Chair's Column:
The conundrum of surgical careers, new surgical graduates, senior surgeons, delayed retirement, health care resources, societal expectations, and politics.

David Latter

As my term as Interim Chair nears its conclusion I would like to thank the many trusted surgical colleagues and Banting staff who helped me during this past year. It was a privilege to serve our Department and I hope that my decisions taken as the Interim Chair were sound and fair. I know I speak for the whole Department when I say we look forward to the new leadership and vision as Jim Rutka assumes his position as the R.S. McLaughlin Professor and Chair of our Department.

True to my roots as a surgical educator I would like to take this opportunity to focus on a topic that received national attention recently. The Globe and Mail recently published an article by Lisa Priest titled Canadian surgeons face flat-lining job market (1). This article focused on the plight of a recently graduated orthopedic surgeon, who despite a solid residency and an additional year of clinical fellowship and one year of searching, had still not landed a permanent position. This young surgeon was "getting by" with a series of different positions as locums, covering on calls for established orthopedic surgeons (the newly coined term is the "on-call-ogist"), and surgical assisting. The article went on to lament about how unfair this was to allow a surgeon to train for so many years and not have a position waiting, and how difficult it is for patients, who wait up to four years for their foot and ankle surgery, to hear that there are surgeons available but who can not operate on them. Of course, a simple article like this cannot possibly explain all the issues at play here. A list of some of the issues not mentioned may include:

• In most high performance jobs not all graduates secure choice positions (for example, business school graduates, lawyers, astronauts, pilots, scientists, etc).
• Willingness to relocate elsewhere in Canada, or the US.
• The delivery of surgical care requires more than just a surgeon and a patient.
• Hospital resources are finite and resources are allocated for many different reasons:
  Surgical services vary according to their area of focus and expertise
  Hospitals have differing strategic plans and global budgets
  Volume funded activities enjoy hospital budget neutral or positive status
  Regional health authorities allocate resources according to their perception of need
  Conditions with higher threats to life and or limb tend to secure more guaranteed resources
• Provincial Government resources are finite
• Competing health care sector needs:
  Outpatient services Hospital based services
  Drug costs
  Allied health services
  Generalists vs. specialists
  Provincial volume funded programs
• Federal Government resources are finite
• The political fallout (federal or provincial) of any political decision regarding health care funding

What I found particularly interesting regarding this Globe and Mail article were the letters to the editors in response published the following day. One questioned the policy that each hospital must balance their budgets (or the CEO may be out of a job), another called for adoption of a UK based National Health Services like model, a third simply said that the solution for this surgeon and his future musculoskeletal patients was to reallocate funds from the provincial cardiac surgery services, and the fourth, from a patient, suggested that specialists should just go out and retrain to be generalists to fill the general practitioner deficit.

Orthopedic surgeons are not alone. For a few years now, there has been difficulty for new cardiac surgeons to secure good positions resulting in a cadre of recent graduates underemployed (2). A recent article published in the Annals of Thoracic Surgery highlighted the difficulties. They contend that as a result of fewer medical students entering cardiac surgery now there is real concern that 10 years from now there will be a serious deficiency of well trained cardiac surgeons (3).

I don't have the answers to this situation where new surgical graduates cannot find suitable jobs, but I do think that as a Department there are things we can and should do. First we must provide our expertise to our governmental leaders in health care resource planning. We should work with our provincial and federal agencies and provide our expert knowledge of the practices of our surgical specialties to assist them in their physician manpower needs projections. One such agency is Health Force Ontario, which publishes reports on their models to project future supply and need for physicians in Ontario (4).

Even if we were able to predict the future manpower needs accurately, we would still not be able to right size the training programs. Our current system allows each university to make its own decisions about how many residents they will accept and train. This results in a supply and demand market place, but with a supply and demand cycle that takes 6-10 years to make the various adjustments. The result is the predicament that orthopedic surgery and cardiac surgery are currently dealing with. Perhaps we should lobby for a national and/or provincial level committee to determine the right number of surgical specialists we should train for the nation.

