The Association of American Medical Colleges’ Center for Workforce Studies estimates that the U.S. will face a shortage of 46,000 surgeons and medical specialists in the next decade.1 For example, New Jersey, the third wealthiest state in the U.S. according to the U.S. Census Bureau’s report on median household income for 2011, is projected to have at least 3,000 fewer physicians than will be needed by 2020 to adequately serve the state’s health care needs.2,3 Unfortunately, other states are facing the same predicament.
In the mid-2000s, national policymakers debated how to better define and overcome these emerging shortages, and the American College of Surgeons (ACS) sought to have a voice in these discussions. As a result, the College established the Health Policy Research Institute (ACS HPRI) at the University of North Carolina (UNC) Cecil G. Sheps Center for Health Services Research in Chapel Hill.
Under the direction of George F. Sheldon, MD, FACS, and Thomas C. Ricketts III, MPH, PhD, the ACS HPRI developed resources aimed at creating a clearer understanding of where disparities in access to surgeons and surgical care are most prevalent.
Over the last two years, the ACS HPRI has steadily relocated to the College’s Washington Office. Dr. Ricketts is now a formal consultant to the College’s Division of Advocacy and Health Policy (DAHP), and UNC now functions as a Health Policy Collaborating Center. These important workforce research activities at UNC continue through the direction of Dr. Ricketts and Erin Fraher, MPP, PhD, at UNC and Don E. Detmer, MD, FACS, Medical Director of the DAHP.
Earlier this year, the ACS HPRI released updated surgical workforce maps that illustrate the distribution of general surgeons and surgeon specialists per 100,000 population across the nation in 2006 and 2011. The maps track the number of surgeons in each county in 2011 and the change in surgeons per population between 2006 and 2011. The data and maps include all 3,107 counties in the U.S.
In 2012, the HPRI released an updated version of the U.S. Atlas of the Surgery Workforce, which is an interactive, Web-based data system that displays surgery and population data on customizable maps. The Atlas details demographic and health access indicators by county and state, and reveals where surgeon and physician shortages threaten patient access to timely, safe, high-quality, affordable health care.
This column provides answers to questions surgeons may have concerning the central focus of the ACS HPRI and the relevance of surgical workforce maps to policymakers, providers, and patients.
What is the ACS HPRI and its purpose?
The College established the HPRI in 2008 to study and report on issues related to the state of the surgical profession, the surgical workforce, and the volume of surgical procedures in the U.S. The HPRI provides expert advice, data analysis, and original research for surgical associations and boards, policymakers, and the health services research community.
Selected HPRI surgical workforce maps are updated every year, but trend data are gathered every five years. Given the quantity and quality of existing data and trends, is more immediate data collection needed?
Acquiring data can be costly, and researchers must consider the amount of time required to prepare the data for analysis. HPRI researchers have captured complete workforce data files from 1981 to 2011 and have completed detailed trend analyses for each file. These trend analyses, in turn, will require additional in-depth review, adding to the cost of the research.
HPRI reviews annual numbers for comparisons of national and state-level numbers. HPRI releases in-depth data in five-year increments as researchers have found this schedule to be the most practical for interpreting data.
What kind of surgical workforce data can I expect to find in these maps?
The maps display data for surgeons in the specialties in one category and general surgeons in another. Subspecialties will be added in the near future. The specific maps include:
- Surgeons per 100,000 population, 2006 and 2011
- Percent change in surgeons per 100,000 population, 2006 and 2011
- General surgeons per 100,000 population, 2006 and 2011
- Percent change in general surgeons per 100,000 population, 2006 and 2011
- Counties that lost all general surgeons between 2006 and 2011
- Counties that saw a decline of 10 percent or greater in general surgeons to population ratio, 2006–2011
- Counties that saw an increase in general surgeons to population ratio, 2006–2011
- Counties that lost all surgeons between 2006 and 2011
- Counties that saw a decline of 10 percent or greater in surgeons to population ratio, 2006–2011
- Counties that saw an increase in surgeons to population ratio, 2006–2011
The ACS HPRI U.S. Atlas of the Surgical Workforce shows state-by-state data. What are the benefits of presenting the information in this manner?
