Future Of Surgery

[hypersomniac]

I have been hearing about how getting OR time is getting increasingly harder and harder.

As a med student who is thinking about surgery, I am definitely considering going into internal/or other nonsurgical specialties, just because of such uncertainty.

Do you guys have any insights about how things will change? Any predictions about reform in OR availability?

[Fresh fry]

Preface: I can speak on my province and my specialty but how generaliazable that is, I have no idea. I also like making up words apparently.

 

 

This is the major detractor for many people looking at surgical specialties; your livelihood and your ability to set your own schedule and pace are not completely in your control. OR time is an almost an absolute necessity to be a surgeon. I say almost because I am aware of a few people, in a few odd situations, who are trained surgeons who do not actually operate. These situations are definitely not the rule and probably only encompass at most 5% of trained surgeons. They also tend to be closer to the end on the retirement spectrum and are from subspecialties where they can rely on niche aspects of their profession. Examples include:

 

Gen surgeon who strictly does ICU

Gen surgeon who does trauma coordinator

O&Gs who has given up gyne and only does obs

Uro and ENT who only do outpatient (scoping) and refer surgical patients to their partners

Various who work as assists (almost 100% people who are retiring/semi-retired)

 

Most people who go on to become surgeons absolutely intend to operate and to be able to maintain your skills and be able to afford to be part of a practice you generally need 4-5 OR days a month (obviously variable). So a graduating surgeon, who probably owes a couple hundred grand, needs to find what we essentially call a "job" but the reality is much more complicated.

 

1st hurdle is location and career stream. Like other aspects of medicine surgery is broken down into academic and community designations. Academics work in what we call the "ivory tower", medical school or university affiliated centers. These are big centers that offer a wide spectrum of care and for most specialties if you want to work as an academic surgeon you need a lot more training and to fill a required niche (last time I will use the word "niche" I promise). This can be surgeon-educator, surgeon-scientist, or specialist-surgeon. These are your PhDs or people with high end fellowships that bring something unique to the center. OR time is usually divided up by the academic center but the total ammount available is dependent on the province. 

 

Aside: To put a rumor to rest it is not about the amount of physical ORs or space. Many large centers have multiple unused ORs and only operate them at a limited capacity. Building one is usually not an issue either. The hold up is always 1) operating and staffing costs 2) post op bed numbers. 

 

Physicians are fee for service but nurses/housekeeping/techs certainly are not. The province pays these people's salary and they pay to maintain, equip, and staff the ORs. Each OR runs at a staggering operating cost per suite and it is always humbling to walk into one knowing that a measurable proportion of our country's GDP is being spent in this one room on a yearly basis. Surgical beds also cost. I have heard many different figures but it is almost certainly in the low thousands of dollars per day per bed. Each surgical bed requires staffing and equipment costs too which all get factored in. The surgeon pays for none of this and it is all provided contractually for them providing a service to the community/province. They are, without blowing up their heads even more, a community resource because they posses a capability to perform a service no one else in the community can. A surgeon is a living breathing angry and bitter MRI machine with legs in one sense.

 

One of the ways provinces/regions control health care costs is OR time. It is a massive part of the budget and is easily controlled by allocation of resources and time. 

 

In short: the ORs are there, there is no shortage of trained people to keep them going or surgeons to operate, the restriction is in the funding department.

 

Back to surgeon types. A community surgeon is someone with a much broader scope of practice. They will work in community hospitals and will provide a base level of capabilities that is usually dictated by their respective colleges. They tend to be the work-a-day type of surgeons and do the bulk of the more common operations. Community Gen surge will do appy's, choley's, maybe some basic bowel work, but the transplants and heavy oncology stuff is all going to the big academic centers. Same goes in most specialties. Community surgeons are the generalists doing the general things that there is a high demand for. To get one of these "jobs" you need OR time and to either make or join a practice.

 

As a rule almost no surgeons go solo they all join a practice. A practice means you can pool resources and more importantly: call. As part of a service a surgeon provides a community they are expected to provide a certain amount of call and support to the community site. They ma have to sit on a board or be available to perform a certain required service. Having never negotiated a contract I am not entirely sure how this works but from what I do understand you basically need to find a community that can support the surgeon with OR time and patient catchment that has an open space or retiring surgeon already filling that role.

