Clinical and Health Affairs
Minnesota General Surgeons
Where Do They Come From?
By Rory L. Smoot, M.D., and David R. Farley, M.D.
Abstract
A downward trend in the number of graduates from U.S. allopathic medical schools applying for general surgery residency positions has raised questions about whether there will be sufficient numbers of general surgeons to meet future needs. Of particular concern are rural areas, which some studies have suggested will increasingly feel the effects of physician shortages because of the aging physician work force, increasing overall population, and aging patient population. Where physicians are educated and trained appears to have a significant effect on where they choose to practice. This article reports on a 2004 study of where practicing general surgeons in Minnesota went to medical school and did their residencies. According to the findings, the majority received their medical school and/or residency training in the Upper Midwest, and many have come from Minnesota’s own medical schools and general surgery residency programs.
The status of the general surgeon work force in the United States has been the focus of concern for some time. Over the past several decades, there has been a downward trend in the number of graduates from U.S. allopathic medical schools applying for general surgery residency positions. This has led to concern about possible future shortages of general surgeons; some have even called the situation an all-out “crisis.”1 One study, using data from 1987 to 2002, estimated the deficiency at 300 surgeons per year.2 However, the decline in the number of U.S. allopathic medical school graduates entering general surgery residencies does not necessarily mean there will be a shortage of general surgeons.3 In fact, the percentage of categorical (5 years of training) general surgery residency positions matched through the National Residency Match Program (NRMP) has remained steady (~1,000/year) thanks to a significant increase in the number of osteopathic and international medical school graduates filling available positions.4 Although the overall number of surgeons has remained stable, there remains concern about regional shortages of general and specialty surgeons. A 2004 study examining the composition of the physician work force in both rural and metropolitan Minnesota identified several key issues that may lead to shortages in the general surgeon work force, particularly in rural areas: a high proportion of rural specialists (including general surgeons) older than 55 years of age, inability to recruit current graduates to a rural practice, and population growth that exceeds work force estimates.5
One of the many factors contributing to physicians’ decisions about where they will practice is the location of their training. Data from the 2002 Minnesota Resident Physician Exit Survey indicated that physicians were more likely to practice in Minnesota if they had attended high school, college, or medical school in the state.6 We examined the location of training for active general surgeons in Minnesota. The following is a report of our findings.
Methods
General surgeons practicing in Minnesota were identified using information compiled by the Minnesota Medical Association (MMA) and published in its 2004 directory and in the physician-locator database on its Web site in 2004 (MMA Physician Finder at http://www.mmaonline.net/cvweb/membersearch.shtml). The MMA directory lists only physicians who are MMA members, but the Physician Finder database includes information about nearly all physicians in the state. We also identified group practices with physicians that may fit into our sample and then searched those practices’ Web sites to identify additional practicing general surgeons in order to include as many as possible in our study. Information about location of medical school and residency training for each physician was obtained from the MMA Physician Finder, the AMA DoctorFinder, a search function on the American Medical Association’s (AMA’s) Web site (http://webapps.ama-assn.org/doctorfinder/home.html), as well as individual practice Web sites.
Surgeons were excluded if complete information was unavailable, if they were known to be retired, if they were known to be a fellow or resident, or if they were known to have had additional fellowship training (other than trauma/critical care) and to practice primarily in that specialty.
Results
We identified complete records for 303 practicing general surgeons in Minnesota. More than one-third (106) completed medical school in Minnesota: 104 at the University of Minnesota and 2 at Mayo Medical School. Table 1 shows 23% (71) graduated from programs in other Upper Midwestern states: Illinois (30), Wisconsin (13), Michigan (9), Iowa (8), North Dakota (6), and South Dakota (5). Nine percent (28) were graduates of international medical schools: Canada (6), India (5), the Philippines (5), Mexico (2), and Argentina, Germany, Greece, South Africa, Jamaica, Nigeria, Puerto Rico, Spain, Thailand, and Turkey (1 each). Two percent (6) were graduates of U.S. osteopathic medical schools. Nearly half (48%) graduated from a medical school in Minnesota or a bordering state or country (Canada, North Dakota, South Dakota, Wisconsin, or Iowa).
Of the general surgeons identified for this study, 47% (143) did their residency training in Minnesota: University of Minnesota (63), Hennepin County Medical Center (55), and Mayo Clinic (25) (Table 2). Of those who trained outside of Minnesota, the majority came from Michigan (20), Wisconsin (20), Illinois (12), and New York (12). Six practicing surgeons were trained outside of the United States: Canada (3), the Philippines (1), Germany (1), and the United Kingdom (1). Six surgeons received their residency training in U.S. military residency programs.
The majority of Minnesota general surgeons completed medical school (61%) and/or general surgery residency training (70%) in the Upper Midwest (North and South Dakota, Iowa, Nebraska, Illinois, Wisconsin, Michigan).
