0
We're unable to sign you in at this time. Please try again in a few minutes.
Retry
We were able to sign you in, but your subscription(s) could not be found. Please try again in a few minutes.
Retry
There may be a problem with your account. Please contact the AMA Service Center to resolve this issue.
Contact the AMA Service Center:
Telephone: 1 (800) 262-2350 or 1 (312) 670-7827  *   Email: subscriptions@jamanetwork.com
Error Message ......
Special Article |

Getting the Science Right on the Surgeon Workforce Issue FREE

David A. Etzioni, MD, MSHS; Samuel R. Finlayson, MD, MPH; Thomas C. Ricketts, PhD, MPH; Dana C. Lynge, MD; Justin B. Dimick, MD, MPH
[+] Author Affiliations

Author Affiliations: University of Southern California, Los Angeles (Dr Etzioni); Dartmouth College, Hanover, New Hampshire (Dr Finlayson); University of North Carolina, Pembroke (Dr Ricketts); University of Washington, Seattle (Dr Lynge); University of Michigan, Ann Arbor (Dr Dimick).


Arch Surg. 2011;146(4):381-384. doi:10.1001/archsurg.2011.64.
Text Size: A A A
Published online

In this article we summarize the perspectives given by a range of health policy researchers as presented at the fifth annual meeting of the Surgical Outcomes Club at the annual meeting of the American College of Surgeons in Chicago, Illinois, on October 11, 2009. During that session, the participants reviewed 3 main areas that are summarized here: history of physician/surgeon workforce policy, current beliefs, recent policy activity, and issues related to forecasting/planning the future surgical workforce.

Figures in this Article

The debate over US physician workforce policy has reached a fever pitch. Surgical leaders and the press have called attention to situations in which the needs of patients are not being met by the regional supply of general surgeons.13 General surgical services are increasingly perceived as vital, not only to patients and communities, but to the financial viability of rural hospitals.4 These articles have raised awareness of the importance of general surgical services within regions and what can happen if the regional supply of general surgeons runs short.

The modern history of physician workforce projections and planning is best reviewed in phases: before 1980, the 1980 Graduate Medical Education Needs Advisory Committee (GMENAC) Report, and the 1980s and 1990s.

In the period leading up to 1980, there was growing consensus of an oversupply and maldistribution of the surgical workforce. Leaders in health policy research called attention to a low operative workload among surgeons in practice.57 The Study on Surgical Services in the United States, published in 1974, led to tightening of the process of accreditation to reduce the number of non–board-certified surgeons.8 While the Study on Surgical Services in the United States report did not recommend restricting the numbers of surgical trainees, it did advocate that training become more centralized in academic medical centers. The study provoked considerable discussion but was felt to support the status quo in surgery.9

The emerging consensus in the 1970s was that there was a significant oversupply of physicians in general, and surgeons specifically. It was within this framework that in 1980 the GMENAC report to the Secretary of the Department of Health and Human Services was released.10 The report suggested a surplus of 140 000 physicians (approximately 25%) and 11 800 general surgeons (approximately 50%) by the year 2000 and gave more than 100 recommendations regarding policy changes by which these surpluses might be reduced. The policy response was to withdraw support for expansion of medical schools and reduce pressure to redistribute incentives among specialties. There were few expansions of medical school classes, and almost no new schools were opened. Graduate Medical Education growth slowed and essentially flattened in this period.

The period following the GMENAC report was most notable for the increased penetration of Health Maintenance Organizations (HMOs) and the belief that such systems would decrease the use of medical care in general. Managed care entities were seen as providing a way to balance population-based needs with the staffing of networks and systems of care.11 A wide range of players in the health care policy arena aligned in agreement with the findings of the GMENAC report and also argued for a reduction in the rate of physician training of up to 25%.1215 Perhaps the most important action during this era was the passage of the Balanced Budget Act in 1997, which capped the number of residency training positions that would be funded through Medicare.

Here we will review the major schools of thought regarding the current state of the physician workforce. Each approach we describe has validity in terms of predicting the surgeon supply relative to demand in the coming decades, and all have significant shortcomings.

