THE COMING SHORTAGE OF SURGEONS
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THE COMING SHORTAGE OF SURGEONS Why They Are Disappearing and What That Means for Our Health Thomas E. Williams, Jr., M.D., Ph.D.; FACS, Bhagwan Satiani, M.D., M.B.A.; FACS, and E. Christopher Ellison, M.D.; FACS Foreword by Thomas R. Russell, M.D.; FACS Executive Director, American College of Surgeons
The Praeger Series on Contemporary Health and Living Julie Silver, M.D., Series Editor
PRAEGER An Imprint of ABC-CLIO, LLC
Copyright 2009 by Thomas E. Williams, Jr., Bhagwan Satiani, and E. Christopher Ellison All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, except for the inclusion of brief quotations in a review, without prior permission in writing from the publisher. Library of Congress Cataloging-in-Publication Data Williams, Thomas Edwards, 1935– The coming shortage of surgeons : why they are disappearing and what that means for our health / Thomas E. Williams, Jr., Bhagwan Satiani, and E. Christopher Ellison ; foreword by Thomas R. Russell. p. ; cm. — (Praeger series on contemporary health and living) Includes bibliographical references and index. ISBN 978-0-313-38070-9 (hard copy : alk. paper) ISBN 978-0-313-38071-6 (ebook) 1. Surgeons—Supply and demand—United States. I. Satiani, Bhagwan. II. Ellison, E. Christopher. III. Title. IV. Series: Praeger series on contemporary health and living. [DNLM: 1. General Surgery—manpower. 2. Education, Medical, Graduate—trends. 3. Specialties, Surgical—trends. WO 21 W727c 2009] RD27.42.W55 2009 338.4'7617—dc22 2009027608 13 12
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This book is also available on the World Wide Web as an eBook. Visit www.abc-clio.com for details. ABC-CLIO, LLC 130 Cremona Drive, P.O. Box 1911 Santa Barbara, California 93116-1911 This book is printed on acid-free paper Manufactured in the United States of America
To my beloved wife, Margaret Barton Williams, to our daughters, Beth, Peggy, and Catherine. And to my best friend and wife, Mira Satiani. And to my beloved wife, Mary Pat Borgess, to our sons, Jonathan and Eric, and daughter-in-law Hillary Dorwart, and to the memory of my father, Edwin H. Ellison, M.D., and Robert M. Zollinger Sr., M.D.
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Contents List of Figures
ix
List of Tables
xiii
Series Foreword by Julie K. Silver, M.D.
xv
Foreword by Thomas R. Russell, M.D., FACS Executive Director, American College of Surgeons
xvii
Preface
xix
Acknowledgments
xxi
Acronyms
xxiii
1.
The Problem
1
2.
Demand for a Surgical/Medical Workforce
10
3.
Surgical Supply: Residents—The Future Surgeons
22
4.
Constraints to Supply: Pertinent Issues
32
5.
Calculating Physician Supply: The Model—Assumptions, Relevant Parameters, and the Algorithm
54
6.
Orthopedic Surgery
67
7.
Cardiothoracic Surgery
72
8.
Otolaryngology
78
9.
Obstetrics and Gynecology
85
10.
General Surgery
93
11.
Neurosurgery
103
12.
Urology
108
viii
13. 14. 15.
Contents
The Last Hurdle: The Balanced Budget Act of 1997 and Graduate Medical Education Funding
114
Is There a Solution? Numerical Projections, and Improving Physicians’ Productivity
127
Challenges and Consequences
144
Epilogue
156
Appendix
159
Notes
165
Index
187
About the Authors
193
About the Series Editor
195
List of Figures 1.1
U.S. Medical School Applicants
3
1.2
U.S. Population and First-Year Medical School Enrollments, 1980–2005
4
1.3
Fourth-Year Medical Students Selecting General Surgery as Their Top Choice Specialty
6
2.1
Staying Alive
12
2.2
Heart Failure Hospitalizations
13
2.3
The Nation’s Health Dollar, Calendar Year 2007: Where It Went
14
2.4
The Nation’s Health Dollar, Calendar Year 2007: Where It Came From 15
2.5
Balance Sheet
16
2.6
Population Growth of People over age 65 Years, 2000–2020
17
2.7
Relationship of GDP and Physician Ratio
18
2.8
Physicians per 1,000 People, 1991 and 2001
19
3.1
National Resident Matching Program, 2008
25
3.2
Residencies
27
3.3
American Board Surgical Certificates Awarded
29
4.1
Median Medical Education Debt
34
4.2
Projected Loan Payments as a Percentage of Projected Physician After-Tax Income
35
4.3
Report Finds Physician Income “Losing Ground” to other Professions
39
4.4
Physician Income
40
4.5
Reimbursements for Open Surgery
41
4.6
Hospital versus Physician Reimbursement
42
4.7
Average CV Physician Compensation per Physician Work RVU, 2002–2006
43
4.8
Ohio Closed Claims in 2006 Outcome of Malpractice Claims
45
4.9
Annual Physician Premium Payments for Selected Specialties
47
x
List of Figures 4.10 Where Malpractice Dollars Go
48
4.11 First-Year M.D. Enrollment per 100,000 Population
49
4.12 Source of Physicians Entering Training, 2005
51
4.13 Physician Morale
52
5.1
U.S Medical Student Enrollment
56
5.2
Medical School Applicants and Matriculants
57
5.3
Relationship of GDP and Physician Ratio: Active Physicians per 100,000 of Population and Gross Domestic Product per Capita (1996 Dollars) in the United States, 1929–2000
58
5.4
U.S. Population Growth
59
5.5
Population Growth of People over age 65 Years, 2000–2020
60
5.6
Retiring Doctors
61
5.7
New Medical School Graduates
62
5.8
Total of Doctors Practicing Each Year
64
5.9
Illustration of Methodology Used in Calculating Physician Supply
65
7.1
Thoracic Surgeons
76
7.2
Applications for First-Year Posts: Thoracic and Cardiovascular Surgery
77
8.1
Cochlear Implant Device
79
8.2
Tracheostomy
80
8.3
Supply of Otolaryngologists
82
9.1
Numbers of ART Cycles Performed, Live-Birth Deliveries, and Infants Born through ART, 1996–2004
86
9.2
Populations and Numbers of Obstetrics and Gynecologists
88
9.3
Caesarian Rates for First Births, for All Women and Low-risk Women: United States, 1990–2003
91
10.1 Surgical Incision for Radical Mastectomy in 1960
94
10.2 Breast Cancer Now
95
10.3 Gallbladder Incisions—1960
96
10.4 Incisions for Minimally Invasive Gallbladder Surgery
97
10.5 Forecasted Increases in Work by Specialty
100
10.6 Decreasing General Surgical Workforce with Increasing Population of the United States
101
12.1 Production Rates of Urologists and General Surgeons
112
13.1 Traditional Pathway for Residency Training
115
14.1 Shortages
128
14.2 Medical School Enrollments and Forecasted Medical School Additions by State, 2006 129 14.3 Physicians Working Part Time, 2005–2006
131
14.4 GME Graduates Pursuing Additional Training
135
List of Figures
xi
14.5 Residents “Significantly Concerned” about Availability of Free Time in Future Practice Setting
136
14.6 Hospitals Extending Information Technology Benefits to Physicians
141
14.7 Physicians Over 55 Years and Retirement
142
15.1 Median Wait Times for Patients from Referral by General Practitioner for Treatment by Specialty
153
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List of Tables 1.1
Physician Shortages
2.1
Leading Causes of Death
11
2.2
Incidence of New Cancer Cases and Deaths
12
2.3
Physician Requirements by Medical Specialty
20
3.1
Years in Training
23
3.2
Demographics of the Emerging Surgical Workforce
23
3.3
First-Year Positions
24
3.4
U.S. Physician and International Medical Graduates Population Overview
26
The American Boards of Medical Specialties Certificates Issued in Surgical Specialties
28
3.5
4
3.6
The American Board of Thoracic Surgery Certification Data: 1996–2008
30
3.7
Mean Stipends for Residents, 2007
30
3.8
Comparison of Resident Salary with other Occupations from May 2007 National Occupational Employment and Wage Estimates
31
4.1
Medical School Tuition, First-Year Students, 2008–2009
33
4.2
Tuition and Fees: Current Dollars and Constant 2004 Dollars
33
4.3
Single Greatest Source of Professional Frustration
37
4.4
Choice of Specialty and Lifestyle
38
4.5
Surgical Compensation
40
4.6
Hospital Reimbursements
41
4.7
Surgeon Reimbursements
42
4.8
Medical Malpractice Claim Disposition and Defense Costs, 2007
44
4.9
Rising Premiums after One Year of Capping Jury Award in Ohio
46
5.1
Physicians Needed by Decade
61
xiv
List of Tables 5.2
Retiring Doctors
62
5.3
New Physicians Added
63
5.4
Total of Practicing Doctors
64
5.5
Shortage Estimates
65
6.1
35 Years to Retirement for Orthopedic Surgeons
69
6.2
30 Years to Retirement for Orthopedic Surgeons
69
7.1
35 Years to Retirement for Thoracic Surgeons
74
7.2
30 Years to Retirement for Thoracic Surgeons
74
8.1
35 Years to Retirement for ENT
81
8.2
30 Years to Retirement for ENT
82
9.1
35 Years to Retirement for OB/GYN
88
9.2
30 Years to Retirement for OB/GYN
89
10.1 35 Years to Retirement for General Surgeons
98
10.2 30 Years to Retirement for General Surgeons
98
11.1 35 Years to Retirement for Neurosurgeons
105
11.2 30 Years to Retirement for Neurosurgeons
106
12.1 35 Years to Retirement for Urologists
109
12.2 30 Years to Retirement for Urologists
110
13.1 Changes in the Add-on Percentage of Indirect Medical Education Adjustment as Set by BBA-1997, BBRA-1999, and MPDIMA-2003, 1997 to 2008
119
13.2 Graduate Medical Education Costs for Training Residents
122
13.3 Present Costs for Surgical Residents
124
13.4 Specialists, Shortages, and Cost of Training
125
14.1 Increasing First Enrollment to 22,000 Places
130
14.2 45 Years to Retirement for Doctors
133
A.1
Retiring Doctors
159
A.2
New Physicians Added
161
A.3
Total of Practicing Doctors
163
Series Foreword CONTEMPORARY HEALTH AND LIVING Over the past 100 years, there have been incredible medical breakthroughs that have prevented or cured illness in billions of people and helped many more improve their health while living with chronic conditions. A few of the most important 20th century discoveries include antibiotics, organ transplants and vaccines. The 21st century has already heralded important new treatments including such things as a vaccine to prevent human papillomavirus from infecting and potentially leading to cervical cancer in women. Polio is on the verge of being eradicated worldwide, making it only the second infectious disease behind smallpox to ever be erased as a human health threat. In this series, experts from many disciplines share with readers important and updated medical knowledge. All aspects of health are considered including subjects that are disease specific and preventive medical care. Disseminating this information will help individuals to improve their health as well as researchers to determine where there are gaps in our current knowledge and policy makers to assess the most pressing needs in healthcare. Series Editor Julie K. Silver, M.D. Assistant Professor Harvard Medical School Department of Physical Medicine and Rehabilitation
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Foreword The Coming Shortage of Surgeons provides a comprehensive look at one of the major ailments afflicting the U.S. health care system: a potential surgical workforce shortage that may leave many Americans with limited access to appropriate and necessary surgical services. The authors are to be commended for tackling this complex issue and for communicating the related problems clearly and forcefully. This book offers a detailed overview of how the government, economists, and nonsurgeon academics have miscalculated the number of surgeons who will be able to care for the growing and aging U.S. citizenry. An older population means more people with chronic medical conditions, and, therefore, a greater demand for health care services. Other developments that the authors identify as drivers of an increasing demand for medical and surgical services include economic expansion and technological innovations. A significant segment of this country’s population, who are either economically comfortable or wealthy, will want and will pay for the latest procedures, even if our economy should remain on shaky ground for the foreseeable future and years beyond. The authors also pinpoint the reasons why patient demand is steadily outpacing physician supply. One explanation is a growing reluctance among medical students to enter surgical training because of concerns about the level of debt, the unbalanced lifestyle, the decreases in reimbursement, and the malpractice worries they will experience in surgical practice. Meanwhile, many international medical school graduates are returning to their native countries and more established physicians are retiring, largely due to the same payment and liability issues that trouble prospective surgeons. These elements combine to yield a shrinking pool of surgeons. In addition, the authors offer an in-depth look at the workforce issues for seven specialties of surgery, probing the potential demand for each specialty’s services in the coming years. They also explore the effects of the Balanced Budget Act of 1997 on residency programs and the problems besetting the
xviii
Foreword
nation’s emergency departments (EDs) due to a dearth of physicians willing and able to take call. Most importantly, the authors do more than outline the symptoms of the workforce shortfalls. They also address the causes and effects of our current condition. Determining how many physicians the United States will need 10, 20, or 40 years from now requires more than number crunching; it also calls for foresight. For instance, workforce analysts need to take into account the fact that continued innovation in pharmacology and technology will make some of the practices, procedures, and operations performed today obsolete tomorrow. Consequently, the workforce will need to evolve and adapt and become more nimble and malleable. Most likely, surgeons will be performing fewer operations and will need to expand their practices to include other treatment options that have been uncovered through comparative effectiveness research and other types of evidence-based medicine. The surgical profession and our training programs also need to respond to the wants and needs of a new generation that considers having a balanced lifestyle to be of paramount importance. In addition, we must reevaluate where and how residents are being trained. As the authors note, many physicians train in major urban areas under the supervision of highly specialized surgeons. As a result, fewer surgeons are able to perform the broad range of procedures needed to treat conditions they are likely to see in an ED or a rural hospital, further complicating the maldistribution of physicians. I particularly appreciate the authors’ “letter to all surgical residents,” which really emphasizes the need to focus on developing competencies and becoming board certified. As long as surgical residents center their attention on these goals, they will have plenty of opportunities to enjoy future success in the surgical profession. In all, the authors have done a remarkable job of drawing attention to the vicissitudes of today’s workforce and to their implications. Furthermore, The Coming Shortage of Surgeons lays out sensible goals for creating a sustainable, reliable, and competent surgical workforce that will be capable of providing high-quality care to an evolving patient population. Thomas R. Russell, M.D., FACS Executive Director, American College of Surgeons, Chicago, IL
Preface In the research for Consumer Driven Health Care, we realized that we would be facing a shortage of physicians in the next 45 years. We set out to estimate what the shortages of surgeons will be. Although physician extenders, nurse practitioners, nurse midwives, physician assistants, and nurse anesthetists can extend health care ably to many patients, nonetheless, there remain some specialties of medicine for which trained physicians are required. Pathology and radiology are two examples in which the image interpretation abilities of the pathologist or radiologist are critical. The same is true of surgeons. Not only are their surgical skills in the operating rooms essential, so also is their judgment of when, or when not, to conduct a surgical procedure on a patient. We will elaborate on some of the factors affecting the supply of surgeons and what must be done about this.
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Acknowledgments The authors wish to thank the many people who have been so helpful to us, particularly Chris Paul, Bernadine Healy, Richard Cooper, Roger Blackwell, Steven Scheiber, Michael Pine, Don Fry, Wiley “Chip” Souba, Steven Gabbe, Benjamin Sun, Dick Briggs, Allen Damschroder, Steve Dutton, Michelle Keith, Gerald Medlin, Alan Ayers, Gary Bos, John Makley, Chris Copeland, Walter Hull, Jerry Kakos, Bill Gay, Rob Michler, Bill Winnenberg, Mary Jo McElroy, Melanie Kennedy, Dave Kelly, Molly Feuer, Steve Moon, Jerrry Johnson, Ron Ferguson, Robert Beran, Harry Siderys, Bob Falcone, Melinda Willis, Renee Troyer, Sueann Treiber, Steve Cotter, Varsha Krishnasamy, Sylvia Kolbes, Andrew Thomas, Kamal Pohar, Garth Essig, Atul Grover, and E. Antonio Chiocca. This effort was partially supported by a grant from the Columbus Medical Association Foundation for “Utilization of Operations Research Techniques in Clinical Medicine.”
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Acronyms FACS GDP OB/GYN ENT FMG IMG MHA ABTS ACGME GME FTE HIPAA AAMC AMGA AAOS AATS STS MGMA CMS
Fellow American College of Surgeons Gross Domestic Product Obstetrician and Gynecology Otolaryngologist Foreign Medical Graduate International Medical Graduate Merritt, Hawkins, and Associates American Board of Thoracic Surgery Accreditation Council for Graduate Medical Education Graduate Medical Education Full-Time Equivalent Health Insurance Portability and Accountability Act Association of American Medical Colleges American Medical Group Association American Association of Orthopedic Surgeons American Association for Thoracic Surgery Society of Thoracic Surgeons Medical Group Management Association Centers for Medicare and Medicaid Services, formerly known as the Health Care Financing Administration (HCFA)
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1 The Problem Early one afternoon in the year 2030 your daughter calls. She is crying. You’re afraid it’s related to her breast cancer. “What happened?” you ask. “I called the surgeon’s office for an appointment.” “What happened?” They said, “Do you belong to our SAM’s club?” “What?” “SAM’s club is their Surgical Access Management business. I’m not a member and therefore I could not get an appointment for three months.” The era of doctors working 60 to 80 hours per week and being at the mercy of the telephone, 24 hours per day, 365 days per year, is over. Medical students are looking for a more scheduled lifestyle that will allow them to coordinate activities for two income families. The authors are surgical educators. We see a time, not too many years away, when people will face the rationing of surgical care. This will result in long waiting times to obtain a doctor’s appointment, or pay access fees to get in line for surgical care. In fact, these things are already happening in primary care. It is called concierge or boutique care. What do we mean by this? How have we arrived at this conclusion? It is increasingly hard to get a doctor’s appointment. Medical recruiting firms find it difficult to recruit surgeons, both in the cities and in rural locations. Hospitals try to employ surgeons to meet the demands of their communities for trauma care and to deliver babies. The baby boomers want service; how will they get it if we don’t have enough surgeons? Somebody will think of a market solution. How did we get to this point? How can we get out of it? How do we recover from this situation? Let’s start at the beginning—medical school.
HAVE WE BEEN OUTSOURCING OUR DOCTORS OF MEDICINE? In the late 1960s and early 1970s, many members of the medical community believed that more physicians were needed to serve America’s growing
2
The Coming Shortage of Surgeons
health care needs. In response, states rushed to open new medical and osteopathic schools and increased class sizes in existing schools. At the Ohio State University College of Medicine, for example, freshman class enrollment increased from 150 students in 1963 to 225 students in 1973. By the 1980s, enrollment levels in existing schools and construction of new schools leveled off due to a projected oversupply of physicians and has remained at the same level for 25 years. In 2008, Ohio State’s medical school freshman class enrollment is 210, slightly lower than its peak. In addition to opening new medical schools and increasing enrollment, America also found another way to solve its physician shortage—by exporting medical education to the poorer, emerging economies of the world and in turn permitting international medical graduates (IMGs) to practice medicine in the United States. Out of necessity these tactics were employed to deal with workforce shortages in rural and underserved areas in the United States. It was certainly cheaper to have other countries pay for medical education than to fork out millions of dollars ourselves. The United States has already debated and witnessed the offshore outsourcing of its auto and textile manufacturers, data processors, computer programmers, and financial analysts. The question for policy makers, Congress, and the public is whether to persist in importing IMGs or ramp up both U.S. medical school and graduate medical education funding, or a combination of both. The total enrollment of first year medical students in the United States has not changed over the past 25 years at about 17,000 (Figure 1.1). There are over 42,000 applicants, or more than 2½ for every available seat in medical school classes, which means that many qualified and well-intentioned American college graduates never get a chance at a medical career.1 At the same time, hospitals and other health care institutions hire physicians trained overseas, filling more than 25 percent of the nation’s 100,000 available residency posts with IMGs.2 This number could get even higher in the future because of the inability to recruit enough U.S. medical graduates into primary care areas such as pediatric and internal medicine programs.3 It is not as much a matter of IMGs being foreigners, as of the 4,563 international medical school participants in the national resident matching program who obtain residency training positions, more than 50% are actually U.S. citizens.4 In fact, one of the Caribbean medical schools has an entering class of 400 students, more than any U.S. medical school, composed largely of American and Canadian citizens. Eighty-five percent of Post-graduate Year One matches in the National Resident Matching Program are U.S. citizens,5 but 15 percent are not. A case can be made for matching an American-educated pool of available medical school applicants who are going to receive a standardized medical school education that is geared towards diseases and illnesses treated in the United States.
The Problem
3
Figure 1.1 U.S. Medical School Applicants 50,000 45,000 40,000 35,000 30,000 25,000 20,000 15,000 10,000 5,000
Applicants
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
0
Matriculants
Source: Copyright © 2005, Association of American Medical Colleges http://www.aamc.org/ data/facts/2008/2008school.htm, accessed July 2, 2009.
Future Demand While the supply of physicians remains constant or even declines, demand on physicians’ time is likely to increase in the next few decades, especially with the epidemics of lifestyle-associated illnesses such as heart disease and cancer—America’s two most common causes of death. Medical science has provided us with new treatments and cures for some of these diseases and other treatments that prolong life, but such advances come at the expense of ongoing care. Demand for these services is likely to increase, especially in critical care areas such as cardiac disease, including chronic congestive heart failure, and cancer. In 1980 400,000 patients were hospitalized for heart failure. By 2000, this rose to almost 1,000,000.6 In addition, these patients require continuing care at least every six months and probably every three months for optimum control of heart failure. In 2004, cancer overtook heart disease in age-adjusted death rates, and is now the leading killer of Americans under the age of 85.7 More cases of cancer are being discovered, and the cancer five-year survival rates have risen from 50 percent to 64 percent in the last 25 years. As a result of advances in science and patient care by oncologists and surgical specialists, there were
4
The Coming Shortage of Surgeons
10,000,000 living cancer patients in the United States in 2000, each needing follow-up visits at least every year.8 Steady medical school enrollment levels also ignore the fact that the population of the United States has increased from 227 million in 1980 to 300 million in 2005—an increase of over 73 million people (Figure 1.2). The Census Bureau predicts that the population of the United States will reach 420 million by 2050, an increase of 40 percent from 2006.9 These and other trends lead us to project a shortage of 500,000 physicians by the year 2050, shown below in Table 1.1.10 Figure 1.2 U.S. Population and First-Year Medical School Enrollments, 1980–2005 300 250 16,000 200 11,000
150 100
6,000 50 1,000
0 # first-year enrollments
U.S. population
1980
2005
Source: AAMC, “U.S. Census Bureau and Medical School Graduates 2005,” Copyright © 2005, Association of American Medical Colleges. http://www.aamc.org/data/facts/2008/2008school. htm, accessed July 2, 2009.
Table 1.1 Physician Shortages Decade
Population
Physicians Needed
Physicians Practicing
Shortage
2010
309,000,000
883,740
787,600
96,140
2020
336,000,000
960,960
757,400
203,560
2030
364,000,000
1,041,040
727,200
313,840
2040
392,000,000
1,121,120
697,000
424,120
2050
420,000,000
1,201,200
697,000
504,200
Source: Roger D. Blackwell, Thomas E. Williams, and Alan Ayers, Consumer Driven Health Care (Ashland, OH: Book Publishing Associates, 2005), 89–96.
The Problem
5
The standard method for measuring physician supply or demand in the United States is calculating the physician-to-population ratio. Currently there are 286 active physicians per 100,000 people in the United States. Based on the increasing population, by 2050 we will need 1.2 million doctors in the United States to maintain this ratio. Assuming that the average physician practices for 40 years from internship to retirement, and that American medical schools will not increase their enrollment, our American medical schools will be able to supply only 58 percent of the physicians needed in 2050. As stated above, this will leave American citizens with a shortage of 500,000 doctors. Who will fill this void? The calculations for these projections will be further explained in chapter 5. Using his own methodology, Dr. Richard Cooper, former Dean of the Medical College of Wisconsin in Milwaukee, arrived at similar conclusions for projected physician shortages. In his paper, published in November, 2004, he estimates the deficit of physicians will be approximately 200,000 by 2025.11 Changing retirement ages adds to the problem. The average age for retirement for a general surgeon was 71 years of age.12 By 2000, it was 58. A survey conducted by Merritt, Hawkins & Associates reported that among physicians who are 50 years old, almost 50 percent of them are planning to retire, limit their practices, or seek other nonclinical opportunities within the next three years.13 How can a doctor limit his or her practice? Performing fewer procedures or seeing fewer patients would allow a more manageable workload for an aging physician. However, in today’s environment of skyrocketing malpractice insurance premiums, a lower volume of procedures or patients seen would not generate enough income to cover a physician’s malpractice cost. For instance, a thoracic surgeon’s malpractice premium of, say, $110,000 is not dependent on the surgeon’s volume of cases. For each open-heart surgery, the surgeon is paid $2,200 and therefore must perform over 50 operations a year just to pay his or her malpractice insurance premiums. Meeting these costs makes it difficult for a surgeon to reduce the number of surgical procedures he or she performs as retirement draws near. Economically, it is nearly impossible to become a part-time physician or surgeon unless the doctor’s entire overhead is covered by a health care institution. Because aging doctors do not want the long hours and overnight call that is demanded of today’s physicians, yet cannot afford to reduce their practices, many feel forced to retire prematurely or choose alternative careers. With rapidly increasing demand, why don’t more people seek admission to medical school?14 Debt is one reason. The average medical school debt for the graduating class of 2007 was $139,517, an almost seven percent increase from the previous year.15 Residents complete their training in general surgery at about the age of 31, and earn approximately $200,000 over the course of their residency. Attempting to pay off a debt of over $139,000 during that time period is not feasible, as it leaves the resident only about $60,000 to survive on over five years. In contrast, a 21-year-old staff nurse who has
6
The Coming Shortage of Surgeons
a four-year diploma or associate degree, as a licensed RN, can start at over $40,000 per year and probably be earning $60,000 a year or more by the age of 25 to 30. Part of the problem, of course, is that the current third-party payer system doesn’t provide for medical education. Rather than invest more than $100,000 in the education of a U.S.-trained physician, it is cheaper to outsource the problem and hire a physician trained elsewhere. In periods of shortages of nonphysician healthcare workers there has also been a reliance on international trainees to increase the workforce for nurses, technicians, and other medical personnel. It’s time that the United States gets serious about helping individuals prepare for healthcare careers, which involves innovative training programs, forgiveness of student debt, and greater utilization of “physician extenders,” including nurse practitioners and physician assistants. Otherwise the United States will be resigned to outsourcing its medical education to developing nations. In the United States the number of applicants from medical school graduates for general surgery residencies dropped 30 percent between 1996 to 2002 (Figure 1.3).16 Will this happen to America’s entire surgical workforce?
Figure 1.3 Fourth-Year Medical Students Selecting General Surgery as Their Top Choice Specialty 12 10 8 6 4 2 0 1996
1997
1998
1999
2000
2001
2002
% of students Source: Brotherton SE, Rockey PH, Etzel SI.U.S Graduate Medical Education, 2002–2003. JAMA. 290:1197–1202, 2003. Copyright © American Medical Association. All rights reserved. JAMA
The Problem
7
Lawyers versus Doctors This comparison is not about malpractice or malpractice premiums; it is about numbers. Stephen T. Schreiber, Executive Vice President and Chief Operating Officer Law School Admission Council, and the Director of the Law School Admissions Test, referred us to the American Bar Association’s Web site.17 In 2004, the first year enrollment in law schools in the United States was 48,239 and between 75,000 and 100,000 people apply to law school each year. If you examine the statistics, since 1990, law school enrollment for the first year is almost three times that of medical school enrollment. By way of comparison, there are nine law schools and seven allopathic and osteopathic medical schools in the state of Ohio. The lawyer versus doctor comparison serves to demonstrate just how severe this numerical disparity has become. Based on current trends, which forecast a growing demand for physicians of all types, especially surgeons, it is increasingly clear that at present rates of physician training demand will vastly outstrip supply in the near future. A striking similarity, however, is the growing number of professionals in both professions who are dispirited and considering retiring or changing occupations. The number of law school applicants has dropped from 98,700 in 2004 to 83,500 in 2006, a 6.7 percent drop. Forty-four percent of lawyers would not recommend their profession to younger people.18
Why It Matters We are facing the “perfect storm” gathering in the shadows of the health care profession. That is a rationing of health care services brought about by an inadequate supply of doctors graduating from medical schools to fill the 100,000—110,000 residencies in the United States. The number of trained surgical specialists needs to be increased but the Balanced Budget Act of 1997 fixed the number of residencies in the United States at 1996 levels. Patients will face the rationing of health care services. That rationing will be either by waiting for a long time or failing to get an appointment for an appropriate surgical specialist. If the United States doesn’t have enough surgeons to perform operations, patients will face massive lines waiting for surgical services all over the country, and particularly in rural areas. This could also be an unsolvable problem both for employers and their employees. It could result in more access fees, in addition to hospital fees and surgical fees. Hospital administrators will find it difficult to recruit some if not all of the surgical specialists they need. To do so, administrators must offer a fair salary and all the benefits, including a pension plan, perhaps educational debt forgiveness, a signing bonus, and in highly competitive areas even considering paying for the education of the specialists’ children. Certainly, this is a problem with no quick or cheap solution. If we have universal insurance with all doctors salaried, there is no incentive to take care of patients after 40 hours of work a week. We cannot solve the problem
8
The Coming Shortage of Surgeons
of access to surgical specialists without an appropriate and adequate surgical workforce. One of the biggest factors contributing to a shortage of surgeons is the issue of work/life balance. Many of these students will be married and part of a two income family. They have to have some time for family life. They will not work the 60 to 80 hours a week worked by the previous generations of surgeons. In fact, one parent must be home to meet the kids, take them to their music lessons, take them to athletic practices, and be there for them through the normal stresses of growing up. Another alternative is to hire a nanny, but to do so is very expensive and denies parents the pleasure of raising their children. Work/life balance is the most meaningful consideration for medical students when selecting their residencies, as we will see later in the book.
OUTLINE OF THE BOOK As you see, the thrust of this book is medical demand, physician supply, and, above all, access to your doctor or surgeon. In chapter 2, we discuss Medical/Surgical Demand as it applies to the physician workforce. Chapter 3 is titled “Surgical Supply: Residents—The Future Surgeons.” In chapter 4, we discuss some of the pertinent issues that constrain the future medical/surgical workforce and the decision to apply for a residency. These issues include malpractice insurance premiums, reimbursements of surgical procedures, medical students’ debt, controllable lifestyle, culture, gender, and retirement. In chapter 5, we outline the assumptions and relevant parameters of the model we have proposed for calculating physician shortages. We will also discuss the algorithm, or the model, and take you through the steps we took in calculating the original model for the shortages of doctors. You will see how by using the model we can estimate the future supply of surgical specialists.19 In chapter 6, we apply the same technique to orthopedic surgeons. Orthopedic surgeons take care of bones and joints and perform hip replacements, knee replacements, and reconstructive surgery for arthritis. Thoracic and cardiovascular surgeons are the surgeons who treat lung cancer, heart disease, and diseases of the esophagus. They treat all the surgical diseases in the chest. In chapter 7, we discuss thoracic and cardiovascular surgery, including workforce estimates derived from the model. Otolaryngologists (ENT surgeons), or head and neck surgeons, treat cancer of the tongue and larynx and perform radical neck dissections. They also put tubes in childrens’ ears. We cover their work estimates in chapter 8. In chapter 9, we discuss obstetrics and gynecologists, the doctors who deliver your babies. General surgeons treat breast cancer, colon cancer, and diseases of the abdomen. In chapter 10, we apply the same technique to general surgeons.
The Problem
9
Neurosurgeons treat brain tumors, brain trauma, and cervical (neck) spine problems and are covered in chapter 11. Urologists treat both men and women for incontinence and urinary problems and treat prostate cancer in men. Our projections for this specialty are covered in chapter 12. In chapter 13, we discuss the Balanced Budget Act of 1997; one of its provisions capped the residencies available in the United States. This Act functions like a valve to prevent the needed increase in training positions to meet the demands of the future medical/surgical workforce. Every state requires one or more years of postgraduate training for a resident to be eligible for a medical license in that state. In chapter 14, we attempt to synthesize this information and recommend steps to increase the numbers of physicians in this country. Finally, in chapter 15, we discuss the challenges and examine the consequences if we fail to act.
2 Demand for a Surgical/Medical Workforce The scene is East Florida; there is a shortage of neurosurgeons; somebody has to take trauma call—to be on hand for all sudden emergencies, including potential neurological injury. A hospital employs two neurosurgeons for $1 million a year each. The hospital then pays for their malpractice and health insurance and gives them retirement benefits, and in return they agree to be on call. Why can neurosurgeons command this salary and these benefits? It is a case of high risk and little reward. Many patients in large hospitals are uninsured, the reimbursement for doctors’ fees is very low, and—perhaps even more importantly—there are more malpractice suits. So why don’t the neurosurgeons go into private practice? The reimbursements in private practice do not provide the same financial benefits. Previous projections of the need for physicians have relied on various scenarios estimating the demand for their services.1 Although there is no ideal measure, demand has been inferred by using population-to-physician ratios, work hours, and procedural or office visit time studies for typical illnesses or similar issues. The stakes are high in being able to correctly predict public demand for these services as there is a substantial lag, often a decade or more, between changing the number of physicians permitted in residency programs and completion of training programs allowing the trainee to enter practice and be counted as part of the available supply of doctors. Chronic illnesses such as cancer and atherosclerotic cardiac and vascular disease will continue to require significant resources in the foreseeable future and therefore make it exceedingly difficult to accurately predict the demand for physicians’ services.
SETTING THE STAGE As shown in Table 2.1, of the top 10 leading causes of death, surgeons treat the following: heart disease, circulatory disorders such as peripheral arterial disease (vascular disease in diabetes causing gangrene, for example), cancer (malignant neoplasms), cerebrovascular disease (carotid artery disease causing
Demand for a Surgical/Medical Workforce
11
Table 2.1 Leading Causes of Death Heart disease: 652,091 Cancer: 559,312 Stroke (cerebrovascular diseases): 143,579 Chronic lower respiratory diseases: 130,933 Accidents (unintentional injuries): 117,809 Diabetes: 75,119 Alzheimer’s disease: 71,599 Influenza/Pneumonia: 63,001 Nephritis, nephrotic syndrome, and nephrosis: 43,901 Septicemia: 34,136 Source: CDC, National For Vital Statistics Deaths: Final Data for 2005, Tables C, 7, 30, http:// www.cdc.gov/nchs/FASTATS/deaths.htm (accessed June 30, 2008).
strokes), and some of both intentional (suicidal) and unintentional accidents with injuries.2 The Scourge of Cancer Cancer overtook heart disease as the leading killer of Americans under the age of 85 in 2004.3 In the United States, half the men and one-third of the women will have cancer in their lifetimes. Table 2.2 shows the incidence and estimated number of deaths on an annual basis caused by some of the most common forms of cancer.4 In the digestive system, the most common cancer is cancer of the large intestine, the colon. With regard to the respiratory system, the most common form of cancer is carcinoma of the lung. Breast cancer is the most common cancer in women. There has been a tremendous effort on the part of oncologists and surgeons to try to cure those women afflicted with breast cancer, as shown in the five-year survival rates in chapter 10. The Burden of Chronic Disease Are we winning the war on cancer? Not yet. We are making tremendous progress in the treatment of cancer. Five-year survival rates have improved, and Americans who have had cancer are living longer. With regard to cancer, in the years since 1975 there has been an extraordinary increase in life expectancy and five-year survival rates, from 50 percent to 64 percent.5 As you can see in Figure 2.1, there are now more than 10,000,000 people who have had cancer and survived in the American population.6 These people must see their physicians at least once or
12
The Coming Shortage of Surgeons
Table 2.2 Incidence of New Cancer Cases and Deaths Estimated New Cases Both Sexes All Sites
Estimated Deaths Both Sexes
1,437,180
Oral Cavity and Pharynx
565,650
35,310
7,590
Digestive System
271,290
135,130
Respiratory System, Including Lungs
232,270
161,840
Breast
184,450
40,480
Genital System, Including Prostate
274,150
57,820
39,510
2,430
Endocrine, Including Thyroid
Source: American Cancer Society, Cancer Facts and Figures, 2008, http://www.cancer.org/down loads/STT/2008CAFFfinalsecured.pdf (accessed January 29, 2009).
Figure 2.1 Staying Alive The number of living Americans who have had cancer diagnoses has more than tripled since 1975.
Millions of Americans with cancer diagnoses
10 8 6 4 2 0 1975
1980
1985
1990
1995
2000
Source: National Cancer Institute, http://seer.cancer.gov/statfacts/html/all.html (accessed July 3, 2009).
twice a year just to make sure their cancer has not recurred. It takes more and more medical manpower, perhaps 5,000 doctors, to fill this need. Heart Failure Eugene Braunwald, in his Presidential Address to the American College of Cardiology, used this graph (Figure 2.2) to emphasize the impact of congestive
Demand for a Surgical/Medical Workforce
13
Figure 2.2 Heart Failure Hospitalizations 600,000
Discharge
500,000 400,000 300,000 200,000 100,000 0
81
83
85
87 Women
89
91
93
95
97
99
00
Men
Source: Reprinted from Braunwald, E. “Cardiology: the Past, the Present, and the Future.” Journal of the American College of Cardiology, 42 (2003): 2031–2041, with permission from Elsevier.
heart failure on the utilization of resources in the American heath care system.7 Hospitalizations due to heart failure for both men and women totaled about 400,000 in 1980. By 2000, this had increased to about 1,000,000 hospitalizations. All these people must be seen regularly in their doctors’ offices to manage their condition and to eliminate or minimize the number of hospitalizations for these patients, both for their health and to save money.
WHAT DOES IT COST? In 2004, the total health care bill for the United States of America was $1.9 trillion, 16 percent of Gross Domestic Product; by 2005 it had increased to $2 trillion, and by 2007 more than $2.2 trillion, almost $7,000 for every person.8 Let us dissect our health care expenditures. In Figure 2.3, we can see how the health dollar for 2007, $2.2 trillion, was spent. About $682 billion was spent on hospital services, $462 billion for physicians services, and $220 billion for prescription drugs. Who paid for this? You the taxpayer, you the employee, and you the citizen. As shown in Figure 2.4, the total bill for Medicare, Medicaid, and SCHIP was about $748 billion, one-third of health care costs for 2004. Including all other public spending you, the taxpayer, spent $1.012 trillion. You, the individual or employee, through your insurance, spent $770 billion, or three-quarters of a trillion dollars. Finally you, the citizen, paid about $264 billion—12 percent— out of your own pocket.
14
The Coming Shortage of Surgeons
Figure 2.3 The Nation’s Health Dollar, Calendar Year 2007: Where It Went Other Spending 25%
Program Administration and Net Cost 7%
Hospital Care 31%
Prescription Drugs 10%
Nursing Home Care 6%
Physician and Clinical Services 21%
Note: Other Spending includes dentist services, other professional services, home health, durable medical products, over-the-counter medicines and sundries, pubic health, other personal health care, research, and structures and equipment. Source: Center for Medicare & Medicaid Services, Office of the Actuary, National Health Statistics Group. http://www.cms.hhs.gov/NationalHealthExpendData/downloads/PieChartSources Expenditures2007.pdf (accessed July 3, 2009).
Trauma is one of the nation’s most expensive surgical problems. Trauma care now exceeds $70 billion annually.9 Our nation today faces a serious lack of specialists—neurosurgeons, orthopedic surgeons, and general surgeons— who see trauma victims. There are several causes for this: (1) Many patients who visit emergency rooms are uninsured, yet they will sue specialists for malpractice; (2) Malpractice premiums are very high for surgical specialists including trauma surgeons; and (3) Being on call for trauma does not allow for a controllable scheduled lifestyle.
WORKFORCE ISSUES There are pro and con arguments about whether the state of the economy drives demand for health care services or whether demand is physician induced.10 Nevertheless, in order to have a rational approach to undertaking a decision that involves billions of dollars and serious public health issues over the next few decades, reviewing supply and demand of physicians at a basic level seems warranted. If one views the supply and demand of physicians as one would an accounting balance sheet, the assets side of the sheet would include input into the health care market, such as new doctors from within the United States, IMGs, and nonphysician personnel (Figure 2.5).
Demand for a Surgical/Medical Workforce
15
Figure 2.4 The Nation’s Health Dollar, Calendar Year 2007: Where It Came From Other Public1 12%
Other Private2 7%
Medicaid and SCHIP 15%
Medicare 19%
Private Insurance 35%
Out-of-pocket 12% Note: The numbers shown may not add up to 100.0 because of rounding. Source: Center for Medicare & Medicaid Services, Office of the Actuary, National Health Statistics Group. http://www.cms.hhs.gov/NationalHealthExpendData/downloads/PieChartSourcesExpen ditures2007.pdf, accessed July 3, 2009.
On the liability side of the balance sheet, entries such as early retirements, death, disability, and those changes that lead to a reduced work output would be listed. However, similar to a balance sheet there are contingencies that have to be disclosed to the reader that may materially affect the future value of a company, such as uncertain liabilities, commitments, or other items. In our scenario, the factors that may affect future projections of demand include population growth, the country’s economic growth, productivity, technology, trends in specialty choice, geographic distribution, and drastic changes in the delivery of health care, such as universal insurance. Let us briefly review these contingencies that may influence the demand for surgical specialties. Population growth & aging. As we have previously discussed, the estimated growth of the U.S. population according to the Census Bureau will be 309 million by 2010, 336 million by 2020, and 420 million by the year 2050. What has a significant impact on the demand side of the equation is the growth of the population of people over the age of 65 years. The population growth curves comparing people over age 65, about 50 percent, and those under 65, less than 10 percent, diverge strikingly even in the next 10 years (Figure 2.6). This difference is important because of the disproportionate utilization of services by those over 65. The 54 million people over 65 in 2020 and the 70 million by 2030 are likely to visit doctors twice as often as those under age 65.11 The mean number of diagnoses per visit and the mean number of drugs
16
The Coming Shortage of Surgeons
Figure 2.5 Balance Sheet Current Physician Supply ‘‘Contingencies’’
‘‘Asset’’ side of balance sheet
# of currently active physicians
# of new U.S. medical graduates
# of IMGs
# of and role of physician extenders
disruptive technology
Population growth & aging Demand for services Trends in specialty choice Economic growth Technology Productivity Change in health care Delivery model
‘‘Liability’’ side of balance sheet
# retiring
# dying or disabled
# career change
# reduced work hours/gender/lifestyle
length of training & debt
Future Physician Supply Legend: IMGs (International Medical Graduates)
mentioned at visits increased by 13 percent and 18 percent, respectively, in patients over the age of 45.12 The aged will require joint replacements (orthopedic surgeons), coronaries and peripheral blood vessels bypasses or repairs (cardiothoracic surgeons or vascular surgeons), vision corrections (ophthalmologists), and other common abdominal ailments attended to (general surgeons). Productivity. An important contingency is the almost certain decline in the physician work effort, which will occur due to several reasons. First, the physician population is aging, as evidenced by the fact that one-third of currently practicing physicians are over 55 years old. Between 1982 and 2001, the proportion of physicians 65 years and older increased from 8 percent to 11 percent.13 Second, 48.3 percent of medical students14 and 28 percent of practicing physicians15 are women. Women physicians work an average of 20–25 percent less than men, particularly in surgical specialties.16 It is estimated that gender distribution will reduce the effective supply of physicians by 5 percent in 2010 and 7 percent in 2020.17 Third, both men and women (particularly women) are opting for controllable lifestyles. In a survey of medical students from 1996–2003, the percentage of women who chose specialties with controllable lifestyles increased from 18 percent in 1996 to
Demand for a Surgical/Medical Workforce
17
Figure 2.6 Population Growth of People over age 65 Years, 2000–2020
Percent Growth in Population
60% 50%
Age 65+
40% 30% 20% Age <65
10% 0% 2005
2010
2015
2020
Year Source: U.S. Department of Health and Human Services Health Resources and Services Administration Bureau of Health Professions, “Physician Supply and Demand: Projections to 2020,” (Health Resources and Services Administration, Department of Health & Human Services, October 2006).
