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Thoracic surgeons and their surgical practice
Original Communications
Thoracic surgeons and their surgical practice The work characteristics of thoracic surgeons were studied as part of a national study of surgeon manpower. Thoracic surgeons were found to have the greatest operative work loads. longest workweeks. and equivalent median incomes compared with all other surgical specialties. The major conclusion that the number of thoracic surgeons was adequate concurs with the findings of the National Thoracic Surgery Manpower Study on number of practitioners.
Bernard S. Bloom, Ph.D.,* Rita J. Nickerson, M.A.,** Walter W. Hauck, Jr., Ph.D.,*** and Osler L. Peterson, M.D., M.P.H.,* Philadelphia, Pa., Boston, Mass., and Chicago, Ill.
A
study of surgical manpower was undertaken in close cooperation with the Study on Surgical Services for the United States (SOSSUS). Earlier published reports of these studies focused on general, summary data for each specialty. 1-6 This report is based on further analyses that provide more detailed data on practice characteristics and operative work of thoracic surgeons. It is one of a series of reports on each of ten surgical specialties. The findings for thoracic surgeons are compared with those for all other surgical specialists, i.e.,
A portion of this study was performed under Contract 231-76-0034, Bureau of Health Resources Development, Health Resources Administration, U.S. Public Health Service. The original data collection and analysis were supported by Grant No. HMS-llO72-125 from the Health Services and Mental Health Administration and Contract No. NOI-MI-24078, Bureau of Health Resources Development, National Institutes of Health, and by the American College of Surgeons, Commonwealth Fund, Henry J. Kaiser Family Foundation, Robert Wood Johnson Foundation, Rockefeller Foundation, and the Walnut Medical Charitable Trust. Received for publication Jan. 26, 1979. Accepted for publication April 18, 1979. Address for reprints: Bernard S. Bloom, Ph.D., Leonard Davis Institute of Health Economics, University of Pennsylvania, Tri-Neb Building (2L) Philadelphia, Pa. 19104. *University of Pennsylvania, and Philadelphia Veterans Administration Medical Center, Philadelphia, Pa. 19104. **Harvard Medical School, Department of Preventive and Social Medicine, Boston, Mass. 02115. ***Illinois Cancer Council, Chicago, Ill. 60603, and Northwestern University Medical School, Department of Community Health and Preventive Medicine, Chicago, Ill. 60611.
physicians whose primary specialty is in another field of surgery. Concurrent with the manpower study reported here, The American Association for Thoracic Surgery appointed a group to conduct the National Thoracic Surgery Manpower Study, which examined the distribution and work loads of surgeons to determine if they were meeting population needs." This group concluded in 1974 that the number, replacement rate, and distribution of thoracic surgeons appeared adequate. That conclusion and the results of this study hold important implications for future planning of thoracic surgery manpower.
Study design The study designs from which the data here presented have been drawn are described in detail elsewhere.v ! In brief, for one study, a questionnaire was sent to a stratified random sample of 10,232 physicians, who reported to the American Medical Association that they had a primary, secondary, or tertiary interest in surgery, and doctors of osteopathy, who reported a surgical specialty to the American Osteopathic Association. Responses were obtained from 7,298 (76%) of those in the one in eight sample who could be contacted. The second study was an analysis of all in-hospital operations for the entire population of four geographic areas, each of about I million population." 4 For each physician who performed an operation during 1970, See editorial comment, page 174.
0022-5223/79(080167+08$00.80(0 © 1979 The C. V. Mosby Co.
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Table I. Mean professional time per week by thoracic surgeons and all other surgical specialists and by principal activity, 1972 Activity"
Thoracic surgeons
Other surgeonst
Total professional time Direct patient care Operating room Hospital Office Practice administration Professional transit
55.6 35.1 13.1 38.0 7.0 6.1 1.6
45.7 34.9 9.1 23.5 16.0 5.5 0.9
'Categories are not mutually exclusive. tAli other surgical specialists.
Table II. Percent distribution of source of hospital and office patients treated by thoracic surgeons and all other surgical specialists, 1972 Hospital patients Source of patients
Self-referred Physician referred Other
Thoracic surgeons
15.3 70.1 14.6
Isurgeons· Other 44.4 40.4 15.2
Office patients Thoracic surgeons
Other surgeons·
21.4 62.6 16.0
51.2 34.4 14.4
• All other surgical specialists.
total in-hospital operative work was aggregated among all hospitals in the study area. Each operation was assigned a California Relative Value (CRV).8 These CR V weights correlate with length and complexity of operations and thus serve as the basic index of a physician's total surgical output. Meaningful comparisons of work loads of different mixes and across specialty lines were thus possible. Only one procedure per hospitalization has been tabulated. If multiple procedures were recorded, only the most complex (highest CR V) was selected. In this report the results for surgical specialists with M.D. and D.O. degrees are combined. "Board certified" is defined as certified in the physician's primary specialty.
Results The first portion of the Results section is based on responses to the questionnaire. Number of thoracic surgeons. Of the surgical specialists who responded to the questionnaire and indicated that they were currently active in surgical practice, 134 were thoracic surgeons. Only one thoracic surgeon was a graduate of an osteopathic medical school. On the basis of these data, we estimated that
there were 1,430 thoracic surgeons past the residency stage in active practice in the United States in 19723% of all surgical specialists. Thoracic surgery was one of the smaller surgical specialties with only plastic and colon-rectal specialties having fewer members. Age, board certification, and training characteristics. Thoracic surgeons were a somewhat younger group than other surgical specialists; 47% as opposed to 43% of all other surgeons were under the age of 45 years. Conversely, 17% of all other surgical specialists were 60 years of age or older, compared with 8% of thoracic surgeons. The over-all board certification rate of thoracic surgeons was the highest (90 percent) of any surgical specialty; 68% of all other surgical specialists were board certified. Nearly two thirds of all thoracic surgeons had at least 4 years of residency training-a percent 3.5 times greater than that of all other surgical specialists. Conversely, the proportion of thoracic surgeons with less than 4 years of clinical training was about half that of all other surgical specialists. Thus they were generally well trained in clinical medicine. Geographic distribution. In general, there was a strong relationship between the number of surgeons in a specialty and the percent who practiced in small towns and rural areas. Only 12% of thoracic surgeons practiced in small towns (under 25,000 population). This was also true for other specialties with few practitioners, such as plastic surgery and neurosurgery. In contrast, about 22% of general surgeons, who made up almost one third of all specialist surgeons, practiced outside urban and suburban areas. Secondary specialties. More thoracic surgeons claimed secondary specialties than any other surgical specialists. Nearly two thirds reported a secondary specialty. General surgery was the most common secondary specialty (about 50%) with cardiovascular or pulmonary diseases comprising most of the remainder. Practice organization. The practices of thoracic surgeons differed substantially from those of all other surgical specialists. Smaller proportions practiced in single or partnership practices; more were found in multispecialty groups. One in eight, or nearly three times as great a percent as all other surgeons, practiced in academic departments. There were also more in full-time hospital practice and in government practice. Their atypical distribution is probably related to their small number and their unusual dependency on hospitals. Workweek. A special feature of the questionnaire was a log diary which respondents were asked to keep for a preassigned day. Reporting days extended over 6
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months to assure representation of busy and slack periods. This diary provided data on total work time per week and time allocated to a variety of major professional activities. The estimated weekly hours reported are based on a 48 week work year. Thoracic surgeons worked the longest mean workweek (56 hours) of any surgical specialty (Table I), as determined from the log diaries. Their workweeks were 22% longer than those of other surgeons. They were 48% longer than those of ophthalmologists (38 hours per week), those with the shortest workweeks. Thoracic surgeons spent 62% more time in the hospital than all other surgical specialists. One third of this time was spent in operating rooms, a figure jl/2 times greater than that of all other surgeons (13 versus 9 hours per week). Professional income. The median net professional income of thoracic surgeons in 1971 ($48, 100) was only 3% above the all other surgeons ($46,700), even though they had the longest workweek and largest CR V operative work loads of any specialty. Thoracic surgeons' reported income was 14% higher than that of otolaryngologists, those with the lowest income ($42,200), and 13% below that of orthopedic surgeons, those with the highest median income ($54,200) of any surgical specialty. Referral patterns. A majority of patients treated by thoracic surgeons, whether in hospital or office, were referred by other physicians-70% of hospital and 63% of office patients (Table II). Only 15% of hospital patients and 21% of office patients were self-referred. Patient referral patterns for thoracic surgeons were quite different from those of all other surgeons, to whom only about one in three patients was referred by a physician; a majority of patients were self-referred. In only one other specialty, neurosurgery, did the members serve mainly as consultants to other physicians. In general, referral patterns differed according to board certification status of the surgeon. Among all surgeons, including thoracic surgeons, those who were board certified received more patient referrals from physicians than did those not board certified. Nonsurgical patients. Surgeons were asked what percent of their patients in hospital and in office during the previous 3 months consulted them for nonsurgical problems. For all thoracic surgeons, 7% to 12% of hospitalized patients and about 14% of office patients consulted for nonsurgical conditions, compared to 35% and 49% respectively, for all other surgeons. Plastic surgeons were the only specialists with a lower percent of patients who consulted for nonsurgical problems (4%).