The state-by-state data provide a sense of variation. It is important that surgeon advocates be able to demonstrate these differences because states control essential policies that affect medical and surgical practice, including tort laws, payments under Medicaid, and funding for medical education and residency training. As Figure 1 shows, the current Atlas allows surgeons and policymakers to view the U.S. distribution of total surgeons, general surgeons, surgical subspecialists, total physicians, and primary care physicians at the state level.4 The state-level maps are also the gateway to county-level maps for each state. By clicking on the individual state, the user is taken to a county-level map with options for displaying various data.
In addition, the Atlas shows the supply and geographic distribution of institutions and individuals providing surgical services so that health care professionals, policymakers, and patients are able to anticipate changes in distribution and to identify places with limited access to surgical services. New Atlas data will be available by the end of this year.
Which areas are most at risk of decreasing health care coverage, and what factors are contributing to the shortage of surgeons in these particular areas?
As Figure 2 demonstrates, counties located in the middle of the country have been experiencing significant surgeon shortages in recent years. The swath of rural counties in the middle of the nation, running from North Dakota to Texas, experienced the greatest shortages in 2006, and not much changed in 2011.5
Some of these states have seen a decrease in their population and/or their employment rate is falling. Physicians and surgeons are responding to the economic realities and choosing to leave or to start practices in other areas. The overall picture is one of change that mirrors general economic trends. There is also a mixed pattern of contraction or expansion of supply across the nation that tends to show a concentration of surgeons in counties with large cities.
The maps indicate that the East Coast has more counties with higher densities of surgeons. What’s the explanation for this trend?
As Figure 2 indicates, the Northeast traditionally had a higher physician supply. There were several reasons for this trend, including a strong economy, more training centers and hospitals, and more practice opportunities. However, a net shift from the Northeast and Midwest to the South and West is occurring, which may not be as apparent in the county-by-county maps. This shift follows the overall pattern of migration of the U.S. population to the Sun Belt as states in that region strengthen their economies and expand practice opportunities and training programs.
Has the HPRI uncovered any inconsistencies in the distribution of surgeons?
One could point to the mixed pattern of gains and losses in Minnesota, Iowa, and Virginia as examples of inconsistencies that may reflect small, regional patterns of economic activity or changes in the health care delivery system.
How can surgeons best use the information in these maps? Are they more beneficial for policymaking, wage negotiation, advocating, or some other purpose?
The maps may provide a general impression of where the surgical workforce situation is getting better or worse. These maps are important for policymaking, wage negotiation, advocating for better health care facilities, and deploying resources to reduce patient mortality. The maps can help surgeons shape the questions they may wish to ask regarding practical realities and the quality of life in the practice locations they are considering. In addition, the maps can help patients determine where surgical access might be more readily available.
How could the maps be used to shape policy at both the federal and state level relative to existing and proposed legislation?
If trends point to state-level policies that may drive surgeons away from a particular state, then those policies require reexamination. There are substantial differences in the conditions surgeons face from state to state, and surgeons will react to negative factors by changing their practice location. Both state and federal legislators have an obligation to examine their policy choices and their impact on access to quality health care. Surgical maps allow legislators to see where surgeon shortages exist, and this information can be used to craft policies that address such disparities.
Dr. Ricketts and the staff at HPRI are available to answer questions concerning the maps highlighted in this article and how best to analyze and display geographic data. Dr. Ricketts can be reached at firstname.lastname@example.org, or contact Katie Gaul, HPRI Research Associate, at k_gaul@ unc.edu. Visit www.acshpri.org/maps.html to access the maps.
- Association of American Medical Colleges Center for Workforce Studies. Physician shortages to worsen without increases in residency training. Available at: www.aamc.org/download/286592/data/physicianshortage.pdf. Accessed August 22, 2012.
- U.S. Census Bureau. Median household income and Gini index in the past 12 months by state and Puerto Rico: 2010 and 2011. Available at www.census.gov/prod/2012pubs/acsbr11-02.pdf. Accessed October 10, 2012.
- Gladden M. Shortages seen growing worse in years ahead. Daily Record.com. Available at: www.dailyrecord.com/article/20120730/NJOPINION06/307300013/Shortages-seengrowing-worsein-years-aheadShortages-seen-growing-worse-years-ahead?nclick_check=1. Accessed November 26, 2012.
- American College of Surgeons Health Policy Research Institute. Surgical Workforce Atlas. Available at: www.acshpri.org/atlas/loadflash.php. Accessed October 10, 2012.
- American College of Surgeons Health Policy Research Institute. Surgical workforce maps. Available at: www.acshpri.org/documents/SurgeonMaps2006-2011_Oct2012.pdf. Accessed October 10, 2012.