36 percent in 2003.18 What makes the impact of lifestyle on any future calculations about supply and demand difficult is the fact that in the same survey, the percentage of men who chose controllable lifestyles grew from 28 percent in 1996 to 45 percent in 2003. Economic growth. It is postulated that economic growth leads to expansion of medical insurance coverage and therefore increases the demand for physician services. In a series of cross-sectional analyses using regression with data from all 50 states and several other countries, Cooper et al found a correlation between the number of physicians per capita and economic growth (Figure 2.7).19 Starting from an assumption that the existing historical ratio of physicians to population reflects actual demand, the aforementioned researchers concluded that every 1 percent increase in GDP per capita results in a 0.75 percent increase in demand for physicians’ services. Some serious objections have been raised based on the assumptions used, data limitations, and the possibly nonlinear correlation between economic growth and physician demand.20 Technology. Advances in technology drive demand. The discovery of CAT scans, MRI scans, PET scans, color-flow ultrasound, less riskier techniques to biopsy breast lumps, and minimally invasive methods to remove diseased organs such as gallbladders influence consumers to agree to interventions they might have refused in the past. In addition, diagnostic scans frequently reveal
18
The Coming Shortage of Surgeons
Figure 2.7 Relationship of GDP and Physician Ratio 350 300 250
#
200 150 100 50 0 1929
1960
1970
1980
1990
2000
Year GDP Per Capita ($100s)
Physicians/100,000 Population
Source: “Active Physicians per 100,000 of Population and Gross Domestic Product per Capita (1996 dollars) in the United States, 1929–2000,” Health Serv Res 38(2) (April, 2003): 675–696, http://www.pubmedcentral.nih.gov/articlerender.fegi?artid=1360909 (accessed July 2, 2008).
abnormal findings that lead to more procedures, often on a preventative basis. Demand for imaging services is also often driven by patients pressuring physicians or by defensive medicine. The estimated cost for imaging in the United States is estimated at $100 billion.21 Similarly, total prescription sales in the United States were estimated at $216.4 billion in 2003.22 While technology often leads to shorter hospital stays and less pain for the patient, it also opens the door to an increase in the volume of procedures or newer, more expensive prescription drugs. It is impossible to look into the future and predict what impact new technology will have on the demand for health care services. Geographic distribution and specialty choice. A general accounting office study in 2002 concluded that the physician population in the United States between 1991 and 2001 increased 26 percent, which was twice the rate of the general population.23 However, disparities between metropolitan and nonmetropolitan areas persisted (Figure 2.8). Twelve percent of the physician increase went to nonmetropolitan areas and 88 percent of the increase went to metropolitan areas. Demand for surgical specialists may change as the issue of lifestyle makes it more acceptable for physicians’ families to settle in rural areas even though it generally takes a large population base to support a specialist. However, since the rural
Demand for a Surgical/Medical Workforce
19
Figure 2.8 Physicians per 100,000 People, 1991 and 2001 300 267 250
239
242
214 200
150 122 99
100
50
0 U.S. 1991
Metropolitan areas
Nonmetropolitan areas
2001 Source: PHYSICIAN WORKFORCE. Physician Supply Increased in Metropolitan and Nonmetropolitan Areas but Geographic Disparities Persisted. Report to the Chairman, Committee on Health, Education, Labor, and Pensions, U.S. Senate October 2003. http://www.gao-gov/newitems/d04124.pdf (accessed June 20, 2008).
population is aging much more rapidly than the general population, there is likely to be faster growth in percentage terms for specialist services compared to demand for primary care physician services.24 For this reason, specialties with the highest percentage growth are cardiology (33%) and urology (30%), as shown in Table 2.3. Historically, 68 percent of graduates entered specialties.25 Factors usually considered in making a choice include lifestyle, income potential, intellectual stimulation, family situation, prestige, and age/gender or ethnic background of the physician. Change in reimbursement and the health care delivery model. There is no question that the type of insurance and the type of insurance plan a person has determines his or her frequency of usage of the health care system. The Health Resources and Services Administration, Department of Health & Human Services has estimated per capita use of physician services under different insurance scenarios after controlling for age and sex.26 Managed care plans and exclusive HMO plans, for instance, were projected to use fewer of these services
20
The Coming Shortage of Surgeons
Table 2.3 Physician Requirements by Medical Specialty Base Year
Projected
Specialty
2000
2005
Medical Specialties
86,400
93,000 100,700 109,800 119,800
29%
Cardiology
20,600
22,200
24,200
26,700
29,600
33%
Other Internal Medicine
65,900
70,800
76,500
83,100
90,200
27%
159,400 169,000 179,900 192,000 205,100
21%
Surgical Specialties
2010
2015
2020
Percent Change from 2005–2020
General Surgery
39,100
41,700
44,800
48,400
52,200
25%
Obstetrics/ Gynecology
41,500
43,100
44,800
46,000
47,200
10%
Ophthalmology
18,400
19,700
21,200
23,100
25,200
28%
Orthopedic Surgery
24,100
25,600
27,300
29,300
31,600
23%
Other Surgery
16,200
17,400
18,800
20,300
22,000
26%
Otolaryngology Urology
9,800
10,300
11,000
11,600
12,400
20%
10,400
11,100
12,000
13,200
14,400
30%
Source: Adapted from U.S. Department of Health and Human Services. Health Resources and Services Administration Bureau of Health Professions, “Physician Supply and Demand: Projections to 2020,” (Health Resources and Services Administration, Department of Health & Human Services, October 2006).
compared to traditional fee-for-service plans. In theory, part of the reason that recent estimates of physician oversupply were significantly off the mark is that some experts projected that demand for services would be severely curtailed with managed care. The public simply refused to buy into a delivery system where their choice of their physician was dictated by an insurer or surrogate. Demand for Nonphysician Services In our book Consumer Driven Health Care, we noted a shortage of nursing personnel, physical therapists, speech therapists, and X-ray technicians.27 Peter Buerhaus, a nurse and a health economist, suggests that the supply of nurses will peak in 2015, but the demand will exceed supply by 2–3 percent per year, resulting in a shortage of 285,000 RNs by 2020 and a shortage of 500,000 by 2025.28 There is a huge shortage of pharmacists as well. The
Demand for a Surgical/Medical Workforce
21
Tennessee legislature has already approved the formation (the state’s second) of a pharmacy school to be located at the University of Eastern Tennessee in Johnson City.29 By 2020, Ohio will have 1,400 fewer pharmacists than it needs. Nationally, the number is even more startling, with a shortfall of 157,000 pharmacists predicted.30 Nonphysician clinical occupations such as pharmacists and nurse practitioners continue to grow in numbers and expand their scope of practice. If physicians are more productive or focused on the more complicated cases, then the number of these nonphysician clinicians is important in any equation that tries to predict future demand for specialists. Public Reaction The general public is learning in a variety of media about an impending shortage of both primary care and specialist physicians. Here is a sample of what has been presented in the news media recently: • “The shortage of surgeons is a particular threat to the health care of 54 million rural Americans, medical specialists say. The impact often is most severe in rural America, where only 9,334 of 211,908 physicians are general surgeons, according to AMA data. The Census Bureau defines rural as open country or small towns with fewer than 2,500 residents.”31 • “You could be waiting weeks or months for a doctor’s appointment, traveling further to get there and spending less time with your doc when you do & that’s if you get to even see a physician! The reason—experts say we’re headed for a doctor shortage in this country.”32 • “Michigan medical students getting slammed by mounting postgraduate debt are shying away from areas of medicine that are in high need and demand, but rank low on the doctor pay scale, a state association asserts.”33 • “The country needs to train 3,000 to 10,000 more physicians a year—up from the current 25,000—to meet the growing medical needs of an aging, wealthy nation, the studies say. Because it takes 10 years to train a doctor, the nation will have a shortage of 85,000 to 200,000 doctors in 2020 unless action is taken soon.” • “The nation now has about 800,000 active physicians, up from 500,000 20 years ago. They’ve been kept busy by a growing population and new procedures ranging from heart stents to liposuction.”34 The supply of physicians will shrink in about 10 years when doctors from the baby boom generation retire in large numbers. Today, new physicians roughly equal the numbers of doctors retiring.
Finally, from the previous article in USA Today is a quotation by Dr. Richard Cooper, a former medical school dean, that sums up the picture: “It’s foolish to limit doctors as a way to control health care costs . . . doctors don’t drive medical costs. . . . sickness does . . . we face at least a decade of severe physician shortages because a bunch of people cooked numbers to support a position that was obviously wrong.” Cooper continues, “This is a desperate situation. And we need to act now because it takes a long time to train a doctor.”35
3 Surgical Supply: Residents—The Future Surgeons The scene is New York in the mid 1990s; a resident makes a mistake and subsequently the state laws change and the American residency systems change to enforce an 80 hour residency work week. Before that residents in surgery worked 100 to 150 hours a week. Mistakes were made when they were tired. What does this have to do with the supply and demand of surgeons? Plenty, as we shall see.
RESIDENCIES Internships and residencies can begin as soon as a doctor graduates from medical school. In the senior year of medical school, medical students interview at selected residency programs and enter the National Residency Matching Program (NRMP), which matches applicants with training institutions. Most residencies are three to five years in duration. The period of residency extends from four years in obstetrics and gynecology (OB/GYN) to seven years in thoracic and cardiovascular surgery. Otolaryngology (ENT, ear, nose, and throat), orthopedic surgery, general surgery, and urology take five years (Table 3.1). Neurosurgeons train for six years. These are the surgery specialties we will cover in this book. A fellow is a doctor who takes one or more years of post graduate training after completing his or her residency, such as a fellowship in plastic or vascular surgery. Demographics of the resident workforce. In 2007, there were a total of 17,359 (51.7% male and 48.3% female) medical school graduates in the United States.1 The demographics of the surgical workforce are shown in Table 3.2. The table shows the following specialties: obstetrics and gynecology, orthopedic surgery, otolaryngology (ear, nose, and throat), general surgery, thoracic surgery, neurosurgery, and urology. The total number of programs for each of those specialties is shown in column 2; that is, 250 in OB/GYN, 104 in otolaryngology, 152 in orthopedic surgery, 251 in general surgery, 118 in urology, 97 in neurosurgery, and 85 in thoracic surgery. The total
Surgical Supply
23
number of resident positions available is shown in column 3 and range from 282 in thoracic surgery to 7,651 in general surgery. The number of females in each residency varies from 33 in thoracic surgery to 3,596 in OB/GYN. In fact, females comprise almost 75 percent of the resident workforce in OB/ GYN. U.S. medical graduates, Canadian graduates, and osteopaths who select
Table 3.1 Years in Training Specialty
Years in Residency
OB/GYN
4
ENT
5
ORTHO
5
GENERAL
5
UROLOGY
5
NEURO
6
THORACIC
7
Source: http://www.abms.org/Who_We_Help/Consumers/About_Physician_Specialties/orthopae dic.aspx; www.abns.org, www.abog.org, www.aboto.org, www.abos.org, www.absurgery.org, www. abu.org, www.abts.org
Table 3.2 Demographics of the Emerging Surgical Workforce
Specialty
Total Number of Residents’ Total Number of Positions Available Programs
Number of USMDs, Number of Canadians, and Number of Osteopaths IMGs Females % % %
OB/GYN
250
4,739
3,596 75.9
3,735 78.8 1,004 21.2
ENT
104
1,292
352 27.5
1,256 97.2
36
2.8
ORTHO
152
3,187
367 11.5
3,114 97.7
73
2.3
GENERAL
251
7,651
2,275 29.7
UROLOGY
118
992
212 21.4
956 96.4
36
NEURO
97
881
95 10.8
789 89.6
92 10.4
THORACIC
85
282
33 11.7
221 78.4
61 21.6
6,189 80.9 1,462 19.1 3.6
Source: “Resident Physicians on Duty in ACGME-Accredited and in Combined Specialty Medical Education (GME) Programs December 1, 2006.” Journal of the American Medical Association (September 5, 2007): Appendix II, Table 2. (3).
24
The Coming Shortage of Surgeons
these residencies comprise close to 80 percent in OB/GYN, general surgery, and thoracic surgery to almost 98 percent in otolaryngology, orthopedic, and urologic surgery; around 20 percent of the surgeons who train in OB/GYN, general surgery, and thoracic surgery are IMGs (international medical school graduates). Table 3.3 shows the number of first-year positions in Accreditation Council for Graduate Medical Education (ACGME) accredited programs in 2007–8. As an example, 118 first year positions in thoracic surgery, 152 positions in neurosurgery, and 2,363 in general surgery were offered in 2007–2008. Thoracic surgery requires a resident to be board certified in general surgery before assuming thoracic surgery residency. Origin of residency applicant pool. Of the entire current physician workforce, 11 percent are osteopathic graduates, five percent are U.S.-born IMGs; and 20 percent are foreign-born IMGs.2 So, approximately 65 percent of the workforce graduated from a Liaison Committee on Medical Education (LCME) school. The LCME is the national accrediting authority for medical education training programs leading to the M.D. degree in U.S. and Canadian medical schools. The LCME is sponsored by the Association of American Medical Colleges (AAMC) and the American Medical Association (AMA).3 U.S.-born IMGs Typically, the U.S.-born IMG leaves the United States to go to a foreign medical school because he or she is not able to gain admission to an accredited medical school. These students subsequently return to the United Table 3.3 First-Year Positions Specialty
Total Number of Residents’ Positions Available
Number of First-Year Positions
OB/GYN
4,739
1,225
ENT
1,292
262
ORTHO
3,187
637
GENERAL
7,651
2,363
UROLOGY
992
178
NEURO
881
152
THORACIC
282
118
Source: “Total Program Size and Number of First Year Positions Available in ACGME-Accredited and Combined Special Programs for the Next Academic Year (2007–2008) as Projected by Program Directors.” Journal of the American Medical Association (September 5, 2007): Appendix II, Table 10. (3).
Surgical Supply
25
States and have to take ECFMG (Educational Commission for Foreign Medical Graduates) certification in order to apply for an ACGME accredited residency position.4 According to ECFMG data, there were 9,759 IMG applicants in the NRMP for residency positions in 2007. Of these 6,992 were non-U.S. citizens and 2,694 were U.S. citizens. Fifty percent of the U.S. citizens and 46 percent of the non-U.S. citizens were eventually matched with an educational institution for residency training (Figure 3.1).5 Foreign-born IMGs U.S. medical graduates generally apply to 5–10 programs, whereas the non-U.S. IMGs submit their applications to a minimum of 25 programs.6 Only 14 percent of IMG applicants are granted interviews, and only 8 percent Figure 3.1 National Resident Matching Program, 2008 12,000
10,000
8,000
6,000
4,000
2,000
0 Total Participants
Non U.S. Citizen IMG Participants
# Participants
U.S. Citizen IMG Participants
# Matched
Source: National Resident Matching Program, Results and Data: 2008 Main Residency Match. National Resident Matching Program, Washington, DC., 2008, http://www.nrmp.org/data/result sanddata2008.pdf (accessed March 11, 2009).
26
The Coming Shortage of Surgeons
of the entire applicant pool will be employed by an institution.7 Once accepted, successful applicants apply for an H-1B or a J-1 visa. The J-1 visa is a temporary nonimmigrant educational visa reserved for participants in the Exchange Visitor Program. Once recipients of J-1 visas complete training they are required to return home for at least two years before they can apply for re-entry on another visa. A waiver from this requirement can be obtained by seeking employment through a medically underserved area (MUA) or Health Professions Shortage Area (HPSA) in the United States.8 IMGs comprise close to 40 percent of the physician workforce in inner city areas in large metropolitan cities.9 However, there is concern among leaders in academic medicine about the inconsistent quality of medical education in international schools. In addition, as Dr. Fitzhugh Mullan, contributing editor for Health Affairs puts it, “Rather than relying on foreign medical school graduates to complete residency classes, the United States should increase its output to fill the gap.”10 Most hospital credentials committees will accept proof of an IMG’s board certification upon successful completion of a residency training program in the United States and passing a certifying examination administered by the appropriate board. The IMG can then be approved for the hospital staff. An overview of the U.S and IMG population is shown in Table 3.4. and is illustrated in Figure 3.2. The proportion of IMGs who research and teach as academic faculty in U.S. medical schools has remained fairly constant at 17 percent in 1981 and 18 percent in 2000.11 American Board Certification The number of board certificates given over the last 10 years in the specialties of obstetrics and gynecology, thoracic surgery, orthopedics, general surgery, otolaryngology, urology, and neurosurgery is listed in Table 3.5. The Table 3.4 U.S. Physician and International Medical Graduates Population Overview Number of physicians in U.S.
902,053
Number of international medical graduates
228,665 (from 127 countries)
% of international medical graduates in U.S.
25.3%
% of international medical graduates in residency programs
28.2%
% of international medical graduates in primary care
37.6%
% of U.S. medical graduates in primary care
31.9%
% of international medical graduates in patient care
80.1%
% of international medical graduates in academics
16.2%
Source: Physician Characteristics and Distribution in the U.S., 2007 edition; AMA, Chicago, Ill.
Surgical Supply
27
Figure 3.2 Residencies Graduates of Foreign and U.S. Medical Schools in Residency Programs in the U.S. | 1985–2002 Number of graduates per year: 80,000 70,000 60,000 50,000 40,000 30,000 20,000 10,000 0 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 00 01 02 U.S. schools
Foreign schools
Graduates of Canadian medical schools and graduates of osteopathic schools are included in the data for U.S. schools Source: Blumenthal D. “New Steam from an Old Cauldron—The Physician-Supply Debate.” The New England Journal of Medicine, 1533–4406, April 22, 2004, Vol. 350, Issue 17. Copyright © 2004 Massachusetts Medical Society. All rights reserved.
average number of certificates awarded in the last 10 years ranges from less than 150 per year in thoracic surgery and neurosurgery to 1200 in obstetrics and gynecology. In orthopedic surgery, the number ranges from 625 to 650 board certified surgeons a year. In general surgery, it is about 1,000, and in otolaryngology and urology, it is between 250 and 300. The trend shows a level or decreasing number of certificates awarded each year except in general surgery (Figure 3.3).12 A review of the American Board of Thoracic Surgery Certification Data from 1996 to 2008 provides an example of how IMGs filled the gap in this specialty (Table 3.6). During this time period, an average of 16 percent of certificates were awarded to IMGs, with 25 percent awarded in 2008. Work Hours Probably the single greatest impact on training residents is the limitation on the hours surgical trainees can work. A typical intern’s schedule in the 1960s was more than 100 hours a week. The event that started legislative action in New York State was in response to the death of a patient, Libby Zion, in which resident physician fatigue was suspected as a factor. The state enacted
28
The Coming Shortage of Surgeons
Table 3.5 The American Boards of Medical Specialties Certificates Issued in Surgical Specialties Year
OB/GYN Eent
Ortho
General
Urology
Neuro
Thoracic
1997
1,201
284
640
947
244
119
121
1998
1,220
282
645
1,001
261
137
168
1999
1,291
305
623
976
247
128
135
2000
1,214
321
639
1,043
290
124
126
2001
1,174
303
621
994
288
120
120
2002
1,119
310
631
995
262
143
162
2003
1,225
250
563
920
245
152
118
2004
1,049
274
594
1,068
255
139
152
2005
1,128
281
645
1,124
249
145
112
2006
1,105
259
593
1,266
211
128
134
Ten Year Total 11,338 2,869 6,194
11,191
2,559
1,335
1,348
1,028
255
134
139
MEAN
1,171
288
628
Source: The American Boards of Medical Specialties, Member Boards, General Surgery Certificates Issued 1995–2002; Available at http://www.abms.org/ (accessed July 4, 2009).
legislation limiting resident work hours to 80 hours per week. Following this, in July 2003 the ACGME instituted standards for all accredited training programs and introduced the same limitation. The average 80 hour work week applies to all time spent in a hospital, including the clinic, operating room, and teaching conferences. A resident can be on call no more than every third day on average and must have at least 24 hours off a week.13 These restrictions are expensive and difficult to enforce, and violations are frequent and not always reported. The data on the impact of the new paradigm on mortality and morbidity among patients is still not clear. A study of 3000 Medicare hospital admissions compared mortality rates prior to and after the new standard showed no difference in mortality.14 Another report on patient care in a Level 1 Trauma Center noted a significant increase in total, preventable, and nonpreventable complications after the 80 hour work week was instituted. No difference in mortality was recorded. The authors of the Trauma Center study blamed the higher complication rate in part on the reduced work hours for various reasons, including poor communication or hand off between resident teams.15 In terms of the impact on the workforce, the fewer ‘man’ hours roughly translate to a 20 percent reduction in work hours of the nation’s approximately 112,000 medical residents and fellows, which is equivalent to losing the workload of about 15,000 to 22,000 full-time positions.16
Surgical Supply
29
Figure 3.3 American Board Surgical Certificates Awarded Certificates Per Year 1,500 1,200 900 600 300
0 1997
1999 ENT General
2001 OB/GYN Neuro
2003 Ortho Thoracic
2005
2007 Urology
Source: The American Boards of Medical Specialties Certificates Issued in Surgical Specialties. The American Boards of Medical Specialties, Member Boards. Available at http:// www.abms.org/ (Accessed July 4, 2009) and at http://www.abms.org/Who_We_Help/ Consumers/About_Physician_Specialties/orthopaedic.aspx, accessed 6/27/2009. Source: www.abns.org, www.abog.org, www.aboto.org, www.abos.org, www.absurgery.org, www.abu.org
Compensation of Residents Residents’ salaries range from $40,000 to about $55,000 (Table 3.7).17 At 80 hours each week for 50 weeks of the year, a resident works 4,000 hours in a year. The average resident is therefore paid about $10.00 to $14.00 per hour for his or her time. Table 3.8 compares these wages with some skilled labor wages as well as the wages of some comparable professions as published by the Bureau of Labor Statistics.18 When trainees finish their residencies, they are between 28 and 35 years old. The typical career path includes 12 years of primary/secondary school with a GPA that exceeds 3.5 and SAT scores greater than 1300, four years of college premed courses, again with a GPA 3.5 or higher, and four years of medical school. Three to five years of residency training is often followed by one to two years of an additional subspecialty fellowship. Doctors then look forward to paying down a median debt of between $145,000 and $180,000, with 23 percent of students reporting a debt principle in excess of $200,000.19
Table 3.6 The American Board of Thoracic Surgery Certification Data: 1996–2008 Year
Total No. of Certifications
1996
160
150
10
1997
121
108
13
1998
168
154
14
1999
135
119
16
2000
126
111
15
2001
120
97
23
2002
162
132
30
2003
118
104
14
2004
152
112
40
2005
112
86
26
2006
134
102
32
2007
116
94
22
2008
126
Total
1,750
U.S. & Canada
101
Fmg/Img
25
1,470 (84%)
280
Source: Patricia Watson. American Board of Thoracic Surgery http://www.abts.org/sections/ Contact%20Us/index.html (accessed June 24, 2008).
Table 3.7 Mean Stipends for Residents, 2007 PGY – 1 Intern
$44,000
PGY – 2
$46,000
PGY – 3
$48,000
PGY – 4
$52,000
PGY – 5
$54,000
PGY – 6
$54,000
Note: These are means based on a national survey by the AAMC; the actual figures can vary by $3,000 to $4,000 on either side of the mean, and at times by more. Chief Residents may receive an additional stipend of $2,000 to $3,500 a year. Source: http://mdsalaries.blogspot.com/2005/10/residency-salaries.html (accessed June 23, 2008).
Surgical Supply
31
Table 3.8 Comparison of Resident Salary with other Occupations from May 2007 National Occupational Employment and Wage Estimates Occupation Code
Occupation Title
Mean Hourly
Surgical Residents
$10–14
51–4111
Tool and Die Makers
$22.36
47–2041
Carpet Installers
$19.21
47–2031
Carpenters
$19.84
53–2021
Air Traffic Controllers
$51.82
47–4021
Elevator Installers and Repairers
$31.89
47–2111
Electricians
$23.12
23–1011
Lawyers
$56.87
Source: http://www.bls.gov/oes/current/oes_nat.htm (accessed June 23, 2008).
CONCLUSIONS Surgical residency training is long and arduous. In general, the compensation for residents at $10–14 an hour is lower than most occupations that require comparable education. Certainly, a resident’s future income level is higher compared to the occupations listed in Table 3.8 when they go into practice. The debt burden is high. The reduced work hours for residents reduce manpower by almost 20 percent. The number of board certified surgeons is on a downward trend for U.S. and Canadian medical graduates. The percentage of IMGs in U.S. surgical residencies has been gradually increasing. With these demographics and the considerations of a “controllable lifestyle,” as we will see in chapter 4, some authorities think we will need 1.3 full-time medical graduates to replace one medical graduate in today’s workforce. In addition to these implications, we must also increase residencies to serve a population that will almost grow 40 percent by 2050. At the same time, the implications of the figures with regard to American Board of Thoracic Surgery (Table 3.6) suggest there will be even more IMGs with certificates granted by the various American Boards. Therefore, the surgical workforce will be increasingly populated by international medical school graduates. What happens if the professional opportunities and/or the job market for IMGs start to improve in their own countries? Will a larger percentage decide to return to their cultures? We have already some evidence that they will. It behooves our policy makers and our government to make preparations to deal with the crisis that is headed our way.
4 Constraints to Supply: Pertinent Issues A young surgeon graduates from her surgical residency. What does she face? Well, let’s see: (1) Over $150,000 of debt; (2) malpractice premiums that range from $75,000 to more than $200,000 per year; (3) reimbursement rates that continuously go down; and (4) an uncertain work and call schedule, in part, due to her partners’ early retirements. Among the most pertinent issues we discuss in this chapter are factors that influence potential applicants to consider medical school, such as medical student debt and graduate medical education funding (covered in a later chapter), which are both barriers to potential students. We consider issues that lead to reduced workload during doctors’ careers, such as lifestyle and gender issues, the influence of decreased reimbursement, and professional liability (malpractice) on the choice of nonsurgical careers, some outside of clinical practice. We review an alternative source of doctors, international medical graduates (IMGs). Finally, we examine the potential of early retirement and its effect on any projections for future manpower.
MEDICAL STUDENTS’ DEBT
S— E— L—
The mean tuition and fees for first year medical students in both private and public medical schools are shown in Table 4.1.1 In the public sector, the mean tuition and fees for a medical student who is a resident of the state in which the school is located is $18,748.00. For a nonresident of that state, it is $37,984.00. With regard to private medical schools, the average tuition for a resident is $37,869.00 and $38,337.00 for a nonresident. The Association of Academic Medical Centers (AAMC) has determined that between 1984 and 2004 the median private medical school tuition increased by 50 percent (real dollars adjusted for inflation) and the median public school tuition by 133 Percent (Table 4.2). For the class of 2007, the average educational debt of those medical students was $139,517, an increase of 6.9 percent over the previous year (Figure 4.1).2
Constraints to Supply
33
Table 4.1 Medical School Tuition, First-Year Students, 2008–2009 Status
Public
Private
Resident
$18,784
$37,869
Non-Resident
$38,082
$38,337
Source: AAMC, “Tuition and Students Fees Reports. Table 1—U.S. Medical Schools Tuition and Students Fees—First Year Students, 2008–2009 and 2007–2008,” http://services.aamc.org/tsfre ports/report_median.cfm?year_of_study=2009 (accessed March 28, 2009).
Table 4.2 Tuition and Fees: Current Dollars and Constant 2004 Dollars 40,000 Private Schools 30,000
20,000 Public Schools
10,000
0 1984–85
1989–90
1994–95
1999–00
Constant dollars
Constant dollars
Current dollars
Current dollars
Source: AAMC, “Tuition and Students Fees Reports. Table 1—U.S. Medical Schools Tuition and Students Fees—First Year Students, 2008–2009 and 2007–2008,” http://services.aamc.org/ tsfreports/report_median.cfm?year_of_study=2009 (accessed March 28, 2009).
Although only 23 percent of medical graduates are more than $200,000 in debt, with inflation-adjusted incomes for physicians falling, the anxiety level of those who incur high debt burdens is palpable.3 It is therefore useful to look at repayment of this large debt from the point of view of future practitioners. If a medical school graduate amortizes his or her debt, say $130,000, after residency with the monthly payment spread
34
The Coming Shortage of Surgeons
Figure 4.1 Median Medical Education Debt Thousands of dollars per year: $150,000
$120,000
$90,000
$60,000
$30,000
0 ’84
’86
Private Public
’88
’90
’92
’94
’96
’98
’00
’02
’04
Numbers have not been adjusted for inflation No data available for 1991
Source: Median Medical Education Costs and Student Debt, Association of American Medical Colleges, p. 5. Copyright © 2004.
over 10 years,4 his or her payment would be $1,827.00 per month with a total interest cost of $104,257.00 and a total repayment of $219,258.00. The maximum interest rate on these debts is 8.25 percent.5 Looking at the projected loan repayments as a percentage of the physician’s after tax income over the next 20 years, the debt service will account for 20 percent or more (Figure 4.2). One of the general rules of family finance is that about 20–25 percent of income should be devoted to housing. A physician’s debt burden is equivalent to an extra house payment every month until the debt is repaid. Steve Dutton is the chief financial officer, and a partner, in the Don Casto organization, a real estate firm in Columbus, Ohio, that develops properties nationally. After reviewing a draft copy of this book he wrote the following in an e-mail with regards to medical student debt:6 The thought that we discussed last night dealt with the idea of how to subsidize the financing cost medical students incur, as an alternative to an outright forgiveness of the debt, which might have complicating negative political overtones.
Constraints to Supply
35
Figure 4.2 Projected Loan Payments as a Percentage of Projected Physician After-Tax Income 70% 60% 50% 40% 30% 20% 10% 0% 2003 Public Private
2007
2011
2015
2019
2023
2027
2031
Assumptions: Indebtedness grows at historic rate of 8.3% for public school students and 8.9% for private school students; physician income grows at 0.6%; average tax rate 33.4%; 30-year loans
Source: Medical School Tuition and Young Physician Indebtedness (An update to the 2004 Report), Copyright © 2004, Association of American Medical Colleges, p. 6. AAMC.
Another way around the issue would be to lengthen maturities and lower the interest rates on the debt. I thought that maybe this could be done by providing a guarantee or other credit enhancement from a governmental agency—similar to the way municipal bonds work. This would provide an investor with a tax free return, hence a lower rate requirement. Also, the government backing should cause the investor to be more comfortable with a longer term, and the ultimate collectivity. Clearly, providing the city, county, state or nation with more competent doctors would be seen to serve the public purpose, and thus be a worthwhile use of the agencies credit enhancing ability.
The legislature of the state of Pennsylvania passed such a bill in 2007. Clearly the prospect of this enormous debt has an impact on the number of people who choose to become doctors, particularly in attracting primary care physicians and medical school applicants from less privileged backgrounds. The debt crisis harms both medical students and patients. Some graduates want to take shorter residencies (three years), like those for primary care physicians
36
The Coming Shortage of Surgeons
(family doctors, internists, or pediatrics), in order to commence paying their debt. Some others want, instead, to either seek specialties that offer higher incomes or more leisure time. The problem of debt also compounds itself in the decreased diversity of the physician workforce, which can prevent students from low-income or minority families from attending medical school. Debt has mental health implications as well. In an already exhausting training program, the likelihood of having to moonlight (work for extra pay) is real and can be extremely stressful. The level of a person’s debt correlates with symptoms of depression and cynicism.7 Controllable Lifestyle and Gender: In Search of Work /Life Balance In today’s hustle and bustle world, which seems to leave little time for the most important things, employees across industries seek to have greater control over their work/life balance. It’s one of the dominant themes found among the cohort of young people of the baby boom echo currently in its teens and 20s, described by marketers as “generation X” or the Xers and “generation Y” or the Millennials (born between 1984 and 1994). College students are increasingly abandoning undergraduate premedical studies, often citing disillusionment with the physician lifestyle. However, the choice of a career based on concerns about lifestyle is true of professions other than medicine also.8 Unlike the days of old, when physicians owned their own practices and thus set their own hours, hired their own staff, and built enduring relationships of loyalty and trust with patients, physicians today, in a sense, are employees of a third-party payer. The proportion of physicians with an ownership stake in their practice decreased from 61.6 percent to 54.4 percent as physicians opted for employment over the 10 year period from 1996 to 2005.9 Studies of physicians’ complaints include workload, administrative paperwork, limitations on referring patients to specialists of a physician’s choosing, financial incentives to curb medical work-ups, and the physician’s role as an agent for insurers, government agencies, and courts (Table 4.3). In a survey taken from Medical Economics in November 2005, the average work hours per week were the highest, 60 hours, for cardiologists, general surgeons, OB/GYNs, neurosurgeons, and thoracic surgeons.10 The average work week for orthopedic surgeons was 50 hours. Work hours were up and patient visits were reported down in a recent survey.11 Why? Because of increased paperwork. Over 80 percent of part-time physicians work at least half a work week; 69 percent of female physicians and 11 percent of male physicians who practiced part-time indicate family responsibilities as the reason for cutting back.12 Male physicians also give unrelated professional or personal pursuits (31%) and preparing for retirement (29%) as the predominant reasons for working part time. Facing these issues, why would anyone expect physicians to put in longer hours than corporate lawyers, accountants, or other well-educated professionals?
Constraints to Supply
37
Table 4.3 Single Greatest Source of Professional Frustration 2007
2004
2000
Long hours
15%
10%
4%
Malpractice worries
18%
28%
6%
Reimbursement issues*
33%
16%
56%
13%
15%
Medicare/Medicaid regulations** Patient attitudes today
8%
5%
8%
Pressure of running a business
11%
10%
6%
Other
15%
9%
5%
N/A
9%
Source: 2007 Survey of Physicians 50 to 65 Years Old http://www.merritthawkins.com/pdf/ mha2007olderdocsurvey.pdf (accessed July 5, 2008).
Even when the income, working hours, and years of required training for a medical career are considered, none approaches the impact of a controllable lifestyle and the time to meet family responsibilities. In a 2003 study of specialty choices by U.S. medical students, the findings suggested a significant shift in specialty preference between 1996 and 2002 (Table 4.4).13 In analyzing the second column (lifestyle) and the fourth column (average work hours per week) in Table 4.4, it is obvious that the practitioners of specialties classified as uncontrollable work over 10 percent longer hours per week with fewer scheduled hours than other specialists. The specialty preferences of U.S. senior medical students reflect these lifestyle variables, particularly in family practice and general surgery. For general surgery, the decline was from 10.4 to 7.6 percent, representing 300 fewer general surgeons training each year and raising concerns about an adequate general surgery workforce. The concern is even greater for family practice, with residency programs declining from a 73 to 43 percent fill rate from 1996 to 2002.14 It is important to understand that a controllable lifestyle and professional satisfaction do not necessarily go together. In a survey of Canadian physicians, some specialties, such as radiation oncology and urology (which are perceived as allowing for a better lifestyle), were actually specialties in which physician groups were the least satisfied.15 Gender also plays a role in the choice of a specialty. However, both men and women are choosing specialties with a more predictable and controllable lifestyle.16 With regard to gender, this same survey showed the median number of hours worked per week by female doctors is 45, while the median number of hours worked per week by male practicing doctors was 54. As you can see, both sexes work more than 40 hours per week. When you have a two income family, someone has to take the kids to basketball practice and music lessons, and pick them up from school.
38
The Coming Shortage of Surgeons
Table 4.4 Choice of Specialty and Lifestyle Years of Graduate Medical Average Work Hours Education Required per Week
Lifestyle
Average Income, $ in Thousands
Anesthesiology
Controllable
225
61.0
4
Dermatology
Controllable
221
45.5
4
Emergency medicine
Controllable
183
46.0
4
Family practice
Uncontrollable
132
52.5
3
Internal medicine
Uncontrollable
158
57.0
3
Controllable
172
55.5
4
Uncontrollable
224
61.0
4
Specialty
Neurolgy Obstetrics and gynecology Ophthalmology
Controllable
225
47.0
4
Uncontrollable
323
58.0
5
Controllable
242
53.5
5
Pathology
Controllable
202
45.5
4
Pediatrics
Uncontrollable
138
54.0
3
Psychiatry
Controllable
134
48.0
4
Orthopedic surgery Otolaryngology
Radiology (diagnostic)
Controllable
263
58.0
4
Surgery (general)
Uncontrollable
238
60.0
5
Urology
Uncontrollable
245
60.5
5
Average for the above specialties
Not applicable
208
53.9
4
Source: E. Ray Dorsey, M.D., MBA, David Jarjoura, PhD, and Gregory W. Rutecki, M.D., “Influence of Controllable Lifestyle on Recent Trends in Specialty Choice by US Medical Students,” JAMA, 290 (2003), http://jama.ama-ssn.org/cgi/content/full/290/9/1173/TABLEJOC30309T1 (accessed July 16, 2008). Copyright © American Medical Association, All rights reserved.
How much will lifestyle and gender issues affect choice of surgical specialties, and what will that do to physician workforce supply?
REIMBURSEMENTS The constant negativity projected by private practitioners and academic physicians about declining reimbursement is bound to influence all potential physicians as well as their relatives, friends, and neighbors and current medical students and residents.
Constraints to Supply
39
In 2008, according to Medical Group Management Association (MGMA), specialists’ income unadjusted for inflation rose 3.16 percent in 2007, but with a 2.85 percent rise in the Consumer Price Index, the increase in real dollars was 0.31 percent. Primary care physicians’ incomes increased by 6.3 percent unadjusted and 3.35 percent adjusted for inflation.17 A telephone survey of over 6000 physicians by the Center for Studying Health System Change in 2006 showed that the average net income adjusted for inflation for all physicians dropped 7 percent from 1995 to 2003 (Figure 4.3). In contrast, professional and technical workers saw a 6.9 percent increase in inflation-adjusted income in the same period. In comparison, income for nonphysician professionals increased 7 percent during the same period.18 In the same survey it was noted that Medicare reimbursements to physicians increased by 13 percent between 1995 and 2003—compared with a general inflation rate of 21 percent—and that reimbursements from private health insurers increased by less than 13 percent. According to The American Medical Association (Figure 4.4), in 1984 physician income was reported as $165,000 in current dollars. In 2000 physicians were making about $175,000 a year, again in current dollars, but purchasing power of the 2000 dollars was only 50 percent of that of the 1984 dollars. In other words, physicians had less disposable income in 2000 than they did in 1984. The American Medical Group Association published these figures in 2007 for surgeons’ salaries (Table 4.5).19 There is no question that physicians are in Figure 4.3 Report Finds Physician Income “Losing Ground” to other Professions Change in inflation-adjusted income 1995–2003 6.9%
All physicians
PCPs
Medical Surgical specialists specialists Professional, technical workers
(2.1%)
(7.1%) (8.2%)
Study methodology
• Results of 1996–1997 telephone survey of 12,000 physicians compared against results from 2004–2005 survey of 6,600 physicians
• Physician income trends pitted against U.S. Bureau of Labor Statistics Employment Cost Index data for professional, specialty, and technical workers.
(10.2%) Source: “Physician Income: Study Shows dip as CMS Proposes Reimbursement Changes,” © The Advisory Board Company. All rights reserved. Reprinted with permission. http://www.advisory. com/members/default.asp?contentID=60277&collectionID=798&program=5&filename=602 77.xml (accessed January 10, 2009).
40
The Coming Shortage of Surgeons
Figure 4.4 Physician Income $250,000 $200,000 $150,000 $100,000 $50,000 0 1984
1986
1988
1990
1992
1994
1996
1998
2000
Current dollars Constant dollars Source: Medical Educational Costs and Student Debt, p. 4. Copyright © 2004, Association of American Medical Colleges.
Table 4.5 Surgical Compensation Surgical Specialty
Median
Orthopedics
$436,481
Otolaryngology
$327,399
Obstetrics and Gynecology
$297,887
General Surgery
$327,902
Thoracic and Cardiovascular Surgery
$460,000
Neurological Surgery
$530,000
Urology
$365,999
Source: American Medical Group Association–2007. American Medical Group Association Compensation Survey Data 2007 Report. Available at http://www.cms.hhs.gov/AcuteInpatient PPS/Downloads/AMGA_2007%20Report.pdf (accessed June 27, 2009).
the top 10 percent of earners and at least half of all physicians earned more than $170,000 in 2003.20 Nevertheless, when nurse anesthetists, who have much less education, no primary responsibility, little overhead, and flexible work hours earn more than physicians, the impact on budding physicians is undeniable.21
Constraints to Supply
41
Jack Matloff, M.D., presented this figure on reimbursement for cardiothoracic surgeons for coronary bypasses in his presidential address to the Society of Thoracic Surgeons in 2001 (Figure 4.5).22 The figure shows that reimbursements have decreased 50 percent since 1987 without correction for the Consumer Price Index, and with correction for the Consumer Price Index, more than 75 percent. Consider physician income relative to hospital reimbursements. As an example, for an aortic valve replacement performed in the year 2000, a large teaching hospital received about $35,000. By 2005, the hospital received almost $45,000, an increase of about 26 Percent (Table 4.6). Similarly, for a Figure 4.5 Reimbursements for Open Surgery $4,000 $3,600 $3,200 $2,800 -50%
$2,400 $2,000 $1,600
-77.5%
$1,200
$800 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 Amount
Amount
Corrected for Consumer Price Index
Corrected for Consumer Price Index
Source: Jack M. Matloff, “The Practice of Medicine in the Year 2010: Revisited in 2001,” Annals of Thoracic Surgery 72 (2001): 1105–1112.
Table 4.6 Hospital Reimbursements 2000
2005
Increase
Percent Increase
Aortic Valve Replacement $35,324.99 $44,506.89 $9,181.90
26.0%
CABGx3 including LIMA
11.9%
$25,213.06 $28,206.83 $2,993.77
Source: Finance Office, Ohio State University Hospitals.
42
The Coming Shortage of Surgeons
triple coronary bypass the hospital received $25,000 in 2000 and by 2005, the reimbursement increased by $3,000, an almost 12 percent increase. Now consider the reimbursement for the surgeon performing this very delicate and life saving procedure (Table 4.7). In 2000, the surgeon who performed the aortic valve replacement was paid about $2,200. By 2005, that number had been reduced by almost $60 or 2.6 percent. Similarly, the surgeon that performed the coronary revascularization got $2,300 in 2000, and by 2005 received about $2000 or about 9 percent less. When we graph the reimbursements shown in Tables 4.6 and 4.7 these decreases become even more vivid (Figure 4.6). Decreasing reimbursement is one reason that more and more specialists are becoming employees of hospitals and hospital systems. Specialists employed by hospitals can make more money and are free of the hassles of administrating
Table 4.7 Surgeon Reimbursements 2000
2005
Decrease
Percent Decrease
Aortic Valve Replacement
$2,221.42
$2,162.96
($58.46)
2.6%
CABGx3
$2,344.29
$2,132.77
($211.52)
9.0%
Source: Executive Director 1986–2009, Ray Manley, OSU Surgery LLC.
Figure 4.6 Hospital versus Physician Reimbursement 51,000 41,000 31,000 21,000 11,000 1,000 CABG Hospital
CABG MD 2000
AVR Hospital 2005
Source: Chief Financial Officer Ray Manley, OSU Surgery LLC.
AVR MD
Constraints to Supply
43
Figure 4.7 Average CV Physician Compensation per Physician Work RVU, 2002–2006 Nominal Dollars CAGR: 1.3% $54.27 $53.53
$53.78
$51.96 $51.01
$52.34
$49.48
$49.99
Real Dollars2 CAGR: 1.5% $47.99
2002
2003
2004
2005
2006
Source: Physician-Hospital Alignment, p. 17. Advisory Board Company. All rights reserved. Reprinted with permission. http://www.advisory.com/members/default.asp?contentid=74287& program=2&collectionid=763 (accessed July 26, 2008).
an office and, of course, because they are in short supply, their actual wages are more than what they could make in private practice. The amount of work performed by physicians is measured by work units called “work relative value units,” or WRVUs. The remuneration for cardiovascular specialists has not kept pace with inflation (Figure 4.7). In the specialty of thoracic surgery, physicians’ reimbursement has decreased nearly 50 percent since 1991.23 This quote on current Medicare reimbursement projections was taken from The Society of Thoracic Surgeons Web page March 14, 2006: “The Society of Thoracic Surgeons . . . is seeking to institute a fair Medicare physician payment formula. The Medicare payment freeze will only apply to 2006. In 2007, . . . physicians could see a five percent payment cut. . . . Medicare trustees predict six straight years of payment cuts ultimately totaling 26 percent.”24 And it keeps on coming. As an aside, an article in the Columbus Dispatch reported that, in New York City, equity law partners took home nearly $770,000 in 2004.25 That is two times what the average surgeon makes, according to the American Medical Group Association figures. Now, would you trust your life to a lawyer? Only on a capital offense. The Medical Malpractice Problem A constant concern for young people contemplating a medical career is the threat of getting sued. Every time a patient has an operation, a sizeable part
44
The Coming Shortage of Surgeons
of the patient’s bill goes to pay for malpractice insurance. Check the financial statements of your hospital, and you will find the hospital is paying more, often much more, for malpractice insurance than all of its utilities—electricity, gas, and water—combined. Skyrocketing malpractice insurance premiums are driving specialists out of some high-risk specialties, forcing part-time or semiretired physicians completely out of practice, and leaving some states without critical specialties Although some consumers perceive malpractice to be when a physician is unable to bring about a cure for a patient, in actuality it is defined by Merriam-Webster as “dereliction from professional duty or a failure to exercise an accepted degree of professional skill or learning by a person (such as a physician) rendering professional services, which results in injury, loss or damage.”26 From the patient’s perspective, malpractice is a two-dimensional problem. First, the occurrence of actual malpractice is detrimental to a patient’s health. Second, the increased cost of health care attributed to alleged or real malpractice affects a patient’s costs. About half of malpractice suits are regarded as nuisance suits that result in no finding of fault and no award (although legal fees are still incurred). More than 90 percent of cases are settled prior to trial, and only a very small percentage are decided in favor of the plaintiff (Table 4.8).27 In Ohio, for example, of 4,004 claims closed in 2006, 80 percent were closed with no indemnity payment; two-thirds of these were dropped or dismissed, and another 8.5 percent were dismissed by summary judgment or directed verdict (Figure 4.8).28 Of the 20 percent that resulted in some payment, 18 percent were settled and only 1% ended with a verdict for the plaintiff. The actual costs to the health care system are much greater because of costs associated with “defensive medicine”—tests and procedures based on the threat of litigation rather than medical need. In a poll of physicians by Harris Interactive about the effect of liability issues on the quality of care, 79 percent say they order unnecessary tests for this reason.29 “One dollar in litigation costs corresponds to more than four dollars of unnecessary hospital costs related to defensive medicine.”30
Table 4.8 Medical Malpractice Claim Disposition and Defense Costs, 2007 Claim Disposition
Share of Claims
Mean Expense Payment
Dropped or dismissed
73%
$15,246
Settled
22%
$46,209
Trial verdict: for defense
4%
$110,346
Trial verdict: for plaintiff
1%
$114,787
Source: Adapted from Physician Insurers Association of America, “PIAA Data Sharing Project,” PIAA (Washington, D.C., 2007).
Constraints to Supply
45
Figure 4.8 Ohio Closed Claims in 2006 Outcome of Malpractice Claims
0.2% Dismissed by Court Summary Judgment Directed Verdict—with Indemnity
55.5% Claim Suit Abandoned without Indemnity Payment, Including Dismissed without Prejudice
0.6% Disposed of by Trial Verdict Jury Verdict— with Indemnity
0.2% Disposed of by Alternative Dispute Resolution— without Indemnity
1.2% Disposed of by Settlement Agreement— without Indemnity
1.4% Disposed of by Alternative Dispute Resolution— 17.6% Disposed with Indemnity of by Settlement Agreement— with Indemnity
8.5% Dismissed by Court Summary Judgment Directed Verdict—without Indemnity
4.8% Disposed of by Trial Verdict Jury Verdict— without Indemnity
65.5% dismissed without indemnity payment 8.5% dismissed by court summary judgment or directed verdict, no indemnity 4.8% disposed of by jury verdict Source: Ohio 2006 Medical Liability Closed Claim Report. January 2008, Available at www.ohio insurance.gov/Legal/REPORTS/MedMal_Closed_Claim_2008.pdf (accessed July 4, 2009).
The severity of the malpractice problem is summarized in testimony before the National Conference on Medical Malpractice held by the Subcommittee on Health and the Environment of the U.S. House of Representatives. How does malpractice affect health care? Physicians face these major problems: 1. The skyrocketing costs of malpractice insurance are forcing some physicians to retire early and new, young physicians to consider malpractice costs when deciding on their specialties and where to open their practices. 2. The system by which malpractice claims are settled is extremely costly to physicians and subsequently to their patients as rates continue to escalate.
46
The Coming Shortage of Surgeons 3. They are forced to practice defensive medicine. 4. They fear that in a profession that depends upon the trust and confidence of their patients, medical malpractice is contributing to erosion of the relationship. 5. The contingent fee system of paying lawyers is an incentive for lawyers to aim for high settlements from physicians.
The Ohio Department of Insurance published data recently tracking premiums shortly after tort reform legislation passed in Ohio (Table 4.9). As shown in Figure 4.9, the data confirms that the surgical specialties have the highest premiums. According to the Washington Post, December 29, 2005, the insurance industry reports huge losses from malpractice suits, now running more than 7 billion dollars a year, and says they have been forced to hike malpractice premiums.31 But, at the same time, insurance companies collect 9.4 billion dollars a year in premiums for malpractice insurance. The premiums, for the most part, are passed on to the consumer/patient in the form of higher health insurance premiums and cost of services at all levels. Mlive.com is an association of Michigan newspapers. They ran an article titled “Four in 10 malpractice cases groundless.” on their Web site on May 10, 2006.32 The Web site reviewed a New England Journal of Medicine medical article titled “Claims, Errors, and Compensation Payments in Medical Malpractice Litigation.”33 The investigators commented as follows: “For 3 percent of the claims, there were no verifiable medical injuries, and 37 percent did not involve errors. Most of the claims that were not associated with errors (370 of 515 [72%]) or injuries (31 of 37 [84%]) did not result in compensation.” Overall, claims not involving errors accounted for 13 to 16 percent of the system’s total monetary costs. For every dollar spent on compensation, 54 cents went to administrative expenses (including those involving lawyers, experts, and courts).” A study by Tillinghast Towers Perrin in 2003 showed that only 22 cents of a dollar moving through the U.S. tort system goes to a plaintiff (and 54 percent of that dollar never even reaches the victim because of lawyers and other Table 4.9 Rising Premiums after One Year of Capping Jury Award in Ohio Insurance Company
2002
2003
2004
Medical Protective
22%
28%
40%
Medical Assurance
44%
19%
13–18%
OHIC
24%
17%
NA
American Physicians
29%
88%
NA
The Doctors
49%
18%
10%
Source: Ohio Department of Insurance, http://www.ohioinsurance.gov/Legal/REPORTS/ MedMal_Closed_Claim_2008.pdf (accessed June 27, 2009).