 

Think of it like this: OR time is like farm land, there is only so much of it and all of it is essentially spoken for. If you want to be a farmer you can take over for someone who is retiring, find someone who is farming and wants to subdivide their land and share it with you, or find some land no one is farming and set up shop. As a rule the first analogy generally applies to academic centers where OR time is tightly regulated and most services are well covered with a waiting list of potential previous surgical graduates waiting on the periphery to pounce on any openings. In my program the people who are retiring have essentially selected their replacements who are undergoing fellowships the practice has pretty much dictated to them to fill the requirements of the center. These people have traded about 95% of their decision making for an academic job with security but will be set for life. This is just becoming the reality of academic surgery. Big centers will need oncology, transplant, and other specialists. These roles have been filled and you need to project many years out to find a gap to fill and then shape your career path toward that end. 

 

Community surgery is much more like the second and third analogies. As smaller centers grow they pick up capabilities and their populace demands better access to services so more surgeons get hired on to provide a new capability or help someone who has been doing it at a limited capacity on their own. The downsides to this is it is very difficult to forecast, the centers are smaller meaning you will have limited support, no residents, and a heavier call burden. You will also not have much choice as to where you live as you basically take a job wherever you can. OR time is usually controlled by a board and you negotiate your access before setting up shop.

 

 

There is obviously more to it than this but this is a general overview. I would say to anyone looking at anything in medicine "get away from your med school and see how they do things in the community". Most of us don't end up working in big centers and you tend to get blinded in med school to a very limited way of how we do things. There is a whole world outside of academics that is worth seeing and knowing about to help you with your career choices. 

 

GL

[NLengr]

Just to add: even if you decide you want an academic career, the odds may be stacked against you.

 

For example, in my specialty, 50% of final year residents say they want to work an academic job. They go and do big name 2 year fellowships and pile in the research. In the end though, only 20% of all residents will end up in academia (40% of final year residents planning to get an academic job). The majority of people, even those desiring academia will end up in the community. However I think that's common in the vast majority of medical specialties.

 

I would also strongly recommend all residents spend some time in the community working with community based physicians. It's eye opening how much nicer everyone is and how much better life is.

[hypersomniac]

Wow, Thank you very much for your comprehensive explanation!

I imagine in this case moving to smaller cities won't help either, since smaller hospitals have lower budgets.

[NLengr]

Wow, Thank you very much for your comprehensive explanation!

I imagine in this case moving to smaller cities won't help either, since smaller hospitals have lower budgets.

Usually the opposite. Smaller places are usually looking for people to fill OR time because not as many people are willing to move there (Try getting someone from Toronto or Montreall to move to Timmins or Edmonston NB).

 

You need a letter from God to get a job in a big city since a dozen people may want the job you are looking at.

[rmorelan]

Usually the opposite. Smaller places are usually looking for people to fill OR time because not as many people are willing to move there (Try getting a Toronto boy or Montreal girl to move to Timmins or Edmonston NB).

 

You need a letter from God to get a job in a big city since a dozen people may want the job you are looking at.

 

there is also a cost argument there as well to run the OR more - the alternative is shipping patients back and forth which is very expensive in its own right. You can argue to keep things local from that point of view. Particularly with follow up etc.

 

Ha, OR are just such a cost sink - the room, the recovery area, the ICU, the followup patients, the complications and further surgeries/procedures, the imaging (pre, post).... really we can just save so much money if they didn't exist (ha!) 

 

there really should be more of a focus on community practice in most fields of medicine. The vast majority of people in my area going into the community but the training is nearly completely academic with subsubspecalists training you. By the fact that they are doing their particular job they are effecting training you to do what they do - yet most people won't end up doing that at all. 

[NLengr]

As a surgeon, community sites are much more likely to try and accommodate your requests for equipment in my experience because they want to keep you in the community. Academic centers seem much less happy to give you things you request because they know if you quit, there are 5 people willing to take your spot and not request new equipment for a couple years at least.

