Do you know how many people are at the table with gloves on, when you have an operation? There’s the surgeon and a scrub nurse, of course. A surgical tech may be there too, suctioning up those queasy fluids, holding the arm or leg we’re working on, cutting sutures and holding retractors. But you have seen enough medical shows to know there’s also always at least one other doctor present. We may not engage in the same kind of dramatic medical banter that fictional surgeons do (like flying a passenger jet, safe surgery should be a little bit boring), but that second doctor — the assistant surgeon — should be in the operating room for all major procedures.
You probably haven’t heard much about the assistant surgeon, but all the same, it might interest you to know that we’re running out of them. In teaching hospitals, the assistant surgeon in most operating rooms is a senior resident or fellow — a medical-school graduate who is in training to become a surgeon. (Sometimes a medical student or intern, a first-year resident, may scrub in as well.) The assistant role of the surgical resident is to learn and gain experience, from just watching to doing the whole procedure. There is some pressure on academic surgeons to let the residents actually do the surgery — after all, when the senior residents graduate, they will be in charge themselves somewhere else. When I trained in the mid-1980s, there were always plenty of residents and fellows vying to “do something” at every case; standing room only was the rule. Having lots of assistants on hand can smooth a case out — if they are good. Nowadays, though, surgical-residency programs are much smaller. And even with fewer slots available — many of them, even in good programs, are going empty. (Read “Understanding the Health-Care Debate: Your Indispensable Guide.”)
The combination of hard work, high risk and low pay has made the general surgery specialty nearly as unattractive to new doctors as primary-care medicine. The statistics are grim: a report in the journal Surgery places the nationwide general-surgeon shortage at 1,300 currently, and estimates that the country will be at least 6,000 surgeons short by the time you need your colon removed in 2050.
The problem is already affecting teaching hospitals, where there are typically not enough residents to help on all the cases. Many programs have resorted to hiring physician assistants (PAs) — they’re like surgical residents who never graduate — to provide support when no residents are available to cover the cases. PAs can be a truly great help, but they don’t have the mind-set of a doctor who stands — or will soon stand — in the lead position. When there’s trouble, that mind-set is invaluable. And in surgery, sometimes there is trouble. (See the most common hospital mishaps.)
Most of the surgery in the country takes place in hospitals without residency programs. In these hospitals, the attending surgeon is paid by an insurance company to do the operation (in contrast, at most teaching hospitals, surgeons are either on a fixed salary or part of a group that pools and divides fees) — and he must arrange for another surgeon’s help. This used to be easy, in 1985, when the standard assistant surgeon’s payment of 20% of the primary surgeon’s fee was a great incentive. Since then, the surgeon’s expenses have more than doubled, while fees have shrunk to a quarter or less of what they were. The assistant’s share has dropped to 16%, and, more frustratingly, even after spending their time helping they often are not paid at all, with insurance companies saying the services of an assistant surgeon are “unnecessary.”
Most docs tend to think they should be the ones to decide what services are necessary or not, since they are personally responsible for the results of the surgery. Yet when insurance companies refuse to pay for an assistant, they cite “American Medical Association (AMA) guidelines,” which list procedures as “assistant required” or “not required” (often “not required”). Not surprisingly, 84% of practicing American doctors do not belong to the AMA, and many in my acquaintance have quite a negative view of this organization.
So what’s the alternative? Hospitals that are flush can hire PAs to assist; the one where I work does. But most can’t afford the hefty expense of PAs. Even the hospitals that have the funds don’t have enough to hire PAs for every case. So I often end up begging older colleagues or a surgeon waiting for the start of his own case for a “freebie”; I’m playing on goodwill, friendship or the promise of his eventually getting a paying case.
If all else fails, you just have to operate without another doctor. This is especially true for middle-of-the-night and weekend emergencies. Common sense and unfortunate anecdotes tell us it is unquestionably less safe for the person on the table to have only one doctor present. But, not surprisingly, no surgeon, hospital, insurance company or government agency has wanted to come up with a hard statistic on how much less safe it actually is. It is clearly against all of their interests to show that assistants are needed. And it’s not something I’ve seen brought up in the already too complicated health-care debate. Yet the issue of the missing second surgeon is hurting patients right now.
So, if you are scheduled to have an operation, here’s something to add to your list of questions for the surgeon: Will you need an assistant surgeon? If the answer is yes, ask who will it be and who will pay him. Make a call to your insurer to ask about payment for that assistant to be there. And wear sneakers. You might get quite a runaround.