Constraints to Supply
47
Figure 4.9 Annual Physician Premium Payments for Selected Specialties
$
$0
$50,000
$100,000
Neurosurgery
Anesthesiology
OB/GYN
Gastroenterology
Orthopedic Surgeon
Internal Medicine
$150,000 Family Practice
Source: Courtesy Berwanger Overmyer Associates.
expenses).34 A similar study found 60 to 70 percent of malpractice claims to be without merit and only 38 percent of the dollars flowing through the litigation system to the plaintiffs (Figure 4.10).35 One of the ways to solve the malpractice problem is compulsory arbitration, a contract between a physician and/or hospital and patients that if anything negative were to happen to the patient, or the patient perceived an adverse outcome, a compulsory arbitration could be arranged by medical experts and lawyers to protect the patient’s rights and the provider’s rights without need for a trial by jury. If either party wanted to sue after the claim had been finalized, they could sue, perhaps, with the loser paying both the plaintiff’s and the defendant’s legal fees, a system such as they have in Great Britain. When we buy stocks or bonds we agree to this compulsory arbitration. Tort reform can have a significant influence on professional liability premiums. In Ohio, for instance, four of the state’s five largest medical malpractice insurers have filed rate changes indicating an average decrease of 1.7 percent in 2006. This, after rate “increases of 30 percent in each of 2002 and 2003, 20 percent in 2004, and 6.7 percent increase in 2005.”36
48
The Coming Shortage of Surgeons
Figure 4.10 Where Malpractice Dollars Go A recent report by the Employment Policy Foundation of Washington, D.C., indicates that plaintiffs receive less than half of the total number of dollars that flow through the malpractice litigation system. Here’s a breakdown of malpractice dollars spent. The number of malpractice claims eventually found to be without merit? Sixty to seventy percent.
to defense, claims adjustment, and investigation
to plaintiffs
30%
to plaintiffs’ lawyers and expert witnesses
38%
32%
Source: Physicians Practice and http://overlawyered.com/2003/08/employment-policy-foundation finds-med-mal-system-lacking (accessed July 30, 2008).
Are there any other solutions for the malpractice situation? Perhaps. One might consider the health courts described in this letter from Philip K. Howard, Chairman, Common Good, located in New York, to the Wall Street Journal, published February 28, 2006 and titled “Juryless Health Courts Could Stabilize ‘Crisis’”:37 According to studies by the Institute of Medicine and others, nearly universal distrust of American justice is causing American health care to suffer a kind of nervous breakdown. Doctors squander tens of billions of dollars in unnecessary “defensive medicine.” Professional interaction is chilled by legal fears, leading to tragic errors. Getting rid of inept doctors is, literally, a trial—the doctors invariably hire a lawyer and threaten to sue the hospital. To begin to restore order to health care, a broad coalition of patient advocates, consumer groups and providers, has come together behind the idea of creating pilot projects for special health courts. These health courts, developed by a joint venture of Common Good and the Harvard School of Public Health, would have judges focused on health care, neutral experts, incentives for prompt
Constraints to Supply
49
compensation, and written opinions to offer guidance on good practices. As with other administrative courts, health courts would have no juries. In a public survey conducted by Harris Interactive and released by Common Good, 63% of people supported medical lawsuits being tried in special health courts when asked “Specifically, would you favor or oppose having medical malpractice cases tried in special courts presided over by medical professionals and other experts to review and decide injury cases?”38
America has a long tradition of specialized courts for areas needing special expertise, including admiralty courts, bankruptcy courts, and workers compensation systems. Several bi-partisan bills have been brought up and passed in the House of Representatives, but because of heavy lobbying by plaintiff attorneys, the legislation has never made it to the Senate floor. We will talk a lot more about malpractice premiums when we discuss the malpractice problem in obstetrics and gynecology. Foreign Medical Graduates, the “Brain Gain/Drain,” and Culture Until the recent recommendations made by AAMC and the expansion that has started towards producing more medical graduates, the number of future M.Ds enrolled per 100,000 population had been steadily decreasing (Figure 4.11). For years the hospitals in the United States have been training foreign medical graduates along with American medical school graduates. A majority of these Figure 4.11 First-Year M.D. Enrollment per 100,000 Population 7.5
Number of Enrollees
7.0
7.3 6.8
6.5
6.4 6.2
6.0
5.8
5.5
5.6
5.4
5.0
5.2 5.0
4.5 4.0 1980
1985
1990
1995
2000
2005
2010
2015
2020
Source: U.S. Census Bureau, Prepared for Center of Workforce, AAMC, Feb 2006, AAMC Center for Workforce Studies, Public Opinion Strategies, Voter Survey, June 2006. Copyright © 2006, Association of American Medical Colleges. http://www.aamc.org/workforce/workforcecharts.pdf (accessed July 11, 2008).
50
The Coming Shortage of Surgeons
foreign medical graduates go into practice in the United States, sometimes serving in rural areas or small cities. Some go to academic medical centers where they have distinguished academic medical careers. What has happened in these 35 years or so has been a brain gain on the part of American medicine. The Metrics of Physician Brain Drain Between 23 and 28 percent of the physicians in the United States, the United Kingdom, Australia, and Canada come from lower income countries.39 In 2007, there were 227,665 IMGs from 127 countries practicing in the United States, about 25 percent of the physician workforce.40 India, the Philippines, and Pakistan are the leading sources of foreign medical graduates here. This medical migration is called “brain drain” from the foreign countries and “brain gain” in the United States. The New York Times published an article titled “Stealing from the Poor to Care for the Rich.”41 Norman Wall, the author, was Chief of Medicine and Director of Medical Education at a small Catholic hospital in a small Pennsylvania town. All of the residents were IMGs, mainly from Asia, and they filled all of the residency spots at the hospital. They tended to stay in his community, where they worked hard. “By luring and keeping large numbers of medical immigrant doctors, the American medical establishment is reducing medical care where it is needed the most, really in the developing countries. In a very real sense, it would be immoral to deprive those developing countries of their educated people—doctors who are educated at the developing countries’ expense,” Hall said. As an example, one of the authors (BS) completed five years of medical school without incurring any expense at all. In fact, he was awarded merits scholarship money each year with which to buy books, even though his parents were wealthy and able to afford tuition and books. Twenty-five percent of U.S. residencies are occupied by IMGs (Figure 4.12). They do a good job and they are well trained by the time they finish their residencies. There is another side to the brain gain, however, and that when IMGs decide to go back to their home countries after finishing medical residencies in the United States. What if many more doctors return to their native countries—as many engineers and PhDs return to India and China after receiving graduate degrees in the United States? We would have an immense problem in servicing our hospitals, clinics, and research institutions. Those foreign countries that have been robbed of their best people are becoming increasingly prosperous with good economies and GDP growth rates better than ours. One can obtain a world class medical or surgical residency in the United States and then go home to India or the Philippines and lead a life in one’s own culture, where the net rewards for practicing medicine outnumber those in the United States. These physicians would be in their own cultures, probably do better in terms of standard of living, and be free of all the hassles that plague American medicine. When the combination of professional opportunities and support systems is better in their native countries, where will they go?
Constraints to Supply
51
Figure 4.12 Source of Physicians Entering Training, 2005
U.S. M.D. Graduates 15,411 (62%)
IMGs 6,436 (26%)
D.O. Graduates 2,888* (12%)
Total 24,735
*All M.D.s, IMGs, and one-half of the D.O. graduates (1,478) enter Accreditation Council for Graduate Medical Education (ACGME) residency programs. Source: AAMC Center for Workforce Studies, Public Opinion Strategies, Voter Survey, June 2006. Copyright © 2006, Association of American Medical Colleges. http://www.aamc.org/workforce/ workforcecharts.pdf (accessed July 11, 2008).
It is happening. At the Ohio State University, two graduates of the thoracic and cardiovascular training program in five years have gone back to their native countries. In Pakistan, by 2004, of the 1100 medical graduates produced by Pakistan’s Aga Khan University, 900 went on to higher-level training in the United States. Of these, 40 have so far returned to Pakistan.42 If this continues to be the case, we could become a net exporter of U.S.-trained foreign medical graduates to their own nations. In so doing, the brain gain that we have had for so many of the last 50 years will become a brain drain for this country as well. What’s wrong with this picture? The problem is that we have to have enough residents to train and to manage the care of patients in large teaching hospitals and be the source of future physicians. If a there is a reversal of the current trends of IMGs staying in the U.S. then this will contribute to the future shortage of physicians as there are insufficient numbers of Americans interested in careers as physicians. Some countries are making efforts to reverse this brain drain with special programs such as the McKenzie Medical
52
The Coming Shortage of Surgeons
and Surgical Repatriation University of Otago Fellowship in New Zealand established through private donations.43 The solution to this problem looming ahead of us is to admit more medical students to our medical schools in the United States.
RETIREMENT The effects of retirement of senior physicians also has a major impact on the physician supply. Many of these are work horse doctors, who have worked many, many hours per week, and whose retirement from medicine will lead to greater difficulties for patients in getting appointments or surgical evaluations. A Merritt Hawkins Survey indicates that about 38 percent of all physicians in the United States are 50 years old or older.44 In a report given to the American Association of Medical Colleges in May 2006, Yamagata presented a survey of the retirement behaviors of 5,330 physicians between 50 and 79 years of age.45 The mean age of retirement was 64, and the median age was 63.5 years. Over 60 percent of physicians had retired from clinical practice of medicine by the age of 65. Female surgeons retired earlier, at an average of about 61 years. The study also included physicians who worked part time and retired later at an average age of 68. In a 2007 survey of physicians aged 50–65 years, 49 percent indicated they planned to make a change in their practices within the next one to three years, and of these 14 percent planned to retire, 7 percent were going to seek Figure 4.13 Physician Morale
MMP 10.5%
Other 5.8%
Loss of autonomy 21.2%
Loss of respect 11.8%
Patient overload 12.1%
Low reimbursement 21.9%
Red tape 16.8% Note: MMP means medical malpractice in this figure. Source: Adapted from American College of Physician Executives 2006 Morale Survey
Constraints to Supply
53
a job in a nonclinical setting, 3 percent were going to pursue a nonmedical job, 12 percent planned to work part time, and 4 percent planned locum tenens, a temporary job substituting for another surgeon in the surgeon’s town.46 Based on this survey, should 20 percent of this age group follow through with retirement or to nonclinical roles in the next one to three years, about 59,650 physicians would leave the clinical workforce. As Merritt and colleagues point out, even if 10 percent of the 50–65 age group follow through with retirement (estimated at 25,000 physicians), about 52 million patient visits (based upon an average of 2100 patient visits yearly) will have to be picked up by other physicians.47 The workload would have to be absorbed by generation Y or the remaining older physicians. Is that realistic given the lifestyle issues we have discussed? Not likely. All of the above factors, such as loss of autonomy, reimbursement issues, and red tape, play a role when physicians are asked about their morale (Figure 4.13). Many physicians we know have chosen to leave medical practice for the reasons stated. Some have chosen fields related to medicine, while others have broken away completely. As an example, recent switches have been made to clinical pharmacology research studies, hospital administration, noninvasive lab directorship, new product development, underwater photography, and medical fiction writing. Many were probably getting ready to retire before the dot-com disaster. When the retirement funds are replenished we may see many more of the middle-aged physicians retiring. It is certainly possible that while many physicians indicate on surveys that they plan to retire, they may get cold feet and stick to something they know. In any case, even in the most optimistic scenario, for all the reasons mentioned, we believe a big enough void will exist to severely affect patient care.
5 Calculating Physician Supply: The Model—Assumptions, Relevant Parameters, and the Algorithm In this chapter we will attempt to calculate the needs for the entire physician work force. In later chapters, we will consider the surgical workforce for six specialties. Finally, in chapter 14, we will come back to the entire physician workforce.
MODELS There are at least four algorithms or models for assessing physician supply. They include (1) the Work Per Capita Analysis by Etzione; (2) Cooper’s Trend Analysis; (3) the Physicians Supply Model (PSM) and Physicians Requirement Model (PRM); and (4) our simplified Population Analysis. The Work Per Capita Analysis by Etzione et al uses age specific rates of current surgical procedures and relative work units expended to estimate the amount of surgical work per capita.1 In that study the authors separate the population into several age groups: patient age group (less than 15 years old, 15–44 years old, 45–64 years old, and 65 years and older). They use agespecific incidence rates for each procedure, and multiply these by the corresponding work related value units (RVUs). All 214 procedures included in the study were analyzed by specialty to allow for forecasting in the various surgical specialties (ENT, Ortho, etc.) based upon population growth in various age groups. Etzioni and colleagues speculate growth of 14–47 percent for the individual surgical specialties by 2020. Their projections are limited because they did not take into account changes in surgical procedural demand due to aging, technology, or other factors. Cooper hypothesizes an economic trend model to measure adequacy of physician supply. Four factors are considered in this macro-analysis: national economic expansion, population growth, physician work effort, and volume of nonphysician clinical services.2 Cooper reports a linear relationship between physician supply, per 100,000 of population, and real (inflation adjusted) per capita gross domestic product (GDP) per capita over a 70 year period between
Calculating Physician Supply
55
1929 and 2000. The authors in that report also show that for every 1 percent increase in GDP, the physician supply increases by 0.75 percent. A greater shortage of specialists is suggested as compared to primary care physicians. Some, including Weiner, have disagreed with Cooper’s model. They, instead, point to specialist physicians driving up the volume of care rendered.3 The PSM & PRM were developed by the Bureau of Health Professions from the Health Resources and Services Administration (HRSA).4 The PSM measures the number of active physicians and the number of full-time equivalents (FTEs) by age, sex, country of medical education, type of degree, medical specialty, and whether the physician is in patient care or nonpatient care. The model then takes the number of physicians in the preceding year, adds the number of U.S. and international medical graduates, and subtracts attrition due to retirement, death, and disability to calculate future supply. The accuracy is limited to the large picture and may not be reliable over the long-term. The PRM utilizes population projections, medical insurance category trends, and physician-to-population ratio. If the gross domestic product remains the same, then population is the greatest predictor for surgical services. We have elected to use a simplification of the Population Analysis model. Rather than slice and dice active physician numbers, we have elected to use gross numbers by specialty, add the number of physicians entering the workforce, subtract those leaving medical practice, and come up with the future demand and supply. In our book Consumer Driven Health Care, our population analysis estimate for the total medical workforce in 2020 was 960,960.5 That compares favorably with the HRSA 2006 model of 951,800 and with the Council of Graduate Medical Education (COGME) model published in 2005, which arrives at physician supply of 971,817.6 The three estimates differ by less than 1.25 percent. In addition, our estimate of a shortage of about 200,000 physicians in 2020 is also in line with Cooper’s shortage figure of about 200,000. We believe that our physician population algorithm has been corroborated by the aforementioned studies.7 Assumptions There are some critical assumptions relevant to the algorithm that have to be discussed in order to understand the limitations of our model. Assumption #1: The ratio of physicians to population will be constant. 286 physicians for each 100,000 people in the United States (for a total of 806,520) is assumed.8 The HRSA estimate that 756,000 physicians under the age of 75 practiced in 2000, and their physician supply model projected 817,000 in 2005.9 Implicit in this assumption is that the 286/100,000 ratio is actually what is needed to care for our future population. We will therefore assume 800,000 practicing doctors for our calculations. Assumption #2: Medical school enrollments will not increase. As demonstrated in Figure 5.1 first year medical school enrollments of about 16,000 to 17,000 remained constant from 1980 to 2005.10
56
The Coming Shortage of Surgeons
Figure 5.1 U.S. Medical Student Enrollment 80,000 70,000 60,000 50,000 40,000 30,000 20,000 10,000 0 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 Source: B. Barzansky, H. S. Jonas, S. I. Etzel, JAMA, September 1, 282(9): 840–846; JAMA, September 3, 290(9): 1190–1196: JAMA, September 7, 294(9): 1068–1074.
Following recommendations to increase medical school enrollment, recent projections by AAMC seem to indicate that there will be about 19,909 enrollments by 2012.11 Whether these increased enrollments materialize remains to be seen. We have therefore chosen to use the current number of medical school enrollments, as shown in Figure 5.2, in our calculations. Assumption #3: Gross domestic product per capita will not decrease, and, therefore, we will maintain our standard of living as the population of the United States increases. Cooper has published extensively on the linear relationship between gross domestic product (GDP) and the number of active physicians per capita (Figure 5.3).12 In the 1960s, the GDP per capita was between $11,000 or $12,000, and the number of physicians was about 140 to 150 per 100,000 population. By the year 2000, the GDP was about $33,000 per capita and there were about 286 physicians per 100,000 people. Weiner and Grumbach have argued against this concept and have interpreted the data to imply that physicians create their own demand and therefore we should not expand medical school enrollment.13 However, as we get older and become more affluent, people care more about their health and can do something about it. There are two sides to demand: 1) Physicians increase demand by their very existence, or 2) consumers increase the demand because of affluence and education. Assumption #4: Census Bureau estimates for the population are accurate. The United States Census Bureau estimates that there will be an increase in
Calculating Physician Supply
57
Figure 5.2 Medical School Applicants and Matriculants 50,000 45,000 40,000 35,000 30,000 25,000 20,000 15,000 10,000
Applicants
2012 (est)
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
0
1996
5,000
Matriculants
Source: AAMC, Medical School Applicants and Matriculants by School and Sex. Copyright © 2005, Association of American Medical Colleges. https://services.aamc.org/Publications/show file.cfm?file=versionl111pdf&prd_id=229&pdf_id=111 (accessed July 2, 2008).
the population in the United States by almost 50 percent between 2000 and 2050 (Figure 5.4). If these figures are accurate, and we remain an affluent society, demand for health care will increase with the growth of the population. Even more important is the aging of the population, which will place further demands on the health care system (Figure 5.5). Assumption #5: Years to retirement will remain constant. In our model regarding the supply of physicians, we estimate that physicians practice for about 40 years from the time they graduate from medical school until they retire. For surgeons, we estimate 30–35 years from board certification to retirement because the training for any given surgical program lasts between five and seven years. Our definition of retirement also includes leaving the surgical workforce because of disability or death of the physician. Assumption #6: The funding for graduate medical education—GME—will remain constant. GME is funding from the government to support residency training programs. Despite pressure from the academic teaching community, think tanks, and some policy experts for more funding, Congress has not yet
58
The Coming Shortage of Surgeons
Figure 5.3 Relationship of GDP and Physician Ratio: Active Physicians per 100,000 of Population and Gross Domestic Product per Capita (1996 Dollars) in the United States, 1929–2000 350 300 250
#
200 150 100 50 0 1929
1960
1970
1980
1990
2000
Year GDP Per Capita ($100s)
Physicians/100,000 Population
Source: Health Serv Res, (April 2003): 38(2): 675-696, http://www.pubmedcentral.nih.gOv/arti clerender.fegi?artid=1360909 (accessed July 7, 2008).
seriously evaluated various proposals for increased funding. With budget deficits as far into the future as one can see, the prospect of a major infusion of dollars seems slim. We make no adjustments or assumptions for gender or controllable lifestyle for physicians. Yet, these factors will affect the supply of practicing physicians. As we mentioned in chapter 3, based on the difference between work hours for men and women, it is estimated that we will need 1.3 full-time equivalents (FTE’s) for every practicing doctor now, if doctors decrease their working hours.14 So, if anything, our estimates may be fairly conservative. We make no adjustments for malpractice effects or malpractice premiums and what they will do, or will not do, in the next 45 years. Yet, malpractice continues to be a concern. It is very difficult to be a part-time surgeon in most states in the United States In most states, malpractice premiums are not adjusted to a physician’s level of practice; in a sense, it is one size fits all. This discourages physicians from practicing surgery part time as they cannot afford the full-time premiums.
Calculating Physician Supply
59
Figure 5.4 U.S. Population Growth 419,854 450,000
335,805
400,000 350,000 300,000 250,000 200,000 150,000 100,000 50,000 0 2000
2008
2010
2020
2030
2040
2050
Millions Source: U.S. Census Bureau, Statistical Abstract of the United States: 2008.
We also make no adjustments for reimbursements from either the government or private insurers, which we expect to decrease and consequently affect physicians’ income and possibly attract fewer medical students into the profession or hasten retirement at an even earlier age. And finally, we make no adjustments in this algorithm for chronic disease. As patients afflicted with cancer live longer, there will be a greater necessity for follow-up appointments for the rest of their lives. Similarly, those who have heart disease and survive require the same sort of follow-up to be provided for them. Relevant Parameters The total physician workforce is estimated at 800,000 for this example. Similarly, we estimate the general surgeon workforce at 7.1/100,000 (total 21,000), orthopedic surgeons at 6.5/100,000 (total 18,000), and thoracic and cardiovascular surgeons at 1.4 per 100,000 (total 4,000). The otolaryngology workforce is estimated at about 3.2/100,000 (total 8900). In obstetrics and gynecology, we estimate 27.1 physicians for each 100,000 women (total 34,000). For neurosurgeons, we use 1.06/100,000; there are about 3,100
60
The Coming Shortage of Surgeons
Figure 5.5 Population Growth of People over age 65 Years, 2000–2020
Percent Growth in Population
60% 50%
Age 65+
40% 30% 20% Age <65
10% 0% 2005
2010
2015
2020
Source: U.S. Department of Health and Human Services Health Resources and Services Administration Bureau of Health Professions, “Physician Supply and Demand: Projections to 2020,” (Health Resources and Services Administration, Department of Health & Human Services, October 2006).
practicing at the time of this writing. For urology we use 3.31/100,000, with 10,000 of them in active practice. Calculation Estimating Physicians Needed To arrive at the number of physicians needed by a specific year, we started with the current number of physicians for each 100,000 (286/100,000) of population and multiplied that by the estimated population based upon the census for 2010, 2020, 2030, 2040, and 2050 (Table 5.1). In round numbers, that means the United States will need almost 880,000 physicians by 2010, 960,000 by 2020, 1.0 million by 2030, 1.1 million by 2040, and 1.2 million by 2050. In other words, we have a need to produce 80,000 more physicians per decade. Retiring Physicians Our definition of retiring includes those who have retired as well as deaths and disabilities in the physician workforce. The number of physicians who are
Calculating Physician Supply
61
retiring in a given year is subtracted from the number of physicians who are practicing in that year. Our baseline is the number of physicians who practiced in the preceding year. The result equals the number of practicing physicians for the next year (Figure 5.6). We repeat this calculation until all of the physicians at the beginning of the time period have retired. As an illustration, let us assume there were 800,000 physicians in the year 2000. Assuming an even distribution of our estimates, 20,000 would retire each year. Based on assumption #5, by 2040 none of these physicians would remain in practice (Table 5.2). New Medical School Graduates We must add new medical school graduates to the pool of practicing physicians each year. From that number we must subtract physicians who have completed 40 years in practice. Similar to the previous calculation, this is repeated until the current crop is retired by 2041 (Figure 5.7).
Table 5.1 Physicians Needed by Decade Year
Population
# Physicians Needed
2010
309,000,000
883,740
2020
336,000,000
960,960
2030
364,000,000
1,041,040
2040
392,000,000
1,121,120
2050
420,000,000
1,201,200
Figure 5.6 Retiring Doctors Number of Old Physicians Practicing
Subtract Old Physicians Retiring Each Year
Equals Old Practicing Doctors
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The Coming Shortage of Surgeons
Table 5.2 Retiring Doctors Year
Old Physicians Retiring Each Year
Number of Old Physicians Practicing
2000
800,000
2001
20,000
780,000
2002
20,000
760,000
2003
20,000
740,000
2004
20,000
720,000
2005
20,000
700,000
2038
20,000
40,000
2039
20,000
20,000
2040
20,000
0
2041
0
0
Note: This table is an abbreviated version of Table A.1 in the Appendix.
Figure 5.7 New Medical School Graduates Total of New Graduates
Subtract New Graduates Who Have Retired
Equals Total of New Graduates Practicing
Table 5.3 shows that if the number of medical school graduates stays constant (assumption #2) at 17,000, and none of the graduates retire, the number of practicing physicians increases to 85,000 by 2005. As we go on in this scenario, by 2035 there are 595,000 practicing physicians, because, again, none of them retire. However, in 2040, the first year of retirement for this group, the number of new medical school graduates stabilizes to 680,000.
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63
Table 5.3 New Physicians Added
Year
Present Graduating Class
Total of New Graduates
New Graduates Who Have Retired
Total of New Graduates Practicing
2000 2001
17,000
17,000
0
17,000
2002
17,000
34,000
0
34,000
2003
17,000
51,000
0
51,000
2004
17,000
68,000
0
68,000
2005
17,000
85,000
0
85,000
2035
17,000
595,000
0
595,000
2036
17,000
612,000
0
612,000
2037
17,000
629,000
0
629,000
2038
17,000
646,000
0
646,000
2039
17,000
663,000
0
663,000
2040
17,000
680,000
0
680,000
2041
17,000
697,000
17,000
680,000
2042
17,000
714,000
34,000
680,000
Note: This table is an abbreviated version of Table A.2 in the Appendix.
The Total Number of Physicians Practicing Each Year To estimate the total number of physicians practicing in a given year, we start with the number of physicians who were practicing the previous year, subtract those who have retired, and add the number of new medical school graduates. In any given year, this equals the grand total of practicing physicians (Figure 5.8). To illustrate the methodology, let us assume that we have 800,000 physicians in the year 2000. 20,000 retire in 2001, leaving a total of 780,000 still in practice (Table 5.4). To this we add 17,000 new medical school graduates for a grand total of 797,000 practicing physicians in 2001. This pattern repeats itself because we have a fixed retirement rate of 20,000 and a fixed incoming rate of 17,000. Therefore, by 2040 we end up with a fixed supply of 680,000 practicing doctors. The results of these calculations are illustrated in Figure 5.9. The complete tables are included in the Appendix; Tables 5.2, 5.3, and 5.4 in this chapter are presented in an abbreviated form.
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The Coming Shortage of Surgeons
Figure 5.8 Total of Doctors Practicing Each Year Number of Old Physicians Practicing
Add Total of New Graduates Practicing
Equals Grand Total of Practicing Doctors
Table 5.4 Total of Practicing Doctors Year
Number of Old Physicians Practicing
Total of New Graduates Practicing
Grand Total of Practicing Doctors
2000
800,000
2001
780,000
17,000
797,000
2002
760,000
34,000
794,000
2003
740,000
51,000
791,000
2004
720,000
68,000
788,000
2005
700,000
85,000
785,000
2038
40,000
646,000
686,000
2039
20,000
663,000
683,000
2040
0
680,000
680,000
800,000
2041
0
680,000
680,000
2042
0
680,000
680,000
Note: This table is an abbreviated version of Table A.3 in the Appendix.
Shortage Estimating the shortage of physicians involves deducting the grand total of practicing physicians (last column of Table 5.4) from the number of physicians needed (Table 5.1) for any year. To estimate the percent shortage, divide the shortage by the number of physicians needed and multiply by 100 (Table 5.5). For instance, in our assumptions for physician retirement we use 20,000/year (800,000 physicians divided by 40 years). We also use 17,000 per year as the number of graduating medical class members. This means
Calculating Physician Supply
65
Figure 5.9 Illustration of Methodology Used in Calculating Physician Supply 1,000,000 900,000 800,000 700,000 600,000 500,000 400,000 300,000 200,000 100,000 0 1990
2000
2010
2020
2030
2040
2050
2060
Year Old
New
Total
Table 5.5 Shortage Estimates Grand Total of Practicing Physicians
Shortage
Percent Shortage
883,740
770,000
113,740
13%
336,000,000
960,960
740,000
220,960
23%
364,000,000
1,041,040
710,000
331,040
32%
2040
392,000,000
1,121,120
680,000
441,120
39%
2050
420,000,000
1,201,200
680,000
521,200
43%
Year
Population
2010
309,000,000
2020 2030
Physicians Needed
that according to our calculations, there is a net deficit of 3,000 physicians every year. Our methodology is straightforward and is based upon population analysis. The projected shortages are very close to the other models cited. Like all other models, ours relies on many assumptions, any one of which, if altered significantly, would result in widely divergent findings.
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The Coming Shortage of Surgeons
CONCLUSION Many previous studies of forecasted workforce needs have proved completely erroneous. Relying on factors such as relative value units produced or number of procedures/visits performed, and allowing for lifestyle changes or trying to guess how many physicians will be working full or part time may be akin to guessing wind direction years from now. Population growth projections have a lower margin of error, and physician-population ratios and fairly standard terms of practice seem to us a better foundation to base our calculations upon.
6 Orthopedic Surgery For the next seven chapters we will talk about various surgical specialties and our projections on their workforce issues.
ORTHOPEDIC MIRACLES Many Americans fear death, but death comes when it comes. A greater fear for most Americans is incurring a significant disability. One of the medical miracles in the last 50 years is the development of reconstructive surgery for arthritis. But, orthopedic care runs the gamut from early childhood (think broken bones), to spine surgery, to joint replacements in older citizens. Twothirds of hip replacements are performed on people over the age of 65. Hips, knees, and even shoulders and ankles are cared for by orthopedic surgeons. In 2005, the American Academy of Orthopedic Surgeons reported over one million joint replacements.1 Patients who undergo joint replacement surgery do so because they feel that they are so disabled they cannot live their lives the way they desire. In 2005, the number of first-time and revision total knee replacements was about 570,000, and hip replacements (new, partial, and revisions) numbered almost 500,000.2 According to the American Academy of Orthopedic Surgeons, the number of first-time total knee replacements is predicted to jump 673 percent to 3.48 million by the year 2030. Similarly, primary total hip replacements will increase by 174 percent. Knee and hip revisions will increase by 522 percent and 237 percent, respectively, as patients’ longevity increases and joints wear out and need to be replaced again.3 Think about all the baby boomers reaching the age when their joints wear out and this fact will increase the need for these services. Famous sports celebrities such as Jack Nicklaus, Mary Lou Retton, and Jimmy Connors are spokespersons for joint replacement hardware manufacturers. The boomers are not likely to sit in their chairs or quietly head off to rest in nursing homes to live with arthritic joints! Will there be enough orthopedic surgeons to meet their needs?
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The Coming Shortage of Surgeons
ORTHOPEDIC SURGEON PROJECTIONS Several studies since the 1970s have predicted a surplus of orthopedic surgeons over the next 30 or 40 years until the mid-21st century.4 In 1995, The RAND Corporation was commissioned by the American Academy of Orthopedic Surgeons to project the workforce in orthopedic surgery. RAND employed the usual factors in the supply side such as number of residents, number of retiring surgeons, changing practice patterns, new technology, number of female and minority surgeons, and the number of subspecialists. On the demand side, they considered population increase, aging of the population, number of visits by the elderly, and new technology and came up with a new methodology to determine the demand side of the equation. Lee et al used utilization data from national inpatient and outpatient datasets to convert factors related to demand to work time. Based on the RAND data and population growth, they projected demand in 1998 to be 14,750 full-time equivalents and a supply of 18,296 surgeons. They further projected a surplus of 3,546 orthopedic surgeons by 2010 and therefore proposed a reduction in residency training positions. In contrast, the Council on Graduate Medical Education (COGME) in 2005 projected a deficit of about 12,000 to 15,000 orthopedic surgeons by 2020.5 The Dartmouth Atlas provides a method of calculating the number of specialists in each community taking into account the prevalent practice style.6 Heckman and Weinstein, in their estimates of need for orthopedic surgeons, suggest that seven orthopedic surgeons per 100,000 population is excessive and suggests as low a number as five per 100,000 population.7 The American Academy of Orthopedic Surgeons estimates that in 2006 the density of orthopedic surgeons was 6.1 per 100,000 population.8 For our projections, we use the following baseline numbers: 1. 6.5 orthopedic surgeons for 100,000 population 2. 650 newly board-certified orthopedic surgeons each year
Our assumption with regard to longevity in practice is 35 years (524 retiring each year) for this estimate. In Table 6.1, one can see that in 2010 20,085 orthopedic surgeons will be needed, but only 18,960 will be in practice, a shortage of 1,125. Similarly, for 2030, 23,660 orthopedic surgeons will be needed, but only 21,480, according to this estimate, will be in practice, for a shortage of 2,180 or about 9 percent. Similarly, in 2050, around 27,000 orthopedic surgeons will be needed, but only about 23,000 will be available, resulting in a shortage of more than 15 percent. If we make the same assumption for the number of board certified surgeons but change the length of practice to 30 years and assume a retirement age somewhere between age 60 and 65, there will be an even greater shortage (see Table 6.2). By 2030, as we said before, 23,660 orthopedic surgeons will be needed, but only 19,305 will be available, resulting in a shortage of 4,355 or 18 percent. By 2050, the shortage will equal 7,800 or almost 30 percent.
Orthopedic Surgery
69
Table 6.1 35 Years to Retirement for Orthopedic Surgeons
Year
Projected Population
Orthopedic Surgeons Needed
Orthopedic Surgeons in Practice
Shortage
Percent Shortage
2000
282,000,000
18,330
2010
309,000,000
2020
336,000,000
20,085
18,960
1,125
6%
21,840
20,220
1,620
7%
2030
364,000,000
23,660
21,480
2,180
9%
2040
392,000,000
25,480
22,750
2,730
11%
2050
420,000,000
27,300
22,750
4,550
17%
Table 6.2 30 Years to Retirement for Orthopedic Surgeons
Year
Projected Population
Orthopedic Surgeons Needed
Orthopedic Surgeons in Practice
Shortage
2000
282,000,000
18,330
2010
309,000,000
2020
336,000,000
20,085
18,525
1,560
8%
21,840
18,915
2,925
13%
2030
364,000,000
23,660
19,305
4,355
18%
2040
392,000,000
25,480
19,500
5,980
23%
2050
420,000,000
27,300
19,500
7,800
29%
Percent Shortage
Workforce Issues According to Gary Bos, M.D., former chairman of the Department of Orthopedic Surgery at Ohio State University, the shortage of orthopedic surgeons is so profound that sometimes there are 18 pages of classified advertisements for these jobs in the orthopedic journals.9 This is particularly the case in small towns. In view of the 80-hour work week limitations and the demand for orthopedic surgeons, the Residency Review Committee has recently increased training positions by 9–10 percent. We must also point out that 29 accredited osteopathic residency programs turned out about 84 surgeons in 2008.10 Is there an emerging star system for orthopedic surgeons? Advertisements such as “Orthopedic Surgeon, Idaho, one hour from Spokane, $600,000+, hospital managed, no malpractice concerns, beautiful area, great schools” are not uncommon. The salary in this advertisement is about two times what the average orthopedic surgeon earns in the United States, according to the Medical Group Management Association. The surgeon who accepts this position
70
The Coming Shortage of Surgeons
will be a hospital-based employee with no office expenses and will have health insurance as well. Why does a rural hospital need to spend so much for a surgeon? There is only one orthopedic surgeon on the staff. What does the hospital do when the orthopedic surgeon has to take his or her daughter to college, go on a family vacation, or becomes disabled? Why would the hospital offer so much for an additional surgeon? An orthopedic surgeon will add $3,000,000 to the hospital’s top line; that is, the revenue line.11 The contribution profits for the hospital industry in 2006 for orthopedic care were over $11 billion.12 That’s why. The hospital has to keep its orthopedic presence in their small town or city in which the hospital is located. It cannot afford to refer all its orthopedic patients out of town or to other hospitals. A survey by Merritt, Hawkins, & Associates (MHA) showed that 46 percent of physicians would not choose a career in medicine again, and 56 percent cited managed care as the biggest source of professional frustration.13 The percentage of orthopedic surgeons over the age of 50 increased from about 41 percent in 1994–5 to 51 percent in 2004–5, and early retirements will have a significant impact on the available workforce in the next decade.14 The mean age of members and fellows of the American Academy of Orthopedic Surgeons (AAOS) was 59 years in 2005, well below the retirement age of 65.15 According to the August, 2001 AAOS Bulletin, almost 25 percent of its active members were contemplating retirement from orthopedic practice within the next five years. In 2006, one in 10 orthopedic surgeons in the AAOS member survey had retired and about 8 percent were considering retiring within the next two years.16 Recent high managed-care penetration with low payments, coupled with high malpractice costs have forced 5 of 15 orthopedists in the Ogden Orthopedic and Neurosurgical Specialists group in Ogden, Utah, to leave. In Pennsylvania, these same issues have forced orthopedists to move out of the state or the operating room. According to Carlos Lavernia, M.D., chief of orthopedics at Cedars Medical Center in Miami, “Many orthopedic surgeons are leaving hospital-based care and going to outpatient surgery centers due to demanding hours and lack of pay for on-call hospital services.”17 Malpractice premiums are a part of the problem as well. Regulatory issues, such as those outlined in the Emergency Medical Treatment and Active Labor Act (EMTALA), affect an orthopedic surgeon’s practice. If an emergency patient comes into the hospital, the hospital is required by law to accept the patient. The surgeons who are on call can be liable for malpractice suits without any protection from the hospital. Many hospitals do not pay their surgeons for on-call hours. In a survey by SullivanCotter of physician on-call pay, out of 35 organizations reporting, the average hourly compensation for orthopedic surgery was $44.29 at trauma centers and $30.65 for nontrauma surgeons.18 Hence, being on call is a no-win situation for the orthopedic surgeon. Based on available trends in the workforce and the above-mentioned factors that influence both supply and demand, there is likely to be a shortage of
Orthopedic Surgery
71
orthopedists who are willing to practice in hospitals and multi-specialty clinics by 2020. In an effort to recruit orthopedists to these centers, salaries have skyrocketed. The MHA study found that the average orthopedic income offer rose from $241,000 in 1997–98, to $287,000 in 2000–01, to more than $350,000 in 2004.19 These larger salaries are attractive to residents who have accumulated large amounts of medical education debt. Currently, orthopedic surgery residency positions are very much sought after, with 0.7 positions available for each applicant who lists the specialty as his or her preferred specialty.20 Unless there is salary support from hospitals or academic centers, most orthopedic specialty groups may not have the financial resources to compete for additional associates without cutting their own compensation.
7 Cardiothoracic Surgery Cardiothoracic (CT) surgery (sometimes referred to as Thoracic or Cardiovascular Surgery) deals with the operative treatment of diseases as well as injuries of the heart, lungs, mediastinum, esophagus, chest wall, diaphragm, and great vessels.
MEDICAL MIRACLES Heart Disease Early efforts in this field were made to correct congenital heart disease. Robert Gross of Boston repaired the first patent ductus of the aorta in the 1930s. A patent ductus is a congenital communication between the aorta and the pulmonary artery; it causes high blood pressure in the pulmonary artery. Craaford, in Sweden, was the first to repair coarctation of the aorta. A coarctation is a congenital narrow spot in the descending thoracic aorta that also causes high blood pressure in the aorta. The mean life expectancy for patients with either of these conditions was less than 40 years until the early 1940s. Alfred Blalock and Helen Taussig of Johns Hopkins Hospital designed an operation to palliate or extend the life of cyanotic blue babies. In this same period, cardiac catheterization was successfully performed. John Gibbon of Philadelphia conducted the first open heart procedure in 1953. He invented the open heart pump. Cardiac valves were repaired and later replaced in the 1960s. Also in the 1960s coronary artery bypass grafts were performed to repair coronary artery disease at the Cleveland Clinic and in Milwaukee, Wisconsin. The first cardiac transplant was performed by Christian Barnard in South Africa in 1967. The first percutaneous transluminal coronary angioplasty (PTCA) for dilating blood vessels was performed in the 1970s; stents came along in the late 1980s. At the same time, in the late 20th century, other devices such as pacemakers and automatic implantable cardiac defibrillators found their places in the
Cardiothoracic Surgery
73
cardiac armamentarium. At first these devices had to be implanted surgically. Now they can be implanted by a short subcutaneous (under the skin) incision. Laman Gray, a surgeon from Louisville, Kentucky, implanted an artificial heart in 2001. Mr. Tools, the first recipient of an artificial heart, lived four months and was preparing to go home when he developed complications. Dr. Gray implanted a second patient who lived for 13 months in his own home. The pharmaceutical industry introduced many families of drugs over several decades, including the beta-blockers to control blood pressure and heart rate, calcium channel blockers to control heart rate and blood pressure, and ACE inhibitors, a new class of drugs, which are also used to treat high blood pressure. Another significant family of drugs is called the statins. These help keep blood cholesterol in balance and reduce the likelihood of developing arteriosclerosis or hardening of the arteries, which give rise to symptomatic coronary artery disease, the cause of heart attacks.
WHAT TO EXPECT IN CARDIAC SURGERY Almost all of the hospitals in America that operate open-heart surgical programs subscribe to the National Database of the Society of Thoracic Surgeons for comparison with other hospitals. In 2000, approximately 200,000 open-heart procedures were performed. By 2006, almost 260,000 procedures were done. In the last 10 years, a little over 2.4 million open-heart surgeries were performed. About 1.65 million of those cases were coronary artery bypass procedures (CABG).1 The mortality rate for an isolated coronary bypass operation is about 2.3 to 2.5 percent. In other words, the patient’s odds of survival are between 97 and 98 percent. With regard to aortic valve replacement, the mortality figures are about 3.4 percent, a little better than 96 percent of patients who undergo aortic valve replacement will live. A mitral valve replacement has about a 6 percent mortality rate, or a 94 percent survival rate. The average length of stay between surgery and discharge for a coronary artery bypass grafting procedure is about five to six days. Thoracic Surgery Projections The assumptions for our projections are, again, that gross domestic product per capita will not change, that medical school enrollments will not change, and that the ratio of physicians to population will not change; that is, that there are 1.42 thoracic and cardiovascular surgeons per 100,000 population.2 In this projection, we are going to assume 35 years to retirement, 114 retirements, and 100 board-certified surgeons produced each year. Table 7.1 indicates that the shortage of thoracic and cardiovascular surgeons will probably not be significant until 2020, when there will be a shortage of about 21 percent. By 2030 we will have a shortage of more than 1,500 thoracic and cardiovascular surgeons. That shortage will be almost 2,500 by 2050, or 41 percent.
74
The Coming Shortage of Surgeons
Table 7.1 35 Years to Retirement for Thoracic Surgeons
Year
Projected Population
Thoracic Surgeons Needed
Thoracic Surgeons in Practice
2000
282,000,000
4,004
2010
309,000,000
4,388
3,930
2020
336,000,000
4,771
3,790
981
21%
2030
364,000,000
5,169
3,650
1,519
29%
2040
392,000,000
5,566
3,510
2,056
37%
2050
420,000,000
5,964
3,500
2,464
41%
Shortage
Percent Shortage
Shortage
458
Percent Shortage
10%
Table 7.2 30 Years to Retirement for Thoracic Surgeons
Year
Projected Population
Thoracic Surgeons Needed
Thoracic Surgeons in Practice
2000
282,000,000
4,004
2010
309,000,000
4,388
3,835
553
13%
2020
336,000,000
4,771
3,505
1,266
27%
2030
364,000,000
5,169
3,175
1,994
39%
2040
392,000,000
5,566
3,000
2,566
46%
2050
420,000,000
5,964
3,000
2,964
50%
Assuming 30 years to retirement (the surgeon’s retirement age between 60 to 65 years), 133 retirements, and 100 board certified surgeons each year, by 2020, the shortage will be more than 25 percent, and by 2050 the shortage will be about 3,000, or 50 percent (Table 7.2). In summary, given our assumptions and our projections, we predict that there will be a shortage of between 2,500 to 3,000 practicing thoracic and cardiovascular surgeons by 2050. These projections are consistent with the Shermin report as well as the recent AATS/ STS/AAMC estimates of future CT workforce.3
WORKFORCE STUDIES OF CT SURGERY There have been several workforce studies detailing the workload in thoracic and adult cardiac surgery. A study by the Thoracic Surgery Workforce in 1995 showed the respondents to be predominantly male with 45 percent
Cardiothoracic Surgery
75
practicing in single-specialty private practice.4 The mean age had increased from previous surveys to 52 years in the 1995 survey. The study concentrated on workforce demographics and procedural volumes and did not inquire about retirement plans. The responses indicated that 2,103 respondents performed a mean of 151 cases for a total caseload of about 317,000. The next important study was by The Workforce Committee of the American Association for Thoracic Surgery and The Society of Thoracic Surgeons (AATS/ STS), which was charged with conducting a membership survey to determine membership demographics, work volume, and practice patterns in thoracic surgery.5 Between August and December of 1999, the AATS/STS designed and sent a comprehensive seven-page questionnaire to all of its members over the course of three separate mass mailings. At the completion of the third mass mailing they had a response rate of 62.6 percent (2,515 of 4,018), which provided a statistically significant sample. The mean age of practicing surgeons had decreased to 50 compared to a peak of 52 years in the 1992 survey. The workload had increased to a mean of 237 cases, and respondents worked 67 hours a week on average. Career satisfaction was highest among retired thoracic surgeons at 85 percent. Career satisfaction also correlated with the number of hours worked per week. The AATS/STS survey gathered data on retirement plans for the first time. Most surgeons were projected to retire by or prior to age 65, and the authors estimated that 50 percent of practicing CT surgeons would retire by 2010. They also pointed out that the increasing female medical class enrollment, lifestyle considerations, length of training, educational debt, medico-legal environment, declining income, and work hours were all factors in a decline in the applicant pool for residency training. The same report also correctly noted the comparative growth in primary care physicians by 25 percent, all specialists by 35 percent, and the number of cardiologists from 6,000 to 15,500 between 1975 and 1995 as compared to a relatively stable pool of 4000 CT surgeons. The report suggested that the CT specialty needed to focus on the recruitment of outstanding talent that it had attracted in the past. CT surgeons were advised to become more proactive in reaching out to and mentoring medical students to demonstrate the unique role that thoracic surgeons play in the healthcare system. Although the specialty appeared to be right-sized in 2002, the report projected a scenario that predicted a likely shortage of CT surgeons in the coming years. According to William Gay, Executive Director of the American Board of Thoracic Surgery, “Fewer than 4,000 physicians are actively practicing thoracic surgery. While the number of candidates for certification has remained stable over the last five to ten years, the number of applicants to thoracic surgery residencies has declined over that period. In fact, last year (2003), there were about the same number of applicants as there were residency positions.”6 Recently, the American Association for Thoracic Surgery (AATS) and the Society of Thoracic Surgeons (STS) commissioned a workforce analysis of CT surgery by the American Association of Medical Colleges (AAMC).7 The boom
76
The Coming Shortage of Surgeons
era of coronary revascularization resulted in a peak of about 4,900 surgeons from 1996 until 2002. The number of active CT surgeons then declined from approximately 5,100 surgeons in 2003 to about 4,000 in 2005. The Dartmouth Atlas investigators hypothesize that the number of CT surgeons would be stable between 1.1 to 1.3 per 100,000 population between 1995 and 2005, followed by a decline to 0.9 per 100,000 by 2020.8 The study conducted by Atul Grover for the AAMC estimates that if 75 residents complete training each year and demand stays at 2005 levels, there will be a shortage of about 3000 CT surgeons by the year 2025.9 The graph in Figure 7.1 represents our estimate, a deficit of almost 2000 by 2030 increasing to about 3000 by 2050. An additional consideration is the fact that a large number of CT surgeons are over 50 years old and expected to retire over the next 10 years.
