A great deal of attention recently has centered on the neurosurgical workforce. There are many facets to this broad topic, but focusing on even the apparent simplest of them — the numbers of neurosurgeons — can become a complicated exercise.
A rapid expansion of residency programs and graduating neurosurgeons occurred in the 1960s and 1970s, with the growth in numbers of neurosurgeons exceeding the growth in population during this period. However, with the advent of managed care in the 1980s and a shifting trend toward primary care at that time, it was assumed that numbers of neurosurgical specialists, among other surgical specialists, exceeded the demand for services. This assumption, manifested in policy, ushered in a period of stasis in the number of training programs and graduates.
More recently, given studies that quantify advertised employment opportunities for neurosurgeons suggesting an increasing demand for these specialists, the wisdom of the 1980s was called into question. The profession began to ask anew whether the number of neurosurgeons is too many, too few, or just right.
In this issue of the AANS Bulletin, Benzil and von der Schmidt report results of the recent neurosurgical workforce assessment conducted by the Council of State Neurosurgical Societies. While the difficulties in obtaining a direct assessment of the workforce are well outlined in their cover story, I personally carry home the following messages.
Meet Demand With Supply
Firstly, there has been stasis in the total number of medical school applicants and enrollment. While the number of medical school applicants actually waned in the latter 1990s (concurrent with the boom in the stock markets!), the number of applicants has been increasing in recent years. Only very recently has there been an increase in the number of neurosurgeons in training, but this increase has been outstripped by the population increase over the same period.
Also, as noted in Figure 4 of the cover story, the number of ABNS diplomates stayed roughly the same from 1991 to 2003. This stability demonstrates the “pipeline effect” from extended training and the specialty’s difficulty adjusting its workforce in response to market demands.
Attract Women to Neurosurgery
Secondly, a major demographic shift has occurred in medical school enrollment. The number of female students in medical school has been increasing, and women now comprise more than 55 percent of enrollees. Women in my own medical school class in the early 1980s comprised only 30 percent of the student body, illustrating the dramatic increase of the last two decades.
Women, however, comprise only 10 percent of neurosurgical trainees. Clearly, the neurosurgical specialty lags behind the medical profession in attracting women candidates. Unless we make our training programs, and neurosurgery as a specialty, more attractive to female applicants, we will continue to face a net reduction in the pool of talent from which we are drawing.
Attracting women to careers in neurosurgery will require infusing neurosurgical residencies with flexibility, making training more compatible with the demands of starting or raising a family. This flexibility will need to extend to both the private and academic practice settings, especially since a recent JAMA review demonstrated that medical students as a whole are significantly weighing lifestyle as a criterion for career choice.
Embrace New Therapies
Lastly, neurosurgeons represent roughly 3 percent of allopathic physicians. Because we are few, our capacity for adopting new therapies into our practices is limited. With the specialty’s existing workforce working hard, as measured by production of significant relative value units, neurosurgeons have less of an opportunity to engage in new areas of practice. Our history has been one of competition from those specialties with greater workforce capacity. For example, neurosurgery has competed with orthopedics in surgery of the spine, with radiology in endovascular therapy (and more recently with cardiology in stent technology), and even with general surgery in trauma cases. We must provide enough workforce capacity to be able to embrace new therapies for treatment of neurological disease.
These should be among the primary considerations in plans for the future, particularly in light of projections that neurosciences represent the largest arena for growth in the next generation.
For Further Information
- Friedlich AB, Feustel PJ, Popp, AJ: Workforce demand for neurosurgeons in the United States of America: A 13-year retrospective study. J Neurosurg 90:993-997, 1999
- Gottfried ON, Rovit RL, Popp AJ, Kraus KL, Stolper-Simon S, Couldwell WT: Neurosurgical workforce trends in the United States. J Neurosurg 102:202-208, 2005
- Lee BY, Hecht T, Volp K: Lifestyle as a major factor in medical student’s choices. JAMA 290:2941, 2003
- Woodrow SI, Gilmer-Hill H, Rutka JT: The neurosurgical workforce in North America: A critical review of gender issues. Neurosurgery 59:749-755, 2006
William T. Couldwell, MD, is editor of the AANS Bulletin. He is professor and Joseph J. Yager Chair of the Department of Neurosurgery at the University of Utah School of Medicine.