The overproduction of neurosurgeons jeopardizes future neurosurgical care

ELSEVIER

Controversy: Neurosurgical Manpower

Worldwide

THE OVERPRODUCTION OF NEUROSURGEONS JEOPARDIZES FUTURE NEUROSURGICAL CARE George Stranjalis, M.D. Department of Neurosurgery, Hygeia Hospital, Athens, Greece

Stranjalis G. The overproduction of neurosurgeons jeopardizes future neurosurgical care. Surg Neurol 1996;45:314-9. In some areas of the world the next generation of neurosurgeons is facing a serious problem. The training of an inappropriately large number of neurosurgeons will lead to underemployment/unemployment, which will have a direct impact on the quality of neurosurgical care. The following statistical data relate to local phenomena but reflect dilemmas to be considered by the international neurosurgical community since they exist in many countries. KEY

WORDS

Neurosurgical training, underemployment, unemployment, neurosuqical care, neurosurgical units, Greece.

STATISTICAL DATA CONCERNING NEUROSURGERYINGREECE

will remain unchanged! We will therefore have 280 neurosurgeons and 18 units (Table 3) for 10 million population. In Greece we have at present 1 neurosurgical operation per 2000 inhabitants per year which means that the operations per neurosurgeon ratio (including trainees) is 21:l. This ratio (including trainee operations) may decrease to 14:l by the year 2000 if we do not increase the number of operations performed nationally (Table 4), or may leave newly trained neurosurgeons unemployed. The consequence of this low operating rate, at the present time, is that the level of surgical experience among qualified neurosurgeons is poor and surgical training, in a practical sense, dangerously inadequate. It is inevitable that this problem will get worse and will influence the future quality of the neurosurgical services. In relation to other countries there are already too many training units and trainees (Table 5).

The present report presents data concerning: 1. the number and categories (state hospital, university, private, trainees) of neurosurgeons; 2. the number, type (academic, state, military or private) and spatial distribution of neurosurgical departments; 3. the ratios of training hospital per population and trainee per population; 4. the number and ratio of operations per neurosurgeon per population; and 5. comparisons with other countries. In Greece there are now 160 certified neurosurgeons and 81 trainees for 10 million people (Table 1). This means that there is one certified neurosurgeon per 62,500 population (Table 2). The number of certified neurosurgeons will be doubled by the beginning of next century, whereas the population Address reprint requests to: George Stranjalis Athens 10673, Greece. Received July 22, 1994; accepted July 18, 1995. 0090-3019/96/$15.00 SSDI 009&3019(95)004351

M.D.,

32 Skoufa

Street,

DISCUSSION The inadequate exposure of trainees to clinical material, followed by a sometimes long period of unemployment when certified, cannot produce neurosurgeons who are able to provide the best quality of care for the patients. Nor can these neurosurgeons adequately train future generations of trainees. Improving this situation will require: 1. An immediate reduction of the number of neurosurgical units (centralisation of facilities to increase the exposure of trainees to clinical experience). 2. A dramatic decrease of residents. The number of trainee posts should be correlated to the number of permanent state jobs. Those training abroad should be required to register this in order to be eligible to apply for permanent jobs. 3. Information campaigns directed towards general 655 Avenue

0 1996 by Elsevier Science Inc. of the Americas, New York, NY 10010

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of Neurosurgeons

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q

Number and Type of Neurosurgical Occupation

‘Ikp~ OF OCCUPATION

56 79 21 22 36 16 3 4 5 4 9 160 81 241

In Greece neurosurgeons are occupied, exclusively, tional Health System or in private practice. Exceptions and military doctors who can work in both sectors.

either in the Naare the academic

practitioners and neurologists about new techniques and methods. This approach should increase the referrals for operations to more appropriate levels. 4. Consideration of subspecialisation as an immediate measure in order to fight underemployment and unemployment. Since the major need for urgent neurosurgical consultation, particularly in the state hospitals, is due to head injury (mild or severe), the establishment of a new specialty or subspecialty, perhaps “neurotraumatology”, and the development of a neurosurgical network which will consist of “consultant neurotraumatologists” in each hospital could create 80 new jobs. Each neurotraumatologist would be able to provide emergency treatment and long term follow up for head trauma and

q

Numbers of Neurosurgeons in Other Countries COUNTRY

NWBER OF NEUROSURGEONS

USA Canada Japan Brazil Mexico Europe European Union Greece (1994) Gkece yeac 2000 Asia: Africa World wide *Clinical

and non-clinical

Number, Type and Distribution of Neurosurgical Units in Different Cities of Greece CITY

No.

