General surgeons in 2010 will need to focus on treating diseases comprehensively rather than just performing operations. Technological advances have allowed other specialties to perform procedures traditionally done by surgeons. Surgeons risk losing practice volumes unless they view themselves as treating overall patient health. Training and practice models will need to adapt to changing healthcare systems focused on quality, safety, and meeting patient and societal needs.

1. What Will a General Surgeon Be in 2010? Frank R. Lewis MD Executive Director, American Board of Surgery Association of Program Directors in Surgery San Francisco October 18, 2005

2. What will a general surgeon be in 2010?: Issues How we define ourselves: Doing operations v. treating diseases Willingness to broaden clinical focus Bad Example: Endoscopy and development of gastroenterology Good Example: Vascular surgery currently Urban v. rural issues and type of practice What is a “rural” surgeon? What is realistic need? Viability of the specialty Changes in multiple areas in 15 yr.

3. What will a general surgeon be in 2010?: Issues Role of generational considerations: Lifestyle/hours Pressures from medical students re: length of training, lifestyle, gender issues, etc. External influences: Quality monitoring/patient safety Volume v. outcome for complex/high end procedures Variation in practice efficiency Transparency in reporting outcomes data Consumerism: Need for service quality, better communication

4. Doing operations v. treating diseases The difference between a technician and a specialist Surgeons like to operate; patients like to have their diseases treated efficiently and comprehensively; any question about who will win? In 1960’s surgeons did virtually all bronchoscopy, rigid UGI endoscopy. Miniature cameras, fiberoptics, etc. made flexible endoscopy possible in 1970’s – no longer coupled to anesthesia / operation. Surgeons chose not to get involved – not as much “fun”, less remuneration. Result is evolution of gastroenterology as a procedural specialty – growth has been tenfold in 30 yr.

5. Doing operations v. treating diseases Revolution in endovascular surgery has caused immense change in vascular disease Rx in 5 yr. Vascular surgeons have belatedly recognized that if they continue to define themselves as “doctors who operate on blood vessels” rather than “doctors who treat vascular disease” they will become extinct Virtually no open aorto-iliac operations performed today; abdominal aneurysms are now > 50% endovascular; carotid surgery about to become endovascular.

6. Doing operations v. treating diseases Biliary tract surgery: 95% of cholecystectomies done laparoscopically today; surgeons readily adapted because OR still necessary. However, virtually no CBD experience because ERCP has become the standard for CD disease – surgeons gave this up voluntarily because they were focussed on procedure, not disease. This type of technological evolution will continue. If surgeons do not adopt a focus on treatment of disease, they will continue to lose volume to other specialists.

7. Rural v. urban surgical needs: Specialization v. generalization What is a “rural” surgeon? GS plus gynecology, urology, orthopedics Trauma – GS plus neurosurgery, orthopedics Three realities: Reality of malpractice standards: There is no “rural” Reality of quality of practice: GS training would have to be radically altered (and lengthened) to accomplish the above Reality of population: Few people are more than 50 miles or 1 hour from a secondary or tertiary hospital (example of Bozeman, MT) with appropriate specialties available

8. Rural v. urban surgical needs: Specialization v. generalization Conclusion: If “rural” means a broadly competent general surgeon, then not different from normal training. However, if model means expansion into other specialties, it is unrealistic and impractical in today’s world. Much more important to focus on what patients need in the average community hospital, and on the “disease” v. “operation” perspective.

9. Myth and Reality in General Surgery H. Brownell Wheeler, MD ACS Bulletin 78:21-27; 1993 2 3.0 81 Carotid CR - 1989 GS-Avg/yr Total (000) Operation 44 20.2 536 Cholecystectomy 42 14.7 391 Groin hernia 27 11.4 303 Appendectomy 11 3.0 79 Incisional hernia 10 3.2 86 CD Explor 5 3.4 91 Hemorrhoidectomy 24 3.9 103 Laparotomy 15 4.6 122 Mod rad mastect 35 7.6 203 Colon resection

10. Myth and Reality in General Surgery (2) H. Brownell Wheeler, MD ACS Bulletin 78:21-27; 1993 7 1.3 35 Blood vessel rep CR - 1989 GS-avg/yr Total (000) Operation 11 2.8 75 Fem Pop Bypass 6 2.6 68 Colostomy 11 2.5 65 Thyroid 3 1.3 34 Abd aneurysm 3 1.3 35 Splenectomy 4 1.3 35 Partial gastrectomy 4 1.9 50 Intestinal anast -- 2.0 52 Umbilical hernia 8 2.3 62 SB Resection

11. Myth and Reality in General Surgery (3) H. Brownell Wheeler, MD ACS Bulletin 78:21-27; 1993 0 0.2 4 Cancer of tongue CR - 1989 GS-Avg/yr Total (000) Operation 2 0.6 15 Abd-perineal res 0 0.5 14 Radical neck dis 0 0.5 13 Rectal prolapse 0 0.2 4 Pancreat cyst drng 0 0.2 5 Adrenalectomy 0 0.2 6 Cancer of lip 2 0.3 8 Total gastrectomy 2 0.3 9 Parathyroidectomy -- 0.4 10 Anterior resection

