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To this point it has been difficult to ascertain the current status of the neurosurgical workforce in Texas. Several factors contribute to this problem: multiple and incomplete databases on neurosurgeons currently in active practice; a recent influx of surgeons relocating to the state following the passage of tort reform in 2003; and the frequency and ease with which surgeons move within and out of the state. Additionally, little information is known about the practice trends, types of practices, recruitment efforts and retirement plans of the state’s actively practicing neurosurgeons.
In order to address these issues, a survey of all identified neurosurgeons practicing in Texas was conducted for the Texas Association of Neurological Surgeons in April 2007. The survey consisted of 12 questions aimed at obtaining demographic data, practice type and scope of practice, recruitment efforts, retirement plans, emergency room coverage and reimbursement, among others. The survey’s response rate was 43.4 percent, far greater than the 16 percent response rate necessary for a valid and representative survey.
Neurosurgery in Texas
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Fellowship and Certification Seventy-one percent of the respondents were board certified in neurosurgery and 25 percent had attained postresidency fellowship training. Only four percent were neither board certified nor fellowship trained. There were seven categories of fellowship training identified by the respondents, and these included: spine, pediatrics, vascular, endovascular, tumors, skull base, and research. Spine fellowships accounted for almost one-third of fellowship training (32 percent), vascular and oncology each accounted for 19 percent, pediatrics 16 percent, skull base 5 percent, with endovascular, epilepsy and research each at 3 percent.
Practice Type When asked what percent of their practice was devoted to any one subspecialty area, 61 percent stated more than 70 percent of their practice cases included spinal surgery (and 12 percent indicated that spine made up more than 91 percent of their practice). Pediatric neurosurgery was practiced exclusively by 10 percent of respondents whereas 84 percent said that up to 20 percent of their practice is composed of pediatric cases. The survey reported 20 full-time pediatric neurosurgeons practicing in five different areas: eight in Dallas-Ft. Worth, five in San Antonio, four in Houston, two in Austin, one in Galveston and one in Corpus Christi.
Only five percent of respondents exclusively practiced neurosurgical oncology (more than 81 percent) whereas 85 percent of respondents said that up to 20 percent of their practice involves tumor surgery. In a similar fashion, 90 percent of neurosurgeons who do cranial surgery said they still perform vascular work but that it comprises a minor part of their practice (20 percent or less). Eighty-seven percent said that they do less than 10 percent of their work in the area of skull base.
Eighty-four percent of respondents said they are in private practice and 16 percent are in full-time academic practice. Eighteen percent are in solo practice, while 5 percent are employed directly by hospitals. Of those in group practice, most are in groups of three or less (52 percent), while 21 percent are in groups of four to six surgeons, 18 percent are in groups of seven to nine surgeons, and 9 percent are in groups of 10 to 12 surgeons.
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Recruitment Thirty-eight percent of respondents were actively recruiting new partners. Of these, 59 percent wanted to add one neurosurgeon, 21 percent wanted two and one practice wanted to add four neurosurgeons to the group. When asked whether they believed that there were enough neuro-surgeons practicing in their community, 18 percent thought that there were not enough, 54 percent believed there were enough and 28 percent thought that there were too many.
Medicolegal Several questions were asked to ascertain the effects of tort reform in Texas following the passage of Proposition 12 in September 2003. When asked whether or not the medicolegal climate has led to changes and/or restriction in the scope of practice, only eighty-five responded (57 percent). Of those responding, 38 percent stated that they do not restrict the scope of their practice in any way. Nineteen percent said that they do restrict their practice, and of those 48 percent restrict cranial surgery, 19 percent restrict pediatrics and only 6 percent restrict their trauma coverage.
The number of malpractice lawsuits filed has dropped significantly since the passage of Proposition 12. There was a 67.6 percent decrease in those reporting having had a single lawsuit filed against them in the three-to-six years before taking the survey (2001-2003) compared to having a single lawsuit filed within the immediately past three years (2004-2007) alone. There was a 64.3 percent decrease in those reporting two suits filed against them during the same periods and a 42.8 percent drop in those who had three lawsuits during that time. Of those who reported between four and eight lawsuits in the earlier period, none reported experiencing similar lawsuit rates in the immediately past three years.
Emergency Coverage Seventy-five percent of respondents said
they take emergency call and 25 percent do not. Of those taking emergency call,
56 percent said they cover only one hospital, 28 percent cover two hospitals,
and 11 percent cover three hospitals. Three respondents said they covered four
hospitals, and one respondent covered five hospitals.