Thoracic surgeons and their surgical practice
1 69
Table III. Percent distribution of thoracic surgeons and all other surgical specialists by opinion about supply of thoracic surgeons, /972 Thoracic surgeons Opinions about supply of thoracic surgeons * Shortage About right Excess
Board certified
Not board certified
All
Other surgeonst
2.6 57.0 40.4
8.3 58.3 33.3
3.2 57.1 38.1
14.6 70.4 15.1
'No opinion group has been excluded. t All other surgical specialists.
Opinions on supply of thoracic surgeons. One question asked surgeons their opinion about the supply of thoracic surgeons in their community. A majority of thoracic surgeon respondents (57%) thought that the supply was about right, whereas 3% thought there was a shortage and 38% a local excess (Table III). More than 70% of all other surgical specialists also thought that the local supply of thoracic surgeons was about right. The remainder, in about equal proportions, thought there was either an excess or a shortage. Data presented in the following sections were based on total in-hospital operative work performed in four areas of the United States. * These results include analyses of operative work loads by age, hospital affiliation, and operative mix. Results for boardcertified and non- board-certified thoracic surgeons are presented in some tables. However, the small number of those not board certified precludes meaningful statistical comparisons. Operative work load. The operative work loads of thoracic surgeons and all other surgical specialists are summarized in Table IV. On average, thoracic surgeons performed 16% fewer operations than all other surgeons. However, their CR V-weighted operative work load was the highest among all surgical specialties. At 2,550 CR V, it was 69% higher than the operative work loads of all other surgical specialists (1,509) and 47% higher than that of neurosurgeons, the specialists who had the next highest CR V-weighted work load (l,730). The complexity of the operative procedures, as reflected by mean CR V weight for all procedures performed by thoracic surgeons (18.4), was twice that of all other surgeons (9.1). Among thoracic surgeons, and similarly for all other surgical specialties, there were substantial variations in operative work loads. The mean work load of the top *Although
these four areas were not a random sample, the operative work performed in the four combined appears to be characteristic of that in the total United States."
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I 70 Bloom et al.
Table IV. Mean number of operations and mean annual total CRV-weighted operative load of thoracic surgeons and all other surgical specialists, 1970 Thoracic surgeons Board certified
No. of operations CRY-weighted work load Base for calculation
145.4 2,774.2 25
I
Not board certified
83.3 681.0 3
All other surgical specialists
I
All
Board certified
138.8 2,549.9 28
179.9 1,703.5 821
I
Not board certified
138.6 1.160.5 459
I
All
165.2 1,508.8 1,280
Legend: CRV. California Relative Value.
Table V. Mean number of operations and mean CRV-weighted operative work loads of thoracic and all other surgical specialists by age, 1970 Thoracic surgeons
All other surgical specialists
Age group (yr)
No. of operations
CRVweighted workload
No. of operations
CRVweighted workload
<40 40-49 ""'50
173.7* 145.9 110.0
3,265.0* 3,424.3 1,300.3
156.2 191.9 149.2
1.364.7 1,794.4 1,369.1
*n
=
<10.
25% of thoracic surgeons (5,674 CR V) was about 7 times higher than that of those in the lowest quartile. This same magnitude of difference was observed for all other surgeons but was related to a much lower work load level (2,856 CR V mean for the top 25%). Typically, there were more surgeons aged 40 to 49 years in the top work load quartile with fewer younger and older surgeons, but even at the extremes of age some had large work loads. The very small work loads were found mainly among older surgeons and younger ones who had entered practice recently. Age and operative work loads. Thoracic surgeons, like other surgeons, required time to build up practices. For all surgical specialists, this peak was reached about 18 years after graduation from medical school. Thoracic surgeons reached their peak CR V-weighted operative output between ages 40 and 50 years (Table V). Like all surgeons, their work load peak was maintained for only a few years. After age 50, on the average, their CR V-weighted work load declined to 37% of that performed by those 40 to 49 years of age. The work loads for thoracic surgeons and all other surgical specialists were similar at the age of 50 years or older. In all age groups, the thoracic surgeons averaged fewer than four operations per week (48 week work year).
Practice arrangement and operative work load. The CR V-weighted work load of board-certified thoracic surgeons in group practices (3,038) was 14% larger than that of surgeons in other practice arrangements. Those in group practice performed on average fewer (130 versus 152) but more complex operations. Thoracic surgeons in both group or other types of practice arrangements performed fewer operations but had mean total CR V-weighted work loads that were much greater than those of all other surgical specialists. Work load by number of hospitals used. Thoracic surgeons utilized more hospitals than other surgical specialists. Approximately 20% limited their work to a single hospital compared to 40% of all other surgical specialists. At the other extremes, more than 46% of thoracic surgeons operated in four or more hospitals-a far higher percent than all other surgical specialists (13%). Multiple hospital use was characteristic of surgeons who performed more operations. Among thoracic surgeons, work loads increased from 1,756 CR V per surgeon using one hospital to 2,766 for those performing operations at more than one hospital. However, the work load did not increase regularly with the number of hospitals used as it did for all other surgeons. The work load for those thoracic surgeons operating at two hospitals was the highest (4,374 CR V per surgeon). Operations performed by thoracic surgeons. Table VI presents surgical procedures that accounted for 1% or more of thoracic surgeons' CR V-weighted work load, These 20 operations contributed about 75% of their total operative work load: The seven procedures that individually made the greatest contributions comprised 50% of operative work load. For most surgical specialties, a small number of surgical procedures accounted for a large proportion of total operative work. The most extreme example was in ophthalmology, where lens extraction accounted for approximately two thirds of CR V-weighted work load. General surgery exhibited the widest range of procedures; 17 procedures
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Thoracic surgeons and their surgical practice
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Table VI. Percent contribution of specific operations to total CRV-weighted operative work of thoracic surgeons. 1970* Not board certified
Principal procedure Operations on valves of heart with inert material Cardiac revascularization, direct method Segmental resection of lung Operations on atrium. septum, and ventricle without prosthetic device Insertion of pacemaker Thoracotomy and pleurotomy Operations on valves of heart, open technique without tissue or inert graft Repair of abdominal aortic aneurysm Repair and anastomosis of thoracic aorta or pulmonary artery Graft reconstruction of intra-abdominal artery Bronchoscopy Graft reconstruction of peripheral artery Endarterectomy. intra-abdominal Endarterectomy. vessels of head. neck, and base of brain Complete lobectomy Cardiac revascularization, indirect method Complete pneumonectomy Repair of aneurysm of intrathoracic vessel Reconstruction of intrathoracic artery by graft Replacement of pacemaker All other procedures
52.0 68.0 26.0 50.0 20.0 12.0 52.0 40.0 30.0 40.0 3.6 28.0 40.0 30.0 26.0 38.0 30.0 56.0 56.0 8.0
Total
*All procedures
All thoracic surgeons
14.0 11.2 7.2 5.7 5.4 3.6 4.0 3.8 2.8 2.6 2.1 2.3 2.3 1.4 1.4 1.4 1.2 1.2 1.2 1.1 24.1
0.0 0.0 14.0 0.0 3.9 17.0 0.0 0.0 0.0 0.0 16.6 0.0 0.0 0.0 1.3 0.0 0.0 0.0 0.0 0.8 46.4
13.6 10.9 7.4 5.5 5.4 4.0 3.9 3.7 2.7 2.5 2.5 2.3 2.2 2.2 1.4 1.4 1.2 1.2 1.2 l.l 24.5
100.0
100.0
100.0
contributing I % or more to total work load of all thoracic surgeons are listed individually.
