Fewer hands for that stitch in time

It is not yet 9am and as most of his 27,000 neighbours are getting ready for Saturday chores, John Phillips has a familiar one in front of him.

Anaesthetised and draped in blue is a 10-year-old boy with an abscess on his belly. An overhead lamp shines on a patch of skin the size of a playing card.

Phillips asks for a scalpel and bisects the glowing rectangle with a single cut.

About 200 miles to the west, Robert Kuhl has started his chores, too.

The first is fixing the broken hip of a 94-year-old widow who fell the night before. Like so many of the 7,500 people in Creston, Iowa, she would rather have the operation where she lives than in a big city miles away.

Through an incision in her thigh, Kuhl will saw off the broken end of the femur and replace it with a metal one that fits the joint socket. The procedure is called a hemiarthroplasty.

Kuhl is the only person in a 130-kilometre radius who can do it. It will take him about 90 minutes.

Phillips, who is 61, and Kuhl, who is 57, are general surgeons. People such as this duo are the backbone of rural medicine. And all across America they are starting to disappear.

For the one-quarter of Americans who live outside metropolitan areas, general surgeons are the essential ingredient that keeps full-service medical care within reach.

But various forces — educational, medical and sociological — are making them an endangered species.

Many young physicians are opting for non-surgical specialties, such as radiology or cardiology, in which they can earn as much money as a surgeon with less gruelling and unpredictable hours.

Many young surgeons, in turn, choose to concentrate in fields such as transplant surgery or plastic surgery, in which they can make more money and don't have to face (usually alone) the wide range of problems a generalist faces.

“The shortage of general surgeons is at crisis dimensions,'' said George Sheldon, director of the American College of Surgery's Health Policy Institute, based at University of North Carolina. If the trend continues, he said, “the quality of healthcare will suffer''.

In 1994, there were 7.1 general surgeons per 100,000 people. Today there are five per 100,000.

The problem is not limited to wide-open spaces such as the Iowa countryside.

Nevertheless, it is in rural America — where some places have only half as many surgeons per capita as cities — that the problem is most acute.

And it is likely to get worse. More than half of rural general surgeons are older than 50 and a wave of retirements is expected in the coming decade.

The federal government, through the Health Resources and Services Administration, offers various incentives to get primary-care physicians and dentists to work in places with “unserved, underserved, vulnerable and disadvantaged populations''.

But general surgeons aren't part of the programme. The American College of Surgery's chief tactic to date has been to try to let people know the problem exists.

In certain places, it is already affecting patients. The 24-bed Northern Cochise Community Hospital in Willcox, Arizona, lost its surgeons five years ago.

Now, emergency cases are flown by helicopter to Tucson, about 130 kilometres away. Each flight costs $14,000; there are about ten a month.

Surgeons help hospitals remain viable in less obvious ways, too. South Sunflower County Hospital in the Mississippi Delta town of Indianola serves one of the poorest and most medically needy populations in the United States.

The 49-bed hospital has four family practitioners who deliver babies and perform Caesarean sections.

Two full-time nurse anaesthetists provided the anaesthesia for the C-section patients and the patients of the hospital's sole surgeon.

When he left two years ago, however, the hospital couldn't afford to keep the anaesthetists unless it could find more work for them. And without anaesthesia services, the obstetrics service would have to close.

Jimmy Blessitt, the hospital administrator, scrambled and finally persuaded a surgeon at a hospital about 60 kilometres away to come in two days a week.

“We would like to have a full-time person in general surgery,'' Blessitt said. “But it is getting more and more difficult.''

John Phillips, the Iowa surgeon, is compact and trim, a fisherman, woodworker and computer geek.

He has worked in Burlington, a city in southeast Iowa on the Mississippi River, since July 1978, the month he finished his five-year general surgery residency in Chicago.

Like internal medicine physicians, general surgeons are trained in a vast field. Many then specialise. Others, such as Phillips, don't.

Phillips performs operations for gall bladders, colon cancer, breast cancer and hernias. He does some easier forms of vascular surgery.

