Toward Harnessing Forces of Change – Assessing the Neurosurgical Workforce

January 1, 2006

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Resident workweek restrictions, changes in practice related to the malpractice crisis, technological advancements leading to new therapies, fluctuating reimbursement, and lifestyle expectations are among the many factors that impact the availability of a neurosurgeon to treat a patient when the need arises. The interplay among these social and economic influences, the profession of neurosurgery, and society constantly shapes the neurosurgical workforce, making this is an important issue to revisit on a regular basis.

In order to harness forces of change rather than simply react to them, a clear view of the present workforce landscape is necessary. Two major efforts to analyze the neurosurgical workforce recently have been undertaken. First, the Workforce Committee of the Council of State Neurosurgical Societies devoted significant resources to complete a comprehensive primary analysis of workforce adequacy. In addition, the AANS appointed an ad hoc committee to reassess the neurosurgical workforce particularly with respect to geographical distribution and limitation of practice. While the final report of the AANS ad hoc committee is pending, the CSNS Workforce Committee presented its primary findings during the CSNS plenary session on April 22, and those findings as well as additional data are reported in this article.

Source: Workforce Committee of the Council of State Neurosurgical Societies
NS = Neurosurgical; NRMP = National Resident Matching Programs

Developing a Model of Workforce Adequacy

Before developing its work plan, the Workforce Committee first evaluated previous efforts to define physician workforce.

Traditionally, physician workforce analysis for assessment of nationwide need focused on a statistical calculation of disease incidence and hours required for treatment; the result was expressed in physician full-time equivalents, or FTEs. Such an approach was used in the 1933 landmark study by the Committee on the Cost of Medical Care. This CCMC study established the basic tools of workforce analysis, reconstructing the system by measuring component parts using time as the primary metric. While this study included the warning that if a reader “expects to find here the finality of judgment and precision of detail, he is doomed to disappointment,” the study’s impact was widespread. Fifty years later, the Graduate Medical Education National Advisory Committee used the same rubric and a panel of experts to predict physician needs 20 years into the future! The same problematic approach was used in the 1990s to extrapolate a significant excess of medical specialists by the end of the 20th century. All of these projects led to major restructuring of medical school education, which affected enrollment and funding.

More recently, the Council of Medical Specialty Societies developed an alternative methodology that utilized a “trend approach.” This model attempts to employ a statistical approach to assign vectors, magnitudes and probabilities to many trends to better assess workforce issues. In this model the economy is seen as the primary trend, but other important trends include technology, demographics, physician productivity and the changing role of nonphysician clinicians. The CSNS Workforce Committee adopted this methodology for much of its analysis.

The Workforce Committee reviewed input, throughput, demand, overall trends and gender trends from 1995 to 2005. Data analyzed included:

applicants to medical school and to the National Resident Matching Program;
neurosurgery residency applicants, positions, programs;
neurosurgery residents: starting and graduating;
regional and nationwide trends in numbers of neurosurgeons;
practice profiles;
demand for neurosurgery care; and
indicators of adequate neurosurgery coverage.

What evolved was the Model of Workforce Adequacy depicted by Figure 1. Evaluating each component of this rubric demonstrates some very important trends.

Entering Neurosurgical Practice: Input
Medical School Statistics Over the last decade, the total number of medical school applicants has dropped dramatically. From 1994 to 2005, the male and female applicant pools have diverged (Figure 2). Using 1994 as an index year, the number of female applicants was largely static while males dropped to 70 percent of their 1994 numbers.

Medical school acceptances over the decade were relatively stable (17,300 in 1994 and 17,900 in 2005). However, since 1998 females have outnumbered males in medical school acceptances with the 2005 class at more than 55 percent female (Figure 3). Currently, only 10 percent of entering neurosurgery resident positions are filled by women.

Source: Association of American Medical Colleges

Residency and Neurosurgical Residency The total number participating in the National Resident Matching Program has remained stable over the last 10 years. During that time, a constant 65 percent of the applicant pool consisted of U.S. medical school graduates.

In contrast, the pattern of applicants to neurosurgery residency showed significant fluctuation (Figure 4). With 1996 used as an index year, applications reached a nadir in 2002. While there has been some recovery since then, numbers have not yet returned to those of 1996. The proportion of U.S. graduates to international medical school graduates matching in a neurosurgery residency has remained fairly constant with very low numbers of IMGs. The total number of offered residency positions has risen just 10 percent during this period, from 140 to 156, with a total of more than 800 neurosurgery residents training in any one year. This trend contrasts sharply with the growth from 1952 to the early 1990s when the total number of residents increased from 241 to more than 800. Despite the increased number of neurosurgery residency positions offered, the number of ranked applicants remained static.

Exiting Neurosurgical Practice: Throughput
Many factors impact neurosurgery throughput including early retirement and limitation of practice. Assessing the complement of American Board of Neurological Surgery diplomates over time reveals some dramatic swings in total numbers (Figure 5). The large drop in ABNS diplomates between 1998 and 2001 has been attributed primarily to early retirement since the number completing training during this time was stable. Following this precipitous decline, the number of diplomates has climbed, reaching 1991 levels in 2003. The current age distribution, however, suggests the high potential for decline during the next five to 10 years since a high proportion of current diplomates (32 percent) were born before 1943 and the average age at which neurosurgeons retire has been estimated at 60.

