How many neurosurgeons does the United States need? Are there too many or too few?
As the cost of medical care has escalated in the U.S., the socioeconomics of medicine has come under increasing scrutiny. In this environment, discussions on “right-sizing” the physician workforce in accordance with the needs of society have become pertinent. How many neurosurgeons does this country need? Are there too many or too few? Should the number of resident training programs be reduced? Answers to these questions are complex, but are illuminated by an evaluation of the supply-and-demand sides of the workforce equation and an understanding of the trends influencing workforce needs.
Neurosurgeons: Too Many or Too Few?
Currently, there is a perception by some that there are too many neurosurgeons to meet the needs of society. From the vantage point of a neurosurgeon, there are too many neurosurgeons if the number and type of operative procedures performed by that neurosurgeon are too few to maintain technical proficiency; or if the neurosurgeon is not sufficiently busy to derive professional satisfaction from his or her practice; or if third-party insurers can easily find neurosurgeons to provide services for an unacceptably low level of compensation, considering the neurosurgeon’s level and length of training.
Conversely, from the perspective of a patient residing in a sparsely populated state who must travel a long distance or wait an excessively long period of time for treatment, or of a hospital administrator unable to arrange neurosurgical emergency room coverage, there may appear to be too few neurosurgeons. Thus, from the perspective of both the specialty and the patients it serves, the question “Are there too many or too few neurosurgeons,” depends on who you ask.
Confounding the issue of workforce size are recommendations by national policy groups, based on an assumption of an abundance of physicians in the specialty workforce, that do not take into account such factors as regional needs, specialty differences, expanding treatment possibilities, growing subspecialization and individual choice.
Methodology for Workforce Analysis
Estimating the correct size of the neurosurgical workforce necessarily involves an evaluation of the supply of neurosurgeons and the demand for neurosurgical services. This evaluation can best be explained through the use of a workforce model that explores the dynamic between the supply of neurosurgeons and the demand/need for their services over time. Such a model is helpful in understanding the numerous influences on workforce needs, as well as in validating the complex backdrop against which workforce size must be evaluated now and in the future.
Factors Influencing Neurosurgeon Supply
Estimating the supply side of the neurosurgical workforce model is a complex task that requires one to calculate the total number of physicians available to provide clinical services. This calculation involves determining the efforts of a single, clinical full-time equivalent (FTE), the combined efforts of the physician pool, and the resultant total number of FTEs delivering service. A component of this computation is the clinical productivity of the FTE pool representing the percentage of time FTE neurosurgeons engage in patient care versus teaching, research, or administrative activities. In some non-neurosurgical workforce analyses, gender also has been shown to influence time spent in clinical activities. Fiscal considerations, such as falling salaries and decreasing clinical loads, and the distribution of neurosurgeons throughout the U.S. also are modulating factors used in calculating the clinical productivity of the neurosurgical workforce.
The changing size and distribution of the neurosurgical workforce (i.e., newly-trained neurosurgeons entering and others leaving the workforce) must also be taken into account if a reasonable model of the neurossurgical supply is to be developed. Factors influencing rate of increase include the number of residents in training in the U.S. and the number emigrating from other countries, particularly Canada. In the future, these numbers may be influenced by such forces as government regulation of either the size of training programs or the number of surgeons emigrating to this country. The numbers involved in training may also be influenced by policies adopted by the specialty of neurosurgery that might reduce or increase the number of residency programs. Perceptual influences due to falling salaries or reduced job opportunities may, as well, influence supply by lessening medical students’ interest in the specialty.
Conversely, the size of the workforce pool is impacted by the rate of attrition attributable to death, decreased volume of clinical practice, or job changes from clinical practice to administration. Finances are a factor too, as some older neurosurgeons in the managed care environment find that, with reduction of salaries, it is no longer desirable or economically feasible to continue practicing.
Thus, estimating the actual number of FTE neurosurgeons providing services now and in the future is a challenge. However, even more daunting are the complex economic and societal variables that must be considered when estimating the demand/need for neurosurgical services.
Factors Influencing Neurosurgeon Demand
The demand/need side of the equation evaluates the pool of patients who require neurosurgical services. The current size of this pool is determined by the types of disorders for which neurosurgeons presently provide care. Disease prevalence, the range of neurosurgical services offered, market share, physician distribution and the ability for patients to pay for services are among the other factors that modulate the size of the patient pool. Furthermore, the size of this pool may increase or decrease according to fluctuations in disease prevalence, or the amount of service provided by neurosurgeons as compared to that provided by physicians in other specialties.
Other significant influences on the demand for neurosurgeons include the availability of and access to insurance that pays for neurosurgical services, as well as the ever-growing population of elderly and uninsured individuals in need of medical services. Recent data suggests that prolonged primary care treatment of some diseases is more expensive in the long term than earlier referral for specialty care, thereby indicating that an adjustment in the definition of need may be necessary when it comes to access to specialty care. Counterbalancing the increasing need for specialty care, however, are mitigating factors such as the trend to use less costly allied health professionals (i.e., physician’s assistants, and nurse practitioners) to deliver some of the outpatient care traditionally provided by neurosurgeons. In the final analysis of the model, the ideal relationship between supply and demand should result in a balanced equation, with just the right number of neurosurgeons to deliver the neurosurgical care needed by society. However, such a balance is difficult to achieve given the numerous variables and changing circumstances involved.