Needs-Based Models

Developing and applying a needs-based model for physician workforce projections is conceptually straightforward. Ideally, a needs-based approach allows for estimates of true population need considering changes in technology and health status. In practice, the method involves an assumption that the rates at which surgical work is performed (per population) remain constant over time and that population growth therefore directly engenders an increase in surgical output. To the extent that the surgical workforce does not grow to meet this increase, there is a workforce shortage. In the last decade, several studies have applied this approach to forecast growth in surgical work; 2 examples are described here. In 2003, Etzioni et al16 found that, as a result of an expanding/aging population, there would be a 31% increase in surgical work between 2001 and 2020. More recently, Williams et al17 estimated that, in 2030, there would be a 9% shortage in the general surgical workforce, with greater shortages in other surgical specialties.

Economic Models

The number of physicians in the United States per capita has grown substantially faster than the population. This observation lies at the heart of a school of physician workforce forecasting described in a 2002 study by Cooper et al.18 Their approach, termed a trend model, is based on the assumption that there is a causal relationship between economic growth and the number of physicians per capita (Figure 1). Other factors also considered in the trend model are population growth, physician work effort, and the availability of nonphysician clinicians. Based on this model, the physician supply will be significantly inadequate to the demands of the population by 2020.

Place holder to copy figure label and caption
Figure 1.

Physician supply and gross domestic product, 1929-2000, projected to 2020. NPC indicates nonphysician clinician. Reprinted with permission from Health Aff (Millwood).18

Graphic Jump Location
Dartmouth Model: Benchmarking Using Regional Variation

Since the 1970s, Wennberg and colleagues at Dartmouth have analyzed regional variations in rates of surgical procedures and concentrations of medical and surgical specialists. The degree of the variation in regional physician supply is significant; in a recent report by Goodman et al, the number of physicians per capita was 1.6 times higher in high-supply regions compared with low-supply regions (Figure 2).19 A natural question arises: is the quality of care worse in regions where physician supply is lower? According to the analyses from the Dartmouth group, the answer is “No.” Patient satisfaction, quality of care, and access to care appear to be no different. Based on these findings, Skinner, Goodman, and Fisher stand against a growing belief that a looming shortage of physicians will compromise quality of care in the US.

Place holder to copy figure label and caption
Figure 2.

The specialist physician workforce per 100 000 population, age and sex adjusted by the Dartmouth Atlas Hospital Referral Regions, 2006. Shown is the marked variation in specialist physician supply. Numbers in parentheses indicate number of hospital referral regions in each group. Reprinted with permission from the Dartmouth Atlas of Health Care Working Group (American Medical Association Masterfile data).

Graphic Jump Location
Increase the Overall Number of Physicians

Although there are several contrasting opinions about the current surgical workforce, most existing policies focus on addressing an overall shortage. In 2006, the Association of American Medical Colleges released a statement advocating an increase in medical school positions by 30% during the 10-year period beginning in 2002.20 While enormously important, such an increase would have no effect on the rate at which trained physicians are produced. Because approximately 25% to 30% of physicians in residency training positions are international medical graduates, this policy action would only serve to displace international medical graduates from domestic training programs. If the number of physicians in the United States is to increase, then the residency caps from the Balanced Budget Act need to be repealed, a move that was proposed in the Resident Physician Shortage Reduction Act of 2009, currently in committee in the US Senate. This bill proposes a 15% increase in the number of residency positions funded through Medicare. Of great interest to general surgeons should be the language included in this piece of legislation, in which specific preference is given to “ . . . hospitals that submit applications for new primary care and general surgery residency positions . . . ” While it is tempting to look at such action as an appropriate and timely reaction to a future physician shortage, it is important to consider the timeline in which such changes might occur. An immediate 15% increase in residency training positions would only result in an increase of 7.5% in trained general surgeons after a 20-year period (assuming a 30-year career in practice).

Focus on Regional Workforce Issues

The adequacy of the surgical workforce should be considered not only in terms of its size, but also its distribution relative to the demands/needs of the population. The regional variation in physicians and surgeons documented by the Dartmouth Atlas highlights this point. Why worry about a 10% shortfall when there are 50% differences across different regions in the United States? Rural areas in particular are known to have a ratio of surgeons to population that is significantly lower than nonrural areas.21,22 If the goal is to alleviate shortage, simply increasing the number of general surgeons will not necessarily lead to an increased supply of surgeons in the areas where the need is greatest. Research has shown that new physicians preferentially settle in areas where supply is already high.23 Simply increasing the surgical workforce is a blunt method by which to address regional shortages of surgeons.

