The production, attrition, and biologic life-time of surgeons in relation to the population of the United States: a look into the future through the clouded computer crystal

A longitudinal analysis of the pediatric surgeon workforce

OBJECTIVE

To describe the trends in the pediatric surgeon workforce during the last 25 years and to provide objective data useful for planning graduate medical education requirements.

SUMMARY BACKGROUND DATA

In 1975, the Study on U.S. Surgical Services (SOSSUS) was published, including a model to survey staffing. A pediatric surgeon workforce study was initiated in conjunction with SOSSUS as a population, supply, and need-based study. The study has been updated every 5 years using the same study model, with the goals of determining the number and distribution of pediatric surgeons in the United States, the number needed and where, and the number of training programs and trainee output required to fill estimated staffing needs. This is the only such longitudinal workforce analysis of a surgical specialty.

METHODS

Questionnaires were sent to 100 pediatric surgeons representing the 62 standard metropolitan statistical areas (SMSAs) in the United States with a population of 200,000 or more to verify the names and locations of all active pediatric surgeons and to gain information about the 5-year need for new pediatric surgeons by region. A program was developed to predict the number of pediatric surgeons relative to the total population and the 0-to-17-year-old population in the subsequent 30 years using updated data on the present number and ages of pediatric surgeons, age-specific death and retirement rates, projections of U.S. population by age group, and varying numbers of trainees graduated per year. As each 5-year update was done, previous projections were compared with actual numbers of pediatric surgeons found. The trends during the last 25 years were analyzed and compared and additional information regarding the demographics of practice, trends in reimbursement, and volume and scope of surgery was obtained.

RESULTS

The birth rate has been stable since 1994. The 0-to-17-year-old population has been increasing at 0.65% per year; a 0.64% annual rate is projected to 2040. At present, 661 pediatric surgeons are distributed in every SMSA of 200,000 or more population, with an average age of 45 and an average age of retirement 65. The actual number of pediatric surgeons in each 5-year survey has consistently validated previous projections. Trainee output has increased markedly in the past 10 years. The rate of growth of the pediatric surgeon workforce at present is 50% greater than the forecasted rate of increase in the pediatric age group, and during the past 25 years the rate of growth of the pediatric surgeon workforce has been double that of the pediatric population growth. Nationally, significant changes in reimbursement, volume of surgery, and demographics of practice have occurred.

Urologic manpower issues for the 21st century: assessing the impact of changing population demographics

OBJECTIVES

To evaluate the impact of changing population demographics on urologic staffing over the coming decades.

METHODS

A model was constructed using data obtained from the U.S. Bureau of the Census for population projections; clinical studies to assess the percentages of men with symptomatic benign prostatic hyperplasia (BPH) and those undergoing prostatectomy; the American Medical Association regarding numbers and annual percent change of practicing urologists; and the American Urological Association regarding numbers of physicians completing residency training programs. Sensitivity analyses were performed varying both the rate of surgical intervention for symptomatic BPH and the annual increase in the number of practicing urologists.

RESULTS

Regardless of variations in the surgical rate to as low as 4%, the average number of transurethral resections of the prostate gland/surgical interventions for BPH per urologist will increase by the year 2020 when compared with the known basepoint value obtained for 1990. Additionally, even with an annual net increase of 200 urologists per year, by 2020, the rapidly expanding population over 65 years of age will nearly offset even such a large increase in the number of practicing urologists.

CONCLUSIONS

The greatest factor concerning future urologic staffing issues will be the changing population demographics. The need for urologic services will continue to rise. An oversupply of urologists can be avoided as long as the net increase does not exceed an average of 200 urologists annually.

Update on the analysis of the need for pediatric surgeons in the United States

Accurate estimations of pediatric surgical manpower needs are necessary if this specialty is to avoid the consequences of under- or oversupply, and reasonable decisions must be made relative to the number of training programs needed.

METHODS

Fifteen, 10, and 5 years ago, pediatric surgeons (PSs) in 62 standard metropolitan statistical areas (SMSAs) having a population of at least 200,000 were asked to estimate the number of PSs needed in their localities. A computer program analogous to the SOSSUS program was designed to project the number of PSs that would result from various numbers of trainee graduates per year. The program has been updated for comparison. Known input data included the present number and age of PSs, age range of trainees, current US population projections to the year 2025, and the average retirement age.

