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March 5, 2008

The Future of General Surgery

JAMA. 2008;299(9):1014-1016. doi:10.1001/jama.299.9.1014-b

To the Editor: In his Commentary predicting the imminent demise of the traditional general surgeon, Dr Fischer1 contends that one of the main reasons for the declining number of surgical residents who pursue a career as a generalist is “redistribution of funds from proceduralists to primary care physicians.”

Although I agree with Fischer's concern regarding potential ill effects on society of this decline in broadly trained surgeons, I disagree that a focus on chronic diseases and better reimbursement for primary care specialties are to blame. There is a widening income gap between primary care and other physicians, and the Medicare Resource-Based Relative Value Scale system may be biased against nonprocedural specialties for many reasons.2 Also, Medicare uses a formula to limit overall increases in spending, which leads to cuts across the board in physician reimbursements.3 Furthermore, if Fischer's contentions are true, there should be increased competition for residency positions in internal medicine, pediatrics, and family practice. Instead, data from the National Residency Matching Program show the opposite.4 In 2007, only 88% of family practice postgraduate-year-1 positions filled, despite a declining number of positions offered in the match. Internal medicine fared better, but only 56% of postgraduate-year-1 internal medicine positions were filled by US seniors, suggesting that internal medicine is becoming one of the least desired medical specialties.

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