What policy levers are available to redistribute surgeons from areas of relative abundance to areas with relative shortage? Geographically focused recruitment/retention with immigration visas, loan forgiveness, and other incentives need to be discussed as ways to optimize the delivery of care by a workforce that is not distributed according to patient needs. The activation of these policy levers would ideally be armed with valid, reliable methods for measuring and reporting the adequacy of surgeon supply within specific regions.

Develop Methods for Reliably Determining the Adequacy of the Surgical Workforce

Validated measures that meaningfully measure and report the adequacy of the surgical workforce need to be developed and implemented. It is in this area that we believe the greatest work needs to be done. Most recent reviews of the status of the surgical workforce are based on surgeon to population ratios, a calculation that is insensitive to regional differences in patient demands and physician practice patterns. A more useful system would investigate the ability of patients and hospitals to access surgical treatment. To best guide policy efforts, this type of system should be detailed enough to analyze specific types of surgical care, including hospital/emergency department coverage, subspecialty surgical services, and trauma care. This information is needed to inform policymakers involved in responding to issues regarding the regional availability of surgical services. Without significant advances in measures that track access to treatment, the policy debate will continue to be driven by opposing analyses of secondary data. The American College of Surgeons is ideally placed to take a leadership role in developing and reporting these types of measures.

During the last 2 decades, the general surgical workforce has remained remarkably stable in terms of overall numbers but has slowly declined in terms of the number of surgeons per population.24 Unless the rate at which general surgeons are trained increases, the number of general surgeons per population will continue to decline. The extent to which these decreases will result in worse access to care or quality of care is difficult to predict. Surgical leadership, especially the American College of Surgeons, needs to become more engaged in this process to ensure its appropriate progress. The health of our patients and communities depends on it.

Correspondence: Justin B. Dimick, MD, MPH, Department of Surgery, University of Michigan, 211 N Fourth Ave, Ste 301, Ann Arbor, MI 48104 (jdimick@med.umich.edu).

Accepted for Publication: March 19, 2010.

Author Contributions:Study concept and design: Etzioni, Finlayson, Ricketts, Lynge, and Dimick. Acquisition of data: Ricketts. Analysis and interpretation of data: Ricketts. Drafting of the manuscript: Etzioni, Ricketts, Lynge, and Dimick. Critical revision of the manuscript for important intellectual content: Finlayson, Ricketts, and Dimick. Administrative, technical, and material support: Etzioni, Ricketts, and Dimick. Study supervision: Finlayson and Lynge.