Reimbursement for emergency call coverage varied across the state. A total
of 54 neurosurgeons (36.2 percent) responded to the question of remuneration
for call coverage. The range of payment varied between $350 and $4,700 per
call shift. The average reimbursement was $1,562, the median was $1,100 and
the mode, $1,500. The highest per diem reimbursement, $4,700, was reported
in San Antonio, and the lowest, $350, in Wichita Falls. The average reimbursement
in the following six cities was: San Antonio, $3,000; Fort Worth, $1,333; McAllen,
$1,500; Corpus Christi, $1,200; Houston, $1,133; and Dallas, $998.
Retirement Plans When asked about plans for retirement from neurosurgical practice, 27 percent of respondents said they plan to retire within six years, 12 percent within three years and 15 percent between three and six years. Twenty-three percent planned to retire between six and 10 years and the rest in more than 10 years. Of those planning to retire within three years, there are four in the Dallas-Fort Worth area, two in Houston, two in Beaumont and two in the Midland-Odessa area. Of those planning retirement in three to six years, there are eight in the Dallas-Fort Worth, five in Houston and three in Austin. Therefore, the Dallas-Fort Worth area stands to lose 19 percent of the currently practicing surgeons. There also will be an 11.3 percent loss of working neurosurgeons in Houston, an 18 percent loss in Austin and a 43 percent loss in Beaumont.
Workforce Distribution and Population There is little consensus on what the adequate and appropriate neurosurgical workforce should be in the United States at either the national or regional level. The Council of State Neurosurgical Societies’ Manpower Committee conducted a survey in 1995 and calculated an overall neurosurgeon-to-population ratio of 1 to 64,000. The area with the highest concentration of neurosurgeons was found to be Washington, D.C., with a ratio of 1 to 16,000, and the lowest was Wyoming with 1 to 250,000. For comparison, Japan has a neurosurgeon-to-population ratio of 1 to 17,000 and Colombia, 1 to 350,000.
The present survey indicates that currently Texas has a neurosurgeon-to-population ratio of 1 to 68,500 which compares favorably with the current national ratio of approximately 1 to 75,000. We also found that Houston has the largest concentration of neurosurgeons (67) and a ratio of 1 to 30,098. The Houston metropolitan area has 101 surgeons and a ratio of 1 to 26,597. Next is Dallas (39) with a ratio of 1 to 31,123, while the Dallas metropolitan area has 105 surgeons with an overall ratio of 1 to 30,300. Next in size is San Antonio with 37 neurosurgeons and a neurosurgeon-to-population ratio of 1 to 34,000. West Texas has the lowest number of practicing neurosurgeons, with the largest city, El Paso, having 11 practicing neurosurgeons and a ratio of 1 neurosurgeon to 54,500 people.
Implications for Neurosurgery
The current neurosurgical workforce in Texas appears to be in line with the
estimated national average. In the three largest metropolitan areas (Dallas-Ft.
Worth, Houston and San Antonio) the workforce needs are at appropriate and
sustainable levels. However, with an estimated retirement of 26 percent of
the neurosurgical workforce within six years, a major and significant impact
on neurosurgical care delivery may develop if adequate replacement does not
occur. Subsequently, recruitment and retention of neurosurgeons must keep
up with retirement rates. Fortunately, Proposition 12 is having a positive
impact on the medicolegal climate in the state, and this has translated into
an influx of 16 neurosurgeons to the state in the last three years, with
two more expected this summer.
It seems that neurosurgeons in Texas are doing their part in caring for neurosurgical emergencies, with 75 percent taking trauma-emergency call. Some areas are not being properly covered such as the Rio Grande Valley and far west Texas, while the large cities with level I trauma centers do an excellent job in trauma coverage.
Furthermore, neurosurgeons are being reimbursed by hospitals for taking trauma call, although the amount paid varies significantly ($350 to $4,700 per diem). On average, a neurosurgeon in Texas can expect to be paid about $1,562 per call.
Thus, this survey seems to indicate that Texas provides the practicing neurosurgeon with a favorable landscape. The medicolegal climate is among the best in the nation, the need for more neurosurgeons is present and the recruitment efforts are strong. It is imperative that we continue to have an excellent working knowledge of the neurosurgical workforce in Texas and elsewhere. The participation of all neurosurgeons in similar future surveys will be invaluable for gaining and accumulating essential knowledge about the neurosurgical workforce.
David F. Jimenez, MD, FACS, is secretary of the Texas Association of Neurological Surgeons. He is professor and chair of the Department of Neurosurgery the University of Texas Health Science Center at San Antonio. The author reported no conflicts for disclosure.