Neurosurgical manpower: What are the issues?

Special Article

Neurosurgical Manpower: What Are the Issues? Clark Watts, M.D.

Various issues are examined that affect the number of neurosurgeons required to deliver quality care to the people of the United States. The primary issues are a need to define the scope of nem~surgery and to ensure patients adequate access to neurosurgical care. Only after these have been satisfactorily dealt with can realistic numerical goals be set. Watts C: Neurosurgicalmanpower:what are the issues? SurgNeurol 18:241-245, 1982

The single most important internal long-term issue facing neurosurgery today is the question of manpower. It is an internal issue in that, although significant pressures are exerted from the outside to "do something" about the rate of production of neurosurgeons, the only suitable solutions to neurosurgical manpower questions must come from within neurosurgery. Neurosurgery manpower statistics have been the fascination and preoccupation of every generation of neurosurgeons since the founding of modem neurosurgery in the United States by Harvey Cushing. He considered a suitable ratio to be one neurosurgeon per million population [15]. The scope of neurosurgery has expanded greatly since Cushing's time, as has the number of neurosurgeons. Currently it is estimated that in the United States the ratio of neurosurgeons to the population is one per 70,000 [7]. This compares with 1 : 500,000 in Britain and 1 : 140,000 in Canada. These comparisons have led some nonneurosurgeon physicians and laymen to proclaim there are too many neurosurgeons in the United States. Similar conclusions are being voiced within the field [2, 3, 19]. Drake [12], Odom [18], and Schneider [20], in their presidential addresses to the American Association of Neurological Surgeons (AANS), have discussed the charge. Individual neurosurgeons have indicated, often in frenzied debate, the bel:Lef that there are too many neurosurgeons and that something must be done. Pleas for a

From the Division of Neurosurgery, Universityof Missouri-Columbia Health SciencesCenter, Columbia,MO. Address reprint requests to Dr. Clark Watts, Divisionof Neurosurgery, University of Missouri-ColumbiaHealth Sciences Center, Columbia, MO 65212. Keywords:access;neurosurgicalcare;education;neurosurgery;manpower.

more objective evaluation of the problem have also been heard [1, 8, 9], and attempts have been made to study the issues. In 1969 an ad hoc committee of five members was appointed by the AANS to develop a means of examining the problem [18]. This led to a contract in 1973 between the National Institute of Neurological and Communicative Disorders and Stroke and the AANS, which resulted in the AANS Neurosurgical Manpower Study completed in 1975 [20]. The AANS report studied practicing neurosurgeons, program directors, neurosurgeons in training, and manpower and workload in neurosurgery. Performed primarily by questionnaire, the study is important in that, for the first time, it defined the scope of neurosurgery as currently practiced, the contents of neurosurgical training, and some of the problems confronted by program directors. In addition, it estimated the total neurosurgical population by 1985 to be approximately 3,950. Somewhat arbitrarily, the report suggested there should be a 20 to 25% reduction in the number of physicians entering neurosurgical training with careful monitoring of the effect of this reduction on the quality of patient care rendered, while at the same time recommending an increase in the number of academic neurosurgical positions [10]. Associated with this study was a more in-depth evaluation of the practice of neurosurgery in North and South Carolina, with an emphasis on prevalence of neurosurgical diseases and procedures [25]. The investigators utilized inpatient data compiled by the Commission of Professional and Hospital Activities and obtained from questionnaires and personal interviews with neurosurgeons. The report is of major interest to neurosurgeons because it indicated that a large number of patients with neurosurgical diseases were being seen, and a large number of neurosurgical procedures were being performed, by nonneurosurgeons. It did not indicate why this state of affairs exists, but concluded that more neurosurgeons may be needed to correct it. The area of neurosurgery was, at about the same time, being evaluated by the Study on Surgical Services for the United States (SOSSUS), jointly sponsored by the American College of Surgeons and the American Surgical Association [26]. Criticized not only by others but also by the American College of Surgeons itself, this study contributed little to the fundamental knowledge of the practice of neurosurgery in the United States [27]. It recommended an immediate 20% reduction in manpower production and a

