IS THERE A SURGEON IN THE HOUSE? MALPRACTICE, LONG HOURS, LOWER PAY DRIVING MANY DOCTORS AWAY FROM THE OPERATING ROOM.

Byline: Mariko Thompson Staff Writer

When Dr. Thomas Russell completed his surgical residency three decades ago, he never left the hospital. He and his fellow residents logged 120-hour work weeks, driven by the idea that the more they worked, the more interesting cases they would see.

``It was total immersion,'' recalls Russell, executive director of the American College of Surgeons in Chicago. ``That's why they were called residents, because they resided in the hospitals. Those days are over.''

Once viewed as a position of prestige, surgery has lost its allure among today's medical students. Factors including long hours, rising malpractice insurance costs and poor reimbursement rates have taken a toll on applications for general surgery residency programs, which have dropped by one-third over the past nine years. The waning interest in surgery couldn't come at a worse time, with aging baby boomers threatening to overwhelm the health-care system.

``We have to train more surgeons in this country,'' says Dr. David Etzioni, a general surgery resident at UCLA's David Geffen School of Medicine. ``It takes a long time to train a surgeon from scratch. You're talking a minimum of nine years and up to 14 years to train one qualified surgeon. If in the year 2005 we don't have enough surgeons, it's going to be hard to crank up the pipeline.''

Help wanted 

Etzioni served as the lead author on a study that found the demand for surgery skyrocketing by 2020 as a result of the graying of America. By 2020, the number of Americans over the age of 65 will have increased 53 percent. Surgical procedures commonly performed on seniors are expected to see the greatest rise in demand, with eye and heart surgeries topping the list.

According to the study, the need for eye procedures such as cataract surgery will jump 15 percent by 2010 and 47 percent by 2020. Heart surgery is projected to rise 42 percent by 2020. About 70 percent of a heart surgeon's workload comes from patients over the age of 65, researchers said.

By contrast, the demand for ear, nose and throat procedures had the smallest projected increase at 14 percent. Most of the patients seeking those procedures are under the age of 15, Etzioni notes.

``The fields that provide services to older patients are the ones that are going to see their patient base increase the most. The number of procedures is going to increase as well,'' he says.

At the same time, medical students are increasingly drawn to specialties that provide more control over their schedules and allow for work-family balance. A 2003 study published in the Journal of the American Medical Association found more medical students influenced by lifestyle rather than pay or prestige when choosing a specialty. Students viewed emergency medicine, anesthesiology and dermatology as attractive specialties based on lifestyle, while surgery received a low rating.

Rarely at rest

``The surgical specialties require being on call, being called in the middle of the night,'' says Dr. Zahi Nassoura, chief of surgery at Encino- Tarzana Regional Medical Center. ``With some of these other specialties, once you go home, that's it.''

To address quality-of-life issues, all residency programs will limit the work week to 80 hours starting in July, Russell says. Doctors also have taken matters into their own hands, seeking the flexibility offered in a group practice instead of establishing solo practices. It's also becoming more common for doctors, usually women, to share a position so each can work part-time, Russell says.

More complex are the issues of medical liability insurance and low reimbursement rates. A handful of states, including California, have set a limit on pain-and-suffering awards, which doctors say helps contain the cost of malpractice insurance coverage. Over a two-year period, doctors in states without the caps saw liability insurance premiums rise 44 percent, compared to 15 percent in states with the caps, according to the American Academy of Family Physicians.

Low reimbursement rates for services pose another challenge. Doctors who find their costs outstrip what insurance companies are willing to reimburse aren't going to stay in business long, Russell says.

Because of the financial challenges, surgeons say students who do pursue surgery must find gratification in the work itself. They must derive a sense of accomplishment from treating patients in need of help. They must enjoy the sense of camaraderie that comes from working as a team with other doctors, nurses and anesthesiologists in the operating room.

``You have to love what you do,'' Nassoura says. ``The reward is in taking care of the patient. You can't go into medicine anymore for money.''

Less competition

While the medical field takes the projected surgeon shortage seriously, Russell sees no need to panic just yet. The number of surgeons completing training each year still remains stable, despite the drop in the applicant pool for surgical residencies. But the lack of competition is cause for concern. In the area of cardiac surgery, programs that used to have several applicants competing for each spot now have about one applicant per opening, according to the Society of Thoracic Surgeons.

``We want to continue to attract the best and the brightest,'' Russell says. ``Surgery is a wonderful profession, a privileged profession, and one that's got a lot of responsibility. We don't want the bottom of the class.''

The medical field also has to look at other options besides recruitment, he says. Nurse practitioners and physicians assistants may be trained to take on some of the surgeon's duties outside of the operating room. New drugs could make some surgeries obsolete. For example, if a safe and effective pill for obesity was developed, the demand for bariatric or weight-loss surgery would evaporate, Russell says.

UCLA's Etzioni says improving technologies such as the move toward minimally invasive procedures will lead more people to elect surgery. With hip replacement surgery, orthopedic surgeons used to make anywhere from an 8- to 14-inch incision. New minimally invasive techniques require only a 3- to 4-inch incision, which means a faster recovery for the patient.

Even if new technologies increase demand for surgery, they also allow for greater efficiency. Operations take less time. Procedures that once required hospitalization can be done on an outpatient basis, Russell says.

``We have better knowledge, technologies and pharmaceutical agents,'' Russell says. ``We have better ways to do it besides surgery. The work changes.''

Mariko Thompson, [phone]

mariko.thompson(at)dailynews.com

CAPTION(S):

4 photos

Photo:

(1 -- cover -- color) THE UNKINDEST CUT

How the growing surgeon shortage threatens your health

Photo by Scott Quintard/courtesy of UCLA 

(2) Dr. Zahi Nassoura, chief of surgery at Encino-Tarzana Regional Medical Center, says long hours and financial concerns have made surgery less attractive to medical students.

(3) no caption (surgeons)

Photo by Mark Harmel, courtesy of UCLA

(4) ``You have to love what you do,'' says Nassoura. ``The reward is in taking care of the patient. You can't go into medicine anymore for money.''

Phil McCarten/Staff Photographer