Limitation of practice also has become an important factor. In the AANS 2006 Workforce Survey, 38 percent of responding neurosurgeons had limited their practices. More than 10 percent had eliminated cranial (11 percent) and trauma (13 percent) procedures from their practices and more than 50 percent no longer provided pediatric neurosurgical care.

Meeting Demand
According to U.S. census information, the total U.S. population increased by more than 30 million between 1990 and 2000, a growth of more than 10 percent. Comparing the number of ABNS diplomates to census population data reveals a marked change in the neurosurgeon-to-population ratio from 1:80,000 in 1990 to 1:91,500 in 2000. During this same period the population in the over 65 and over 85 age groups increased across the United States.

Between 1990 and 2000 neither the overall population nor the aging population increased uniformly across the country (Figures 6 and 7). The top 10 most populous states remained the same but their ranking changed, with Texas leapfrogging New York and Illinois topping Pennsylvania. While growth in the over 65 population was seen in all states, there was disproportional growth in California, Florida and Texas (Figure 7). It is not clear if neurosurgeons have similarly distributed, but a study currently underway at Columbia University should give answers to this important question.

Source: Association of American Medical Colleges

Source: San Francisco Matching Programs

Regarding “Supply” One of the most important issues identified by the CSNS project is the difficulty of fully defining the current or past numbers of neurosurgeons actively practicing at any given time in any given place. Not all neurosurgeons are members of the AANS or the Congress of Neurological Surgeons, and some who are “Active” members no longer actively practice. Further, a search of state medical licenses would overestimate the number of current neurosurgeons in practice because some physicians maintain licensure in states after they retire or relocate, while others practice simultaneously in several states.

The Workforce Committee conducted a meticulous effort to count neurosurgeons in New Jersey and found that neither of the utilized sources provided accurate data. The AANS roster of practicing neurosurgeons was compared with the results of an exhaustive telephone census that involved contacting all N.J. hospitals to identify practicing neurosurgeons and then calling each neurosurgeon to identify practice status. The AANS roster listed 79 neurosurgeons versus 83 identified by the telephone census; however 22 of the 79 AANS-listed neurosurgeons were no longer actively practicing, and 25 of the 83 neurosurgeons identified in the telephone census were not listed with the AANS. Only 57 names appeared in both neurosurgical data sources. A significant variance of more than 25 percent between data sources was demonstrated.

Because reliable numbers of actively practicing neurosurgeons were unavailable, ABNS numbers were used in this study. However, it should be noted that ABNS certification is not a requirement for the active practice of neurosurgery.

Source: American Board of Neurological Surgery

Workforce Adequacy?
Some trends are more difficult to quantify and analyze than others. If one accepts the premise of the Council of Medical Specialty Societies Workforce project that the dominant trend is the economy, the overwhelming forces of change within neurosurgery have been declining reimbursement, the growth of managed care, and increasing overhead primarily as a result of high malpractice premiums. What is not known is whether these economic changes definitely have led to changes in neurosurgical practice. For instance, does the average neurosurgeon perform more cases each year to improve revenues?

Has there been an increase in the use of ancillary personnel to lower the practice’s overhead? Is the impact sufficient to speed throughput of neurosurgeons by practice limitation or early retirement or to impact input of physicians into neurosurgery residencies? Has there been redistribution of neurosurgeons between academic and nonacademic practices or in the geographic areas where they practice?

In addition to the aging of the U.S. population, there also is the important trend of increasing obesity. It is clear that degenerative spine disease is aggravated by weight, and obesity can increase the complications of all neurosurgery. However, how this obesity epidemic will impact neurosurgical practice remains to be seen.

Many authors also have speculated on the impact of changes in resident training. The length of training has increased gradually over time, and since July 2003 residents have been restricted to an average workweek of 80 or 88 hours. Will the current residents reduce the output of a neurosurgical FTE by working fewer hours? Are future neurosurgeons destined to become ever more specialized? Can work hour restrictions help attract more medical students to our demanding and long residency training programs?

Implications for the Workforce
In summary, this study suggests that serious concerns regarding current neurosurgical workforce adequacy are warranted. Further, the trends of growth, aging and changing distribution in the general population will exacerbate the problem unless the specialty can increase proportionally the number of qualified physicians entering neurosurgery residencies. It will remain difficult for organized neurosurgery to respond quickly to needed changes in the neurosurgical workforce because of the specialty’s small numbers and the lengthy training period. However, this study demonstrates the importance to organized neurosurgery of knowing how many neurosurgeons are actively practicing, where they are, and what they are doing. The specialty must attend to the important trends that will influence workforce adequacy such as the changing demographics of medical students, critical population shifts, changes in demand related to an aging population and widespread obesity, and the potential for economic trends to influence many aspects of practice.

Source: U.S. Census Bureau

Source: U.S. Census Bureau

As many before have stated, no model exists that can accurately predict the future workforce issues for medicine, medical subspecialties, or neurosurgery. Attention to workforce adequacy will remain critical for many years to come, and educating students, residents and practicing neurosurgeons about workforce and socioeconomic issues is critical. Clearly, analysis of workforce adequacy must be a continual effort rather than the subject of sporadic refocusing.

Deborah L. Benzil, MD, and Edward von der Schmidt III, MD, are respective chair and vice chair of the Workforce Committee of the Council of State Neurosurgical Societies.

The authors acknowledge the contributions of the entire Workforce Committee of the Council of State Neurosurgical Societies, www.csnsonline.org