Fuhrmans  V Surgeon Shortage Pushes Hospitals to Hire Temps. Wall Street Journal. January13 , 2009:A1
Brown  D Shortage of General Surgeons Endangers Rural Americans. Washington Post. January1 , 2009:A1
Fischer  JE The impending disappearance of the general surgeon. JAMA 2007;298 (18) 2191- 2193
PubMed Link to Article
Doty  BZuckerman  RFinlayson  SJenkins  PRieb  NHeneghan  S General surgery at rural hospitals: a national survey of rural hospital administrators. Surgery 2008;143 (5) 599- 606
PubMed Link to Article
Hughes  EFFuchs  VRJacoby  JELewit  EM Surgical work loads in a community practice. Surgery 1972;71 (3) 315- 327
PubMed
Hughes  HFLewit  EMLorenzo  FV Time utilization of a population of general surgeons in community practice. Surgery 1975;77 (3) 371- 383
PubMed
Longmire  WP  Jr Problems in the training of surgeons and in the practice of surgery. Am J Surg 1965;11016- 20
PubMed Link to Article
American College of Surgeons and the American Surgical Association Surgery in the United States: A Summary Report of the Study on Surgical Services for the United States.  Baltimore, MD: American College of Surgeons and the American Surgical Association; 1975
Hughes  EFLewit  EMPauly  MV “The study on surgical services for the United States”: a valid prescription for American surgery? Milbank Mem Fund Q Health Soc 1977;55 (4) 465- 484
PubMed Link to Article
 Summary Report of the Graduate Medical Education National Advisory Committee to the Secretary, September 20, 1980. Vol 1. Washington, DC: Dept of Health and Human Services; 1980
Goodman  DCFisher  ESBubolz  TAMohr  JEPoage  JFWennberg  JE Benchmarking the US physician workforce: an alternative to needs-based or demand-based planning. JAMA 1996;276 (22) 1811- 1817
PubMed Link to Article
Institute of Medicine Nation's Physician Workforce: Options for Balancing Supply and Requirements.  Washington, DC: National Academy Press; 1996
 AAMC policy on the generalist physician. Acad Med 1993;68 (1) 1- 6
PubMed Link to Article
Pew Health Professions Commission Critical Challenges: Revitalizing the Health Professions for the Twenty-First Century.  San Francisco, CA: UCSF Center for the Health Professions; 1995
Council on Graduate Medical Education (U.S.) Improving Access to Health Care Through Physician Workforce Reform: Directions for the 21st Century: Third Report.  Rockville, MD: United States Department of Health and Human Services, Public Health Service, Health Resources and Services Administration, Bureau of Health Professions, Division of Medicine; 1992
Etzioni  DALiu  JHMaggard  MAKo  CY The aging population and its impact on the surgery workforce. Ann Surg 2003;238 (2) 170- 177
PubMed
Williams  TE  JrSatiani  BThomas  AEllison  EC The impending shortage and the estimated cost of training the future surgical workforce. Ann Surg 2009;2727
PubMed
Cooper  RAGetzen  TE McKee  HJLaud  P Economic and demographic trends signal an impending physician shortage. Health Aff (Millwood) 2002;21 (1) 140- 154
PubMed Link to Article
Goodman  DCFisher  ES Physician workforce crisis? wrong diagnosis, wrong prescription. N Engl J Med 2008;358 (16) 1658- 1661
PubMed Link to Article
American Association of Medical Colleges Statement on the Physician Workforce Accessed August 26, 2008. http://www.aamc.org/download/55458/data/workforceposition.pdf
Lynge  DCLarson  EHThompson  MJRosenblatt  RAHart  LG A longitudinal analysis of the general surgery workforce in the United States, 1981-2005. Arch Surg 2008;143 (4) 345- 351
PubMed Link to Article
Thompson  MJLynge  DCLarson  EHTachawachira  PHart  LG Characterizing the general surgery workforce in rural America. Arch Surg 2005;140 (1) 74- 79
PubMed Link to Article
Goodman  DC Twenty-year trends in regional variations in the US physician workforce. Health Aff (Millwood) 2004;(suppl Web exclusives)VAR90- VAR97
PubMed
Sheldon  GF Surgical workforce since the 1975 study of surgical services in the United States: an update. Ann Surg 2007;246 (4) 541- 545
PubMed Link to Article

Figures

Place holder to copy figure label and caption
Figure 2.

The specialist physician workforce per 100 000 population, age and sex adjusted by the Dartmouth Atlas Hospital Referral Regions, 2006. Shown is the marked variation in specialist physician supply. Numbers in parentheses indicate number of hospital referral regions in each group. Reprinted with permission from the Dartmouth Atlas of Health Care Working Group (American Medical Association Masterfile data).

Graphic Jump Location
Place holder to copy figure label and caption
Figure 1.

Physician supply and gross domestic product, 1929-2000, projected to 2020. NPC indicates nonphysician clinician. Reprinted with permission from Health Aff (Millwood).18

