Why the Numbers Are Dropping in General Surgery:  The Answer No One Wants to Hear—Lifestyle! FREE

America is captivated by the surgeon—perhaps more so than by any other servant in medicine. Channel surfing through daytime soap operas and prime-time television shows, for instance, inevitably displays the drama of the operating room, a domain otherwise foreign to the lay public. Surgery's allure likewise extends to most medical students; many are fascinated by their operating room experiences during the surgery clerkship and enjoy the combination of procedures, teamwork, and patient care. If medical students continue to be intrigued by surgery as a discipline, though, why do they not appear to be as interested in general surgery as a career?

After the 2000 residency match, when the percentage of students who matched in general surgery dipped into the single digits, concerned individuals in the field attempted to explain the recent decline. Although plausible, most of the theories conjectured seem unlikely from my student perspective. For instance, some suggested that surgeons are too quick to complain about their jobs in front of students. My response is that professors in any field of medicine experience occasional job dissatisfaction or red tape, not just surgeons. Others have mentioned that surgeons do not recruit or have job fairs like some other specialists. I think this is also unlikely to turn students away; my medical school recently held its annual Primary Care Week, and at last count, our class has the highest proportion of students entering nonprimary care fields to date. Some have even suggested that increased proportions of female medical students, who may desire more flexible careers for family or maternity considerations, are responsible for the decline. Although an interesting concept, it fails to explain why more women than ever are choosing general surgery.

I believe the answer is one no one wants to hear.

In the classic 1980s movie St. Elmo's Fire, an elderly woman believes that some words can only be whispered—eg, sex and cancer. I think that lifestyle can be safely added to the list. The definition of the concept varies widely, depending on the source. In the surgical community, lifestyle has come to be equated with material wealth and sloth, but this is not the lifestyle to which I am referring. Although reimbursement may be a factor in some students' decisions, few would be willing or foolish enough to endure the sacrifices of medicine simply for monetary gain, especially when much easier ways of achieving financial security (eg, business school) exist. Similarly, I discount the notion that students who consider other fields are lazy. One of my medical school classmates, who plans to enter general surgery, explained the declining numbers with the proclamation that "people just aren't hardworking or helpful anymore like they were in the greatest generation Tom Brokaw wrote about." We all know that such narrow, blanket statements are untrue, especially in light of the way our nation pulled together in response to our national tragedy on September 11, 2001.

The definition of lifestyle for most students today is time. With a finite amount of time in the day, more time at work necessarily means less time with family or friends. This household time has become increasingly important in our society. Spouses—male and female alike—are no longer satisfied with the paradigm of one breadwinner and one caretaker in the family. As marriage comes to be viewed as a partnership, with 2 parents providing for and nurturing the family unit, quality time becomes even more significant. Physicians want to be involved in their communities and want to give their families the same care and respect they give their patients. As a reader of Newsweek recently wrote to the editor¹:

When I'm lying on my back in the last moments of my life, I doubt very much I will be concerned about any of the plaques on my wall, or where I fit in the executive food chain. Genuine satisfaction comes from a life of giving, supporting and being a significant person in the life of your children.

Although not every medical student chooses a career other than surgery for lifestyle issues, long hours, being on call, and family considerations are often enough to make some students think twice about general surgery, which traditionally is a very demanding career. If you exclude students who have little interest in the surgical experience (a group who cannot and probably should not be swayed to consider general surgery as a career), it is possible to divide the senior medical student population into 3 groups. Although these student paradigms have always existed in medicine, the proportions are changing.

The first group, "renaissance" students, includes those who like everything and find fulfillment in surgical and nonsurgical experiences in medicine. They are positive, bright, well-rounded, hard-working individuals who have the potential for happiness and success in a variety of fields. Assuming that their technical prowess matches their intellect and spirit, they have the capacity to become phenomenal surgeons and, as such, should be courted. Some choose to go into general surgery, but, often, renaissance students become "the ones that got away." When other fields provide them with equal job satisfaction and more time for family, spiritual, or recreational activities, the choice becomes one of prudence.

Unlike the renaissance students, the second group has a definite preference for a surgical career. However, despite their possible interest and talent to become successful general surgeons, they opt not to follow that road. Some, but not all, of the students entering surgical subspecialties fall into this category; they perceive a more conventional lifestyle and retain the opportunity to operate. My problem with this group is that I have always advocated following one's passion, even if it might be the harder road. However, who am I to judge someone whose priorities place more value on other pursuits than on their careers?

The third group, like the first two groups, consists of students who enjoy surgery and who might make excellent surgeons. They are distinguished from the aforementioned groups, however, in that they cannot imagine themselves in any other career. They are focused on general surgery as an end or on a specific fellowship that requires the completion of the general surgery residency. Unfortunately for general surgery residency programs, this group appears to be dwindling.

In summary, the first 2 groups appear to me to include most medical students. Regardless of whether surgeons actually have a decreased quality of life relative to other physicians, many medical students perceive that to be the case. So what must be done? Depending on how you look at it, either student perceptions or the reality of surgeons' working conditions must be altered if bright students from diverse backgrounds are to commit their lives to general surgery. Younger surgeons, having not been far removed from the decision-making process themselves, are perhaps most aware of current student views and can serve as an excellent resource for isolating the drawbacks of a surgical career and working with their peers to reduce them.

The traditional response to such medical student concerns has been to criticize or to trivialize them. Granted, it is easier and less time-consuming to condemn than to attempt to identify the nidus of such concerns. However, if current trends continue, change—ever dreaded—must be implemented. Perhaps it is best to begin with careful introspection: Do you live to work, or work to live?

Corresponding author: Joy A. Henningsen, (e-mail: JoyHenningsen@aol.com).