Private State Hospital Directors Senior specialists Junior specialists Academics Professors Associate Professors Assistant Professors Instructors Military Certified neurosurgeons Residents Total

NEUROSURGEON/ POPULATION

4,156 193 3,561 1,609 280 6,594 2,200 160 280 9,618 361 23,940 neurosurgeons

1:61,000* 1:142,000 1:35,000 1:96,000 1:377,000 1:121,000 1:160,000 1:62,500 1:36,000 1:336,000 1:1,900,000 1:210,000 included.

3 15

Athens Thessaloni~ Heraklio (Crete) Patra Ioannina Larisa Total

Urns

(JWMBm-TypE)

10 state 2 university 1 state 1 university (under establishment) 1 state 1 university 1 university (under establishment) 1 state 18

spinal injuries. It is important that this should be a defined subspecialty and not seen as “failed neurosurgeons”. It should have its own specific training programs and be able to coordinate specialist trauma care. This analysis applies specifically to Greece, but the professional problem exists elsewhere, including the USA, Japan, and Brazil. More does not mean better. Perhaps this contribution will stimulate thought and comment in other countries. REFERENCES 1. World Directory of Neurological Surgeons. 7th Ed. Congress of Neurological Surgeons, 1993. 2. Residency programs in Neurological Surgery United States and Canada. Neurosurgery 1991;28:Sl-114. COMMENTARY

This paper by George Stranjalis is a very objective analysis of the situation as it is in Greece. I do not have the exact numbers on the situation here in Brazil, because there are many uncertified neurosurgeons working here, and worse, some of them are training young “neurosurgeons”. So the situation in Brazil is similar or worse. It seems to me that the recommendations suggested by the author are very appropriate and logical. Unfo~unately, in Brazil it is very difficult to solve many of the problems in the ways suggested by Dr. Stranjalis, because most solutions depend on political decisions and because Brazil is very large, with many regional differences. Our medical societies, specialized or not, are always trying to make things better, but the political obstacles are many. In summary, my impression of this paper is that the author is very courageous in saying many of these things, but the problem is not easy to solve, especially in Brazil. For sure, there are more neurosur-

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Surg Neural 1996:45:314-g

q,

Number of Operations Performed in 1994 and Expected Numbers for the Year 2000 in Relation to the Number of

Surgeons

POEM OPERATOR~~

YEAR

1994

NUDER OF OPERATIONS~

241

2000

OP~~ONS~OPU~~ON/ YEAR=

1:2,000

5,000

? 5,000

? 360

OP~~ONS~~~OS~GEON/ YEAR

21

? 1:2,000

? 14

aPotential operators are considered to be all the certified neurosurgeons and all the residents. bInciudes the total number of operations performed in Greece in all state and private hospitals during one year. ‘The respective number for North America and Western Europe is 1 operation per 1000-1500 inhabitants per year.

geons than we need, and most of them, usually undertrained, are doing very few surgeries. Cilherto

Machado

de Almeida, M.D. S&I Paulo, Brazil

Dr. George Str~jalis highlights the di~culties which are facing neurosurgical training in certain parts of the world where overcoverage rather than undercoverage has become the salient problem. It has long been known that the result of producing too many neurosurgeons leads to inadequate expe rience for the majority, and the unspoken but recognized corollary of that is an increase in unnecessary operations or operations which, from the most charitable point of view, are of doubtful value. One might therefore be concerned by the suggestion from Dr. Stranjalis that general practitioners be encouraged to refer for further procedures but, of course, if a full range of neurosurgery is not avaiiable in the particular circumstances to which he refers, then that would be worthwhile. The paradox is that in many areas of the world, neurosurgical coverage is either inadequate or does not exist. In these circumstances it is clearly the responsibility of government to train more people, to provide adequate funds for them to go abroad to study if training is not available in their own countries, and to see that they are properly supported with a salary and equipment when they return home. That is a major global problem. Where over-production of surgeons is a problem, the fiscal responsibility of government impinges

ia

Ratio of Neurosurgica~ Training Units/PopuIation and Neurosurgical Residents/Population

COUNTRY

TRAINING HOSP/ POPULATION

RESIDENT+# POPIJLATION

USA United Kingdom Greece

1:2,700,000* 1:1,600,000 1:660,000

1:350,000 1:700,000 1:125,000

%ew

vacancies

in training

programmes/year:

USA 130, Greece 20.