CURRENT THORACIC SURGICAL WORKFORCE It takes an average of 8.3 years of training after graduation from medical school for a CT surgeon to start practicing their craft. CT surgery residency training is generally two to three years in length. However, 33 percent of CT surgeons train nine years or longer.10 The National Resident Matching Program Figure 7.1 Thoracic Surgeons Demand versus Supply 7,000 6,000
Surgeons
5,000 4,000 3,000 2,000 1,000 0 1990
2000
2010
2020
2030
2040
2050
2060
Years Demand
Supply
Legend: Demand is taken from column 3 (Thoracic Surgeons Needed) of Table 7.2 and supply is taken from column 4 (Thoracic Surgeons in Practice) of that table.
Cardiothoracic Surgery
77
Figure 7.2 Applications for First-Year Posts: Thoracic and Cardiovascular Surgery 200 160 120 80 40 0
’93 ’94 ’95 ’96 ’97 ’98 ’99 ’00 ’01 ’02 ’03 ’04 ’05 ’06 ’07 Total number of applicants Active positions available U.S. medical school graduate applicants
Source: American Board of Thoracic Surgery.
(NRMP) conducts the annual matching of training programs with potential applicants. In 2007, of the 92 certified programs in the match and 130 positions available, only 61 percent (56) were filled, leaving 39 percent unfilled. From the applicant’s perspective, 87 (91%) of the 96 certified applicants matched. Of the 87 who matched, 62 were U.S. graduates and the remaining were international graduates, U.S. foreign graduates, and osteopaths. Some of the most prestigious programs in the United States did not fill their first-year residency positions (Figure 7.2).11 Based on these data, the number of applicants for CT surgery training dropped approximately 47 percent between 1997 and 2007. In contrast, the number of active positions available in the same decade dropped only 13.7 percent. For the past five years, from 2004–2008, fewer than 100 American medical school graduates applied in each year. Grover points out that anesthesiology went through a similar decrease in the applicant pool and it took about six years to return to stability.12 Will this happen with CT surgery? Perhaps.
8 Otolaryngology Otolaryngology (OL)—head and neck or ear, nose, and throat (ENT) consists of physicians that specialize in the diagnosis and treatment of ear, nose, throat, and head and neck disorders. Common disorders treated by these specialists include chronic ear infection, sinusitis, snoring and sleep apnea, hearing loss, allergies and hay fever, swallowing disorders, nosebleeds, hoarseness, dizziness, and head and neck cancer.1 These surgical specialists train for five years, including at least one year in general surgery. Various subspecialties include head and neck surgery, facial plastics, otology, neuro-otology, laryngology, sleep medicine, sinus diseases, and pediatric ENT.
MEDICAL MIRACLES Cochlear Implants What is a cochlear implant? A cochlear implant is a small, complex electronic device that can help provide the sense of sound to a person who is profoundly deaf. It is very different from a hearing aid,2 which amplifies sound, but cochlear implants compensate for damaged or nonworking parts of the inner ear. The cochlear implant bypasses damaged cells and converts speech and environmental sounds into electrical signals, which are sent to the hearing nerve (Figure 8.1). According to the Food and Drug Administration in their 2006 data, approximately 112,000 people worldwide have received implants.3 In the United States alone, about 13,000 adults have cochlear implants and nearly 10,000 children have received them. In a recent Johns Hopkins study of 35 school age children, about 75 percent were in mainstream classes full time.4 Laryngeal Cancer Laryngeal cancer is cancer of the voice box or Adam’s apple and occurs in approximately 10,000 Americans per year with a five year survival rate
Otolaryngology
79
Figure 8.1 Cochlear Implant Device
External Components
Internal Components
Source: Courtesy of Molly Feuer.
of 65.1 percent.5 A total laryngectomy (complete removal of the voice box) means that a person will have to have a hole in the front part of his or her neck (a permanent tracheostomy) just above the breast bone (Figure 8.2). Most people who have undergone this operation can learn to speak with a speech therapist’s help. Prognosis for cancers involving the glottis (true vocal cords) is much better, with a five year survival of almost 85 percent compared to cancers affecting the supra-glottic area (area above the vocal cords).6 New techniques include transoral endoscopic removal of cancers, robotic assisted endoscopic
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The Coming Shortage of Surgeons
Figure 8.2 Tracheostomy
Source: Courtesy of Catherine Williams.
surgery, microvascular techniques for covering large defects from cancer removal, and concurrent administration of radiation and chemotherapy for malignancies. ENT Projections In 2004, C. Ron Cannon and his associates re-assessed the ENT workforce and made recommendations for a future national practice model.7 The number of practicing ENT increased from 8,514 in 1995 to 9,252 in 2002. The number of residents entering the workforce was also discussed in this study. Cannon, et al estimated a fairly stable number of about 300 residents graduating each year, although they noted an overall decline in the number of training positions, an increase in female residents, and a clear desire for family priorities expressed by newer graduates. These figures were utilized to prepare the following estimates: We estimated that there were about 8,900 ENT surgeons in the United States in 2000, or a ratio of 3.2 for every 100,000 people. These figures project the ENT workforce with regard to 35 years of service (Table 8.1).
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81
Table 8.1 35 Years to Retirement for ENT ENT Surgeons Needed
ENT Surgeons in Practice
Year
Projected Population
2000
282,000,000
8,911
2010
309,000,000
9,764
2020
336,000,000
10,618
9,586
1,032
10%
2030
364,000,000
11,502
10,036
1,466
13%
2040
392,000,000
12,387
10,500
1,887
15%
2050
420,000,000
13,272
10,500
2,772
21%
9,136
Shortage
628
Percent Shortage
7%
It is anticipated that about 255 ENTs will retire each year and that there will be about 300 new board-certified ENT surgeons per year as mentioned. By 2030, the ENT surgeons required for the U.S. population will be about 11,500 (Figure 8.3). Our projections with regard to 2030 indicate a 13 percent shortage. By 2050, the number of ENT surgeons that will be needed to service our patients’ needs is about 13,000, with an estimated shortage of 21 percent or 2,772 ENTs. If ENT surgeons retire after 30 years of service, again using the 3.2 per 100,000 number, 297 would retire each year (and 300 new board-certified ENTs would enter the specialty each year) (Table 8.2). In that case, by 2030, there would be about a 22 percent shortage compared to the 11,502 surgeons needed. It becomes even more alarming in 2050 when 13,272 ENTs will be required to give patient care and the United States will be about 4,272 (32%) short of this number.
ENT WORKFORCE ISSUES In one of the first studies to look at future workforce in the specialty, Miller in 1992 attempted to predict the future workforce in the year 2010 based upon a model that included the number of residents in training, age distribution of currently practicing specialists, and death rates of doctors.8 He estimated that there would be a 21 percent increase in practicing ENTs between 1995–2010 and that the ratio of ENTs to population would climb from 2.5 to 2.8 per 100,000 population. Fully 49 percent of practitioners at the time of the study were less than 45 years of age. In 1996, Jafek et al reported an increase in the supply of ENTs from 2.38 to 3.1 per 100,000 population over a 20-year period.9 In 1994, Anderson and co-authors, , relying on data from three health maintenance organizations and other sources, reported an undersupply of ENTs.10 However, based on the number of trainees and requirement
Figure 8.3 Supply of Otolaryngologists 10
8
6
4
2
0 1980
1990 Number (thousands)
2000
2020
Per/100,000 population
Source: American Medical Association, Chicago, Illinois. Copyright, 2007. Physician characteristics and distribution in the U.S. annual. Projections for 2020 based upon our analysis as shown in Table 1.
Table 8.2 30 years to retirement for ENT ENT Surgeons Needed
ENT Surgeons in Practice
Year
Projected Population
2000
282,000,000
2010
309,000,000
9,764
8,926
838
9%
2020
336,000,000
10,618
8,956
1,662
16%
2030
364,000,000
11,502
8,986
2,516
22%
2040
392,000,000
12,387
9,000
3,387
27%
2050
420,000,000
13,272
9,000
4,272
32%
Shortage
Percent Shortage
8,911
Otolaryngology
83
of ENTs, they also suggested an oversupply by 2010 with a ratio between 2.69 and 3.77 per 100,000 population. The first major study on workforce issues in OL was commissioned by the American Academy of OtolaryngologyHead and Neck Surgery and reported in 2000.11 The study collected information on practice patterns, geographic distribution, and supply and demand for ENTs between 1993 and 1995. In this study the workforce had aged, and with 47.6 percent were more than 50 years old and only 37 percent were younger than 45 years of age. According to this report based on the AMA master file, there were 3.240 ENTs per 100,000 population in 1995. Their actuarial supply model was based upon base supply, retirements, deaths, and entrance of new graduates. The formula they used was: Supply N+1 = Supply N - Retirements N+1 —Deaths N+1 + Graduates N+1 where N represented the current year.
Their conclusions, which were based upon administrative claims data, noted that 50–60 percent of charges were for office or evaluation and management services rather than procedural codes. This algorithm is similar to ours. In 1996, Jafek and his co-authors observed that market forces, rather than the political process and government, would dictate practice patterns for the immediate future.12 They posited that perceived problems would then negatively affect the number of applicants for otolaryngology residencies. Additionally, they raised concerns about the health care market’s commitment to quality, teaching, academia, and research. Lastly, the lack of predictability in the medical practice was considered responsible for much of the stress and frustration felt by many otolaryngologists. There are several other trends that bear watching that may change our models for supply and demand in this specialty. Although the number of new residents entering training remains stable at roughly 300 per year, the number of applicants for these training slots has decreased by 30 percent over the past five years. In addition to allopathic residency programs, the American Osteopathic Association reports that 19 programs in ENT have 100 available training slots, of which only 76 were filled in 2007.13 The priorities of these residents are changing as well. In 1984, a study reported that practice potential and quality of the medical community were considered important priorities in a resident trainee’s choice of a specialty.14 In a recent study about the influence of lifestyle and income on medical students’ career specialty choices, both lifestyle (p = .018) and income (p = .011), both very significant, were found to increasingly influence medical students’ career choices.15 Gender issues are also an important part of any specialty’s effort to understand its workforce and attempt to change recruitment and training methods. In a 1996 report, the OL specialty was 93.5 percent male and 6.5 percent female; however, in 2000 the figures showed that 91.9 percent of physicians were male and 8.13 percent were female.16 Thus, there was an increase in the number of women entering the workforce, especially between the ages
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The Coming Shortage of Surgeons
of 30 and 49. Other surgical specialties have also documented an increase in the number of women. The increased presence of women does present some interesting scenarios. Female surgeons tend often to marry other professionals, which can lead to two physician families and complicated work schedules.17 The result is that female ENTs may not practice as many hours per week or as long as their male counterparts. In a 2006 Association of American Medical Colleges survey, 28 percent of female physicians worked part time compared with 4 percent of male physicians.18 The survey results indicate that the most common type of practice is that of a specialty practice, with the median size of the practice being 3.1 full-time equivalent (FTE) otolaryngologists per group. Results also indicated that otolaryngologists spent an average of 27.1 hours per week in the office and 11.3 hours per week in the OR. The general trend to earlier retirement has been observed across all specialties. When asked about retirement, the average age of planned retirement for ENTs was 64 years. In a 2002 survey conducted by the American Academy of Otolaryngology-Head and Neck, the following factors influenced retirements: finances (61%), practice hassle (59%), age (49%), lack of enjoyment (43%), health concerns (40%), loss of autonomy (32%), and decreasing Medicare reimbursement rates (31%).19 As is true for many of the specialties, the main marketplace concern for this specialty lies with flat or reduced reimbursement in the face of increased practice expenses (particularly malpractice expenses). In addition, there will be more of a demand for geriatric ENT services as the population ages. When coupled with declining Medicare reimbursements, it is not clear who will provide these services for patients over the age of 65. Because Medicare has become the gold standard on which all payers base their fees, physicians are currently faced with inadequate payment to sustain their practices. As a result, many are in fact closing their practices or declining to accept new Medicare patients. This creates a constant challenge for physicians trying to sustain their practices while providing quality patient care. In the final analysis, flat and decreasing reimbursements in the face of increased office expenses, regulatory mandates such as HIPAA, changing priorities, and the liability insurance crisis are factors that are likely to make an ENTs survival a daunting task. And while it is impossible to predict how each of these factors will come to bear on the profession as a whole, it is safe to say that all will have a substantial impact on the specialty.
9 Obstetrics and Gynecology An obstetrician/gynecologist (OB/GYN) specialist is a physician who provides medical and surgical care to women and has particular expertise in pregnancy, childbirth, and disorders of the reproductive system. This includes preventative care, prenatal care, detection of sexually transmitted diseases, Pap test screening, and family planning.1 A minimum of four years of training after medical school is required for a physician to be eligible to take the board certification examination prior to becoming a specialist. An OB/GYN is often a primary care physician for many women in addition to acting as a specialist in his or her own area. Subspecialties within OB/GYN include female pelvic medicine and reconstructive surgery, gynecologic oncology, maternal-fetal medicine and reproductive endocrinology/infertility.
OB/GYN MIRACLES In Vitro Fertilization Who will help us to conceive? Who will help us get pregnant? One of the miracles of obstetrics and gynecology in the last 30 years is that of in vitro fertilization and assisted reproductive technology (ART). Of the approximately 62 million women of reproductive age in 2002, about 1.2 million, or 2 percent, had had an infertility-related medical appointment in 2001 or 2002, and 10 percent had had an infertility-related medical visit at some point in the past.2 The 134,260 ART cycles with eggs implanted performed at these reporting clinics in 2005 resulted in 38,910 live births (deliveries of one or more living infants) and 52,041 infants (Figure 9.1).3 Ovarian Cancer Ovarian cancer is the fifth most common cancer among women, excluding skin cancers. Ovarian cancer accounts for about 3 percent of all cancers in
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The Coming Shortage of Surgeons
Figure 9.1 Numbers of ART Cycles Performed, Live-Birth Deliveries, and Infants Born through ART, 1996–2004 140,000 120,000
Number
100,000 80,000 60,000 40,000 20,000 0
1996
1997
1998
1999
2000
2001
2002
2003
2004
Year Number of ART cycles Number of infants born Number of live-birth deliveries Source: CDC, “2004 Assisted Reproductive Technology (ART) Report: Section 5—Trends in ART,” 1996–2004.
women.4 The American Cancer Society estimates that about 21,550 new cases of ovarian cancer will be diagnosed in the United States during 2009.5 It is estimated that there will be about 14,600 deaths from ovarian cancer in the United States during 2009. The overall five-year survival rate for ovarian cancer is 45 percent. Although only 20 percent of ovarian cancers are found at an early stage, the five-year survival after treatment for these early cancers is 92 percent! Other major advances in this field include robotic surgery, minimally invasive procedures for ectopic pregnancy, infertility, uterine fibroids, and urinary incontinence, as well as the exciting frontier that is fetal surgery and placental surgery.
A WORD TO THE WISE The Threat of Premature Delivery One in eight babies is born prematurely. That is over 500,000 babies a year. The cost of the effort to save their lives is about $26 billion per year,
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87
according to the Institute of Medicine.6 Full-term pregnancy lasts from 38 to 42 weeks. Babies born before the completion of week 37 are premature. Those babies born before 32 weeks have the greatest risk of death; at least one-fifth don’t survive. Who is at risk? Previous preterm delivery doubles the risk of delivering prematurely, and carrying twins increases the prematurity risk by 40 percent. Women younger than 16 or older than 35 are more at risk as well. Close supervision of these pregnancies by an obstetrician, early in the prenatal period, can reduce the incidence of premature births.
OB/GYN WORKFORCE PROJECTIONS The need for obstetrics and gynecologists is based on the number of women in the United States. The number of females in the United States as of October 1, 2007, was 153.6 million. The female population is projected to be 157 million in 2010, 170 million in 2020, and 213 million in 2050.7 The reported trend of OB/GYNs per 100,000 women has increased from 23.0 in 1978, 25.0 in 1988, 27.0 in 1993, to 27.2 in 1997.8 We have used 27.2 per 100,000, which translates to 39,000 OB/GYNs, as the estimate of the number of specialists practicing in 2000. This is consistent with the ABOG actual number of OB/GYNs in practice, about 40,241 in 2000 (Figure 9.2).9 There was a significant decline in the number of U.S. medical graduates electing to practice OB/GYN between 1997 and 2004.10 In 2006, women represented only 27 percent of active physicians in the United States, but 42 percent of all residents/fellows in ACGME accredited programs.11 Women represent about 23–24 percent of graduates of surgical graduate medical education. The proportion of female residents increased every year between 1997 and 2004 in primary care and surgery, but the highest proportion of first year female graduates entered OB/GYN. For the years 1997–2004, 73.3 percent of residents who chose OB/GYN were female in contrast to 21.6 percent who chose surgery and 47 percent who chose primary care.12 Assuming board certification of 1,200 each year (see chapter 2), and retirement after practicing for 35 years, in 2010, about 42,000 OB/GYN specialists will be needed to take care of our women’s’ needs. In 2050, that number will increase to almost 58,000. Unfortunately, with the present rate of 1,200 board- certified OB/GYNs entering the new workforce, the number in practice will be constant at 42,000 from 2040 to 2050 (Table 9.1). By 2030, there will be a shortage of about 18 percent (9,000) OB/GYNs compared to the estimated 50,000 needed. By 2050, that shortage will increase to 25 percent or 15,723 OB/GYNs. Now let’s examine the projections based on 30 years of clinical practice. The 30-year horizon may be more relevant than 35 years to retirement since female physicians may take time off from their practices in their childbearing years. It also may be in the practitioners’ interest to have shorter work weeks
Figure 9.2 Populations and Numbers of Obstetrics and Gynecologists 250
200
150
100
50
0
2010
2020
2030
2040
2050
Projected female population (hundreds of thousands) Projected number OB/GYN in practice (hundreds) Source: http://www.census.gov/ipc/www/usinterimproj/natprojtab02a.pdf (accessed June 3, 2008).
Table 9.1 35 Years to Retirement for OB/GYN
Year
Projected Population
OB/GYN Surgeons Needed
OB/GYN Surgeons in Practice
2000
144,000,000
39,024
2010
157,000,000
42,547
39,449
3,098
7%
2020
171,000,000
46,341
40,299
6,042
13%
2030
185,000,000
50,135
41,149
8,986
18%
2040
200,000,000
54,200
42,000
12,200
23%
2050
213,000,000
57,723
42,000
15,723
27%
Shortage
Percent Shortage
Obstetrics and Gynecology
89
Table 9.2 30 Years to Retirement for OB/GYN
Year
Projected Population
OB/GYN Surgeons Needed
OB/GYN Surgeons in Practice
2000
144,000,000
39,024
2010
157,000,000
42,547
38,519
2020
171,000,000
46,341
37,509
8,832
19%
2030
185,000,000
50,135
36,499
13,636
27%
2040
200,000,000
54,200
36,000
18,200
34%
2050
213,000,000
57,723
36,000
21,723
38%
Shortage
4,028
Percent Shortage
9%
during that particular time of their lives. In this scenario, after 30 years of practice, there will be about 1,300 obstetricians retiring each year, and with 1,200 new board certified surgeons, there will be a net shortage of 100 OB/ GYNs each year. By 2030, the OB/GYNs actively in practice will total 36,499; that shortage will amount to more than 25 percent of the workforce needed. By 2050, with 36,000 OB/GYNs in practice, the shortage will be more than 35 percent (Table 9.2).
OB/GYN WORKFORCE ISSUES One of the few studies on the future workforce in the specialty was conducted by Jacoby and associates.13 They predicted slow or no growth in OB/ GYN-to-population ratio until 2014 based upon an actuarial supply model and analysis of practice patterns. The authors also expressed concern about an oversupply based on implementation of managed care staffing models throughout the country. In addition, they noted a higher attrition rate for female OB/ GYNs due to slow downs in childbearing years. Based upon American Medical Association data on the number of Board Certified OB/GYNs, their number per 100,000 population has increased from 11.4 in 1975 to 14.1 in 2006.14 Almost 20 percent of OB/GYNs do not practice obstetrics and quit doing so at an average age of 48, which obviously will influence any forecasting of manpower needs.15 Therefore, there are multiple factors that may influence the accuracy of any projection of the future need for OB/GYNs. One issue that may alter projections for the future need for OB/GYNs is the error in estimation of workload if these specialists provide more or less primary or generalist care than is generally calculated in most workforce studies. Some female Medicare beneficiaries, about 13 percent based on relative value units billed, received more than half of all their medical and surgical care from an OB/GYN. Yet, for instance, Jacoby and
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The Coming Shortage of Surgeons
associates observed that only 7.5 percent of female Medicare beneficiaries were ever seen by an OB/GYN.16 Another factor in projecting the need for OB/GYNs in the future is the issue of lifestyle and the fact that OB/GYN is one of the uncontrolled lifestyle specialties.17 Most OB/GYNs currently work about 60 hours per week. In chapter 4 in the section on “Controllable Lifestyle and Gender: In Search of Work/ Life Balance” we indicated that the average female physician works about 45 hours per week. Based on a 45-hour work week, the figures for female obstetricians have to be multiplied by 1.3. Twenty-three percent of female OB/GYNs under 40 years of age reduce or cease practice for family reasons compared to only 5 percent of male OB/GYNs in the same age group.18 In a survey of work hours, the aggregate productivity of female OB/GYNs is about 85 percent that of their male counterparts.19 Recall that about 73 percent of the obstetrician residencies are occupied by female residents. The number of residency training positions has stayed stable at about 4700 annually (1,225 first year positions) since a high of 5000 in 1993.20 In OB/GYN News in April 2004, there was a report stating that the number of OB/GYN residency spots filled by U.S. senior medical students dropped. The fill rate by seniors was only 61.5 percent of the total number of available residencies.21 Despite a declining proportion of U.S. medical graduates entering OB/GYN programs, current training programs are maintained due to an increase of U.S. osteopathic, Canadian, and non-U.S. citizens filling the positions. Escalation of medical liability premiums and a sharp uptick in the average payment per case has had an impact on the potential choice of career specialty among doctors. The average annual liability premium for an OB/ GYN has increased dramatically from $30,682 in 1996 to $92,834 in 2006.22 Medical liability premium prices have gone from the second most to the most serious problem for people going into OB/GYN. A recent survey assessing professional liability of 2,185 American Academy of Obstetrics and Gynecology fellows found that one in seven have stopped practicing due to the risk of liability claims, and that more than 76 percent had a liability claim filed against them, half of these within the past 10 years.23 Five percent of these respondents have stopped performing major gynecological surgery. Another report shows that, as of 2004, Florida had the highest liability premiums in the United States, at more than $175,000 annually.24 The states with the lowest premiums, at $17,000 on the average, included Oklahoma, Nebraska, South Dakota, Indiana, Idaho, and North Dakota. In Dade County, Florida, which includes Miami, premiums went from $149,000 in 2003 to $207,000 in 2004. In the same period, in Cook County, Illinois, the premiums jumped from $138,000 to more than $230,000. In Wayne County, Detroit, they went up from $164,000 to nearly $194,000. OB/GYN malpractice premiums are so high because “the statute of limitations for malpractice claims by a minor ends one year after the minor reaches 18” years old, as opposed to the two year statute of limitations for a practicing
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91
surgeons in other specialties.25 Would it be difficult to get a delivery in some of the major cities in the United States? Perhaps. According to one of the authors of a very good paper on OB/GYN working issues, “As a specialty we are threatened by rising malpractice premiums, lower job satisfaction, intrusion of policymakers, and insurance companies demanding better service and access while providing few resources, and decreased interests in obstetrics and gynecology among senior medical students are formidable challenges.”26 Who Will Deliver Our Babies? Midwives and obstetricians deliver babies, but midwives cannot perform caesarean section deliveries. This presents a problem (Figure 9.3). Approximately 4 million women were hospitalized for delivery in 2005, and their average stay was 2.6 days.27 Caesarean sections per 100 deliveries increased from 20.8 in 1995 to 31.3 in 2005, and the rate of primary cesareans per 100 deliveries without a previous caesarean increased from 15.5 to 21.7 during this period. Caesarean section rates rose 6 percent in 2004 and have gone up 46 percent since 1996.
Figure 9.3 Caesarian Rates for First Births, for All Women and Low-risk Women: United States, 1990–2003 30% 25% 20% 15% 10% 5% 0% 1990
1992
All women Low-risk women
1994
1996
1998
2000
2003
Note: Data for 1990 excludes data from Oklahoma, which did not report method of delivery on the birth certificate.
Source: National vital statistics reports: from the Centers for Disease Control and Prevention, National Center for Health Statistics, National Vital Statistics System.
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The Coming Shortage of Surgeons
What will happen in 2050 when we have an estimated population of 420 million people? If this trend continues, there will be 1.8 million babies or more delivered by cesarean section. There are several reasons for the increase in caesarean sections. Experts point to several factors, particularly malpractice. If a baby has birth difficulties, the obstetrician is liable for 18 to 21 years of the baby’s life in most states and so would perform a caesarean section to comply with the standard of care. Obstetrics Hospitalists: Laborists—an Emerging Field Walter Hull, who spent 20 years of his life as a missionary in Zaire, is an obstetrician and gynecologist. Walter has returned to the United States as an OB/GYN faculty staff member at The Ohio State University Hospital. He says that the way that we deliver babies in the United States is inefficient. He says this is because, sometimes, in one hospital in one day, 12 babies are delivered by 10 to 12 obstetricians. Perhaps it would be better to assign two obstetricians to deliver babies over a 24-hour period so that the other obstetricians could get some rest and provide prenatal care to expecting mothers and their fetuses. That would make for a scheduled or controllable lifestyle. This may well be the case as time goes on, considering that 75 percent of OB/GYN residents are female. Laborists are OB/GYNs who work in hospitals delivering babies.28 They can be hospital employees or independent contractors. They work seven or eight 24-hour shifts per month. Part of the job is delivering babies for uninsured women who appear in the emergency room. Besides improving patient care, laborists can lower a hospital’s malpractice liability and insurance premiums. Laborists also reap rewards, too—predictable schedules, relief from running a practice, and competitive compensation. With the hospitals paying for malpractice coverage, as employees, laborists can afford to deliver babies.
A FINAL NOTE What do all of these considerations do to the relationship between a mother and her obstetrician? What does this mean to the private practice of obstetrics and gynecology?
10 General Surgery WHAT IS GENERAL SURGERY? The American Board of Surgery defines general surgery as “. . . a discipline encompassing the following essential content areas: Alimentary Tract, Abdomen and its Contents, Breast, Skin and Soft Tissue, Endocrine System, Head and Neck Surgery, Pediatric Surgery, Surgical Critical Care, Surgical Oncology, Trauma/Burns and Vascular Surgery.”1 In other words, general surgery encompasses the core of all surgical training, and practitioners are taught to care for common surgical problems relating to and ranging from accidents and injuries to cancers. Medical Miracles Advances in the field of general surgery have benefited the entire spectrum of surgical specialties from plastic surgery to gynecology. Some examples of recent progress in this specialty are discussed in the following sections. Breast Cancer One of the real miracles, with regard to cancer, is what is happening in breast surgery. In the 1960s and before, the standard curative surgical procedure for breast cancer was a radical mastectomy, which involved very long scars and prolonged recovery (Figure 10.1). This disease in the 1960s was associated with a mortality rate of 30 to 40 percent within five years, or a five-year survival rate of 60 to 70 percent. The five-year survival is now almost 88 percent, the 10-year survival rate 80 percent, the 15-year rate 71 percent, and the 20-year rate 63 percent.2 Here are many factors that have contributed to the improved statistics for breast cancer. The most important thing in the last 25 years, perhaps, is the increased awareness of the disease among women. The Komen Race for the Cure has made more and more women aware of the seriousness of this cancer
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The Coming Shortage of Surgeons
Figure 10.1 Surgical Incision for Radical Mastectomy in 1960
that could await them.3 At the same time, improved techniques for diagnosis, mammography, and needle biopsy have been developed. Improved surgical techniques such as lumpectomy, perhaps with ‘sentinel’ lymph node biopsy, as well as marked advances in radiation methods and new chemotherapy drugs have all played a part in the goal toward eliminating breast cancer. Monoclonal antibodies such as Herceptin have been approved as immunotherapy for breast cancer, and various other specific antigen vaccines are also on the horizon (Figure 10.2). Gallbladder In the past, before the development of minimally invasive surgery, a six- to eight-inch incision along the ribs or a paramedian incision from the ribs to the belly button was made to remove a diseased gallbladder (Figure 10.3). A remarkable innovation in general surgery is the minimally invasive approach of introducing a laparoscope through four one-inch openings (ports) through which a gallbladder can be removed with much less pain and disfigurement and a quick recovery (Figure 10.4). In the new era, only 10 percent of all cholecystectomies (gallbladder removals) are done with open surgery,
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95
Figure 10.2 Breast Cancer Now
A B
Woman with lumpectomy A = Tumor (dark area) B = Tissue removed at lumpectomy (lighter area) Five year survival rate—88%
and almost 750,000 laparoscopic cholecystectomies are performed annually in the United States.4 In most cases, cholecystectomy is a same-day procedure with discharge from the hospital the next day.
NOTES PROCEDURE (NATURAL ORIFICE TRANSLUMENAL ENDOSCOPIC SURGERY) Incisionless surgery through an endoscope performed via a natural orifice in the body is the next frontier in minimally invasive procedures. Approaching intra-abdominal organs through natural orifices such as the mouth, anal canal, and vagina leads to less pain, quicker recovery, and fewer or no external scars even compared to laparoscopic surgery. Several venture capital firms are investing hundreds of millions of dollars into new technology that promises to
96
The Coming Shortage of Surgeons
Figure 10.3 Gallbladder Incisions —1960
alter the landscape of minimally invasive surgery even more dramatically than laparoscopic procedures. Will there be enough general surgeons to perform these procedures and lead the way to even further innovation directed towards making procedures less invasive, painless, and safe? General Surgery Projections and Scenarios General surgery is facing a shortage similar to that of other surgical specialties. There has been a decrease in the relative number of general surgeons of about 26 percent since 1981, from 7.6 to 5.6/100,000 population.5 Until recently, the number of applicants for general surgery residency had dropped 30 percent. In 1987, about 7.8 percent of medical school graduates elected
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Figure 10.4 Incisions for Minimally Invasive Gallbladder Surgery
general surgery residencies.6 By 2002, the figures were down to about 5.8 percent. One of the workforce studies projected that by 2005, only 4.8 percent of U.S. medical school graduates would be interested in general surgery. The number of applicants for the National Residency Matching Program in general surgery declined from 2,000 in 1994 to 1,500 in 2001; however, in a recent turnaround, 83.1 percent of available categorical general surgery positions in 2008 were filled by U.S. medical school seniors.7 At the present time, the American Board of Surgery awards approximately 1,000 certificates each year. About 150 of these recipients will take other residencies, such as thoracic surgery, vascular surgery, and pediatric surgery. For our estimates, we will assume that 850 newly board certified surgeons will actually practice general surgery. The first projection assumes a career spanning 35 years with 604 retirees during the same period. Again, the relevant surgeon-to-population ratio used is 7.5 per 100,000.8 Under this scenario, by 2050 we will have a shortage of 1,750 or about 6 percent of general surgeons (Table 10.1). If we change our assumption to a career of 30 years of service instead of 35 years and 705 retiring surgeons by 2030, we will have a shortage of about 2,500 surgeons or about 9 percent. By 2050, that shortage will have increased to 6,000 or about 19 percent (Table 10.2). General Surgery Workforce Issues The landmark study on the surgical workforce was conducted in the 1970s by the American Surgical Association and the American College of Surgeons and is known as the SOSSUS (Study on Surgical Services for the United States).9 The study was completed in 1975 and was based on population estimates and workload. The authors concluded that 1600–2000 surgeons completing their
98
The Coming Shortage of Surgeons
Table 10.1 35 Years to Retirement for General Surgeons Year
Projected Population
Surgeons Needed
Surgeons in Practice
2000
282,000,000
21,150
2010
309,000,000
23,175
22,380
795
3%
2020
336,000,000
25,200
24,840
360
1%
2030
364,000,000
27,300
27,300
0
0%
2040
392,000,000
29,400
29,760
(360)
–1%
2050
420,000,000
31,500
29,750
1,750
6%
Shortage
Percent Shortage
Table 10.2 30 Years to Retirement for General Surgeons Year
Projected Population
Surgeons Needed
Surgeons in Practice
Shortage
2000
282,000,000
21,150
2010
309,000,000
2020
336,000,000
2030
Percent Shortage
23,175
21,875
1,300
6%
25,200
23,325
1,875
7%
364,000,000
27,300
24,775
2,525
9%
2040
392,000,000
29,400
25,500
3,900
13%
2050
420,000,000
31,500
25,500
6,000
19%
residencies each year from 1976 to 2012 should satisfy the country’s need surgical services. The ratio of general surgeons to the population was estimated at 6.93/100,000. The authors of the study did not identify any particular undersupply or oversupply within various parts of the United States. The next influential report, called the GMENAC (Graduate Medical Education National Advisory Committee) report, is considered one of the most comprehensive at evaluating physician workforce, although it continues to receive criticism for its methodology, modeling, and analysis.10 The GMENAC report evaluated the physician workforce in 1978, issued its findings in 1980, and predicted an oversupply of 145,000 physicians by the year 2000. In regard to surgery, the predicted manpower need for 1990 was estimated between 23,000 and 24,000 general surgeons, and this was projected to be between 9.4 to 9.8/100,000 population. The GMENAC report also documented 30,700 general surgeons in 1978 and predicted an increase of 15 percent to 35,300 general surgeons by 1990. Therefore, the report concluded that there would be an oversupply of surgical specialists in the years following 1978.
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99
The Council on Graduate Medical Education (COGME) was created under the Consolidated Omnibus Budget Reconciliation Act of 1983 (COBRA) to monitor physician supply and demand.11 COGME recommendations included training 50 percent specialists and 50 percent generalists with total graduate medical and surgical positions fixed at 110 percent of all U.S. medical graduates; international medical graduates, often from foreign nations, comprised the other 10 percent. A reduction in the number of residency training positions followed as policy makers relied upon recommendations of the GMENAC report as well as the COGME report. One of the few earlier assessments to have predicted an undersupply of general surgeons was an AMA report in 1986.12 This study, which used the AMA master file as a basis, calculated that there were 32,100 general surgeons, including 8,900 surgical residents prior to 1986. In the later 1980s, only 1000 residents graduated compared to the 1600 to 2000 that SOSSUS had predicted. The AMA concluded that the workload for surgeons would go up by almost 20 percent, but that the workforce would increase by only 6 percent. Using different databases, the American Board of Medical Specialties had the number of general surgeons in the U.S. as 22,470 and the American Board of Surgery came up with 19,917 general surgeons. However, as George Sheldon, the former chair of the department of surgery at the University of North Carolina points out, board-certified active general surgeons probably numbered between 17,829 and 19,520, which was about half the number used by the AMA and other planning committees.13 COGME was to later completely reverse its earlier stance and state its position as being in favor of expanding undergraduate and graduate medical education programs in 2003.14 One of the first thoughtful challenges to the GMENAC and COGME reports was a 1991 study that employed modified needs-based models updated with population projections.15 This study predicted a 33 percent (37,022 general surgeons) increase in needs between 1990 and 2010 and only a 10 percent increase in the supply of general surgeons, with a resulting shortage of about 5000 general surgeons by 2010. In 1996, Kwakwa and Jonasson reported that board certifications in general surgery had been stable at 1000 for 12 years.16 In addition, the ratio of 7.1 general surgeons/100,000 population observed in 1994 was less than the population ratio predicted by GMNEC and the revised update. The number of general surgeons decreased, according to the AMA master file, from 27,509 in 1998 to 24,902 in 2002.17 Sheldon opines that even though the number of osteopathic general surgeons (1,037 in 2007) is not considered in many estimates of the workforce, their small numbers do not substantially alter his view that the shortage is significant. Academia has been persuaded by a steady flow of data confirming the future undersupply of general surgeons. The decline in the relative number of general surgeons from 6.93/100,000 in the SOSSUS study, and 7.1/100,000 in Sheldon’s report to 6/100,000 or lower has received attention.18 A survey
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The Coming Shortage of Surgeons
of 70 responding deans of medical schools showed that 89 percent could cite shortages in at least one specialty, 17 percent in general surgery and 21 percent in surgical subspecialties.19 The total percentage of U.S. medical school graduates matching to general surgery or one of its subspecialties stayed steady from 1987–2002 at around 11–12 percent.20 During the same time frame, the number of medical students who chose general surgery declined from 7.8 percent in 1987 to 5.8 percent in 2002. An attrition rate of about 20 percent based on lifestyle issues has also been documented.21 There is declining interest in general surgery among medical students because of the long years of training, the difficult work hours, the lifestyle, the debt, and professional liability issues, as well as other factors such as declining reimbursement. In a presidential address at the annual meeting of the Western Surgical Association in November 2002, J. David Richardson delivered a talk entitled “Work Force Issues in Surgical Figure 10.5 Forecasted Increases in Work by Specialty 50% 45% 40% 35% 30% 25% 20% 15% 10% 5% 0% 2001 U.S. Population Cardiothoracic General Surgery
2010 Neurosurgery Ophthalmology Orthopedics
2020 Otolaryngology Urology
Note: General surgery includes vascular, breast, hernia, abdominal, gastrointestinal, and pediatric procedures. Source: D. Etzioni, J. Liu, M. Maggard, et al., “The Aging Population and Its Impact on the Surgery Workforce,” Annals of Surgery 238 (2003): 170–176.
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Training and Practice.” He said that lifestyle issues remain at the forefront of students concerns:22 I posed . . . this question to the students. Do you view your medical career as a job or a profession? Eighty percent of the women stated it is a job while 50% of the men had the same response. Women usually state that the all-consuming commitment to the profession is not what they want. Before rushing to judge me as an anti-woman, let me tell you that I have a daughter in medicine who has made me sensitive for a need to have life away from our patients. The balance of work with home and family is a feeling stated by virtually all students regardless of gender. The need for a balanced life is crucial and should be encouraged.23
International medical graduates have stepped in to fill about 15 percent of ACGME-approved general surgical residency positions. Approximately half of general surgical residents have previously sought advanced training. The Figure 10.6 Decreasing General Surgical Workforce with Increasing Population of the United States 20,000 17,394
18,000
17,757
17,922 16,662
7.68
16,000
7.04 14,000
7 6.29
12,000 10,000
5.69
5
8,000 6,000
3
4,000 2,000
1
1,000
995
1,064
1,124
1981
1991
2001
2005
0 # General Surgeons #/100,000 Population # ABS Certificates Awarded Source: F. Kwakawa and O. Jonasson, “The General Surgery Workforce,” Advisory Council for General Surgery, http://www.facs.org/about/councils/advgen/gstitlpg.html (accessed May 17, 2008); D. C. Lynge, E. H. Larson, M. Thompson et al., “A Longitudinal Analysis of the General Surgery Workforce in the United States, 1981–2005,” Archives of Surgery 143 (2008): 345–350. Copyright © 2008 American Medical Association. All rights reserved.; Census bureau.
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The Coming Shortage of Surgeons
proportion of general surgical trainees going on to further specialty training has recently increased from 55 percent to 70 percent.24 Surgical oncology, colorectal surgery, vascular surgery, pediatric surgery, and cardiac surgery are among the specialties they choose. Another concern with regard to the general surgery workforce is an earlier age of retirement. Kwakwa and Jonasson noted an increase in retirement age from 60 to 63 years in the years 1984–1995.25 In 1990, general surgeons retired at about the age of 71. By 2000, general surgeons were retiring at the age of 58. Etzioni and co-authors have examined the impact of the aging population on the demand for surgical services.26 Based on estimated population increases of 7.9 percent by 2010 and 17 percent by 2020, they predict a 31 percent growth in procedure-based work in general surgery (Figure 10.5). Why is there such great disparity in attempts by serious and well-informed individuals to ascertain the approximate number of general surgeons required to serve our communities? There are multiple reasons, most of which are articulated by Cooper.27 One basic reason stands out: the models commonly used for predicting demand were probably in error. Most studies used patient visits or procedures and physician full-time equivalents for estimating demand. Methodologies having to do with estimation of workloads and then computation of demand for surgical services have been inconsistent. Cooper used a trend model which took into account economic expansion (gross domestic product), population growth, physician work effort, and a trend of increasing services provided by physician extenders such as nurse clinicians. In our projections, we have not taken into account the increased surgical workload forecasted by most experts. However, it is now clear that despite a new desire to train more general surgeons for the future, we may find ourselves behind the curve (Figure 10.6).
11 Neurosurgery Neurosurgery is the specialty that involves the surgical treatment of diseases of the nervous system. A more comprehensive definition of neurosurgery is that it is a specialty that involves the operative and nonoperative management involved in the diagnosis, treatment, and rehabilitation of a patient with disorders of the central and peripheral nervous system.1 The training of a neurosurgeon involves a rigorous five to seven year program with the first year consisting of general surgery/rotating internship and one to two later years gaining research experience in the top tier programs. Subspecialty programs within neurosurgery include cerebrovascular surgery, neurocancer, pediatric neurosurgery, skull-base surgery, stereotactic surgery, complex spine surgery, and epilepsy surgery.
NEUROSURGICAL MIRACLES Brain Trauma—Two Cases Neurosurgeons treat brain trauma. Whenever any tissue gets injured, swelling occurs. If that swelling is confined to a narrow space, for instance the skull, and there is no relief for the pressure, the brain herniates down towards the spinal column through the opening connecting it with the skull. This can cause death or severe disability. One of the current miracles of neurosurgery is the management of severe brain trauma. In 2005, Peter Jennings, the news anchor for the ABC evening news, died of lung cancer. Bob Woodruff was appointed to be his successor. In the course of the first months of his reporting he went to Baghdad, where he was injured by an improvised explosive device. He suffered severe head and brain trauma.2 Because of the swelling of his brain, the doctors removed a large piece of his skull to relieve the swelling. Over the course of a year, Woodruff recovered to the point where he is now reporting again for ABC news. The same techniques have been brought into general use as well. In Worthington, Ohio, in the Halloween season of 2006, some teenage girls wanted
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The Coming Shortage of Surgeons
to visit what they thought was a haunted house. As they entered the yard of the haunted house on a dare, the owner shot one of the girls from the window of the house with a rifle.3 She had severe brain trauma, and the technique of removing a piece of her skull to control the brain swelling was used. For several months she had to wear a helmet in order to protect her brain. Eventually her skull was reconstructed. She was well enough to attend her high school graduation.
SELECTIVE BRAIN SURGERY Bernadine Healy, M.D., and her husband, Fred Loop, M.D., are a distinguished medical couple. She is a cardiologist, former director of the National Institutes of Health, and dean of the Ohio State University Medical School. Fred is a heart surgeon and retired head of the Cleveland Clinic. Bernadine was right handed, what she calls “a left brain,” and so the speech center was on the left side of her brain. In 1999 she learned that she had a malignant brain tumor. The brain tumor was close to the speech center on the left side. This passage is taken from her book, Living Time, Faith and Facts to Transform Your Cancer Journey with her permission:4 I was clearly harnessed to the operating table with my head immobilized by some kind of paraphernalia. I had no pain medically or physically. Dr. Barnett had already numbed my scalp with a local anesthetic and opened up a 4–5” window into the left side of my skull to expose the tumor. . . . My brief reverie was interrupted when neurologist, Hans Luders, an expert on brain geography appeared before me in full surgical garb. . . . He now stood over me holding my neurosurgical homework, a literary passage I was to read again and again during the operation. This was strangely satisfying: I was a part of the team, aware of what was going on, able to influence my own outcome, never entirely relinquishing whatever meager control over my fate I can muster. Like a third grader reading aloud in front of the class, I tried to pronounce each word perfectly, though the words seemed odd. I asked Dr. Luders if this passage made a lot of sense to him, and he laughed. To me it seemed out of context and very flowery, not at all a passage I would have chosen for this critical moment in my life. But hey, who was I to be choosy. Just as I was feeling comfortable about my ability to handle this strange experience, Dr. Barnett told me he was finishing up and all was well.
Dr. Healy is an nine-year survivor of this malignant tumor. She is the health care correspondent for U.S. News and World Report.
NEUROSURGICAL ADVANCES 1. Image-guided surgery and radiosurgery, including neuronavigation with preoperative/intraoperative guidance.5 Neuronavigation uses computer assisted technologies to navigate within the skull or vertebral column during surgery.
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105
2. Intracranial and spinal minimally invasive and/or endoscopic assisted surgery with small incisions using endoscopes (small tubes used to look inside the body).6 3. Complex spinal instrumentation used in surgical procedures to implant materials like titanium alloys or steel into the spine with the use of rods, hooks, plates, screws, and threaded interbody cages to stabilize the spine.7 4. The management of brain trauma.
PROJECTIONS FOR NEUROSURGERY We use the same assumptions in this chapter that we have used throughout the book, which are that the ratio of physicians to population will not change, that medical school enrollments and the number of board certifications will not change, that the gross national product will not change, and that population estimates are accurate. The relevant parameter for neurosurgeons we have used for our assumptions is 1.06 per 100,000 population. The number of practicing neurosurgeons in 2003 was 3,080 according to a press release by the American Academy of Neurosurgery (AANS), with about 125 neurosurgeons being newly certified each year.8 In Table 11.1 we assume 35 year projections to retirement and 88 retirees. According to these projections, by 2030 there will be a surplus of 147 neurosurgeons. By 2050, we project that there will be a shortage of about 77 neurosurgeons or two percent. If we assume 30 years as an average time of a neurosurgeon’s medical career, from entering practice to retirement (103 retire each year), the shortage is projected at only six percent or 228 neurosurgeons in 2030 (Table 11.2). It becomes worse by the year 2050 with a shortage of 700 or about 16 percent.
