Medical Staff

Going, going, gone...

Medical Staff Affairs Monthly, December 12, 2007

Add general surgeons to the endangered species list. Josef Fischer MD, in a November 14 article in the Journal of the American Medical Association, outlines the case for this proposition. Cited are the AMA's own figures showing a precipitous decline in the population of general surgeons over the period between 1975 and 2005. Simultaneously, there has been an increasing tendency toward subspecialization. Of approximately 1,000 residents completing general surgery programs, 70% pursue specialized surgical training. Doing the math, that leaves 300 general surgeons per year entering the work force while existing general surgeons retire in equal or greater numbers and emergency department visits for surgical conditions and trauma continue to rise. Fischer asks whether a general surgeon will be available when you need one, and his answer is no if the current situation remains unchanged.

If this all sounds vaguely familiar, it's because it is. Last year's endangered species list was amended to include primary care medicine. In its seminal 2006 report, The Impending Collapse of Primary Care Medicine and Its Implications for the State of the Nation's Health Care, the American College of Physicians stated that "primary care, the backbone of the nation's healthcare system, is at grave risk of collapse due to a dysfunctional financing and delivery system." Although the number of U.S. graduates entering internal medicine residencies is reportedly stable, career plans for current and future graduates of internal medicine residency programs show that approximately 80% plan further training in a subspecialty or a career as a hospitalist. Comparable trends are cited for pediatrics: The number of U.S. graduates entering pediatric residencies remains stable, but a significant increase has been seen in pediatric residents entering pediatric subspecialty training.

Family Medicine fares no better. Data from the American Academy of Family Physicians lists 2,727 residency positions available in 2006, of which 1,132 were filled by U.S. graduates. This is a fill rate of 41.5%, and there is no change in sight.

All of this affects the other endangered species whose demise has been predicted for some time, namely the organized medical staff. The loss of primary care specialties has led to employed/contracted models for adult and pediatric hospitalists, laborists (OB hospitalists), and now surgical hospitalists to cover basic medical, surgical, and trauma call. In increasing numbers, remaining community-based primary care physicians have migrated more and more to an exclusively ambulatory setting, accelerating the hospitalist trend. Simultaneously, specialists (both medical and surgical) are pursuing different relationships with hospitals as employees, medical directors, contractors for specified services, etc., or just leaving hospitals altogether. These changes are not linear but exponential and are causing physicians and hospitals to reexamine the ways in which hospitals and medical staffs relate to ensure each other's success. There is not a one-size-fits-all answer, and new models and experiments are seen across the country. Some of these new models for the organized medical staff include:

  • A self-governed medical staff with fewer but more committed physicians
  • Physician employment
  • Physician executives and managers
  • Service line management
  • Contracts
  • Physician-hospital compacts
  • Intended practice plan
  • Invitation only
  • Others not yet defined or widely recognized

The recruitment and retention of physicians becomes a major board-driven strategy that will require new approaches going forward. It is essential that healthcare leaders appreciate the logarithmic change occurring and the conflict that it inevitably produces. The management of change and conflict has become a core competency of effective healthcare leaders.

To begin to understand the management of change and conflict, the initial question becomes, Why is this all occurring? The answers are multifactorial and often complex; however, most experts keep coming back to two fundamental issues: money and lifestyle. Because of the importance of these two key components, they will be probed in greater depth in next month's column.

The Greeley Company has long provided practical strategies to many organizations facing these challenges. Let us know if we can be of help. Until next time, be the best that you can be.

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