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242 Surgical Neurology Vol 18 No 4 October 1982

subsequent growth rate of 1% per five years. Finding a reduced number of skilled neurosurgical procedures being done per neurosurgeon along with an increased number of neurosurgeons being trained, it advised careful consideration of the potential benefits to be gained by regionalization of care. The Mendenhall study, based on week-long professional diaries completed by 426 neurosurgeons chosen randomly (a 63% response rate), established nationally and by U.S. census region, several important facts about the practice of neurosurgery in the United States, and did so with more accuracy than had been previously obtained [16]. For example, the mean number of professional hours per week of a neurosurgeon varied from 63.3 in the New England area to 50.6 in the Mountain area of the Western region. The number of direct patient encounters per week varied from 161.0 in the East South Central area of the Southern region to 69.8 in the Pacific area of the Western region. Similar marked regional differences were noted throughout the study. This suggests that any policy which determines future manpower numbers in neurosurgery must be based upon a close scrutiny of these regional differences--their extent and explanations. The Graduate Medical Education National Advisory Committee (GMENAC) of the Department of Health and Human Services (formerly the Department of Health, Education, and Welfare) of the federal government established a basic need of 2,793 neurosurgeons for 1990, with a range of 2,500 to 2,800 [23]. These requirements were developed through a modified Delphi process utilizing a needs-based model. Although the model has been criticized, the study is important because for the first time an attempt was made to calculate the number of neurosurgeons needed, based on an estimate of the incidence and prevalence of diseases treated by neurosurgeons. The scope of neurosurgical practices was arbitrarily defined, hQwever, based on the traditional functions of neurosurgeons without much attempt to be innovative or to propose a broadening of the scope of neurosurgery as suggested by the Carolinas study report [25]. These data and conclusions lead to the questions: How many neurosurgeons are there currently?; How many will there be in the years 1990 and 2000 if we make no changes in current policy?; and How many do we need? The most reliable data relating to the first two questions appears to be that contained in the Mendenhall report, based on the study conducted in 1977 [16]. At that time, using the American Medical Association tapes, approximately 2,800 neurosurgeons were identified, 17% of whom were residents, leaving a net total of approximately 2,300 practicing neurosurgeons. (A comparison of the AMA tapes with the World Directory of Neurological Surgeons compiled by the Congress of Neurological Surgeons yielded an error of approximately 5% in the AMA tapes.) Added

to this 2,300, the current yearly production of neurosurgeons ( 125)* yields a number of 2,800 practicing neurosurgeons in 1980. Extrapolation to 1990, considering the loss of practicing neurosurgeons due to attrition, indicates there will be 3,800 to 4,000 neurosurgeons. This figure agrees with the predictions of both the American Medical Association [3] and the Graduate Medical Education National Advisory Committee [23]. Realizing the danger of predicting beyond that point, current trends in the policies of resident training suggest that more than 5,000 neurosurgeons will be practicing by the year 2000. More difficult to ascertain are the numbers of neurosurgeons actually needed. Some have tried to predict this need. The GMENAC report suggested a maximum of 2,800 neurosurgeons would be needed by 1990 [23]. Bucy, as a result of his evaluation of the AANS ManPower Report, concluded that "in the foreseeable future" 278 additional neurosurgeons will be needed simply to supply the needs of the country, 1,000 to provide partners in solo practice, 175 additional neurosurgeons for unfilled faculty positions, 80 per year to replace neurosurgeons now 60 to 69 years of age, and 200 per year to replace neurosurgeons now 50 to 59 years of age [6]. He believed that if the average work week were reduced to 8 hours a day, 5 days a week, and the number of work weeks to 46 to 48 per year, as the result of regulations imposed by national health insurance or other regulatory activities of the federal government (which some have predicted [11]), the "demand for neurosurgeons would far exceed our present ability to supply them." From this discussion it is clear there are several unanswered questions. Preeminently, the future scope of neurosurgical practice must be clearly defined. Will it be as narrow as the GMENAC report suggests [23]? Should it be as broad as Bucy [4, 5, 7, 8] and as the Carolinas study [24] suggest it need be? Only after supplying this definition can the true need for neurosurgeons be estimated. The noted economist Eli Ginzberg [13], who considers neurosurgery a frontier specialty, thereby implying that there is considerable room for growth, cautioned against developing future manpower policies on the basis of such studies as SOSSUS because the data "are too soft, the inference is too uncertain, the recommendations too radical." He further recommended that neurosurgery continue a close monitoring of the manpower situation and that it profit from the Carolinas study regarding "practice modes and seek to stimulate the state and regional bodies to assume a more active role in bringing about changes that would contribute to patient care." To assess future educational policies, we should understand how neurosurgery has changed since Cushing's days. Approximately 30% of the neurosurgeon's time is involved *Kline D (Secretary,American Boardof NeurologicalSurgery):Personal communication, 1980