comprised 52% of the operative work load, and the largest contribution of a single procedure was 10%. Bronchoscopy, one of the more commonly performed procedures of thoracic surgeons, when done as the principal procedure during a single hospitalization, comprised less than 3% of the work load. This procedure and others when performed as a secondary procedure to one more complex were not included in this study (only the principal procedure performed was tabulated) . The percent of thoracic surgeons who performed these 20 specific procedures, the number done, along with the median and maximum, are presented in Table VII. Relationship between patient outcome and surgeon (or team) experience is widely accepted for thoracic surgery. To identify those operative procedures for which the surgeon's skills might overlap, we consulted an advisory group of thoracic surgeons. These advisors felt that because of differences in technology, maintenance of skill was specific to pulmonary, vascular, or cardiac surgery. Thus, because of these differences, greater experience in pulmonary operations is unlikely to maintain skills in cardiac surgery. In Table VII, thoracic procedures have been grouped under these headings to indicate experience with specific operations. Within each category, operations are ranked
by the number of surgeons performing each one. Over 90% of all thoracic surgeons performed at least one pulmonary operation, 75%, a vascular procedure, and about 43% a major cardiac operation. If adequate experience was defined as more than 10 operations per year, more than two thirds of thoracic surgeons met this standard for pulmonary surgery, but only one third had sufficient experience for vascular or cardiac operations. Among the surgeons doing direct cardiac revascularizations, amount of experience (median of 21.5 operations per year) was somewhat more than for surgeons doing a number of other procedures. Thoracic surgeons displayed an interesting generational effect. Those aged 55 years or older performed mainly operations on the chest and lungs, whereas those younger than 55 did mainly cardiac and vascular procedures. The consensus of the advisory group was that maintenance of skill required more than one cardiac operation per week. In Table VIII, operative loads have been related to this standard. Virtually all surgeons, for example, performed at least one pulmonary procedure during the study year. However, only about one in five met the performance standard of one procedure per week and less than 4% performed more than two per week. For the operations grouped under "Major cardiac"-for which the relationship of experience to
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Thoracic and Cardiovascular Surgery
Table VII. Percent distribution of thoracic surgeons by numbers of specific operations performed, 1970 Percentages of thoracic surgeons who performed: Principal procedure'
None
Pulmonarys Thoracotomy and pleurotomy Segmental resection of lung Complete lobectomy Complete pneumonectomy Vascular:!; Graft reconstruction of peripheral artery Repair of abdominal aortic aneurysm Graft reconstruction of intra-abdominal artery Endarterectomy, intra-abdominal Endarterectomy, vessels of head, neck, and base of brain Major cardiac i Operations on valves of heart, with inert material Operations on valves of heart, open technique without tissue or inert graft Repair of aneurysm of intrathoracic vessel Repair and anastomosis of thoracic aorta or pulmonary artery Operations on atrium, septum, and ventricle without prosthetic device Recontrustion of intrathoracic artery by graft Cardiac revascularization, direct method Cardiac revascularization, indirect method Other cardiac's Insertion of pacemaker Replacement of pacemaker Endoscopvs Bronchoscopy
(7.1) 10.7 25.0 53.6 57.1 (25.0) 39.3 42.9 46.4 57.1 64.3 (42.9) 50.0 57.1 60.7 64.3 64.3 71.4 78.6 85.7 (14.3) 21.4 28.6 (14.3) 14.3
I
1-5
(14.3) 25.7 25.0 35.8 39.3 (35.7) 50.0 46.5 46.4 35.7 32.2 (10.7) 17.9
25.0 39.2 28.6 14.3 28.6 3.6 7.1 (28.6) 32.2 53.6 (7.1) 7.1
I
6-10
I
(17.9) 21.4 21.4 10.7 3.6 (10.7) 10.7 3.6 7.1 3.6 0.0 (14.3) 10.7 14.3 0.0 3.6 7.1 0.0 3.6 3.6 (14.3) 21.4 7.1 (7.1) 7.1
>10
(60.7) 32.1 28.6 0.0 0.0 (28.6) 0.0 7.1 0.0 3.6 3.6 (32.1) 21.4 3.6 0.0 3.6 14.3 0.0 14.3 3.6 (42.9) 25.0 10.7 (71.4) 71.4
Mediant
(16) 8 7 2
2.5 (6)
3 2.5 2
2.5 2.5 (17.5)
8.5 3 I
2
7.5 1.5 21.5 3.5 (10) 7.5 3.5 (19.5) 19.5
Maximum
(66) 29 34 8 6
(52) 10 21 10 12 13 (126) 38 14 3 40 17 4
32 18 (36) 26 17 (49) 49
• All procedures are listed that contributed I % or more to the total operative work load of thoracic surgeons. tMedian number performed among those who performed the procedure. :j:Percentages of specialists who performed any of the individual procedures listed in the table under each general heading.
results is clear-the proportion of surgeons performing one or more operations per week was about one in six. The distribution shows that the frequency of vascular operations was more restricted. Thus, while the study demonstrated that thoracic surgeons as a group had large mean CR V operative work loads, the experience of many with these comparatively complex and highrisk operations seemed to be less than optimal. These data represent operative work performed during the year 1970. The current operative mix and percent of thoracic surgeons who performed specific procedures may have shifted to reflect the increase in cardiac revascularizations during the past few years. Duration of thoracic surgical operations. One portion of the area studies, not previously reported, was based on a one-in-ten sample of days during the study year. For these randomly selected days, additional data on duration of operations were collected. Mean duration of an operation was defined as the time from the first incision to the last stitch. Mean duration for the individual specialties varied
by 2.5 times. Neurosurgery had the longest mean time per operation, 132 minutes, and otolaryngology had the shortest mean, less than 52 minutes per operation. Thoracic surgeons averaged the second longest time per operation, 130 minutes. Thoracic surgeons' mean weekly time in actual performance of operations was 6 hours, ranking them first among all surgical specialties by this measure. Plastic surgeons ranked next with 5 hours, and ophthalmologists spent the fewest hours (I hour) per week in actual operation time. These estimated hours are fewer than those obtained in the questionnaire (Table II). The latter includes in addition to actual operating time, preparation, scrubbing, assisting other surgeons, and similar tasks. From the sample day data, it was possible to estimate the number of days per year on which thoracic surgeons performed operations. They performed operations on an average of 118 days per year, or about every second working day. On an operating day, they performed about 1.3 operations. Members of only one other spe-
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Table VIII. Percent distribution of thoracic surgeons according to the number of procedures performed by categories. 1970 Category
Pulmonary All cardiac Major cardiac Other cardiac Vascular Endoscopy All othert Total procedures performed
HICDA Code (/968 Rev.)