RESULTS

These PSs estimated that 88 additional PSs are needed in the next 10 years. Currently, 26 programs in the United States graduate an average of 24 trainees per year, and six programs in Canada graduate six trainees per year. The previous projection indicated that 20 trainees per year would result in 525 PSs in 1993, and the actual number is 559; so the figures indicate that 27 or 28 PSs are entering practice each year. The apparent increase in numbers is related to entry of Canadian trainees primarily, and a few others, into practice. The current computer projection indicates that 20 graduate trainees per year would result in an absolute increase of 0.55% per year, and 25 per year would result in an increase of 1.43% per year, to 2020, while the increases in the US population would be 1.02% per year for all ages and 0.52% for 0 to 15 year olds. If all programs currently being considered for approval are certified, as many as 36 trainees per year--or 7 times the rate of the 0-15-year population increase--will result.

CONCLUSION

Although an average of 20 graduates per year entering practice would keep pace with the pediatric population, 25 to 27 graduates per year--or 3.5 to 4 times the rate of the 0- to 15-year population increase--can be accommodated now into the current system of delivery of pediatric surgical care on the basis of estimated need. Many more graduates than this would create an excess of surgeons before long.

Surgical manpower: past and present reality, estimates for 2000

The growth in the number of board-certified surgeons in the 1970s, projections of the need for surgeons in the year 2000, and possible factors softening the impact of surgical expansion are discussed in detail. The best index for the optimal supply of surgeons in the United States is related to the phenomenon of local community needs.

Update on the analysis of the need for pediatric surgeons in the United States

An updated version of the 1975 analysis of pediatric surgical manpower needs in the United States by regional questionnaire analysis indicates that pediatric surgeons and capable hospital facilities are unusually well-distributed and that the estimated need is close to the present number practicing. Pediatric surgery grew by a factor of over 30% relative to population over the last five years, but this growth rate would be excessive if it continued. The growth included not only graduates from approved training programs but also from nonapproved training programs and from immigration. Limitations should probably be placed on the latter two sources of entry into the practice system. A computer analysis was made to project numbers of pediatric surgeons per unit population until the year 2010 with differing levels of trainee output. The study indicates that 15-17 individuals entering the system from all sources are sufficient to allow for modest continued growth of the specialty if current population trends continue.

Forecasting health manpower requirements: the case of thoracic surgeons

This paper presents projections of the future demand for thoracic surgery. Estimates of the future supplies of thoracic surgeons are constructed based on three alternative annual Board-certification rates. The consequences of varying supplies of thoracic surgeons, for a given level of expected demand, are presented in terms of expected work-load levels. Since it is costly to society if there are too few thoracic surgeons and since it is an obvious waste of resources if there are too many, no single estimate for an optimal annual increase in the number of thoracic surgeons is suggested. Important inadequacies of data for both forecasting demand and determining work loads are noted.

Urologists and their surgical practice

The work characteristics of urologists were studied as part of a national study of surgeon manpower. Urologists were found to work short hours relative to other surgical specialties, and their operative work load ranked sixth among the ten surgical specialties. The major conclusion was that the supply of urologists was greater than necessary to meet the need for urologic consultants.

Doctors who perform operations. A study on in-hospital surgery in four diverse geographic areas (first of two parts)

The generous supply of surgeons in the United States stimulated a study of their operative work based on all operations performed by all physicians in hospitals of four geographic areas. Each operation was assigned a California Relative Value to permit work-load comparisons between specialties and practices. General practitioners constituted more than one quarter of physicians who performed operations but accounted for less than one tenth of total work. Surgical specialists, about half the physicians in the study, performed about 80 per cent of total operative work. Work loads of surgical specialists varied by certification, specialty, age and practice organization status. We conclude that far too many physicians perform surgical operations and that work loads of surgical specialists are modest. Calculations involving reallocation of operative work loads suggest that the total volume of operations in this study could have been handled by a substantially smaller cadre of busier surgical specialists.

An analysis of the need for pediatric surgeons in the United States

A questionnaire study covering all major population areas in the United States indicated that pediatric surgeons and potentially capable hospitals are already well-distributed throughout the country. The estimation of need for pediatric surgeons based on the area questionnaires is close to the present number of surgeons. A computer analysis was made to project numbers of pediatric surgeons per unit population to the year 2000 with differing levels of trainee output. The study indicates that 14-15 training programs are sufficient to allow for slow, modest growth of the specialty if current population trends continue.

