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Thoracic surgery manpower
J THoRAc
CARDIOVASC SURG
84:921-932, 1982
Thoracic surgery manpower The third manpower study of thoracic surgery: 1980 report of the Ad Hoc Committee on Manpower of The American Association for Thoracic Surgery and The Society of Thoracic Surgeons An ad hoc committee was appointed by The Society of Thoracic Surgeons (STSj in 1977 in order to determine the available manpower and workload of thoracic surgeons in 1976. This committee conducted a survey of the professional activities and geographic location of all known surgeons certified by the American Board of Thoracic Surgery (ABTS) at that time. A summary of this study indicated the available and projected thoracic surgery manpower. The report also determined the present and projected health care needs of the population of the United States through 1993. Because thoracic surgery needs to continue to meet the health care needs of the United States in an appropriate yet economical fashion, the STS and The American Association for Thoracic Surgery (AATSj undertook a joint review to determine again the available manpower and its workload in calendar year 1980. In addition, this study compared its findings with the 1976 report in order to detect changes in the workload and need for thoracic surgical services. A questionnaire was mailed to 3,584 certified thoracic surgeons. There were 2,675 responses. The material was sent to the Academic Computer Services at George Washington University Medical Center for tabulation and data processing. This report summarizes the results of this survey. It also compares these data with those obtained in the 1976 study and, based on this information, attempts to project the thoracic surgery manpower needs in the next decade by using several hypothetical models.
Richard J. Cleveland, M.D.,* Helmuth F. Orthner, Ph.D.,* Henry T. Bahnson, M.D.,** Thomas B. Ferguson, M.D.,** Frank C. Spencer, M.D.,** Lawrence I. Bonchek, M.D.,*** Marvin M. Kirsh, M.D.,*** and Floyd D. Loop, M.D.***
In order to determine the available manpower and workload of thoracic surgeons in the United States, two previous manpower studies have been conducted as a joint effort of The American Association for Thoracic Surgery (AATS) and The Society of Thoracic Surgeons (STS). The first study was completed in early 1974 under the direction of a committee chaired by Lyman Brewer III, M.D.l In 1976, to attempt to project future manpower needs, the STS appointed an ad hoc committee chaired by the late Dr. Paul Adkins in June, 1977. The manpower survey conducted by this committee for the calendar year 1976 was completed and published in
*Representing the Manpower Committee. **Representing the AATS. ***Representing the STS.
0022-5223/82/120921+12$01.20/0
© 1982 The C. V. Mosby Co.
1979. 2 At the same time an article was published entitled "Forecasting Health Manpower Requirements: The Case of Thoracic Surgeons."3 This report, prepared by Feldstein and Viets, was based upon mathematical projections estimating the probable available thoracic surgical manpower if the American Board of Thoracic Surgery (ABTS) certified varying numbers of surgeons in future years. They also estimated the total thoracic surgical health care needs of the United States in 1976 based upon data obtained from the Hospital Record Study of that year. The authors then attempted to project the workload for thoracic surgeons in 5 year increments through 1993 by projecting the health care needs of the population by applying various percentage increases to their combined data. In 1980, the Graduate Medical Education National Advisory Committee (GMENAC) filed a report which predicted the work921
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Cleveland et al.
load for thoracic surgery in 1990. 4 This report, rather than being based on statistical data such as those gathered in the 1976 STS manpower surveyor the statistical projections of Feldstein and Viets, relied primarily on developing a consensus of estimates of available manpower and health needs as determined by a panel of experts. Each of these studies, whatever their defects, examined data at one point in time and then attempted to make long-term projections of the expected supply of surgeons and demand for thoracic surgical services. Since it is not in society's best interest to have too few thoracic surgeons to provide needed health care services and it is too costly if there are too many surgeons, periodic review is needed to detect changes in trends in order to assist in the continuing planning process. Because of the need for thoracic surgery to meet the health care needs of the United States in an appropriate yet economical manner, it was felt by the STS and the AATS that a second review of the available thoracic surgical manpower and its workload should again be undertaken. Accordingly, in October, 1981, a joint ad hoc manpower committee was appointed by the AATS and STS to determine the available manpower in thoracic surgery and its workload during the calendar year 1980. The complete record of the survey in its entirety is on file in the offices of the AATS and STS. This report is a summary based on the results of that survey and the committee's projections based on the accumulated current data. Manpower survey In June, 1981, a questionnaire was sent to alI known diplomates of the ABTS believed to reside in the United States. A second mailing in September, 1981, and the third and final mailing in February, 1982, resulted in 2,675 responses from an estimated potential of 3,164 certified thoracic surgeons. This response represents slightly over 84% of the potential total. The lack of information from nonresponders did not affect the validity of the data base and the statistical conclusions of this study. The information requested was similar to that of the second manpower survey in 1976. However, the questionnaire was slightly modified in order to determine better the subsets of professional activity, satisfaction with current workload, and what possible increased clinical capacity was currently available. The following information was requested: (1) date of birth and date of certification by the ABTS, (2) whether the respondent was in active practice, (3) whether the practice was a solo or group practice and of what size if the latter were the case, (4) the ZIP code and commu-
Thoracic and Cardiovascular Surgery
nity size where the practice was carried out, (5) a practice profile including the percentage spent performing various types of cardiothoracic, vascular, and general surgery, (6) the total numbers of hours spent in professional activities each week and the number of weeks worked each year, (7) the percentage of time spent in patient care tasks and non-patient care tasks (administrative, teaching, and research along with other professional activities), (8) the number of general thoracic, cardiac (with its subsets), and peripheral vascular operations performed by the respondents during the year, and (9) whether the current workload of the individual was about right, too much, or too little and, if so, by how many operations per year. To preserve the confidentiality of the information requested on the questionnaire and to encourage the maximum number of responses, two envelopes were provided with each questionnaire. The outer envelope had the name of the respondent and was checked against a list at the headquarters of the STS. The completed questionnaire was placed in a sealed inner envelope without identification and was to be returned in the outer envelope, which identified the respondent and was used only to compare with the mailing list to determine who had responded. The unopened, unidentified inner envelopes were then sent to the Academic Computer Services at the George Washington University Medical Center in Washington, D. C., for tabulation and data processing. The inner envelopes were then opened. Each question was numbered and entered into an on-line data base. Extensive validation, review, and colIation of the data were then undertaken and completed on May 10, 1982. Although the exact number of Board-certified thoracic surgeons alive in 1980 is not certain, a total of 3,584 questionnaires were mailed. Of these, 420 were deemed not deliverable either because of known death or lack of known address. Of the remaining 3, 164 potential respondents, 2,675 individuals have replied. Of the 489 nonrespondents, 294 are carried on the membership role of the STS and 195 are not members of either the STS or AATS. Of the 2,675 individuals who have replied, 2,394 are Board-certified in 1980 and in active practice. The remaining 281 individuals include 101 physicians certified in 1981, 165 inactive physicians (most of them retired), 10 individuals returning blank forms, and five individuals responding from outside the United States. Assuming that there were 2,883 Board-certified thoracic surgeons in active practice in the United States in 1980 (3,584 - 420 - 281), the response rate of acceptable completed questionnaires exceeded 80%.
Volume 84
Thoracic surgery manpower
Number 6 December, 1982
923
510
50 0
-
410
r--
400
428
......re te u 2,378 32 Ma x.: 79 Mean : 48 Median : 48 Min . :
333
.--
Number 300 of Thoracic Surgeons
.
- -
-"- "-
-
191
200 10 0
306
-
Respondent Yeo rs i n 19 80
59
66
.--, ~
2
30 35 40 45 50 55 60 65 70 175 1 34 39 44 49 54 59 64 69 74 79
AGE GROUPS
Fig. 1. Number of Board-certified thoracic surgeons in active practice by age groups in 1980.
Results The following summarizes the important information obtained in this survey. In subsequent paragraphs and figures, the number of respondents for a particular category deviates from the total number of Board-certified thoracic surgeons active in 1980 (2,394), since not all respondents answered all questions. Age distribution. Based on this survey, the youngest Board-certified thoracic surgeon in 1980 was 32 years old and the oldest was 79 years. As can be seen in Fig. I, the majority of active thoracic surgeons in 1980 were between 40 and 54 years of age. There were 272 active surgeons who were 60 years of age or older. Median age of the 165 inactive surgeons was 66 years and of the 2,378 active surgeons, 48 years. The median years of experience from certification for those active in the field was 12 years. Analysis of the practice profile indicated that the number of all types of thoracotomies performed per surgeon rose until age 59 years and then rapidly decreased. With regard to all types of cardiac surgery, the majority of the procedures (67%) were performed by surgeons between the ages of 35 and 54 years. There was a steady decrease in the number of cases in all categories of cardiac surgery after 50 years, with only a few (16) surgeons performing any significant number of cardiac procedures after age 64 years (Fig. 2). When these data are compared with those of the 1976 survey, they demonstrate that, in general, thoracic surgeons are older. The mean age of a surgeon is now 48 instead of 46 years. There are more surgeons over the age of 65 (81 versus 47) in active status. Most of the clinical activity (63%) is performed by those between 40 and 54
150
.... Cardiac Operations • - Non Cardiac Thor. • - Peripheral Vasco
100
K - Pacemaker Prot.
