Maintaining Balance in the Neurosurgical Workforce
How many neurosurgeons are needed to fill the nation’s medical needs? What geographic area or population number should a neurosurgeon serve? How many neurosurgeons should be in training? How many in practice? Are there too many, too few, or the right number?
These workforce questions have been debated since the beginnings of neurosurgery as a distinct specialty. The answer depends upon whom you ask, and varies over time. Harvey Cushing believed a 1:1 million neurosurgeon-to-population ratio to be a generous plenty, while today’s 1:65,000 ratio proves inadequate, based on an analysis of the growing number of unfilled positions advertised.
The workforce issue has been discussed before in the AANS Bulletin. The controversy was covered in the Spring 2000 issue in articles by current AANS President A. John Popp, MD, and Richard Cooper, MD. These articles are still timely and can be referenced online at www.AANS.org/bulletin.
The art and science of estimating the number of neurosurgeons needed in our nation’s healthcare system is akin to forecasting the weather years in advance. Like the “butterfly effect”-described by James Gleick in Chaos: Making a New Science as the impact of minor, remote, random atmospheric conditions on major meteorological events around the globe-a multitude of changing factors affects the need or demand for neurosurgeons’ services.
Profound changes in neurosurgical treatment often result from apparently inconsequential scientific discoveries or technical reports, commonly dismissed as inappropriate, unnecessary or just irrelevant when first introduced. The transformations wrought upon neurosurgical practice by computed tomography scanning and magnetic resonance imaging; the surgical microscope and more recently the endoscope; an exponentially expanding number of spinal internal fixation devices; growing applications of functional neurosurgery; and stereotactic guidance, endovascular techniques, and radiosurgery, are far reaching. They not only improve standard treatment, but also expand the volume of surgical cases, and the demand for neurosurgical services.
So the estimate of neurosurgical supply shifts with changing circumstances. Some of the reasons for prognostic inexactitude are:
- Neurosurgeons are unevenly distributed. An average number obscures regional imbalances of excess, as evidenced by concentration of neurosurgeons in urban areas, and inadequate supply, as often is the case in rural areas.
- The need for neurosurgeons depends on the range of services provided. Britain’s controlled neurosurgeon-to-population ratio of 1:500,000 works by limiting the range of services provided by neurosurgeons; this is not the case in the United States.
- The demand for neurosurgical services expands as risk is reduced, recovery is shortened, and success is proven. Minimally invasive and noninvasive techniques lower the threshold for initiation of elective procedures.
- Neurosurgeons are more subspecialized. Now multiple neurosurgeons with special interest or training fill the need formerly satisfied by one general neurosurgeon performing less complex procedures on fewer patients.
- Interspecialty competition affects workforce needs. While neurosurgery may have lost ground to vascular surgery and neuroradiology with respect to treating cerebrovascular disease, it has gained ground with expanded spinal surgery services, especially minimally invasive decompression and complex stabilization surgery.
- Medical liability risk is changing the number of neurosurgeons available. Some neurosurgeons in states that are experiencing a medical liability crisis have
- relinquished cranial privileges to lower premium costs and exposure to liability claims. Others have lost coverage altogether, moved, retired, or switched to nonsurgical practice. As the liability crisis worsens, the gap between the need for neurosurgeons and available neurosurgeons will grow in high-risk states.
- An 80-hour workweek during training and an expectation of a less rigorous lifestyle with more available personal time may reduce the hours worked by the coming generation of neurosurgeons.
- The expanding role of physician extenders in neurosurgery practice may reduce the need for additional neurosurgeons, easing the supply problem.
What the “right” size of the neurosurgical workforce is, is not merely idle speculation. Since training time is up to seven years, and longer if a fellowship is included, early recognition of insufficient numbers is important to keep a healthy balance between the training program pipeline and medical market demand.
New analysis of the neurosurgical workforce is timely in a changing medical market. This issue of the Bulletin brings the question to the forefront once again and, we hope, provides new information and insight that will aid in maintaining balance between the numbers and the need in the future.
James R. Bean, MD, is editor of the Bulletin and chair of the AANS/CNS Washington Committee. He is in private practice in Lexington, Ky.