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Expanding the National Health Service Corps Scholarship Program to General Surgery: A Proposal to Address the National Shortage of General Surgeons in the United States.

The surgical workforce is predicted to be in crisis. The Association of American Medical Colleges forecasts a deficit of 41 000 general surgeons by 2025, which is 33% of the predicted total physician shortage.1 Much has been written describing the crisis, particularly in rural and underserved urban populations, but few workable solutions have been proposed. The situation is further complicated by the long process to produce a surgeon: medical school followed by 5 to 7 years of residency training and even more as most graduates opt for fellowships beyond.2 A simple solution would be to increase the number of medical school and residency positions. Increasing training positions was proposed by the Council on Graduate Medical Education and the Association of American Medical Colleges following their physician workforce studies in 2006 and 2008, respectively.1,3 The medical education community responded, and we are now on track to meet the recommended 30% increase in medical school enrollment by 2019.4 This has not been matched with a similar increase in federally supported residency positions. A cap on the number of residency positions has been in place since the Balanced Budget Act of 1997. The Resident Physician Shortage Reduction Act, designed to establish 15 000 new residency positions over 5 years, was first introduced in 2009 but did not pass. The most recent iteration (2015) is still in committee at the time of this writing. One must consider whether an increase in trainees will produce the number of surgeons needed, primarily general surgeons. There has been a modest increase in general surgery residency positions under the Affordable Care Act (2010), as one provision of the law allowed for a redistribution of unused residency slots to fund new positions in primary care and general surgery. Also, new training programs have opened. Review of National Residency Matching Program (NRMP) general surgery categorical positions offered in the past 2 decades shows an initial decline followed by an increase in recent years. An overall 7.4% increase in categorical surgery positions has been observed in the period from 1990 to 2015.5 However, one must also consider that most general surgery trainees choose to specialize with additional fellowship training, noted as high as 70% in 2008.2 There is anecdotal evidence that the percentage of trainees entering fellowship is even higher in 2016. It is not clear how many trainees who choose to specialize will also include general surgery as a component of their practice. Thus, the number of general surgery positions does not directly translate to practicing general surgeons. More research is needed to better quantify how many general surgeons vs surgical specialists our training programs are producing and whether this is the right proportion for our workforce. If our aim is to provide access to surgical care for all, then preserving general surgery as a career is a priority. The trend toward specialization is multifactorial: the contemporary proliferation of surgical and medical advancements, the public’s perception that care from a specialist is of higher quality, and trends in reimbursement are only a few of the contributing factors in the growth of the surgical specialties. There are many situations where specialized care is very appropriate and desired, and there is evidence demonstrating that outcomes for complex high-risk procedures are better when performed in a high-volume center.6 However, should quality outcomes be our only metric for high-quality surgical care? Economic and geographic barriers can limit access to regional centers for some patients, potentially leaving segments of the population without any surgical services. Quality outcomes measure those who have had access to undergo the procedure in the first place: those who never had access to the surgeon are simply not in the numbers, overlooking many who needed care but perhaps never received it. We would argue that for health care to be high quality it must first be accessible. The rural and underserved urban general surgeon is essential in providing access to surgical care for these resource-limited communities. The Ensuring Access to General Surgery Act of 2016 is a bipartisan bill recently introduced to both the legislative bodies that will require the US Department of Health and Human Services to study access by underserved populations to general surgeons. Research defining and characterizing gaps in surgical care to underserved populations is essential for logically guiding future policies aimed at strengthening our surgical workforce. It is time to help incentivize general surgery as a career to ensure it remains a strong profession within our nation, for the sake of accessible care. A large number of surgery residents train in academic centers, which are environments oriented toward surgical specialties with few opportunities for mentorship by surgeons who practice general surgery. This is further promulgated by the fact that compensation for general surgery is generally less than many of the surgical specialties (and the call burden often greater), leading the trainee who is in their early 30s with a young family and hundreds of thouVIEWPOINT