Mean Number of Services per Surgeon
50
Fig. 2. Mean number of services per surgeon according to age in 1980. Included are Board-certified thoracic surgeons who reported numbers of cases for cardiac, thoracic, pacemaker, or peripheral vascular surgery.
years. This represents no significant change from the 1976 study. Group size. Of the active thoracic surgeons who responded, 43% were in solo practice, 48% in groups numbering two to five surgeons, and 9% in groups of six or more. When the workload was reviewed with reference to the type of practice, it was found that solo practitioners (43% of respondents) performed 44% of all thoracotomies but only 18% of all cardiac procedures reported. Of those surgeons in group practice (two to five members), 48% of respondents performed 47% of all thoracotomies but 62% of the cardiac proce-
924
The Journal of Thoracic and Cardiovascular
Cleveland et al.
Surgery
1000
955
900 Total: 2,351 Respondents
800
Mean: 62 Hours per Week
700 Number of Respondents
600
Min.:
6
Mox.:
136
500 400 300 200 100 0
9
Fig. 3. Working hours per week of Board-certified thoracic surgeons in active practice in 1980.
200 Meon Number of Services per 150 Thorocic Surgeon per Yeor
.. - Cardiac Operations •
- Non Cardiac Thoracotomies
• - Pacemaker Procedures • - Peripheral Vascular Ops.
100
50
2
Census Division
~.
Code
1
PAC
PACIFIC
2 3
MNT NWC
MOUNTAIN
4 5 6 7
swc NEC SEC SAT
NW CENTRAL SW CENTRAL HE CENTRAL CENTRAL
SE 5
ATLANTIC
8
MAT
M ATLANTIC
9
HEN
NEw ENGLAND
345 6 789 CENSUS DIVISIONS
Fig. 4. Mean number of services per surgeon according to region (ZIP code). Included are Board-certified thoracic surgeons who reported cases for cardiac, thoracic, pacemaker, or peripheral vascular surgery.
dures. Groups comprising six or more surgeons (9% of respondents) performed 9% of all thoracotomies but 20% of all cardiac operations. Comparison with the previous study in 1976 indicates that the number of solo practitioners has decreased (43% versus 67%) and that they perform a smaller amount of cardiac surgery (18% versus 37%). In general, therefore, in 1980 a smaller percentage of thoracic surgeons were in solo practice and their clinical activities were predominantly in the practice of general thoracic surgery. Second, a clear majority of cardiac surgery was performed by surgeons practicing in groups containing two to five practitioners.
Practice profile. In order to determine the practice profile of the respondents, regardless of group size, the questionnaire requested information regarding each surgeon's individual professional activities. This information was further broken down as to the activity by regions utilizing the first three digits of the ZIP code listed by the respondent. The average time spent by thoracic surgeons in clinical activities is 62 hours per week (SD 13; N = 2,351) (Fig. 3). The average number of weeks worked per year was 48. Thoracic surgeons devote 62% of their professional activity to cardiothoracic work, 16% to peripheral vascular surgery, 13% to general surgery, 7% to pace-
Volume 84 Number 6 December. 1982
Thoracic surgery manpower
925
1000 900
844 Total:
800
Median:
700 Number of Surgeons
2,356
< 500,000
600
500 400 300 200
100
<1M
>IM
COMMUNITY SIZE
Fig. 5. Distribution of Board-certified thoracic surgeons by community size in 1980.
maker procedures, and 2% to other professional activities. In terms of time, 80% was spent for patient care tasks, 15% for non-patient care tasks (e.g., administration, research, teaching), and 5% for other tasks such as continuing medical education. Some differences were noted in the practice profile depending upon the geographical region of the respondent's practice. This can be seen from analysis of Fig. 4, which summarizes the total number of all clinical services provided per surgeon by region. Cardiac surgery occupies most of the clinical activity of a majority of the surgeons and also demonstrates the greatest variation in number of cases done by region. When the percentage of professional time spent in 1980 for each category was compared with that of the 1976 survey, there was an increase in cardiothoracic surgery (62% versus 58%), a decrease in peripheral vascular surgery (16% versus 19%), and essentially no change in the manner in which the remainder of time was spent. Community size. Respondents were asked to indicate the size of the community in which they practice. The groupings were as follows: less than 50,000; 50,000 to 100,000; 100,000 to 500,000; 500,000 to 1 million; and greater than I million. Examination of Fig. 5 indicates that approximately 80% of practicing thoracic surgeons work in metropolitan areas whose populations are 100,000 or more. Within those large metropolitan areas, about 87% of the surgeons do noncardiac thoracic surgery, 59% of them do some cardiac operations, 72% of the surgeons perform pacemaker procedures, and 65% of the surgeons are involved in peripheral vascular surgery (the
percentages do not add up to 100% because most surgeons provide typically more than one type of surgery). The number of thoracic surgeons living in communities smaller than 100,000 is only 20% (478). About 91% of these physicians are involved in noncardiac thoracotomies, 34% of them do cardiac work, 74% of them perform pacemaker procedures, and 73% of them perform peripheral vascular surgery (Table I). When the number of services rendered are considered, the difference between cardiac and noncardiac work becomes even more striking. In large communities (greater than 100,(00), not only more surgeons (percentage-wise) are involved in cardiac work but each of them performs, on the average, more cardiac operations per year than their colleagues in smaller communities. Specifically, surgeons who perform cardiac operations in large communities do, on an average, about 144 cases per year while those in smaller communities do only 95 cases per year. The difference for noncardiac cases is not as great: noncardiac thoracotomies (48 versus 43 cases per year), pacemaker procedures (31 versus 27 cases per year), and peripheral vascular surgery (57 versus 52 cases per year). The average number of cases per year is always smaller in the smaller communities, regardless of the type of service performed (as shown in Table I). A comparison of these data with results from the 1976 study shows that the number of Board-certified physicians in active practice increased about 7%. The increase in the small communities is higher (13%) than in large communities (5%) (Table II). In all communities, the average number of services of a thoracic surgeon in a particular community (regardless of the kind
The Journal of Thoracic and Cardiovascular Surgery
926 Cleveland et al.
Table I. Number of services and thoracic surgeons by community size Large communities «100,000)
Small communities «100,000)
All communities
Noncardiac thoracotomies Services Surgeons No. % Services/surgeon
18,468
78,236
96,704
434 91 43
1,631 87 48
2,065 88 47
Services Surgeons No. % Services/surgeon
15,536
160,344
175,880
163 34 95
1,116 59 144
1,279 54 138
Services Surgeons No. % Services/surgeon
9,460
42,142
51,602
353 74 27
1,351 72 31
1,704 72 30
Services Surgeons No. % Services/surgeon
18,229
69,001
87,230
351 73 52
1,216 65 57
1,567 67 56
Services Surgeons No. % Services/surgeon
61,693
349,723
411,416
478 100 129
1,878 100 186
2,356 100 175
Cardiac operations
Pacemaker procedures
Perivascular operations
All services
Table II. Comparison of 1976 and 1980 data
No, of thoracic surgeons Noncardiac thoracotomies per surgeon Cardiac operations per surgeon
Year
Small communities «100,000)
Large communities (>100,000)
All communities
1976 1980 Change 1976 1980 Change 1976 1980 Change
423 478 +13% 35.2 38.6 +10% 19.9 32.5 +63%
1,785 1,878 +5% 39.8 41.7 +5% 56.2 85.4 +52%
2,208 2,356 +7% 39.0 41.0 +5% 49.2 74.7 +52%
of services that are provided) shows a modest increase of 5% for noncardiac thoracotomies but a substantial increase of 52% for cardiac operations. Finally, when the overall major cardiothoracic and vascular surgical services rendered per physician are correlated with community size (Fig. 6), the data indi-
cate that there is a gradual increase in the number of all surgical procedures provided per surgeon per year as the size of community in which he practices increases. This trend is most dramatic with regard to provision of cardiac surgical services: There is a marked increase in the number of cases performed per surgeon per year as
Volume 84
Thoracic surgery manpower
Number 6 December, 1982
927
.. - Cardiac Operations
200
• - Non Cardiac Thoracotomies • - Pacemaker Procedures • - Peripheral Vascular Opl.