25.0-26.9 30.0-33.9 30.0-31.7 33.0-33.9 32.0-32.9 34.0-36.9 91.3-91.4
O/yr
"31/mo
"31/wk
"32/wk
("3//)*
("348)*
("396)*
3.6 (3.6) (17.9)
96.4 (96.4) (82.1)
71.4 (57.1) 39.3
17.9 (25.0) 17.9
3.6 (10.7) 3.6
14.3 14.3 7.1 0 0
85.7 85.7 92.9 100.0 100.0
42.9 39.3 75.0 89.3 96.4
0 3.6 10.7 32.1 92.9
0 0 0 7.1 78.6
'Number of procedures performed per year.
t Any procedure not included in preceding categories.
cialty, obstetrics-gynecology, operated on a greater number of days per year, an estimated 199 days per year. These sample-day data enabled us to examine the correlation between CR V weight assigned a procedure and time required to perform this procedure. For thoracic surgeons, this correlation was quite high (r = 0.88). Distribution of thoracic surgeons by type ofhospital. Thoracic surgeons concentrated their work mainly at teaching and larger nonteaching hospitals. Thoracic surgeons performed operations at 78% of all teaching hospitals and 24% of all nonteaching hospitals. Among nonteaching hospitals, the proportion at which thoracic' surgeons operated varied directly with bed size-62% of those with 200 beds or more, 36% of those with 100 to 199 beds, 8% of those with 50 to 99 beds, and 6% of those with less than 50 beds. Procedures performed by thoracic surgeons accounted for about 5% of all operations in teaching hospitals, 3% in the largest nonteaching hospitals, and 0.5% or less in the remaining nonteaching hospitals. Discussion Thoracic surgeons have many notable attributes. They are usually well trained, a large percent are board certified, and most practice in teaching hospitals. They work relatively long hours in hospital and spend much time in the operating room. They provide very little nonsurgical care and treat mainly physician-referred patients. Their operative work load is the highest of any surgical specialty. They perform fewer but more complex operations than all other surgeons. In contrast to other surgeons, they give relatively little time to office practice.
Thoracic surgery thus represents a prototype of what a surgical specialty should be. It is important as a model because the achievement of a single standard of surgical care will require other surgical specialties also to function as consultants. If general practitioners are to be induced to cease doing operations, surgeons will, at a minimum, have to stop providing general medical care. Surgeons cannot be both competitors with and consultants to family physicians. The high operative work loads, 2,774 CR V, of board-certified thoracic surgeon can serve as a standard for levels of work of all surgical specialties. This high average CR V work load is not indicative of an excess of board-certified thoracic surgeons. Even so, more than 38% of thoracic surgeons thought they were in excess, as did about 15% of all other surgeons. Opinions of medical practitioners often have been used to justify recommendations to decrease or increase numbers of a given specialty without a question of validation. It is clear from the results of these studies that such opinions are of little value and, indeed, are often wrong. For example, ophthalmology manpower was thought to be in short supply by 30% of all other surgeons. However, ophthalmologists worked the shortest workweek, 37 hours, and had the smallest operation loads. On the other hand, general surgeons were regarded as excessively numerous by 55% of all other surgical specialists. General surgeons had the third highest operative work loads per surgeon. Physicians' opinions about manpower thus are not concordant with objective measures. The relationship between patient safety and surgeon experience is clearer in thoracic surgery than in other specialties, because thoracic and cardiac operations are complex and entail relatively high risks. It seems prob-
The Journal of Thoracic and Cardiovascular Surgery
I 74 Bloom et al.
able that this relationship would be found among lower risk operations of other surgical specialists if there were appropriate data available. Given these considerations, it is suggested that thoracic and all other surgeons seek to maintain what Eli Ginzberg" called a "taut supply. " A better alternative to expanding manpower, the usual reflex response to rising demand, would be efforts to increase productivity and efficiency. Deliberate efforts to increase outputs per surgeon while maintaining a taut supply should assure that all, including the most recent graduates, can use their skills intensively. No one would argue that young surgeons should spend years building up a surgical practice, as is now necessary. Some argue, without supporting data, that there is much unmet need that could benefit from more operations. A population survey in England, where operation rates are lower than in the United States, found few surgically treatable diseases, few of which produced troublesome symptoms. 10 Very few persons with treatable conditions were interested in an operation. However, the recent development of coronary bypass operations may, in some measure, identify unmet need. These procedures may not prove to be useful, as early uncontrolled studies have indicated, in which case the large work loads of thoracic surgeons would not be affected greatly. Scientific and secular changes in work loads of other specialties, for example, otolaryngologists and obstetrician-gynecologists (the reduction in tonsillectomy and obstetrical delivery can affect work loads) further argues against more expansion. Finally, it is germane to mention that the work loads of thoracic surgeons were similar to the mean work loads for all surgeons in several European countries. 11-13 By this yardstick, their work loads are not extraordinarily high. It is only in comparison with the small operative work loads of other surgeons in the United States that they seem to be uniquely hard working. In planning for future thoracic surgeon manpower needs, the results of this study, which complement and confirm those of the National Thoracic Surgery Manpower Study, should prove helpful in maintaining the taut supply. We wish to thank Howard Frank, M.D., for his assistance, comments, and criticisms on a draft of this paper. REFERENCES Hauck WW, Colton T: Surgical manpower questionnaire, Surgery in the United States. A Summary Report of the Study on Surgical Services for the United States, GD Zuidema, ed., Baltimore, 1975, R. R. Donnelley and Sons, pp 56-78 2 Hauck WW, Bloom BS, McPherson CK, Nickerson RJ,
Colton T, Peterson OL: Surgeons in the United States. Activities, output and income, JAMA 236:1864-1871, 1976 3 Nickerson RJ, Colton T: Area studies, Surgery in the United States; A Summary Report of the Study on Surgical Services for the United States, GD Zuidema, ed., Baltimore, 1975, R. R. Donnelley and Sons, pp 36-55 4 Nickerson RJ, Colton T, Peterson OL, Bloom BS, Hauck WW: Doctors who perform operations. A study on inhospital surgery in four diverse geographic areas. N Engl J Med 295:921-926 and 982-989, 1976 5 Bloom BS, Hauck WW Jr, Peterson OL, Nickerson RJ, Colton T: Surgeons in the United States. Opinions on current issues related to surgical practice. Surgery 82:635-642, 1977 6 Bloom BS, Hauck WW, Peterson OL, Nickerson RJ, Colton T: Surgeons in the United States. Practice characteristics. Arch Surg 113:188-193, 1978 7 Brewer LA, Ferguson TB, Langston HT, Weiner JM: National Thoracic Surgery Manpower Study. Final report. February, 1974 8 California Relative Value Studies, 1969: San Francisco, 1969, California Medical Association 9 Ginzberg E: Physician shortage reconsidered. N Engl J Med 275:85-87, 1966 10 Logan RFL, Ashley JSA, Klein RE, Robson DM: Dynamics of Medical Care. The Liverpool Study into Use of Hospital Resources, London, 1972, London School of Hygiene and Tropical Medicine II Department of Health and Social Security: Report on Hospital In-Patient Enquiry for the Year 1970, London, 1972, Her Majesty's Stationery Office 12 Department of Health and Social Security; Annual Report 1970, Cund. 4714, London, 1971, Her Majesty's Stationery Office 1971 13 Socialstyrelsen: Rapport on Operationsverksambeten vid 27 Sjukhus vecka 18 1972, Stockholm, 1974, Socialstyrelsen
Editorial comment The review process for this article was extraordinary in the number of reviewers requested and in the disparity of their comments. Some reviewers were primarily impressed by the relevance and significance of the data presented, whereas the others were concerned that the data base for the study is now nearly 10 years old. Furthermore, it was pointed out that, in this study, the definition of a thoracic surgeon is broad, since board certification is not a requirement and since one third classified as thoracic surgeons had less than 4 years of residency training. Therefore, in publishing this interesting study, it is necessary to advise the reader to exercise care in extrapolating from these data to a setting 10 years later, or to a somewhat different specialty grouping. This is particularly true in view of the rapid evolution of thoracic and cardiovascular surgical practice during this decade.