Graphic Jump Location

Tables

References

Fuhrmans  V Surgeon Shortage Pushes Hospitals to Hire Temps. Wall Street Journal. January13 , 2009:A1
Brown  D Shortage of General Surgeons Endangers Rural Americans. Washington Post. January1 , 2009:A1
Fischer  JE The impending disappearance of the general surgeon. JAMA 2007;298 (18) 2191- 2193
PubMed Link to Article
Doty  BZuckerman  RFinlayson  SJenkins  PRieb  NHeneghan  S General surgery at rural hospitals: a national survey of rural hospital administrators. Surgery 2008;143 (5) 599- 606
PubMed Link to Article
Hughes  EFFuchs  VRJacoby  JELewit  EM Surgical work loads in a community practice. Surgery 1972;71 (3) 315- 327
PubMed
Hughes  HFLewit  EMLorenzo  FV Time utilization of a population of general surgeons in community practice. Surgery 1975;77 (3) 371- 383
PubMed
Longmire  WP  Jr Problems in the training of surgeons and in the practice of surgery. Am J Surg 1965;11016- 20
PubMed Link to Article
American College of Surgeons and the American Surgical Association Surgery in the United States: A Summary Report of the Study on Surgical Services for the United States.  Baltimore, MD: American College of Surgeons and the American Surgical Association; 1975
Hughes  EFLewit  EMPauly  MV “The study on surgical services for the United States”: a valid prescription for American surgery? Milbank Mem Fund Q Health Soc 1977;55 (4) 465- 484
PubMed Link to Article
 Summary Report of the Graduate Medical Education National Advisory Committee to the Secretary, September 20, 1980. Vol 1. Washington, DC: Dept of Health and Human Services; 1980
Goodman  DCFisher  ESBubolz  TAMohr  JEPoage  JFWennberg  JE Benchmarking the US physician workforce: an alternative to needs-based or demand-based planning. JAMA 1996;276 (22) 1811- 1817
PubMed Link to Article
Institute of Medicine Nation's Physician Workforce: Options for Balancing Supply and Requirements.  Washington, DC: National Academy Press; 1996
 AAMC policy on the generalist physician. Acad Med 1993;68 (1) 1- 6
PubMed Link to Article
Pew Health Professions Commission Critical Challenges: Revitalizing the Health Professions for the Twenty-First Century.  San Francisco, CA: UCSF Center for the Health Professions; 1995
Council on Graduate Medical Education (U.S.) Improving Access to Health Care Through Physician Workforce Reform: Directions for the 21st Century: Third Report.  Rockville, MD: United States Department of Health and Human Services, Public Health Service, Health Resources and Services Administration, Bureau of Health Professions, Division of Medicine; 1992
Etzioni  DALiu  JHMaggard  MAKo  CY The aging population and its impact on the surgery workforce. Ann Surg 2003;238 (2) 170- 177
PubMed
Williams  TE  JrSatiani  BThomas  AEllison  EC The impending shortage and the estimated cost of training the future surgical workforce. Ann Surg 2009;2727
PubMed
Cooper  RAGetzen  TE McKee  HJLaud  P Economic and demographic trends signal an impending physician shortage. Health Aff (Millwood) 2002;21 (1) 140- 154
PubMed Link to Article
Goodman  DCFisher  ES Physician workforce crisis? wrong diagnosis, wrong prescription. N Engl J Med 2008;358 (16) 1658- 1661
PubMed Link to Article
American Association of Medical Colleges Statement on the Physician Workforce Accessed August 26, 2008. http://www.aamc.org/download/55458/data/workforceposition.pdf
Lynge  DCLarson  EHThompson  MJRosenblatt  RAHart  LG A longitudinal analysis of the general surgery workforce in the United States, 1981-2005. Arch Surg 2008;143 (4) 345- 351
PubMed Link to Article
Thompson  MJLynge  DCLarson  EHTachawachira  PHart  LG Characterizing the general surgery workforce in rural America. Arch Surg 2005;140 (1) 74- 79
PubMed Link to Article
Goodman  DC Twenty-year trends in regional variations in the US physician workforce. Health Aff (Millwood) 2004;(suppl Web exclusives)VAR90- VAR97
PubMed
Sheldon  GF Surgical workforce since the 1975 study of surgical services in the United States: an update. Ann Surg 2007;246 (4) 541- 545
PubMed Link to Article

Correspondence

CME
Also Meets CME requirements for:
Browse CME for all U.S. States
Accreditation Information
The American Medical Association is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The AMA designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 CreditTM per course. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Physicians who complete the CME course and score at least 80% correct on the quiz are eligible for AMA PRA Category 1 CreditTM.
Note: You must get at least of the answers correct to pass this quiz.
Please click the checkbox indicating that you have read the full article in order to submit your answers.
Your answers have been saved for later.
You have not filled in all the answers to complete this quiz
The following questions were not answered:
Sorry, you have unsuccessfully completed this CME quiz with a score of
The following questions were not answered correctly:
Commitment to Change (optional):
Indicate what change(s) you will implement in your practice, if any, based on this CME course.
Your quiz results:
The filled radio buttons indicate your responses. The preferred responses are highlighted
For CME Course: A Proposed Model for Initial Assessment and Management of Acute Heart Failure Syndromes
Indicate what changes(s) you will implement in your practice, if any, based on this CME course.

Multimedia

Some tools below are only available to our subscribers or users with an online account.

663 Views
10 Citations
×

Related Content

Customize your page view by dragging & repositioning the boxes below.

Articles Related By Topic
Related Collections
PubMed Articles
Jobs
JAMAevidence.com

The Rational Clinical Examination: Evidence-Based Clinical Diagnosis
Evidence to Support the Update

The Rational Clinical Examination: Evidence-Based Clinical Diagnosis
Original Article: Does This Patient Have an Instability of the Shoulder or a Labrum Lesion?