Mean Number
150
of Services per
100
Thoracic Surgeon
:
:
50
•
<50K
<500K
<1M
>IM
COMMUNITY SIZE
Fig. 6. Mean number of services per surgeon according to size of their community in 1980. Included are Board-certified thoracic surgeons who reported numbers of cases for cardiac, thoracic, pacemaker, or peripheral vascular surgery.
Table llI. Population and thoracic surgeons by region
No.
Region
Code
Population
I
Pacific Mountain NW Central SW Central NE Central SE Central South Atlantic Mid Atlantic New England All regions
PAC MNT NWC SWC NEC SEC SAT MAT NEN USA*
31,7%,869 11,368,330 17,184,066 23,743,134 41,669,738 14,662,882 36,943,139 36,788,174 12,348,493 226,504,825
2 3 4 5 6 7 8 9
Surgeons
398 III
172 221 342 129 424 359 151 2,394
Table IV. Services by region Region Surgeons per jOO,OOO
1.25 0.98 1.00 0.93 0.82 0.88 1.15 0.98 1.22 1.06
No.1 Code
I 2 3 4 5 6 7 8 9
PAC MNT NWC SWC NEC SEC SAT MAT NEN USA*
Noncardiac thoracotomies
13,260 3,269 6,877 10,737 14,807 6,442 17,689 13,811 6,885 97,619
Pacemaker Perivascular Cardiac operations procedures operations
27,803 8,275 14,526 24,811 31,227 11,005 24,152 24,649 7,895 177,703
6,704 2,012 4,075 5,319 7,518 3,017 9,249 9,472 3,180 52,139
10,112 4,035 6,641 13,732 11,912 4,915 15,580 12,469 4,522 88,097
'IncludesIslands and responses without ZIP codes.
'IncludesIslands and responses without ZIPcodes.
the community size exceeds 100,000. In summary, in regard to services provided by surgeons per year with relation to community size, more cardiac procedures are performed by surgeons in larger communities. Second, thoracic surgeons tend to locate in communities of over 100,000 and the surgeons located in these communities perform more cardiothoracic and peripheral vascular operations per surgeon per year than do those in the small communities. Regional distribution. The regional distribution of active Board-certified thoracic surgeons was estimated by utilizing the ZIP code of each respondent. These data were analyzed in terms of the nine geographic regions corresponding to the major census divisions of the United States. The regional distribution of thoracic surgeons and services rendered was analyzed from several viewpoints. The total population in 1980 based on information from the Bureau of Census was 226,504,825
as compared to an estimated population of 212, 145,000 in 1976. Based on the number of Board-certified thoracic surgeons, there was approximately one thoracic surgeon per 100,000 population in 1980. Analysis of each region indicates that the ratio of Board-certified thoracic surgeons to 100,000 of population ranged from a high of 1.25 per 100,000 in region I (Pacific) to the low of 0.82 in region 5 (North East Central). As in the 1976 study, four regions accounted for approximately two thirds of all Board-certified thoracic surgeons. Also, these regions contained approximately two thirds of the total population (Table ill). The distribution of services provided with relation to the distribution of surgeons was analyzed by the categories of noncardiac thoracotomies, cardiac operations, pacemaker procedures, and peripheral vascular operations (Tables IV and V). This analysis indicated that there was variation within a given region in the number of
928
The Journal of Thoracic and Cardiovascular Surgery
Cleveland et al.
110 100
Number of Services per 100,000 persons
90
... - Cardiac Operations
80
• - Pacemaker Procedures
•
- Non Cardiac Thoracotomies
• - Peripheral Vascular Ope.
70 60 50 40
...
30
~._~.
20
•
No.
Code
1
PAC
2
MNT
MOUNTAIN
3 4
NWC
NW CENTRAL
SWC
sw
5
NEC
NE
CENTRAL
6
SEC
SE
CENTRAL
7 8
SAT MAT
S ATLANTIC M ATLANTIC
9
NEN
NEW ENGLAND
Census Division PACIFIC
CENTRAL
10 23456789 CENSUS DIVISIONS
Fig. 7. The total number of services per 100,000 persons living in a census division, provided by Board-certified thoracic surgeons in 1980.
Table V. Services per 100,000 by region Region No.1 Code
1 2 3 4 5 6 7 8 9
PAC MNT NWC SWC NEC SEC SAT MAT NEN USA*
Noncardiac thoracotomies
41.7 28.8 40.0 45.2 35.5 43.9 47.9 37.5 55.8 43.1
Table VI. Mean number of services per thoracic surgeon per year
Pacemaker Perivascular Cardiac operations procedures operations
84.3 72.8 84.5 104.5 74.9 75.1 65.4 67.0 63.9 78.5
21.1 17.7 23.7 22.4 18.0 20.6 25.0 25.7 25.8 23.0
31.8 35.5 38.6 57.8 28.6 33.5 42.2 33.9 36.6 38.9
"Includes Islands and responses without ZIP codes.
Region
Noncardi-
No.1 Code
ac thoracotomies
1 2 3 4 5 6 7 8 9
PAC MNT NWC SWC NEC SEC SAT MAT NEN USA*
38 34 44 52 50 58 49 44 53 47
Cardiac Pacemaker Perivascular operations procedures operations
111 124 144 175 157 164 123 142 121 138
23 25 31 31 30 37 31 36 32 30
42 52 52 78 52 58 53 57 54 56
Legend: Only those surgeons are counted who have reported cases of the indicated service.
operations performed on a population-adjusted base (Fig. 7). For noncardiac thoracotomies, the mean number of procedures per thoracic surgeon per year throughout the United States was 47. When this was compared with the physician-patient ratio, it indicated that in four regions surgeons did not perform to the mean level of 47 whereas in five regions the mean was exceeded. When the same comparison was made with regard to cardiac procedures, where the mean number of operations per surgeon per year was 138, four re-
"Includes Islands and responses without ZIP codes.
gions were below the mean number (Fig. 4). Analysis of the number of pacemaker procedures performed per surgeon per year indicated that in each region, regardless of the surgeon density, essentially the same number of procedures were performed-a mean of 30 operations per surgeon per year-except in regions I and 2, where slightly fewer were performed. When peripheral vascular operations per region were compared
Volume 84
Thoracic surgery manpower
Number 6 December, 1982
Table
929
vn. Services per number of thoracic surgeons in a region Region
No.
I
Code
No. of surgeons
2
PAC
389
MNT
III
3 4 5 6
NWC SWC NEC SEC SAT MAT NEN USA*
I
7
8 9
172 221 342 129 424 359 151 2,394
Noncardiac thoracotomies
33 29 40
49 43 50 42 38 46 41
Cardiac operations
Pacemaker procedures
Perivascular operations
17 18 24 24 22 23 22 26 21 22
25 36 39 62 35 38 37 35 30 37
67 75 84 112
91 85 57 69 52 74
Legend: The number of thoracic surgeons in a region is tbe total number of active thoracic surgeons responding to tbe survey. 'Includes Islands and responses without ZIP codes.
Table
vm. Percent of thoracic surgeons Region
No.
I
Code
No. of surgeons
I
PAC
389
2 3 4 5 6 7 8 9
MNT
III
NWC SWC NEC SEC SAT MAT NEN USA*
172 221 342 129 424 359 151 2,394
in a region reporting the indicated service Noncardiac thoracotomies
Cardiac operations
Pacemaker procedures
87 86 92 93 86 87 86 88 87 87
61 60 59
72 76 77 85 73 63 70 73
64
58 52 46 48 43 54
66 72
Perivascular operations
60
69 74 80 67 66
69 61 54 66
Legend: One hundred percent indicates all thoracic surgeons in a region performing the indicated service. 'lncludes Islands and responses without ZIP codes.
to the national mean of 56 major operations per thoracic surgeon per year, it was found that only in region 4 (Southwest Central) was the mean number greatly exceeded whereas the rest of the regions were closer to the mean. Fig. 4 and Table VI summarize the data with regard to the four categories reviewed above. In computing the mean numbers of services per surgeon per year (Table VI) in a region, only those surgeons are counted who reported cases of the particular service. The mean numbers are therefore higher than the numbers derived by dividing the total number of services by the total number of Board-certified thoracic surgeons in a region, as shown in Table VII. For example, of the total number of thoracic surgeons responding (2,394), 87% perform noncardiac thoracotomies (2,094), only 54% perform cardiac operations (l,291), 72% perform pacemaker procedures (l,727), and 66% perform peripheral vascular surgery (l,586).