NEUROSURGERY WORKFORCE In this book we have tried to keep our estimates of the shortages of physicians at a minimum instead of a maximum. As you can see, the estimates we Table 11.1 35 Years to Retirement for Neurosurgeons Year
Projected Population
Neurosurgeons Needed
Neurosurgeons in Practice
2000
282,000,000
3,080
2010
309,000,000
3,275
3,265
10
7%
2020
336,000,000
3,562
3,635
(73)
–2%
2030
364,000,000
3,858
4,005
(147)
–4%
2040
392,000,000
4,155
4,375
(220)
–5%
2050
420,000,000
4,452
4,375
77
2%
Shortage
Percent Shortage
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The Coming Shortage of Surgeons
Table 11.2 30 Years to Retirement for Neurosurgeons Year
Projected Population
Neurosurgeons Needed
Neurosurgeons in Practice
2000
282,000,000
3,080
2010
309,000,000
3,275
3,190
85
3%
2020
336,000,000
3,562
3,410
152
4%
2030
364,000,000
3,858
3,630
228
6%
2040
392,000,000
4,155
3,750
405
10%
2050
420,000,000
4,452
3,750
702
16%
Shortage
Percent Shortage
have given for the neurosurgical workforce might not seem significant in terms of total numbers. The Health Resources Services Administration (HRSA) has projected a total supply of 5,570 neurosurgeons in 2010, and 5,670 in 2020.9 However, in terms of clinical full time equivalents, after excluding residents and those not in clinical practice, these numbers show that there will be 4,490 neurosurgeons available to practice in 2010 and 2020. This, we believe, is an overestimate. Compare the numbers used by HRSA with the numbers based on the AANS data.10 A recent paper by Gottfried et al approaches the workforce issue from a different angle.11 The study attempted to evaluate the neurosurgical workforce by reviewing journal advertisements for available positions from 1994–2003. The number of practicing neurosurgeons declined after 1998, and by 2002 it was less than it had been in 1991, whereas the number of incoming and matriculating residents remained stable. The study noted that from 1999—2001, 25 percent of the board-certified neurological surgeons retired and concluded that the number of positions advertised had increased significantly in the face of the declining number of neurosurgeons and a static supply of residents. Merritt, Hawkins & Associates confirmed this demand for neurosurgeons in their “Summary Report, 2005 Review of Physician Recruitment Incentives.”12 The report said that neurosurgeons were in the “top 15 most recruited specialties, the first time it has been on the list.” In Merritt, Hawkins & Associates’ 2007 report of the 20 most recruited specialties, the average salary offer for neurosurgeons was the highest at $530,000 (range $350,000 to $850,000).13 The most publicly identified need for neurosurgeons, particularly in smaller communities, is about availability of neurosurgeons who can take trauma call for brain injuries.14 Here is increasing specialization in neurosurgery, as in other fields. Neurosurgeons who specialize in spinal disease and other kinds of specialized neurosurgery may feel unable to take trauma calls because of their inexperience, as the years go on, in head and brain trauma. Small communities are feeling a severe shortage of neurosurgeons capable of handling brain
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trauma patients. General guidelines call for 1.1 brain surgeons to 100,000 population, and business newspaper columns are full of recruiting pitches for these specialists.15 A previous study has suggested, based upon time and distance factors, that a distance of 100 miles and ground travel time of two hours may be acceptable when a neurosurgeon is needed.16 However, even with air ambulance transportation, press reports of inadequate care for brain injuries put pressure on politicians to address the issue.17 South Carolina has approximately 83 neurosurgeons, but six are residents and 22 are retired, which leaves 53 neurosurgeons to care for a population of 4.3 million.18 There is also some evidence that the wave of retiring neurosurgeons is a result of the malpractice insurance situation that has occurred in the last 10 years.19 Neurosurgeons pay some of the highest annual malpractice premiums of any specialty, with an average of over $100,000 and up to $300,000 per year in some states.20 The evidence shows that the liability crisis may not affect the number of neurosurgeons practicing in plaintiff-friendly states. However, in those plaintiff-friendly states some neurosurgeons restrict their practices to low-risk procedures; there may be a need for two neurosurgeons to care for the population instead of one for every 100,000 people.21 Opinion polls in the 1970s indicated that almost 45 percent of neurosurgeons felt that there were too many neurosurgeons, and that 50 percent considered the numbers adequate.22 Most neurosurgical program directors currently think that they are training too few neurosurgeons. Although the total number of applicants is large enough to fill the positions, there is a significant downward trend in the number of applications. Again, one of the things that program directors conclude is that their field, particularly with respect to trauma, is precluded from having a regular work schedule.23
12 Urology Urologists deal with the diagnosis and treatment of diseases of the urinary tract and genital systems in both males and females. Generally, in order to be eligible for board certification, residency training consists of one year of general surgery rotations plus another four years of urologic surgery. Some trainees elect to do a year of research or alternatively train for another one to two years to subspecialize in one of several highly specialized areas such as: andrology (diseases of men and of the male sexual organs) infertility and urologic prosthetics endourology, laparoscopy, and robotic surgery neurourology, urodynamics, and incontinence pediatric urology oncologic (cancer) urology
UROLOGY MIRACLES Robotic Urology. We never expected to see a symphony conducted in the operating room. Nonetheless, we were treated to just such an experience in the operating room that morning. The conductor was seated at the robotic console while the players were scrubbed, playing robotic arms as was appropriate. It was a seamless performance that was conducted in about two hours and 15 minutes. The patient had six one-inch incisions to accommodate the operative ports, and the bladder was joined with the urethra with the precision of detail that is only possible with a binocular 3-D magnifying system. After the operation, the patient was returned to the recovery room and then later to his room. He walked later that day. A student who is a pilot, was observing the operation and commented, “This is like a flight simulator.” Most patients go home after one day in the hospital.1 The blood loss in these operations is less than 150 cubic centimeters or five ounces. Patients return to
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have their urinary catheters out within a week of their surgery. The surgeon who sits at the console can do a meticulous dissection of the prostate such that about 75 percent of those who undergo the operation will have their sexual function intact. Penile prosthesis. When pharmacological methods (oral medication or penile injections) to address erectile dysfunction fail, mechanical prostheses can be inserted with a five year mechanical failure-free rate of up to 93.6 percent.2 Neurourology is a highly specialized subspecialty that is involved in the diagnosis and treatment of conditions such as neurogenic bladder (urine leakage, retention, or incontinence), multiple sclerosis, spinal cord injury, spinal bifida, strokes, brain or spinal cord tumors, and herniated discs. Sophisticated urodynamic testing is now available to accurately diagnose these conditions.
WORKFORCE PROJECTION The demand for urologists was illustrated in a recent news report entitled “Is There a Urologist in the House, Maybe Not For Long” in the Urology Times.3 The report stated that 45 percent of urologists are 55 years, and older, that urologists are among the 15 most sought out specialists, and that they command a salary of over $300,000 often with a substantial signing bonus.4 Why is this? Aging of the baby boomers and relief for previously untreatable conditions such as large kidney stones, paralyzed bladders, and impotence has created an increasing demand for urology services. The early detection of prostate cancer with the Prostate Specific Antigen or PSA test has meant earlier diagnosis and therefore earlier surgery for these patients. The number of currently active urologists is taken from the AAMC Specialty Chart Book.5 The ratio to population used is 3.31/100,000. A projection for urologists practicing for an average of 35 years is shown in Table 12.1. There were fewer than 10,000 urologists in the year 2000, but 282 surgeons will retire each year and only 260 will be newly board certified. Because the Table 12.1 35 Years to Retirement for Urologists Year
Projected Population
Urologists Needed
Urologists in Practice
2000
282,000,000
9,864
2010
309,000,000
10,228
9,754
474
7%
2020
336,000,000
11,122
9,534
1,588
14%
2030
364,000,000
12,048
9,314
2,734
23%
2040
392,000,000
12,975
9,100
3,875
30%
2050
420,000,000
13,902
9,100
4,802
35%
Shortage
Percent Shortage
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The Coming Shortage of Surgeons
Table 12.2 30 Years to Retirement for Urologists Year
Projected Population
Urologists Needed
Urologists in Practice
2000
282,000,000
9,854
2010
309,000,000
10,228
9,524
704
7%
2020
336,000,000
11,122
8,844
2,278
20%
2030
364,000,000
12,048
8,164
3,884
32%
2040
392,000,000
12,975
7,800
5,175
40%
2050
420,000,000
13,902
7,800
6,102
44%
Shortage
Percent Shortage
population will increase, there will be a demand for about 12,000 in 2030 and almost 14,000 by 2050. This will lead to shortages of more than 2,500 in 2030, and almost 5,000 by 2050. The number of urologists in practice stabilize at 9,100 in 2040, resulting in a shortage of urologists of about 23 percent in 2030, 30 percent in 2040, and 35 percent in 2050. Projections for the supply of urologists assuming 30 years of service before retirement are even more alarming. In this situation 328 will retire each year and only 260 will be board certified annually, so that only 7,800 will be practicing between the years 2040 and 2050. There will be a shortage of almost 4,000 in 2030 or 32 percent, and by the year 2050 the shortage will be greater than 6,000 or 44 percent (see Table 12.2). In similar projections, the Department of Health & Human Services projects a full-time equivalent physician supply of about 8400 urologists in 2020, or a shortage of 9 percent compared to the 9,200 urologists in the base year (2000) number.6
WORKFORCE ISSUES One of the earliest assessments of urologic manpower was in 1977,7 followed subsequently by a survey of 154 training programs in 1979.8 The survey concluded that there were too many urologists being trained. This opinion was based on the fact that the ratio of urologists to the population was projected to increase from 1:32,416 in 1978 to 1:25,972 by the year 2000. Subsequently, several other publications supported the idea of an oversupply of urologists. In 1978, based upon a population of approximately 218 million and a ratio of 1:35,000, the existing supply of 7,242 urologists was seen as being far in excess of the stated need for 6,229 urologists.9 Fraley et al, assuming a population increase of about 1% per year and an attrition rate of 2% per year, suggested that the 386 urologists being trained in 1979 were in excess of the estimated need.10 The authors noted that the number of board certificates granted had increased by 90 percent (four times more than the average
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for all surgical specialties) from 1969–1973 to 1974–1978. Furthermore, 69 percent of program directors in the survey opined that there were too many residents being trained. The authors recommended a drastic 50 percent cut in resident trainees. Similarly, Gee and his associates published a telephone survey of academic urologists in which half of respondents thought that too many new residents were being trained.11As a result, the number of training programs gradually declined from 153 to 120 in the early 1980s.12 At the same time, the number of residency positions declined from 253 to 220 in a three year period. Later, in the mid 1980s, the number of programs increased to 131 with a total of 260 residents trained per year. The earlier dire predictions of an oversupply appear not to have come true. The ideal ratio of urologists to the general population has been a matter of debate. Allen and associates pegged the ideal ratio as between 1:35,000 to 1:40,000.13 The ratio has varied from 1:35,000 in 1975 to 1:30,000 or 31,000 in 1995 to the current 1:30,200.14 While the number of urologists added to the pool has varied over the years, data from the American Urologic Association indicates that the average is 260 trainees entering the workforce annually.15 The number of international medical graduates in the urology workforce ranged from 2–4 percent in the 1980s and 1990s and has not been a factor in manpower estimates in the past. However, data from the AAMC show that international graduates represented almost 17 percent of practicing urologists in 2006.16 Despite this additional manpower, the trend or percentage change (increase) in the number of active urologists between 1995–2004 was only about 8 percent, one of the lowest positive growths among specialties.17 As an example, vascular surgery increased 41 percent, plastic surgery 20 percent, and neurologic surgery 10 percent during the same period.18 In addition, if one looks at the ratio of board certifications to active physicians in accredited programs, urology is the one of the lowest (2.5%). Urologists would have to practice for 40 years to keep the numbers constant (see Figure 12.1). The study by Gee et al also noted that the average urologist plans to retire at a mean age of 64 years.19 Urology happens to have the fourth highest number of active physicians aged 55 years or older, at approximately 45 percent compared to the 33.3 percent for the average specialty.20 Urologists in the younger age group (37–45 years of age) tended to indicate an even earlier retirement age. According to David L. McCullough, “The market forces, program directors, and economics had resulted in the decreasing number of training programs, decreasing from 153 to 120.”21 McCullough was probably the first to realize that by 2020 there would not be enough urologists to treat the people. Aging of the population has a particular impact on the demand side of the urology equation because of prostatic hyperplasia (enlargement) and prostatic cancer, which occur in the aging male. The 65-plus age group accounts for about 44 percent of visits to the urologist.22 Despite new pharmacological
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The Coming Shortage of Surgeons
Figure 12.1 Production Rates of Urologists and General Surgeons 5.00% 4.50% 4.00% 3.50% 3.00% 2.50% 2.00% 1.50% 1.00% 0.50% 0.00% Urology
General Surgery Production Rate %
Legend: Comparison of % production rates of urologists and general surgeons legend; Assumption of 280 new urologists joining workforce annually and approximately 9,864 urologists in practice. Assumption of 1,027 general surgeons joining the workforce annually and 21,150 already in practice.
medications for prostatic pathology and new less invasive technology to treat the prostate gland, the need for increasing urologic consultation or intervention seems a certainty. Steers and Shaeffer, in an editorial in the Journal of Urology, declared that there were not enough urologists to meet the demands of the aging population.23 In response, Allison Stewart and John Bolton, who are practicing urologists in the United Kingdom, recommended a curriculum change in urologic residencies.24 Stewart and Bolton related their experience in the United Kingdom, where a modification of the training curriculum was necessary. The Senior Urological Registrars Group in England, analogous to our residents, has stated that more than 95 percent of their members were not happy to go to a shorter training program. So, there are both supply issues and curriculum issues as urologic training programs take on the new sciences and
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new operative techniques. In addition, a factor not to be dismissed in the continuing supply of manpower is medical students. Medical students are a vital link in recruitment to understaffed specialties. A recent investigative report showed alarming trends in exposure to urology for medical students.25 The major finding was that training program directors felt that urology was not being taught in the medical schools. In the last five decades there has been a decline in medical student exposure to urology. There were required rotations in urology in almost all of the medical schools in the United States in the mid-1950s; by the late 1970s these rotations were optional, and only 40 percent of medical schools required urology rotation. Although 97 percent of the medical schools offered some urology rotation during the clinical years, now only 20 percent require it. Loughlin, in a survey of 118 residency program directors, found that in almost one-third of medical schools no urology lectures were given in the preclinical years. Additionally, 50 percent of schools lacked lectures in the physical diagnosis course, and twothirds of program directors stated that it was possible for a student to graduate without any clinical exposure to urology.26 The author of this report was particularly concerned with the management of urinary tract infections and urinary incontinence in women and men, let alone the management of benign hypertrophy of the prostate gland and its consequences, and the management of cancer of that gland.27 In summary, based upon current supply, anticipated future supply of urologists , and population growth, particularly in the aged, a significant shortage of urologists is predicted.
13 The Last Hurdle: The Balanced Budget Act of 1997 and Graduate Medical Education Funding THE BALANCED BUDGET ACT OF 1997 AND GRADUATE MEDICAL EDUCATION FUNDING Graduate medical education (GME) or residency training after medical school in a program approved by the American Council of Graduate Medical Education, the ACGME, or AOA (American Osteopathic Association) is necessary for licensure to practice medicine in the United States. The term “resident” implies that a physician has completed his or her medical school and is practicing medicine under supervision while learning a specialty. Even though the term “intern” is used in the media and refers to graduates in their first year of training postmedical school, first-year trainees are now referred to as postgraduate year one residents (PGY-1). Fellows are usually trainees pursuing subspecialization following residency training but are also included under GME (Figure 13.1). For example, a fellow in gastroenterology is in his or her first year of specialty training after three years of internal medicine residency and is a PGY-4 resident.
THE EARLY HISTORY OF GME From its inception in 1965, Medicare has served as the major source of GME funding. Other sources of revenue for funding medical education include Medicaid in some states, patient care revenues from commercial payers, the Veterans Administration, and nonprofit foundations. Disproportionate Share Payments (DSP) also compensate teaching hospitals for serving lowincome patients outside the GME funding mechanism. Prior to 1984, Medicare simply paid expenses allocated to medical training programs under an open ended, cost based, retrospective reimbursement system. In an oversimplification, if Medicare utilization of a hospital was 35 percent, the GME reimbursement was 35 percent of GME costs of the hospital. In 1986, the Consolidated Omnibus Budget Reconciliation Act (COBRA)
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Figure 13.1 Traditional Pathway for Residency Training Medical School: MD or DO Degree (Four Years) PGY1 or Internship
“Match” Through National Residency Matching Program
Licensure Examination PGY2 PGY3 PGY4 PGY5 PGY6 PGY7
Practice of Family Practice, General Medicine, General Pediatrics Fellowships in Subspecialties Gastroenterology, Cardiology, etc. Practice OB/GYN General Surgery Orthopedics Cardiac Surgery Neurosurgery Vascular Surgery Plastic Surgery
Fellowships in Subspecialties Infertility, etc. Extra Training in Subspecialties Laparoscopy, etc.
further modified GME reimbursement from a system of pass throughs to a “per- resident amount” (PRA) for reimbursing GME costs. COBRA left the decision relevant to GME funding policies to Congress rather than the Health Care Financing Administration (HCFA). Under COBRA, the measurement of full-time equivalents (FTE) of residency positions was determined by the initial residency period (IRP), the shortest amount of time required for a trainee to become board certified. For instance, internal medicine was allotted three years and general surgery was allotted five years. The training program was only allowed funding for the specified IRP, with complicated formulas for residents who changed their minds about their final specialty or decided to obtain two certificates. HCFA (later to be called Health & Human Services or HHS) set up the Intern & Resident Information System (IRIS) to monitor the accuracy of the trainees’ information, since reimbursement was based on exactly how they were counted. Congress also established the Council On Graduate Medical Education (COGME) as the official advisor to Health & Human Services.
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Medicare was subsidizing GME programs by $7 billion a year for physician and nurse training. The main focus of revamping GME funding was to encourage market forces to curb costs, encourage private sector support of GME, standardize payment for training, encourage primary care growth, and promote training in ambulatory care. Pre Balanced Budget Act (BBA) of 1997 The prospective payment system instituted in 1983 allowed payments to hospitals for each discharge. Teaching hospitals were also reimbursed for additional costs incurred teaching and training residents. GME was subsidized by two mechanisms. Direct Medical Education (DME) Reimbursement. DME costs were for Medicare’s share of direct expenses associated with resident and intern training, such as salaries and benefits of residents and teaching faculty, GME administrative office costs, laboratory, and teaching space costs. In addition to Medicare, other payers included the Department of Veterans Affairs, the Department of Defense, appropriations from state and local governments, faculty practice plans, and charitable organizations.1 The baseline PRA for each hospital was based on 1984 levels and updated each year depending on changes in the consumer price index (CPI). Medicare DME payments were calculated by multiplying the PRA (per-resident amount) by the weighted number of full-time equivalent (FTE) residents working in all areas of the hospital (and nonhospital sites, when applicable), and the Medicare share of total inpatient days for each hospital.2 The formula used was (number of Medicare inpatient days) × (number of FTE residents) × PRA (total inpatient days). As an example, let us assume that there were 200 resident FTEs in the 1984 base year and 230 in the current year. Let us also assume that hospital audited costs were $12 million in 1984. The hospital PRA would be calculated as $12,000,000/200 FTEs = $60,000 PRA. Then using the CPI, the base year PRA would be updated to the current year. Let us assume that the adjusted PRA amount after CPI adjustment was $85,000. To determine the aggregate DME payment, the PRA would be multiplied by the number of resident FTEs. If total Medicare inpatient days were 45,000 out of a total of 150,000, the Medicare share would have been 30 percent. The aggregate DME amount is multiplied by 30 percent to give the final DME payment. Hospital DME payment = $85,000 × 230 × .30 = $5,865,000 It is important to understand the financial consequences for a teaching hospital related to the initial residency period referred to earlier. For example, a general surgery resident is counted as one FTE for the five-year period of general surgery training for purposes of DME reimbursement under Medicare. Any training after this period may only be counted as 0.5 FTE. There are a few programs, such as preventive medicine and geriatrics, that have been
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excluded from this limitation. However, this limitation only applies to reimbursement under DME, not to Indirect Medical Education (IME) adjustment payments. In other words, if a surgery resident pursues a two year vascular or plastic surgery fellowship (PGY-6 and 7), the position is one FTE for purposes of IME adjustment. It is also relevant to note that payment for IME adjustments are generally larger than DME payments, so the impact of additional trainees for most hospitals may be limited depending on circumstances, such as number of inpatient Medicare days or PRAs. Indirect Medical Education (IME) reimbursement. The IME is intended to reimburse teaching hospitals for higher costs incurred because of extra testing, new technology, indigent care, research, and higher costs due to expenses associated with teaching residents. The basis for this reimbursement is the correlation between the hospital’s intern and resident-to-bed ratio and hospital costs. The higher the ratio, the greater the hospital’s costs. The IME payment was established in 1982 by The Tax Equity and Fiscal Responsibility Act (TEFRA). It was initially estimated that “Medicare inpatient operating cost per case increased approximately 5.79 percent with each 10 percent increase in the number of residents per hospital bed.”3 Soon after TEFRA was introduced, because of projections showing serious financial consequences for hospitals, the adjustment was increased to 11.59 percent for each 10 percent increase in the resident-to-bed ratio. This was later reduced to 8.1 percent in 1986 and to 7.7 percent prior to the BBA of 1997. The IME is paid by Medicare as a percentage add-on to the amount Medicare pays the hospital for each beneficiary under the PPS (prospective payment system). Again, the amount paid is proportional to the ratio of interns and residents to the number of hospital beds. Because IME payments are only approximate for actual costs, there is a wide variation among payments, with some hospitals receiving Medicare mark-ups in excess of 40 percent, although the median mark-up is less than eight percent.4 For calculating IME payment the formula used is: IME = C × [ (1 + r) .405—1] where r is the residents-to-bed ratio and C is a multiplier set by Congress. Medicare payments under both DME and IME in 1997 were $6.8 billion, with IME constituting two-thirds of the payments. In fiscal year 2006, it is estimated by the Congressional Budget Office that IME payments amounting to $5.6 billion were paid out to 1,100 teaching hospitals.5 In 2007, the Congressional Budget Office estimated that IME expenses were $5.7 billion and DME costs were $2.8 billion, with DSP totaling another $9.4 billion.6 Some hospitals, such as psychiatric, children’s or cancer hospitals, are paid on a cost basis and excluded from IME adjustment payments. Academic Medical Centers (AMC) derive enough of their revenues from Medicare’s GME funding that any small decrease has a significant impact on their bottom lines. Thirty percent of total revenues of AMC hospitals were a result of Medicare funds, and DME/IME represented about 10 percent of that amount.7
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The Coming Shortage of Surgeons
Because of the large amount of funds paid to teaching hospitals, and with no end in sight for yearly positive adjustments and decent hospital margins, Congress began to look at this program for some savings. The Balanced Budget Act (BBA) of 1997. For the most part, reforms enacted by the Balanced Budget Act of 1997 were intended to curb Medicare expenditures rather than truly base Medicare GME policy on workforce requirements for the next few decades. The BBA included changes that drastically altered GME funding to reduce the growth and number of intern/resident training positions while attempting to maintain primary care positions. Congress had several reasons for reducing funding for medical education. Congress wanted to reduce hospitals’ incentives for profiting by adding more residents at a time when health care experts were expressing the opinion that there was an adequate supply of physicians, particularly specialists.8 Basically, the legislation halted the open-ended financial support of GME. The intent was to force teaching hospitals to deal with the true costs of the residency programs. It set the December 31, 1997, cost reporting period to cap the number of FTE trainees to calculate DME and IME payments. After this date, a three year rolling average was to be used. Essentially, the number of residents that could be claimed by hospitals for reimbursement was fixed as of that date. The BBA also split payments to hospitals for patient care and medical education into separate pots. Subsidies to teaching hospitals were reduced by 5.6 billion dollars for IME over five years (1998–2002). In addition, disproportionate share and IME adjustments for outlier cases of $2.2 billion were also decreased over five years. As mentioned previously, an adjustment of 7.7 percent for each 10 percentage point increase in the intern/resident-tobed ratio was made. This was now decreased every year from 7.7 percent to 7% in fiscal year 1998, 6.5 percent in fiscal year 1999, 6 percent in fiscal year 2000, and to 5.5 percent by 2001, for a cumulative payment reduction of 28.5 percent (Table 13.1). There were some positive aspects of the BBA for GME. The BBA changed the funding of GME as related to managed care plans. Instead of paying the managed care companies for the care of Medicare managed care enrollees, Medicare would now pay teaching hospitals directly. This significant change in GME funding of $4 billion over four years somewhat offset the large BBA cuts. Another positive step was to allow teaching hospitals to include residents rotating off-site in calculating IME reimbursement in order to allow ambulatory experiences in primary care training. A new outpatient prospective payment system (OPPS) similar to the Diagnosis Related Group (DRG) was instituted for out patient care based on a mix of cost and charge payments. Hospitals were encouraged to reduce their residency training programs by 20–25 percent in general except for primary care residents. To encourage primary care programs, the BBA also expanded the type of facilities that could receive funds to include rural health clinics and community health centers, Medicare managed care plans, and others.
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Table 13.1 Changes in the Add-on Percentage of Indirect Medical Education Adjustment as Set by BBA-1997, BBRA-1999, and MPDIMA-2003, 1997 to 2008
Balance Budget Act Balance Budget Refinement Act
Medicare, Prescription Drug Improvement, and Modernization Act
Period
IME%
IME Multiplier
FY 1997
7.50%
1.83
FY 1998
7.00%
1.71
FY 1999
6.50%
1.59
2000
6.50%
1.59
FY 2002
5.50%
1.35
FY 2003
5.50%
1.35
Jan-Mar 2004
5.50%
1.34
Mar-Sept 2004
6.00%
1.47
FFY 2005
5.80%
1.42
FFY 2006
5.55%
1.37
FFY 2007
5.35%
1.32
FFY 2008 & beyond
5.50%
1.35
Source: Otero, H. J., Parra, S. O., Erturk, S. M., Ros, P. R., adapted from “Financing Radiology Graduate Medical Education: Today’s Challenges,” ( J Am Coll Radio: 2006), 3: 207–212.
Post BBA The period following BBA was followed by several legislative victories as a result of intense lobbying efforts by academic medical centers. As can be expected, there was a loud chorus of protest from academic institutions that led to some relief in the form of the passage of the Medicare, Medicaid and SCHIP Balanced Budget Refinement Act of 1999 (BBARA). The BBARA delayed the schedule for reducing the IME and DSP payments, maintained the IME factor at 6.5 percent, and postponed the 5.5 percent goal until 2002. In addition to this, changes were made that somewhat softened the OPPS and physician payment methodologies. The Medicare, Medicaid, and SCHIP Benefits Improvement and Protection Act of 2000 (BIPA) passed in December 2000 and further increased Medicare outlays by approximately $36 billion over five years. BIPA again froze IME payments at 6.5 percent in fiscal years 2001 and 2002 before reducing them to 5.5 percent in fiscal year 2003 and thereafter allowing teaching hospitals another $700 million over five years. In addition, BIPA increased the inflation update adjustment to Medicare reimbursements for inpatient services
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The Coming Shortage of Surgeons
and eliminated Medicaid DSP payment reductions. The DSP allotment provisions alone translated to $1.25 billion in increased reimbursement for GME over five years in payments to hospitals from Medicaid. The Medicare Prescription Drug, Improvement, and Modernization Act (MMA) of 2003 included a program to redistribute Medicare resident caps between hospitals with below-cap resident counts and hospitals seeking to expand their caps. This basically allowed for a trading system of resident counts. MMA changed resident numbers and the process by which the slots could be increased. The legislation also increased IME adjustment to 6 percent in April 2004 and scheduled for it to decrease to 5.5 percent in fiscal year 2008. These changes cumulatively increased payments for teaching hospitals by about $400 million over five years. The changes outlined above have forced teaching hospitals to come to depend on clinical income as their chief source of revenue. This has had far reaching consequences related to town and gown competition, a re-evaluation of the previous emphasis on research and teaching as the pillars of academia, and the types of faculty recruited for academic medical centers. Time for teaching, research, and the weighting given to academic publications, for example, has fallen victim to relative value units and clinical productivity. In a study of radiology residency training, one-on-one teaching was estimated to reduce productivity (examination volume, RVUs, and dollars billed) by almost 50 percent.9 Teaching hospitals typically take on a large number of uninsured patients and use the clinical experiences offered by these patients for teaching purposes. If productivity suffers as a result of the time that is expended by faculty for teaching instead of producing work units, it follows that someone has to subsidize these nonrevenue producing but necessary activities. In total, it is estimated that Medicare contributes $7.5 billion (DME & IME), Medicaid from several states $3 billion, and the Veterans Administration $1.1 billion for a sum of $11.6 billion in total governmental support for teaching hospitals annually.10 Several experts have proposed all-payer funding of GME without much success.11 The proposed plan includes a per capita assessment on health plan enrollees in addition to contributions from Medicare and other federal payers. However, payers have argued that they are already subsidizing GME through higher payments that are made as a result of inflated charges by hospitals due to decreasing margins from Medicare and Medicaid. In a broader context, the PEW Commission has suggested a public-private partnership and identified seven major issues that have to be addressed:12 1. Lack of a mechanism to ensure that private beneficiaries contribute to subsidization of GME 2. Insufficient incentives to permit market forces to regulate the training of physicians, particularly international medical graduates (IMGs) 3. Illogical variation in reimbursement for direct medical education (DME) expenses
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4. Insufficient incentives for training physicians in generalist disciplines (family practice, general internal medicine, and general pediatrics) 5. Insufficient incentives for training residents in nonhospital settings 6. Lack of incentives for cost control and sound cost accounting and 7. Inadequate support for advanced clinical education of advanced practice nurses (APNs) and physician assistants (PAs)
Beyond just the financial implications for teaching hospitals, the BBA attempted to slow the growth of the physician workforce by freezing the FTE resident cap at 1996 levels and creating incentives to reduce resident positions. The effect of the BBA on the number of residents trained in the United States has recently been reported. Immediately after passage of the BBA, the number of physicians trained in GME programs declined. However, after 2002 the number of trainees gradually increased. New entrants into the system have increased over the past decade by 7.6 percent due primarily to IMGs.13 As Salsberg et al have pointed out, even though the growth in residents was 8 percent between 1997–2007, the U.S. population increased 12.6 percent during the same period. This resulted in a net decrease in the ratio of resident physicians from 36.7/100,000 to 35.1/100,000 population in 2007.14 In the face of projected physician shortages, how does the big ship (of physicians training) get turned around 180 degrees?
GRADUATE MEDICAL EDUCATION FUNDING There were about 105,000 residency positions listed in ACGME approved programs in 2007.15 Richard Cooper has suggested that Congress should increase the residency slots in graduate medical education by 1,000 a year for 10 years.16 We accept his recommendations and therefore by 2020 we will increase the available residency posts to 115,000 in each training year. If we assume salaries at $50,000 per year between 2011 and 2030, we will have to spend almost $113 billion just for residents’ salaries (Table 13.2).17 If we include benefits at 30 percent, that figure increases by almost $34 billion. The total figure for resident salaries and benefits at $65,000 per year (not adjusted for inflation and with no other direct medical education costs) for the 20 year period 2011 to 2030 would be almost $150 billion. The additional funding required would be about $10 billion for the 20-year period, or 500 million dollars per year. In Table 13.3, we list each of the specialties under discussion, the years of training, and the board certifications for obstetrics and gynecology, otolaryngology, orthopedic surgery, general surgery, neurosurgery, and thoracic surgery. If certifications in the surgical specialties remain constant over the next 20 years, we will train between 100 surgeons a year in thoracic surgery and 1,200 in OB/GYN. The cost for training these individuals is about $1.1 billion for each class with a total of about $22 billion for the cost of training from 2011 to 2030 (Table 13.3).
Table 13.2 Graduate Medical Education Costs for Training Residents Salaries at $50,000
Benefits at 30%
Total
Additional Funding Required
Year
Residents Positions
2010
105,000
2011
106,000
$5,300,000,000
$1,590,000,000
$6,890,000,000
$65,000,000
2012
107,000
$5,350,000,000
$1,605,000,000
$6,955,000,000
$130,000,000
2013
108,000
$5,400,000,000
$1,620,000,000
$7,020,000,000
$195,000,000
2014
109,000
$5,450,000,000
$1,635,000,000
$7,085,000,000
$260,000,000
2015
110,000
$5,500,000,000
$1,650,000,000
$7,150,000,000
$325,000,000
2016
111,000
$5,550,000,000
$1,665,000,000
$7,215,000,000
$390,000,000
2017
112,000
$5,600,000,000
$1,680,000,000
$7,280,000,000
$455,000,000
2018
113,000
$5,650,000,000
$1,695,000,000
$7,345,000,000
$520,000,000
2019
114,000
$5,700,000,000
$1,710,000,000
$7,410,000,000
$585,000,000
2020
115,000
$5,750,000,000
$1,725,000,000
$7,475,000,000
$650,000,000
2021
115,000
$5,750,000,000
$1,725,000,000
$7,475,000,000
$650,000,000 (Continued )
Salaries at $50,000
Benefits at 30%
Total
Additional Funding Required
115,000
$5,750,000,000
$1,725,000,000
$7,475,000,000
$650,000,000
2023
115,000
$5,750,000,000
$1,725,000,000
$7,475,000,000
$650,000,000
2024
115,000
$5,750,000,000
$1,725,000,000
$7,475,000,000
$650,000,000
2025
115,000
$5,750,000,000
$1,725,000,000
$7,475,000,000
$650,000,000
2026
115,000
$5,750,000,000
$1,725,000,000
$7,475,000,000
$650,000,000
2027
115,000
$5,750,000,000
$1,725,000,000
$7,475,000,000
$650,000,000
2028
115,000
$5,750,000,000
$1,725,000,000
$7,475,000,000
$650,000,000
2029
115,000
$5,750,000,000
$1,725,000,000
$7,475,000,000
$650,000,000
2030
115,000
$5,750,000,000
$1,725,000,000
$7,475,000,000
$650,000,000
Totals
2011 to 2030
$112,750,000,000
$33,825,000,000
$146,575,000,000
$10,075,000,000
Year
Residents Positions
2022
Note: All estimates are in nominal dollars unadjusted for inflation.
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The Coming Shortage of Surgeons
Table 13.3 Present Costs for Surgical Residents
Specialty
Number Certifi- of Trainee Cost of Training Per Class Years in cations Per Years Per Class at $65,000 Residency Year
OB/GYN
4
1,200
4,800
ENT
5
300
ORTHO
5
650
GENERAL
5
UROLOGY
Cost of Training 2011 to 2030
$312,000,000
$6,240,000,000
1,500
$97,500,000
$1,950,000,000
3,250
$211,250,000
$4,225,000,000
1,000
5,000
$325,000,000
$6,500,000,000
5
260
1,300
$84,500,000
$1,690,000,000
NEURO
6
125
750
$48,750,000
$975,000,000
THORACIC
7
100
200
$13,000,000
$260,000,000
3,635
16,800
TOTAL
$1,092,000,000 $21,840,000,000
A formidable task lies before us. Our problem is that we will have a shortage of surgeons. The most severe shortage will occur in obstetrics and gynecology, at almost 14,000. In Table 13.4, we review the seven specialties, the years to train specialists, the present number of certifications per year, and the total number trained if we maintain the certifications at the present level. We note the shortage of surgeons as a result of our calculations in the previous chapters. If we assume 30 years from board certification to retirement, the shortage for all specialties totals more than 29,000 doctors. We total the number of surgical specialists to be trained between 2011 to 2030, including the shortage in each of the specialties and then divide that by 20 to obtain the number per class in column 7. We calculate the trainee years per class by multiplying the years to train in column 2 by number per class. We then calculate per class cost assuming $50,000 income and 30 percent benefits for a total of $65,000 per trainee per year. In the last column, we calculate the training cost for each specialty to get the appropriate costs of the surgeons to be trained by 2030 to take care of the needs of our population. At the date of publication of this book, there are about 100,000 surgeons, or fewer, practicing in the United States. In essence, we have to train an entire new surgical workforce (101,838) to manage our increasing population. The total annual cost for this will be $1.6 billion (column 9), amounting to more than $31 billion by 2030 (column 10). The greatest costs will be in OB/GYN, orthopedic surgery, and general surgery. The cost of training the surgeons we need is slightly less than 500 million dollars per year. This is a formidable task.
Table 13.4 Specialists, Shortages, and Cost of Training Total Trained 2011 to 2030 Shortage
Total to Be Trained 2011 to Number Per 2030 Class
Trainee Years Per Class
Per Class Cost at $65,000 Millions
Total Cost 2011 to 2030 Millions
Specialty
Years to Train
Certifications Per Year
OB/GYN
4
1,200
24,000
13,636
37,636
1,882
7,527
$489
$9,785
ENT
5
300
6,000
2,516
8,516
426
2,129
$138
$2,768
ORTHO
5
650
13,000
4,355
17,355
868
4,339
$282
$5,640
GENERAL
5
1,000
20,000
2,525
22,525
1,126
5,631
$366
$7,321
UROLOGY
5
260
5,200
3,884
9,084
454
2,271
$148
$2,952
NEURO
6
125
2,500
228
2,728
136
818
$53
$1,064
THORACIC
7
100
2,000
1,994
3,994
200
1,398
$91
$1,817
3,635
72,700
29,138
101,838
5,092
23,115
$1,567
$31,348
TOTAL
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The Coming Shortage of Surgeons
In this chapter we have traced the history of graduate medical education and the role of the government as the major payer. Funding for GME was altered significantly with passage of the BBA of 1997. Besides other changes, the major impact of this legislation was a cap on funding the number of residency positions regardless of population changes. We have illustrated, as an example, the nominal costs associated with an increase in 1000 residency positions annually. We believe there will be a profound shortage in surgical specialties in future years. It is entirely relevant to run “what if” simulation scenarios related to the cost of funding a number of residency positions depending on the severity of the impending shortage. To provide education for our future surgical workforce, without any question, we have to revise the Balanced Budget Act of 1997. Otherwise, we will have to ration surgical services!
14 Is There a Solution? Numerical Projections, and Improving Physicians’ Productivity
While there is no magic bullet to improve the impending shortage in the immediate future, there are multiple factors that have to be considered in coming up with a comprehensive solution. It has become clear to all stakeholders that the shortage of physicians is real. In a survey of 400 hospital CEOs, 82 percent agreed that the United States has too few physicians, and greater than 66 percent agreed that the physician shortage is a serious problem (Figure 14.1).1 This has directly impacted hospitals’ and physician groups’ ability to recruit new physicians. In a Health Care Advisory Board survey of almost 400 hospital administrators, 49 percent indicated that recruiting new physicians was “extremely challenging” and 55 percent felt that it had become more difficult in the last two years.2 Let us return to the subject of the whole physician workforce including surgeons. It is clear from our discussion in the chapters on supply and demand that a shortage of physicians, including surgical specialists, is on the horizon. Both sides of the supply and demand equation, much like the energy crisis in our nation, have to be addressed in a comprehensive and thoughtful fashion taking into account budgetary implications. We will now attempt to analyze the possible solutions being considered to forestall the impending shortage.
PRODUCE MORE DOCTORS This story entitled “University of Maine’s President Wants the School to Offer a Medical Degree” appeared in the Portland, Maine Press Herald in late September, 2005. It was a pointed effort at keeping Maine students in Maine to practice medicine. The University of Maine’s President was told by Robert Edwards, former Bowdoin College president and member of the University of
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The Coming Shortage of Surgeons
Figure 14.1 Shortages “The U.S. Has Too Few Physicians”
“Physician Shortage Is a Serious Problem”
400 Hospital CEOs
400 Hospital CEOs
82% Agree
>66% Agree
Source: Advisory Board, “Physician Recruitment: Attracting Talent in a Competitive Market,” (Washington, DC: The Advisory Board Company, May 1, 2008), http://www.advisory.com/mem bers/default.asp?contentID=77362&collectionID=1720&program=7&filename=77362.xml (accessed May 27, 2008). © 2006 The Advisory Board Company. All rights reserved. Reprinted with permission.
Maine’s Board of Visitors, that “they will face several challenges including trying to raise money to offset declining state support.”3 A similar headline in the Orlando Business Journal, November 16, 2005, read “University of Central Florida Makes Pitch for Medical School.” After years of planning, talking, and fundraising, the University of Central Florida President, John Hitt, made the case for a new medical school in Orlando.4 There are currently 126 medical schools in the United States, to reach 130 by late 2009. The average first year enrollment is about 130. Shortly after the American Association of Medical Colleges (AAMC) publicized its recommendations for more medical schools, plans were made for an additional 14 medical schools (Figure 14.2). In March 2008, three new schools opened their doors. Texas Tech University’s Paul L. Foster School of Medicine at El Paso (El Paso, Texas), Florida International University College of Medicine (Miami, Florida), and University of Central Florida College of Medicine (Orlando, Florida) were accredited by the Liaison Committee on Medical Education (LCME).5 Class Size Jordan J. Cohen, M.D., the President of AAMC, said in February 2005 that AAMC supports a 15 percent increase in medical school enrollments because of a projected shortage in the number of physicians needed to serve the nation’s growing population. Subsequently in November of 2005, Dr. Cohen revised his estimate to a 30 percent increase translating to roughly 5,000
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Figure 14.2 Medical School Enrollments and Forecasted Medical School Additions by State, 2006
Washington
University of Washington (Spokane) Oregon
Montana
Maine
North Dakota
Michigan
Minnesota
Idaho
Nebraska
New Hampshire
Beaumont Hospital & Wisconsin Oakland University (Auburn Hills)
South Dakota Wyoming
Nevada
Vermont
Mass.
Iowa Illinois
Utah
Indiana
Ohio
Colorado
California
Missouri
Arizona State University & University of Arizona (Phoenix)
South Carolina
Arkansas
New Mexico
Georgia
Mississippi
University of Texas (El Paso)
Texas
Hawaii
University of North Carolina & Carolina Medical Center (Charlotte)
Mercer University (Savannah) Florida
University of Houston, Methodist Hospital, & Cornell University (Houston)
University of Central Florida (Orlando) Florida International University (Miami)
Alaska
Delaware Maryland
Alabama
Louisiana
Texas Tech University Health Sciences Center (El Paso)
New Jersey
Virginia Tech University & Carilion Health Systems (Roanoke) North Carolina
Kentucky Tennessee
Oklahoma
Arizona
Touro University (Florham Park) West Virginia Virginia
Kansas
University of California (Merced & Riverside)
Massachusettes
New York Pennsylvania Northeastern R.I.Rhode Island Education Development Conn. Consortium (Scranton) Connecticut Pennsylvania
Number of matriculants Over 1,000 800–899 600–699 400–499 300–399 200–299 100–199 0–99
Source: http://www.teachinghosp.org/pdf/pwchealthstaffingshortage.pdf (accessed August 5, 2008). Used with permission of PriceWaterhouseCoopers.
new positions. He cited two factors for revising his opinion. They were (1) the looming shortage of physicians, and (2) to reduce the unacceptably high number of U.S. students flocking to foreign medical schools.6 The entering class of 2005–6 cracked the 17,000 mark for the first time with a 2.1 percent increase over the previous year and marked the third consecutive year of an increase in applications for medical school. The 2007 class topped 17,800 students, a 2.3 percent increase over 2006. The 2007 class had the highest MCAT (Medical College Admission Test) scores and cumulative grade point averages on record.7 A large number of medicals schools (86%) have expanded their class size or intend to within five years.8 A recent AAMC survey suggests that first year student enrollment is expected to grow to 19,900 students by 2012, an increase of 3400 students or 21 percent. We have estimated the effect of increasing first-year medical enrollments by 30 percent to 22,000 positions in Table 14.1. Again, we are using our
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The Coming Shortage of Surgeons
Table 14.1 Increasing First Enrollment to 22,000 Places Doctors Needed
Grand Total of Practicing Doctors
Shortage
Shortage Percent
Year
Population
2010
309,000,000
883,740
775,000
108,740
12%
2020
336,000,000
960,960
795,000
165,960
17%
2030
364,000,000
1,041,040
815,000
226,040
22%
2040
392,000,000
1,121,120
835,000
286,120
26%
2050
420,000,000
1,201,200
880,000
321,200
27%
usual algorithm of 286 physicians per 100,000 population, a starting number of 800,000 doctors practicing in 2000, and 40 years from graduation from medical school to retirement. In other words, raising the initial medical class enrollment to 22,000 would result in almost 200,000 more doctors by 2050. However, this still leaves us with a shortage of more than 300,000 doctors. The barriers to expansion of medical school enrollments have to do with both financial investments and investments in our youth. New clinical sites, laboratory space, medical education buildings, support services, and additional faculty will all require additional resources.
REVERSE GRADUATE MEDICAL EDUCATION (GME) MORATORIUM We discussed in detail the history, mechanisms, and roadblocks to funding of GME in chapter 13. It is clear that some of the wounds related to the cap on the number of residency training positions are self-inflicted. Almost all major medical societies or organizations supported, indeed, actively pushed the federal government to limit funding due to the perceived future oversupply of physicians. The same organizations, including AAMC and the AMA, have now completely reversed course and called for elimination of the cap and an increase in entry level training positions. One wonders how policymakers will react to these organizations now asking for a 180 degree reversal. Some of the severe consequences of the BBA were blunted somewhat by subsequent legislative remedies sought by various academic medical organizations. However, the basic restriction or cap on funding of the number of residents is still in place. Our estimates in Table 13.2 for additional funding for 1000 additional physicians per year from 2011 to 2020 unadjusted for inflation would amount to roughly $10 billion over a 20-year period starting in 2011. Despite budget deficits and unfunded liabilities in the Social Security system, we believe this relatively modest investment would partially
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address the physician shortage. In return for accommodating the need to adjust the cap and increasing entry level positions, there are likely to be demands for much greater accountability.9 While Iglehart and others have used the momentum to change direction to produce more physicians and also to promote shifting even more dollars away from specialists to primary care, it is not clear that the American public will tolerate further shortages in surgical specialists.
TAKE ADVANTAGE OF RETIREES: PART-TIME WORK The percentage of part-time physicians increased from 13 percent in 2005 to 20 percent in 2007, shown in Figure 14.3.10 Another survey by the Advisory Board shows similar numbers, with more than a 50 percent increase in part-time physician staff over a one year period (2005–6).11 More than 80 percent of physicians who practice part time are at least 0.5 FTE, and expectedly the workforce in this category consists mostly of preretirement males and early career females. Interestingly, there is a higher turnover rate among part-time physicians of either gender as opposed to full time physicians. There are many reasons to consider utilizing those recently retired or considering retirement as a valuable resource in addressing a potential shortage Figure 14.3 Physicians Working Part Time, 2005–2006 12%
Senior and midlife physicians most interested in part-time work
8%
Over 50 percent increase in parttime staff over one-year period
8%
5%
2005
2006 Male
Female
Source: http://www.advisory.com/members/defauIt.asp?contentlD=73082&program=14&collec tionid=1021 (accessed August 6, 2008). © 2006 The Advisory Board Company. All rights reserved. Reprinted with permission.
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of specialists. When one sets out to appraise the capability of surgeons, there are four things that must considered. The first thing a surgeon must have is the physical capability to perform operations. Secondly, he or she must have the technical ability, and thirdly, a surgeon must have the ability to plan an operation. But the fourth consideration, and the most important, is the judgment to select the patients for whom the goals of an operation and the operation itself will be a complete success. For instance, it may not be wise to perform an open heart procedure on an 80-year-old patient who has Alzheimer’s disease or cancer. Even if the problem is technically fixable, an alternative approach might be to counsel the family against an aggressive approach due to a higher risk of death and limited life expectancy. Further discussions may involve a second opinion. Since every patient is different and each family has unique dynamics, it takes time to develop sound surgical judgment. The problem is that sometimes young surgeons view patients as surgical or technical problems that need to be solved. More mature surgeons views patients as people, and therefore take into account all relevant factors, including technical problems, and, in so doing, can act as counselors to patients’ families. With the large numbers of physicians retiring or planning to retire, part of the solution may lie in tapping what should be a fairly large pool of experienced physicians to work part-time hours on terms suitable to them. These physicians have wisdom and judgment accumulated over years of practice. Their experience is invaluable both to the patients and to young surgeons. While this solution may not be practical for some specialties because of continuity of care or the necessity of sharing call, for other specialties it may provide needed relief. The principle barrier to this course of action in many states is the malpractice premium ,particularly for part-time independent surgical practitioners. Until comprehensive tort reform is enacted, one way for hospitals to take advantage of the older doctors’ experience is to employ them under hospital malpractice programs. An Estimate Based on Raising the Retirement Age to 70 With increasing longevity, another option is to consider raising the retirement age to 70 barring health issues that may prevent the practice of a physician’s surgical specialty. Using the same algorithm as we used in Table 14.1 but with 45 years in practice instead of 40 years, we have estimated the additional workforce requirements and the effect on the shortage in Table 14.2. In this table, we have combined increasing initial medical school enrollments to 22,000 and lengthened the time of the average practice to 45 years. These would result in an additional 290,000 doctors from American medical schools in practice by 2050. The point of all these numbers is to show that some of the deficit could be met by “function shifting.” Function shifting is a business term for giving the
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Table 14.2 45 Years to Retirement for Doctors Doctors Needed
Grand Total of Practicing Doctors
Shortage
Shortage Percent
Year
Population
2010
309,000,000
883,740
797,220
86,520
10%
2020
336,000,000
960,960
839,440
121,520
13%
2030
364,000,000
1,041,040
881,660
159,380
15%
2040
392,000,000
1,121,120
923,880
197,240
18%
2050
420,000,000
1,201,200
970,000
231,200
19%
appropriate job to the appropriate person in any given business environment. It works very well in Toyota automobile manufacturing where every team member is trained in multiple skills. The opposite was true of the Big Three auto manufacturers in North America, where their contracts with the United Auto Workers (UAW) did not allow for job rotations—thus making them less flexible or adaptable to an ever-changing global marketplace.12 How could function shifting work to meet the deficit of doctors? We know that a combat corps-man or corps-woman in the U.S. military has vast clinical experience. We also know that there are nurse practitioners and physician assistants who are experts in providing health care. Think of the Minute Clinic in the Target stores or CVS pharmacies. We see this function shifting as one of the ways to meet the demands caused by the coming shortage of doctors. CASE STUDY OF HARRY SIDERYS Harry Siderys called one of the authors one afternoon in 2005. After we passed the time of day, I said, “Harry, what are you doing these days?” He said, “Well, I am working part time in my group. I go to the operating room two or three times a week to help the other partners, see some patients, and take care of the Society of Thoracic Surgeons’ database for our group in the hospitals.” I said, “Can you come and go as you please?” He said “Sure.” Harry Siderys is an accomplished cardiac surgeon who has been in surgical practice between 35 and 40 years. He was one of the first cardiothoracic surgeons to perform cardiac surgery in a private hospital—in the late 1960s. The practice is rewarding for him clinically. He draws a small salary. The thing that is amazing about Harry is that he is 79 years old, he lives in Indianapolis, Indiana, and he can practice because his malpractice premiums there are $8,000 per year. Contrast that to one of our groups in Columbus that at one time was paying $123,000 per surgeon. In Ohio, even if you have a limited practice, it is one-size-fits-all malpractice premiums for every surgeon.
