1. Training General Surgeons for Tomorrow Thomas V Whalen, MD

2. Predictions are Difficult… “The future ain’t what it used to be.” “The future ain’t what it used to be.”

3. New and Old Technologies Ulcer Surgery Ulcer Surgery Bariatrics Bariatrics Breast conservation Breast conservation Hernia Watch and Wait Hernia Watch and Wait NOTES NOTES Interventional Radiology Interventional Radiology Telerobotics Telerobotics

4. AAMC Workforce Policy: 2006 Twelve point policy Twelve point policy Called for a 30% Increase in US Allopathic Graduates Called for a 30% Increase in US Allopathic Graduates BBA of 1997 and the GME cap BBA of 1997 and the GME cap Medicare GME funding and service versus education Medicare GME funding and service versus education

5. Lifestyle Issues Only 46.5% of US Medical graduates plan to engage in full time practice Only 46.5% of US Medical graduates plan to engage in full time practice Impact of the female Physician Workforce Impact of the female Physician Workforce

6. Regionalized Acute Care Surgery On call crisis in urban areas On call crisis in urban areas Need for a multi-talented specialist who is available at all times Need for a multi-talented specialist who is available at all times Possible synergies with Rural Surgery Possible synergies with Rural Surgery

7. Current Workforce

8. AAMC Projections to 2025

9. AAMC Projection: Most Plausible

10. AAMC Projection: Worst Case

11. By Specialty

12. Nurse Practitioners All new NPs as of 2015 must be DNPs All new NPs as of 2015 must be DNPs CACC: Council for the Advancement of Comprehensive Care NBME: “the ” NBME: “the exam will utilize test items previously used in the USMLE Step 3 examination”

13. Solutions Even a robust expansion of GME capacity (from 25,000 new entrants per year to 32,000) would only reduce the projected shortage in 2025 by 54,000 physicians (43 %). Even a robust expansion of GME capacity (from 25,000 new entrants per year to 32,000) would only reduce the projected shortage in 2025 by 54,000 physicians (43 %).

14. Definition of General Surgery In Manhattan In Manhattan In Willcox, Arizona In Willcox, Arizona In Iraq and Afghanistan In Iraq and Afghanistan And as cited by Claude Organ, And as cited by Claude Organ, Friday night at midnight and Monday at Noon Friday night at midnight and Monday at Noon

15. Production Programs: 249 Programs: 249 Graduates: 1050 Graduates: 1050 Specialization: 79% Specialization: 79% Some continue as General Surgeons Some continue as General Surgeons Number of Surgeons Certified: Number of Surgeons Certified: 1980: 945 1980: 945 2008: 972 2008: 972

16. Demand 7.53 per 100,000 population 7.53 per 100,000 population Maryland, Statewide: 5.2 Maryland, Statewide: 5.2 Far fewer in remote areas where they are most needed Far fewer in remote areas where they are most needed

17. Willcox, AZ

22. Retirement Was decreasing… Was decreasing… The Economy The Economy

23. Surgical Workforce GMENAC Study (1971): All of Surgery except Otolaryngology deemed in surplus GMENAC Study (1971): All of Surgery except Otolaryngology deemed in surplus SOSSUS (1975): Concluded that the existing number of surgeons was sufficient to provide needed services SOSSUS (1975): Concluded that the existing number of surgeons was sufficient to provide needed services Did highlight maldistribution Did highlight maldistribution AMA CLRPD (1989): General Surgical Shortage by 2000 predicted AMA CLRPD (1989): General Surgical Shortage by 2000 predicted

24. Surgical Workforce Number of General Surgery Training Programs Flat (249) Number of General Surgery Training Programs Flat (249) Production of those Programs Flat (1000) Production of those Programs Flat (1000)

25. Dartmouth Atlas: 1996 to 2006 Number of General Surgeons declined 16.3% Number of General Surgeons declined 16.3%

26. Bureau of Health Professions From 2005 to 2020: From 2005 to 2020: Surgeons overall will increase 3% Surgeons overall will increase 3% General Surgery will decrease 7% General Surgery will decrease 7%

27. AAMC Center for Workforce General Surgeons < 55 YO: 42% General Surgeons < 55 YO: 42% FP: 37% and Internal Med: 32% FP: 37% and Internal Med: 32%

28. Rural General Surgery Over 50 Million of our US Citizenry Over 50 Million of our US Citizenry Greater on call demands Greater on call demands Lower reimbursement Lower reimbursement

