Editor’s note: The American College of Surgeons (ACS) Board of Governors (B/G) conducts an annual survey of its domestic and international members. The purpose of the survey is to provide a means of communicating the concerns of the Governors to the College leadership. The 2020 ACS Governors Survey, conducted in June and July 2020 by the B/G Survey Workgroup, had a 96 percent (272/282) response rate. For the first time, the leadership of the ACS Young Fellows Association (YFA, Fellows younger than 45 years old), completed the survey. Several results from the YFA survey have been included in this article for comparison.
One of the survey’s topics was evolving surgical practice trends and needs. This article outlines the Governors’ and YFA leadership feedback on these issues.
Transformational change continues in the delivery of health care and, as a result, many surgical practices have developed and adopted new arrangements for providing patient care. In the 2020 ACS Governors Survey, only 48 Governors (17 percent) were in private practice—28 in the U.S. and 20 international surgeons. Twenty-five percent of the private-practice Governors believed they would not finish their careers in private practice. This trend was slightly lower (14 percent) for the international private practice respondents.
Since 2017, the number of private-practice Governors has decreased from 21 percent to 17 percent (see Table 1). This decline is consistent with the decreasing trend of independent private practitioners in the last decade. An even greater disparity between employed and independent physicians emerged when analyzing the YFA leadership results—only 8 percent were in private practice, more than 80 percent in full-time academic practice, and 12 percent were hospital-employed.
TABLE 1. GOVERNORS’ PRACTICE TYPES
Although a small percentage of Governors are in private practice, approximately 80 percent of Governors believed that the preservation of independent practices in some form was moderately important/quite important/essential (see Figure 1). More than 70 percent of international Governors stated that they believe the preservation of private practice was necessary, and 95 percent of the YFA leadership agreed it was important to preserve private practice. Nonetheless, nearly all the YFA leadership respondents indicated that it would be extremely difficult to remain in private practice in the present health care climate.
To help preserve private practice, the College should continue to focus on the drivers of the sharp decrease in private practice and the subsequent rise in hospital employment and academic careers. Strategies to address and preserve independent practices also should be explored.
FIGURE 1. HOW IMPORTANT IS IT THAT INDEPENDENT PRIVATE PRACTICES CONTINUE IN SOME FORM?
Likely use of new ACS resources
To determine how the College might assist surgeons with their practices, Governors were queried on their use of new products and services, such as credentialing assistance, liability products, and billing assistance. Most Governors (75 percent) responded they would be moderately/extremely likely to use assistance with establishing credentialing guidelines. A slightly larger proportion (86 percent) of international Governors were moderately/extremely likely to use assistance with establishing credentialing guidelines.
Interestingly, although fewer than half of the Governors (49 percent) would use liability products if offered, more than 78 percent of surgeons in private practice said they would use them. Most likely this is because those in private practice are more directly affected by medical liability claims and also have greater difficulty bargaining with insurance companies than surgeons in other practice arrangements. Similarly, 72 percent of international Governors would use liability products.
TABLE 2. LIKELIHOOD OF USING ACS RESOURCES
Slightly fewer than half of the Governors (48 percent) indicated they were very likely/moderately likely to use centralized billing services. Likewise, 51 percent of Governors in private practice and 51 percent of international Governors would use these services.
If the College were to offer a fee schedule, most Governors (77 percent) would find this service somewhat/moderately/extremely helpful. Private practitioners (83 percent) were most likely to value this product, with international surgeons (66 percent) placing less value on an ACS-created fee schedule. Less than one-third of the Governors (28 percent) believed an ACS fee schedule would be extremely helpful.
Overwhelming, the Governors indicate a desire to use these resources if the College offered them. The development of these resources should be explored (see Table 2).
Significant changes in physician retirement planning have occurred recently, in large part because of the coronavirus 2019 (COVID-19) pandemic. More than half of the Governors (52 percent) indicated they recently have adjusted their retirement plans. In fact, 66 percent of the Governors who have altered their retirement plans will delay it, whereas 34 percent plan to retire earlier than originally anticipated. Among international Governors who have revisited their retirement plans, 89 percent said they will delay retirement (see Figure 2).
FIGURE 2. COMPARED WITH YOUR INITIAL PLANS, WHEN DO YOU PLAN TO RETIRE?
In recent years, the physicians choosing early retirement have indicated excessive regulations, the increasing inability for surgeons to control operating room business decisions, and burnout as the major deciding factors in those decisions. This survey found similar reasons for early retirement.
Interestingly, 33 percent of the YFA leadership indicated they would change their retirement plans, with 20 percent planning to retire earlier and 13 percent delaying retirement. The reasons for retiring earlier also remained consistent for the YFA leadership. The reduction of young surgeons in the workforce because of early retirement is particularly disconcerting and will significantly affect patient care. The early retirement of many young surgeons will have a dramatic impact on the future workforce and is a call for action for the College to address these issues and attempt to reverse the trend.
Young surgeon involvement in the ACS
To emphasize the important role of young surgeons in moving the surgical profession into a new era, the survey asked about this group’s unique needs and perceptions of the ACS. Most Governors (66 percent) said they believe younger surgeons were adequately included in College activities. Similarly, 75 percent of the YFA leadership agreed with this perception, whereas only 57 percent of international Governors expressed the same sentiment.
Respondents offered several constructive suggestions for changes and improvements to increase the involvement of young surgeons in College activities, such as making greater use of social media and other digital communication vehicles (including videos, virtual lectures, webinars, and so on). Another common recommendation was that the College explore additional formal mentorship programs.
YFA leaders also recommended increased opportunities for young surgeons to chair or co-chair ACS committees and to moderate or co-moderate Clinical Congress sessions. They suggested formalizing specific leadership roles for young surgeons throughout the College, similar to how many chapters have designated key leadership roles for YFA and Resident and Associate Society members on their boards or executive councils.
Additional recommendations focused on increasing heterogeneity in the surgical workforce and providing short-term nonclinical practice options for personal or other reasons, as well as pathways to safely and effectively reenter the surgical workforce. A progressive approach should be implemented to accommodate the changing culture of the surgical profession, especially as it relates to younger surgeons.
As the surgical profession continues to evolve, the need to preserve, protect, and support private practices increases. Without interventions or changes, private practices as we know them will perish. Credentialing and navigating the intricacies of fee scheduling remain a challenge and potentially undermine the physician-patient relationship. The College should continue to explore ways to improve, reduce, or eliminate these drivers.
Governors also believe that the College needs to continue a strong integration of the next generation of surgeons, as they represent the future of the profession. Chapters can play a critical role by actively encouraging the participation of younger surgeons, as well as providing leadership opportunities for the next generation. Continued emphasis also should be placed on the importance of mentorship opportunities.
Early retirement is another area that the College should continue to focus on in light of evidence that burnout and decreasing reimbursement are accelerating surgeon retirements and thereby decreasing the surgical workforce. ♦
Members of the Board of Governors Survey Workgroup want to thank the College for the privilege of working on the survey. We owe a great debt of gratitude to Emily Kalata, Manager, Board of Governors, Division of Member Services, Chicago, IL, for the immense amount of work she has done on behalf of the workgroup, as well as her wonderful insight. We thank all the Governors for their participation in this important survey.
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