Manpower goals in American surgery. Implications for residency training. Future surgical manpower in the framework of total United States physicians

Constraints on manpower are intrinsic in the establishment of standards of excellence. When such constraints are exerted by individual Boards, Societies, Colleges or Academies they should act to improve the quality of care; their weakness lies in their lack of control over non-members, or those who have failed to pass the examinations. Such manpower constraints become specific objectives or goals when the number of accredited specialists is specifically related to the size of the population served. Any such manpower planning must recognize the many uncertainties in the future of American medicine, and maintain wide elasticity in the planning process. Social and economic pressures render the consideration of specific manpower goals essential at this time. Data from the national surgical study (SOSSUS) make it possible to consider such goals. Manpower objectives for surgery or any other branch of medicine should be considered as a part of the total medical manpower outlook for the United States. Pressures to reduce the number of surgeons entering practice are notable at this time. These should be evaluated against other pressures to maintain or increase the number of hospital-based specialists in all fields as the total number of practitioners undergoes a major expansion over the next 25 years, and the pressure for specialty care is thereby increased. A reasonable balance between these two pressures would be a manpower goal for surgery that allowed a modest growth rate over the next 25-50 years. An example of such is the goal of limiting surgical practitioner growth to a 1% increase in the ratio to population, every 5 years. This would be in sharp contrast to the continuous explosive growth of numbers of surgeons, since World War II.

Problems of eye care delivery

The past 50 years have seen the development of ophthalmology as a sophisticated specialty with improved training programs, increased output of ophthalmologists and growth of knowledge and technology. In spite of this progress, serious problems and conflicts impair the delivery of eye care. One solution may be found in a cooperative Screening Consultation Team system, such as the one currently being evaluated at the University of Florida.

The breeding and feeding of thoracic surgeons

A brief recapitulation of the history of The American Board of Thoracic Surgery reveals that in its 27-year lifetime it has strived to improve the quality of thoracic surgical training. Most recently the Board has decided that candidates from unapproved programs who begin their training after June 30, 1976, will be ineligible for the Board examination. A population of approximately 2,000 thoracic surgeons should be more than adequate to provide patient care in the United Sates. At the present rate of certification the thoracic surgeon population would number about 4,000 within 25 years. With the birth rate in the United States nearing zero population growth, the number of new thoracic surgeons trained and certified each year must be limited, and it is imperative that the profession rather than the federal government be in control of this. Continuing education and evaluation of clinical competence will soon be required in the specialty of thoracic surgery. Cooperation among the major groups concerned with thoracic surgery is necessary for successful development of continuing education and the necessary evaluation of competence.

Internal medicine and family practice. Controversies, conflict and compromise

Internal medicine and family practice have come into conflict because both specialties consider primary care to be part of their "turf". Moreover, in academic medical centers there is competition for scarce resources, including patients and support for residents. Analysis of the number of physicians in practice as well as in training shows clearly that both internists and family physicians, as well as pediatricians and obstetricians, must participate in rendering primary care if the needs for this type of physician are to be met. Internal medicine also has to achieve a better balance between generalists and subspecialists, and family practice must define its limitations, monitor its rapid growth and assure the quality of its training programs. Most of these problems are internal to each speciality rather than between two specialties, and, where there is conflict, compromise is clearly possible.

Head and neck cancer manpower study

1. Approximately 40,000 cases of cancer of the head and neck (excluding skin) are diagnosed each year. 2. Approximately 20,000 of these cases and 30,000 cases of skin cancer are treated by 366 head and neck cancer surgeons. 3. Ninety per cent of the cases are treated by 63 per cent of the surgeons. 4. Fifty-eight per cent of the surgeons care for between 50 and 300 cases per year. 5. While 2,759 new board-certified surgeons of all specialties are recruited annually to maintain a work force of 46,000 board-certified surgeons (3), apparently 730 potential head and neck cancer surgeons are being prepared to maintain a work force of approximately 450 head and neck cancer surgeons. 6. These findings indicate the need for in-depth study of the manpower needs in head and neck cancer surgery by all who are responsible for the training of surgeons in this field.