Since it is apparent that we cannot fix the surgery "manpower market" overnight, our Department must continue to make sure our graduates are truly the most outstanding graduates in their specialties across the country. It is true that "there is always room for the best". It is my belief that our University of Toronto Department of Surgery graduates compete extremely well, and have better job prospects than their competitors from other training programs. To verify whether this is true or not, the Department is undertaking a survey of the last 5 years of our graduates to determine exactly what kind and what quality of positions they have secured. When this information is obtained I will share it with the Department.

I must discuss the subject of resource allocation. There is not a shortage of patients, or of surgeons. From time to time there may be shortages of anaesthetists and OR nursing personnel, but the real shortage is hospital resources (i.e. money). Since OR resources are limited, it is up to hospitals and individual surgical services to determine how to allocate those resources to the surgeons of the service. Depending on a myriad of factors, that include job description (clinician-teacher, investigator, scientist), technical abilities, volume funded programs, seniority, position status, and other factors, OR "time" is allocated. A finite resource allocated to a defined number of surgeons. Bringing on another surgeon to the service equates to less resource being allocated to the pre-existing members of the group. This is sure to discourage recruitment of new surgeons unless there is a model of remuneration that does not rely on fee for service.

What about the new phenomenon where a senior well established surgeon hires a newly graduated surgeon who does not have a permanent job to take on call duties for nighttime and weekends? To keep the resources provided for elective cases during weekday day hours, and leave the far less desirable leftover resources for urgent and emergency care that occurs in the night, weekends, and holidays, is truly taking advantage of one's own position/ status to the detriment of the young unestablished, underemployed surgeons. Surgeons-in-chief and hospitals must not allow this inappropriate practice of opting out of on call duties but keeping daytime OR resources.

Finally, I want to say something about the relationship between the start and the end of a surgical career. I support the notion that mandatory retirement is undesirable in Canada (except perhaps in the airline industry, but this too is now being challenged). Nevertheless, we must recognize that every surgeon needs to retire eventually. Some surgeons retire relatively early to take up other careers, while others opt for delayed retirement and keep on practicing. The reasons for retirement vary from loss of technical abilities, failure to keep up with technical skill development, personal health reasons, family reasons, financial reasons, and simply "the right time". Whatever the reason, the decision is almost completely up to the individual, while departments and hospitals only participate if there is an issue of competence.

In reality it is common to see surgeons well past usual retirement age (whatever that may be) opt for delayed retirement who remain competent and have a full allocation of OR/hospital resources. But this happy scenario has a reverse side to it. The fact is that under current market conditions, for every surgeon who keeps his or her OR resources past usual retirement age there is a young surgeon who is being denied their opportunity to start their career. I just don't think we can ignore this simple reality any longer.

There is no easy solution to this unfortunate equation, but we must start talking about it. One suggestion for discussion that I would like to put forward is the concept of matching a new recruit with a trusted respected senior surgeon near the end of his/her career. Not all senior surgeons would qualify for this prestigious mentoring role - it would be reserved only for the really deserving and trusted surgeons. This mentoring relationship might last 5 years during which the senior surgeon gradually ramps down his/her OR resource allocations and the new recruit gradually ramps up his/her OR resources. During this transition period the new recruit will have the time and support to establish his or her academic career, and make the transition from being the resident surgeon-in-training to the staff surgeon fully responsible for the care of the patient. This relationship should be a real mentorship where the senior surgeon advises, assists, and helps the new recruit to become a fully functioning capable surgeon who can operate with skill and judgment, who can teach with effectiveness, and who can attend to his or her other academic interests to contribute to the advancement of medical science. At the end of the defined period, the new recruit is fully independent, and the senior surgeon retires triumphantly, having trained one last surgeon.

References:

(1) The Globe and Mail. Canadian surgeons face flat-lining job market. Friday February 25, 2011, A8-9.

(2) MacLean's Magazine. The first signs of a coming health care crisis. August 10, 2010

(3) Ouzounian et al. The Cardiac Surgery Workforce: A Survey of Recent Graduates of Canadian Training Programs. Ann Thorac Surg 2010;90:460-466

(4) http://www.healthforceontario.ca/upload/en/whatishfo/ 2010-10-20-radius-4-physician-simulation-model.pdf