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The Coming Shortage of Surgeons
CASE STUDY OF AL DAMSCHRODER: WINE OR VINEGAR Allen Damschroder, M.D., is a medical school classmate of one of the authors. Dr. Damschroder practices in Petoskey, Michigan. These are his words: It came as a complete surprise to me when, after 5 years of retirement following 30 years as an orthopedic surgeon, I was invited to return to part-time practice with a very active orthopedic group. What an opportunity this was. This group is well respected and consists of seven younger active orthopedic surgeons and two consultants or senior surgeons. One was the chief of a major orthopedic department at a major teaching institution in Michigan and the other senior was one of the founders of the group. This mix of the new and the old may be part of the success of the group. Last year and again this year we have been selected as one of the top 5% of hospitals in the USA in the performance of total hip and knee arthroplasty. During those five years of retirement I had busied myself with travel, land preservation interests and outdoor activities. In spite of all these activities I still felt professionally unfulfilled. I did not miss the nights and weekends of a busy call schedule or the worries that are part and parcel of caring for sick patients. I did miss the personal contact and the immense satisfaction that comes from challenging surgeries skillfully accomplished. I was invited to return as a physician surgical assistant to help with joint replacement and technically demanding cases. I had kept in place my license and CME requirements, but my professional corporation and credentialing had to start from scratch. All of the hurdles were cleared, including malpractice insurance (which was partially covered by the group). About 1 year ago I re-entered the surgical suite. It has been an exhilarating experience! The interface with younger surgeons has been an exceptional opportunity for me. I hope that it has been worthwhile for them, also, and that in the final analysis patients and Medicine have benefited. I have compared my medical career to the process of winemaking. First is all of the preparation including planting, pruning, harvesting, pressing, barreling, mixing and bottling. I compare the early product to Nuevo Beaujolais (French), refreshing and new but lacking in complexity. Next in viniculture comes aging with a gradual improvement in quality as with QBA, Kabinet and finally Spatelese (German). For me there was one final step—late harvest! I see many professionals who never have this opportunity and become cynical and critical of their professions, especially of the younger people who are now practicing. Too bad, as that has not been my experience working with my new colleagues. I have chosen late harvest and not vinegar.
SHORTENING THE DURATION OF TRAINING The duration of residency programs has gone from four to five years to six or even eight years, delaying the entry of physicians into the workforce. The Advisory Board estimates that the number of graduates pursuing additional training increased from 27.2 percent in 1999 to 33.8 percent in 2005 (Figure 14.4).13
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Figure 14.4 GME Graduates Pursuing Additional Training 34%
33.8 32.1
29.6
27.2
26% 1999
2001
2003
2005
Source: http://www.advisory.com/members/defauIt.asp?contentlD=7308 2&program=14&collec tionid=1021 (accessed September 9, 2008). © 2006 The Advisory Board Company. All rights reserved. Reprinted with permission.
The reasons for this increase include an increasing database of knowledge, demand for subspecialization within specialties, cutting edge technology such as laparoscopic, robotic, and minimally invasive procedures, and the desire of graduates to become subspecialized and stand out in their own niches within the broader specialty. Academic programs also use graduates for their own research purposes by creating mandatory research years within residency programs or chief administrative resident positions to allow for junior faculty-type positions without the compensation that goes with regular faculty appointments. There has been a recent movement to shorten surgical training programs and enable those physicians who decide on their specialties early to spend more time in their chosen specialties instead of training in general surgery. For instance, the American Board of Plastic Surgery will now permit trainees with three years of general surgery training followed by at least two years in plastic surgery to appear for their board examinations. The traditional pathway of five years of general surgery followed by two years of plastic surgery is still available. Similarly, the thoracic surgery board now also allows an alternative pathway of a six-year integrated thoracic surgery residency, which saves trainees one year. As is the case with the 80-hour work week, we do not yet have solid evidence of any deleterious effects of shortened training programs.
IMPROVING PHYSICIANS’ PRODUCTIVITY Perhaps the most significant change in attitudes is reflected by the change in priorities of recent graduates looking for jobs. For those over the age of 41,
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The Coming Shortage of Surgeons
compensation and practice setting were among the top five factors when choosing a job, and spouse/family consideration ranked last.14 For those between ages 36 and 40 years, geographic location was first and spouse/family consideration was again last. But, for those younger than 35 years, geographic location and call schedule were the top two factors, while compensation and professional growth opportunity were last. In addition, the percentage of current Generation Y residents who are significantly concerned about available free time in a future practice has increased from 13 percent in 1999 to 63 percent (Figure 14.5). This generation has therefore changed the rules of the game somewhat. The new roles for physicians are partly the result of the demand for subspecialization and improvement in the quality of care, but acceptance has come because younger physicians see these new roles as a better fit with the lifestyle they have in mind. Many of these changes have a profound effect on productivity as well. We will now discuss these new roles and their impact on productivity.
Hospitalists The trend to training and employment of hospitalists started about a decade ago, when, because of declining reimbursement, primary care physicians significantly curtailed their inpatient load to focus on outpatient care. Initially
Figure 14.5 Residents “Significantly Concerned” about Availability of Free Time in Future Practice Setting
63%
Recent resident corps significantly more lifestyle-oriented
51%
13%
15%
1999
2001
2003
2005
Source: http://www-advisory.com/merribers/default-asp7contentlD=73082&coHectionlD=1021 &program=14&filename=73082.xml (accessed August 7, 2008). © 2006 The Advisory Board Company. All rights reserved. Reprinted with permission.
Is There a Solution?
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they handed off the care of their patients to other internists who had inpatient consultative practices. An increasing number of internists realized that outpatient evaluation and management services were being rewarded with better reimbursement, and this led to a demand for hospital-based primary care physicians. Current estimates of the need for 30,000 hospitalists by 2010 are due to fewer graduates choosing primary care.15 Hospitals have also started surgical hospitalist programs due to the delay in calling in general surgeons and overcrowding of emergency rooms during evening and weekend hours. The program at the University of California in San Francisco has reported that 85 percent of patients see a hospitalist surgeon within 45 minutes of arriving in the emergency room.16 Emergency Medical Services In the 1960s, every physician in every hospital was on call for emergencies in the hospitals’ emergency rooms. As we went into the 1970s, it became obvious that more effective emergency care could be delivered by emergency physicians. Now almost every hospital in the United States has a corps of emergency medical physicians who evaluate the patients presenting to their emergency room, admit them to the hospital, if necessary, treat them for other diseases in which they are experts, and call consultants to see them for emergency operations, broken bones, and so forth. This is an evolution of the practice of medicine in the last 35 years. In many respects it is more efficient for all physicians. Emergency physicians have regular hours and can therefore meet the needs for emergency care readily and efficiently. This system also allows for a predictable lifestyle and days off during the week to attend to personal and family issues. Again, lifestyle issues and productivity are both front and center. The Grant Trauma Service Robert Falcone, M.D., a surgeon, developed a trauma program at Grant Hospital, Columbus, Ohio, in the early 1980s. It was one of the first hospitals in which a group of surgeons were contracted as surgical hospitalists for trauma care. One surgeon would give 24 hours, one day in five, to emergency trauma surgery. Another surgeon would do the rounds on the trauma patients. The surgeons were accompanied on their rounds by an associated staff of RNs, which would today be called Nurse Practitioners, a social worker, and a pharmacist. It was an immensely successful effort that is still running as a very successful Level I trauma facility. The Grant Trauma Service admits 3600 patients per year. Dr. Falcone was appointed CEO of Grant Hospital and has retired from that post. Trauma care has also evolved because it promises better quality of care, highly specialized service, and, despite a very intensive call schedule, a certain predictability of fixed days off.
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The Coming Shortage of Surgeons
Electronic Intensive Care Units The scene is Riverside Methodist Hospital, Columbus, Ohio. Riverside is the flagship of the Ohio Health system. In the south office building there is a suite on the third floor that is similar to the suites of the other offices except that it has four computers; one of them is assigned to Melanie Kennedy, RN. On her computer there are five screens; one is for a patient’s history and allergies, the second is for the patient’s drugs, the third is for laboratory results, the fourth is for the vital signs, and the fifth is the monitor for a mini camera that is focused on the patient’s bed. Melanie and her physician colleagues run an electronic Intensive Care Unit, an e-ICU. The e-ICU rooms are outfitted with microphones and call buttons to link the patient and the nurse to the remote monitoring site. Each e-ICU room has a video camera that the intensivist nurse can use to zoom in on the patients Also available on the computer are the patient’s X-rays. Mary Jo McElroy, R.N., one of the nursing directors, and Bill Winnenberg, the Chief Information Officer of the system, show us around the room. The e-ICU staff is monitoring 12 beds from Doctor’s West Hospital and 34 beds from Riverside Methodist Hospital. Two years ago the Ohio Health Board committed $6 million to an electronic ICU. By the time this is published, the e-ICU unit will be monitoring almost 100 patients in five separate hospitals from Delaware, Ohio, 30 miles away from Columbus, to the downtown Grant Hospital. This is one way to improve the productivity of physicians.17 Again, it appeals to a lot of physicians because it is a highly specialized service and, in most ICUs, offers predictability based on a rotating call schedule. There is a nationwide shortage of intensivists, doctors who specialize in critical care medicine.18 By improving the efficiency of an ICU’s operation and turning it into an e-ICU, one intensive care nurse or doctor can serve multiple patients. The technology holds the potential to improve care and shorten ICU stays by catching complications and small changes in vital signs. The demand for intensive care for the aging population is one of the reasons for this. The original installation of an e-ICU was in the Sentara Healthcare in southeastern Virginia. According to Information Week, in May 2003, Cap Gemini, Ernst & Young, a consulting firm, completed a study in two of the Sentara Health e-ICUs in Norfolk, Virginia. The study showed a 25 percent drop in the mortality rate. There was also a 17 percent shorter stay in the units, allowing the units to treat 20 percent more patients. The study calculated a $3 million net gain for the 16 ICU beds. Visicu, Inc. is a company founded by two doctors from Johns Hopkins University who were seeking a way to better take care of patients in critical care units.19 In a sense, they combined intensive care provided by hospitalists with telemedicine. Many hospitals are using the Visicu system, including Sutter Health in Sacramento, California, the Tripler Army Medical Center in Texas, and Jewish Hospital in Louisville, Kentucky.
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In its 1999 report “To Err Is Human: Building a Safer Health System,” the National Academy of Sciences Institute of Medicine concluded that 44,000 to 98,000 patients died from medical errors each year. Many, if not most of those, are admitted to an intensive care unit before they die.20
NIGHTHAWK AND TELERADIOLOGY—EXPORTING AND IMPORTING Naiyer Imam is a graduate of Brown University and its medical school. He completed his training in radiology at the University of Southern Florida and Johns Hopkins. He developed a fascination with telemedicine and formed American Teleradiology, which later became Nighthawk Radiology Services, a corporation that does teleradiology all over the world.21 Where do you get your emergency room film read, particularly if you are in some places in rural America, where there are no radiologists in the communities? What would you do if you had access by teleradiology to 125 board certified American radiologists? With its team of U.S. board-certified, statelicensed, and hospital-privileged physicians, NightHawk services over 1,350 hospitals and medical groups in the United States 24 hours a day, seven days a week from centralized facilities located in the United States, Australia, and Switzerland. This is a case of exporting radiologic images—chest X-rays, CT scans, MRIs, and so forth—and importing their interpretations by the Nightshawk staff of American board certified radiologists. Medical Tourism—Outsourcing or Exporting our Patients This is the final chapter in increased physician efficiency—outsourcing our surgery. Medical tourism now represents a $2.1 billion business. Probably more than 6,000,000 Americans will go outside the country to get medical care, especially surgical care, by 2010, according to Medical Economics.22 More than 40 percent of Americans would consider traveling outside the country for surgical care because it is cheaper. Uninsured U.S. citizens represent the largest group of perspective medical tourists. The Joint Commission for Accreditation for Hospitals, the certifying agency for the United States, has already certified 250 hospitals in more than 30 countries. They think that figure will double by 2012. The American Medical Association unveiled its first set of medical tourism guidelines in 2008.23 Blue Cross and Blue Shield of South Carolina have already provided employers with a medical tourism package. According to the Wall Street Journal, in an article published September 30, 2008, some companies are paying their workers to go for surgery abroad. There is a company in Maine that gives its employees the option to fly to Singapore for hip or knee replacements while “pocketing an extra $10,000”; in essence, the company and the employee split the difference from the money
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The Coming Shortage of Surgeons
saved for not having such a procedure in the United States. That hip replacement costs $12,000 in Singapore.24 A heart bypass procedure can be done for less than $19,000 in Singapore, or for $10,000 to $12,000 in India or Thailand. It would cost $30,000 to $40,000 in the United States. Patients can get high quality care in these countries, and many of the doctors who conduct the surgeries are certified by the American Board of Surgery or other American boards, or have surgical certificates from the English health care system. One of the difficulties one sees with medical tourism, however, is getting appropriate postoperative follow-up in this country because of our fear of potential malpractice situations, especially with an untoward result. According to Wikipedia’s article on medical tourism, 750,000 Americans went abroad for health care in 2007.25 People go to Costa Rico, Singapore, Hong Kong, Thailand, and India. In the Union of South Africa, medical tourism is known as “medical safaris.” In Singapore there is a multi-agency government— industry partnership to facilitate medical tourism. Fortune Magazine published a special advertising segment on Thailand two years ago. One advertisement was from a Bangkok Heart Hospital. It mentioned a distinguished cardiovascular surgeon, Kit V. Arom, M.D., who had practiced in the United States but returned to his native Thailand to lead the hospital’s open heart surgery program, which attracts many medical tourists. There are eight other cardiac surgeons on his staff.26 Dr. Arom practiced in Minneapolis, Minnesota, and had a distinguished academic and clinical career. He founded the Minneapolis Heart Institute, one of the most prestigious groups in cardiac surgery in the nation. In a letter to the editor of the Wall Street Journal published Wednesday, August 27, 2008, Ronald M. Becker wrote, “Aggressive harassment from insurance companies, government agencies, hospital administrators, and ignorant nonmedical persons is doubtless a major factor in the early burnout and decline of cardiac surgery as a “hot” specialty; residency slots, coveted a generation ago, now go begging.” Less than 50 percent of these positions are filled by American graduates. Again, if the support systems and professional opportunities are better in Thailand, Singapore, or India, where will our surgeons go? Can we export our surgical cases to these countries?
OTHER RECOMMENDATIONS • While PA’s and NP’s production may somewhat make up for a lack of enough primary care physicians, there is no similar solution for all specialists. Specialization and subspecialization among future physicians will likely continue for the reasons stated earlier. Providing physicians with assistance in the form of physician assistants and nurse practitioners may, however, improve doctors’ productivity and decrease their stress level in busy practices. Some specialties, such as cardiac surgery and vascular surgery, are ideal for physician assistants, whereas specialties such as plastic surgery may not be well suited.
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• Reduce nonclinical duties of physicians: increase incentives and funding for electronic medical records. The Department of Health and Human Services (HHS) announced some rules in 2008 that addressed exceptions to Stark laws and safe harbors for anti-kickback laws. These Stark law regulations were the main hurdles that discouraged hospital assistance for physicians in electronic prescribing and electronic medical records.27 The number of hospitals extending information technology assistance to physicians has increased due primarily to some relaxation of regulatory restrictions. For example, in a recent survey 41 percent of hospitals already provided some assistance, and another 29 percent were considering plans to do so within two years (Figure 14.6).28 We still have a long way to go, however, because the adoption rate by office-based physicians is only 12 percent. It is worse for solo physicians (7%) because of the expense of implementing electronic medical records in a private practice. It remains to be seen how the stimulus plan of the current administration will actually improve efficiency. • Decrease regulatory burdens by making coding/documentation requirements easier. The complexity of coding and the byzantine rules for correctly billing for services is a major source of frustration and inefficiency for physicians. The Department of Justice, using fraud and abuse regulations, has aggressively gone after billing errors by physician offices. The vast majority of errors are clerical or unintentional due to the pressure of time, understaffing, and an inadequate understanding of the complicated rules governing coding. A recent study reported on five evaluation and management codes that represented 70 percent of the codes utilized by emergency physicians to bill for services.29 Five coding specialists reviewed the records and could agree in only 15 percent of cases. They disagreed completely in 6 percent. Furthermore, the disagreement in 29 percent of these was significant Figure 14.6 Hospitals Extending Information Technology Benefits to Physicians (survey of senior health executives)
NO 58.6%
YES 41.4%
50% plan to do so in next 24 months Source: Conn J.I.T. subsidies embraced. http://www.modernhealthcare.com/apps/pbcs. dll/article?AID=/20080225/REO/60045 8706/-l/toc25.02.08&nocache=l (accessed September 9, 2008).
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The Coming Shortage of Surgeons enough that prosecution may have been considered against the physicians! A public/private taskforce should be convened to vastly simplify the system so as to allow physicians more face-to-face time with patients instead of wasting it on deciphering an ever increasing number of diagnosis and procedure codes.
FOCUS ON RETENTION OF YOUNGER AND MIDDLE AGED PHYSICIANS With 35 percent of physicians currently over the age of 55, attention should focus on the middle aged and younger physicians. In the 55–65 age group, the percentage of physicians planning to retire in the next three years has more than doubled from 9 percent in 2004 to 20 percent in 2007 (Figure 14.7).30 The brunt of the work, will be performed by the middle aged and younger physicians when older physicians retire or begin working part-time hours. With the lifestyle choices they are making, is this group ready to assume the burden of patient care with all the stresses that accompany a specialty practice? Given the lifestyle preference of this group, it is highly likely that full-time Figure 14.7 Physicians Over 55 Years and Retirement Percentage of Physicians over the Age of 55
Percentage of Physicians Age 55 to 65 That Plan to Retire in Next 3 Years
35%
24% 20%
9%
1985
2006
2004
2007
Source: Health Care Advisory Board, Physician Recruitment: Attracting Talent in a Competitive Market (Washington, DC: The Advisory Board Company, May 1, 2008), http://www.advisory.com/ members/default.asp?contentID=77362&collectionID=1720&program=7&filename=77362. xml (accessed May 27, 2008). © 2006 The Advisory Board Company. All rights reserved. Reprinted with permission.
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employment by hospitals will suit their goals. Newer alternative practice structures, such as joint practice ownership or partnership with hospital systems, may be the trend of the future. Another tactic to increase retention in the older group of physicians is to offer sabbaticals in order to avoid burnout and provide intellectual stimulation. This may not be possible in small specialty groups or health systems. Mentoring programs to assist younger physicians to start on a positive note are an important part of any large health system that wants to encourage longevity in the physician workforce. For instance, a surgeon fresh out of training should have a senior surgeon available to assist on difficult or re-do cases or give curbside consultations freely to develop confidence. The first few months can be fairly traumatic for a young surgeon if a rash of unexpected complications occur and there is no one to counsel the young practitioner. In summary, there are no simple solutions, and simply cycling more medical students through the system without the infrastructure ready to receive them will fail. We have shared some of many possible solutions that seem to us to be within reach.
15 Challenges and Consequences
OUR LETTER TO ALL SURGICAL RESIDENTS For the rest of your career you will be in demand. There is an emerging shortage of surgeons that can only be dealt with by increasing the surgical workforce in the next 40 years. This will be difficult to do, and for that reason, you will be in demand. You will enjoy your practice and we wish you much success. The key to your practice will be the close patient relationships that you develop in your career. They are meaningful for both you and your patients, and for your patients’ families. Follow them for as long as they want to see you. As these relationships develop, you will see, they will confide in you more and more. That confidence is a sacred trust. You will be successful financially. Most of you will be in two-income families and will need a scheduled or a more controllable lifestyle. The employment model in the surgical world is becoming more and more attractive to surgical specialists, as well as hospitals and regional health care organizations. Hospitals cannot deliver patient care without specialists. Some of you may go into private practice, but others may not want the hassles of coding, the paperwork, and all the administrative frustrations that come with the territory. While insurance reimbursements for physician services may decrease, because you will be in demand and not supply, a salaried model of hospital employment will pay you a fair rate for your services. Their motive will be to minimize turnover in their surgical staffs. Remember, an operation cannot be performed without a surgeon. In your negotiations with your employer, think about these things: a fair salary, perhaps a signing bonus or a contract that involves assistance in paying off your medical school debt, and, certainly, payment of all of your malpractice premiums. You should also arrange for disability insurance and life insurance. Remember, the odds of your becoming disabled are far greater than the odds of your dying. Save for retirement. Make sure that your employer has a good
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retirement plan, but also save in your own name. Our advisors recommend that you save $5,000 a year for your children’s education, if you can. The hospital-physician relationship is evolving, perhaps into a clinic-based model such as those in the Mayo Clinic and the Cleveland Clinic, where the doctors have a significant say in running the business and the organization. This model makes for a closer and more efficient relationship between hospitals and the physicians who practice there and allows you to know the markets wherever you are practicing. As a result of this evolution, more and more of you will have administrative responsibilities later on in your careers. Certainly, both the Mayo and the Cleveland Clinics were originated by doctors, and both have had doctors for chief executive officers many times. The number of hospitals that have physician chief executive officers is on the rise.1 Above all, pass your boards. Once you are board certified, all of these opportunities lie before you. Good luck. Thomas E. Williams, M.D.; Ph.D. Bhagwan Satiani, M.D.; M.B.A E. Christopher Ellison, M.D. Future Doctors of America Chris Paul, who did research for this book, is attending medical school. Chris graduated from Middlebury College, was on the ski patrol at Alta, Utah, and has an Emergency Medical Technician certificate. He wants to be an orthopedic surgeon. The authors asked him to summarize his feelings after doing the research. Here is his letter:2 An ancient Chinese proverb states, “May you live in interesting times,” and for those of you in high school and college who are considering a career in medicine no one line could be more appropriate. Over the past 15 years the face of medicine has changed dramatically, and the one thing we know about change is that it never ceases. The practice of medicine today is significantly different from what it was when our grandparents practiced, and some might argue that it has not changed for the better. But for those of you holding onto the dream of becoming a physician, do not lose hope. Much of what we are seeing in medicine today is cyclic; meaning that bad times inevitably will give rise to better ones. But before we address how things will improve for physicians in the future it is imperative to identify what has gone haywire with medicine in its current state. Medicine today has undergone a fundamental change in that many of the systems that have been put into place over the course of recent history have changed the way medical care is being delivered and compensated for. For instance, as the cost of medical care has increased over the years, private insurance companies, which help to defer the expense of large medical bills by charging reasonable monthly amounts (premiums), have been forced to increase the size of premiums and scrutinize your medical bills more closely. The government also provides its own form of medical coverage for persons over the age of 65 in the
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form of Medicare. Medicare’s sister program, Medicaid, provides coverage for low-income individuals and families. This all seems reasonable so far, right? Well, not quite. Today there are some 78 million baby boomers in the United States. Just to remind you, the term “baby boomer” was affectionately given to those born between 1946 and 1964. This alone wouldn’t be a huge problem except that they are all reaching the age of 65+ around the same time. Now let’s also remember that statistically, persons aged 65 and over require almost 40 percent of all surgical services! You can see that problems begin to arise when these roughly 78 million people who require access to these medical services also need the government to help pay for it all. But how does this impact doctors today and in the future? Well, anticipating this problem the federal government passed the Balanced Budget Act of 1997, which in itself was a sweeping piece of legislation. However, a very important part of that bill stated that from 1996 onward the amount that the government would pay to physicians for services or procedures provided to patients who are covered through Medicare would systematically decrease over time. Just recently additional decreases in reimbursement rates have been approved through 2011. Okay, so essentially you’ll be receiving less money. Not a big deal if you’re not dealing with people on Medicare, which is why initially the Balanced Budget Act of 1997 didn’t raise such a backlash. However, as more people have moved and continue to move to Medicare, more doctors are finding that they are having to see greater numbers of patients to compensate financially for the reduced fees. This is resulting in longer waiting times for patients and less quality time between the patients and their physicians. As a result, some physicians have simply stopped seeing Medicare patients, while others have decided to retire early. Not an encouraging thought. Yet Medicare alone might not drive these physicians from practice altogether. In reality, a myriad of other factors have all worked to make the working environment less hospitable for today’s physicians. Here is what has happened. Medicare in the insurance world acts as the gold standard. You know, the basis for which all insurance companies adjust their rates of compensation. As Medicare reimbursements have dropped in recent years, other insurance companies have taken notice and have lowered their rates of reimbursement as well. Why should Blue Cross/Blue Shield® pay a physician $500.00 for a procedure that Medicare pays only $300.00 for? From an economic standpoint this makes total sense; however, it spells trouble for physicians. FROM BAD TO WORSE Okay, so physicians today don’t make as much as they used to; big deal. Well, actually it is. Especially, because some of these physicians, such as those in private practice, cannot afford to keep up with rising rates of malpractice premiums and practice costs. What do I mean by this? Just like anyone else physicians need insurance to protect themselves in the event that something should go wrong and a patient decides to file a lawsuit. The problem is that some of these lawsuits against physicians have awarded so much money to the patients and their lawyers (through contingency fees) that insurance companies, afraid of going bankrupt while paying out these settlements from these lawsuits, have dramatically increased the amount of the premiums for physicians. For example,
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in Columbus, Ohio, if you are a cardiothoracic surgeon (meaning you work on the heart, lungs, and all major vessels in the chest), you pay over $100,000 per year in malpractice insurance premiums. To many surgeons, especially those who are nearing the end of their practicing years and may wish to work on a part-time basis, the cost of remaining in practice is just too great. Many are discovering that they cannot afford the costs of practicing, even if they still find the practice of medicine rewarding, and so are forced to retire. The other piece of the puzzle here are the practice costs associated with running a private practice. But wait, don’t most doctors work at the hospital? Well, some do and others do not. If you’re a hospitalist you see patients in the hospital itself. However, if you have a clinic you may have an office and a practice in a building that is not associated with a specific hospital. The problem today is that practice expenses have been skyrocketing, particularly staffing expenses. Those physicians who work in private practice act as employers and thus are feeling the pinch of rising staffing expenses, lease agreements, and paper products—just like any other business. . . . AND THE HITS JUST KEEP ON COMING The result of all of these changes is a net loss of doctors from not just the back end of the workforce supply, but from the front end as well. What is meant by this? Well, a loss of doctors reflects older surgeons who are choosing to retire. The front-end losses are just as concerning, however, and refer to our generation of medical students. There are three principal reasons for this. First, today more than ever, problems concerning the medical profession’s ability to adequately meet workforce demands are the subject of much speculation. Much of this speculation revolves around the debate as to whether our medical schools should be/could be producing more medical students per year. At present, according to AMA medical school enrollment statistics, roughly 17,000 new doctors enter the workforce each year. This number has remained more or less constant over the past 25 years. Now, remembering that there are some 34,000 candidates applying to medical schools each year, this means that nearly onehalf of all U.S. applicants are required to seek their medical education elsewhere (i.e., outside the United States), reapply the following year, or pursue an alternate career. To most, this statistic may not seem alarming, but the reality is that it is quite disconcerting given the current state of the medical workforce amidst a growing and aging population. The good news, however, is that by acting now we can avert future shortages in specific specialties and the physician workforce in general. Second, in our time there has been a fundamental change in the priorities of our generation. Where in the past the mentality was to work and save what was earned, our generation has grown up in the wake of our historically affluent parents, the baby boomers. As a result, our priorities regarding work, family, and leisure have shifted as well. Many medical students today dream of practicing medicine, of course, but not at the tremendous cost to family and leisure life that has historically been indicative of life as a physician. This has created a shift away from those medical specialties that place large time demands on the physician such as thoracic surgery, orthopedic surgery, and obstetrics, and towards specialties with controllable lifestyles, like dermatology and radiology.
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Third, there is the word-of-mouth dilemma that has been plaguing many of these surgical specialties. Have you ever had a class, or maybe even a major, that you were unsure about so you looked to older students for advice? Well, the same thing happens with medical students. And believe it or not, these bad vibes often start with the surgeons. Surgeons, upset and perhaps disenchanted with the current reimbursement, malpractice situations, etc, etc, often talk to their colleagues and residents about the hardships in their specialties. The residents, in turn, often echo these sentiments to 3rd- and 4th- year medical students doing rotations with them. These students then decide that whatever specialty they are rotating through, let’s say its OB/GYN, is not for them. They then relay this same disenchanted theme to other students in turn. It is a brutal cycle that ultimately hurts those specialties as a whole, because a negative impression of the specialty is created before the students ever get a chance to see what the specialty is all about. So far in this book we have tried to accurately portray the current state of medicine and the challenges that face it. How will the numerous problems that have been addressed play out and affect both patient and physician populations? With regard to both patients and physicians, rest assured the climate under which medicine is practiced will be different. So how does this all play out in the future? Well, for one, if current conditions persist, we will continue to see greater numbers of physicians leaving the profession, opting instead for an early retirement. The loss of these experienced physicians will place even greater pressure on practicing physicians to pick up the slack in order to attend to a growing patient population. In addition, losses not only from the back-end but from the front-end of the surgical workforce, in the form of fewer medical students, will occur as well. (Ironically, we are not seeing this trend develop. As of January of 2009, with the U.S. economy tanking, many new college graduates, unable to secure a job, are applying to graduate schools in the hopes of making themselves more competitive in the future. As a result, medical school applications have risen, as have GPAs and MCAT scores, which are the basis of the medical school admission criteria.) As students begin to assert their desire for career satisfaction, the specialties that will be hardest hit will be the ones that cannot provide a controllable overall lifestyle. WHO WILL LOSE OUT? Mainly it will be you, the consumer of health care, who will in all likelihood suffer the most from these changes. You will lose out in the form of greater upfront fees and longer waiting periods to see a physician. You will lose out in the nature of your relationship with your physician; it may not be what it once was. He or she will be unable to spend time attending to your needs and concerns due to the amazing demands that will be placed on his or her time in the clinic or operating room. Physicians will also lose out in that they will lose not only income, but practice time. For some physicians, especially older ones, even part-time work towards the end of one’s career is valuable and challenging. It also gives these senior doctors a chance to pass on valuable knowledge to their successors. As you can see, these are some issues that need to be ironed out in the coming years. The solutions will be neither simple nor quick; in reality, a combination of measures will need to be enacted to right this ship. The good news is that if you’ve read this far then you’ve read the worst. In truth, medicine remains an
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incredibly rewarding and invaluable profession. The amount of good that you will be able to do on behalf of others will amaze you. There is no doubt that you will have to work very hard to achieve your dream of becoming a physician, but I believe that in the end, for all the flaws and imperfections that are associated with practicing physicians today, medicine it is still one of the greatest journeys you will ever undertake. I wish you all the best in your future endeavors. Very respectfully yours, Christopher M. Paul
Challenges In this book, we have pointed out a number of challenges that face us. These are all real challenges. They require a multi-pronged approach to a complicated issue during a time when the financial health of our country is not good. But, we have to invest in our youth, who are going to be taking care of our health. At the same time, there is maybe an even more pressing challenge, and that is to make the career of medicine or surgery appealing to all who wish to make a commitment to helping the sick. We must make the profession of medicine appeal to all high school graduates and college students. One example of promoting the profession to disadvantaged groups is close to home for us. At The Ohio State University there is a M.D. camp for those who come from a racial or ethnic identity, such as African American, Latino, and American Indian, that is underrepresented in medicine.3 This could be expanded to every race and ethnicity. The camp meets for three weeks in early summer. They meet from Monday to Friday, from 8:00 A.M. to 5:00 P.M. The cost is $650.00, and scholarships are based on need and academic merit. As you can see, this could be expanded and the necessary scholarships could be provided by local industry, local manufacturing companies, and local businesses. In some colleges, there are premed clubs for those students interested in the profession of medicine. We have to organize more of these clubs in order to meet the demands that we will face in 2050. Local medical societies should cooperate with high schools to assist them with ambassadors to speak or host students on career day. Physicians who are excited about their profession should be on the front line to display their passion for service to fellow citizens. We also have to make surgical disciplines more attractive to medical students, and particularly women. Part of the blame lies with current faculty and practicing physicians. All residents and medical students hear the constant whining about reimbursement, malpractice cost, endless paperwork, and a promise (threat) of early retirement. There is no question that we have challenges, but every generation of physicians has had their own hills to climb. No wonder our future physicians are apprehensive about their future. This negativity is then conveyed to parents of prospective students and others contemplating a career in medicine. Those of us who see the impending shortages
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have to educate the younger generation about the opportunity that exists for them among the many challenges. There are surgery interest clubs in many medical schools. Perhaps we should have more of them. We should introduce medical students to the concepts and ideas of surgery early on in their medical school careers. One of the authors (TEW) spent the summer of 1960 as a part-time scrub technician in the operating rooms of University Hospital in Columbus, Ohio. By the end of the summer he had determined that he would go into surgery. Another author (BS) encouraged his operating room scrub technician to apply for medical school and wrote a strong recommendation letter for the highly motivated individual. The same author has also provided part-time research jobs to prospective medical school applicants to assist them in building their resumes. People enter medicine for different reasons. There are generational differences, and we should take advantage of the motives of “generation Y” to encourage them to serve humanity. While some in the older generation had expectations of income and lifestyle that were consistent with better times, the current generation may have lower expectations in terms of income levels. In a recent survey by Kaplan Test Prep and Admissions of premed and pre-law students regarding their reasons for future careers, less than one-half were “very much” or “somewhat” influenced by earning potential as a reason for choosing medicine.4 The prime motivation of 461 students taking the MCAT was the desire to help others. In contrast, 71 percent of pre-law students gave money as the main reason for choosing law as a career. Is there a better contrast between the two professions? In a survey of women physicians 76 percent were either “very satisfied” or “satisfied” with their choice of medicine as a career.5 Only 11 percent were “dissatisfied” or “very dissatisfied” with their choice. The greater the number of hours worked, the higher the rate of dissatisfaction. Interestingly, those women with four children had the highest rate of satisfaction with work life balance. Two-thirds said they would pick medicine as a profession if they had to start all over again. This is encouraging news. Medical schools and residency programs must have mentorship programs for women and minorities of various ethnic backgrounds to aggressively encourage them to choose medicine as a profession that will satisfy their personal needs as well as provide them with opportunities to give back to their own communities. We also need many more role models among women and minorities to be available to their communities in order to attract future physicians. In addition to the challenges to make surgery or medicine a more desirable career for many people, there are other challenges as well. We have to do something with regard to scheduled lifestyles and off hours. While the definitive answer in terms of the safety of the 80-hour work week that is now mandated for residents is not in yet, there is little question that shorter hours fit in with this generation’s preference for a more relaxed lifestyle. There is now word that a 56-hour work week instead of the current 80-hour work week for residents is under discussion.6 As we have pointed out, one answer may be the
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intensivists and hospitalists in the hospitals for 24 hours in internal medicine, for surgical hospitalists, and perhaps similar in-house obstetricians as well. One thing educators can do to provide some comfort and decrease the apprehension of prospective physicians is to give them the tools to deal with the business side of medicine. The main reason for medical school residents second guessing the choice of medicine as a career (25%) is the business side of medicine. In an Epocrates future physician of America survey of 1000 medical students, only 12 percent were receiving a course in practice management and 78 percent said the course would be valuable.7 In 2003, when residents were asked about their degree of concern in this regard, 47 percent rate themselves “unprepared” for the business side of their medical career, and 51 percent say they felt “somewhat prepared.” Over half stated they had had no exposure to the business side of medicine in their training. In the same survey in 2006, the “unprepared” number dropped significantly from about 47 percent to only 15 percent. Only 30 percent of residents get any formal training in the business or practice management issues they will be deeply involved in when they graduate. Medical schools and residency training programs must restructure their programs and abandon the rut they are in to address the changes in medicine to train our physicians to deal with the future with confidence. At Ohio State, one of the authors (BS) has established an 18-month curriculum of Practice Management Seminars for senior surgical residents, which has mandatory attendance requirements. Topics covered include health care economics, contract negotiations, choosing a practice, how to purchase insurances (life, disability, liability, and health), personal finance, basic accounting, billing and coding, and fraud and abuse regulations. Residents from other specialties also attend when they hear about the monthly sessions that are oriented to provide very practical information. When residents graduate they take with them an entire folder of valuable handouts that serve as a reference book. Something must also be done about medical school debt. There are several programs that exist to assist graduating students, such as the First for Medical Education debt assistance program run by the Association of American Medical Colleges (AAMC).8 We need more of these programs in order to get the medical students interested, particularly in surgical careers with their long residencies. A quarter of residents polled by Merritt Hawkins & Associates stated that medical school debt was a concern.9 Almost 47 percent of residents in the same survey said that a deal involving payoff of the debt would affect their choice of a job. Something has to be done about physicians’ malpractice premiums and insurance options. Some states are making some progress, but the cost of the malpractice premiums and the associated liability for 2 to 18 years in most states will still discourage those who want to go into surgical and OB/GYN residencies. In a survey of current residents by Merritt Hawkins & Associates, two-thirds said that malpractice issues gave them the biggest reasons for concern.10 Since liability reform was passed in Texas in 2003, malpractice
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premiums have dropped 24 percent and medical license applications have jumped 59 percent!11 Lowering premiums works. It can be done. As we have discussed in detail, we must challenge our Congress and the executive branch of our government to change funding for the required residency positions for post graduate medical education to accommodate the increasing population. Something must be done about residents’ salaries. First year salaries for corporate attorneys in Baltimore, for instance, averaged $145,000 in 2008.12 That is about three times what a surgical resident makes. We estimated per hour wages of residents to be in the $10–14 range and compared them to other skilled labor wage profiles in chapter 3. That, combined with the debt burden and the clear preference of all educators that all residents avoid any moonlighting jobs, makes it imperative that we pay a fair wage to residents. And, finally, something has to be done about reimbursement. As we have discussed in previous chapters, hospitals are getting regular market basket updates in reimbursement for the services they provide. For example, for the fiscal year 2009, Congress has been asked to increase hospital payments by the projected rate of increase in the hospital market basket index, currently estimated at 3.0 percent.13 Contrariwise, physician reimbursement is always on the chopping block each year until it receives a last minute reprieve by Congress. But, without medical reimbursements for physicians that allow them to pay off their medical school debts, and provide for retirement, and their children’s education, they will not go into medicine. Medical private practice groups will not hire new physicians and hospitals will be the only ones left with enough capital to hire physicians. Do we want all physicians to be employed by large healthcare megasystems?
A BRIEF REVIEW OF HEALTHCARE IN CANADA We are reviewing the Canadian health care system because some version of that health care system might form the template of universal health care in the United States. We want particularly to review the waiting times for surgical services in Canada. A more complete review of the Canadian health care system can be found in our book Consumer Driven Health Care and in the Sally C. Pipes book Miracle Cure: How to Solve America’s Health Care Crisis and why Canada Isn’t the Answer.14 Ms. Pipes is a Canadian citizen and former head of the Fraser Institute in Vancouver, British Columbia. In 2003, Canada’s health care spending was about $3,000 per citizen, about half of what we spent in the United States.15 Now, Canada is beginning to privatize some of its medical care. Even the European nations, including Great Britain and Sweden, are advocating more and more private health care.16 There are about 220 doctors per 100,000 population in Canada, as opposed to about 286 in the United States, split about evenly between primary care and specialty care.17 About 1 in 12 Canadian doctors have immigrated to the United States. There are three levels of difficulty in negotiating the Canadian health care system. The first is in getting an initial doctor’s appointment so that a primary
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care doctor can diagnose your problem and refer you for tests or to the appropriate specialist if, indeed, you need consultation. The second difficulty is in getting appropriate diagnostic tests scheduled in a timely manner when the general practitioner recommends it. The third difficulty is in getting consultant appointments for their diagnoses and treatment. In 2003, 15 percent of Canadians reported difficulties for routine health care matters and 23 percent for minor health problems.18 Some of the leading critics of the Canadian health care systems are Canadians themselves. In Investors Business Daily, David Gratzer, a Canadian doctor associated with the Manhattan Institute, said that about 1.5 million people in Ontario, almost oneeighth of the population of Ontario, cannot find family physicians. That results in overcrowded emergency rooms.19 According to the Fraser Institute, in 2005 the median waiting time after a patient’s initial visit to a general practitioner to provision of treatment was almost 18 weeks or 4½ months. For cardiovascular surgery, it is eight weeks from initial visit to completion, in general surgery it is 10.4 weeks or 2½ months, in orthopedic surgery, it is nine months. In chest surgery, abdominal surgery, and hip surgery there is usually another three months after the operation to complete rehabilitation (Figure 15.1).20
Figure 15.1 Median Wait Times for Patients from Referral by General Practitioner for Treatment by Specialty Canada (median)
Specialty
OB/GYN Ortho Uro Cardiovascular Plastics GenSurg 0
10
20
30
40
50
Weeks Wait times from GP to Specialist Wait times from Specialist to treatment Source: R. Steinbrook, “Private Healthcare in Canada,” New England Journal of Medicine 354:16 (2006) 1661–1664.
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Dr. Gratzer’s article compares the five-year survival rate obtained in American medicine to European results. For leukemia, the American survival rate is almost 50 percent; in Europe it is 35 percent. For esophageal carcinoma, one of the most lethal of cancers, the five year survival rate is 12 percent in the United States and six percent in Europe. The survival rate of prostate cancer is more than 80 percent in the United States, just over 60 percent in France, and just 40 percent in England.21 In fact, there is a firm headed by a Canadian who describes himself as a medical broker; that is, Canadians pay him to set up surgical procedures, diagnostic testing, and specialist consultations privately and quickly.22 A prominent doctor from British Columbia, head of the Canadian Medical Association, said, “This is a country in which dogs can get a hip replacement in under a week and in which humans can wait for two to three years.”23 The issue of private insurance, which was banned in the province of Quebec, resulted in a lawsuit filed by a patient and his doctor against the province. The patient was placed on a waiting list for his hip replacement to have the operation in one year. The judges in the Supreme Court of Canada found for the patient, saying that “access to a waiting list is not access to health care.”24 The purpose of this section on Canadian medical care is not to criticize it, but to emphasize that if we don’t have the doctors, we will ration surgical care by both the doctor’s time to see patients, but more importantly, the patient’s time. Consequences Finally, let’s talk about consequences. In the face of increasing demand and decreasing supply, we will have a four-tier health care system. Let us explain. The wealthy can afford anything that modern health care can provide. So they will make up the first class of health care. They will have no rationing at all. The second class will be those who have advocates in the healthcare fields; people who have an inside track to arrange for their medical appointments and procedures. They will face rationing only in terms of the time it takes to get a medical or surgical appointment. The third class will be the rest of the insured. They will face rationing by time. They will not be able to get a prompt medical appointment and will have long wait times, particularly for surgical appointments. And finally, the fourth class will be the under insured or uninsured. This is a problem for 45,000,000 or more Americans. If we don’t do something about it, it will be a problem for about 70,000,000 Americans by 2050. If we fail to increase medical school enrollments, fail to create the residencies, and fail to meet these other challenges, we will be in a position where every practice could become a boutique practice. That is, we will sell access to physicians for their opinions, and the access fee will not be included in the
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physicians’ fees. In other words, we will be operating like a Sam’s Club, selling access to the store. Merchandise fees will apply after you gain entry to the store. There is much that needs to be fixed in our current system of delivering health care, but we doubt that the American public is ready for a Sam’s Club approach.
Epilogue
A LETTER TO OUR PATIENTS Multiple surveys of our citizens have shown areas of dissatisfaction with our health care system. In a 2009 CNN/Opinion Research Corporation survey more than 8 in 10 were satisfied with the quality of care they received, nearly 3 of every 4 expressed satisfaction with their overall health coverage but as expected, 3 of 4 people were dissatisfied with the cost of healthcare in the United States. We may have the best “sick care” system in the world but the inefficiencies, including excess litigation, are a burden we cannot pay for anymore. You can render primary care with primary care physicians and other professionals such as nurse practitioners and physician assistants. Unfortunately, you cannot provide hospital care without medical and surgical specialists. Surgeons are unique in being able to deliver life-saving interventions that no other health care professional can provide. But, to render surgical care, we must have an adequate surgical workforce. That is the point of this book. As a patient, you must understand that if we don’t increase medical school enrollments and amend the Balanced Budget Act of 1997 to allow enough surgical trainees, we will not have enough surgeons to meet the increasing needs of our population. There are many stakeholders at the table discussing ways to reform the healthcare system in the United States. Who would you trust the most in looking out for you? In a recent Gallup poll, 73 percent of people polled expressed confidence that physicians would recommend the right thing when reforming the system. This high vote of confidence exceeded that of all other parties including the President, Congress, researchers, insurers, or pharmaceutical companies. Physicians hold the patient-doctor relationship sacred. But, would you trust doctors to write law or to engineer legislation or foreign policy? You would not. So, why would you entrust the responsibility to enact reform to so-called experts who have never delivered health care? Together, we must speak up and insist on a health policy that has the patient at the heart of any change.