12. Myth and Reality in General Surgery (4) H. Brownell Wheeler, MD ACS Bulletin 78:21-27; 1993 0 <0.08 <2 Pelvic exenteration CR - 1989 GS-Avg/yr Total (000) Operation 0 0.1 3 Partial hepatect 0 0.1 3 Portal syst shunt 0 0.1 3 Ilioanal anast 0 <0.08 <2 Liver abscess drn 0 <0.08 <2 Panc-jejun-ostomy 0 <0.08 <2 Panc-duod-ostomy 0 0.08 2 Pancreatectomy 0 0.08 2 Esophagectomy

16. Viability of the Specialty Change in 15 years: Acid reducing drugs/Rx of Helicobacter  Elimination of peptic ulcer surgery, except for emergency procedures ERCP  Treatment of CD stones Trauma – Penetrating trauma decreased 60-70% Automotive trauma decreased 20% Better imaging (CT) allowed non-operative treatment of most blunt trauma  Trauma decreased in volume and largely non-operative

17. Viability of the Specialty Present Reality: 10 years ago  Laparoscopic Nissens were unknown Bariatric surgery was uncommon Advanced laparoscopic procedures were unknown  There are gainers as well as losers Consider three possibilities: Accurate ablation of breast lesions with RF energy or other non-operative technique becomes feasible Most colon surgery is done laparoscopically A safe/effective drug is developed which curbs appetite

18. Viability of the Specialty Elective care – “specialist” High quality care; comprehensive disease treatment Knowledge of outcomes, choice Regionalized care for high end/complex procedures Emergency/urgent care – “acute care surgeon” Broadly competent in general surgery/critical care/trauma Access/availability for public “ surgical hospitalist” Probably the most urgent need today-services most hospitals want 25-40% of hospital budgets are for critical care

19. Viability of the Specialty Central question: How can surgical training encompass the “specialist” v. “generalist” needs? Can both be accomodated? What would certificates say? “ We need to educate in what we practice and certify by what we do.” Murray Brennan, MD and Haile Debas, MD (2004)

20. Generational Considerations Undersupply of medical students  interspecialty competition for most talented students (25% of resident force are IMG’s) Attractiveness of medicine v. other careers is less than 15 yr ago Number of women in college approaching 60% - similar ratio will evolve in medical schools Specialties which are attractive only to men will be disadvantaged; surgery needs to attract more women Need for specialists (medical and surgical) will increase by 200,000 physicians in next 15 yr. (Cooper)

21. Generational Considerations Eighty hour week is a reality and may decrease Medical students want control of time (“lifestyle”), ability to move in and out of workforce for pregancy/family “ Team” medicine v. individual practitioner Shift work v. 24/7 availability Continuity of care suffers; need better monitoring methods Medical students want shorter training times and earlier focus on ultimate area of practice Residency training needs a defined curriculum, more organized training, and competency based evaluation

22. External Influences Quality movement is large and is increasing rapidly in influence P4P has become a reality overnight – all large insurance companies and Medicare are now implementing plans Organized medical involvement in setting these up has been minimal Multiple organizations competing for influence in the quality debate – Leapfrog, NQF, AHRQ, HEDIS, NCQA – none of which agree with the other “Where are the doctors?”

23. US Healthcare System Earns C+ for Patient Safety Robert Wachter, M.D. Health Affairs November 30, 2004 Little progress since IOM reports in last five years Error reporting systems have had little impact No progress in making clinicians or health systems more accountable for actions Recent Kaiser Foundation report: One half of Americans worry about safety of care One quarter perceive quality has worsened since 1999

24. What is needed in surgery? Outcomes reporting/transparency in system Surgeons have long tradition of critical evaluation of results and focus on improvement (M&M). Need to support widespread adoption of such systems with public reporting. Procedures with high volume/outcome correlation (esophagectomy, hepatectomy, pancreatectomy) should be regionalized. Procedural variations should be examined/resolved. Evaluation of communication / interpersonal skills should be taught / evaluated. Need for service standards (access, information, continuity of care, standardized electronic records)  All of the above are as/more important than many of the research questions of the past and should attract equal interest.

25. Conclusions Surgery has changed from 20 yr ago, and will continue to do so. Need for operative intervention in gastric surgery, common duct surgery, and trauma has decreased dramatically; laparoscopic and bariatic surgery have increased Major lesson from last 30 years: failure to define ourselves as specialists in a disease rather than a procedure results in loss of coverage. Urgent need today to address issues of quality, variability, service, communication (consumerism) rather than have this done from outside the specialty.

26. Conclusions Residency training will change to better reflect current needs and medical student preferences. “Competency based” training will be increasingly adopted Use of simulation, models, non-clinical training will increase Women will be a steadily larger part of the surgical workforce Limited work hours and “lifestyle” considerations will be ongoing important considerations in training