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574 Letters J Am Coll Surg

13. Sherman R, Magee W. International missions: Cleft care. In:Losee JE, Kirschner RE, eds. Comprehensive Cleft Care. NewYork: McGraw-Hill Medical; 2009:1029–1038.

Disclosure Information: Drs Campbell and Lopez areboth salaried staff surgeons at Operation Smile.

Gaps in the Supply of Physicians,Advanced Practice Nurses, andPhysicians Assistants

Antonio Vittorio Sterpetti, MD, FACS, FRCS

Rome, Italy

I read with much interest the article by Drs Sargen,Hooker, and Cooper,1 which appeared in the June issue ofhe Journal of the American College of Surgeons. Based onheir careful analysis of the overall data available, they pre-ict a significant shortage of physicians, advanced practiceurses, and physician assistants in the near future.This shortage seems to depend on many factors, all well

nalyzed. Their solution is to increase the number of resi-ent positions in the medical system. All sounds quite log-

cal. Then there is always the idea that the US will goankrupt, sooner or later, because of the expenses of theealth system. Everything is based on statistics and math-matical equations.

But let us look at things in another way:

. The steady shortage of physicians in the US has at-tracted, in the past and today, the best minds and themost motivated people from all around the world, giv-ing new enthusiasm and new blood to the Americanhealth system.

. Tight control of the quality of the training system (notjust to increase the number of PGY positions) has al-lowed the formation of a “first class” generation of phy-sicians and advanced practice nurses, who have allowedthe American medical system to remain at the forefrontof medical sciences.

. Everybody looks at how much the US spends onmedical care. Nobody looks at 3 other importantaspects: the well being of the community (with itseconomic significance); the legitimate expectationsof a person who has worked all his life to have ade-quate medical care when needed, without discussinghow much it costs (with its economic significance,including the willingness to pay the exact amount oftaxes); and the economic rewards from being at the

forefront of medicine.

Just let us talk about the last matter, forgotten by many:he fact that the US is at the forefront of medicine (thankso the money spent in the health system and education) hasrought the American pharmaceutical and medical instru-ent industry to first place in the world, selling products

n all 5 continents. Nobody takes this aspect into consid-ration. How much money in taxes is given back by theseompanies?

Finally if we want to attract more people in medicine,e should give physicians, advanced practice nurses, andhysician assistants the respect they deserve for a lifepent in the service of people in need; this does notnclude only the economic aspect but the right publicecognition of their role in this society. In the past it haseen too easy, via every possible medium, to criticize theedical system.Let us be optimistic and do the right things; problems

ill disappear by themselves.

REFERENCE

1. Sargen M, Hooker RS, Cooper RA. Gaps in the supply of physi-cians, advanced practice nurses, and physicians assistants. J AmColl Surg 2011;212:991–999.

Disclosure Information: Nothing to disclose.

Reply

Richard A Cooper, MD

Philadelphia, PA

Dr Sterpetti is correct that our conclusions are based onmathematical equations. Health care follows the economyboth up and down. We assumed slow, continued growth ofboth the economy and health care spending. Recall that thecenterpiece of health care reform was to reduce growthfrom gross domestic product (GDP) � 2.5% to GDP �1.0%. But also recall that the call was for less spending butnot for fewer benefits, which means lower fees. Indeed, ifthe result is that services grow more rapidly than expendi-tures, our projections of the future demand for physiciansand other advanced clinicians may be too low.

Dr Sterpetti’s observation that steady shortages of phy-sicians in the past attracted the best minds from around theworld is also correct. This happened because the number ofresidency positions continually increased, even though USmedical schools had ceased expanding in 1980, leaving

unfilled slots. But residency growth largely stopped in