Discussion
Using self-reported information from publicly accessible databases (the MMA and AMA Web sites), we compiled information about the medical school and residency location of 303 practicing general surgeons in Minnesota. The majority were trained in the Midwest; very few went to medical school or did their residencies in international locales (9% and 2%, respectively). The number of surgeons with international training or osteopathic training is comparable to current national figures, although it is unclear how current trends in the NRMP match and surgeon recruitment will affect these numbers.7
A decline in matched categorical general surgery positions was first noted in 1997. In 1996, 858 positions were filled by graduates of U.S. allopathic medical schools, and by 2002 this number had decreased to 717. As the absolute number of U.S. allopathic medical school graduates in the match decreased, the percentage of international medical school and osteopathic graduates significantly increased.4 Overall, from 1987 to 2002 the percentage of U.S. allopathic medical school graduates choosing general surgery decreased from 7.8% to 5.8%.2 Although these data reveal nothing about the quality of surgical trainees, such trends among American medical students raise concerns regarding the future general surgery work force and its distribution throughout the country.
With regard to Minnesota, concern has been raised about the distribution of physicians in metropolitan and rural areas and the inability to recruit physicians to rural practices. Previous studies have demonstrated that physicians who are educated in Minnesota high schools, undergraduate schools, or medical schools are more likely to stay here.6 Approximately half of all Minnesota medical school graduates eventually practice in our state.8 In 2005, Minnesota had 263 first-year medical students at its 3 medical school locations: Mayo (43), University of Minnesota, Twin Cities campus (165), and University of Minnesota, Duluth campus (55).9 The proportion of students from Minnesota in each first-year class is sizable, for example, 71% in 2004-2005.10 This is comparable to the percentages of in-state applicants in other states. In addition, about half of medical students from Minnesota medical schools go on to residency training in the state. This number has been stable for many years: 51% in both 1994-1995 and 2004-2005. This percentage is higher than the national mean of 39%, but takes into account all medical specialties.10
Minnesota has 3 accredited general surgery training programs: Hennepin County Medical Center, Mayo Clinic College of Medicine, and the University of Minnesota. Collectively, they have a total of 20 categorical general surgery positions to fill each year and are the pool from which future Minnesota general surgeons are most likely to come. This pool appears to be shrinking, however, because many general surgeons seek further training and subspecialize.3 For example at Mayo, 104 general surgery chief residents completed training during the past 13 years. Thirty-seven became general surgeons, and 67 took fellowship training. Although 13 of the physicians completing fellowship training (19%) reside in our state, 54 practice elsewhere. Interestingly, only 7 of the last 32 graduating chief residents have opted to stay in general surgery. National norms suggest at least 60% of U.S. general surgery graduates will take specialty training, and our recent experience at Mayo suggests the percentage may be closer to 80%.
Conclusion
According to the data gathered in this study, most general surgeons practicing within the state of Minnesota received their medical school and/or residency training in the Upper Midwest, and many have come from Minnesota’s own medical schools and general surgery residency programs. Very few general surgeons practicing in Minnesota graduated from international medical schools or trained in foreign residency programs. Although the results of this study do not settle the debates about whether we are preparing enough general surgeons to meet future demands, or how to attract general surgeons to rural areas, or how to combat pressure to subspecialize, it supports the point that general surgeons, like other physicians, tend to practice in a location close to where they were educated and/or trained. It would seem clear that Minnesota medical schools should work diligently to attract and retain their most capable students and trainees. MM
Rory Smoot is a general surgery resident and David Farley is a general surgeon and program director in the Department of Surgery at Mayo Clinic, Rochester.
References
1. Sanfey H. General surgery training crisis in America. Br J Surg. 2002;89(2):132-3.
2. Newton DA, Grayson MS. Trends in career choice by US medical school graduates. JAMA. 2003;290(9):1179-82.
3. Brotherton SE, Rockey PH, Etzel SI. US graduate medical education, 2003-2004. JAMA. 2004;292(9):1032-7.
4. Andriole DA, Klingensmith ME, Schechtman KB. Diversity in general surgery: a period of progress. Curr Surg. 2005;62(4):423-8.
5. Buck ST, Trauba V, Christensen RG. Minnesota physician workforce analysis: rural supply and demand. Minn Med. 2004;87(9):40-3.
6. Rydrych D. New findings from the 2002 Minnesota Resident Physician Exit Survey. Minn Med. 2003;86(8):34-8.
7. Brotherton SE, Rockey PH, Etzel SI. US graduate medical education, 2002-2003. JAMA. 2003;290(9):1197-202.
8. State Health Workforce Profile: Minnesota. Rockville, MD: National Center for Health Workforce Analysis; 2000.
9. AAMC, FACTS: Applicants, Matriculants, and Graduates. 2005. Available at http://www.aamc.org/data/facts/2005/2005school.htm. Accessed September 27, 2006.
10. Barzansky B, Etzel SI. Educational programs in US medical schools, 2004-2005. JAMA. 2005;294(9):1068-74.