Watts: Special Article: Neurosurgical Manpower 243

with "primary care," or principal encounters [ 16]. Of these encounters, approximately two-thirds result in no diagnostic or specific therapeutic activities. Almost 50% of the time is spent with disorders related to the spine, and another 10% with cranial trauma. Less than 10% of the average neurosurgeon's time is spent evaluating and managing patients with high-risk lesions such as aneurysms and basal tumors, with even less time devoted to actual surgical procedures. From an examination of the incidence of disease, it was estimated in 1972 that the average neurosurgeon surgically treated four brain tumors and less than three aneurysms per year [18]. "[here is no reason to believe the workload is any heavier today [16]. It is difficult to examine these statistics without asking if the changing practice of neurosurgery by the average neurosurgeon should be coupled with a changing emphasis on neurosurgical education, not only for the medical student and nonneurosurgical house officer but also for the neurosurgical resident.

Options Many have expressed concern that the number of neurosurgeons has reached the saturation point [2, 12, 16, 19, 20, 22, 27, 28], but few have proffered solutions [2, 3, 10, 21]. The very lively extemporaneous debate about this point suggests that this is the "official" posture of neurosurgery. However, the options have. not been examined objectively. Our first option is to ilgnore the problem, and let the "marketplace," through the economics of supply and demand, provide the solution. This is untenable. First, the control of the practice of :medicine in this country is such that standard economic theories do not apply [14]. This is due in part to the restrictions on the entry into medical school and the licensing of practitioners, the location and equipping of facilities, and the very practice of neurosurgery itself. Additionally, the demands of the public, our political leaders, our lawmakers, and neurosurgeons themselves indicate that if we ignore the. problem someone else will take it upon themselves to "correct" it. Past experience with "corrections" of problems within the health care delivery system by such individuals guarantees that neurosurgery and the people of the United States will suffer. Recent state proposals to control physician manpower through "certificates of need" are unsettling in their implications. A simple answer, and one that will be popularly received, is to declare that too many neurosurgeons are being produced, and to significeLntly reduce this production. In essence, we would adopt the more narrow definition of the scope of neurosurgery, relegating neurosurgeons to the more populated areas of the sl:ates and making neurosurgical coverage more inaccessible to the more than 40% of people in the United States who reside in nonmetropolitan areas (communities with a population of less than 200,000) [24, 25]. If we assume this posture, we must examine critically the