upon direction of labor, control of the medical profession, and the establishment of a fully state-supported service, all measures which many doctors find unacceptable and which, in some countries where tight control has already been established, have proved inimical to the free development of the surgical specialties. There is no short answer to this problem. Some measure of control of training and neurosurgica~ coverage is clearly the responsibility of governments-where there is under-provision, the problem is financial; where there is over-pro~sion, the problem is direction and control. Lindsay

Symon,

CBE, TD, FRCS London, England

l read this paper with interest. Ob~ously, this problem is not unique to Greece, but it is common in several other European countries. It is being debated even in the United States. In contrast, we in India face exactly the opposite situation; that is, a paucity of neurosurgeons. There are approximately 400 fully qualified neurosurgeons serving a population of nearly 900 million people (1 neurosurgeon for 2.5 million people). At any given time, there are an additional 120-150 trainees in the specialty, who no doubt contribute to the workforce. To achieve even a modest ratio of one neurosurgeon for one million people, we would need to triple the existing numbers. The situation is no better in other southeast Asian countries. To the best of my knowledge, there are approximately 40 neurosurgeons for 128 million population in Pakistan, less than 10 for 122 million in Bangladesh, 3-4 for 21 million in NepaI, and 4-5 for 18 million in Sri Lanka. Dr. Stranjalis’ concern regarding the adequacy of training under the prevailing conditions in Greece, where a consultant plus trainees perform only 21 major operations per year, is no doubt very genuine. In contrast, the situation in most neurosurgical services in India is excessive clinical burden on the limited staff, resulting in long waiting lists. In addition, it leaves little time for academic and research

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Surg Neurol 1996;45:314-9

activities. In 1993, the Neurosurgery Department at the All India Institute of Medical Sciences in New Delhi, with six full-time faculty and ten residents, operated on 2405 patients. The operations included 386 gliomas, 120 meningiomas, 111 pituitary adenomas, 54 craniopharyngiomas, 81 cerebellopontine-angle tumors, and 85 other intracranial space-occupying lesions. In addition, there were 367 operations for head injuries, 99 intracranial aneurysms, and 28 arteriovenous malformations. The 363 spinal operations included surgery for disc prolapse (203) spinal tumors (91) and craniovertebral anomalies (47). There were 212 shunts and 84 operations for peripheral nerve and brachial plexus injuries. A similar situation exists in several major centers in this country. One of the problems of major concern to Dr. Stranjalis and others in similar situations is the lack of adequate clinical material to train future neurosurgeons. In contrast, one of the important concerns we in developing countries have is that of exposure of our trainees to newly~merging subspecialties and advanced technology, in order to maintain high professional standards. I have no doubt that the global neurosurgical fraternity, preferably under the aegis of the World Federation of NeurosurgicaI Societies, could organize programs of mutual benefit. This could help resolve, at least partly, the perpetual dilemma of a certain number of trainees required to run the existing services and the need to provide for adequate training and the future career prospects of these trainees. All over the world, even where there is concern about the “overpopulation” of neurosurgeons, there is a paucity of those willing to work in remote areas or to participate in preventive and promotive work as well as research. Creating circumstances which will attract trained manpower for such activities is another way to remedy the current imbalances. I hope that the two extremes reflected in the situations prevailing in Greece and India will stimulate wider debate on the subject.

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Manpower of neurosurgeons is a serious problem not only in Greece as Dr. Stranjalis has described, but also in several other areas of the world. I would like to present the statistical data about the number of neurosurgeons and their activities in Japan, and make a comment on the specific problems in my

