The Outlook for Surgery in the United States

THE OUTLOOK FOR SURGERY IN THE UNITED STATES GEORGE D. ZUIDEMA, M.D.* Health care and the performance of the medical profession are issues which are of great interest in today's society. The extraordinary publicity encountered in the lay press is clear evidence of public concern. The present climate is contentious and uneasy; and on the face of it, at least, many of the problems of the health-care industry appear almost insoluble . Congress has approached the situation by nibbling at the periphery, but each new bit of legislation seems to add to the total complexity. Some problem areas are politically sensitive and are simply ignored. It is relatively easy, however, to identify an emerging trend which will transform the health professions to the status of a public utility, operating under consumer control. The fundamental question is whether our voluntary system will be permitted to survive. There is an obvious implication that the voluntary sector will fail and that only a national health-insurance system will be able to solve the nation's problems. Some understanding of the nature and dimension of the problem can be achieved by looking at the issues facing one component of our health-care system. The field of surgery will be used as my model for this kind ofanalysis. It will suit this purpose well because it is of sufficient size to have some statistical meaning, it has been thoroughly studied within the past 5 years, and we have good information available to us relating to manpower, work loads, and delivery systems. What happens in the area of surgical care is important to the health of our citizens. The publicity surrounding what is termed "unnecessary surgery" and the obviously escalating problem of professional liability have combined to put the spotlight on surgery. For all of these reasons, then, it will be useful to look at surgery in our contemporary society, see how the issues will affect its performance, and attempt to discern its future. There are many factors which come into play in any such exercise. The facts upon which to base our discussion are available from the recently published Study on Surgical Servicesfor the United States (SOSSUS) [1, 2]. This study was a joint venture, sponsored by the American CoI- *Surgeon-in-Chief, The Johns Hopkins Hospital, 601 North Broadway, Baltimore, Maryland 21205. 586 I George D. Zuidema ¦ Outlookfor Surgery in the United States lege of Surgeons and the American Surgical Association and supported by the Department of Health, Education, and Welfare; seven foundations ; and several regional and national surgical organizations. It took 5 years to complete and report the work of 10 committees, each of which examined a portion of the surgical-research and care-delivery systems. Surgical manpower and work loads were studied in depth by Dr. Francis D. Moore and his committee on manpower evaluation. Their findings are basic to an understanding of the real issues involved. For example, we read that there are "too many surgeons," with the obvious implication that this leads to "unnecessary surgery." What are the facts, then, regarding surgical manpower? Every physician who is licensed to practice medicine in the United States of America is licensed as a physician and surgeon. The American Medical Association records for 1970 show that 92,000 of the 272,000 physicians in active practice identified themselves as surgeons. This means that 30 percent of the nation's doctors practice surgery to some degree. It is also reasonable to ask, however , about their qualifications to practice. Here the picture is quite different, if you use certification by one of the nine surgical specialty boards as your yardstick. Table 1 shows that, excluding all interns and residents in training, 60.5 percent ofthe practicing surgeons were board certified. The group of noncertified and general-practitioner surgeons comprised 39.5 percent of surgical manpower [I]. The well-publicized conclusion that we have "too many surgeons" should be amended to read "too many people performing surgery." Obviously a second component of major importance in the issue of surgical manpower has to do with the work loads of surgical practitioners . This aspect of the problem was studied by Dr. Moore and Dr. Osier TABLE...