The variation between regions is smallest for noncardiac thoracotomies, ranging from a low of 86% in regions 2 (Mountain), 5 (Northeast Central), and 7 (South Atlantic) to a high of 93% in region 4 (Southwest Central). The largest variation among the nine census divisions is seen in the performance of peripheral vascular surgery. Region 4 (Southwest Central) leads with 80% and region 9 (New England) is lowest with only 54%. Table VIII summarizes this pattern of activity. The workload in thoracic surgery-1980. The results of this survey indicate that, in 1980, 2,394 surgeons certified by the ABTS performed 275,322 major thoracic and cardiac operations. This resulted in an overall workload of 115 major cardiothoracic cases per year per active thoracic surgeon. This number excluded pacemaker-related procedures, minor thoracic and diagnostic procedures, as well as vascular and other operations. Of the total major cardiothoracic operations,
The Journal of Thoracic and Cardiovascular Surgery
930 Cleveland et al.
200
Mean Number of Services per Surgeon per Year
150
•
- Cardiac Operations
• - Non Cardiac Thoracotomies
• - Pacemaker Procedures • - Peripheral Vascular Ops
100
50
Low Surgeons: 704
OK WORKLOAD
High
1509
121
Fig. 8. Mean number of services per surgeon provided by Board-certified thoracic surgeons who reported cases for cardiac, thoracic, pacemaker, or peripheral vascular surgery. Services were divided according to low. satisfactory, or high workload in 1980.
97,619 thoracotomies were performed for noncardiac indications. There were 177,703 cardiac operations performed, of which 117,559 were aorta-coronary bypass procedures and 31,817 were valvular heart operations. A total of 20,303 operations were performed for congenital heart disease, of which 11,691 were open procedures and 8,612 were closed operations. Major peripheral vascular operations numbered 88,097 during the year. Comparing these data with those of the 1976 survey indicates an increase in major cardiothoracic procedures (275,322 versus 195,850). In general, the increase in thoracic surgical procedures was 13% (97,619 versus 86,734) and the increase in the areas of cardiac operations (excluding pacemaker and peripheral vascular operations) was 63% (177,703 versus 109,116). The number of pacemaker procedures and peripheral vascular operations cannot be compared with the 1976 survey, since these questions were not asked in the 1976 survey. In 1980, a total of 52,139 pacemaker procedures were performed by 1,727 thoracic surgeons and 88,097 peripheral vascular operations were performed by 1,586 Board-certified thoracic surgeons. In the area of cardiac operations, the workload increased substantially in the category of coronary artery surgery (117,559 versus 71,551), whereas for congenital heart disease the number of operations showed no significant change (20,302 versus 19,005). The latter holds true for both the open (11,691 versus 11,449) and the closed heart procedures (8,612 versus 7,556). A comparison between the number of valvular heart operations performed in 1980 and 1976 is not possible since this question was not asked in the 1976 survey. However, Adkins and Orthner" estimated the number of "valve replacements or repairs" to be 18,560
in 1976. This number compares with 31,817 valvular operations performed by 1,122 thoracic surgeons in 1980. Examination of data obtained from the Hospital Record Study for 19805 disclosed that approximately 149,000 operations were performed on the larynx, chest wall, diaphragm, and intrathoracic structures during the period of this study. This would appear to indicate that, since 97,619 noncardiac thoracotomies were performed by Board-certified surgeons, 34% were performed by noncertified surgeons. However, on closer examination, and employing the same criteria used in this review to define major cardiothoracic surgical procedures, only approximately 105,500 major noncardiac thoracotomies were performed in the United States in 1980 according to the Hospital Record Study. Therefore, this would indicate that approximately 93% of major noncardiac thoracotomies were performed or supervised by Board-certified thoracic surgeons. Further review of the data indicates that virtually all cardiac surgical operations are performed or supervised by surgeons certified by the ABTS. Estimates of additional capacity. One of the goals of this study was to attempt to determine what, if any, residual surgical capacity was available to handle the present and possibly projected health care needs of the specialty. If this could be determined, it could be of value to a wide variety of agencies and organizations charged with the responsibility of providing sufficient thoracic surgical services at reasonable human and economic costs. In order to get a reasonably accurate estimate of the current manpower capacity, the questionnaire requested that the respondent indicate whether the surgeon's workload in his or her opinion was too small, too large, or about right. Further, if the work-
Volume 84 Number 6 December, 1982
load was felt to be inappropriate, the respondent was requested to indicate what the estimated differential in the individual's workload might be. In addition, the total number of hours worked per week and weeks worked per year were requested. As previously noted, the vast majority of surgeons engaged in professional activities between 50 and 79 hours per week, with the average work week being 62 hours (Fig. 3). In addition, the national average of major thoracic and cardiac operations performed per year by Board-certified surgeons was 115 cases, an increase from 87 per year in 1976. When the respondents answered the question as to the adequacy of their volume (Fig. 8), 704 surgeons felt they could provide more clinical services and 121 surgeons felt that they were too busy. The vast majority of respondents (1,509) felt that their workload was about right. When these data were calculated as possible additional cases per week which might be performed per surgeon, it revealed but an additional 1.9 cases of major cardiothoracic nature might be done by 704 surgeons. If the same calculations are performed by those who indicated that the workload was too heavy, one finds that the 121 respondents felt that they would like to reduce their workload by 1.6 cases per week. Using the projections of Feldstein and Viets," if 120 surgeons are certified each year through 1993, the projected number of practicing Board-certified surgeons will be 3,736; if 160 surgeons are certified each year, the total is projected to be 4,128. Using the percent increase in major cardiothoracic procedures between the last study and the current review and projecting that increase forward to 1993 in a compound manner, there will be a total of 743,668 major cardiothoracic procedures to be performed in that year. This figure is reached by projecting general noncardiac procedures at a compounded rate of 2.75% per year and cardiac cases at a rate of 10% per year. In the former, the 2.75% per year growth rate is that which was actually experienced between 1976 and 1980. The rate of growth in cardiac procedures was actually 13% per year, so that the projected 10% per year increase is somewhat less than the historical data demonstrated. When these data are translated in cases per year per surgeon, certifying 120 surgeons per year would result in a projected workload of 199 cases per surgeon per year or 4.1 per week. Should 160 surgeons be certified, the workload would be 180 cases per surgeon per year or 3.75 cases per week. The validity of this type of linear projection in the growth rate of cardiothoracic surgery is certainly open to debate and basically results from the rapid increase in the number of aorta-coronary bypass procedures performed
Thoracic surgery manpower
93 1
between 1976 and 1980. It is probably fair to assume that at some time in the future the number of these procedures performed each year may plateau. This may result from several factors including the development of preventive measures, differing patterns of treatment, and elimination of a supposed backlog. If one wishes to make a conservative projection of future medical needs, development of another hypothetical model may be of value. First assume that there will be no significant increase in general thoracic, valvular, and congenital heart surgery performed but that the growth rate of aortacoronary bypass surgery will increase from the 1980 figure of 117,000 to 150,000 or 200,000 cases per year in 1993. Further assume that 120 thoracic surgeons will be certified each year. There will then be 3,736 Boardcertified surgeons available to provide thoracic surgical services. This will result in a workload of 80 cases per surgeon per year or 1.7 cases per week if 150,000 coronary procedures are performed and 96 cases per surgeon per year or 2.0 cases per week if 200,000 coronary procedures are done. These data may be compared with the 1980 workload of 128 cases per surgeon per year or 2.7 cases per week, which most surgeons found to be satisfactory. It should be emphasized that these 1993 projections are merely estimates of the varying rates of growth both in manpower and thoracic surgical services needed. Workload estimates are probably inflated when the compounded linear growth rate is used and extremely low when the general estimates of limited growth in aorta-coronary bypass and no growth in the other areas of activity are used. None of the projections takes into account the fact that some procedures may become obsolete, that new procedures may be developed, and that the population requiring thoracic surgical procedures will vary in number because of multifactorial pressures placed upon the health care system in the future. However, accepting all of these possible variables which may affect the validity of any long-term projections, it appears that the current workload of 128 major cardiothoracic cases per year satisfied both the available manpower and medical needs of the population in 1980. On a predictive basis, the certification of approximately 120 thoracic surgeons per year will probably continue to meet the medical needs of the cardiothoracic surgical patients during the next decade. Because projections of future medical needs and available manpower remain unclear, it is prudent to continue to monitor the services available with regard to health care needs of the population of the United States.
932
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REFERENCES Brewer LA III, Ferguson TB, Langston HT, Weiner JM: National Thoracic Surgery Manpower Study, Los Angeles, 1974, Cunningham Press, Publisher 2 Adkins PC, Orthner HF: The Society of Thoracic Surgeons manpower survey for 1976. A summary. Ann Thorac Surg 28:407-412,1979 3 Feldstein PJ, Viets PH: Forecasting health manpower re-
The Journal of Thoracic and Cardiovascular Surgery
quirements. The case of thoracic surgeons. Ann Thorac Surg 28:413-422, 1979 4 Report of the Graduate Medical Education National Advisory Committee to the Secretary, Department of Health and Human Services, Washington, D. C., 1980, Public Health Service, Health Resource Administration 5 Hospital Record Study. A Joint Survey by CPHA and IMS American Ltd., Ambler, Pa., 1980, IMS America Ltd.