(March 1994). The annual ratio increase in population compared to the previous year was 0.29%, historically the lowest figure. The total population of Japan is expected to reach a plateau of less than 130 miIlion before 2010. The average life expectancy at birth today is 83 years for women and 78 years for men. Regarding the number of members registered in the Japanese Neurosurgical Society, in 1993 there were 3654 board-certified neurosurgeons and 2517 trainees (total 6171); however, this does not really represent the total number of active neurosurgeons. Neurosurgeons working in hospitals officially registered with the Japanese Neurosurgical Society numbered 2841 board-certified and 1696 trainees (total 4537). Other members are working as general practitioners or investigators in fields other than neurosurgery. Therefore, there is one active certified neurosurgeon per 43,700 population. The total number of certified neurosurgeons will be about 5200 by the year 2000, but only about 3300 of those will be active. This expectation is based on the number of young neurosurgical trainees and pre-retirement neurosurgeons. The number of young active trainees reached a maximum of 1741 in 1986, and has already reached a plateau (there were 1690 in 1993). The number of neurosurgeons who will retire within the next six years will gradually increase. There are 955 neurosurgical clinics certified by the Japanese Neurosurgical Society; they include 80 universities, 186major hospitals, and 689 small clinics. There are two hospital categories: Class A and Class C. Class A neurosurgical units are composed of university and major hospitals, and they have their own training systems. Class C hospitals are small units and all of them are affiliated with a Class A hospital; they provide training jointly with the a&hated class A hospital. The number of neurosurgical operations was 125,970 in 1993. This means 45 operations per active certified neurosurgeon, or 28 operations per neurosurgeon, including trainees, per year. The total number of operations in 1983 was 69,500, performed by 2800 active neurosurgeons-about 25 operations per neurosurgeon, including trainees. The ratio has shown only a slight increase in the last 10 years. On the other hand, there are about 1600 boardcertified neurologists in Japan, which is a small number compared with neurosurgeons. Stroke patients are generally cared for by neurosurgeons, although they are treated conservatively. Spine sur-

country.

gery is done by orthopedists,

Prakash

N. Tandon,

M.S., FRC3

New Delhi, India

Japan now has a population of 124.3 million

but the number

of

spinal surgeries performed by neurosurgeons has

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Surg Nemo1 1996;45:314-9

been increasing rapidly in recent years. The clinical work for strokes, chemo/radiotherapy of brain tumors, neuropatholo~, inte~entional neuroradiology, etc., is currently taken care of by neurosurgeons. Many young neurosurgical trainees are selecting their life’s work in various related fields of neurosurgery, and are becoming specialists in those fields. Most young neurosurgeons are also encouraged to spend some time during their training doing research in related fields of neuroscience. We are, of course, seriously concerned about the level of surgical experience among qualified neurosurgeons and trainees. But in my opinion, I am not so seriously worried about the future overproduction of neurosurgical manpower in Japan. Kintomo

Takakura,

M.D., Ph.D. Tokyo, dawn

Regarding the overproduction of neurosurgeons, the total population of Pakistan is approximately 120 million, and there are 50 certified neurosurgeons in 22 centers. There are 40 trainee neurosurgeons. At the moment, there is one certified neurosurgeon for every 2.4 million people. The average increase in certified neurosurgeons is between 3 and 5 per year. By the year 2000, there will be an additional 30 neurosurgeons; however, the population is increasing at an annual rate of 3.1%. The number of operations performed in all units in Pakistan is about 10,000 per year, which equals one operation for every 12,000 inhabitants each year. One certified neurosurgeon performs about 200 operations each year; if the 40 trainees are included, there are approximately 110 operations per surgeon per year. This is the maximum number of operations a neurosurgeon can perform in the hospital. Patients with brain and spine lesions have to wait for a while before they can be operated on, and I am sure that if there were more neurosurgeons, the number of operations would increase. The exposure of trainees to clinical material is adequate in Pakistan given the present system of training and the increase in population, The opportunities to perform neurosurgical operations will still be adequate even in the year 2000. Unemployment or underemployment of neurosurgeons is not currently a problem in Pakistan. There are 50 neurosurgeons in various categories (military, academic, private) currently in service, and four more who are retired but still working (all in private hospitals). At the moment, all available jobs are full, and we are planning for the future. Suggestions given to the government for increasing the number of jobs available include:

1. Every medical school should have five teaching positions: one Professor, one Associate Professor, one Assistant Professor, and two Senior Registrars. There are 19 medical schools in Pakistan, and although there should be 95 jobs available, there are only 39 existing academic jobs. 2. There are six private hospitals where neurosurgery is performed, and four retired neurosurgeons working at hospitals which also employ in-service neurosurgeons. The hospitals have been requested to employ full-time neurosurgeons, according to their requirements, 3. It has been suggested that every military hospital should have a neurosurgeon on staff. There are 24 military hospitals in Pakistan. 4. The suggestion mentioned by Dr. Stranjalis of creating a new subspecialty of “neurotraumatology” is interesting. We have suggested that the government create regular jobs for neurosurgeons in various districts in Pakistan-approximately 50 in number. However, it will be difficult to restrict the district neurosurgeons to trauma surgery, as many of them will be tempted to operate on cold cases, especially when plenty are available for operation. In summary, 1) Pakistan needs more neurosurgical units, rather than fewer; 2) we need to increase the number of residents; and 3) an information campaign is already being conducted in many ways. Iftikhar

AH Raja, M.D.

