Editor’s note: The American College of Surgeons (ACS) Board of Governors (B/G) conducts an annual survey of its domestic and international members. The purpose of the survey is to provide a means of communicating the concerns of the Governors to the College leadership. The 2019 ACS Governors Survey, conducted in July 2019 by the B/G Survey Workgroup, had a 95 percent (276/289) response rate.
One of the survey’s topics was surgeon workforce. This article outlines the Governors’ feedback on this issue.
Recent literature reveals a growing need for more information on, and awareness of, the surgeon workforce shortage. For example, the Bulletin published an article by Mark W. Puls, MD, FACS, a general surgeon and an ACS Governor in Alpena, MI, on the increasing shortage of surgeons in rural settings, a trend that has been attributed to an aging workforce and other factors. This shortage has left many rural U.S. counties without any surgeons, even though more than half of the counties have a local hospital.
Another study by E. Christopher Ellison, MD, FACS, chief, division of general surgery and the Robert M. Zollinger Professor, The Ohio State University, Columbus, and colleagues showed that although the number of general surgery resident positions and graduating surgical residents has been rising in the U.S. for more than 10 years, these increases have been insufficient to maintain the ideal number of surgeons for the population.
Several surgical specialties also face workforce challenges. A 2019 Association of American Medical Colleges (AAMC) report predicted a U.S. surgeon shortage of 23,000 surgeons in 2032. (Note: At press time, the AAMC has just released a report estimating that the surgeon shortage could be as high as 28,700 by 2033.) The AAMC projects that clinical demand will continue to outpace the supply of surgeons with a projected total shortfall of 46,900−121,900 by 2032. This projected shortfall range is based on a model that accounts for population projections, demand and supply projections, estimates of physician specialty choice, recently revised federal health professional shortage area designations for primary care and mental health, and lower projections of future insurance coverage expansion. A shortage of physicians in surgical specialties is estimated to be between 14,300 and 23,400.
In 2016, the U.S. Department of Health and Human Services issued a report on national and regional projections of supply and demand for surgical specialty practitioners from 2013 to 2025. The study projected that a shortage of surgical specialists would rise to 24,330 by 2025, with wide geographic variation: 1,750 in the Northeast, 7,040 in the Midwest, 10,210 in the South, and 5,330 in the West.
Practice settings and geography
Because surgeon workforce needs can differ based on practice settings and geographic location, a closer look at the practice settings of the survey’s respondents was warranted: 75 percent were in full-time academic practice or hospital employment (see Figure 1), and only 24 percent of respondents practice in settings with a population of less than 250,000 (see Figure 2). In addition, 74 percent of ACS Governors indicated they worked in groups of five or more surgeons. This finding is important in light of an article by Jonathan Ford Hughes that examined physician shortages by U.S. regions. He predicted greater shortages in the South and Midwest, as well as higher shortages in rural settings—geographic areas and practice types less commonly represented in the Governors’ sample.
Figure 1. Type of surgical practice
Figure 2. Population of practice location
Research findings on physician shortages may vary depending on the specialty and the location under analysis. For example, surgeons in academia or hospital employment may be less affected than surgeons in rural settings. Rural general surgeons continue to face an increasing workload demand, but with a median age in the late 50s, they also are aging out of practice.
Most Governors (65 percent) indicated they did not perceive workforce shortages in their geographic area. Although 55 percent indicated that their specialty was experiencing no shortages, further analysis revealed that while obstetrician-gynecologist Governors did not see shortages in their respective geographical areas, they did recognize overall specialty shortages. Governors from other specialties reported similar observations, with more global shortages in the following specialties: vascular (60 percent), wound care (58 percent), cardiothoracic (57 percent), colorectal (52 percent), and pediatric surgery (50 percent).
Quality of care
The survey also sought to determine if workforce shortages led to treatment delays and reduced quality of care. Most Governors (75 percent) indicated they did not perceive significant delays in the delivery of patient care, and 74 percent noted they had not seen a negative effect on the quality of care rendered because of a perceived shortage of surgeons. Although 34 percent of international Governors indicated they experienced shortages of surgeons in their geographic area and specialty, this shortage was reported to be the cause of less than 20 percent of the signiﬁcant delays in elective surgical procedures and adversely affected the quality of care in less than 20 percent of the cases.
Most Governors (78 percent) said it takes at least six months to replace a partner or add a new surgeon to their practice (see Figure 3), but variances were seen among practice settings. Many solo private practice surgeons (47 percent) indicated they needed more than a year to add a partner. More than six months was needed for new surgeon recruitment for a variety of practice settings: private practice multispecialty (67 percent), hospital employment (65 percent), government (60 percent), and military service (60 percent). Governors in solo private practice (57 percent) needed more than six months to recruit another surgeon. Forty percent of private practice single-specialty groups with more than five members indicated they needed more than a year for recruitment. Interestingly, 33 percent of Governors in government practices were able to successfully recruit in less than six months.
Figure 3. Estimated time to replace and/or add a surgeon
Overall, Governors in private practice multispecialty groups with primary care and surgical care settings were the most successful: 25 percent fulfilled positions in less than six months, 50 percent within six months to a year, and 25 percent needed more than a year to recruit. Internationally, 40 percent of Governors were able to replace surgeons in fewer than six months, but one-third needed more than a year. Interestingly, only 11 percent of all Governors used locum tenens for unfilled positions (see Figure 4).
Figure 4. Is locum tenens used for unfilled positions?
Addressing workforce needs
Most Governors (73 percent) said they believe ACS chapter and specialty society meetings provide the best platform for addressing workforce needs and deficiencies (see Figure 5). Discussions about workforce needs also occurred at residency programs (55 percent) and local medical schools (43 percent). Most Governors did not appear to seek out the ACS as a national organization for solutions to surgeon practice recruitment or more global workforce issues, suggesting an opportunity for ACS action.
Figure 5. Where workforce needs and deficiencies, such as rural surgery shortages, are discussed
Despite most Governors not recognizing a workforce shortage in their practice geographic area, 94 percent (see Figure 6) believed it was an important issue for the ACS to continue addressing in the future, especially by creating more surgical residency programs and training positions (60 percent).
Figure 6. How important is it for the College to continue addressing surgical workforce issues?
Although most Governors report that they have yet to personally experience a workforce hardship that impedes access or the provision of quality care in their practice area, they do recognize that a more global problem exists and encourage the College to keep this issue a high priority. Many Governors (142) offered recommendations on how the ACS could better address surgical workforce issues. For example, international Governors suggested enhancing collaboration between the international chapters and the ACS, as well as among international surgeon groups. International Governors also asked for additional statistics and resources to better understand surgeon workforce needs through both dedicated meetings and presentations at the Clinical Congress.
Within the U.S., rural communities seem to be experiencing the greatest surgeon workforce challenges. Many Governors called for additional funding for rural surgery and targeted rural residency training positions and programs. Governors also recommended increasing advocacy focused on federal legislative efforts, such as the Ensuring Access to General Surgery Act (H.R. 1841) and Keep Physicians Serving Patients Act of 2019 (H.R. 3302). The College supports both bills. Additional outreach to state and local government leaders, ACS chapters, medical schools, and residency programs is encouraged as well.
The surgeon workforce shortfall is a multifaceted issue that requires both national and regional, practice-specific solutions. An additional in-depth study and analysis of surgeon workforce shortages is warranted to better understand its complexities and refine long-term solutions. Governors strongly encourage the College to continue focusing on surgeon workforce concerns to ensure access to optimal surgical care for all patients and the future success of the profession.
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