CARDIOVASC SURG
84:921-932, 1982
Thoracic surgery manpower The third manpower study of thoracic surgery: 1980 report of the Ad Hoc Committee on Manpower of The American Association for Thoracic Surgery and The Society of Thoracic Surgeons An ad hoc committee was appointed by The Society of Thoracic Surgeons (STSj in 1977 in order to determine the available manpower and workload of thoracic surgeons in 1976. This committee conducted a survey of the professional activities and geographic location of all known surgeons certified by the American Board of Thoracic Surgery (ABTS) at that time. A summary of this study indicated the available and projected thoracic surgery manpower. The report also determined the present and projected health care needs of the population of the United States through 1993. Because thoracic surgery needs to continue to meet the health care needs of the United States in an appropriate yet economical fashion, the STS and The American Association for Thoracic Surgery (AATSj undertook a joint review to determine again the available manpower and its workload in calendar year 1980. In addition, this study compared its findings with the 1976 report in order to detect changes in the workload and need for thoracic surgical services. A questionnaire was mailed to 3,584 certified thoracic surgeons. There were 2,675 responses. The material was sent to the Academic Computer Services at George Washington University Medical Center for tabulation and data processing. This report summarizes the results of this survey. It also compares these data with those obtained in the 1976 study and, based on this information, attempts to project the thoracic surgery manpower needs in the next decade by using several hypothetical models.
Richard J. Cleveland, M.D.,* Helmuth F. Orthner, Ph.D.,* Henry T. Bahnson, M.D.,** Thomas B. Ferguson, M.D.,** Frank C. Spencer, M.D.,** Lawrence I. Bonchek, M.D.,*** Marvin M. Kirsh, M.D.,*** and Floyd D. Loop, M.D.***
In order to determine the available manpower and workload of thoracic surgeons in the United States, two previous manpower studies have been conducted as a joint effort of The American Association for Thoracic Surgery (AATS) and The Society of Thoracic Surgeons (STS). The first study was completed in early 1974 under the direction of a committee chaired by Lyman Brewer III, M.D.l In 1976, to attempt to project future manpower needs, the STS appointed an ad hoc committee chaired by the late Dr. Paul Adkins in June, 1977. The manpower survey conducted by this committee for the calendar year 1976 was completed and published in
*Representing the Manpower Committee. **Representing the AATS. ***Representing the STS.
0022-5223/82/120921+12$01.20/0
© 1982 The C. V. Mosby Co.
1979. 2 At the same time an article was published entitled "Forecasting Health Manpower Requirements: The Case of Thoracic Surgeons."3 This report, prepared by Feldstein and Viets, was based upon mathematical projections estimating the probable available thoracic surgical manpower if the American Board of Thoracic Surgery (ABTS) certified varying numbers of surgeons in future years. They also estimated the total thoracic surgical health care needs of the United States in 1976 based upon data obtained from the Hospital Record Study of that year. The authors then attempted to project the workload for thoracic surgeons in 5 year increments through 1993 by projecting the health care needs of the population by applying various percentage increases to their combined data. In 1980, the Graduate Medical Education National Advisory Committee (GMENAC) filed a report which predicted the work921
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922
Cleveland et al.
load for thoracic surgery in 1990. 4 This report, rather than being based on statistical data such as those gathered in the 1976 STS manpower surveyor the statistical projections of Feldstein and Viets, relied primarily on developing a consensus of estimates of available manpower and health needs as determined by a panel of experts. Each of these studies, whatever their defects, examined data at one point in time and then attempted to make long-term projections of the expected supply of surgeons and demand for thoracic surgical services. Since it is not in society's best interest to have too few thoracic surgeons to provide needed health care services and it is too costly if there are too many surgeons, periodic review is needed to detect changes in trends in order to assist in the continuing planning process. Because of the need for thoracic surgery to meet the health care needs of the United States in an appropriate yet economical manner, it was felt by the STS and the AATS that a second review of the available thoracic surgical manpower and its workload should again be undertaken. Accordingly, in October, 1981, a joint ad hoc manpower committee was appointed by the AATS and STS to determine the available manpower in thoracic surgery and its workload during the calendar year 1980. The complete record of the survey in its entirety is on file in the offices of the AATS and STS. This report is a summary based on the results of that survey and the committee's projections based on the accumulated current data. Manpower survey In June, 1981, a questionnaire was sent to alI known diplomates of the ABTS believed to reside in the United States. A second mailing in September, 1981, and the third and final mailing in February, 1982, resulted in 2,675 responses from an estimated potential of 3,164 certified thoracic surgeons. This response represents slightly over 84% of the potential total. The lack of information from nonresponders did not affect the validity of the data base and the statistical conclusions of this study. The information requested was similar to that of the second manpower survey in 1976. However, the questionnaire was slightly modified in order to determine better the subsets of professional activity, satisfaction with current workload, and what possible increased clinical capacity was currently available. The following information was requested: (1) date of birth and date of certification by the ABTS, (2) whether the respondent was in active practice, (3) whether the practice was a solo or group practice and of what size if the latter were the case, (4) the ZIP code and commu-
Thoracic and Cardiovascular Surgery
nity size where the practice was carried out, (5) a practice profile including the percentage spent performing various types of cardiothoracic, vascular, and general surgery, (6) the total numbers of hours spent in professional activities each week and the number of weeks worked each year, (7) the percentage of time spent in patient care tasks and non-patient care tasks (administrative, teaching, and research along with other professional activities), (8) the number of general thoracic, cardiac (with its subsets), and peripheral vascular operations performed by the respondents during the year, and (9) whether the current workload of the individual was about right, too much, or too little and, if so, by how many operations per year. To preserve the confidentiality of the information requested on the questionnaire and to encourage the maximum number of responses, two envelopes were provided with each questionnaire. The outer envelope had the name of the respondent and was checked against a list at the headquarters of the STS. The completed questionnaire was placed in a sealed inner envelope without identification and was to be returned in the outer envelope, which identified the respondent and was used only to compare with the mailing list to determine who had responded. The unopened, unidentified inner envelopes were then sent to the Academic Computer Services at the George Washington University Medical Center in Washington, D. C., for tabulation and data processing. The inner envelopes were then opened. Each question was numbered and entered into an on-line data base. Extensive validation, review, and colIation of the data were then undertaken and completed on May 10, 1982. Although the exact number of Board-certified thoracic surgeons alive in 1980 is not certain, a total of 3,584 questionnaires were mailed. Of these, 420 were deemed not deliverable either because of known death or lack of known address. Of the remaining 3, 164 potential respondents, 2,675 individuals have replied. Of the 489 nonrespondents, 294 are carried on the membership role of the STS and 195 are not members of either the STS or AATS. Of the 2,675 individuals who have replied, 2,394 are Board-certified in 1980 and in active practice. The remaining 281 individuals include 101 physicians certified in 1981, 165 inactive physicians (most of them retired), 10 individuals returning blank forms, and five individuals responding from outside the United States. Assuming that there were 2,883 Board-certified thoracic surgeons in active practice in the United States in 1980 (3,584 - 420 - 281), the response rate of acceptable completed questionnaires exceeded 80%.
Volume 84
Thoracic surgery manpower
Number 6 December, 1982
923
510
50 0
-
410
r--
400
428
......re te u 2,378 32 Ma x.: 79 Mean : 48 Median : 48 Min . :
333
.--
Number 300 of Thoracic Surgeons
.
- -
-"- "-
-
191
200 10 0
306
-
Respondent Yeo rs i n 19 80
59
66
.--, ~
2
30 35 40 45 50 55 60 65 70 175 1 34 39 44 49 54 59 64 69 74 79
AGE GROUPS
Fig. 1. Number of Board-certified thoracic surgeons in active practice by age groups in 1980.
Results The following summarizes the important information obtained in this survey. In subsequent paragraphs and figures, the number of respondents for a particular category deviates from the total number of Board-certified thoracic surgeons active in 1980 (2,394), since not all respondents answered all questions. Age distribution. Based on this survey, the youngest Board-certified thoracic surgeon in 1980 was 32 years old and the oldest was 79 years. As can be seen in Fig. I, the majority of active thoracic surgeons in 1980 were between 40 and 54 years of age. There were 272 active surgeons who were 60 years of age or older. Median age of the 165 inactive surgeons was 66 years and of the 2,378 active surgeons, 48 years. The median years of experience from certification for those active in the field was 12 years. Analysis of the practice profile indicated that the number of all types of thoracotomies performed per surgeon rose until age 59 years and then rapidly decreased. With regard to all types of cardiac surgery, the majority of the procedures (67%) were performed by surgeons between the ages of 35 and 54 years. There was a steady decrease in the number of cases in all categories of cardiac surgery after 50 years, with only a few (16) surgeons performing any significant number of cardiac procedures after age 64 years (Fig. 2). When these data are compared with those of the 1976 survey, they demonstrate that, in general, thoracic surgeons are older. The mean age of a surgeon is now 48 instead of 46 years. There are more surgeons over the age of 65 (81 versus 47) in active status. Most of the clinical activity (63%) is performed by those between 40 and 54
150
.... Cardiac Operations • - Non Cardiac Thor. • - Peripheral Vasco
100
K - Pacemaker Prot.
