Surgery far from top choice for doctors-in-training, says Stanford researcher

06/15/04

STANFORD, Calif. - Who wants to be a surgeon? Not nearly as many people as there once were. A new study gives insight into this decline in interest - deemed a crisis by those in the profession.

Students believe that a career in surgery cuts deeper than the scalpel. According to the study, led by Susan Brundage, MD, associate professor of surgery at the Stanford University School of Medicine, the profession slices into family and personal time, a key factor feeding disenchantment with the field.

The study reports on a series of focus groups that zeroed in on factors influencing the career choices of 29 University of Texas-Houston medical students. At the time of the study, Brundage was an assistant professor at Baylor College of Medicine in Houston. The study, a collaboration with the University of Texas and Baylor, is published in the June 15 issue of the Journal of Surgical Research.

Medical student interest in surgery as a career peaked in 1981, with 12.1 percent of senior med students choosing the specialty. Since then, interest has dropped, reaching a low of 5.3 percent in 2002.

"There is a concern," said Brundage. "Surgery is a highly valuable commodity and as the numbers of surgeons are on the decline, access to surgical care will be more difficult. Even at this time in the United States, there are waiting lists of six to eight months for some non-emergency surgical procedures. Rural communities and inner cities are particularly underserved. As the numbers of surgeons decline, there is bound to be an even more pronounced shortage of surgeons.

"The profession is asking itself, why is something that's so valuable and that we enjoy so much not attractive to students in the year 2004?" Brundage added.

To get some answers, she and her colleagues staged focus groups, luring second-year medical students with free lunches. Their key finding was that perceptions of a surgeon's lifestyle turned many off to the specialty.

Students who said they were not considering surgery as a career ranked family and personal time as their top priorities. In contrast, most students interested in surgery felt the requisite sacrifice was necessary and acceptable. One female student went so far as to say, "There are video cameras to see your kids [grow up]."

Brundage said the profession does truly demand great commitment. Hours worked are generally longer than in other medical fields. Workweeks of 120 hours were common for surgery trainees until last year when the national accreditation agency for training programs limited the time to an 80-hour ceiling. Still, this workload is more grueling than that of many other specialties. For instance, dermatology residents average 42 hours per week; allergy residents average 44 hours; and emergency medicine residents average 45.

Additionally, the training period for surgery is longer than for most other disciplines. Certification as a general surgeon requires a minimum of five years. Training in a subspecialty - such as cardiac, pediatric or trauma surgery - requires an additional two to three years.

"You make a minimum seven- to eight-year commitment before you can get your first real job for a clinical practice," said Brundage. "This is in contrast to standard family practice doctors, internal medicine doctors, pediatricians or emergency medicine doctors, for example, who undergo a much shorter training period of three years."

Brundage herself is unusual not only because she's a woman in the traditionally male field of surgery but because she has chosen the subspecialty of trauma surgery - one of the most macho subspecialties there is. "Everyone told me not to do surgery. They warned me about the demanding lifestyle, told me that the people who do it are malicious, that it's not a good career for women. But I fell in love with it."

Few students, male or female, have Brundage's zeal, however. "They take less of a passion and more of a lifestyle approach," she said.

"Students today are more interested in being with their family and having free time. In some ways they are very smart," she said. "If they can work in a less-demanding specialty to economically support the lifestyle they want, maybe the attractiveness of surgery doesn't compensate for the lost time and money."

Some have attributed the sharp decrease in interest surgery to the rising number of women in medical schools: Through the 1960s most medical students were male but these days close to half are female. And female students are less likely to choose surgery than males.

The reasons behind women's choices aren't known but Brundage hazards a guess. "Surgery might not appeal to women in particular since many seek careers that will give them the flexibility to be pregnant and spend time with their families," she said.

A surgery career is hard work, but it might not be quite as tough as students imagine, said Brundage. Interaction with surgeons earlier in students' educations could dispel misconceptions, noting that the students in the focus groups had not yet encountered surgeons in their classes.

Contact with surgeons might also change the perception, common among the students, that surgeons are "jerks" - a word some used in the focus groups. This impression came largely from portrayals in the media and comments made by non-surgeon physicians and fellow students. Among the comments made in the focus groups was, "I heard people say in our class, 'I don't have to be nice, I'm going to be a surgeon.' "

And the profession has to continue the trend toward balancing excellence in surgery with a healthy perspective regarding life outside the hospital, said Brundage. Stanford's surgery department leads this trend, she said. Possibly as a result, the department has a greater proportion of female faculty than almost any other surgery department in the nation. Of the department's 62 professors, 17 are women.

"As people choose careers, they look at role models. When they look at the department chair, Tom Krummel, and see how important family is to him and see the number of women in the department and the number of faculty who have kids and family, you get the message that surgery doesn't have to be your only priority," Brundage said. "That's a big part of why I came to Stanford," she said.

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