Thoracic surgeons and their surgical practice The work characteristics of thoracic surgeons were studied as part of a national study of surgeon manpower. Thoracic surgeons were found to have the greatest operative work loads. longest workweeks. and equivalent median incomes compared with all other surgical specialties. The major conclusion that the number of thoracic surgeons was adequate concurs with the findings of the National Thoracic Surgery Manpower Study on number of practitioners.
Bernard S. Bloom, Ph.D.,* Rita J. Nickerson, M.A.,** Walter W. Hauck, Jr., Ph.D.,*** and Osler L. Peterson, M.D., M.P.H.,* Philadelphia, Pa., Boston, Mass., and Chicago, Ill.
A
study of surgical manpower was undertaken in close cooperation with the Study on Surgical Services for the United States (SOSSUS). Earlier published reports of these studies focused on general, summary data for each specialty. 1-6 This report is based on further analyses that provide more detailed data on practice characteristics and operative work of thoracic surgeons. It is one of a series of reports on each of ten surgical specialties. The findings for thoracic surgeons are compared with those for all other surgical specialists, i.e.,
A portion of this study was performed under Contract 231-76-0034, Bureau of Health Resources Development, Health Resources Administration, U.S. Public Health Service. The original data collection and analysis were supported by Grant No. HMS-llO72-125 from the Health Services and Mental Health Administration and Contract No. NOI-MI-24078, Bureau of Health Resources Development, National Institutes of Health, and by the American College of Surgeons, Commonwealth Fund, Henry J. Kaiser Family Foundation, Robert Wood Johnson Foundation, Rockefeller Foundation, and the Walnut Medical Charitable Trust. Received for publication Jan. 26, 1979. Accepted for publication April 18, 1979. Address for reprints: Bernard S. Bloom, Ph.D., Leonard Davis Institute of Health Economics, University of Pennsylvania, Tri-Neb Building (2L) Philadelphia, Pa. 19104. *University of Pennsylvania, and Philadelphia Veterans Administration Medical Center, Philadelphia, Pa. 19104. **Harvard Medical School, Department of Preventive and Social Medicine, Boston, Mass. 02115. ***Illinois Cancer Council, Chicago, Ill. 60603, and Northwestern University Medical School, Department of Community Health and Preventive Medicine, Chicago, Ill. 60611.
physicians whose primary specialty is in another field of surgery. Concurrent with the manpower study reported here, The American Association for Thoracic Surgery appointed a group to conduct the National Thoracic Surgery Manpower Study, which examined the distribution and work loads of surgeons to determine if they were meeting population needs." This group concluded in 1974 that the number, replacement rate, and distribution of thoracic surgeons appeared adequate. That conclusion and the results of this study hold important implications for future planning of thoracic surgery manpower.
Study design The study designs from which the data here presented have been drawn are described in detail elsewhere.v ! In brief, for one study, a questionnaire was sent to a stratified random sample of 10,232 physicians, who reported to the American Medical Association that they had a primary, secondary, or tertiary interest in surgery, and doctors of osteopathy, who reported a surgical specialty to the American Osteopathic Association. Responses were obtained from 7,298 (76%) of those in the one in eight sample who could be contacted. The second study was an analysis of all in-hospital operations for the entire population of four geographic areas, each of about I million population." 4 For each physician who performed an operation during 1970, See editorial comment, page 174.
0022-5223/79(080167+08$00.80(0 © 1979 The C. V. Mosby Co.
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Table I. Mean professional time per week by thoracic surgeons and all other surgical specialists and by principal activity, 1972 Activity"
Thoracic surgeons
Other surgeonst
Total professional time Direct patient care Operating room Hospital Office Practice administration Professional transit
55.6 35.1 13.1 38.0 7.0 6.1 1.6
45.7 34.9 9.1 23.5 16.0 5.5 0.9
'Categories are not mutually exclusive. tAli other surgical specialists.
Table II. Percent distribution of source of hospital and office patients treated by thoracic surgeons and all other surgical specialists, 1972 Hospital patients Source of patients
Self-referred Physician referred Other
Thoracic surgeons
15.3 70.1 14.6
Isurgeons· Other 44.4 40.4 15.2
Office patients Thoracic surgeons
Other surgeons·
21.4 62.6 16.0
51.2 34.4 14.4
• All other surgical specialists.
total in-hospital operative work was aggregated among all hospitals in the study area. Each operation was assigned a California Relative Value (CRV).8 These CR V weights correlate with length and complexity of operations and thus serve as the basic index of a physician's total surgical output. Meaningful comparisons of work loads of different mixes and across specialty lines were thus possible. Only one procedure per hospitalization has been tabulated. If multiple procedures were recorded, only the most complex (highest CR V) was selected. In this report the results for surgical specialists with M.D. and D.O. degrees are combined. "Board certified" is defined as certified in the physician's primary specialty.
Results The first portion of the Results section is based on responses to the questionnaire. Number of thoracic surgeons. Of the surgical specialists who responded to the questionnaire and indicated that they were currently active in surgical practice, 134 were thoracic surgeons. Only one thoracic surgeon was a graduate of an osteopathic medical school. On the basis of these data, we estimated that
there were 1,430 thoracic surgeons past the residency stage in active practice in the United States in 19723% of all surgical specialists. Thoracic surgery was one of the smaller surgical specialties with only plastic and colon-rectal specialties having fewer members. Age, board certification, and training characteristics. Thoracic surgeons were a somewhat younger group than other surgical specialists; 47% as opposed to 43% of all other surgeons were under the age of 45 years. Conversely, 17% of all other surgical specialists were 60 years of age or older, compared with 8% of thoracic surgeons. The over-all board certification rate of thoracic surgeons was the highest (90 percent) of any surgical specialty; 68% of all other surgical specialists were board certified. Nearly two thirds of all thoracic surgeons had at least 4 years of residency training-a percent 3.5 times greater than that of all other surgical specialists. Conversely, the proportion of thoracic surgeons with less than 4 years of clinical training was about half that of all other surgical specialists. Thus they were generally well trained in clinical medicine. Geographic distribution. In general, there was a strong relationship between the number of surgeons in a specialty and the percent who practiced in small towns and rural areas. Only 12% of thoracic surgeons practiced in small towns (under 25,000 population). This was also true for other specialties with few practitioners, such as plastic surgery and neurosurgery. In contrast, about 22% of general surgeons, who made up almost one third of all specialist surgeons, practiced outside urban and suburban areas. Secondary specialties. More thoracic surgeons claimed secondary specialties than any other surgical specialists. Nearly two thirds reported a secondary specialty. General surgery was the most common secondary specialty (about 50%) with cardiovascular or pulmonary diseases comprising most of the remainder. Practice organization. The practices of thoracic surgeons differed substantially from those of all other surgical specialists. Smaller proportions practiced in single or partnership practices; more were found in multispecialty groups. One in eight, or nearly three times as great a percent as all other surgeons, practiced in academic departments. There were also more in full-time hospital practice and in government practice. Their atypical distribution is probably related to their small number and their unusual dependency on hospitals. Workweek. A special feature of the questionnaire was a log diary which respondents were asked to keep for a preassigned day. Reporting days extended over 6
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months to assure representation of busy and slack periods. This diary provided data on total work time per week and time allocated to a variety of major professional activities. The estimated weekly hours reported are based on a 48 week work year. Thoracic surgeons worked the longest mean workweek (56 hours) of any surgical specialty (Table I), as determined from the log diaries. Their workweeks were 22% longer than those of other surgeons. They were 48% longer than those of ophthalmologists (38 hours per week), those with the shortest workweeks. Thoracic surgeons spent 62% more time in the hospital than all other surgical specialists. One third of this time was spent in operating rooms, a figure jl/2 times greater than that of all other surgeons (13 versus 9 hours per week). Professional income. The median net professional income of thoracic surgeons in 1971 ($48, 100) was only 3% above the all other surgeons ($46,700), even though they had the longest workweek and largest CR V operative work loads of any specialty. Thoracic surgeons' reported income was 14% higher than that of otolaryngologists, those with the lowest income ($42,200), and 13% below that of orthopedic surgeons, those with the highest median income ($54,200) of any surgical specialty. Referral patterns. A majority of patients treated by thoracic surgeons, whether in hospital or office, were referred by other physicians-70% of hospital and 63% of office patients (Table II). Only 15% of hospital patients and 21% of office patients were self-referred. Patient referral patterns for thoracic surgeons were quite different from those of all other surgeons, to whom only about one in three patients was referred by a physician; a majority of patients were self-referred. In only one other specialty, neurosurgery, did the members serve mainly as consultants to other physicians. In general, referral patterns differed according to board certification status of the surgeon. Among all surgeons, including thoracic surgeons, those who were board certified received more patient referrals from physicians than did those not board certified. Nonsurgical patients. Surgeons were asked what percent of their patients in hospital and in office during the previous 3 months consulted them for nonsurgical problems. For all thoracic surgeons, 7% to 12% of hospitalized patients and about 14% of office patients consulted for nonsurgical conditions, compared to 35% and 49% respectively, for all other surgeons. Plastic surgeons were the only specialists with a lower percent of patients who consulted for nonsurgical problems (4%).