Epilogue
157
You, as citizens and taxpayers of the United States, must make sure that our government does not make fatal mistakes that will result in rationing of health care to all of you. Witness the waiting times in Canada and the five-year survival rate for cancers in Europe, as we alluded to in chapter 15. Very respectfully submitted, Thomas E. Williams, Jr. Bhagwan Satiani E. Christopher Ellison
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Appendix The tables (A.1, A.2, and A.3) contained in this Appendix are the original tables from which shorter tables in chapter 5 were taken. The table titles are the same. Table A.1 Retiring Doctors Year
Old Physicians Retiring Each Year
2000
Number of Old Physicians Practicing 800,000
2001
20,000
780,000
2002
20,000
760,000
2003
20,000
740,000
2004
20,000
720,000
2005
20,000
700,000
2006
20,000
680,000
2007
20,000
660,000
2008
20,000
640,000
2009
20,000
620,000
2010
20,000
600,000
2011
20,000
580,000
2012
20,000
560,000
2013
20,000
540,000
2014
20,000
520,000
2015
20,000
500,000
2016
20,000
480,000
(continued )
160
Appendix
Table A.1 Retiring Doctors (continued ) Year
Old Physicians Retiring Each Year
Number of Old Physicians Practicing
2017
20,000
460,000
2018
20,000
440,000
2019
20,000
420,000
2020
20,000
400,000
2021
20,000
380,000
2022
20,000
360,000
2023
20,000
340,000
2024
20,000
320,000
2025
20,000
300,000
2026
20,000
280,000
2027
20,000
260,000
2028
20,000
240,000
2029
20,000
220,000
2030
20,000
200,000
2031
20,000
180,000
2032
20,000
160,000
2033
20,000
140,000
2034
20,000
120,000
2035
20,000
100,000
2036
20,000
80,000
2037
20,000
60,000
2038
20,000
40,000
2039
20,000
20,000
2040
20,000
0
2041
0
0
2042
0
0
2043
0
0
2044
0
0
2045
0
0
2046
0
0
2047
0
0
2048
0
0
2049
0
0
2050
0
0
Appendix
161
Table A.2 New Physicians Added
Year
Present Graduating Class
Total of New Graduates
New Graduates Who Have Total of New Retired Graduates Practicing
2000 2001
17,000
17,000
0
17,000
2002
17,000
34,000
0
34,000
2003
17,000
51,000
0
51,000
2004
17,000
68,000
0
68,000
2005
17,000
85,000
0
85,000
2006
17,000
102,000
0
102,000
2007
17,000
119,000
0
119,000
2008
17,000
136,000
0
136,000
2009
17,000
153,000
0
153,000
2010
17,000
170,000
0
170,000
2011
17,000
187,000
0
187,000
2012
17,000
204,000
0
204,000
2013
17,000
221,000
0
221,000
2014
17,000
238,000
0
238,000
2015
17,000
255,000
0
255,000
2016
17,000
272,000
0
272,000
2017
17,000
289,000
0
289,000
2018
17,000
306,000
0
306,000
2019
17,000
323,000
0
323,000
2020
17,000
340,000
0
340,000
2021
17,000
357,000
0
357,000
2022
17,000
374,000
0
374,000
2023
17,000
391,000
0
391,000
2024
17,000
408,000
0
408,000
2025
17,000
425,000
0
425,000
2026
17,000
442,000
0
442,000
2027
17,000
459,000
0
459,000
2028
17,000
476,000
0
476,000
2029
17,000
493,000
0
493,000
2030
17,000
510,000
0
510,000
2031
17,000
527,000
0
527,000
(continued )
162
Appendix
Table A.2 New Physicians Added (continued ) New Graduates Who Have Retired
Total of New Graduates Practicing
Year
Present Graduating Class
Total of New Graduates
2032
17,000
544,000
0
544,000
2033
17,000
561,000
0
561,000
2034
17,000
578,000
0
578,000
2035
17,000
595,000
0
595,000
2036
17,000
612,000
0
612,000
2037
17,000
629,000
0
629,000
2038
17,000
646,000
0
646,000
2039
17,000
663,000
0
663,000
2040
17,000
680,000
0
680,000
2041
17,000
697,000
17,000
680,000
2042
17,000
714,000
34,000
680,000
2043
17,000
731,000
51,000
680,000
2044
17,000
748,000
68,000
680,000
2045
17,000
765,000
85,000
680,000
2046
17,000
782,000
102,000
680,000
2047
17,000
799,000
119,000
680,000
2048
17,000
816,000
136,000
680,000
2049
17,000
833,000
153,000
680,000
2050
17,000
850,000
170,000
680,000
Appendix
163
Table A.3 Total of Practicing Doctors Year
Number of Old Physicians Practicing
Total of New Graduates Practicing
Grand Total of Practicing Doctors
2000
800,000
2001
780,000
17,000
797,000
2002
760,000
34,000
794,000
2003
740,000
51,000
791,000
2004
720,000
68,000
788,000
2005
700,000
85,000
785,000
2006
680,000
102,000
782,000
2007
660,000
119,000
779,000
2008
640,000
136,000
776,000
2009
620,000
153,000
773,000
2010
600,000
170,000
770,000
2011
580,000
187,000
767,000
2012
560,000
204,000
764,000
2013
540,000
221,000
761,000
2014
520,000
238,000
758,000
2015
500,000
255,000
755,000
2016
480,000
272,000
752,000
2017
460,000
289,000
749,000
2018
440,000
306,000
746,000
2019
420,000
323,000
743,000
2020
400,000
340,000
740,000
2021
380,000
357,000
737,000
2022
360,000
374,000
734,000
2023
340,000
391,000
731,000
2024
320,000
408,000
728,000
2025
300,000
425,000
725,000
2026
280,000
442,000
722,000
2027
260,000
459,000
719,000
2028
240,000
476,000
716,000
2029
220,000
493,000
713,000
2030
200,000
510,000
710,000
2031
180,000
527,000
707,000
800,000
(continued )
164
Appendix
Table A.3 Total of Practicing Doctors (continued ) Year
Number of Old Physicians Practicing
Total of New Graduates Practicing
Grand Total of Practicing Doctors
2032
160,000
544,000
704,000
2033
140,000
561,000
701,000
2034
120,000
578,000
698,000
2035
100,000
595,000
695,000
2036
80,000
612,000
692,000
2037
60,000
629,000
689,000
2038
40,000
646,000
686,000
2039
20,000
663,000
683,000
2040
0
680,000
680,000
2041
0
680,000
680,000
2042
0
680,000
680,000
2043
0
680,000
680,000
2044
0
680,000
680,000
2045
0
680,000
680,000
2046
0
680,000
680,000
2047
0
680,000
680,000
2048
0
680,000
680,000
2049
0
680,000
680,000
2050
0
680,000
680,000
Notes CHAPTER 1—THE PROBLEM 1. B. Barzansky and S. I. Etzel, “Educational Programs in U.S. Medical Schools,” JAMA 290 (2003): 1190–1196. 2. S. E. Brotherton, P. H. Rockey, and S. I. Etzel, “U.S. Graduate Medical Education, 2002–2003,” JAMA 290 (2003): 1197–1202; American Medical Association, “International Medical Graduates in the U.S. Workforce. October 2007,” http://www. ama-assn.org/ama1/pub/upload/mm/18/img-workforce-paper.pdf (accessed June 16, 2008). 3. American Medical Association, “International Medical Graduates in the U.S. Workforce,” October 2007, http://www.ama-assn.org/ama1/pub/upload/mm/18/ img-workforce-paper.pdf (accessed June 16, 2008). 4. ECFMG, “Fact Card—Summary Data—2006 2007,” http://www.ecfmg.org/ cert/factcard.pdf (accessed June 15, 2008). 5. “Charting Outcomes in the Match.” National Resident Matching Program, http://www.nrmp.org/data/chartingoutcomes2007.pdf (accessed July 3, 2009). 6. Eugene Braunwald, “Cardiology: The Past, the Present, and the Future,” Journal of the American College of Cardiology 42 (2003): 2031–2041. 7. “Public Enemy No. 1,. Fortune, March 22, 2004. 8. “Living Longer,” Wall Street Journal, June 9, 2004; “Staying Alive,” New York Times, June 1, 2004. 9. “USA in 2050: Population projected over five decades,” USA Today, March 18, 2004. 10. Roger D. Blackwell, Thomas E. Williams, and Alan Ayers, Consumer Driven Health Care (Ashland, OH: Book Publishing Associates, 2005) 89–96. 11. Richard A. Cooper, “Weighing the Evidence for Expanding Physician Supply,” Annals of Internal Medicine 141 (2004): 705–714. 12. “Demands on Surgeon Work Force to Grow Rapidly through 2020,” Physician Compensation Report, September 2003, http://findarticles.com/p/articles/mi_m 0FBW/ is_9_4/ai_106954764?tag=content;col12/19/2009 (accessed February 5, 2009). 13. Merritt Hawkins and Associates, “White Paper: An Analysis of the Emerging Physician Shortage in the United States,” October, 2004, http://www.mhagroup.com/ (accessed June 16, 2008).
166
Notes
14. AAMC, “Table 1: U.S. Medical School Applications and Matriculants by School, State of Legal Residence, and Sex, 2007,” http://www.aamc.org/data/facts/ 2007/2007school.htm (accessed June 16, 2008). 15. Emily Lee, “UW Study Finds a Decline in General Surgeons,” The Daily of University of Washington, May 28, 2008, http://thedaily.washington.edu/2008/5/28/ uw-study-finds-decline-general-surgeons/ (accessed June 15, 2008). 16. D. A. Newton and M. S. Grayson, “Trends in Career Choice by U.S. Medical School Graduates,” Journal of the American Medical Association 290 (2003): 1179– 1182; “National Residency Matching Program. Advance Data Tables—2008 Main Residency Match,” http://www.nrmp.org/data/advancedatatables2008.pdf (accessed May 16, 2008). 17. The American Bar Association, www.abanet.org (accessed November 5, 2005). 18. Alex Williams, “YOU can’t say Law Firms aren’t Trying,” New York Times, January 6, 2008, http://www.nytimes.com/2008/01/06/fashion/06professions.html?pa gewanted=1&_r=1 (accessed June 16, 2008). 19. T. E. Williams, B. Satiani, A.Thomas, and E. C. Ellison, “The Impending Shortage and the Estimated Cost of Training the Future Surgical Workforce,” Annals of Surgery. In press.
CHAPTER 2—DEMAND FOR A SURGICAL/ MEDICAL WORKFORCE 1. 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 (SOSSUS),” (Baltimore: 1975); R. A. Cooper, T. E. Getzen, H. J. McKee, P. Laud, “Economic and Demographic Trends Signal an Impending Physician Shortage,” Health Affairs 21 (2002): 140–154; Council on Graduate Medical Education, “Physician Workforce Policy Guidelines for the U.S. for 2000–2020,” (Rockville, MD: U.S. Department of Health and Human Services: 2005). 2. CDC, “National For Vital Statistics Deaths: Final Data for 2005,” http://www. cdc.gov/nchs/data/nvsr/nvsr56/nvsr56_10.pdf (accessed June 18, 2008). 3. C. Leaf, “Why We’re Losing The War on Cancer [and How to Win It],” Fortune Magazine, March 22, 2004, http://www.healingcancernaturally.com/conventionalcancer-treatment.html (accessed June 18, 2008). 4. ACS, “Cancer Facts & Figures—2007,” http://www.cancer.org/downloads/ STT/caff2007PWSecured.pdf (accessed June 19, 2008). 5. “Living Longer,” Wall Street Journal, June 9, 2004. 6. “Staying Alive,” New York Times, June 1, 2004. 7. Eugene Braunwald, “Cardiology: The Past, the Present, and the Future,” Journal of the American College of Cardiology 42 (2003): 2031–2041. 8. “Health Care Spending Slows in 2004,” Modern Health Care’s Daily Dose, January 10, 2006; Cynthia Smith, Cathy Cowan, Stephen Heffler, Aaron Catlin, and the National Health Account Team, “National Health Spending In 2004 Recent Slowdown Led by Prescription Drug Spending,” Health Affairs 25 (2006): 186–196; “U.S. Spending Rose,” Modern Health Care Alert, February 22, 2006; Alex Berenson and Reed Abelson, “Weighing the Costs of a CT Scan’s Look Inside the Heart,” New York Times, June 29, 2008. 9. “Trauma now Nation’s Costliest Medical Problem,” Modern Health Care’s Daily Dose, January 25, 2006.
Notes
167
10. R. A. Cooper, T. E. Getzen, H. J. McKee, P. Laud, “Economic and Demographic Trends Signal an Impending Physician Shortage,” 2002; M. Barer, “New Opportunities for Old Mistakes,” Health Affairs 21 (2002): 169–171. 11. United States Census Bureau. http://www.census.gov/ipc/www/usinterimproj/ natprojtab02a.xls (accessed June 18, 2008); Federal Interagency Forum on Aging Related Statistics, “Aging Stats 2008 Report,” http://www.agingstats.gov/agingstatsdot net /Main_Site/Data/Data_2008.aspx (accessed June 18, 2008). 12. D. K. Cherry, C. W. Burt, and D. A. Woodwell, “National Ambulatory Medical Care Survey: 2001 Summary. Advance Data from Vital and Health Statistics; no. 337,” (Hyattsville, MD: National Center for Health Statistics, 2003). 13. Council on Graduate Medical Education, “Physician Workforce Policy Guidelines for the U.S. for 2000–2020,” 2005. 14. AAMC, Data Warehouse, Total U.S. Medical School Enrollment by Race and Ethnicity within Sex, 2003–2008. “Applicant Matriculant File as of September 25, 2007.” 15. statehealthfacts.org, “Distribution of Nonfederal Physicians by Gender, 2007,” http://www.statehealthfacts.org/comparetable.jsp?ind=430&cat=8 (accessed July 3rd, 2009). 16. R. A. Cooper, T. E. Getzen, H. J. McKee, P. Laud, “Economic and Demographic Trends Signal an Impending Physician Shortage,” 2002; S. Evans and B. Sarani, “The Modern Medical School Graduate and General Surgical Training. Are They Compatible?” Archives of Surgery 137 (2002): 274–277. 17. R. A. Cooper, T. E. Getzen, H. J. McKee, P. Laud, “Economic and Demographic Trends Signal an Impending Physician Shortage,” 2002. 18. E. M. Lambert and E. M. Holmboe, “The Relationship Between Specialty Choice and Gender of U.S. Medical Students, 1990–2003,” Academic Medicine 80 (2005): 791–796. 19. R. A. Cooper, T. E. Getzen, H. J. McKee, P. Laud, “Economic and Demographic Trends Signal an Impending Physician Shortage,” 2002. 20. M. Barer, “New Opportunities for Old Mistakes,” 2002; K. Grumbach, “The Ramifications of Specialty-Dominated Medicine,” Health Affairs 21 (2002): 155–157. 21. Hamilton DP, “Overtreatment in Action: $30 Billion Wasted on Unnecessary MRI, CT Scans,” BNET Healthcare, http://industry.bnet.com/healthcare/1000138/ overtreatment-in-action-30-billion-wasted-on-unnecessary-mri-ct-scans/ (accessed July 3, 2009). 22. J. Merritt, J. Hawkins, and P. B. Miller, “Will the last physician in America please turn off the lights?” 3rd ed. (Irving, TX: Practice Support Publisher, 2006), 18. 23. United States General Accounting Office, “Physician Workforce—Physician Supply Increased in Metropolitan and Nonmetropolitan Areas but Geographic Disparities Persisted,” http://www.gao.gov/new.items/d04124.pdf (accessed June 20, 2008). 24. U.S. Department of Health and Human Services Health Resources and Services Administration Bureau of Health Professions, “Physician Supply and Demand: Projections to 2020,” (Health Resources and Services Administration, Department of Health & Human Services, October 2006). 25. Council on Graduate Medical Education, “Physician Workforce Policy Guidelines for the U.S. for 2000–2020.” 2005. 26. U.S. Department of Health and Human Services Health Resources and Services Administration Bureau of Health Professions, 2006. 27. Roger D. Blackwell, Thomas E. Williams, and Alan Ayers, Consumer Driven Health Care, (Ashland, Ohio: Book Publishing Associates, 2005), 86–89.
168
Notes
28. Marquette Tribune, “Nursing Shortage to Worsen, 500,000 will be Needed by 2025,” http://media.www.marquettetribune.org/media/storage/paper1130/news/ 2008/04/03/News/Nursing.Shortage.To.Worsen-3298458.shtml (accessed June 20, 2008). 29. East Tennessee State University College of Pharmacy, http://www.pharmcas. org/collegesschools/schoolETSUpage.htm (accessed June 21, 2008). 30. Public Broadcasting Systems, transcript of “Bill of Health-Pharmacist Shortage,” http://www.pbs.org/nbr/site/onair/transcripts/080327c/ (accessed June 20, 2008). 31. Robert Davis, “Shortage of Surgeons Pinches U.S. Hospitals,” USA Today, February 26, 2008, http://www.usatoday.com/news/health/2008–02–26-doctorshortage_N.htm (accessed June 20, 2008). 32. Margot Kim, “Doctor Shortage,” February 29, 2008, http://abclocal.go.com/kfsn/ story?section=news/health/health_watch&id=5931876 (accessed June 20, 2008). 33. Christina Rogers, “Doctor Shortage Worsens as Student Debt Rises,” The Detroit News June 18, 2008, http://www.detnews.com/apps/pbcs.dll/article?AID= 2008806180336 (accessed June 21, 2008). 34. Dennis Cauchon, “Medical Miscalculation Creates Doctor Shortage,” USA Today, March 3, 2005, http://www.usatoday.com/educate/college/healthscience/ar ticles/20050306.htm (accessed June 21, 2008). 35. Dennis Cauchon, “Medical Miscalculation Creates Doctor Shortage,” USA Today, March 3, 2005.
CHAPTER 3—SURGICAL SUPPLY: RESIDENTS—THE FUTURE SURGEONS 1. AAMC, “Table 1: U.S. Medical School Applications and Matriculants by School, State of Legal Residence, and Sex, 2007,” http://www.aamc.org/data/facts/ 2007/2007school.htm (accessed June 30, 2008). 2. The Liaison Committee on Medical Education, http://www.lcme.org/ (accessed June 25, 2008). 3. The Liaison Committee on Medical Education. 4. “A Word from the President: Filling the Workforce Gap,” AAMC Reporter (April 2005), http://www.aamc.org/newsroom/reporter/april05/word.htm (accessed June 24, 2008). 5. ECFMG, “Fact Card—Summary Data—2006 2007,” http://www.ecfmg.org/ cert/factcard.pdf (accessed June 23, 2008). 6. American Medical Association, “International Medical Graduates in the U.S. Workforce. A discussion paper.” October 2007. http://www.ama-assn.org/ama1/pub/ upload/mm/18/img-workforce-paper.pdf (accessed June 25, 2008). 7. American Medical Association, “International Medical Graduates in the U.S. Workforce. A discussion paper.” October 2007. 8. American Medical Association, “International Medical Graduates in the U.S. Workforce. A discussion paper.” October 2007. 9. American Medical Association, “International Medical Graduates in the U.S. Workforce. A discussion paper.” October 2007. 10. American Medical Association, “International Medical Graduates in the U.S. Workforce. A discussion paper.” October 2007; Fitzhugh Mullan, “The Case for More U.S. Medical Students,” New England Journal of Medicine 343 (2000): 213–217. 11. American Medical Association, “International Medical Graduates in the U.S. Workforce. A discussion paper.” October 2007.
Notes
169
12. The American Boards of Medical Specialties, Member Boards, General Surgery Certificates Issued 1995–2002. Available at http://www.abms.org/, (accessed July 4, 2009) and at http://www.abms.org/Who_We_Help/Consumers/About_Physi cian_Specialties/orthopaedic.aspx, accessed 6/27/2009. Source: www.abns.org,www. abog.org, www.aboto.org, www.abos.org, www.absurgery.org, www.abu.org. 13. Christopher L. Skelly, “Medical Student Education and the 80 Hour Work Week,” http://www.facs.org/education/gs2003/gs26skelly.pdf (accessed June 23, 2008). 14. K. G. Volpp, A. K. Rosen, P. R. Rosenbaum, P. S. Romano, et al., “Mortality Among Hospitalized Medicare Beneficiaries in the First 2 Years Following ACGME Resident Duty Hour Reform,” JAMA 298 (2007): 975–983. 15. A. Salim, P.G.R. Texeira, L. Chan, D. Oncel, et al., “Impact of the 80-Hour Workweek on Patient Care at a Level I Trauma Center,” Archives of Surgery 142 (2007): 708–714. 16. J. Merritt, J. Hawkins, and P. B. Miller, “Will the last physician in America please turn off the lights?” 3rd ed. (Irving, TX: Practice Support Publisher Inc., 2006), 18. 17. MD Salaries, “Residency Salaries in the United States,” http://mdsalaries.blog spot.com/2005/10/residency-salaries.html (accessed June 23, 2008). 18. Bureau of Labor Statistics, “May 2007 National Occupational Employment and Wage Estimates,” http://www.bls.gov/oes/current/oes_nat.htm (accessed June 23, 2008). 19. Robert Steinbrook, “Medical Student Debt—Is There a Limit,” New England Journal of Medicine 359 (2008): 2629–2632.
CHAPTER 4—CONSTRAINTS TO SUPPLY: PERTINENT ISSUES 1. AAMC, “Tuition and Students Fees Reports. Table 1—U.S. Medical Schools Tuition and Students Fees—First Year Students, 2004–2005 and 2003–2004,” https://services.aamc.org/Publications/showfile.cfm?file=version103.pdf&prd_ id=212&prv_id=256&pdf_id=103 (accessed January 20, 2008). 2. AAMC, “Medical School Tuition and Young Physician Indebtedness An Update to the 2004 Report. October, 2007.” 3. Robert Steinbrook, “Medical Student Debt—Is There a Limit?” New England Journal of Medicine 359 (2008): 2629–2632. 4. Association of American Medical Colleges, “Congratulations to the Class of 2005,”from The AAMC MEDLOANS Program. 5. AAMC, “Medical School Tuition and Young Physician Indebtedness An Update to the 2004 Report. 6. S. Dutton, personal communication. 7. American Medical Association, “Figure 1 –Medical Education Debt Has Outpaced Inflation,” http://www.ama-assn.org/ama1/pub/upload/mm/15/debt_ figures_1_2.pdf (accessed July 10, 2008). 8. J. Bond, E. Galinsky, and J. S. Wanberg, National Study of the Changing Workforce, (New York: Families and Work Institute, 1998); J. Lang, “It’s Time Over Money for this Generation,” Journal Commerce 1 (2000): 7. 9. A. Liebhaber and J. M. Grossman, “Physicians Moving to Mid-Sized, Single-Specialty Practices,” http://www.hschange.org/CONTENT/941/ (accessed July 4, 2008). 10. Gail Garfinkel Weiss, “Productivity Takes a dip,” Medical Economics 18 (2005): 86–94.
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11. Gail Garfinkel Weiss, “Exclusive Survey—Productivity: Work Hour up, Patient Visits down,” Medical Economics, (2006), http://www.memag.com/memag/Medical+ Practice+Management%3A+Productivity/Exclusive-SurveymdashProductivity-Workhours-up-pa/ArticleStandard/Article/detail/382220?contextCategoryId=38712, (accessed December 16, 2007). 12. American Medical Group Association, “Media Alerts,” http://www.amga.org/ MediaAlerts/article_mediaAlerts.asp?k=267 (accessed July 25, 2008). 13. E. Ray Dorsey, David Jarjoura, and Gregory W. Rutecki, “Influence of Controllable Lifestyle on Recent Trends in Specialty Choice by U.S. Medical Students,” Journal of American Association 290 (2003): 1173–1178. 14. National Resident Matching Program, Tables 10–11, NRMP Data, (Washington, DC: National Resident Matching Program, March 1996): 14–15.; National Resident Matching Program, Tables 10–11, Results and Data 2002 Match (Washington, DC: National Resident Matching Program, April 2002): 20–21. 15. B. Satiani, The Smarter Physician, Vol. 3, (Englewood, CO: Medical Group Management Association, 2007; M.O. Baerlocher, “Happy Doctors? Balancing Professional and Personal Commitments,” Canadian Medical Association Journal 174 (2006): 1070. 16. E. M. Lambert and E. S. Holmboe, “The Relationship Between Specialty Choice and Gender of U.S. Medical Students, 1990–2003,” Academic Medicine 80 (2005): 797–802; E. Ray Dorsey, David Jarjoura, and Gregory W. Rutecki, “Influence of Controllable Lifestyle on Recent Trends in Specialty Choice by U.S. Medical Students,” 2003. 17. fiercehealthcare, “Specialty physician compensation barely keeps up with inflation,” http://www.fiercehealthcare.com/press-releases/specialty-physician-compensa tion-barely-keeps-inflation-primary-care-physicians-repor (accessed March 20, 2009); 18. D. Adams, “Physician income not rising as fast as other professional pay,” http://www.ama-assn.org/amednews/2006/07/24/prsc0724.htm (accessed March 20, 2009). 19. Physician Compensation, “Physician Pay, Doctor Salary, Doctor Pay,” http:// www.cejkasearch.com/conpensation/amga_physician_compensation_survey.htm (accessed May 20, 2008). 20. D. Adams, “Physician Income not Rising as Fast as Other Professional Pay. 2006/2007. 21. “Some Nurses Land Higher Salaries Than Primary Care Doctors,” Wall Street Journal, http://blogs.wsj.com/health/2008/06/18/some-nurses-land-higher-salariesthan-primary-care-doctors/ (accessed July 25, 2008). 22. Jack M. Matloff, “The Practice of Medicine in the Year 2010: Revisited in 2001,” Annals of Thoracic Surgery 72 (2001): 1105–1112. 23. STS Urgent Action Alert, “Take Action Now to Stop Medicare Cuts,” email to Thomas E. Williams M. D., November 10, 2005. 24. American Medical Association, “Ask your federal representatives to stop the Medicare payment cuts,” http://www.ama-assn.org/ama1/pub/upload/mm/15/i05_ cola_news.pdf (accessed February 20, 2009); “Physician Payment Cut Reversed,” Society of Thoratic Surgeons, e-mail to Thomas E. Williams, M.D., March 14, 2006. 25. “Law-firms partnerships harder to get, survey says,” Columbus Dispatch, March 1, 2005, http://abovethelaw.com/2008/05/ (accessed February 20, 2009). 26. Merriam-Webster, “Definition,” http://medical.merriam-webster.com/medical/ malpractice (accessed July 30, 2008). 27. B. Satiani, “Demystifying the Business of Medicine in your Practice,” The Smarter Physician, Vol. 1 (Englewood, CO: Medical Group Management Association, 2007) 166–167.
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28. Ohio Department of Insurance, “Ohio 2006 Medical Liability Closed Claim Report January 2008,” http://www.ohioinsurance.gov/Legal/Reports/MedMal_Closed_ Claim_2008.pdf (accessed March 20, 2009). 29. Commongood, “Fear of Litigation: The Impact on Medicine,” http://common good.org/healthcare-reading-cgpubs-polls-6.html (accessed July 26, 2008). 30. D. P. Kessler and M. McClellan, “How Liability Law Affects Medical Productivity,” National Bureau of Economic Research, (February 2000), http://www.nber.org/ digest/aug00/w7533.html (accessed July 30, 2008). 31. D. Starkman, “Calculating Malpractice Claims- Study by Consumers Group Suggests Insurers Set Premiums Based Market, Not Their Losses,” Washington Post, http://www.washingtonpost.com/wp-dyn/content/article/2005/12/28/AR2005122 801490.html (accessed July 30, 2008). 32. Alicia Chang, “Four in 10 malpractice cases groundless,” http://www.high beam.com/doc/1P1–123318675.html (accessed February 20, 2009). 33. D. M. Studdert, M. M. Mello, A. A. Gawande, et al., “Claims, Errors, and Compensation Payments in Medical Malpractice Litigation,” New England Journal of Medicine 354 (2006): 2024–2033. 34. Tillinghast Towers Perrin, “U.S. Tort Costs, 2003 Update,” (December 2003) 17. 35. “Employment policy foundation finds medical malpractice system lacking,” Physicians Practice, http://overlawyered.com/2003/08/employment-policy-founda tion-finds-med-mal-system-lacking (accessed July 30, 2008). 36. State of Ohio, Department of Insurance, “Medical Liability Insurance Rates for 2006 Decrease by 1.7 Percent,” http://www.ohioinsurance.gov/newsroom/scripts/ Release.asp?ReleaseID=3963 (accessed March 20, 2009). 37. Phillip K. Howard, “Juryless Health Courts Could Stabilize Crisis,” letter to the editor, Wall Street Journal, February 28, 2006, http://commongood.org/learn-readingcgpubs-opeds-47.html (accessed July 30, 2008). 38. Common Good, “Majority of Americans Support Creating Special Health Courts,” http://commongood.org/healthcare-reading-cgpubs-polls-7.html (accessed July 26, 2008). 39. Fitzhugh Mullan, “The Metrics of the Physician Brain Drain,” New England Journal of Medicine 353 (2005): 1810–1818. 40. American Medical Association, “International Medical Graduates In the U.S. Workforce. A Discussion Paper October 2007,” http://www.ama-assn.org/ama1/pub/ upload/mm/18/img-workforce-paper.pdf (June 25, 2008). 41. Norman M. Wall, “Stealing From the Poor to Care for the Rich,” New York Times, December 14, 2005, http://www.nytimes.com/2005/12/14/opinion/14walln. html (accessed July 30, 2008). 42. S. Shafqat and A. K. Zaidi, “Pakistani Physicians and the Repatriation Equation,” New England Journal of Medicne 356 (2007): 442–443. 43. News-Medical.Net, “Reversing Medical Brain Drain in New Zealand,” http:// www.news-medical.net/?id=1814 (accessed July 26, 2008). 44. Merritt, Hawkins & Associates, “Summary Report 2004 Survey Of Physicians 50 to 65 Years Old,” http://www.merritthawkins.com/pdf/Survey_2004_survey_of_ physicians_50–65.pdf (accessed July 30, 2008). 45. H. Yamagata, “Retirement Behaviors of Physicians Based on the Physicians Over 50 Survey Preliminary Findings,” (paper presented at the 2006 AAMC Physician Workforce Research Conference, Washington DC, May 5, 2006).
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46. Merritt, Hawkins & Associates. “2007 Survey of Physicians 50 to 65 Years Old,” http://www.merritthawkins.com/pdf/mha2007olderdocsurvey.pdf (accessed July 5, 2008). 47. J. Merritt, J. Hawkins, and P. B. Miller, Will the Last Physician in America Please Turn the Lights Off? 3rd ed. (Irving, Texas: Practice Support Publisher, 2006).
CHAPTER 5—CALCULATING PHYSICIAN SUPPLY: THE MODEL—ASSUMPTIONS, RELEVANT PARAMETERS, AND THE ALGORITHM 1. D. Etzioni, J. Liu, M. Maggard, C. Y. Ko, “The Aging Population and Its Impact on the Surgery Workforce,” Annals of Surgery 238 (2003): 170–176. 2. Richard A. Cooper, “There’s a Shortage of Specialists: Is Anyone Listening?” Academic Medicine 77 (2002): 761–766; R. A. Cooper, T. E. Getzen, and P. Laud, “Economic Expansion Is a Major Determinant of Physician Supply and Utilization,” Health Services Research 38 (2003): 675–696; R.A. Cooper, T. E. Getzen, H. J. McKee, and P. Laud, “Economic and Demographic Trends Signal an Impending Physician Shortage,” Health Affairs 21 (2002): 140–154. 3. J. P. Weiner, “A Shortage of Physicians or a Surplus of Assumptions?” Health Affairs (Millwood) 21 (2002): 160–162. 4. U.S. Department of Health and Human Services Health Resources and Services Administration Bureau of Health Professions, Physician Supply and Demand: Projections to 2020 (Health Resources and Services Administration, Department of Health & Human Services, October 2006), ftp://ftp.hrsa.gov/bhpr/workforce/PhysicianFore castingPaperfinal.pdf (accessed July 11, 2008). 5. Roger D. Blackwell, Thomas E. Williams, and Alan Ayers, “Consumer Driven Health Care,” (Ashland, Ohio: Book Publishing Associates, 2005) 127–130. 6. Council On Graduate Medical Education, “Physician Workforce Policy Guidelines for the United States, 2000—2020, January 2005,” Sixteenth Report, https://ser vices.aamc.org/Publications/showfile.cfm?file=version111.pdf&prd_id=229&prv_ id =279&pdf_id=111 (accessed July 2, 2008). 7. Richard A. Cooper, “There’s a Shortage of Specialists: Is Anyone Listening?” 2002; R. A. Cooper, T. E. Getzen, and P. Laud, “Economic Expansion Is a Major Determinant of Physician Supply and Utilization,” 2003; R. A. Cooper, T. E. Getzen, H. J. McKee, and P. Laud, “Economic and Demographic Trends Signal an Impending Physician Shortage,” 2002; Council On Graduate Medical Education, “Physician Workforce Policy Guidelines for the United States, 2000–2020, January 2005. 8. D. Scalise, “2005 Physician Supply. The Physician Workforce,” November 17, 2005, http://www.hhnmag.com/hhnmag_app/hospitalconnect/search/article.jsp?dcrpath =HHNMAG/PubsNewsArticle/data/0511HHN_FEA_gatefold&domain=HHNMAG (accessed March 19, 2008). 9. U.S. Department of Health and Human Services Health Resources and Services Administration Bureau of Health Professions, “Physician Supply and Demand: Projections to 2020,” 2006. 10. AAMC, “Questions and Answers About the AAMC’s New Physician Workforce Position,” http://www.aamc.org/workforce/workforceqa.pdf (accessed March 20, 2009). 11. AAMC. “U.S. Medical School Enrollment Projected to Rise 21 Percent by 2012. Both New and Existing Schools Will Fuel Growth,” http://www.aamc.org/newsroom/ pressrel/2008/080501.htm (accessed March 20, 2009).
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12. R. A. Cooper, T. E. Getzen, H. J. McKee, and P. Laud, “Economic and Demographic Trends Signal an Impending Physician Shortage,” 2002. 13. J. P. Weiner, “A Shortage of Physicians or a Surplus of Assumptions?” 2002. K. Grumbach, “The Ramifications of Specialty-Dominated Medicine,” Health Affairs (Millwood) 21 (2002): 155–157. 14. Gail Garfinkel Weiss, “Productivity Takes a dip,” Medical Economics 18 (2005): 86–94.
CHAPTER 6—ORTHOPEDIC SURGERY 1. American Academy of Orthopedic Surgeons, “Patient Demographics—Information about Orthopaedic Patients and Conditions,” http://www.aaos.org/Research/stats/patient stats.asp (accessed May 4, 2008). 2. American Academy of Orthopedic Surgeons, “Patient Demographics—Information about Orthopaedic Patients and Conditions.” 3. “Replaceable You—Can the System Keep Up with Demand for New Hips and Knees?” http://stanmeddev.stanford.edu/2008spring/replaceable_you.html (accessed May 9, 2008). 4. P. Lee, C. A. Jackson, D. A. Relles, “Demand-Based Assessment of Workforce Requirements for Orthopaedic Services,” Journal of Bone and Joint Surgery 80 (1998): 313–326; J. D. Heckman, P. P. Lee, J. N. Weinstein, et al., “Orthopaedic Workforce in the Next Millennium,” Journal of Bone and Joint Surgery 80 (1998): 1533–1551. 5. Frances A. Farley, James N. Weinstein, Gordon M. Aamoth, et al., “Workforce Analysis in Orthopaedic Surgery: How Can We Improve the Accuracy of Our Predictions?” Journal of American Academy of Orthopedic Surgeons 15 (2007): 268–273. 6. Wennberg J. E., Cooper M., The Dartmouth Atlas of Healthcare, (Chicago, Ill: American Hospital Publishing, 1998). 7. J. D. Heckman, P. P. Lee, J. N. Weinstein, et al., “Orthopaedic Workforce in the Next Millennium,” Journal of Bone and Joint Surgery 80 (1998): 1533–1551. 8. American Academy of Orthopaedic Surgeons, “Density of Orthopaedic Surgeons 2000 to 2004 by State,” http://www.aaos.org/Research/stats/Density.pdf (accessed May 4, 2008). 9. Gary Bos M.D., personal communication. 10. American Osteopathic Academy of Orthopedics, http://www.aoao.org/aoao/ Residencies/FAQ.html#Q2 (accessed May 13, 2008). 11. “Why Hospitals Love You,” Medical Economics, November 5, 2004. 12. Innovations Center Future Database, Future of Orthopedics, Page 2, The Advisory Board Company, http://www.advisory.com/members/default.asp?contentid= 72712&collectionid=1188&program=14&contentarea=606583 (accessed July 3, 2009). 13. Merritt Hawkins & Associates, “Survey Report, 2004 Survey of Physicians 50–65 Years of Age, Based on 2003 Data,” www.merritthawkins.com/pdf/2004_phy sician50_survey.pdf (accessed July 25, 2006). 14. American Academy of Orthopaedic Surgeons, “Orthopaedic Practice in the U.S. 2005–2006 Final Report,” http://www.aaos.org/Research/stats/2006opus.pdf (accessed May 10, 2008). 15. American Academy of Orthopaedic Surgeons, “Orthopaedic Practice in the U.S. 2005–2006 Final Report.”
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16. S. W. Castillo, “Orthopedic practice in the U.S. 2005–2006. Final report. June 2006,” American Academy of Orthopedic Surgeons. 17. Carlos Lavernia M.D., personal communication. 18. SullivanCotter Associates, ‘2006 On Call Survey Report,” http://www.sullivan cotter.com/ (accessed April 26, 2007). 19. Merritt, Hawkins & Associates, “2007 review of Physicians and CRNA recruiting incentives,” www.merritthawkins.com (accessed February 9, 2008). 20. E. S. Salsberg, A. Grover, M. A. Simon et al., “An AOA Critical Issue. Future Physician Workforce Requirements: Implications for Orthopaedic Surgery Education,” Journal of Bone and Joint Surgery 90 (2008): 1143–1159.
CHAPTER 7—CARDIOTHORACIC SURGERY 1. “Executive Summary of the Society of Thoracic Surgeons, Fall Report 2007,” http://www.sts.org/documents/pdf/ndb/Fall_2007_Executive_Summary.pdf (accessed May 11, 2008). 2. William Gay, personal communication. 3. R. J. Shemin, S. W. Dziuban, L. R. Kaiser et al., “Thoracic Surgery Workforce: Snapshot at the End of the Twentieth Century and Implications for the New Millennium,” The Annals of Thoracic Surgery 73 (2002): 2014–32; A. Grover, American Association of Medical Colleges Workforce Analysis for Cardiothoracic Surgery, personal communication, 2008. 4. L. H. Cohn, R. P. Anderson, F. D. Loop et al., “Thoracic Surgery Workforce Report,” The Journal of Thoracic and Cardiovascular Surgery 110 (1995): 570–585. 5. R. J. Shemin, S. W. Dziuban, L. R. Kaiser et al., “Thoracic Surgery Workforce: Snapshot at the End of the Twentieth Century and Implications for the New Millennium,” 2002. 6. William Gay, personal communication. 7. A. Grover, American Association of Medical Colleges Workforce Analysis for Cardiothoracic Surgery, personal communication, 2008. 8. Wennberg D. E., Birkmeyer J. D, Eds., The Dartmouth Atlas of Cardiovascular Care, (Chicago: AHA Press, 1999), http://www.dartmouthatlas.org/atlases/atlas_se ries.shtm (accessed May 8, 2008). 9. A. Grover, personal communication, 2008. 10. R. J. Shemin, S. W. Dziuban, L. R. Kaiser et al., “Thoracic Surgery Workforce: Snapshot at the End of the Twentieth Century and Implications for the New Millennium,” 2002. 11. National Residents Matching Program, “Match Results Statistics Thoracic Surgery Fellowship,” http://www.nrmp.org/fellow/match_name/thoracic/stats.html (accessed May 7, 2008): 2.1. 12. Frederick L. Grover, “The Bright Future of Cardiothoracic Surgery in the Era of Changing Health Care Delivery: An Update,” The Annals of Thoracic Surgery 85 (2008): 8–24.
CHAPTER 8—OTOLARYNGOLOGY 1. American Academy of Otolaryngology, “Head and Neck Surgery,” http://www. entnet.org/ (accessed May 19, 2008).
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2. Federal Drug Administration, “Cochlear Implants—Center for Devices and Radiological Health,” http://www.fda.gov/cdrh/cochlear/index.html (accessed May 11, 2008); ENT Link, “Cochlear Implants,” http://www.entnet.org/healthinfo/ears/cochle ar-implant.cfm (accessed May 18, 2008); “Cochlear Implants,” http://www.nidcd.nih. gov/health/hearing/coch.asp (accessed May 18, 2008). 3. National Institute on Deafness and Other Communication Disorders, “Cochlear Implants,” http://www.nidcd.nih.gov/health/hearing/coch.asp (accessed May 19, 2008). 4. “Cochlear Implant Increases Access To Mainstream Education,” http://www. hopkinsmedicine.org/press/1999/APRIL99/990429.HTM (accessed May 19, 2008). 5. American Cancer Society, “Cancer Facts and Figures, 2005,” (Atlanta: American Cancer Society, 2005). 6. “Laryngeal Cancer,” http://www.origin8.nl/medical/alaryngea2.htm (accessed May 19, 2008). 7. C. R. Cannon, E. M. Giaimo, T. L. Lee et al., “Special Report: Reassessment of the ORL-HNS Workforces: Perceptions and Realities,” Otolaryngology—Head and Neck Surgery 131 (2004): 1–15. 8. Robert H. Miller, “Otolaryngology Manpower in the Year 2010,” Laryngoscope 103 (1992): 750–753. 9. B. W. Jafek, N. Slenkovich, S. Sheikali, “Physician Workforce in Otolaryngology,” Otolaryngology—Head and Neck Surgery 115 (1996): 306–311. 10. G. F. Anderson, K. C. Han, R. H. Miller et al., “A Comparison of Three Methods for Estimating the Requirements for Medical Specialists: The Case of Otolaryngologists,” Health Services Research 32 (1997): 139–53. 11. H. C. Pillsbury, R. C. Cannon, S. E. Sedory Holzer et al., “The Workforce in Otolaryngology—Head and Neck Surgery: Moving into the Next Millennium,” Otolaryngology – Head and Neck Surgery 123 (2000): 341–56. 12. B. W. Jafek, N. Slenkovich, S. Sheikali, “Physician Workforce in Otolaryngology,” Otolaryngology—Head and Neck Surgery, 1996. 13. “Osteopathic Otolaryngology/Facial Plastic Surgery Residencies,” (Rev. October, 2006), http://www.aocoohns.org/pdf/ENT_RESIDENCY_LISTrev_10_2006.pdf (accessed May 14, 2008). 14. B. W. Pearson, J. D. Osguthorpe, “What Our Residents Think,” Otolaryngology— Head and Neck Surgery 94 (1986): 139–142. 15. D. A. Newton, M. S. Grayson, L. F. Thompson, “The Variable Influence of Lifestyle and Income on Medical Students’ Career Specialty Choices: Data from Two U.S. Medical Schools, 1998–2004,” Academic Medicine 80 (2005): 809–14. 16. C. R. Cannon, E. M. Giaimo, T. L. Lee et al., “Special Report: Reassessment of the ORL-HNS Workforces: Perceptions and Realities,” 2004; H. C. Pillsbury, R. C. Cannon, S. E. Sedory Holzer et al., “The Workforce in Otolaryngology—Head and Neck Surgery: Moving into the Next Millennium,” 2004. 17. F. Kwakawa, O. Jonasson, “The Longitudinal Study of Surgical Residents, 1993–1994,” Journal of the American College of Surgeons 183 (1996): 425–433. 18. D. G. Kirch, E. Salsberg, “The Physician Workforce: Response of the Academic Community,” Annals of Surgery 246 (2007): 535–540. 19. C. R. Cannon, E. M. Giaimo, T. L. Lee et al., “Special Report: Reassessment of the ORL-HNS Workforces: Perceptions and Realities, 2004.
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CHAPTER 9—OBSTETRICS AND GYNECOLOGY 1. “What Is an Obstetrician/Gynecologist (OB/GYN)?” http://www.womenshealth channel.com/obgyn.shtml (accessed May 28, 2008). 2. Centers for Disease Control and Prevention, “Assisted Reproductive Technology: Home,” http://www.cdc.gov/ART/ (accessed May 28, 2008). 3. Centers for Disease Control and Prevention, “Assisted Reproductive Technology Surveillance—United States, 2005,” http://www.cdc.gov/mmwr/preview/mmwrhtml/ ss5705a1.htm?s_cid=ss5705a1_e/ (accessed May 28, 2008). 4. “Ovarian Cancer,” http://www.cancer.org/docroot/CRI/content/CRI_2_4_1X_ What_are_the_key_statistics_for_ovarian_cancer_33.asp?sitearea=(accessed May 28, 2008). 5. “Ovarian Cancer,” What are the key statistics for ovarian cancer. 6. Institute of Medicine, “Preterm Birth: Causes, Consequences, and Prevention,” Released on July 13, 2006 http://www.iom.edu/CMS/3740/25471/35813.aspx, (accessed June 27, 2009); Institute of Medicine, “Preterm Birth: Causes, Consequences, and Prevention. Report Brief, July 2006.” 7. United Census Bureau, http://www.census.gov/ipc/www/usinterimproj/natproj tab02a.pdf (accessed June 3, 2008). 8. W. H. Pearse, W.H.J. Haffner, and A. Primack, “Effect of Gender on the ObstetricGynecologic Workforce,” Obstetrics & Gynecology 97 (2001): 794–97. 9. ACOG Resource Center, “Manpower Statistics,” (Washington DC, 2004),
[email protected] May 30, 2008). 10. M. Signer, “National Residency Matching Program: results and data 2004 match,” Report of the National Resident Matching Program (Washington, DC: National Resident Matching Program, 2004). 11. Association of American Medical Colleges, “A Chart Book. Center for workforce studies. August 2006,” Physician Specialty Data. 12. R. P. McAlister, D. A. Andriole, S. E. Brotherton et al., “Are Entering Obstetrics/Gynecology Residents More Similar to the Entering Primary Care or Surgery Resident Workforce?” American Journal of Obstetrics and Gynecology 197 (2007): 536. e1–536.e6. 13. I. Jacoby, G. S. Meyer, W. Haffner et al., “Modeling the Future Workforce of Obstetrics and Gynecology,” Obstetrics and Gynecology 92 (1998): 450–456. 14. ACOG Resource Center, “Manpower Statistics,” (Washington DC, 2004). 15. ACOG Resource Center, “Manpower Statistics,” (Washington DC, 2004). 16. I. Jacoby, G. S. Meyer, W. Haffner et al., “Modeling the Future Workforce of Obstetrics and Gynecology,” Obstetrics and Gynecology, 1998. 17. E. M. Lambert and E. S. Holmboe, “The Relationship between Specialty Choice and Gender of U.S. Medical Students, 1990–2003,” Academic Medicine 80 (2005): 797–802. 18. W. H. Pearse, W.H.J. Haffner, and A. Primack, “Effect of Gender on the ObstetricGynecologic Workforce,” Obstetrics & Gynecology 97 (2001). 19. W. H. Pearse, W.H.J. Haffner, and A. Primack, “Effect of Gender on the ObstetricGynecologic Workforce,” Obstetrics & Gynecology 97 (2001). 20. W. H. Pearse, W.H.J. Haffner, and A. Primack, “Effect of Gender on the ObstetricGynecologic Workforce,” Obstetrics & Gynecology 97 (2001). 21. P. Robinson, X. Xu, K. Keeton et al., “The Impact of Medical Legal Risk on Obstetrician-Gynecologist Supply,” Obstetrics and Gynecology 105 (2005): 1296–1301.
