The impending disappearance of the general surgeon.

IN THE UNITED STATES, APPROXIMATELY 1000 GENERAL SURgeons complete their residency training each year. These surgeons have completed 4 years of medical school and 5 clinical years of residency, and during residency many also have spent 1 or 2 years in a research laboratory. Thus, these physicians enter the workforce between the ages of 33 and 35 and usually have $150 000 to $250 000 in educational debt. The training of surgeons has been stable since the early 1970s, and the number of general surgery residency training programs will not likely increase. Even if new medical schools were established the number of surgeons trained would not likely increase much, because many medical students have lost interest in pursuing a career in surgery. In small urban or rural hospitals, which care for approximately 54 million patients, general surgeons care for emergencies and trauma and perform a variety of operations. They are essential to the provision of adequate health care and often are the most well-rounded surgical clinicians in the area. Therefore, training only 1000 general surgeons per year will not meet demands. Specialization also affects the general surgical workforce. Presently, approximately 70% of graduating surgical residents pursue specialized surgery training, and this percentage may be increasing. Thus, only about 300 to 400 of the 1000 general surgeons completing residency each year will choose general surgery practice. There are several reasons for surgeons to specialize. To be thoroughly competent in the face of a knowledge base that is increasing in all areas, many surgeons choose to limit the number and types of surgical procedures they perform. Additionally, it may be easier to develop expertise in some subspecialties, and more refined expertise often leads to economic rewards. In some large urban environments, subspecialists bill at higher fees than general surgeons performing the same procedures. A career as a specialist caters to the lifestyle preference of medical school graduates, who have little desire to work 80 to 100 hours per week with little time for families. They are less focused on being entrepreneurial and accept being employed by large group practices if it means they need not worry about the economics of practice and if they can have less demanding on-call schedules, which enable them to spend more time with their families. Furthermore, current surgical residents are being trained in the environment of an 80-hour work week. These individuals have come to understand that even if they have a sick patient who has not been totally stabilized, they must hand over the care of the patient to someone else. Residents are forced to be content with this system, in which they are instructed about number of work hours. While limited work hours and a lifestyle conducive to family priorities are desirable, the nature of surgical problems remains unchanged or may be more intense because of an aging patient population. For example, the situation of a patient with a perforated colon who will die in 12 to 24 hours if peritonitis is not controlled does not change so a surgeon can go home at a decent hour.