Thoracic surgeons and their surgical practice
1 69
Table III. Percent distribution of thoracic surgeons and all other surgical specialists by opinion about supply of thoracic surgeons, /972 Thoracic surgeons Opinions about supply of thoracic surgeons * Shortage About right Excess
Board certified
Not board certified
All
Other surgeonst
2.6 57.0 40.4
8.3 58.3 33.3
3.2 57.1 38.1
14.6 70.4 15.1
'No opinion group has been excluded. t All other surgical specialists.
Opinions on supply of thoracic surgeons. One question asked surgeons their opinion about the supply of thoracic surgeons in their community. A majority of thoracic surgeon respondents (57%) thought that the supply was about right, whereas 3% thought there was a shortage and 38% a local excess (Table III). More than 70% of all other surgical specialists also thought that the local supply of thoracic surgeons was about right. The remainder, in about equal proportions, thought there was either an excess or a shortage. Data presented in the following sections were based on total in-hospital operative work performed in four areas of the United States. * These results include analyses of operative work loads by age, hospital affiliation, and operative mix. Results for boardcertified and non- board-certified thoracic surgeons are presented in some tables. However, the small number of those not board certified precludes meaningful statistical comparisons. Operative work load. The operative work loads of thoracic surgeons and all other surgical specialists are summarized in Table IV. On average, thoracic surgeons performed 16% fewer operations than all other surgeons. However, their CR V-weighted operative work load was the highest among all surgical specialties. At 2,550 CR V, it was 69% higher than the operative work loads of all other surgical specialists (1,509) and 47% higher than that of neurosurgeons, the specialists who had the next highest CR V-weighted work load (l,730). The complexity of the operative procedures, as reflected by mean CR V weight for all procedures performed by thoracic surgeons (18.4), was twice that of all other surgeons (9.1). Among thoracic surgeons, and similarly for all other surgical specialties, there were substantial variations in operative work loads. The mean work load of the top *Although
these four areas were not a random sample, the operative work performed in the four combined appears to be characteristic of that in the total United States."
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I 70 Bloom et al.
Table IV. Mean number of operations and mean annual total CRV-weighted operative load of thoracic surgeons and all other surgical specialists, 1970 Thoracic surgeons Board certified
No. of operations CRY-weighted work load Base for calculation
145.4 2,774.2 25
I
Not board certified
83.3 681.0 3
All other surgical specialists
I
All
Board certified
138.8 2,549.9 28
179.9 1,703.5 821
I
Not board certified
138.6 1.160.5 459
I
All
165.2 1,508.8 1,280
Legend: CRV. California Relative Value.
Table V. Mean number of operations and mean CRV-weighted operative work loads of thoracic and all other surgical specialists by age, 1970 Thoracic surgeons
All other surgical specialists
Age group (yr)
No. of operations
CRVweighted workload
No. of operations
CRVweighted workload
<40 40-49 ""'50
173.7* 145.9 110.0
3,265.0* 3,424.3 1,300.3
156.2 191.9 149.2
1.364.7 1,794.4 1,369.1
*n
=
<10.
25% of thoracic surgeons (5,674 CR V) was about 7 times higher than that of those in the lowest quartile. This same magnitude of difference was observed for all other surgeons but was related to a much lower work load level (2,856 CR V mean for the top 25%). Typically, there were more surgeons aged 40 to 49 years in the top work load quartile with fewer younger and older surgeons, but even at the extremes of age some had large work loads. The very small work loads were found mainly among older surgeons and younger ones who had entered practice recently. Age and operative work loads. Thoracic surgeons, like other surgeons, required time to build up practices. For all surgical specialists, this peak was reached about 18 years after graduation from medical school. Thoracic surgeons reached their peak CR V-weighted operative output between ages 40 and 50 years (Table V). Like all surgeons, their work load peak was maintained for only a few years. After age 50, on the average, their CR V-weighted work load declined to 37% of that performed by those 40 to 49 years of age. The work loads for thoracic surgeons and all other surgical specialists were similar at the age of 50 years or older. In all age groups, the thoracic surgeons averaged fewer than four operations per week (48 week work year).
Practice arrangement and operative work load. The CR V-weighted work load of board-certified thoracic surgeons in group practices (3,038) was 14% larger than that of surgeons in other practice arrangements. Those in group practice performed on average fewer (130 versus 152) but more complex operations. Thoracic surgeons in both group or other types of practice arrangements performed fewer operations but had mean total CR V-weighted work loads that were much greater than those of all other surgical specialists. Work load by number of hospitals used. Thoracic surgeons utilized more hospitals than other surgical specialists. Approximately 20% limited their work to a single hospital compared to 40% of all other surgical specialists. At the other extremes, more than 46% of thoracic surgeons operated in four or more hospitals-a far higher percent than all other surgical specialists (13%). Multiple hospital use was characteristic of surgeons who performed more operations. Among thoracic surgeons, work loads increased from 1,756 CR V per surgeon using one hospital to 2,766 for those performing operations at more than one hospital. However, the work load did not increase regularly with the number of hospitals used as it did for all other surgeons. The work load for those thoracic surgeons operating at two hospitals was the highest (4,374 CR V per surgeon). Operations performed by thoracic surgeons. Table VI presents surgical procedures that accounted for 1% or more of thoracic surgeons' CR V-weighted work load, These 20 operations contributed about 75% of their total operative work load: The seven procedures that individually made the greatest contributions comprised 50% of operative work load. For most surgical specialties, a small number of surgical procedures accounted for a large proportion of total operative work. The most extreme example was in ophthalmology, where lens extraction accounted for approximately two thirds of CR V-weighted work load. General surgery exhibited the widest range of procedures; 17 procedures
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Thoracic surgeons and their surgical practice
171
Table VI. Percent contribution of specific operations to total CRV-weighted operative work of thoracic surgeons. 1970* Not board certified
Principal procedure Operations on valves of heart with inert material Cardiac revascularization, direct method Segmental resection of lung Operations on atrium. septum, and ventricle without prosthetic device Insertion of pacemaker Thoracotomy and pleurotomy Operations on valves of heart, open technique without tissue or inert graft Repair of abdominal aortic aneurysm Repair and anastomosis of thoracic aorta or pulmonary artery Graft reconstruction of intra-abdominal artery Bronchoscopy Graft reconstruction of peripheral artery Endarterectomy. intra-abdominal Endarterectomy. vessels of head. neck, and base of brain Complete lobectomy Cardiac revascularization, indirect method Complete pneumonectomy Repair of aneurysm of intrathoracic vessel Reconstruction of intrathoracic artery by graft Replacement of pacemaker All other procedures
52.0 68.0 26.0 50.0 20.0 12.0 52.0 40.0 30.0 40.0 3.6 28.0 40.0 30.0 26.0 38.0 30.0 56.0 56.0 8.0
Total
*All procedures
All thoracic surgeons
14.0 11.2 7.2 5.7 5.4 3.6 4.0 3.8 2.8 2.6 2.1 2.3 2.3 1.4 1.4 1.4 1.2 1.2 1.2 1.1 24.1
0.0 0.0 14.0 0.0 3.9 17.0 0.0 0.0 0.0 0.0 16.6 0.0 0.0 0.0 1.3 0.0 0.0 0.0 0.0 0.8 46.4
13.6 10.9 7.4 5.5 5.4 4.0 3.9 3.7 2.7 2.5 2.5 2.3 2.2 2.2 1.4 1.4 1.2 1.2 1.2 l.l 24.5
100.0
100.0
100.0
contributing I % or more to total work load of all thoracic surgeons are listed individually.
