The Estimated Cost of Training the Future Surgical Workforce

Thomas E. Williams, Jr., MD,PHD, Bhagwan Satiani, MD,MBA, Andrew Thomas, MD,MBA, and E. Christopher Ellison, MD

The Ohio State University Medical CenterDepartments of Surgery and Internal Medicine

DISCLOSURE: This effort was partially supported by a grant from Columbus Medical Association Foundation

HISTORY

– 1910 Flexner – 1959 Bane – 1975 SOSSUS [ Rural Shortage] – 1981 GMENAC – 1986 COGME, IOM, PEW, AAMC, AMA – 1994 COGME – 1995 PEW – 2004 Cooper – 2006 HRSA – 2008 Dill & Salsberg, AAMC

Surplus

Shortage

PHYSICIAN SHORTAGES

MEDICAL SCHOOL ENROLLMENTS PER 100,000 POPULATION

227,000,000 300,000,000

Medical School Enrollments – no increases between 1980 and 2005

BALANCED BUDGET ACT

Post Graduate Positions capped in 1997 by BBA No revision of the BBA so far

SUPPLY AND DEMANDAging Population

INCREASED WORK LOAD FOR THESE SEVEN SPECIALTIES

OBGYN also

Objectives

• To estimate the workforce needed by 2030 in seven surgical specialties to serve a population of 364 million people

• To quantify the cost associated with training additional surgeons.

Assumptions• Unchanged physician to population ratio• 30 years in practice from completion of

residency to retirement, • No revision of the Balanced Budget Act of

1997 and therefore no additional residency positions offered.

• Per resident expenses were estimated at $80,000 including salaries, benefits, and other direct medical education costs.

Methods• A review of the certificates granted in

otolaryngology, orthopedic surgery, thoracic surgery, obstetrics and gynecology, neurosurgery, urology, and general surgery was conducted.

• Population estimates of U.S Census bureau

• Population-based algorithm

• Baseline Supply + New Entrants (U.S & IMG’s) - Attrition

RESULTS: UROLOGY WORKFORCE

0

2000

4000

6000

8000

10000

12000

2005 2010 2020 2030 2040 2050

Practicing current

New graduates

Total practicing

RESULTS SHORTAGES

SPECIALTY YEARS CERTIFIC- TOTAL TOTAL SHORTAGE

TO ATIONS/ TRAINEDNEEDED2011 TO

TRAIN YR

2011 TO 2030 2030

OB-GYN 4 1,200 24,000 37,636 13,636

ENT 5 300 6,000 8,516 2,516

ORTHO 5 650 13,000 17,355 4,355

GENERAL 5 1,000 20,000 22,525 2,525

UROLOGY 5 260 5,200 9,084 3,884

NEURO 6 125 2,500 2,728 228

THORACIC 2 100 2,000 3,994 1,994

TOTAL 3,635 72,700 101,838 29,138

Cost of training surgical specialists at present certification levels

SPECIALTY YEARS INRESIDENCY

CERTIFICATIONSPER YEAR

TOTAL TO BE

TRAINED2011 TO

2030

TOTALTRAINEEYEARS

TOTAL COSTAT $80,000

PER TRAINEEYEAR

OB-GYN 4 1,200 24,000 96,000 $7,680,000,000

ENT 5 300 6,000 30,000 $2,400,000,000

ORTHO 5 650 13,000 65,000 $5,200,000,000

GENERAL 5 1,000 20,000 100,000 $8,000,000,000

UROLOGY 5 260 5,200 26,000 $2,080,000,000

NEURO 6 125 2,500 15,000 $1,200,000,000

THORACIC 2 100 2,000 4,000 $320,000,000

Total 3,635 72,700 336,000 $26,880,000,000

Cost of training surgical specialists at certification levels needed

SPECIALTYTOTAL TO BE

TRAINED2011 TO 2030

NUMBER PER

CLASS

TRAINEE YEARS PER

CLASS

PER CLASS COST

AT $80,000

TOTAL COST2011 TO 2030

OB-GYN 37,636 1,882 7,527 602,176,000 12,043,520,000

ENT 8,516 426 2,129 170,320,000 3,406,400,000

ORTHO 17,355 868 4,339 347,100,000 6,942,000,000

GENERAL 22,525 1,126 5,631 450,500,000 9,010,000,000

UROLOGY 9,084 454 2,271 181,680,000 3,633,600,000

NEURO 2,728 136 818 65,472,000 1,309,440,000

THORACIC 3,994 200 399 31,952,000 639,040,000

           

TOTAL 101,838 5,092 23,115 1,849,200,000 36,984,000,000

Incremental Cost: $10B

LIMITATIONS

• Validity of US Census numbers

• Surgical demand of the aged

• Shortened training programs

• Specialization

• Misdistribution of surgeons

• Impact of the economy

• Disruptive technology

CONCLUSION

• There will not be a sufficient number of trained surgeons to care for the American people as early as 2030.