Mean Number of Services per Surgeon
50
Fig. 2. Mean number of services per surgeon according to age in 1980. Included are Board-certified thoracic surgeons who reported numbers of cases for cardiac, thoracic, pacemaker, or peripheral vascular surgery.
years. This represents no significant change from the 1976 study. Group size. Of the active thoracic surgeons who responded, 43% were in solo practice, 48% in groups numbering two to five surgeons, and 9% in groups of six or more. When the workload was reviewed with reference to the type of practice, it was found that solo practitioners (43% of respondents) performed 44% of all thoracotomies but only 18% of all cardiac procedures reported. Of those surgeons in group practice (two to five members), 48% of respondents performed 47% of all thoracotomies but 62% of the cardiac proce-
924
The Journal of Thoracic and Cardiovascular
Cleveland et al.
Surgery
1000
955
900 Total: 2,351 Respondents
800
Mean: 62 Hours per Week
700 Number of Respondents
600
Min.:
6
Mox.:
136
500 400 300 200 100 0
9
Fig. 3. Working hours per week of Board-certified thoracic surgeons in active practice in 1980.
200 Meon Number of Services per 150 Thorocic Surgeon per Yeor
.. - Cardiac Operations •
- Non Cardiac Thoracotomies
• - Pacemaker Procedures • - Peripheral Vascular Ops.
100
50
2
Census Division
~.
Code
1
PAC
PACIFIC
2 3
MNT NWC
MOUNTAIN
4 5 6 7
swc NEC SEC SAT
NW CENTRAL SW CENTRAL HE CENTRAL CENTRAL
SE 5
ATLANTIC
8
MAT
M ATLANTIC
9
HEN
NEw ENGLAND
345 6 789 CENSUS DIVISIONS
Fig. 4. Mean number of services per surgeon according to region (ZIP code). Included are Board-certified thoracic surgeons who reported cases for cardiac, thoracic, pacemaker, or peripheral vascular surgery.
dures. Groups comprising six or more surgeons (9% of respondents) performed 9% of all thoracotomies but 20% of all cardiac operations. Comparison with the previous study in 1976 indicates that the number of solo practitioners has decreased (43% versus 67%) and that they perform a smaller amount of cardiac surgery (18% versus 37%). In general, therefore, in 1980 a smaller percentage of thoracic surgeons were in solo practice and their clinical activities were predominantly in the practice of general thoracic surgery. Second, a clear majority of cardiac surgery was performed by surgeons practicing in groups containing two to five practitioners.
Practice profile. In order to determine the practice profile of the respondents, regardless of group size, the questionnaire requested information regarding each surgeon's individual professional activities. This information was further broken down as to the activity by regions utilizing the first three digits of the ZIP code listed by the respondent. The average time spent by thoracic surgeons in clinical activities is 62 hours per week (SD 13; N = 2,351) (Fig. 3). The average number of weeks worked per year was 48. Thoracic surgeons devote 62% of their professional activity to cardiothoracic work, 16% to peripheral vascular surgery, 13% to general surgery, 7% to pace-
Volume 84 Number 6 December. 1982
Thoracic surgery manpower
925
1000 900
844 Total:
800
Median:
700 Number of Surgeons
2,356
< 500,000
600
500 400 300 200
100
<1M
>IM
COMMUNITY SIZE
Fig. 5. Distribution of Board-certified thoracic surgeons by community size in 1980.
maker procedures, and 2% to other professional activities. In terms of time, 80% was spent for patient care tasks, 15% for non-patient care tasks (e.g., administration, research, teaching), and 5% for other tasks such as continuing medical education. Some differences were noted in the practice profile depending upon the geographical region of the respondent's practice. This can be seen from analysis of Fig. 4, which summarizes the total number of all clinical services provided per surgeon by region. Cardiac surgery occupies most of the clinical activity of a majority of the surgeons and also demonstrates the greatest variation in number of cases done by region. When the percentage of professional time spent in 1980 for each category was compared with that of the 1976 survey, there was an increase in cardiothoracic surgery (62% versus 58%), a decrease in peripheral vascular surgery (16% versus 19%), and essentially no change in the manner in which the remainder of time was spent. Community size. Respondents were asked to indicate the size of the community in which they practice. The groupings were as follows: less than 50,000; 50,000 to 100,000; 100,000 to 500,000; 500,000 to 1 million; and greater than I million. Examination of Fig. 5 indicates that approximately 80% of practicing thoracic surgeons work in metropolitan areas whose populations are 100,000 or more. Within those large metropolitan areas, about 87% of the surgeons do noncardiac thoracic surgery, 59% of them do some cardiac operations, 72% of the surgeons perform pacemaker procedures, and 65% of the surgeons are involved in peripheral vascular surgery (the
percentages do not add up to 100% because most surgeons provide typically more than one type of surgery). The number of thoracic surgeons living in communities smaller than 100,000 is only 20% (478). About 91% of these physicians are involved in noncardiac thoracotomies, 34% of them do cardiac work, 74% of them perform pacemaker procedures, and 73% of them perform peripheral vascular surgery (Table I). When the number of services rendered are considered, the difference between cardiac and noncardiac work becomes even more striking. In large communities (greater than 100,(00), not only more surgeons (percentage-wise) are involved in cardiac work but each of them performs, on the average, more cardiac operations per year than their colleagues in smaller communities. Specifically, surgeons who perform cardiac operations in large communities do, on an average, about 144 cases per year while those in smaller communities do only 95 cases per year. The difference for noncardiac cases is not as great: noncardiac thoracotomies (48 versus 43 cases per year), pacemaker procedures (31 versus 27 cases per year), and peripheral vascular surgery (57 versus 52 cases per year). The average number of cases per year is always smaller in the smaller communities, regardless of the type of service performed (as shown in Table I). A comparison of these data with results from the 1976 study shows that the number of Board-certified physicians in active practice increased about 7%. The increase in the small communities is higher (13%) than in large communities (5%) (Table II). In all communities, the average number of services of a thoracic surgeon in a particular community (regardless of the kind
The Journal of Thoracic and Cardiovascular Surgery
926 Cleveland et al.
Table I. Number of services and thoracic surgeons by community size Large communities «100,000)
Small communities «100,000)
All communities
Noncardiac thoracotomies Services Surgeons No. % Services/surgeon
18,468
78,236
96,704
434 91 43
1,631 87 48
2,065 88 47
Services Surgeons No. % Services/surgeon
15,536
160,344
175,880
163 34 95
1,116 59 144
1,279 54 138
Services Surgeons No. % Services/surgeon
9,460
42,142
51,602
353 74 27
1,351 72 31
1,704 72 30
Services Surgeons No. % Services/surgeon
18,229
69,001
87,230
351 73 52
1,216 65 57
1,567 67 56
Services Surgeons No. % Services/surgeon
61,693
349,723
411,416
478 100 129
1,878 100 186
2,356 100 175
Cardiac operations
Pacemaker procedures
Perivascular operations
All services
Table II. Comparison of 1976 and 1980 data
No, of thoracic surgeons Noncardiac thoracotomies per surgeon Cardiac operations per surgeon
Year
Small communities «100,000)
Large communities (>100,000)
All communities
1976 1980 Change 1976 1980 Change 1976 1980 Change
423 478 +13% 35.2 38.6 +10% 19.9 32.5 +63%
1,785 1,878 +5% 39.8 41.7 +5% 56.2 85.4 +52%
2,208 2,356 +7% 39.0 41.0 +5% 49.2 74.7 +52%
of services that are provided) shows a modest increase of 5% for noncardiac thoracotomies but a substantial increase of 52% for cardiac operations. Finally, when the overall major cardiothoracic and vascular surgical services rendered per physician are correlated with community size (Fig. 6), the data indi-
cate that there is a gradual increase in the number of all surgical procedures provided per surgeon per year as the size of community in which he practices increases. This trend is most dramatic with regard to provision of cardiac surgical services: There is a marked increase in the number of cases performed per surgeon per year as
Volume 84
Thoracic surgery manpower
Number 6 December, 1982
927
.. - Cardiac Operations
200
• - Non Cardiac Thoracotomies • - Pacemaker Procedures • - Peripheral Vascular Opl.
Mean Number
150
of Services per
100
Thoracic Surgeon
:
:
50
•
<50K
<500K
<1M
>IM
COMMUNITY SIZE
Fig. 6. Mean number of services per surgeon according to size of their community in 1980. Included are Board-certified thoracic surgeons who reported numbers of cases for cardiac, thoracic, pacemaker, or peripheral vascular surgery.