Multan, Pakistan I have puzzled a great deal about this matter in my lifetime: the appropriate number of doctors in any community and the appropriate number of specialists-neurosurgeons in particular. You will understand that in a developing country, these considerations are of prime importance because they determine which way one must invest manpower and money in order to provide an adequate and affordable service. If you look at the African continent, there are some countries with either no neurosurgeon, or just one or two (sometimes the two do not speak to one another!). It is not only a matter of placing a neurosurgeon there, but the availability of an infrastructure which will provide the capacity to perform the investigations which are essential for neurosurgical practice as judged by Western standards today. Often this is not possible because of difficulties in maintaining complex machinery in far-off regions. There are innumerable examples of splendid machines standing idle because there is no one to

Overproduction

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understand the basic mechanisms to get the machine going and keep it going. Therefore, there are in Africa, millions of people without neurosurgical care. We see this as a gross deficit. The counter argument to this is whether one should spend money, time, and effort on an “esoteric” subject like neurosurgery when people are dying of hunger, tuberculosis, and AIDS. How valid this argument is, I do not know. My own feeling, and that of many practicing in Africa, is that one should have a health-care pyramid with good primary health care available to all, and then secondary and tertiary health care facilities stratified on that, so that whatever condition is diagnosed at a primary health care level could be referred to the correct specialist, including the neurosurgeon. That would be an adequate health care service. To make it affordable and practicable is another matter, because with a population scattered over a wide area, transport becomes a major factor in making services available to patients or bringing them to appropriate doctors. This in itself carries a heavy burden of cost. As far as neurosurgeons go in such an environment, in the first instance one needs a general neurosurgeon. Indeed, one almost needs a general surgeon who is also a neurosurgeon. This may sound abhorrent to some, but the luxury of new neurosurgical “toys” or new fads which are chased with great enthusiasm because they are the “in thing” to talk about cannot be afforded if there isn’t even basic neurosurgery available. Please do not misunderstand me. I do not want to regress to something inferior, but I also do not want to waste money on things which are truly esoteric. I will not mention any by name, but your imagination need not be tasked too much by calling to mind a number of such topics. Some neurosurgeons equate these hyperspecialties in neurosurgery with high-quality care, but does this stand up to careful, critical analysis? What is the quality of life after some of these remarkable procedures and for how long? Are they costeffective-cost in money, disability, and suffering? Would one be able to justify such procedures in places where patients may die of untreated aneurysms and intracerebral tumours which could easily have been dealt with by an adequately trained, good general neurosurgeon? It has been pointed out repeatedly that to send neurosurgeons who have been trained in a highlysophisticated, Western technologically-oriented institution to work in Africa, a Third World continent,

Surg Neural 1996;45:314-9

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is doomed to failure. They are so accustomed to the rarified atmosphere of perfection in which they have lived and practised, that they are totally overcome by the reality of primitive conditions. Yet, in Africa, one finds people who have practiced for years independently and have given a remarkable service at the price of great personal commitment and sacrifice of personal comfort and ambition. Without them, this dark continent may, neurosurgically speaking, have been even darker! The degree of sophistication present in some countries in Africa, such as Morocco, Egypt, and South Africa, should not blind the outside observer to the stark realities of the rest of this continent’s neurosurgical plight. How does one calculate the number of neurosurgeons to function in a scene such as this? One cannot approach neurosurgery in isolation, but only as part of a total health care system. I have written a great deal, and yet not answered your questions, but a simple answer may be as misleading in effect as no answer at all! Jacques

C. de Villiers,

M.D., FRCS

Wynbeq,

South Africa

The problem raised by Dr. Stranjalis is a real one, and cannot be solved by dividing, for instance, the number of inhabitants by the number of beds or specialists. In our country, there is a great problem with overproduction of medical students and medical specialists. We need three times fewer neurosurgeons than we actually have in Greece. An epidural hematoma is a general surgeon’s problem in most cases. There are only a few neurosurgical departments that are big enough and have adequate staff to provide strict educational programs for the trainees and a sufficient number of beds. Concerning subspecialization by creating, perhaps, “neurotraumatology”, it is an old subject of discussion; it was tried in Africa many years ago, without good results. As to an immediate reduction in the number of neurosurgical units (to centralize facilities and increase the experience of trainees), it was proposed by the Hellenic Neurosurgical Society and approved by all members 10 years ago. By the next day, every senior member of that “historic meeting” asked the Ministry of Health to be allowed to chair his own department! George

Foroglou,

Thessaloniki,

M.D.

Greece