long-term effects. Most likely, more and more "neurosurgery" will be performed by nonneurosurgeons; there is little indication that physicians in related specialties are actively reducing their numbers [17]. Less neurosurgery will be available in smaller communities. One of the results of the increased numbers of neurosurgeons produced in the past two decades is that the percentage of communities with populations of 50,000 to 200,000 having Board-certified neurosurgeons has increased from 40% in 1960 to 74% in 1977 [21]. For towns of 30,000 to 50,000 that percentage has risen from 8% in 1960 to 27% in 1977. While some of this movement to smaller communities may be the result of a general belief in this country that the quality of life is better away from major metropolitan areas, the inescapable conclusion remains that it is largely the result of increased numbers of neurosurgeons in the major metropolitan areas. Increasing the quality of neurosurgical care delivered throughout the country while at the same time cutting back on the number of neurosurgeons who deliver that care will require increased efforts to educate physicians in other specialties to recognize the presence of neurosurgical disease, to support the patient in the initial throes of that disease, and to ensure an adequate network of transportation and communication so the patient has ready access t o a neurosurgeon [24]. This will require greater cooperation between academic neurosurgeons and practicing neurosurgeons on a regional and state level. The major educational focus of the academic neurosurgeon will be toward the medical student and the nonneurosurgical house officer, especially those in family practice and neurology. While practicing neurosurgeons will participate at this level in some instances, they will also be important in continuing postgraduate educational programs. The cooperation of both groups of neurosurgeons will be required to successfully compete with other interests in the establishment of local, state, and regional communication and transportation networks. The reduction in numbers of neurosurgeons in general may mean a reduction in academic neurosurgeons, perhaps contributing to decreased teaching and research efforts [22]. A distinct possibility is that this could result in failure to deliver new technology to the practicing neurosurgeon that could be applied in the field. Any absolute move to reduce significantly the number of neurosurgeons in practice or the rate of production of neurosurgeons must consider the effects of uncontrolled political influences outside neurosurgery on the manpower pool. An example of this is the dramatic potential reduction in the number of neurosurgeons in training created by PL 94-484 (Immigration and Naturalization Act), which restricts the number of foreign medical graduates who can enter and successfully complete a neurosurgery training program in the United States.

244 SurgicalNeurology Vol 18 No 4 October 1982

Another option is to consider the scope of neurosurgery to be as broad as Bucy and the investigators of the Carolinas study suggest it should be. This would be appropriate if it is considered that optimal health care will be delivered only when all patients with surgically treatable diseases of the nervous system have timely access to neurosurgical care. Certainly, some believe a major interest of the public is improved access to essential health care [14]. This attitude may result in a trend toward even more neurosurgeons. This development is in keeping with the concept that neurosurgery is a frontier specialty and society will benefit by expanding that frontier. The Joint SocioEconomic Committee (JSEC) of the American Association of Neurological Surgeons and the Congress of Neurological Surgeons recently defined neurosurgery as "the medical and surgical treatment of diseases of the nervous system" (JSEC minutes, April, 1979). The Board of Directors of the AANS rejected that definition, suggesting it be broadened to include, among other components: "[the] operative and nonoperative management involved in the diagnosis, treatment, and rehabilitation of a patient [with disorders of the central, peripheral, and vegetative nervous system] utilizing all of the modalities in medicine" (JSEC minutes, October, 1979). In essence, this means that the practicing neurosurgeon is the primary physician in the care of diseases of the nervous system. If there are large numbers of patients suffering from diseases of the nervous system who are undergoing diagnostic procedures and treatment by nonneurosurgeons, this definition suggests the specialty should expand itself to encompass these patients. If one accepts the axiom that disease of the nervous system is best treated by neurosurgeons, this expansion is inescapable. Since the average neurosurgeon today works about 60 hours per week [16], this expanded patient population will require greater workloads and productivity of existing neurosurgeons.or an increased number of neurosurgeons. In order to extend neurosurgical care to this increasing number of patients, either the patients must be brought to the neurosurgeon, or the neurosurgeon must be brought to them. Intensified educational efforts in medical schools and institutions for postgraduate training to increase the awareness of nonneurosurgical physicians to the presence of neurosurgical disease will be required for improving patient care. It can safely be said that, given the pluralistic nature of our health care delivery system, this tack alone will not be successful if nonneurosurgical physicians treating diseases of the nervous system are more conveniently available in the communities. It is reasonable to believe that if physicians are to be continuously made aware of the nature of neurosurgical disease and the benefits of early diagnosis and treatment, and that if the neurosurgeon is the appropriate physician to render that treatment, a neurosurgical presence must be felt within the appropriate physician community. As an example, Drake [12] has stressed that, despite the