Trends Influencing the Debate
Given the relatively small size of the specialty, it may seem somewhat surprising that neurosurgery has been a prominent focus in the current national debate surrounding “right-sizing” the physician workforce. Its position of prominence is likely attributable to some recent estimates of workforce need that show neurosurgery at or near the top of the list of overpopulated medical specialties. To understand this phenomenon, it may be helpful to examine some of the current economic and medical trends in the U.S. that have a bearing on the issue of neurosurgical workforce.
- Managed Care. In the ’90s, managed care was hailed as the solution for health care coost containment in the U.S. The decline in the fee-for-service mode of health care delivery, accompanying the rise of health maintenance organizations as the coverage of choice, brought free market and corporate economic incentives to what was once a supplier-dominated industry. Patient choice and physician-to-physician referrals have become less significant, as cost containment has become the driving force in medical care. As a result, the primary care physician’s value has risen, while the specialist has been devalued- viewed as an expense to be avoided by managed care organizations. Most analyses show that this need for neurosurgical care in a managed care setting is far less than the current national density of one FTE neurosurgeon per 55,000 population.
- Growth in Neurosurgical Workforce. The number of neurosurgeons in training has steadily increased over the past several decades. According to German et al., in 1952 there were 94 approved institutions for neurosurgical training, with a total of 241 trainees in all years of training. By 1998, that number grew to 94 neurosurgical training programs, with a total of 818 residents.
Despite this growth in the size of training programs over the past 40 years, the American Board of Neurological Surgery has continued to certify an average of only 113 new neurosurgeons annually (1975-1999). The total number of Board-certified neurosurgeons in the U.S. has remained approximately 3,500 for the past decade.
- International Medical Graduates (IMGs). The training of IMGs is often cited as a source of surplus. Indeed, the growth in the total number of IMGs has been dramatic, accounting for approximately 20 percent of all residents in training in the U.S. However, the number of IMGs concluding a successful match in neurosurgery has changed little over the past decade. Considering the small number in neurosurgical training programs, IMG’s impact on workforce strategy in the near future will be minimal.
There are philosophical issues concerning IMGs, however, that should be addressed by the neurosurgical community, including 1) should training slots be based on merit, regardless of an applicant’s country of origin; and 2) should IMGs be required to return to their country of origin once training is complete? Such issues, if not addressed, will continue to impact the percentage of IMG residents in training, even in a small specialty like neurosurgery.
- Scope of Neurosurgical Practice. The scope of neurosurgical practice is defined by the breadth of training provided and the development of new science, technology, treatments and techniques. It is inevitable, with the advances occurring in medicine, that neurosurgery’s scope of practice will conflict with other specialties. In this regard, spine care, carotid endarterectomy and peripheral nerve surgery either represent areas of opportunity or lost market share for the specialty of neurosurgery. -Role of Allied Health Professionals. The increasing role of allied health professionals in delivering patient care traditionally provided by physicians appears to be attributable partly to economic factors and partly to the willingness of physicians and patients to allow care to be rendered by allied health professionals. Although such care can increase the efficiency of a neurosurgeon, the use of allied health professionals in an outpatient setting or in a managed care environment could, in theory, decrease the need for trained neurosurgeons.
- Government’s Role in Workforce Policy. The federal and state governments have had a long-term interest in physician workforce issues. From implementing programs in the 1960s to increase the number of applicants enrolling in medical schools to subsidizing graduate medical education directly and indirectly through Medicare supplementary payments, and from developing Medicare’s resource-based relatiive value scale to budget-driven reductions in reimbursements for GME, the government has had a profound influence on the size of the physician workforce.
- National Policy Groups. Concern about physician workforce has led to recommendations by several national policy groups, including the Institute of Medicine, the Council on Graduate Medical Education, the PEW Commission and several professional medical associations, to reduce the number of resident positions available, while maintaining funds for graduate medical education programs and monitoring physician workforce. Although these recommendations draw attention to the topic and may influence future government policy, none have had a direct bearing on the specialty of neurosurgery at this time and some of these workforce estimates have been flagrantly inaccurate.
- Local Initiatives. Health care initiatives also are occurring at the state level. For example, the Health Care Financing Administration’s initiative to pay New York State hospitals $400 million over six years was conceived as a solution to physician excess. It was created in an effort to assist teaching hospitals in redesigning their graduate medical education programs, while at the same time providing a vehicle of funding during a period of transition. Whether such programs will impact neurosurgical residency programs and, hence, the size of the neurosurgical workforce is still being examined.
- Initiatives of Neurosurgical Organizations.Many practitioners have questioned how “organized” neurosurgery can affect the workforce in a positive way. The American Board of Neurological Surgery and Residency Review Committee for Neurological Surgery have been a positive influence in preserving the quality of residency training programs. Their continuing efforts to develop and maintain policies that assure the educational quality of the training programs have enhanced the ability of those in training to be a successful part of the neurosurgical workforce.
Likewise, the AANS has enhanced the neurosurgical environment through its ongoing commitment to education and professional development-important facets of improving neurosurgeons’ position as competitive providers of health care.
Strategies for the Future
Despite the complexity of workforce issues and the difficulty in determining the best course of action, neurosurgeons must take an active part in the workforce dialogue. They must become galvanized in their efforts to maintain their scope of practice. They must fight to ensure that residency programs maintain their standards and prepare trainees for the challenges of the current medical environment. More important, neurosurgeons must speak with one voice. They must support the role of the AANS and the role of the Washington Committee, which serves as a voice for neurosurgery at the federal level. By taking these steps, neurosurgery, not policymakers or the marketplace, will have an active role in guiding workforce decisions.