Table llI. Population and thoracic surgeons by region
No.
Region
Code
Population
I
Pacific Mountain NW Central SW Central NE Central SE Central South Atlantic Mid Atlantic New England All regions
PAC MNT NWC SWC NEC SEC SAT MAT NEN USA*
31,7%,869 11,368,330 17,184,066 23,743,134 41,669,738 14,662,882 36,943,139 36,788,174 12,348,493 226,504,825
2 3 4 5 6 7 8 9
Surgeons
398 III
172 221 342 129 424 359 151 2,394
Table IV. Services by region Region Surgeons per jOO,OOO
1.25 0.98 1.00 0.93 0.82 0.88 1.15 0.98 1.22 1.06
No.1 Code
I 2 3 4 5 6 7 8 9
PAC MNT NWC SWC NEC SEC SAT MAT NEN USA*
Noncardiac thoracotomies
13,260 3,269 6,877 10,737 14,807 6,442 17,689 13,811 6,885 97,619
Pacemaker Perivascular Cardiac operations procedures operations
27,803 8,275 14,526 24,811 31,227 11,005 24,152 24,649 7,895 177,703
6,704 2,012 4,075 5,319 7,518 3,017 9,249 9,472 3,180 52,139
10,112 4,035 6,641 13,732 11,912 4,915 15,580 12,469 4,522 88,097
'IncludesIslands and responses without ZIP codes.
'IncludesIslands and responses without ZIPcodes.
the community size exceeds 100,000. In summary, in regard to services provided by surgeons per year with relation to community size, more cardiac procedures are performed by surgeons in larger communities. Second, thoracic surgeons tend to locate in communities of over 100,000 and the surgeons located in these communities perform more cardiothoracic and peripheral vascular operations per surgeon per year than do those in the small communities. Regional distribution. The regional distribution of active Board-certified thoracic surgeons was estimated by utilizing the ZIP code of each respondent. These data were analyzed in terms of the nine geographic regions corresponding to the major census divisions of the United States. The regional distribution of thoracic surgeons and services rendered was analyzed from several viewpoints. The total population in 1980 based on information from the Bureau of Census was 226,504,825
as compared to an estimated population of 212, 145,000 in 1976. Based on the number of Board-certified thoracic surgeons, there was approximately one thoracic surgeon per 100,000 population in 1980. Analysis of each region indicates that the ratio of Board-certified thoracic surgeons to 100,000 of population ranged from a high of 1.25 per 100,000 in region I (Pacific) to the low of 0.82 in region 5 (North East Central). As in the 1976 study, four regions accounted for approximately two thirds of all Board-certified thoracic surgeons. Also, these regions contained approximately two thirds of the total population (Table ill). The distribution of services provided with relation to the distribution of surgeons was analyzed by the categories of noncardiac thoracotomies, cardiac operations, pacemaker procedures, and peripheral vascular operations (Tables IV and V). This analysis indicated that there was variation within a given region in the number of
928
The Journal of Thoracic and Cardiovascular Surgery
Cleveland et al.
110 100
Number of Services per 100,000 persons
90
... - Cardiac Operations
80
• - Pacemaker Procedures
•
- Non Cardiac Thoracotomies
• - Peripheral Vascular Ope.
70 60 50 40
...
30
~._~.
20
•
No.
Code
1
PAC
2
MNT
MOUNTAIN
3 4
NWC
NW CENTRAL
SWC
sw
5
NEC
NE
CENTRAL
6
SEC
SE
CENTRAL
7 8
SAT MAT
S ATLANTIC M ATLANTIC
9
NEN
NEW ENGLAND
Census Division PACIFIC
CENTRAL
10 23456789 CENSUS DIVISIONS
Fig. 7. The total number of services per 100,000 persons living in a census division, provided by Board-certified thoracic surgeons in 1980.
Table V. Services per 100,000 by region Region No.1 Code
1 2 3 4 5 6 7 8 9
PAC MNT NWC SWC NEC SEC SAT MAT NEN USA*
Noncardiac thoracotomies
41.7 28.8 40.0 45.2 35.5 43.9 47.9 37.5 55.8 43.1
Table VI. Mean number of services per thoracic surgeon per year
Pacemaker Perivascular Cardiac operations procedures operations
84.3 72.8 84.5 104.5 74.9 75.1 65.4 67.0 63.9 78.5
21.1 17.7 23.7 22.4 18.0 20.6 25.0 25.7 25.8 23.0
31.8 35.5 38.6 57.8 28.6 33.5 42.2 33.9 36.6 38.9
"Includes Islands and responses without ZIP codes.
Region
Noncardi-
No.1 Code
ac thoracotomies
1 2 3 4 5 6 7 8 9
PAC MNT NWC SWC NEC SEC SAT MAT NEN USA*
38 34 44 52 50 58 49 44 53 47
Cardiac Pacemaker Perivascular operations procedures operations
111 124 144 175 157 164 123 142 121 138
23 25 31 31 30 37 31 36 32 30
42 52 52 78 52 58 53 57 54 56
Legend: Only those surgeons are counted who have reported cases of the indicated service.
operations performed on a population-adjusted base (Fig. 7). For noncardiac thoracotomies, the mean number of procedures per thoracic surgeon per year throughout the United States was 47. When this was compared with the physician-patient ratio, it indicated that in four regions surgeons did not perform to the mean level of 47 whereas in five regions the mean was exceeded. When the same comparison was made with regard to cardiac procedures, where the mean number of operations per surgeon per year was 138, four re-
"Includes Islands and responses without ZIP codes.
gions were below the mean number (Fig. 4). Analysis of the number of pacemaker procedures performed per surgeon per year indicated that in each region, regardless of the surgeon density, essentially the same number of procedures were performed-a mean of 30 operations per surgeon per year-except in regions I and 2, where slightly fewer were performed. When peripheral vascular operations per region were compared
Volume 84
Thoracic surgery manpower
Number 6 December, 1982
Table
929
vn. Services per number of thoracic surgeons in a region Region
No.
I
Code
No. of surgeons
2
PAC
389
MNT
III
3 4 5 6
NWC SWC NEC SEC SAT MAT NEN USA*
I
7
8 9
172 221 342 129 424 359 151 2,394
Noncardiac thoracotomies
33 29 40
49 43 50 42 38 46 41
Cardiac operations
Pacemaker procedures
Perivascular operations
17 18 24 24 22 23 22 26 21 22
25 36 39 62 35 38 37 35 30 37
67 75 84 112
91 85 57 69 52 74
Legend: The number of thoracic surgeons in a region is tbe total number of active thoracic surgeons responding to tbe survey. 'Includes Islands and responses without ZIP codes.
Table
vm. Percent of thoracic surgeons Region
No.
I
Code
No. of surgeons
I
PAC
389
2 3 4 5 6 7 8 9
MNT
III
NWC SWC NEC SEC SAT MAT NEN USA*
172 221 342 129 424 359 151 2,394
in a region reporting the indicated service Noncardiac thoracotomies
Cardiac operations
Pacemaker procedures
87 86 92 93 86 87 86 88 87 87
61 60 59
72 76 77 85 73 63 70 73
64
58 52 46 48 43 54
66 72
Perivascular operations
60
69 74 80 67 66
69 61 54 66
Legend: One hundred percent indicates all thoracic surgeons in a region performing the indicated service. 'lncludes Islands and responses without ZIP codes.
to the national mean of 56 major operations per thoracic surgeon per year, it was found that only in region 4 (Southwest Central) was the mean number greatly exceeded whereas the rest of the regions were closer to the mean. Fig. 4 and Table VI summarize the data with regard to the four categories reviewed above. In computing the mean numbers of services per surgeon per year (Table VI) in a region, only those surgeons are counted who reported cases of the particular service. The mean numbers are therefore higher than the numbers derived by dividing the total number of services by the total number of Board-certified thoracic surgeons in a region, as shown in Table VII. For example, of the total number of thoracic surgeons responding (2,394), 87% perform noncardiac thoracotomies (2,094), only 54% perform cardiac operations (l,291), 72% perform pacemaker procedures (l,727), and 66% perform peripheral vascular surgery (l,586).