• The shortage will grow to almost 30,000 surgeons by 2030.

• Cost of $ 36.9 B– Current cost $ 26,8B– Incremental cost $ 10.1B

CHALLENGES - CREATING THE RESIDENCIES

GOAL – REVISION OF BBA OF 1997

CHALLENGES

• Convince policymakers of consequences of shortages– Revise the BBA of 1997

• Find alternative funding – Apply H.R 2583 The Physician Work

Enhancement Act of 2008 to Surgery– Non-governmental

• Recruitment– Life style– Rural Practice

IMPACT OF SHORTAGE

ACCESS TO CARE

• WILL PORTSMOUTH, OHIO HAVE THESE SERVICES ???– APPENDECTOMY– BROKEN ARMS– DELIVERY of BABIES

• INCREASES IN – TIME TO APPOINTMENTS – TRAVEL TIMES

WILL IT COME TO THIS ??

RATIONING OF SURGICAL SERVICES

SOURCE: NEJM

SHORTAGES

• # Job solicitations

• Recruiting hard• Salary/bonus

offers• Hospital

employment

Source: Advisory Board (2007)

THORACIC SURGERY

HEALTH CARE $$$

Source: Modern Healthcare

LIMITATIONS OF STUDY• POPULATION BASED• VARIABLES NOT CONSIDERED:

– WORKLOAD– GENDER, – AGING OF POPULATION & SURGEONS– NON-PHYSICIAN CLINICIANS– LIFESTYLE– EARLY RETIREMENTS– EFFICIENCY & DISRUPTIVE TECHNOLOGY– SALARIED PRACTICE ??

• TIME• BIDDING WARS

• COST FIGURES ‘NOMINAL’ (UNADJUSTED FOR INFLATION)

COOPER

Relationship of GDP & Physician Ratio

0

50

100

150

200

250

300

350

1929 1960 1970 1980 1990 2000

Year

#

GDP PER CAPITA ($100'S)

PHYSICIANS/100,000POPULATION

% Growth in surgical residents% Growth in Surgical Specialty Residents 2002-2007

0.00%

5.00%

10.00%

15.00%

20.00%

25.00%

30.00%

35.00%

Allopathic IMG's Osteopathic

Change in Total Residents

% % Growth

Source: AAMC

SURGICAL WORKFORCESSPECIALTY PRESENT SURGEONS SURGEONS SURGEONS

WORK FORCE PER 100,000 IN PRACTICE PER 100,000

IN 2030 IN 2030

OB-GYN 34,000 27.10 36,499 19.73

ENT 8,900 3.16 8,986 2.47

ORTHO 18,000 6.50 19,305 5.30

GENERAL 21,000 7.50 24,775 6.81

UROLOGY 10,000 3.49 8,164 2.24

NEURO 3,100 1.09 3,630 1.00

THORACIC 4,000 1.42 3,175 0.87

TOTAL 99,000 104,534

GENERAL SURGERYGENERAL SURGERY

0

5

10

15

20

25

30

35

40

POPULATIONS X10,000,000

WORKFORCE X 1,000 SURGEONS PER100,000

2005

2030

7.5 6.81

24,77521,000

340M

364M

NEEDED VERSUS SUPPLYTHORACIC SURGEONS

0

1000

2000

3000

4000

5000

6000

7000

2000 2010 2020 2030 2040 2050

YEAR

# O

F S

UR

GE

ON

S

NEEDED

PRACTICING

RESULTS: UROLOGY WORKFORCE

0

2000

4000

6000

8000

10000

12000

2005 2010 2020 2030 2040 2050

Practicing current

New graduates

Total practicing

SUMMARYPossible Cure for the Shortage

• Increase training positions– Funding

• Interest trainees in small town USA– Role models– Rural tracking or training programs– Incentives for rural practice

• Increase interest of X and Y generation and women in surgery