29. US Medical Graduates Five specialties have more applicants than positions: Five specialties have more applicants than positions: Plastic Surgery Plastic Surgery General Surgery General Surgery Dermatology Dermatology Orthopedic Surgery Orthopedic Surgery Radiation Oncology Radiation Oncology

30. Resident Attrition Approaching 30% Approaching 30% The Best and the Brightest: “Academically highly qualified graduates and graduates who chose training in general surgery or in a 5- year surgical specialty were at increased risk of attrition during GME.” The Best and the Brightest: “Academically highly qualified graduates and graduates who chose training in general surgery or in a 5- year surgical specialty were at increased risk of attrition during GME.”

31. IMGs Constitute 25% of the nation’s Physicians Constitute 25% of the nation’s Physicians Many from other countries are the “best and the brightest” Many from other countries are the “best and the brightest” Twenty percent of Categorical General Surgery Residents are IMGs Twenty percent of Categorical General Surgery Residents are IMGs A transgression of Distributive Justice in the World A transgression of Distributive Justice in the World

32. Ohio State Study Assumes that 85% of certified surgeons will practice general surgery and 705 will annually retire Assumes that 85% of certified surgeons will practice general surgery and 705 will annually retire Restricts analysis to allopathic production Restricts analysis to allopathic production Static Assumptions as to disease demand Static Assumptions as to disease demand

33. Ohio State Study Projects shortage of 1300 in 2010 Projects shortage of 1300 in 2010 Grows to 6000 in 2050 Grows to 6000 in 2050 Proportionate to population, General Surgeons decreased 25% from 1981 to 2005 Proportionate to population, General Surgeons decreased 25% from 1981 to 2005

34. Ohio State Study – Comments Hiram Polk: “The pundits on the East and West Coasts don’t have a clue…” Hiram Polk: “The pundits on the East and West Coasts don’t have a clue…” Polk: “…we ought to open (a) thousand slots” at good programs Polk: “…we ought to open (a) thousand slots” at good programs Resident comment on remuneration and lifestyle Resident comment on remuneration and lifestyle

35. The RRC The ACGME The ACGME Nominating Organizations Nominating Organizations ABS ABS ACS ACS AMA-CME AMA-CME

36. What the RRC Does Program Review and Accreditation Program Review and Accreditation Citations Citations Cycle Length Cycle Length Requirements for Training Requirements for Training Additional Rural Surgery elements?? Additional Rural Surgery elements?? Coordination with the ABS Coordination with the ABS General, Pediatric, Vascular, Surgical Critical Care (Hand) General, Pediatric, Vascular, Surgical Critical Care (Hand)

37. What the RRC Does NOT Do Set Production Quotas Set Production Quotas Certify Individuals Certify Individuals

38. Current RRC Issues Milestones Milestones Duty Hours Duty Hours Accelerated Visits Accelerated Visits Preliminary Residents Preliminary Residents Essential Content Area Experience Essential Content Area Experience International Rotations International Rotations Seventh Competency Seventh Competency Fellowship Minimum Pass Rates Fellowship Minimum Pass Rates

39. International Rotations Non-Chief rotation up to six months Non-Chief rotation up to six months Faculty members from the parent program or equivalently-trained host faculty Faculty members from the parent program or equivalently-trained host faculty Clearly state educational rationale Clearly state educational rationale Appropriate educational environment Appropriate educational environment Appropriate supervision Appropriate supervision Educational resources Educational resources

40. The ACGME and the RRC New Leadership New Leadership New model of the CRCC and the ACGME Board New model of the CRCC and the ACGME Board

41. What Else Can Be Done? GME Funding GME Funding General Surgery as Surgical Primary Care General Surgery as Surgical Primary Care Title VII Health Professions Program Title VII Health Professions Program Alleviate Medical School Debt Burden Alleviate Medical School Debt Burden Extend Loan Deferment Extend Loan Deferment

42. Conclusion There is little question that there is a shortage of general surgeons There is little question that there is a shortage of general surgeons The shortage will worsen The shortage will worsen The dynamic environment makes planning difficult The dynamic environment makes planning difficult The pipeline is long The pipeline is long General Surgeons have job security General Surgeons have job security The RRC stands ready to approve appropriate additional positions and programs The RRC stands ready to approve appropriate additional positions and programs

43. Questions??