Table 1. U.S. surgeons per 100,000 population, ordered by percent change since 1981. *Data were not available for vascular surgeons in 1981.
Table 2. Supply of U.S. urologic surgeons, 1981–2009
Amid federal efforts to restructure health care, and possible threats to graduate medical education funding, it is important to understand the demographic and practice characteristics of the surgical health care workforce—whether it is growing or contracting—and whether supply will be adequate to meet future demand. In the coming months, the American College of Surgeons Health Policy Research Institute (ACS HPRI) will be producing a series of policy briefs illustrating workforce trends for 12 surgical specialties (see Table 1). The aim of these brief reports is to provide decision makers with important data on the workforce that can be used to inform health policy. This article focuses on trends in the urologic surgical workforce since 1981.
Key findings
There has been a decrease in the supply of urologic surgeons relative to population growth, a slight increase in female urologic surgeons, an aging urology workforce (especially in rural areas), and an increase in group practice. In 2009, 9,775 urologic surgeons were actively practicing in the U.S. (not including residents in training) (see Table 2). The supply of urologic surgeons per capita in the U.S. has declined more than all surgical specialties except for general surgery and thoracic surgery (see Table 1). During the period 1981–2009, urologic surgeons per 100,000 population declined by 1.3 percent. Until 1991, the supply of urologic surgeons grew faster than the population. In 1991, that trend reversed, and since then, the decline has accelerated. After 2006, the number of urologic surgeons fell below the 1981 ratio to 3.18 urologic surgeons per 100,000 population.
Figure 1. Change in urologic surgeons per 100,000 population: 2004–2009. Produced By: American College of Surgeons Health Policy Research Institute, Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill. Source: AMA Physician Masterfile, 2004 and 2009. Data include non-federal, non-resident, clinically active physicians less than 70 years old reporting a primary specialty classified by the ACS HPRI as “urological surgery.”
Geographic distribution
To examine geographic variation in the urologic surgeon supply, surgeon and population data were analyzed for all counties in the U.S. from 2004 to 2009. In 2009, urologic surgeons practiced in 39 percent of U.S. counties (1,209); representing an increase from 2004 of 20 counties. From 2004 to 2009, 24 percent of counties (750) lost urologists relative to population (see Figure 1). Of these counties, 89 lost all urologic surgeons. During the same period, 18 percent of counties (548) gained urologic surgeons relative to population. Of the counties that gained urologic surgeons, 109 had no urologists in 2004 and gained at least one urologist by 2009. Just more than 58 percent of counties (1,809) had no urologists in 2004 and 2009. For the period 1981 to 2009, the urban concentration of urologic surgeons has remained stable, with seven urban urologic surgeons for every one urologic surgeon in rural areas.
Age and gender
With an average age of 52.5 years, urologists are among the oldest surgical specialists, second only to thoracic surgeons (53.6 years). In 2009, the average age for all surgical specialists was 50.9, and 14 percent were 65 and older. More than 18 percent of urologic surgeons were 65 and older. This represents more than a 10 percent increase in urologic surgeons 65 and older since 1981, when these physicians were just 7.69 percent of the urology workforce.
Figure 2. Gender and distribution of urologists, 1981 and 2009
Urology is a male-dominated specialty. Women have been entering the surgical workforce with increasing frequency since 1981, although at different rates in different specialties. Since 1981, the number of female urologic surgeons has grown from 34 to 512, increasing their share of the total urology workforce by nearly 5 percent (see Figure 2). Still, men continue to make up a strong majority of urologic surgeons representing 94.8 percent of the workforce.
Since 1981, the age gap between male and female urologists has increased by more than four years to an average difference of 10.3 years in 2009 (with males being older). In 2009, female urologists were 42.7 years old on average, and males were 53 years old. For all surgeons, males are slightly younger at 52.5 years old, while females are older at 44.5 years of age on average. As seen in Figure 2, more female urologists have recently entered the urology workforce.