[rmorelan]

As a surgeon, community sites are much more likely to try and accommodate your requests for equipment in my experience because they want to keep you in the community. Academic centers seem much less happy to give you things you request because they know if you quit, there are 5 people willing to take your spot and not request new equipment for a couple years at least.

 

so you and others would know know this a lot better than I would - the difficulties in surgery jobs has been going on for a while. First is it getting worse - I mean we are still graduating increased numbers of everything at the moment and you would think eventually even less desired places would fill up etc, etc - there are just only so many jobs period. 

 

Where are we at now vs say 5 years prior? 

[Fresh fry]

Here are a couple of things that keep me going despite watching countless grads go unemployed.

 

1) I think you hit it on the head. It is about where you are willing to work versus actual job shortages. For my specialty anyway there is work out there and many places that will be opening up, they are just not in major centers. Personally i will live anywhere that is within 2 hours of an international airport so it really doesn't matter to me. 

 

2) There is so much grey hair that is hanging on past expiration date. This is especially true in ortho at my center. Most surgeons are out by 60-65 and winding down in late 50s but since the recession people have been hanging on longer and longer. In my center and specialty i would say 50% of current docs will be retired by the time I graduate.

 

3) Aging population. 10 years from now this will be a very different country, much more like japan. And all these boomers who have been paying taxes for 40-50 years will start coming to collect on all the hips, prostates, and hysterectomies they paid for. There is no way we will be able to keep up with demand at our current operating levels and these people vote and complain. Things are at the threshold of changing, just no idea when the waves will crash.

 

How this gets paid for I have no idea. We can't possibly actually do all these operations at current costs it would swallow our economy. Which leads me to #4:

 

4) Private surgery centers. It is coming. Like I will bet anything on it that in 5 years you will be able to pay out of pocket in Canada for almost any surgery or procedure. Don't believe me watch the supreme court as the cases from BC and Quebec make their way through. Don't want to get into the ups and downs but it is a definite reality. The people who will be able to take advantage are the surgeons who are established and have money to set up a private practice. no one will pay for an inexperienced surgeon and new grads don't have money to pay for set up. I see a two tiered system where provincial funded surgeons are young and recent grads and private guys are people who worked their way through the system.

 

The jobs are coming.

[rmorelan]

getting a little tired of the recession excuse ha. I mean they may be using that still as an explanation but that was 8 years ago now, and the markets not only completely recovered but actually have further increased dramatically. Plus it wasn't like that was the only recession we ever had. and Plus number 2 they now have 8 less years to worry about paying for in retirement as they were well still working. 

 

It is starting to sound more and more like an cover because they just don't want to say they like their job and want to keep doing it (which is fine - I am not pushing anyone towards the door if they are good at what they do). I don't think we live in a world anymore where we should expect anyone to retire automatically at 60-65 so they can sit around for the next 25 years. 

[Fresh fry]

I don't think it is a definite number thing but there comes a point where people need to let go. Surgery is a skill that fades with age and many of teh old guys still do things the way they were taught when they went through because learning new procedures and stuff takes time/costs money.

 

I hate it when I am on call with one of the old guys. They are the least likely to come in to operate meaning cases get pushed back and back, falling on the guy on call the next day. Getting them to come in takes an act of jebus when they have no choice. They are not able to operate as well as the young guys in the middle of the night, and they definitely don't teach when they do because they want to get back to bed as fast as possible. 

 

I have seen so much outdated crap that goes down in terms of meds/approaches because the surgeon is close to retirement and refuses to change. It actually keeps me up at night sometimes. It is scary in this country that you get the surgeon you get and have no choice. We don't publish stats or keep track of anything publicly. It all comes down to who is on call when you get sick and where you live.

 

Problem is all the old guys have the power. It is a total boys club even worse than the mafia. They control the OR time, the distribution of labor, everything. It is impossible to get rid of them no matter how dangerous they are.

