice suits.
They need to act soon and show that I’m not the only one worrying about what will happen to my patients.
Anne Williams, MD, FACS, is a general surgeon with a private practice in Glasgow, Mont. She is board certified by the American Board of Surgery, a fellow of the American College of Surgeons (ACS) and a member of the Association of Women Surgeons and the Parkland Surgical Society. Dr. Williams also serves as member-at-large of the board of governors of the ACS, and is a member of the Montana Committee on Trauma, the Eastern Montana Regional Trauma Advisory Committee, and the Montana EMS Medical Directors Subcommittee.Dr. Williams received her medical degree from the University of California, San Diego and completed her residency at the University of Texas Southwestern Medical Center.
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Barry– perhaps in exchange for the ‘right’ to practice medicine, every doctor put themselves at the mercy of the government for food, shelter, and a place to work?
Oh, that is what you are suggesting.
Dr Williams- I share your concern.
I also worry that tele-medicine advocates/vendors believe that their technolgies can,in large part, solve this issue.
It cannot.
Tele-medicine has value but it should not be used to thwart the movement to incent physicians to serve in underserved areas of our nation.
Thank you for your service in Gasgow,Montana
Be Well,
Dr. Rick Lippin
Southampton,Pa
Interesting post but most of the policy ideas I have seen on solving rural healthcare provider problems are generally temporary band-aid approaches largely focused on a few years of service for some type of loan forgiveness or other compensation.
I see a couple of problems/issues with this:
– I guess it is not a bad idea but certainly wonder if the federal gov’t is getting much bang for the buck here in the mid/long run.
– If were are supposedly moving towards a medical home model and some of the research that has focused on provider-patient relations as being a key to several quality-related areas, developing a temporary solution in a place for 2 or 3 years max seems it would be mixed at best and more problematic in the longer haul.
– This really is just part of a larger issue in the U.S. with rural policies and depopulation. One of the things I am amazed to see is maps of population density of the U.S. over the last 100-120 years. If you look, there are huge regions of the upper Midwest (e.g., ND, SD) and other central Plain states that have had huge decrease in their population density since the 1920s/1930s.
Basically you have broad swathes of the U.S. that essentially have become almost completely depopulated after dramatic rises in the late 19th century/early 20th century. Several reasons why this has occurred but I don’t see how you address health care provider issues until larger issues (such as agricultural policy) are addressed too.
I wonder how feasible it would be if general surgeons who live in large metropolitan areas and worked most of the time for an area hospital rotated one week a month or so to a distant regional hospital that also served a large surrounding rural area. Patients in rural areas could, for the most part, be transported by air or land ambulance to the regional hospital. If most surgeons or doctors in general don’t find the rural lifestyle and culture attractive, there are probably alternative ways to address the issue. I doubt that even free medical education in exchange for agreeing to live and work in a rural area would be an attractive proposition for a sufficient number of doctors. Besides, lots of people in other professions routinely spend 25%-50% or more of their time on the road.
Anne,
The distribution of physicians remain a challenge. I am not sure if there is shortage at cumulative level though. Here are some of the things that have crossed my mind
1) Make rural service a mandatory for all those who receive government help. And as I understand every physician costs the government at least $100K. I bet it is more than that.
2) Every one writes profusely in their application how they are dedicatd to community service. We need to ask people to show some of these. The generation before meant what they said…generation now has mixed commitment. A friend who is a physician from recent times told me that community service is just a front…now people are coming for money. I am sure there are many still motivated by passion and commitment. But this is not about them…this is about many who are not.
3)In terms of specialists, surgeon etc., they are needed but how much is the debate. What if focus so much on the wellness, the need for specialist is reduced. It is like we are not changing oil and engine goes bad and we need engine expert while just a oil change could have done to work.
I am sure there are much more. Many of the thoughts are also expressed at the blog in my signature.
rgds
ravi
blogs.biproinc.com/healthcare
http://www.biproinc.com
This posting is spot on. Surgery is disappearing from the under 100 bed hospitals, and the decline in young people electing General Surgery as a specialty is directly related. Young people do not appear to want to practice 24 hrs a day, and basically being on call all the time is what happens in smaller communities, unless you are married to another general surgeon and you both move a small town. There is a strong argument for loan forgiveness programs here and for Medicare payment differentials for practicing in shortage areas (basically the entirety of small town America).