Experts Say Projected Surgeon Shortage a “Looming Crisis” for Patient Care

Since the economic nosedive began, orthopedic surgeon Thomas Fehring, MD, has watched his 3-month patient wait list for joint replacement surgery shrink to about 6 weeks. Facing a recession, some patients will delay elective surgical procedures and some surgeons may postpone retirement as they wait for the economy to rebound. But Fehring and others say the country's economic woes cannot derail a projected shortage of surgeons that will endanger patient care in the coming years.

“There's a looming crisis,” says Fehring, of OrthoCarolina Hip and Knee Center in Charlotte, NC.

During the American Academy of Orthopedic Surgeons' annual meeting earlier this year, Fehring presented a workforce analysis based on data from the academy. His calculations show that if recent trends continue in numbers of joint replacements performed annually, in surgeon retirement, and in residents' waning interest in pursuing careers in joint replacement surgery, by 2016 only 28% of needed knee replacements and 54% of needed hip replacements will be able to be completed.

Further complicating the scenario, says Fehring, are an aging population and increasing rates of obesity that are projected to double the demand for these procedures over the next decade. But joint replacement specialists are not alone in issuing warnings about upcoming surgeon shortages.

According to one report, the United States faces a potential shortage of 1300 general surgeons as early as next year (Williams TE, Ellison CE. Surgery. 2009;144[4]:548-554). Another recent study noted that by 2025, demand for cardiothoracic surgeons is projected to increase by 46% while the number of active cardiothoracic surgeons is expected to decrease by 21% (Grover A et al. Circulation. 2009;120[6]:488-494). Leaders in other surgical specialties, including neurosurgery and vascular surgery, also have warned that their ranks soon will be in short supply.

“We have fewer surgeons of all types, from general surgeons to urologists, per population than we did 10 years ago,” says George Sheldon, MD, director of the American College of Surgeons (ACS) Health Policy Research Institute. A number of factors set in motion decades ago created the declines now being observed, he notes, adding, “We have the perfect storm.”

In the late 1970s, the Graduate Medical Education National Advisory Committee launched an exhaustive study that predicted a surplus of 145 000 physicians by 2000. But Sheldon says that figure was based on an estimate that the US population would be 250 million in 2000—an underestimate. US Census Bureau figures report a 2000 population of 282 million.

By 1994, the Council on Graduate Medical Education (COGME) predicted that managed care would become dominant, and physician supply would shift toward a shortage of primary care physicians and a surplus of specialists. COGME said that the country should reduce the annual number of physicians entering practice by 25%. Then the Balanced Budget Act of 1997 capped federal funds for graduate medical education at 1996 levels.

From 1996 to 2006, the Association of American Medical Colleges (AAMC) has reported that the number of active general surgeons in the United States decreased by 2.3% and thoracic surgeons declined by 0.8%. But the number of orthopedic surgeons increased by 6.7%, neurological surgeons by 7.2%, plastic surgeons by 19.6%, and vascular surgeons by 41.7% (http://www.aamc.org/workforce/specialtydatabook/specialtydata.pdf).

Looking ahead, the federal Health Resources and Services Administration (HRSA) projects an overall 3% increase from 2005 to 2020 in the number of full-time equivalent (FTE) physicians practicing in surgical specialties. But these figures report wide variations among surgical subspecialties. For example, HRSA projects a 15% decrease in FTE physicians in thoracic surgery, but a 15% increase in FTEs in obstetrics and gynecology (http://bhpr.hrsa.gov/healthworkforce/reports/physiciansupplydemand/physiciansupplyprojections.htm).

The AAMC predicts an overall shortage of 124 000 FTE physicians by 2025, with 37.3% of the shortage in general primary care and 32.9% in surgery (http://services.aamc.org/publications/showfile.cfm?file=version122.pdf&prd_id=244&prv_id=299&pdf_id=122).

“It's hard to find a specialty that we think will have a surplus,” says Edward Salsberg, MPA, director of the AAMC's Center for Workforce Studies. “This is a serious matter,” adds Richard Cooper, MD, professor of medicine and senior fellow at the Leonard Davis Institute of Health Economics at the University of Pennsylvania, Philadelphia. “It used to be an interesting debate in the 1990s but now it's a crisis.”