comprised 52% of the operative work load, and the largest contribution of a single procedure was 10%. Bronchoscopy, one of the more commonly performed procedures of thoracic surgeons, when done as the principal procedure during a single hospitalization, comprised less than 3% of the work load. This procedure and others when performed as a secondary procedure to one more complex were not included in this study (only the principal procedure performed was tabulated) . The percent of thoracic surgeons who performed these 20 specific procedures, the number done, along with the median and maximum, are presented in Table VII. Relationship between patient outcome and surgeon (or team) experience is widely accepted for thoracic surgery. To identify those operative procedures for which the surgeon's skills might overlap, we consulted an advisory group of thoracic surgeons. These advisors felt that because of differences in technology, maintenance of skill was specific to pulmonary, vascular, or cardiac surgery. Thus, because of these differences, greater experience in pulmonary operations is unlikely to maintain skills in cardiac surgery. In Table VII, thoracic procedures have been grouped under these headings to indicate experience with specific operations. Within each category, operations are ranked
by the number of surgeons performing each one. Over 90% of all thoracic surgeons performed at least one pulmonary operation, 75%, a vascular procedure, and about 43% a major cardiac operation. If adequate experience was defined as more than 10 operations per year, more than two thirds of thoracic surgeons met this standard for pulmonary surgery, but only one third had sufficient experience for vascular or cardiac operations. Among the surgeons doing direct cardiac revascularizations, amount of experience (median of 21.5 operations per year) was somewhat more than for surgeons doing a number of other procedures. Thoracic surgeons displayed an interesting generational effect. Those aged 55 years or older performed mainly operations on the chest and lungs, whereas those younger than 55 did mainly cardiac and vascular procedures. The consensus of the advisory group was that maintenance of skill required more than one cardiac operation per week. In Table VIII, operative loads have been related to this standard. Virtually all surgeons, for example, performed at least one pulmonary procedure during the study year. However, only about one in five met the performance standard of one procedure per week and less than 4% performed more than two per week. For the operations grouped under "Major cardiac"-for which the relationship of experience to
The Journal of
I 72 Bloom et al.
Thoracic and Cardiovascular Surgery
Table VII. Percent distribution of thoracic surgeons by numbers of specific operations performed, 1970 Percentages of thoracic surgeons who performed: Principal procedure'
None
Pulmonarys Thoracotomy and pleurotomy Segmental resection of lung Complete lobectomy Complete pneumonectomy Vascular:!; Graft reconstruction of peripheral artery Repair of abdominal aortic aneurysm Graft reconstruction of intra-abdominal artery Endarterectomy, intra-abdominal Endarterectomy, vessels of head, neck, and base of brain Major cardiac i Operations on valves of heart, with inert material Operations on valves of heart, open technique without tissue or inert graft Repair of aneurysm of intrathoracic vessel Repair and anastomosis of thoracic aorta or pulmonary artery Operations on atrium, septum, and ventricle without prosthetic device Recontrustion of intrathoracic artery by graft Cardiac revascularization, direct method Cardiac revascularization, indirect method Other cardiac's Insertion of pacemaker Replacement of pacemaker Endoscopvs Bronchoscopy
(7.1) 10.7 25.0 53.6 57.1 (25.0) 39.3 42.9 46.4 57.1 64.3 (42.9) 50.0 57.1 60.7 64.3 64.3 71.4 78.6 85.7 (14.3) 21.4 28.6 (14.3) 14.3
I
1-5
(14.3) 25.7 25.0 35.8 39.3 (35.7) 50.0 46.5 46.4 35.7 32.2 (10.7) 17.9
25.0 39.2 28.6 14.3 28.6 3.6 7.1 (28.6) 32.2 53.6 (7.1) 7.1
I
6-10
I
(17.9) 21.4 21.4 10.7 3.6 (10.7) 10.7 3.6 7.1 3.6 0.0 (14.3) 10.7 14.3 0.0 3.6 7.1 0.0 3.6 3.6 (14.3) 21.4 7.1 (7.1) 7.1
>10
(60.7) 32.1 28.6 0.0 0.0 (28.6) 0.0 7.1 0.0 3.6 3.6 (32.1) 21.4 3.6 0.0 3.6 14.3 0.0 14.3 3.6 (42.9) 25.0 10.7 (71.4) 71.4
Mediant
(16) 8 7 2
2.5 (6)
3 2.5 2
2.5 2.5 (17.5)
8.5 3 I
2
7.5 1.5 21.5 3.5 (10) 7.5 3.5 (19.5) 19.5
Maximum
(66) 29 34 8 6
(52) 10 21 10 12 13 (126) 38 14 3 40 17 4
32 18 (36) 26 17 (49) 49
• All procedures are listed that contributed I % or more to the total operative work load of thoracic surgeons. tMedian number performed among those who performed the procedure. :j:Percentages of specialists who performed any of the individual procedures listed in the table under each general heading.
results is clear-the proportion of surgeons performing one or more operations per week was about one in six. The distribution shows that the frequency of vascular operations was more restricted. Thus, while the study demonstrated that thoracic surgeons as a group had large mean CR V operative work loads, the experience of many with these comparatively complex and highrisk operations seemed to be less than optimal. These data represent operative work performed during the year 1970. The current operative mix and percent of thoracic surgeons who performed specific procedures may have shifted to reflect the increase in cardiac revascularizations during the past few years. Duration of thoracic surgical operations. One portion of the area studies, not previously reported, was based on a one-in-ten sample of days during the study year. For these randomly selected days, additional data on duration of operations were collected. Mean duration of an operation was defined as the time from the first incision to the last stitch. Mean duration for the individual specialties varied
by 2.5 times. Neurosurgery had the longest mean time per operation, 132 minutes, and otolaryngology had the shortest mean, less than 52 minutes per operation. Thoracic surgeons averaged the second longest time per operation, 130 minutes. Thoracic surgeons' mean weekly time in actual performance of operations was 6 hours, ranking them first among all surgical specialties by this measure. Plastic surgeons ranked next with 5 hours, and ophthalmologists spent the fewest hours (I hour) per week in actual operation time. These estimated hours are fewer than those obtained in the questionnaire (Table II). The latter includes in addition to actual operating time, preparation, scrubbing, assisting other surgeons, and similar tasks. From the sample day data, it was possible to estimate the number of days per year on which thoracic surgeons performed operations. They performed operations on an average of 118 days per year, or about every second working day. On an operating day, they performed about 1.3 operations. Members of only one other spe-
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Thoracic surgeons and their surgical practice
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August. 1979
Table VIII. Percent distribution of thoracic surgeons according to the number of procedures performed by categories. 1970 Category
Pulmonary All cardiac Major cardiac Other cardiac Vascular Endoscopy All othert Total procedures performed
HICDA Code (/968 Rev.)