The variation between regions is smallest for noncardiac thoracotomies, ranging from a low of 86% in regions 2 (Mountain), 5 (Northeast Central), and 7 (South Atlantic) to a high of 93% in region 4 (Southwest Central). The largest variation among the nine census divisions is seen in the performance of peripheral vascular surgery. Region 4 (Southwest Central) leads with 80% and region 9 (New England) is lowest with only 54%. Table VIII summarizes this pattern of activity. The workload in thoracic surgery-1980. The results of this survey indicate that, in 1980, 2,394 surgeons certified by the ABTS performed 275,322 major thoracic and cardiac operations. This resulted in an overall workload of 115 major cardiothoracic cases per year per active thoracic surgeon. This number excluded pacemaker-related procedures, minor thoracic and diagnostic procedures, as well as vascular and other operations. Of the total major cardiothoracic operations,
The Journal of Thoracic and Cardiovascular Surgery
930 Cleveland et al.
200
Mean Number of Services per Surgeon per Year
150
•
- Cardiac Operations
• - Non Cardiac Thoracotomies
• - Pacemaker Procedures • - Peripheral Vascular Ops
100
50
Low Surgeons: 704
OK WORKLOAD
High
1509
121
Fig. 8. Mean number of services per surgeon provided by Board-certified thoracic surgeons who reported cases for cardiac, thoracic, pacemaker, or peripheral vascular surgery. Services were divided according to low. satisfactory, or high workload in 1980.
97,619 thoracotomies were performed for noncardiac indications. There were 177,703 cardiac operations performed, of which 117,559 were aorta-coronary bypass procedures and 31,817 were valvular heart operations. A total of 20,303 operations were performed for congenital heart disease, of which 11,691 were open procedures and 8,612 were closed operations. Major peripheral vascular operations numbered 88,097 during the year. Comparing these data with those of the 1976 survey indicates an increase in major cardiothoracic procedures (275,322 versus 195,850). In general, the increase in thoracic surgical procedures was 13% (97,619 versus 86,734) and the increase in the areas of cardiac operations (excluding pacemaker and peripheral vascular operations) was 63% (177,703 versus 109,116). The number of pacemaker procedures and peripheral vascular operations cannot be compared with the 1976 survey, since these questions were not asked in the 1976 survey. In 1980, a total of 52,139 pacemaker procedures were performed by 1,727 thoracic surgeons and 88,097 peripheral vascular operations were performed by 1,586 Board-certified thoracic surgeons. In the area of cardiac operations, the workload increased substantially in the category of coronary artery surgery (117,559 versus 71,551), whereas for congenital heart disease the number of operations showed no significant change (20,302 versus 19,005). The latter holds true for both the open (11,691 versus 11,449) and the closed heart procedures (8,612 versus 7,556). A comparison between the number of valvular heart operations performed in 1980 and 1976 is not possible since this question was not asked in the 1976 survey. However, Adkins and Orthner" estimated the number of "valve replacements or repairs" to be 18,560
in 1976. This number compares with 31,817 valvular operations performed by 1,122 thoracic surgeons in 1980. Examination of data obtained from the Hospital Record Study for 19805 disclosed that approximately 149,000 operations were performed on the larynx, chest wall, diaphragm, and intrathoracic structures during the period of this study. This would appear to indicate that, since 97,619 noncardiac thoracotomies were performed by Board-certified surgeons, 34% were performed by noncertified surgeons. However, on closer examination, and employing the same criteria used in this review to define major cardiothoracic surgical procedures, only approximately 105,500 major noncardiac thoracotomies were performed in the United States in 1980 according to the Hospital Record Study. Therefore, this would indicate that approximately 93% of major noncardiac thoracotomies were performed or supervised by Board-certified thoracic surgeons. Further review of the data indicates that virtually all cardiac surgical operations are performed or supervised by surgeons certified by the ABTS. Estimates of additional capacity. One of the goals of this study was to attempt to determine what, if any, residual surgical capacity was available to handle the present and possibly projected health care needs of the specialty. If this could be determined, it could be of value to a wide variety of agencies and organizations charged with the responsibility of providing sufficient thoracic surgical services at reasonable human and economic costs. In order to get a reasonably accurate estimate of the current manpower capacity, the questionnaire requested that the respondent indicate whether the surgeon's workload in his or her opinion was too small, too large, or about right. Further, if the work-
Volume 84 Number 6 December, 1982
load was felt to be inappropriate, the respondent was requested to indicate what the estimated differential in the individual's workload might be. In addition, the total number of hours worked per week and weeks worked per year were requested. As previously noted, the vast majority of surgeons engaged in professional activities between 50 and 79 hours per week, with the average work week being 62 hours (Fig. 3). In addition, the national average of major thoracic and cardiac operations performed per year by Board-certified surgeons was 115 cases, an increase from 87 per year in 1976. When the respondents answered the question as to the adequacy of their volume (Fig. 8), 704 surgeons felt they could provide more clinical services and 121 surgeons felt that they were too busy. The vast majority of respondents (1,509) felt that their workload was about right. When these data were calculated as possible additional cases per week which might be performed per surgeon, it revealed but an additional 1.9 cases of major cardiothoracic nature might be done by 704 surgeons. If the same calculations are performed by those who indicated that the workload was too heavy, one finds that the 121 respondents felt that they would like to reduce their workload by 1.6 cases per week. Using the projections of Feldstein and Viets," if 120 surgeons are certified each year through 1993, the projected number of practicing Board-certified surgeons will be 3,736; if 160 surgeons are certified each year, the total is projected to be 4,128. Using the percent increase in major cardiothoracic procedures between the last study and the current review and projecting that increase forward to 1993 in a compound manner, there will be a total of 743,668 major cardiothoracic procedures to be performed in that year. This figure is reached by projecting general noncardiac procedures at a compounded rate of 2.75% per year and cardiac cases at a rate of 10% per year. In the former, the 2.75% per year growth rate is that which was actually experienced between 1976 and 1980. The rate of growth in cardiac procedures was actually 13% per year, so that the projected 10% per year increase is somewhat less than the historical data demonstrated. When these data are translated in cases per year per surgeon, certifying 120 surgeons per year would result in a projected workload of 199 cases per surgeon per year or 4.1 per week. Should 160 surgeons be certified, the workload would be 180 cases per surgeon per year or 3.75 cases per week. The validity of this type of linear projection in the growth rate of cardiothoracic surgery is certainly open to debate and basically results from the rapid increase in the number of aorta-coronary bypass procedures performed
Thoracic surgery manpower
93 1
between 1976 and 1980. It is probably fair to assume that at some time in the future the number of these procedures performed each year may plateau. This may result from several factors including the development of preventive measures, differing patterns of treatment, and elimination of a supposed backlog. If one wishes to make a conservative projection of future medical needs, development of another hypothetical model may be of value. First assume that there will be no significant increase in general thoracic, valvular, and congenital heart surgery performed but that the growth rate of aortacoronary bypass surgery will increase from the 1980 figure of 117,000 to 150,000 or 200,000 cases per year in 1993. Further assume that 120 thoracic surgeons will be certified each year. There will then be 3,736 Boardcertified surgeons available to provide thoracic surgical services. This will result in a workload of 80 cases per surgeon per year or 1.7 cases per week if 150,000 coronary procedures are performed and 96 cases per surgeon per year or 2.0 cases per week if 200,000 coronary procedures are done. These data may be compared with the 1980 workload of 128 cases per surgeon per year or 2.7 cases per week, which most surgeons found to be satisfactory. It should be emphasized that these 1993 projections are merely estimates of the varying rates of growth both in manpower and thoracic surgical services needed. Workload estimates are probably inflated when the compounded linear growth rate is used and extremely low when the general estimates of limited growth in aorta-coronary bypass and no growth in the other areas of activity are used. None of the projections takes into account the fact that some procedures may become obsolete, that new procedures may be developed, and that the population requiring thoracic surgical procedures will vary in number because of multifactorial pressures placed upon the health care system in the future. However, accepting all of these possible variables which may affect the validity of any long-term projections, it appears that the current workload of 128 major cardiothoracic cases per year satisfied both the available manpower and medical needs of the population in 1980. On a predictive basis, the certification of approximately 120 thoracic surgeons per year will probably continue to meet the medical needs of the cardiothoracic surgical patients during the next decade. Because projections of future medical needs and available manpower remain unclear, it is prudent to continue to monitor the services available with regard to health care needs of the population of the United States.
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Cleveland et al.
REFERENCES Brewer LA III, Ferguson TB, Langston HT, Weiner JM: National Thoracic Surgery Manpower Study, Los Angeles, 1974, Cunningham Press, Publisher 2 Adkins PC, Orthner HF: The Society of Thoracic Surgeons manpower survey for 1976. A summary. Ann Thorac Surg 28:407-412,1979 3 Feldstein PJ, Viets PH: Forecasting health manpower re-
The Journal of Thoracic and Cardiovascular Surgery
quirements. The case of thoracic surgeons. Ann Thorac Surg 28:413-422, 1979 4 Report of the Graduate Medical Education National Advisory Committee to the Secretary, Department of Health and Human Services, Washington, D. C., 1980, Public Health Service, Health Resource Administration 5 Hospital Record Study. A Joint Survey by CPHA and IMS American Ltd., Ambler, Pa., 1980, IMS America Ltd.