 

Now add in the robot and the equation gets even worse. You have a tool that allows aging surgeons to extend their practice by 5-10 years but costs 5-10x as much and is 2-3 times longer to do the procedure. Of course the old guys want the robot at millions of dollars per unit. It is an interesting time for medicine in Canada no matter which way you slice it.

[NLengr]

so you and others would know know this a lot better than I would - the difficulties in surgery jobs has been going on for a while. First is it getting worse - I mean we are still graduating increased numbers of everything at the moment and you would think eventually even less desired places would fill up etc, etc - there are just only so many jobs period.

 

Where are we at now vs say 5 years prior?

For my specialty, probably the same. There are jobs around if you are flexible with location and don't mind community work. If you are someone who just has to be in a big city (GTA, Ottawa, Calgary etc), it can be harder but everyone I know who has graduated recently has got a job somewhere in the country (either pre or post fellowship).

 

Lots of people are doing fellowships but I'd say 50% of them are just stall tactics hoping that their dream job opens up. Once the realities of bills and money hits at the end of fellowship, they find work somewhere in the country in a community job.

[NLengr]

I don't think it is a definite number thing but there comes a point where people need to let go. Surgery is a skill that fades with age and many of teh old guys still do things the way they were taught when they went through because learning new procedures and stuff takes time/costs money.

 

I hate it when I am on call with one of the old guys. They are the least likely to come in to operate meaning cases get pushed back and back, falling on the guy on call the next day. Getting them to come in takes an act of jebus when they have no choice. They are not able to operate as well as the young guys in the middle of the night, and they definitely don't teach when they do because they want to get back to bed as fast as possible.

 

I have seen so much outdated crap that goes down in terms of meds/approaches because the surgeon is close to retirement and refuses to change. It actually keeps me up at night sometimes. It is scary in this country that you get the surgeon you get and have no choice. We don't publish stats or keep track of anything publicly. It all comes down to who is on call when you get sick and where you live.

 

Problem is all the old guys have the power. It is a total boys club even worse than the mafia. They control the OR time, the distribution of labor, everything. It is impossible to get rid of them no matter how dangerous they are.

 

Now add in the robot and the equation gets even worse. You have a tool that allows aging surgeons to extend their practice by 5-10 years but costs 5-10x as much and is 2-3 times longer to do the procedure. Of course the old guys want the robot at millions of dollars per unit. It is an interesting time for medicine in Canada no matter which way you slice it.

Damn robot is like dumping money into a barrel and lighting it on fire. Its a ton of cash for very little gain. I think the system as a whole would be much better off putting that money into senior care or psych support or something.

[Lactic Folly]

there really should be more of a focus on community practice in most fields of medicine. The vast majority of people in my area going into the community but the training is nearly completely academic with subsubspecalists training you. By the fact that they are doing their particular job they are effecting training you to do what they do - yet most people won't end up doing that at all. 

 

I agree residents could benefit from more community exposure, as the academic setting can be quite a different environment and leave trainees with an incomplete impression of what constitutes the full scope of general practice.

 

That being said, even though someone in the community might never have the referral base that would require X subsubspecialized type of study, those subspecialists are still the people that any rad-in-training should want to read with. Someone who spends all their time immersed in a subfield, with feedback and followup on those cases, will be able to gain a level of experience that leads to increased confidence in diagnosis (when should you call 'x'), ease in dismissing normal variants, sensitivity for nuances that affect management, and comfort in managing commonly encountered indeterminate findings.  

 

These are the types of practical questions that commonly plague those not specialized in the area (and are brought to conferences/'Q&A sessions with the experts'). If you hear someone say "we saw so many cases that had this finding, and they turned out to be...", that is who you want to learn from - just try to grab a variety of case types to review with them    

[GrouchoMarx]

Damn robot is like dumping money into a barrel and lighting it on fire. Its a ton of cash for very little gain. I think the system as a whole would be much better off putting that money into senior care or psych support or something.

 

Meanwhile pathology departments hiring new pathologists is under the control of hospital administration and why would they pay for more pathologists when the ones they have will work as hard as two for the price of one (coming in on weekends and taking no vacation etc.). 

 

Avoid pathology if you can. It's the place for desperate IMGs.