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. In 1980, 945 newly trained general surgeons were certified in the United States. In 2008, the number was essentially the same—972—even though the population has increased by 79 million. In 1994, there were 7.1 general surgeons per 100,000 people. Today there are five per 100,000.