Not everyone agrees. “It's hyperbole to say we're in crisis,” says Sam Finlayson, MD, vice chair of surgery at Dartmouth Medical School, Hanover, NH. The problem, says Finlayson, is not an overall shortage of surgeons but an imbalance in supply.

“Undersupply may be a problem in some areas, but oversupply is a problem in others,” he added.

An ACS map of national surgeon supply shows that about 30% (925) of the 3107 US counties have no surgeons, whereas the national average is about 45 surgeons per 100 000 population.

Projections of shortages or surpluses should be considered in a context of overall population growth over the next few decades. HRSA notes that the US population is projected to grow about 14% from 2005 to 2020, while the number of FTE primary care physicians is expected to increase by 19% during that time period.

An equally important part of discussions of physician supply is if or how patients' needs for health care services will change in the future. The US Census Bureau predicts that by 2030 nearly 20% of the US population will be 65 years and older. Between 2008 and 2050, the number of US residents 65 years and older is expected to double (to 88.5 million) and the 85 years and older population is projected to triple (to 19 million).

One forecast predicted that even if surgical utilization rates among various age groups remain constant, the overall amount of surgical work will increase by 14% to 47% between 2010 and 2020 (Etzioni et al. Ann Surg. 2003;238[2]:170-177).

“We're doing surgery on people at an older age than in the past,” says Salsberg. “Urology is definitely an aging specialty. There are several surgical specialties, in addition to general surgery, where there's room for concern.”

In fact, general surgery generates some of the greatest concern in debates about what constitutes adequate physician or surgeon supply. HRSA projects a 7% decrease in FTE general surgeons by 2025, continuing a trend that began more than 2 decades ago. Last year researchers at the University of Washington School of Medicine in Seattle reported that the number of general surgeons per 100 000 population has decreased by 25.9% over the past 25 years. Even though the rate of decline was greater in urban (27.2%) than rural (21%) areas, rural areas had fewer general surgeons per 100 000 population (5.02) compared with urban areas (5.85) (Lynge DC et al. Arch Surg. 2008;143[4]:345-350).

“The total number of surgeons has increased, but specialization also has increased and therefore the general surgeon-to-population ratios have decreased,” says Finlayson.

In some ways, general surgery is its own unique universe. Often the backbone of small, rural hospitals, general surgeons influence other medical specialties in their communities as well as their communities' economic viability.

“Without the general surgeon, family practice is hampered in delivering babies; the [emergency department] can't effectively take care of trauma patients; and the internists don't want to do complicated procedures, the example being colonoscopies,” says Brock Slabaugh, MPH, a senior vice president of the National Rural Health Association (NRHA).

Also, a study last year estimated that a general surgeon's economic worth to his or her hospital is between $1 million and $2.4 million annually (Cofer JB, Burns RP, J Am Coll Surg. 2008;206[5]:790-795). “The health care economy within a rural community is extremely significant,” adds Slabaugh. He says reaction to decreasing numbers of general surgeons in rural communities ranges “from concern to desperation.”

Experts say general surgeons and communities that need them are on a collision course with several important factors. In rural areas, the lifestyle of a single general surgeon—on call 7 days a week, 24 hours a day—is unattractive to many young physicians. Rural areas also have high proportions of citizens who are uninsured or living in poverty.

The trend toward specialization also plays an important role. “The work of general surgeons has become narrower and narrower,” says David Goodman, MD, director of Dartmouth’s Center for Health Policy Research in Lebanon, NH. “It's perfectly reasonable that general surgery has shrunk, for good or for bad, as orthopedics, otolaryngology, and gynecology have become more dominant in the care of certain kinds of patients. This creates a dilemma for rural areas; it is a real problem that has many dimensions.”

Proposed health system reform measures in the House and Senate include various incentives to strengthen primary care, but none of these are specifically aimed at surgery. The ACS is on record supporting a rollback of the Balanced Budget Act caps on graduate medical education funding, as well as liability insurance reform and expansion of medical school enrollment and residency programs. The NRHA is pushing to open the National Health Service Corps loan repayment program to general surgeons, and it supports federal tax deductions or credits created for general surgeons working in rural communities.

But Sheldon of the ACS and others say some changes will have to come from within the medical profession. They may include increased numbers of physician assistants and advanced practice nurses becoming involved in surgical procedures. Another option is having 3 or 4 surgeons in a rural area or small town share on-call hours instead of going it alone. “That's going to have to be one of the short-term solutions,” says Sheldon.