lowered mortality associated with surgical management of aneurysms done by skilled microneurosurgeons in the most modem facilities, the overall morbidity and mortality for intracranial aneurysms has not been altered significantly. The reason for this is that the disease is not being recognized early enough and not being managed appropriately from the outset. One method of dealing with this problem is through increased educational efforts in medical schools, in postgraduate institutions, and in continuing education programs. A more sure way to improve the treatment of intracranial aneurysms is to situate neurosurgeons in the smaller communities where their influence will constantly reinforce the principles of early detection and management of this disease. If this concept !s true for aneurysms, it is also true for cranial trauma, spinal trauma, disease of the lumbar discs, and the other conditions that occupy the major portion of the neurosurgeons' time. If a community desires the presence of a physician dedicated to the management of all forms of nervous system diseases and it has the resources to support only one such person, the most complete coverage will be rendered by a physician labeled by some a "surgical neurologist," a euphemism for a general neurosurgeon with both medical and surgical orientations. If our goal is to improve the total care of nervous system disease (including "classic" neurosurgical diseases) by improving the access of patients to neurosurgical care in smaller and smaller communities, the emphasis of our neurosurgery training programs has to be reevaluated through cost/benefit and cost/effectiveness analyses. The focus of present training programs will have to change to better prepare the neurosurgeon as the "primary physician" for diseases of the nervous system. Less emphasis must be placed on the acquisition by the general neurosurgical practitioner of the skills required in the operative management of high-risk and low-volume neurosurgical diseases. More emphasis must be placed on those conditions and procedures with which the practicing neurosurgeon will be most occupied. The process of the delivery of neurosurgical care will have to be restructured to recognize these changes. Greater access to supporting facilities must be available to the general neurosurgeon wherein reside the neurosurgeons who have dedicated themselves to the investigation and management of the high-risk, low-volume diseases. In a definition of these diseases, Drake [12] has used as examples aneurysms, basal skull tumors, and intramedullary spinal tumors. The support facilities must contain the high-cost technology that would not be economically feasible for low-volume demand but would be cost-effective for highvolume demand. The general neurosurgeon in his or her training must be educated to the inefficiency of dealing personally and infrequently with high-risk neurosurgical diseases. If this expanded scope of neurosurgery is accepted, we

Watts: Special Article: Neurosurgical Manpower

must be ready to accept and defend the concept that the number of neurosurgeons trained cannot be reduced; in fact, expansion may be necessary. In medical school and in the training of nonneurosurgical house officers, greater emphasis must be placed upon the primary role of the neurosurgeon. Support must be given to expanded programs for additional specialized training of those dedicated to the treatment of high-risk, low-volume disease and to basic neurosurgical research to expand the therapeutic armamentarium of all neurosurgeons.

Conclusions The practitioners of neurosurgery have performed excellent service for our society by ensuring improved access of the public to quality neurosu~:gical care. Academicians have augmented this service by dedicated attention to the quality training and continuing education of neurosurgeons. U n fortunately, these service:~ have, in the past, been performed without much atte.ntion to the changing scope of neurosurgical practice. This has resulted in the charge that there are too many neurosurgeons, at the same time that increasing numbers of patients with neurosurgical disease are being treated by nonneurosurgeons. The question that remains to be answered is: What will be the neurosurgical needs of this country and how are they to be met? We can only answer this question in terms of our objectives and goals for the delivery of quality health care, not in terms of individual economics. Future neurosurgery manpower policies must be based upon these answers. These answers, and their dictated implementation, will only evolve from a systematic and continued review of neurosurgical need. Through this review, the process of delivery of neurosurgical health care can be continuously reassessed, manpower goals for 1990, 1995, and 2000 realistically set, and a course cl,early mapped. The penultimate goal of this course will be a system of delivery of neurosurgical care in this country tlhat guarantees all potential patients access to quality neurosurgical care.