He doesn't do chest surgery. Burlington also supports a few orthopaedic surgeons but their skills are not interchangeable with those of general surgeons.

When Phillips started, there were four general surgeons in Burlington. Now there are three — he and two younger partners.

Every third weekend, it is his responsibility to see, treat or ship every general surgery case in Great River Medical Centre's catchment area — a region stretching east across the Mississippi into Illinois and south into Missouri. People such as the fifth-grader Luis Rascon Jr.

It takes Phillips less than 15 minutes to clean and drain the infection, pack the unsutured wound with gauze and cover it with a bandage.

It turns out it is an MRSA infection — “methicillin-resistant Staphylococcus aureus'' — a once-rare hospital-acquired bug that is now in “the community'' nationwide.

Phillips, in blue scrubs, steps out and tells the Rascon family that all is well. The boy will have to stay in the hospital a couple of days until the redness on his skin goes away. Repacking the wound will hurt.

“He'll do fine, though,'' the doctor says, adding he will see them in the morning, if not before.

Halfway across Iowa, Kuhl is even more overworked than Phillips and his partners. Kuhl also has spent his career in one place — in his case, where he grew up and where his father practised general surgery for 32 years.

Iowa has 117 hospitals. All but nine of its 99 counties have one. The vast majority have fewer than 25 beds and are what the federal Medicare programme designates “critical access'' institutions.

Nevertheless, in many towns such as Creston, the hospital is in good financial shape, the result of civic commitment and six decades of growth in healthcare spending.

The incongruously named Greater Regional Medical Centre — it has 25 beds — has a $12-million addition that includes a new emergency room, cancer centre and radiation therapy suite.

Out back is a new $1.6 million hospice. Responsible for one third of the hospital's revenue is the surgery department — Kuhl and one other surgeon.

“A hospital such as this one would fold quickly without surgery,'' he says matter-of-factly.

He had another partner for 22 years but that man left 18 months ago.

His new, younger partner has a smaller repertoire of operations that doesn't include orthopaedics, which means Kuhl is summoned for those cases even when he is off duty.

The new man didn't perform C-sections either until Kuhl taught him, scrubbing in to supervise the first dozen. Kuhl still does 67 per cent of Creston's surgeries.

Things aren't as bad as they were in the 1980s, when Kuhl was the only surgeon in Creston for two and a half years.

Nevertheless, at 57, he is on call every other night — a frequency not allowed for young surgeons in training — which he says “gets tiresome''.

Sitting at the empty nursing station in the intensive-care unit — no critically ill patients are in the hospital at the moment — he talks about a less obvious burden.

Much research has revealed that volume and quality often go hand-in-hand in medicine.

Doctors who perform a procedure often tend to have fewer complications than doctors who do it rarely. But rural general surgeons are necessarily “low-volume'' practitioners of many operations they are expected to perform.

Knowing which patients to keep — and which to refer elsewhere — requires that a surgeon continually reassess his own skill and experience.

For example, Kuhl no longer operates on the pancreas (which many surgeons liken to disarming a landmine).

He acknowledges that if he had a patient with “a nasty gastric cancer, I don't know if I'd do it now''. Those patients go to Des Moines, Omaha or Iowa City — 128, 160 and 305 kilometres away.

He has been sued for malpractice only twice and on neither occasion successfully.

He also has a civic life that included coaching his sons' sports teams and 18 years on the school board.

But many younger surgeons are not interested in this kind of life — and when they are, their spouses often aren't. It takes a lot to lure them to places such as working-class Creston.

When the hospital hired Kuhl's younger partner, it guaranteed him a salary greater than the $185,000 the older man had been making.

Kuhl threatened to quit; arrangements were made to assure him a higher income, too. Kuhl wants to retire in about five years. He has all kinds of plans.

But he won't rule out doing orthopaedic cases part-time. Without him, he knows, patients such as the 94-year-old widow would have to go nearly130 kilometres to have their hip fractures treated.

“Lots of old farm folk around here,'' Kuhl says in the dim light of the empty ICU. “They're the most loyal people. Some of these people would literally rather die than go to Des Moines.''