25.0-26.9 30.0-33.9 30.0-31.7 33.0-33.9 32.0-32.9 34.0-36.9 91.3-91.4
O/yr
"31/mo
"31/wk
"32/wk
("3//)*
("348)*
("396)*
3.6 (3.6) (17.9)
96.4 (96.4) (82.1)
71.4 (57.1) 39.3
17.9 (25.0) 17.9
3.6 (10.7) 3.6
14.3 14.3 7.1 0 0
85.7 85.7 92.9 100.0 100.0
42.9 39.3 75.0 89.3 96.4
0 3.6 10.7 32.1 92.9
0 0 0 7.1 78.6
'Number of procedures performed per year.
t Any procedure not included in preceding categories.
cialty, obstetrics-gynecology, operated on a greater number of days per year, an estimated 199 days per year. These sample-day data enabled us to examine the correlation between CR V weight assigned a procedure and time required to perform this procedure. For thoracic surgeons, this correlation was quite high (r = 0.88). Distribution of thoracic surgeons by type ofhospital. Thoracic surgeons concentrated their work mainly at teaching and larger nonteaching hospitals. Thoracic surgeons performed operations at 78% of all teaching hospitals and 24% of all nonteaching hospitals. Among nonteaching hospitals, the proportion at which thoracic' surgeons operated varied directly with bed size-62% of those with 200 beds or more, 36% of those with 100 to 199 beds, 8% of those with 50 to 99 beds, and 6% of those with less than 50 beds. Procedures performed by thoracic surgeons accounted for about 5% of all operations in teaching hospitals, 3% in the largest nonteaching hospitals, and 0.5% or less in the remaining nonteaching hospitals. Discussion Thoracic surgeons have many notable attributes. They are usually well trained, a large percent are board certified, and most practice in teaching hospitals. They work relatively long hours in hospital and spend much time in the operating room. They provide very little nonsurgical care and treat mainly physician-referred patients. Their operative work load is the highest of any surgical specialty. They perform fewer but more complex operations than all other surgeons. In contrast to other surgeons, they give relatively little time to office practice.
Thoracic surgery thus represents a prototype of what a surgical specialty should be. It is important as a model because the achievement of a single standard of surgical care will require other surgical specialties also to function as consultants. If general practitioners are to be induced to cease doing operations, surgeons will, at a minimum, have to stop providing general medical care. Surgeons cannot be both competitors with and consultants to family physicians. The high operative work loads, 2,774 CR V, of board-certified thoracic surgeon can serve as a standard for levels of work of all surgical specialties. This high average CR V work load is not indicative of an excess of board-certified thoracic surgeons. Even so, more than 38% of thoracic surgeons thought they were in excess, as did about 15% of all other surgeons. Opinions of medical practitioners often have been used to justify recommendations to decrease or increase numbers of a given specialty without a question of validation. It is clear from the results of these studies that such opinions are of little value and, indeed, are often wrong. For example, ophthalmology manpower was thought to be in short supply by 30% of all other surgeons. However, ophthalmologists worked the shortest workweek, 37 hours, and had the smallest operation loads. On the other hand, general surgeons were regarded as excessively numerous by 55% of all other surgical specialists. General surgeons had the third highest operative work loads per surgeon. Physicians' opinions about manpower thus are not concordant with objective measures. The relationship between patient safety and surgeon experience is clearer in thoracic surgery than in other specialties, because thoracic and cardiac operations are complex and entail relatively high risks. It seems prob-
The Journal of Thoracic and Cardiovascular Surgery
I 74 Bloom et al.
able that this relationship would be found among lower risk operations of other surgical specialists if there were appropriate data available. Given these considerations, it is suggested that thoracic and all other surgeons seek to maintain what Eli Ginzberg" called a "taut supply. " A better alternative to expanding manpower, the usual reflex response to rising demand, would be efforts to increase productivity and efficiency. Deliberate efforts to increase outputs per surgeon while maintaining a taut supply should assure that all, including the most recent graduates, can use their skills intensively. No one would argue that young surgeons should spend years building up a surgical practice, as is now necessary. Some argue, without supporting data, that there is much unmet need that could benefit from more operations. A population survey in England, where operation rates are lower than in the United States, found few surgically treatable diseases, few of which produced troublesome symptoms. 10 Very few persons with treatable conditions were interested in an operation. However, the recent development of coronary bypass operations may, in some measure, identify unmet need. These procedures may not prove to be useful, as early uncontrolled studies have indicated, in which case the large work loads of thoracic surgeons would not be affected greatly. Scientific and secular changes in work loads of other specialties, for example, otolaryngologists and obstetrician-gynecologists (the reduction in tonsillectomy and obstetrical delivery can affect work loads) further argues against more expansion. Finally, it is germane to mention that the work loads of thoracic surgeons were similar to the mean work loads for all surgeons in several European countries. 11-13 By this yardstick, their work loads are not extraordinarily high. It is only in comparison with the small operative work loads of other surgeons in the United States that they seem to be uniquely hard working. In planning for future thoracic surgeon manpower needs, the results of this study, which complement and confirm those of the National Thoracic Surgery Manpower Study, should prove helpful in maintaining the taut supply. We wish to thank Howard Frank, M.D., for his assistance, comments, and criticisms on a draft of this paper. REFERENCES Hauck WW, Colton T: Surgical manpower questionnaire, Surgery in the United States. A Summary Report of the Study on Surgical Services for the United States, GD Zuidema, ed., Baltimore, 1975, R. R. Donnelley and Sons, pp 56-78 2 Hauck WW, Bloom BS, McPherson CK, Nickerson RJ,
Colton T, Peterson OL: Surgeons in the United States. Activities, output and income, JAMA 236:1864-1871, 1976 3 Nickerson RJ, Colton T: Area studies, Surgery in the United States; A Summary Report of the Study on Surgical Services for the United States, GD Zuidema, ed., Baltimore, 1975, R. R. Donnelley and Sons, pp 36-55 4 Nickerson RJ, Colton T, Peterson OL, Bloom BS, Hauck WW: Doctors who perform operations. A study on inhospital surgery in four diverse geographic areas. N Engl J Med 295:921-926 and 982-989, 1976 5 Bloom BS, Hauck WW Jr, Peterson OL, Nickerson RJ, Colton T: Surgeons in the United States. Opinions on current issues related to surgical practice. Surgery 82:635-642, 1977 6 Bloom BS, Hauck WW, Peterson OL, Nickerson RJ, Colton T: Surgeons in the United States. Practice characteristics. Arch Surg 113:188-193, 1978 7 Brewer LA, Ferguson TB, Langston HT, Weiner JM: National Thoracic Surgery Manpower Study. Final report. February, 1974 8 California Relative Value Studies, 1969: San Francisco, 1969, California Medical Association 9 Ginzberg E: Physician shortage reconsidered. N Engl J Med 275:85-87, 1966 10 Logan RFL, Ashley JSA, Klein RE, Robson DM: Dynamics of Medical Care. The Liverpool Study into Use of Hospital Resources, London, 1972, London School of Hygiene and Tropical Medicine II Department of Health and Social Security: Report on Hospital In-Patient Enquiry for the Year 1970, London, 1972, Her Majesty's Stationery Office 12 Department of Health and Social Security; Annual Report 1970, Cund. 4714, London, 1971, Her Majesty's Stationery Office 1971 13 Socialstyrelsen: Rapport on Operationsverksambeten vid 27 Sjukhus vecka 18 1972, Stockholm, 1974, Socialstyrelsen
Editorial comment The review process for this article was extraordinary in the number of reviewers requested and in the disparity of their comments. Some reviewers were primarily impressed by the relevance and significance of the data presented, whereas the others were concerned that the data base for the study is now nearly 10 years old. Furthermore, it was pointed out that, in this study, the definition of a thoracic surgeon is broad, since board certification is not a requirement and since one third classified as thoracic surgeons had less than 4 years of residency training. Therefore, in publishing this interesting study, it is necessary to advise the reader to exercise care in extrapolating from these data to a setting 10 years later, or to a somewhat different specialty grouping. This is particularly true in view of the rapid evolution of thoracic and cardiovascular surgical practice during this decade.