Training in urologic surgery
According to the Accreditation Council for Graduate Medical Education’s (ACGME’s) data, from 1994 to 2001, the number of urology residents and accredited programs declined by 2.3 percent and 2.4 percent, respectively. However, since 2001, urology residents have increased by 7 percent despite another 2 percent decline in the number of programs through 2009.1,2 At the end of training, urology residents achieving American Board of Medical Specialties (ABMS) certifications declined by 19.7 percent from 2000 to 2009.3 Annual trend data are available from the 2010 ABMS Certificate Statistics booklet.
The proportion of urologic surgeons trained in the U.S. has increased. In 1981, 79 percent of urologists were U.S. medical graduates (USMGs). By 2009, this percentage had increased to 83.3 percent. There has been a shift in the average age of USMGs versus international medical graduate (IMG) urologic surgeons. USMG urologists were nearly three years older than IMG urologists in 1981. By 2009, this trend had reversed, and the average age of USMGs is now more than eight years younger than IMGs.
Group practice growing—but not in rural areas
Figure 3. Practice type, U.S. urologists, 2001–2009
Following the trends for all practicing surgeons, urologic surgeons are increasingly likely to be employed in a group practice (see Figure 3).4 The percent of the urologic workforce in group practice increased from 42 percent in 2001 to 60 percent in 2009. As the number employed in group practices increased, the percentage of surgeons employed in solo practice sharply declined between 2001 and 2009. In 2001, slightly more than one in four (26 percent) urologic surgeons were in solo practice compared with one in five (20 percent) in 2009. The percentage of surgeons employed by health maintenance organizations, nonhospital government, and other entities (defined in Figure 3, as “other setting”) also declined substantially between 2001 and 2009.
Figure 4. U.S. average age of urologists, urban and rural counties, 1981–2009
Urban urologic surgeons have chosen to practice in groups more often between 2001 and 2009, while group practice among rural practitioners has actually declined slightly (less than 1 percent), and solo practice has increased by nearly 2 percent. Overall, urologists in group practice are almost nine years younger than urologists in solo practice. In general, urologic surgeons practicing in rural areas (average age 54.7) were 2.2 years older than those in urban areas, a trend that has reversed since 1981 (see Figure 4).
Policy implications
Research has demonstrated an association between a higher density of urologists and lower mortality from prostate, bladder, and kidney cancer at the county level.5 The relative concentration of urologic surgeons in urban areas and an aging workforce is associated with urology-related health outcomes.5 Despite small recent gains in the number of residents in the urology training pipeline, ABMS certifications have decreased significantly since the 1970s.3 As overall supply contracts, rural areas are likely to lose even more urologic surgeons because they are, on average, 2.2 years closer to retirement age than urologic surgeons in urban areas. Consequently, rural patients may have decreased access to screening, medical treatment, and surgical treatment for urologic conditions.
While the growth in group practice for urban urologic surgeons provides benefits for call coverage, quality of life, and subspecialization, this trend is moving in the opposite direction in rural communities. Older, rural urologists are more often in solo practice and less often in group practice. As older urologists in rural areas retire, this maldistribution of access will continue to rise.
Urologist supply per capita is at its lowest point in 30 years. Removing the cap on Medicare GME funds, which remain at 1996 levels, would help all medical and surgical specialties (including urology) to increase their training output. Further cuts to GME funds could create more access problems as even fewer surgeons could be trained.
References
- Brotherton SE, Etzel SI. Graduate medical education, 2008-2009. JAMA. 2009;302(12):1357-1372.
- Miller DC, Link RE, Olsson CA. Trends in urology graduate medical education: A brief update from the Urology Residency Review Committee. J Urol. 2004;172(3):1062-1064.
- American Board of Medical Specialties. 2010 ABMS Certificate Statistic. Chicago, IL: American Board of Medical Specialties. 2010, 1-48.
- Poley ST, Newkirk V, Thompson K, Ricketts TC. Independent Practice Becoming Increasingly Rare Among Surgeons. ACS HPRI Fact Sheet, 2011.
- Odisho AY, Cooperberg MR, Fradet V, Ahmad AE, Carroll PR. Urologist density and county-level urologic cancer mortality. J Oncol Pract. 2010;28(15):2499-2504.
