In the first two months of his surgical training, Dr. Jason Williams has helped remove a gallbladder, excise tumors, repair hernias, save damaged limbs and patch up gunshot victims.
With eight years of college and medical school behind him, Williams will spend about a decade under the tutelage of senior surgeons before he can practice on his own. Then, when he is pushing 40, he will launch a demanding career that could cost him some family dinners, Thanksgivings and birthday parties.
What drives Williams, a resident in general surgery at the Johns Hopkins and Bayview hospitals, is the exhilaration of using his hands to heal sick patients. But his numbers are dwindling. Fewer medical students are choosing to become surgeons, opting instead for specialties that require less training, leave more time for family and pay just as well.
"It's a real trend, and the main thing is lifestyle," said Dr. Jack Gladstein, associate dean for student affairs at the University of Maryland School of Medicine. "For surgeons in practice, surgery is their primary life and the rest is secondary."
Last year, 782 graduates of U.S. medical schools entered residencies in general surgery, down from 853 five years earlier. Though hospitals have filled the gap by accepting a larger number of foreign applicants, some experts worry about a long-term impact if the problem continues.
"If the trend keeps going south, we could end up with a shortage of surgeons," said Dr. George Sheldon of Atlanta, who is past president of the American College of Surgeons. "And there are a lot of services that only surgeons can provide."
The result could be shrinking surgical departments; longer waits for elective procedures such as joint replacements, cataract surgery and hernia repairs; and fewer top-notch surgical candidates.
"It's a huge concern for us," said Dr. John Harmon, a surgeon at the Johns Hopkins Bayview Medical Center. "We've always gotten the best and the brightest, but the pool of excellent candidates is growing smaller."
Veteran surgeons agree that several factors have worked against the profession. One is the length of the surgical residency, at least five years but as many as 10 for doctors seeking to conduct research or "sub-specialize" in such fields as cardiac or neurosurgery. By contrast, residencies in popular specialties including emergency medicine, radiology and dermatology can be completed in three years.
Surgeons well paid
Surgeons' salaries remain high by any standard, with the average general surgeon who has been in practice at least three years earning about $260,000 annually, according to a recent survey by the private group Physician Search.
Reimbursements for each procedure, however, have declined in recent years as Medicare and private insurers have sought to curb costs. As a result, surgeons need to perform more operations or see their earnings drop.
Radiologists average $309,000, dermatologists $232,000 and emergency medicine specialists $210,000. Generally, those specialties do not consume as many hours treating patients or answering phones and pagers.
Though the importance of family issues crosses gender lines, it might loom larger for women, who today make up about half of the nation's graduating medical-school class.
"There's a much greater percentage of women entering the physician work force in this generation than in the last," said Dr. David Nichols, vice dean of education at Hopkins. "This group does tend to factor in family considerations when considering a career."
Having a life
Women and men who have flocked to emergency medicine concede that they were drawn, in part, by the fact that the job is shift work. After finishing a residency, a physician can work four 12-hour shifts a week and go home without answering the pager.
And they don't have to take care of patients who have been admitted to hospital rooms, unlike surgeons, who are still responsible for their patients once they have left the operating room.
Dr. Shira Kansas, a second-year resident in emergency medicine at the University of Maryland Medical School, said she thrives on the fast pace and intellectual demands of her job, but added that the time away from the hospital will make it easier to raise a family, an important goal for her.
"You can have a life free of the pager," said Kansas, 26. "It's still a difficult lifestyle but you can have more control over your life."
Sharon Swencki, a first-year Maryland resident, is married and hopes also to raise children. Like Kansas, she considered surgery but dismissed the idea because she couldn't imagine juggling the job with family.
And like her colleague, she said she is pleased by the endless variety and intellectual demands of emergency medicine.
In recent weeks, she has treated heart failure, emphysema, gunshot wounds and anxiety. She has learned to suture, perform spinal taps and insert intravenous lines and breathing tubes.
"As an emergency physician, you have to be second-best at everything," she said with some pride. "If you need an airway, the best person is an anesthesiologist. If you need a baby delivered, the best person is an obstetrician." But in a pinch, the "ER" doctor can do everything.
Making it work
To some doctors, the allure of surgery remains strong. Dr. Genevieve Melton-Meaux, a second-year surgical resident at Hopkins, says she doesn't consider the long hours an impediment to raising a family.
"I think it's going to be difficult," said Melton-Meaux, 30, who is married to an attorney and hopes to have children. "But I think that you find ways to fit in your priorities."
On a recent morning, she began her day assisting in two thyroid operations, then spent the afternoon visiting patients recovering from cancer surgery. She spent the night working on the pediatric trauma service, where her patients included a little boy burned over half his body and several youngsters injured in car accidents.
When morning came, she finished her duty by lending a hand in two additional thyroid cases.
"It's a privilege to do what I do," she said. "The skill you gain is just incredible."
So far, top residency programs have had little trouble filling their training positions through the national, computerized "matching" system that pairs graduating medical students with hospitals seeking candidates.
But some of the smaller residency programs run by community hospitals have had a more difficult time.
St. Agnes Hospital in Baltimore, which annually hires three residents seeking careers in general surgery, had filled only one slot through the match conducted last spring. Ultimately, the hospital was able to fill its remaining slots, choosing a student who wasn't initially selected by a hospital and another who decided late to seek a residency.
Dr. John Singer, who runs the St. Agnes program, said the three surgeons are all excellent but concedes that hospitals might find it increasingly difficult to fill their positions unless steps are taken to boost enthusiasm for the specialty.
"I'm worried about general surgery as a profession," Singer said.
The specialty could receive a boost next July by a new rule, adopted by the Accreditation Council for Graduate Medical Education, that will limit residencies to 80-hour work weeks.
The rule, which is aimed at protecting patients by reducing on-the-job fatigue, applies to all specialties. But it could have its greatest impact on the grueling surgical residency, which routinely has young doctors working 100 hours a week or more.
Dr. Keith Lillemoe, who runs Hopkins' general surgery residency, said many program directors are talking about shaving a year off the training regimen to make it more palatable. Once in practice, he added, surgeons in group practice spell one another by taking their colleagues' phone calls and pages.
"But the truth is, it's 5:30 and I've just walked back to my desk," Lillemoe said one evening. "I've got a slip telling me a patient in the intensive care unit has g.i. [gastrointestinal] bleeding and they want me to see him."
One morning in a Bayview operating room, intern Jason Williams and 20-year veteran John Harmon stood with their backs arched over a middle-aged man undergoing a hernia repair. Their gloved hands converged in a flurry of cutting, clamping and suturing.
As operations go, this one was routine. Still, Williams said he took satisfaction from the fact that he has helped to end the hernia patient's pain.
"When you find something that you like to do, and you can actually go and do it, it's a great experience," he said. "You're taking an active role in making somebody better. It's part of a dream."