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3. Bergland RiM: Neurosurgery in a zero-sum society. Neurosurgery 8:280-282, 1981 4. Bucy PC: How many neurosurgeons? Surg Neurol 3:201-206, 1975 5. Bucy PC: Neurosurgical manpower (editorial). Surg Neurol 4:209210, 1975 6. Bucy PC: Neurosurgical manpower (editorial). Surg Neurol 4:485488, 1975 7. Bucy PC: The distribution of neurological surgeons in the United States and Canada. Surg Neurol 6:201-203, 1976 8. Bucy PC: Who! (editorial). Surg Neurol 7:161-162, 1977 9. Clark WK: Manpower surveys and other myths. Clin Neurosurg 2:566-572, 1975 10. Clark WK, Wrenn F1R,RansohoffJ: Manpower Resourcesand Needs in Neurosurgery:Research, Teaching, and Patient Service (NIH-NS 72-2308). Chicago: American Associationof Neurological Surgeons, 1975 11. Creech O: Medical practice in 1990. Bull Tulane Univ Med Faculty 25:229-237, 1966 12. Drake CG: Neurosurgery:considerations for strength and quality: the 1978 AANS presidential address. J Neurosurg 49:483-501, 1978 13. GinzbergE: Manpowerfor neurosurgery:seeing ourselvesas others see us: the 1977HarveyCushing oration. J Neurosurg47:803-809, 1977 14. Ginzberg E: The competitive solution: two views. Competition and cost containment. N Engl J Med 303:1112-1115, 1980 15. MayfieldFH: Should the number and quality of neurosurgeons be determined by control or by the market, in Morley TP (ed): Current Controversies in Neurosurgery. Philadelphia: Saunders, 1976, pp 5-14 16. Mendenhall RC, Watts C, Radicki SE, Girard R.A: A study of the practice in the United States. Neurosurgery8:267-276, 1981 17. Menken M: The coming oversupplyof neurologists in the 1980s: implications for neurology and primary care. JAMA 245:2401-2403, 1981 18. Odom GL: Neurological surgery in our changing times: the 1972 AANS presidential address. J Neurosurg 37:255-268, 1972 19. Odom GL: Over-all view of neurosurgical manpower and training. Clin Neurosurg 22:59-66, 1975 20. Schneider RC: The "future trends" in neurosurgeryare here: the 1975 AANS presidential address. J Neurosurg 43:651-660, 1975 21. Schwartz WB, Newhouse JP, Bennett BW, Williams AP: The changing geographicdistribution of board-certified physicians. N Engl J Med 303:1032-1038, 1980 22. Sun M: Too many doctors in the house. Science 210:756-757, 1980 23. Watts C: Neurosurgicalmanpowerrequirements for 1990: an estimate of the Graduate Medical Education National Advisory Committee. Neurosurgery 8:277-279, 1981 24. Watts C, Adelstein W: Access to neurosurgical care: a critical component of the manpower equation. Surg Neurol 17:223-226, 1982 25. Wrenn FR, DeFriese GH, Sullivan R: Neurosurgeryin the Carolinas and its relation to national neurosurgical manpower requirements. Clin Neurosurg 22:526-565, 1975 26. Zuidema GD (ed): Surgeryin the United States: A Summary Report of the Study of Surgical Services in the United States. Baltimore: Donnelley, 1975 27. ZuidemaGD: The SOSSUS report and its impact on neurosurgery. J Neurosurg 46:135-144, 1977