DETROIT - Rural hospitals will need to devise unique strategies to enhance hiring and retention in the face of a looming shortage of almost 30,000 surgeons over the next 20 years.
"We think this shortage will result in competition between urban and rural hospitals, maybe perpetuating in bidding wars," Dr. Thomas E. Williams Jr. said at the annual meeting of the Central Surgical Association.
Dr. Thomas E. Williams Jr.
"In a sense, this shortage could be a perfect storm; an imperative for both the urban and rural hospitals we see in America today."
The researchers previously reported that an estimated 101,838 surgeons will need to be trained by 2030 to address a projected shortage in the United States of 29,138 surgeons in seven surgical specialties: obstetrics and gynecology, orthopedic surgery, general surgery, otolaryngology, urology, neurosurgery, and thoracic surgery (Ann. Surg. 2009;250:590-7)
The current analysis went one step further, focusing on the average recruitment needs for the seven specialties in rural vs. urban hospitals in light of the projected U.S. population of 364 million by 2030. The model assumed that there will be equal population growth in urban and rural areas; that rural hospitals will need to recruit obstetric/gynecologic, orthopedic, and general surgeons; and that the percentage of the population receiving care at urban and rural hospitals will remain constant, Dr. Williams explained.
Currently, the American Hospital Association estimates that there are 3,012 urban hospitals in the United States. serving 82% of the population or 253 million Americans, and 1,998 rural hospitals serving 18% or 56 million Americans.
Based on these assumptions, the total number of surgical hires over the next 19 years will be 83,507 for urban hospitals and 13,953 for rural hospitals. This means urban hospitals must hire and retain 4,175 surgeons per year or 27.7 surgeons per hospital, while rural hospitals will need to hire 698 surgeons per year or 7 surgeons per hospital, said Dr. Williams of the department of surgery at Ohio State University in Columbus.
While the recruitment goals for urban hospitals might appear more daunting, rural hospitals are already facing a dramatic loss of general surgeons.
"In rural hospitals, general surgery is essential," he said. "[General surgeons] account for 60% of the revenue. What’s happening now is that about 34% of general surgeons are notifying their administrators of retiring or leaving in 2 years. Thirty-three percent of rural hospitals are recruiting now."
Factors that might make rural recruitment more difficult include professional and social isolation, cross coverage, insufficient training for the variety of procedures performed and pathologies encountered, and women’s preference for urban areas, he said.
Factors that positively influence rural recruitment include the chance to be a critical part of the community, independence, the wide spectrum of procedures, and hailing from a rural area.
One strategy that can tip a surgeon toward a rural hospital is doing a residency in a rural training program. The researchers estimate that half of general surgery residents who rotate through such a program will go on to practice in rural towns.
"It’s to the advantage of rural hospital administrators to establish rotations with medical schools in their hospitals, so they can have the opportunity to recruit some of the people that rotate through their rural hospitals," Dr. Williams said.
Consideration of the needs of the surgeon’s family is another factor. Typically, this will be a two-income family that values education and will need either good public schools or the means to pay for private schools. Most couples will also have educational debts, some as high as $400,000 for a two-physician couple. Thus, educational loan repayment could be a potential "trump card" for rural hospitals in the future, he said.
Rural hospitals are already throwing out the welcome mat. Most offer hiring incentives such as a relocation allowance; signing bonus; health, disability, and life insurance; and malpractice coverage. Educational loan forgiveness was offered by 38% of hospitals last year, up 7% from 2009, Dr. Williams said. Still, competition for new hires is fierce.
"In many general surgery programs in the United States, senior residents are receiving as many as 50 offers for employment today," he said.
To illustrate the point, Dr. Williams showed a recent classified ad in the New England Journal of Medicine offering a starting base salary of $600,000 for an orthopedic surgeon in coastal Georgia plus a sign-on and relocation bonus, full benefits, and a high-yield bonus. This is nearly double the median starting salary of $370,000 for an orthopedic surgeon identified in a recent Cejka Executive Search survey, he pointed out.