Median starting salaries for the seven surgical specialties studied ranged from a low of $260,000 for a general surgeon to a high of $450,000 for a neurosurgeon in the Cejka survey.
Invited discussant Dr. Nathaniel Soper, chair of the department of surgery at Northwestern University in Chicago, said, "It may end up being ultimately that these bidding wars are good for general surgeons, but I think it’s not going to be good for the population we serve, as there is going to be a shortage unless something is done."
Dr. Sober suggested that the basic problem is not so much the division between rural vs. urban, but the supply of surgeons, and asked what can be done to meet the estimated shortfall. He also questioned the model’s assumption that the population would remain equal in rural and urban areas.
Dr. Bhagwan Satiani
Co-author and colleague Dr. Bhagwan Satiani replied that the analysis included a simplified version of the federal model used to calculate supply and demand, but added that every projection in the last 50-75 years has been wrong. "You have to look at this model and say, ‘This is the best we can do right now," he said.
According to Dr. Satiani, one of the best ways to increase the rural surgeon supply is through a comprehensive medical school rural program (MSRP). "If you took 10 medical students out of the class and put them into the MSRP program, you could double the number of rural surgeons. That’s how important that is," said Dr. Satiani, medical director of the vascular surgery laboratory and a professor of clinical surgery at Ohio State University.
A recently published report from the Physician Shortage Area Program (PSAP) at Jefferson Medical College in Philadelphia provides a similar calculation for rural physicians and reports that 79%-87% of graduates from the two MSRPs with long-range rural outcomes – the PSAP and University of Minnesota at Duluth – remained in rural practice for up to 20 years (Acad. Med. 2011;86:272). It also notes that the Affordable Care Act authorized a new Rural Physician Training Grants program to provide grants to medical schools to develop or expand MSRPs.
Only 25 of the roughly 250 medical schools have general surgery programs, and just 10% of these could be considered programs that attract rural surgeons, according to Dr. Satiani. "I think American surgery is going to have to give this a separate tract within residency programs."
Audience member Dr. Mark Malangoni, associate executive director of the American Board of Surgery in Philadelphia, pointed out that in such rural areas as Wyoming, the closest medical school is more than 1,000 miles away in Washington state. He suggested that one way to link rural hospitals and to counteract the professional isolation experienced by some rural physicians is through Web-based surgeon-to-surgeon consultations, an idea strongly supported by a recent survey of American College of Surgeons fellows.
If a new medical school were located in a rural area, Dr. Satiani said it could feed two to three nearby states, but not one of the new medical schools built in the last 5 years has been in truly rural areas.
Finally, several audience members suggested that efforts need to be made to eliminate the perception among residents that surgical specialists are somehow better than general surgeons.
"It’s the one-on-one thing that’s going to work with the residents, because all they see are these super-specialists," Dr. Satiani said. "I think it has to come from the programs and the leadership; defining general surgery better, even going as far as changing the name, if that becomes an important issue."
When asked in an interview what that new name might be, Dr. Satiani said the terms "master surgeon" and "omni surgeon" have been floated, with master surgeon more likely to resonate with the general public.
The authors reported no conflicts of interest.