Then What?

The WSJ had an interesting take on the general surgery crisis hitting American cities. Now the primary care of the surgery world, general surgeons, highly qualified in their craft, are exiting the pool of relative financial bottom feeders called general surgery. For further reading, Dr Wes gave an excellent read here, last year.

As they state:

The number of general surgeons per capita has fallen by about 25% in the past quarter century, researchers are reporting this afternoon.

One key driver of this trend is a move toward specialization by young docs. In 1992, 55% of surgeons did a subspecialty fellowship after finishing surgical residency; now that figure is over 70%, the authors report.

This sounds a lot like what’s happening on the medical side of the profession, as younger docs increasingly head for medical subspecialties that often pay more and give doctors more control over their work life than primary care jobs.

As a hospitalist, my relationship with general surgeons is one of critical importance. Not a week goes by where I admit an abdominal pain that turns out to be cholecystitis. Or a diverticulitis that perforates. Or an abscess that needs incised and drained. As a hospitalist I get what ever comes my way. Whether it's Medicare, Medicaid, Blue Cross or self pay. I have no control over the payment source or the degree of illness. I can't schedule a hospitalization for my patient population. What a general surgeon gets from me is a roll of the dice. And that can lead to some hard feelings. Grumblings about always getting the uninsured. Grumblings about always getting the difficult surgical patients. Grumblings about getting the terribly sick patients that will need to be followed for weeks and weeks. Patients that may skew their mortality data on their report card.

That's the life of a general surgeon on call for a hospital. And their payments are in the shitter, when compared with their subspecialist surgeons. The lifestyle financially and personally of an outpatient hand surgeon surely beats that of a general orthopod on call of for hip fractures in demented oxygen dependent nursing home patients. As Aggravated DocSurg points out previously to the WSJ, and rehashed today:

There are now people coming out of training who only want to do advanced laparoscopic surgery. But you can’t do that and take care of sick patients. If you have complications for one of your nice elegant laparoscopic procedures, you need to know how to fix them. I think the hidden value of general surgery is that we’ll do all the elegant procedures–laparoscopic cholecystectomy, gastric bypass, and colon resections–but we’ll also do the dirty work when grandma shows up in the ER at 2am desperately ill with pain in her abdomen. We shortchange patients when we focus only on the easy elective things. But taking care of the 80-year-old lady on Medicare reimburses a lot less. In fact, the harder the patient, the less the reimbursement we usually get.


A very astute observation. Primary care has been assaulted for the very same reasons. Internists choosing to continue their education in the form of lucrative fellowships in search of markedly higher incomes, or hospitalists who have left the failed system and are thriving within new relationships. On the other end, bottom feeders (in terms of complexity of illness) in the form of physician extenders at Walmart, are successfully taking away the easy volume that pays proportionally higher in terms of time spent for revenue achieved and subsidized the payment rates for time consuming chronic illness consumers of this great land of ours.. The 5 minute cold visit that pays $50. What's left is the 80 year old with 15 medical problems and a list of 10 complaints at every visit. These 45 minute visits that pay $90. That's the direction of primary care. And the direction has been straight into the grave yard of comprehensive, coordinated care.

Now me on the other hand, a great deal of my job involves coordination of comprehensive care, hospitalist style. I have been afforded an opportunity to practice coordinated comprehensive care, by nature of the business model of hospitalist medicine. But what's left of out patient primary care and general surgery?

I see it only getting worse, as third parties have created extraordinary profit gradients in the care of illness. The third parties, lead by the Medicare National Bank, and their failed SGR/RVU policies are to blame in the natural gravitation by highly intelligent, hard working type A personalities into fields that promise to take them to peak of Mount Security. It's happening within the surgical field with migration to subspecialists. It has happened in primary care with migration towards medical specialties with high procedure=money:cognition ratio. It's already happened with the explosion of specialty hospitals that create huge profit gradients in the care of procedural related/surgical related medical illness.


Primary care is stuck with the paperwork from hell and documentation rules that straddle them with inefficiencies in their time management. Primary care is a game of volume. The seams have ripped. Given time, all fields of medicine and surgery will collapse under the weight of regulatory and financial destruction. When I get a terribly sick patient from Dinkle Town USA in septic shock with a perforated belly and no surgeon to come to the rescue, I might as well be in Dinkle Town.

Then what?

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