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22. W. H. Pearse, W.H.J. Haffner, and A. Primack, “Effect of Gender on the ObstetricGynecologic Workforce,” Obstetrics & Gynecology 97 (2001). 23. J. Silverman, “Malpractice crisis blamed; Fewer U.S. seniors match to ob. gyn residency slots: the fill rate for this group falls to 65.1%,” OB GYN News, April 01, 2004. 24. M. D. Pearlman and P. A. Gluck, “Medical Liability and Patient Safety: Setting the Proper Course,” Obstetrics and Gynecology 105 (2005): 941–943. 25. Robert C. Preston, J. D., personal communication. 26. Katie Gazella, “High cost of malpractice insurance threatens supply of ob/gyns, especially in some urban areas,” http://www.med.umich.edu/opm/newspage/2005/ obgyn.htm (accessed June 27,2009). 27. Centers for Disease Control and Prevention, “National Hospital Discharge Survey: 2005 Annual Summary With Detailed Diagnosis and Procedure Data,” Vital and Health Statistics, http://www.cdc.gov/nchs/data/series/sr_13/sr13_165.pdf (accessed May 28, 2008); T. Zwillich, “Preterm Birth and C-Section Rates Up Surgical Deliveries Continue Rapid Rise, CDC says,” WebMD Medical News, Nov. 15, 2005, http://www.webmd.com/content/Article/115/111635.htm (accessed June 9, 2008). 28. “Some health systems explore laborists idea,” USA TODAY, August 8, 2005.
CHAPTER 10—GENERAL SURGERY 1. American Board of Surgery, “Specialty of General Surgery Defined,” http:// home.absurgery.org/default.jsp?aboutsurgerydefined&ref=about (accessed May 14, 2008). 2. American Cancer Society, “Breast Cancer Facts and Figures, 2005–2006,” http://www.cancer.org/docroot/STT/content/STT_1x_Breast_Cancr_Facts__ Figures_2005–2006.asp (accessed January 21, 2008); SEER, “5-Year Relative Survival Rates by Race,” http://seer.cancer.gov/faststats/sites.php?site=Breast=Cancer&stat= Survival (accessed January 21, 2008). 3. Susan G. Komen Race for the Cure, http://ww5.komen.org/ (accessed June 28, 2009). 4. M. J. Mack, “Minimally Invasive and Robotic Surgery,” Journal of the American Medical Association 285 (2001): 568–572; Up to Date, “Laparoscopic Cholecystectomy,” http://www.uptodate.com/patients/content/topic.do?topicKey=biliaryt/6036& title=Gallstones (accessed May 16, 2008). 5. D. C. Lynge, E. H. Larson, M. Thompson et al., “A Longitudinal Analysis of the General Surgery Workforce in the United States, 1981–2005,” Archives of Surgery 143 (2008): 345–350. 6. D. A. Newton, and M. S. Grayson, “Trends in Career Choice by U.S. Medical School Graduates,” Journal of the American Medical Association 290 (2003): 1179–1182. 7. National Residency Matching Program, “Advance Data Tables—2008 Main Residency Match,” http://www.nrmp.org/data/advancedatatables2008.pdf (accessed May 16, 2008). 8. D. A. Newton, and M. S. Grayson, “Trends in Career Choice by U.S. Medical School Graduates,” 2003; F. Kwakawa and O. Jonasson, “The General Surgery Workforce,” Advisory Council for General Surgery, http://www.facs.org/about/councils/adv gen/gstitlpg.html (accessed May 17, 2008).
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9. 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 (SOSSUS),” (Baltimore: 1975). 10. Graduate Medical Education National Advisory Committee, “Summary Report to the Secretary,” Department of Health and Human Services (HRA 81–653), Health Resources Administration, Hyattsville, MD (1980) III. 11. Council on Graduate Medical Education (COGME), “Patient care physician supply and requirements: Testing COGME recommendations,” 8th Report, (Washington, DC: Department of Health and Human Services, 1996). 12. AMA Council on Long Range Planning and Development, “The Future of General Surgery,” Journal of the American Medical Association 262 (1989): 3178–3183. 13. G. F. Sheldon and A. T. Schroen , “Supply and demand—surgical and health workforce,” (Surgical Clinics of North America, September 2004). 14. Council on Graduate Medical Education, “Statement on the physician workforce,” (Washington, DC: Council on Graduate Medical Education, 2003). 15. Abt Associates, “Re-examination of the adequacy of physician supply made in 1980 by the Graduate Medical Education National Advisory Committee for selected specialties: Final Report,” HRSA 240–89–0041, (Springfield, VA: National Technical Information Service, United States Department of Commerce, 1991). 16. F. Kwakawa and O. Jonasson, “The Longitudinal Study of Surgical Residents, 1993–1994,” Journal of the American College of Surgery 183 (1996): 425–433. 17. G. F. Sheldon, “Surgical Workforce Since the 1975 Study of Surgical Services in the United States; An Update,” Annals of Surgery 246 (2007): 541–545. 18. North Carolina IOM Task Force on Primary Care and Specialty Supply, “Examining Provider Need by Specialty Area,” http://www.nciom.org/projects/supply/chap ter4.pdf (accessed May 17, 2008). 19. R. A. Cooper, S. J. Stoflet, and S. A. Wartman, “Perceptions of Medical School Deans and State Medical Society Executives about Physician Supply,” Journal of the American Medical Association 290 (2003): 2992–2995. 20. D. A. Newton, and M. S. Grayson, “Trends in Career Choice by U.S. Medical School Graduates,” 2003. 21. L. A. Neumayer, A. Cochran, S. Melby, et al., “The State of General Surgery Residency in the United States: Program Director Perspectives, 2001,” Archives of Surgery 137 (2002): 1262–1275. 22. J. D. Richardson, “Workforce and Lifestyle Issues in General Surgery Training,” Archives of Surgery 137 (2002): 515–520. 23. J. D. Richardson, “Workforce and Lifestyle Issues in General Surgery Training.” 24. K. B. Stitzenberg and G. F. Sheldon, “Progressive Specialization within General Surgery: Adding to the Complexity of Workforce Planning,” Journal of the American College of Surgeons 201 (2005): 925–932. 25. F. Kwakawa and O. Jonasson, “The General Surgery Workforce,” Advisory Council for General Surgery. 26. D. Etzioni, J. Liu, M. Maggard, et al., “The Aging Population and Its Impact on the Surgery Workforce,” Annals of Surgery 238 (2003): 170–176. 27. R. A. Cooper, T. E. Getzen, H. J. McKee et al., “Economic and Demographic Trends Signal an Impending Physician Shortage,” Health Affairs 21 (2002): 140–154.
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CHAPTER 11—NEUROSURGERY 1. C. Watts, “Neurosurgical Manpower,” Surgical Neurology 18 (1982): 241–245. 2. ABC News, “Woodruff, Cameraman Seriously Injured in Iraq,” January 29, 2006. 3. Encarnation Pyle, “What Now?” Columbus Dispatch, July 17, 2007. 4. Bernadine Healey, Living Time, Faith and Facts to Transform Your Cancer Journey, (New York, New York: Bantam Dell, 2007): 10. 5. E. Chiocca, personal communication, May 28, 2008. 6. E. Chiocca, personal communication, May 28, 2008. 7. E. Chiocca, personal communication, May 28, 2008. 8. American Academy of Neurosurgeons, “Relative Shortage of Neurosurgeons in the U.S. Alarms the Medical Society,” Press Release: May 3, 2004. 9. U.S. Department of Health and Human Services Health Resources and Services Administration Bureau of Health Professions, “Physician Supply and Demand: Projections to 2020,” (Health Resources and Services Administration, Department of Health & Human Services, October 2006), ftp://ftp.hrsa.gov/bhpr/workforce/Physi cianFore castingPaperfinal.pdf (accessed June 2, 2008). 10. Medical News Today, “Study Analyzes How The Malpractice Environment Impacts Practicing Neurosurgeons,” http://www.medicalnewstoday.com/articles/105599. php (accessed June 2, 2008). 11. O. N. Gottfried, R. L. Rovit, A. J. Popp et al., “Neurosurgical Workforce Trends in the United States,” Journal of Neurosurgery 102 (2005): 202–208. 12. Merritt, Hawkins & Associates, “Summary Report: 2005 Review of Physician Recruitment Incentives,” http://www.merritthawkins.com/pdf/2005_incentive_sur vey.pdf (accessed June , 2009). 13. “MD Salaries,” http://mdsalaries.blogspot.com/2007/10/2007-usa-physiciansalaries-survey.html (accessed June 2, 2008). 14. The Sun News, http://www.myrtlebeachonline.com/101/story/466769.html (accessed June 2, 2008); “Hospitals risk losing specialists in Ers,” Dayton Business Journal, November 18, 2005; “Rising fees for on-call specialists have hospitals seeing red,” San Jose Business Journal, October 24, 2005. 15. News Day, “Special Report: Saving Bobby,” http://www.newsday.com/news/ local/ny-bobby-main,0,4964596.story?page=3 (accessed June 2, 2008). 16. C. Watts, W. Adelstein, “Access to Neurosurgical Care,” Surgical Neurology 17 (1982): 223–226. 17. News Day, “Special Report: Saving Bobby.” 18. News Day, “Special Report: Saving Bobby.” 19. C. Cassels. Aggressive Malpractice Environments Dictate How, Not Where, Neurosurgeons Practice. Available at Medscape, http://www.medscape.com/view article/573903 (accessed June 2, 2008); Todd C. Hankinson, Leif Bohman, Monique Vanaman, et. al. “Geographical Workforce Analysis from 1990–2005 Improves Our Understanding of the Role of Market Factors,” Clinical Neurosurgery 55 (2008): 145–149. 20. Medical News Today, “Study Analyzes How The Malpractice Environment Impacts Practicing Neurosurgeons,” http://www.medicalnewstoday.com/articles/105599. php (accessed June 2, 2008). 21. C. Cassels. Medscape, http://www.medscape.com/viewarticle/573903; Medical News Today, “Study Analyzes How The Malpractice Environment Impacts Practicing Neurosurgeons,”
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22. W. K. Clark and Ransohoff J. Wrenn, “Summary. Neurosurgical manpower monitoring committee. 1976 Report,” American Association of Neurological Surgeons, (Chicago: 1976). 23. L. D. Lunsford, A. Kassam, Y. F. Chang et al., “Survey of United States Neurosurgical Residency Program Directors,” Neurosurgery 54 (2004): 239–245.
CHAPTER 12—UROLOGY 1. V. R. Patel, R. Thaly, and K. Shah, “Robotic Radical Prostatectomy: Outcomes of 500 Cases,” BJU International 99 (2007): 1109–1112; K. Baduani, S. Kaul, and M. Menon, “Evolution of Robotic Radical Prostatectomy: Assessment after 2776 Procedures,” Cancer 100 (2007): 1951–1958. 2. “Contemporary Aspects of Penile Prosthesis Implantation,” Urologia Internationalis, http://content.karger.com/ProdukteDB/produkte.asp?Doi=68189 (accessed June 11, 2008). 3. Urology Times, “Is There a Urologist in the House, Maybe Not For Long,” http:// urologytimes.modernmedicine.com/urologytimes/News=Feature/Is-there-a-urologistin-the-house-Maybe-not-for-lo/ArticleStandard/Article/detail/423954 (accessed May 27, 2008). 4. Urology Times, “Is There a Urologist in the House, Maybe Not For Long.” 5. Association of American Medical Colleges, Physician Specialty Data: A Chart Book, August 2006. 6. U.S. Department of Health and Human Services Health Resources and Services Administration Bureau of Health Professions, “Physician Supply and Demand: Projections to 2020,” (Health Resources and Services Administration, Department of Health & Human Services, October 2006). 7. J. F. Glenn, “Urologic Manpower and Training Program Survey,” The Journal of Urology 117 (1977): 137–142. 8. E. E. Fraley and E. Watkins, “Surgical and Urologic Manpower in the United States 1969–1978,” The Journal of Urology 127 (1982): 218–223. 9. J. S. Ansell, “Trends in Urological Manpower in the United States in 1986,” The Journal of Urology 138 (1987): 473–476. 10. E. E. Fraley and E. Watkins, “Surgical and Urologic Manpower in the United States 1969–1978,” 1982. 11. W. F. Gee, H. L. Holtgrewe, P. C. Albertsen et al., “Sub Specialization, Recruitment and the Retirement Trends of American Urologists,” The Journal of Urology 159 (1998): 509–511. 12. W. F. Gee, H. L. Holtgrewe, P. C. Albertsen et al., “Sub Specialization, Recruitment and the Retirement Trends of American Urologists,” 1998. 13. T. D. Allen, J. F. Glenn, R. T. Plumb, and W. J. Staubitz, “Too Much of a Good Thing. Editorial,” The Journal of Urology 120 (1978): 267. 14. Association of American Medical Colleges, Physician Specialty Data: A Chart Book 2006; D. L. McCullough, “Manpower Needs in Urology in the Twenty-first Century,” Urologic Clinics of North America 25 (1998): 15–22. 15. D. M. Weiner, R. McDaniel, and F. C. Lowe, “Urologic Manpower Issues for the 21st Century: Assessing the Impact of Changing Population Demographics,” Urology 49 (1997): 335–342. 16. Association of American Medical Colleges, Physician Specialty Data: A Chart Book 2006.
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17. Association of American Medical Colleges, Physician Specialty Data: A Chart Book 2006. 18. Association of American Medical Colleges, Physician Specialty Data: A Chart Book 2006. 19. W. F. Gee, H. L. Holtgrewe, P. C. Albertsen et al., “Sub Specialization, Recruitment and the Retirement Trends of American Urologists,” 1998. 20. Association of American Medical Colleges, Physician Specialty Data: A Chart Book 2006. 21. D. L. McCullough, “Manpower Needs in Urology in the Twenty-first Century,” Urologic Clinics of North America 25 (1998): 15–22. 22. D. M. Weiner, R. McDaniel, and F. C. Lowe. Urology 49 (1997). 23. W. D. Steers andA. J. Schaeffer, “Is It Time to Change the Training of Urology Residents in the United States?” The Journal of Urology 173 (2005): 1451. 24. A. Stewart and J. Bolton, “Re: Urology Residency Training: Time to Speed up or Slow Down?” The Journal of Urology 175 (2006): 811–812. 25. Kevin B. Loughlin, “The Current Status of Medical Student Urological Education in the United States,” The Journal of Urology 179 (2008): 1087–1091. 26. Kevin B. Loughlin. The Journal of Urology 2008. 27. Kevin B. Loughlin. The Journal of Urology 2008.
CHAPTER 13—THE LAST HURDLE: THE BALANCED BUDGET ACT OF 1997 AND GRADUATE MEDICAL EDUCATION FUNDING 1. AAMC, “Medicare Direct Graduate Medical Education (DGME) Payments” http://www.aamc.org/advocacy/library/gme/gme0001.htm (accessed July 14, 2008). 2. Centers for Medicare and Medicaid Services, “Direct Graduate Medical Education (DGME),” http://www.cms.hhs.gov/AcuteInpatientPPS/06_dgme.asp#TopOfPage (accessed July 14, 2008). 3. AAMC, “Medicare Indirect Medical Education (IME) Payments,” http://www. aamc.org/advocacy/library/gme/gme0002.htm (accessed July 14, 2008). 4. S. Nicholson and D. Song, “The Incentive Effects of the Medicare Indirect Medical Education Policy,” Journal of Health Economics 20 (2001): 909–33. 5. Congressional Budget Office, “CBO’s March 2008 Baseline: MEDICARE,” http://www.cbo.gov/budget/factsheets/2008b/medicare.pdf (accessed September 12, 2008). 6. Congressional Budget Office, “CBO’s March 2008 Baseline: MEDICARE.” 7. J. A. Reuter, “The balanced budget act of 1997: Implications for graduate medical education. The Balanced Budget Act of 1997 [executive summary],” The Commonwealth Fund. 8. Council on Graduate Medical Education (COGME), “Patient Care Physician Supply and Requirements: Testing COGME Recommendations,” 8th Report, (Washington, DC: Department of Health and Human Services, 1996). 9. D. A. Jamadar R. Carlos, et al., “Estimating the Effects of Informal Radiology Resident Teaching on Radiologist Productivity: What is the Cost of Teaching?” HTAcademic Radiology 2 (2005): 123–128. 10. Richard A. Cooper, “It’s Time to Address the Problem of Physician Shortage: Graduate Medical Education is the Key,” Annals of Surgery 246 (2007): 527–534.
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11. Pew Commission Federal Policy Task Force, “Strengthening federal GME policy,” http://futurehealth.ucsf.edu/press_releases/pewgme.htm (accessed July 13, 2008). 12. Pew Commission Federal Policy Task Force, “Strengthening federal GME policy.” 13. E. Salsberg, “Medical School Expansion: On Track for a 30% Increase But Only One Part of the Solution,” (paper presented at The Fourth Annual AAMC Physician Workforce Research Conference, Crystal City, Virginia, May 1, 2008). 14. E. Salsberg, “Medical School Expansion: On Track for a 30% Increase But Only One Part of the Solution.” 15. D. N. Burkhart and T. A. Lischka, “Osteopathic Graduate Medical Education,” Journal of American Osteopathic Association 108 (2008): 127–137; Sarah E. Brotherton and Sylvia I. Etzel, “Appendix II, Table 1,” Journal of American Medical Association 298 (2007): 1081–1096. 16. Richard A. Cooper, “It’s Time to Address the Problem of Physician Shortage: Graduate Medical Education is the Key,”2004; Richard A. Cooper, “The Coming Era of Too Few Physicians,” Bulletin of the American College of Surgeons 93 (2008): 11–18. 17. AAMC, “AAMC survey of Housestaff Stipends, Benefits, and Funding. Autumn 2007 Report,” http://www.aamc.org/data/housestaff (accessed June 26, 2008).
CHAPTER 14—IS THERE A SOLUTION? NUMERICAL PROJECTIONS, AND IMPROVING PHYSICIANS’ PRODUCTIVITY 1. Health Care Advisory Board, “Physician Recruitment: Attracting Talent in a Competitive Market,” (Washington, DC: The Advisory Board Company, May 1, 2008), http://www.advisory.com/members/default.asp?contentID=73082&collectionID= 1021&program=14&filename=73082.xml (accessed May 27, 2008). 2. Health Care Advisory Board, “Physician Recruitment: Attracting Talent in a Competitive Market. 3. “University of Maine’s President Wants the School to Offer a Medical Degree,” Press Herald (Portland, Maine: September 24, 2005). 4. “UCF makes pitch for med school,” http://www.wesh.com/news/5341985/de tail.html (accessed September 8, 2008). 5. Medical News Today, “Three New Medical Schools Join AAMC Membership, USA,” http://www.medicalnewstoday.com/articles/99385.php (accessed Septmeber 8, 2008); PricewaterhouseCoopers’ Health Research Institute, “What works, Healing the healthcare staffing shortage,” http://www.teachinghosp.org/pdf/pwchealthstaffing shortage.pdf (accessed August 5, 2008). 6. “AAMC Head Calls for Increasing Enrollments by 30 Percent,” Chronicle of Higher Education, November 7, 2005, http://chronicle.com/daily/2005/11/2005110702n. htm (accessed September 8, 2008). 7. AAMC, “2007 U.S. Medical School Entering Class is Largest Ever.” http://www. aamc.org/newsroom/pressrel/2007/071016.htm (accessed September 8, 2008). 8. AAMC, “U.S. Medical School Enrollment Projected to Rise 21 Percent by 2012,” http://www.aamc.org/newsroom/pressrel/2008/080501.htm (accessed September 8, 2008). 9. John K. Iglehart, “Medicare, Graduate Medical Education, and New Policy Directions,” New England Journal of Medicine 359 (2008): 643–650.
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10. Cejka Search & American Medical Group Association, “2007 physician retention survey,” http://www.cejkasearch.com/media/news/physician-retention-survey2007-pr.htm (accessed September 1, 2008). 11. Advisory Board, “Physician Recruitment: Attracting Talent in a Competitive Market,” http://www.advisory.com/members/default.asp?contentID=77362&collecti onID=1720&program=7&filename=77362.xml (accessed August 6, 2008). 12. “Look south to see factory flexibility the Big 3 need,” The Detroit Times. August 26, 2007. 13. Advisory Board, “Physician Recruitment: Attracting Talent in a Competitive Market,” (Washington, DC: The Advisory Board Company, May 1, 2008), http://www. advisory.com/members/default.asp?contentID=77362&collectionID=1720&progra m=7&filename=77362.xml (accessed May 27, 2008). 14. Advisory Board, “Physician Recruitment: Attracting Talent in a Competitive Market” http://www.advisory.com/members/default.asp?contentID=73082&collectio nID=1021&program=14&filename=73082.xml (accessed August 7, 2008). 15. The Hospitalist, “As need for hospitalists grows, recruiters sweeten the pot to attract talent,” http://www.the-hospitalist.org/uploads/articles/THJuly2008Ar ticle268.pdf (accessed September 7, 2008). 16. The UCSF Surgical Hospitalist Program, http://medschool.ucsf.edu/news/ features/patient_care/20070604_SurgicalHospitalists.aspx (accessed September 7, 2008). 17. Jeff Bell, “ICU docs getting help,” Business First Of Columbus, October 29, 2004, http://www.bizjournals.com/columbus/stories/2004/11/01/story4.html?t=printable (accessed September 30, 2008). 18. “Shortage of intensivists physicians looms: report,” Modern Physician. July, 2006, http://www.modernphysician.com/Assets/DOC/2006MP/07MP2006.pdf (accessed September 30, 2008). 19. “Virtual Intensive Care Unit—ICU of the Future,” press release, Visicu Inc., July 17, 2002, https://www.visicu.com/press/news/storyItem109.html (accessed June 30, 2009). 20. “To Err Is Human: Building a Safer Health System,” Institute of Medicine, http:// www.nap.edu/catalog.php?record_id=9728 (accessed june 30, 2009). 21. NightHawk Radiology Services, “About NightHawk Radiology Services,” http:// www.nighthawkrad.net/index.php?page=about (accessed June 30, 2009). 22. Steve Twedt, “Medical tourism represents a $2.1 billion business, study shows,” Pittsburgh Post-Gazette, September 23, 2008, http://www.post-gazette.com/ pg/08267/914244–28.stm (accessed September 23, 2008); Medical Economics, October 3, 2008; 23. American Medical Association, “New AMA guidelines on medical tourism,” http://www.ama-assn.org/ama1/pub/upload/mm/31/medicaltourism.pdf (accessed July 1, 2009). 24. M. P. McQueen, “Paying Workers to Go Abroad for Health Care,” Wall Street Journal, September 30, 2008, http://online.wsj.com/article/SB122273570173688551. html (accessed September 30, 2008). 25. Linda A. Johnson, “Americans Look Abroad to Save on Health Care” San Fransisco Chronicle, August 3, 2008, http://www.sfgate.com/cgi-bin/article.cgi?f=/c/ a/2008/08/03/BUGA121GPF.DTL&type=health (accessed July 3, 2009). 26. Bangkok Heart Hospital, http://www.bangkokheart.com (accessed June 30, 2009).
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27. Schottenstien, Zox, and Dunn, L.P.A, “E-Prescribing and Electronic Health Record Technology Donation Rules Finalized.” http://www.szd.com/resources.php?Publi cationID=592&method=unique (accessed Spetember 1, 2008). 28. Conn J.I.T., “Subsidies Embraced,” http://www.modernhealthcare.com/apps/ pbcs.dll/article?AID=/20080225/REG/600458706/-1/toc25.02.08&nocache=1 (accessed September 9, 2008). 29. P. N. Bentley, A. G. Wilson , M. E. Derwin, et al., “Reliability of Assigning Correct Current Procedural Terminology- 4 E/M Codes,” Annals of Emergency Medicine 40 (2002): 269–274. 30. Advisory Board, “Physician Recruitment: Attracting Talent in a Competitive Market,” (Washington, DC: The Advisory Board Company, May 1, 2008).
CHAPTER 15—CHALLENGES AND CONSEQUENCES 1. Robert E. Falcone and Bhagwan Satiani, “Physician as Hospital Chief Executive Officer,” Vascular and Endovascular Surgery 42 (2008): 88–94. 2. Christopher M. Paul, personal correspondence to Thomas E Williams. Used with permission. 3. The Ohio State University College of Medicine, “MD Camp,” http://medicine. osu.edu/odca/7278.cfm (accessed September 22, 2008). 4. Student Doctor Network, “Why study medicine? Pre-meds not in it for the money, survey says,” http://www.studentdoctor.net/2008/04/why-study-medicinepre-meds-not-in-it-for-the-money-survey-says/ (accessed September 21, 2008). 5. MomMD, “Career and Life Balance Satisfaction—MomMD Women in Medicine Survey Results,” http://www.mommd.com/surveysatisfaction.shtml (accessed September 21, 2008). 6. Medschoolhell, “56 Hour Work Week Is On The Horizon,” http://www.med schoolhell.com/2008/05/22/56-hour-work-week-is-on-the-horizon/ (accessed September 22, 2008). 7. “One in four new MDs would pick another career, survey says” Physician Compensation Report, ( June, 2003), http://findarticles.com/p/articles/mi_m0FBW/is_6_4/ ai_102502935 (accessed September 21, 2008); Medical News Today, “Medical Students Open Up To Epocrates, Survey says.” 8. AAMC, “Financial Information, Resources, Services, and Tools,” http://www. aamc.org/programs/first/ (accessed September 22, 2008). 9. BNet, “One in Four new MDs Would Pick Another Career, Survey says,” http:// findarticles.com/p/articles/mi_m0FBW/is_6_4/ai_102502935 (accessed September 21, 2008). 10. BNet, “One in Four new MDs Would Pick Another Career, Survey says,” 11. Citronlegal.wordpress.com, “Texas challenges to medical malpractice law and damage caps,” http://citronlegal.wordpress.com2008/09/18/texas-challenges-to-med ical-malpractice-law-and-damage-caps/ (accessed September 22, 2008). 12. The Maryland Lawyer Blog, “Starting Salaries for First Year Lawyers in Baltimore: On the Rise?” http://www.marylandlawyerblog.com/2008/05/starting_sala ries_for_first_ye.html (accessed September 22, 2008). 13. The Rural Assistance Center, “MedPAC Recommends a Full Market Basket Update for Hospitals,” http://www.raconline.org/news/news_details.php?news_id= 7903(accessed September 22, 2008).
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14. Roger D. Blackwell, Thomas E. Williams, and Alan Ayers, Consumer Driven Health Care (Ashland, Ohio: Book Publishing Associates, 2005) 39–42.; Sally Pipes, Miracle Cure: How to Solve America’s Health Care Crisis and why Canada Isn’t the Answer (Vancouver: Fraser Institute, 2004). 15. Robert Steinbrook, “Private Health Care in Canada,” New England Journal of Medicine 354 (2006): 1661–1664 16. David Gratzer, Investor’s Business Daily “A Canadian Doctor Describes How Socialized Medicine Doesn’t Work,” http://www.manhattan-institute.org/html/_ibdcanadian_doctor_describes_how.htm (accessed October 26, 2008). 17. OECD Health Data 2009, “How Does Canada Compare,” http://www.oecd. org/dataoecd/46/33/38979719.pdf (accessed July 3, 2009). 18. “Study: Accessing first-contact health care services,” The Daily, February 13, 2006, http://www.statcan.ca/Daily/English/060213/d060213a.htm (accessed on October 26, 2008). 19. David Gratzer, Investor’s Business Daily. “A Canadian Doctor Describes How Socialized Medicine Doesn’t Work.” 20. Robert Steinbrook, 2006. 21. David Gratzer, Investor’s Business Daily. “A Canadian Doctor Describes How Socialized Medicine Doesn’t Work.” 22. David Gratzer, Investor’s Business Daily. “A Canadian Doctor Describes How Socialized Medicine Doesn’t Work.” 23. OECD Health Data 2009, “How Does Canada Compare.” 24. “Unsocialized Medicine,” Wall Street Journal, June 13, 2005, http://www.opin ionjournal.com/editorial/feature.html?id=110006813 (accessed October 26, 2008).
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Index Academic Medical Centers (AMC), 117 Accidents, unintentional, 11 Accreditation Council for Graduate Medical Education (ACGME), 24, 25, 28, 114 American Academy of Orthopedic Surgeons (AAOS), 67, 70 American Academy of OtolaryngologyHead and Neck Surgery, 83 American Association for Thoracic Surgery (AATS), 75 American Association of Medical Colleges (AAMC), 128 American Bar Association, 7 American board certification, 26 – 27 American Board of Medical Specialties, 99 American Board of Surgery, 97 American Board of Thoracic Surgery, 27 American Cancer Society, 86 American College of Cardiology, 12 American College of Surgeons, 97 American Medical Association (AMA), 24, 39, 89 American Medical Group Association (AMGA), 39 American Osteopathic Association (AOA), 114 American Surgical Association, 97 Arom, Kit V., 140 Arterial disease, 10
Assisted reproductive technology (ART), 85 Association of Academic Medical Colleges (AAMC), 32, 75 – 76, 84 Baby boom echo, 36 Balanced Budget Act (BBA) of 1997, 7, 114 – 21; post, 119 – 21; pre, 116 – 19 Balanced Budget Refinement Act (BBARA), 119 Barnard, Christian, 72 Becker, Ronald M., 140 Blalock, Alfred, 72 Bolton, John, 112 Bos, Gary, 69 Boutique care, 1 Brain drain, 49 – 52 Brain gain, 49 – 52 Brain surgery, selective, 104 Brain trauma, 103 – 4 Braunwald, Eugene, 12 Breast cancer, 93 – 94 Buerhaus, Peter, 20 Caesarian section deliveries, 91 – 92 Canada, health care in, 152 – 55 Cancer, 10 – 11 Cannon, C. Ron, 80 Cardiac defibrillators, 72 – 73
188 Cardiothoracic surgeons: board certification, 26–27; employment outlook, 73 –74; graduate medical education funding, 121; IMGs, 24; reimbursement, 43; residency program, 22 –23; retirement, 74; workforce issues, 74–77; work hours, 36 Cardiothoracic (CT) surgery, 72 – 77; heart disease, treatments for, 72 – 73 Cardiovascular surgery. See Cardiothoracic (CT) surgery CAT scans, 17 Center for Studying Health System Change, 39 Cerebrovascular disease, 10 Cholecystectomies, 94 – 95 Chronic diseases, 11 – 12 Circulatory disorders, 10 – 11 Class size of medical students, 128 – 30 Cochlear implants, 78 Cohen, Jordan J., 128 Color-flow ultrasounds, 17 Compensation, 29 – 31 Complaints, physician, 36 Concierge care, 1 Connors, Jimmy, 67 Consolidated Omnibus Budget Reconciliation Act (COBRA), 99, 114 – 15 Consumer price index, 39, 41, 116 Cooper, Richard, 5, 21, 121 Cooper’s Trend Analysis, 54 – 55 Coronary artery bypass procedures (CABG), 73 Council of Graduate Medical Education (COGME), 55, 68, 99, 115 Dartmouth Atlas, 8, 76 Death, treatment for leading causes of, 10 – 11 Defensive medicine, 44 Delivery model of health care, 19 – 20 Diagnosis Related Group (DRG), 118 Direct medical education (DME) reimbursement, 116 – 17 Disproportionate share payments (DSP), 114 Dutton, Steve, 34
Index Ear, nose and throat (ENT) surgeons. See Otolaryngologists Economic growth, 17 Educational Commission for Foreign Medical Graduates, 25 Edwards, Robert, 127 Electronic Intensive Care Units (e-ICUs), 138 – 39 Emergency medical services, 137 Emergency Medical Treatment and Active Labor Act (EMTALA), 70 ENT surgeons. See Otolaryngologists Exchange Visitor Program, 26 Falcone, Robert, 137 Fee-for-service plans, 20 Foreign-born international medical graduates (IMGs), 25 – 26, 49 – 50 Fraser Institute, 153 Full-time equivalents (FTE’s), 58, 84, 115, 116 Function shifting, 132 – 33 Funding for graduate medical education (GME), 121 – 26 Gallbladder, 94 – 95 General surgeons: board certification, 26 – 27; employment outlook, 96 – 97; graduate medical education funding, 121; medical student statistics, fourth year, 6; residency program, 22, 24; retirement, 98; statistics, 59; workforce issues, 97 – 102; work hours, 37 General surgery, 93 – 102; breast cancer, 93 – 94; defined, 93; gallbladder, 94 – 95; natural orifice translumenal endoscopic surgery, 95 – 96 Generation X (Xers), 36 Generation Y, 36 Gibbon, John, 72 Graduate medical education (GME). See also Graduate medical education funding: history of, 114 – 16; reverse, 130 – 31
Index Graduate medical education funding, 121 – 26; cardiothoracic surgeons, 121; general surgeons, 121; gynecologists/obstetrics surgeons, 121; Medicare, 114; neurosurgeons, 121; orthopedic surgeons, 121; otolaryngologists, 121 Graduate Medical Education National Advisory Committee (GMENAC), 98 Graduate medical student statistics, 61 – 63, 161 – 62 Grant Trauma Service, 137 Gratzer, David, 153 – 54 Gross, Robert, 72 Gross Domestic Product (GDP), 13, 17, 54, 56 Grover, Atul, 76 – 77 Gynecologists/obstetrics surgeons: board certification, 26 – 27; employment outlook, 87 – 89; graduate medical education funding, 121; residency program, 22, 24; retirement, 88 – 89; statistics, 59; workforce issues, 89 – 91; work hours, 36 Gynecology. See Obstetrics and gynecology (OB/GYN) Harris Interactive, 44 H-1B visa, 26 Health care: Canada, 152 – 55; cost of, 13 – 14; delivery model, 19 – 20; rural, 21 Health Care Advisory Board, 127 Health Care Financing Administration (HCFA), 115 Health & Human Services (HHS), 115 Health Professions Shortage Area (HPSA), 26 Health Resources and Services Administration (HRSA), 19, 55, 106 Healy, Bernadine, 104 Heart disease, treatments for, 72 – 73 Heart failure, 12 – 13 Herceptin, 94 Hip replacement, 67 Hospital: physician reimbursement vs., 42; reimbursement, 41 – 42 Hospitalists, 136 – 37 Howard, Philip K., 48
189 Imam, Naiyer, 139 Indirect medical education (IME) reimbursement, 117 – 18 Initial residency period (IRP), 115 Insurance, medical malpractice, 44 Intern, defined, 114 International medical graduates (IMGs), 2, 24 – 26; cardiothoracic surgeons, 24; foreign-born, 25 – 26, 49 – 50; statistics, 50; United States, 24 – 25 Intern & Resident Information System (IRIS), 115 In vitro fertilization, 85 Jennings, Peter, 103 Joint Commission for Accreditation for Hospitals, 139 Joint replacements, 16, 67 J-1 visa, 26 Knee replacement, 67 Komen Race for the Cure, 93 – 94 Laborists, 92 Laryngeal cancer, 78 – 80 Lavernia, Carlos, 70 Law School Admission Council, 7 Law School Admissions Test, 7 Lawyers vs. physicians, 7 Left brain, 104 Liaison Committee on Medical Education (LCME), 24 Loop, Fred, 104 Lumpectomy, 95 Malpractice. See Medical malpractice Malpractice insurance, 44 Managed care plans, 19 Matloff, Jack, 41 McCullough, David L., 111 McElroy, Mary Jo, 138 Medicaid, 13 Medical broker, 154 Medical College Admission Test (MCAT), 129 Medical College of Wisconsin, 5 Medical Economics, 139 Medical Group Management Association (MGMA), 39, 69
190 Medical malpractice, 43 – 49; defensive medicine, 44; defined, 44; insurance, 44; issues, current, 45 – 46; Michigan, 46; Ohio, 44 – 46; tort reform, 47 Medical safaris, 140 Medical students: class size, 128 – 30; graduate statistics, 61 – 63, 161 – 62; international graduates, 24 – 26; statistics, 2 – 3, 4; tuition, 32 – 38 Medical tourism, 139 – 40 Medical workforce. See Surgical/medical workforce Medically underserved area (MUA), 26 Medicare, 13, 28; graduate medical education funding, 114; indirect vs. direct medical education reimbursement, 117 – 18; reimbursement, 43, 84 Medicare, Medicaid and SCHIP Benefits Improvement and Protection Act (BIPA), 119 – 20 Medicare Prescription Drug, Improvement, and Modernization Act (MMA), 120 Merritt, Hawkins & Associates (MHA), 70 – 71, 106 Merritt Hawkins Survey, 52 – 53 Michigan medical malpractice, 46 Midwives, 91 – 92 Millennials, 36 Moonlight hours, 36 Morale, physician, 52 – 53 MRI scans, 17 Mullan, Fitzhugh, 26 National Academy of Sciences Institute of Medicine, 139 National Conference on Medical Malpractice, 45 National Institute of Health, 104 National Residency Matching Program (NRMP), 2, 22, 76 – 77 Natural orifice translumenal endoscopic surgery (NOTES), 95 – 96 Neurosurgeons: board certification, 26 – 27; employment outlook, 105; graduate medical education
Index funding, 121; residency program, 22; retirement, 105 – 6; statistics, 59 – 60; workforce issues, 105 – 7; work hours, 36 Neurosurgery, 103 – 7; advances in, 104 – 5; brain surgery, selective, 104; brain trauma, 103 – 4 Neurourology, 109 Nicklaus, Jack, 67 Nighthawk Radiology Services, 139 – 40 Nonphysician services, demand for, 20 – 21 Nurse Practitioners, 137 Obstetric hospitals, 92 Obstetricians. See Gynecologists/ obstetrics surgeons Obstetrics and gynecology (OB/GYN), 85 – 92; ovarian cancer, 85 – 86; premature delivery, 86 – 87; residency program, 22; in vitro fertilization, 85 Ohio Department of Insurance, 46 Ohio medical malpractice, 44 – 46 Ohio State University College of Medicine, 2, 51, 104 Ohio State University Hospital, 92 Open surgery reimbursement, 41 Orthopedic surgeons: board certification, 26 – 27; employment outlook, 68 – 69; graduate medical education funding, 121; residency program, 22, 24; retirement, 69; statistics, 59; workforce issues, 69 – 71 Orthopedic surgery, 67 – 71; reconstructive surgery, 67 Otolaryngologists: board certification, 26 – 27; employment outlook, 80 – 81; graduate medical education funding, 121; residency program, 22, 24; retirement, 82; statistics, 59; workforce issues, 81 – 84; work hours, 36 Otolaryngology (OL), 78 – 84; cochlear implants, 78; laryngeal cancer, 78 – 80 Outpatient prospective payment system (OPPS), 118 Outsourcing physicians, 1 – 8, 139 – 40 Ovarian cancer, 85 – 86
Index Pacemaker, 72 Part-time physicians, 131 – 32 Paul, Chris, 145 Penile prosthesis, 109 Percutaneous transluminal coronary angioplasty (PTCA), 72 Per-resident amount (PRA), 115, 116 Perrin, Tillinghast Towers, 46 PET scans, 17 Pharmacists, 20 – 21 Physician reimbursement, 38 – 52; vs. hospital, 42 Physicians: complaints, 36; lawyers vs., 7; morale, 52 – 53; outsourcing, 1 – 8, 139 – 40; part-time, 131 – 32; primary care, 35 – 36; productivity, improving, 135 – 39; reimbursement, 38 – 52; retirement, 52 – 53, 60 – 61, 132 – 34, 159 – 60; shortages, 4; statistics, 63 – 65, 163 – 64; supply and demand, 3 – 6, 14 – 21, 60; work force assessment models (See Physician supply); work/life balance, importance of, 36 – 38; younger generation, retention of, 142 – 43 Physicians Requirement Model (PRM), 54, 55 Physicians Supply Model (PSM), 54, 55 Physician supply, 54 – 65; assumption models, 54 – 59; calculating, 60 – 65; parameters, relevant, 59 – 60 Population aging, 15 – 16 Population Analysis, 54 Population growth, 15 – 16 Post Balanced Budget Act (BBA) of 1997, 119 – 21 Postgraduate year one residents (PGY-1), 2, 114 Pre Balanced Budget Act (BBA) of 1997, 116 – 19 Premature delivery, 86 – 87 Prescriptions, 18 Primary care physicians, 35 – 36 Private medical school tuition, 32 Public medical school tuition, 32 Radical mastectomy, 94 RAND Corporation, 68 Reconstructive surgery, 67
191 Registered nurses (RNs), 20 Reimbursement, 19 – 20; cardiothoracic surgeons, 43; direct medical education, 116 – 17; hospital, 41 – 42; indirect medical education, 117 – 18; Medicare, 43, 84; open surgery, 41; physician, 38 – 52; surgeon, 42; surgical, 40 Residency program, 22 – 31; American board certification, 26 – 27; applicants, origin of, 24; cardiothoracic surgeons, 22 – 23; compensation, 29 – 31; general surgeons, 22, 24; gynecologists/obstetrics surgeons, 22, 24; IMG, 50; letter to surgical, 144 – 52; neurosurgeons, 22; obstetrics and gynecology (OB/GYN), 22; orthopedic surgeons, 22, 24; otolaryngologists, 22, 24; surgical, letter to, 144 – 52; surgical supply, 22 – 31; training, shortening duration of, 134 – 35; urologists, 22; workforce, demographics of, 22 – 24; work hours, 27 – 29 Residency Review Committee, 69 Resident, defined, 114 Retirement: cardiothoracic surgeons, 74; general surgeons, 98; gynecologists/ obstetrics surgeons, 88 – 89; neurosurgeons, 105 – 6; orthopedic surgeons, 69; otolaryngologists, 82; physician, 52 – 53, 60 – 61, 132 – 34, 159 – 60; urologists, 109 – 10 Retton, Mary Lou, 67 Reverse graduate medical education (GME), 130 – 31 Richardson, J. David, 100 Robotic urology, 108 – 9 Rural health care, 21 SCHIP, 13 Schreiber, Stephen T., 7 Senior Urological Registrars Group, 112 Sheldon, George, 99 Social workers, 137 Society of Thoracic Surgeons (STS), 41, 73, 75 Stewart, Allison, 112
192 Study on Surgical Services for the United States (SOSSUS), 97 Suicide, intentional, 11 Supply and demand of physicians, 3 – 6, 14 – 21, 60 Surgeon reimbursement, 42 Surgical/medical workforce: cancer, 11; chronic diseases, 11 – 12; demand for, 10 – 21; employment outlook, 14 – 21; heart failure, 12 – 13; workforce issues, 14 – 20 Surgical reimbursement, 40 Surgical supply: constraints, 32 – 53; residencies, 22 – 31 Taussig, Helen, 72 Tax Equity and Fiscal Responsibility Act (TEFRA), 117 Technology advancement, 17 – 18 Teleradiology, 139 – 40 Thoracic Surgery. See Cardiothoracic (CT) surgery Thoracic Surgery Workforce Committee, 74 – 75 Tort reform, 47 Training, shortening duration of residency, 134 – 35 Tuition, 32 – 38 United Auto Workers (UAW), 133 United States Bureau of Health Professionals, 55 United States Bureau of Labor Statistics, 29 United States Census Bureau, 15, 56 United States Department of Health and Human Services, 19, 110
Index United States Food and Drug Administration, 78 United States international medical graduates (IMGs), 24 – 25 University of California, 137 University of Central Florida, 128 University of Eastern Tennessee, 21 University of Maine, 127 – 28 University of North Carolina, 99 Urologists: board certification, 26 – 27; employment outlook, 109 – 10; residency program, 22; retirement, 109 – 10; statistics, 60; workforce issues, 110 – 13 Urology, 108 – 13; neuro, 109; penile prosthesis, 109; robotic, 108 – 9 Veterans Administration, 114, 120 Visas, 26 Visicu, Inc., 138 Vision corrections, 16 Wall, Norman, 50 Western Surgical Association, 100 Woodruff, Bob, 103 Work force assessment models. See Physician supply Work horse doctors, 52 Work hours, residency, 27 – 29 Work/life balance, importance of, 36 – 38 Work Per Capita Analysis, 54 Work relative value units (WRVUs), 43 Zion, Libby, 27 – 28
About the Authors THOMAS E. WILLIAMS, JR., M.D., PH.D.; FACS, completed his surgical internship at The Presbyterian Hospital in New York City in 1964 and his residency at The Ohio State where he is Clinical Associate Professor of Surgery. He won the Excellence in Teaching award for the Department of Surgery in 2004. He is author of Consumer Driven Health Care with Roger Blackwell and Alan Ayers. Dr. Williams has served on many boards and has contributed to more than 70 journal articles and presentations. Some of his professional affiliations include the American Medical Association, the Society of Thoracic Surgeons, and the American Association for Thoracic Surgery. Dr. Williams has also served as a physician on missions in Vietnam, Cambodia, New Guinea, Rwanda, Malawi, and the Dominican Republic. BHAGWAN SATIANI, M.D., M.B.A; FACS, is a professor of clinical surgery in the Division of Vascular Diseases & Surgery, and medical director of the Non-Invasive Vascular Laboratory at The Ohio State University College of Medicine in Columbus. He has practiced vascular surgery since 1978. He has 115 peer-reviewed publications and has been a speaker at numerous national and international meetings. Dr. Satiani has an M.B.A. in Healthcare Management and is a Fellow of the American College of Healthcare Executives. He is president of Savvy Medicine Inc., which was formed to provide leadership in the area of business education for physicians, and he lectures frequently on business education/practice management to physicians. His three-volume set The Smarter Physician, published by MGMA in 2007, is a comprehensive resource for physicians to assist them in dealing with the economic, legal, and personal finance challenges ahead. Dr. Satiani also teaches an 18-month practice management curriculum for surgical residents in the Department of Surgery. Dr. Satiani’s many community interests include serving on the board
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About the Authors
of ASHA-Ray of Hope, a Columbus, Ohio, organization to prevent domestic violence among South Asians. E. CHRISTOPHER ELLISON, M.D.; FACS, is currently the Robert M. Zollinger Professor of Surgery and Chairman of the Department of Surgery at Ohio State University. He also serves as the Associate Vice President for Health Sciences and Vice Dean of Clinical Affairs of the College of Medicine. A Columbus, Ohio, native, Dr. Ellison received his undergraduate degree from the University of Wisconsin and his medical degree from the Medical College of Wisconsin. He returned to Columbus for general surgery residency at Ohio State. Dr. Ellison then joined the university in 1984 as assistant professor, and also served for six years as director of the general surgery residency program. His research interests include pancreatic disease, hepatic cancer, wound healing, and Zollinger-Ellison Syndrome. Dr. Ellison is a recent past president of the Central Surgical Association, as well as a past chapter president and governor-at-large of the American College of Surgeons (ACS) and currently serves on the ACS Advisory Council for General Surgery. He is a past vice president of the American Association of Endocrine Surgeons. He also serves on the editorial board of the American Journal of Surgery. Dr. Ellison was elected in 2003 to the American Board of Surgery as a representative of the ACS. For the past three years he has served as chair of the ABS Examination Committee. He was elected this winter as vice chair of the American Board of Surgery for 2009–2010. He will serve as chair of the ABS in 2010–2011.
About the Series Editor JULIE SILVER, M.D., is Assistant Professor, Harvard Medical School, Department of Physical Medicine and Rehabilitation, and is on the medical staff at Brigham & Women’s, Massachusetts General and Spaulding Rehabilitation Hospitals in Boston, Massachusetts. Dr. Silver has authored, edited, or co-edited more than a dozen books, including medical textbooks and consumer health guides. She is also the Chief Editor of Books at Harvard Health Publications. Dr. Silver has won many awards, including the American Medical Writers Association Solimene Award for Excellence in Medical Writing and the prestigious Lane Adams Quality of Life Award from the American Cancer Society. Dr. Silver is actively teaching health care providers how to write and publish, and she is the founder and director of an annual seminar titled Publishing Books, Memoirs and Other Creative Non-Fiction, facilitated by the Harvard Medical School Department of Continuing Education.
