Publication history, Reflections & comments
Sir:: There are too many general surgeons in Australia. This opinion is based on over a year of personal-inquiry, comprising conversations and correspondence with surgeons and academics in three capital cities, with general practitioners and anaesthetists, medical agents, and reference to a variety of published' material.
The hearsay evidence indicates that despite the lack of family doctors and of specialists in many fields, there is a significant proportion of underworked general surgeons. Because of this, some have joined group practices to ensure both income and adequate amount of surgical work, while others fill in time with medical reports, teaching and other activities they would prefer to replace with surgery.
The consequences of a surplus of surgeons are of the greatest importance. First and most important is the dilution of experience and skill. Second is the diversion of medical manpower from other fields where the numerical need is greater. Third is the cost of training to the community, which incidentally contradicts the claims of some departments for more "material" for postgraduate teaching. Fourth is the bitter disappointment for the surgical graduate and his young family when he fails to find suitable work after years of hard preparation. Fifth is the disappointment for newcomers to Australia who expect to find full-time surgical work, and whose arrival aggravates the existing problem. Sixth, and doubtless not the last reason, is the temptation to carry out avoidable and even unnecessary surgery.
There are various explanations for the present surplus of surgeons. The two decades, after the Second World War saw a great increase in surgical training based on a pyramid structure of hospital units, with one consultant, a succession of registrars, and greater numbers of residents. Today it may be questioned that every medical graduate should be capable of appendicectomy, not just for the easy case, but where extra skill and experience are needed. Perhaps it is time to invert the pyramid, with fewer registrars in training, and much greater use of up-graded surgical ward sisters who are capable of much greater responsibility than in the past, given correct opportunity.
Other reasons for the popularity of surgical training are less clear. One may be financial, helping also to attract those from abroad whose work in their own country may be less attractive. Another may be a charisma perpetrated by the media and exaggerated by popular and medical attitudes. One important reason may be the past failure of responsible authorities to predict surgical training needs some years ago, so that young graduates made wrong choices because of lack of information.
What is the desirable surgeon-to-population ratio? A personal opinion may at least provide an initial reference point while more valid figures are still being worked out. I believe there should be one general surgeon for 25,000 people, give or take 20% according to age structure of the population, accident rates, surgical work carried out by other doctors, and doubtless other factors. This figure assumes the surgeon does no gynaecology, orthopaedics, or ENT surgery because of the availability of consultants in these fields, though his work may include some that might be done by urologists and plastic surgeons. This bald estimate is based on personal information acquired about several geographically isolated centres in Australia, with data about population figures from the Commonwealth Year Book and about medical graduates from the Medical Directory of Australia, together with operation statistics from some annual hospital reports and privately compiled figures.
How busy should a surgeon be? A study in "Surgery" in January, 1972, of a medium-sized hospital in New York State showed the workloads of individual surgeons varied from 25 to 14 hernia equivalents per week. A number of uncomfortable questions arise. How often should particular procedures be carried out to maintain skill?
Some superficial analogies may be drawn with commercial air pilots who must maintain flying hours for aircraft of different ratings. In addition, pilots, like marine biologists and doctors of philosophy, are expensive trainees who lack sufficient work.
If my opening statement has any significant truth, I believe several steps should be taken without delay. First, a surgical manpower survey should be undertaken by a full-time ad-hoc team including a senior surgeon, a demographer, another doctor well acquainted with Australian medical practice, and skilled statistical and secretarial help, with assistance from other informed people including medical agents. A. provisional report should be issued quickly with acceptance of the chance of later modifications. Secondly, it- should be clear to intending trainees and migrants in some detail what the prospects are in various fields of medicine. Third, training posts and the pyramid structure of hospital units should be reviewed. Over a longer period, the vexed question of the nature of so-called general surgery should be examined.
Similar questions can be posed in other fields of medicine. Should there be 4 neurosurgeons per million, or one California-type non-operating neurosurgeon per 50,000 people? Is one anaesthetist per 14,000 people a useful reflection of needs? How many ENT surgeons should be taken into training programmes in each State? Are there too many renal physicians? How many operable aortic aneurysms present in each major city per year, and how many units could maintain adequate experience in their care? (For the intending sarcastic critic, I am not advocating anything more than questions, nor suggesting medical dictatorships.)
I apologize, Sir, for the length of this letter despite its abbreviated analysis, but I think the questions raised are long overdue for close examination, and hope for light rather than heat in any comment that may follow.
24 Brimage Street, Whyalla, S.A. 5600. .