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The Health Workforce: A Position Statement

Grosfeld, Jay L. MD; Polk, Hiram C. Jr MD; Pelligrini, Carlos A. MD; Mulholland, Michael W. MD; Lillemoe, Keith D. MD; Bass, Barbara L. MD; Busuttil, Ronald W. MD; Kron, Irving L. MD; Jones, R Scott MD; Townsend, Courtney M. Jr MD; Sheldon, George F. MD

doi: 10.1097/SLA.0b013e3181571b49
Forum on the State of the Health Workforce
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President Council, American Surgical Association

The Symposium on workforce April 27, 2007, during the 127th annual meeting of the American Surgical Association (ASA) is published in this issue of the Annals of Surgery. The Council of the American Surgical Association believes this adds considerable support to the growing evidence of a substantial health workforce shortage.

The evidence for a shortage is based on many factors, including an increase in US population by 25 million citizens each decade, the aging health workforce with 1/3 of all physicians over 55 years of age, and an aging population expected to double the over 65 age group by 2030.

Rapid advances in technological innovations and biologic breakthrough, such as mapping of the human genome, are examples of research whose impact on the practice of medicine cannot accurately be predicted. Our health system is seeing an unprecedented environment with the scientific and social dimensions of health care changing at the same time. Health care is no longer a cottage industry in that over 1 in 52 Americans work in an academic health center.

The long education track to becoming a physician and surgeon challenges the curriculum and educational planning for future physicians and society This issue was addressed by the Blue Ribbon Committee on Surgical Education initiated during the ASA Presidencies of Drs. Murray Brennan and Haile Debas, and continues in a variety of formats today.

The Panel on Health Workforce at the 127th meeting of the Association, organized by President Jay Grosfeld, focuses on the societal responsibilities of the academic surgical community to anticipate the needs of and for the surgeon of the future. Although we cannot be exactly sure what the training and education will require, we can clearly anticipate that a significant shortage of surgeons is currently evolving. The recent Institute of Medicine study demonstrating the increasing lack of availability of surgical specialists for emergency room consultation is an early sign of shortage, limiting access to needed services. Professional recruiting groups are having increased difficulty finding surgeons for attractive practice opportunities. The ongoing threat of terrorism in an unsafe world further complicates the picture, especially for emergency care.

The response to the evolving likelihood of a shortage of physicians has been slow. Most studies in the 1970s and 1980s predicted an excess of physicians for target times that have now passed with shortages, not excesses, occurring. In 2005 the Association of American Medical Colleges acknowledged a physician shortage and recommended a 30% increase in output of physicians by increasing class size, building new medical schools, and expanding regional campuses. That response removed the voluntary freeze on medical school size and production that had characterized the previous 25 years. Many states and schools are now planning to implement these changes.

The problem, however, cannot be solved by increasing the number of US medical schools and class size alone. Currently, there are 30% more residency positions than graduates of the 125 US medical schools and more than 25% of residents are international medical graduates, US citizens from Caribbean schools, or Doctors of Osteopathy. Moreover, only 64% of physicians currently practicing in the United States are graduates of US medical schools.

The Balanced Budget Act of 1997 fixed the number of Medicare-funded residency positions. It is almost certain, therefore, that the increased number of US students graduating from new and expanded medical schools will not by itself increase the physician workforce pool. What will likely occur is the US medical graduates will displace the international medical graduates from the residency positions currently in excess of the US medical graduation numbers with no net gain in physicians. With an increase in US medical graduates beginning to occur, there is an urgent need to either remove the artificial and outdated cap on Medicare-funded resident positions or find some other funding source.

The need for an increase in surgeons is becoming acute. The number of general surgeons—the largest surgical specialty completing training each year—is approximately 1000. In the decade of 1980–1990, 9445 surgeons were certified by the American Board of Surgery, which is approximately 1000 each year. This demonstrates the number of surgeons has remained virtually unchanged for approximately 30 years. Meanwhile, the population has increased by 25 million each decade. The surgeon-to-population ratio of 6.93/100,000 was reported in the American Surgical Association and American College of Surgeons Study of the Surgical Services in the United States (SOSSUS) in 1974. The1994 Journal of the American Medical Association manuscript by Jonasson, Kwaka, and Sheldon, revealed a slight increase to 7.1/100,000. With the number of general surgery trainees completing residency unchanged at 1000 per year and the population growing faster than physician output, the ratio is now approximately 5/100,000. Previous studies have clearly underestimated the need for physicians and population growth (now more than 300 million and anticipated to be 400 million by 2050). Moreover, with progressive specialization a narrowing of scope of practice occurs for almost 80% of general surgery residency graduates now focusing on a specific area of interest before they enter practice. Additionally, current trends now show fewer general surgery residents pursuing further training in the complex specialties of cardiothoracic surgery and vascular surgery—specialties that previously were highly competitive for graduates of general surgical programs. These specialties (in addition to orthopedic surgery) are among the ones most in demand by an aging population, strongly suggesting that we are evolving rapidly into a situation of shortage and lack of access to care.

The Council of the American Surgical Association believes that a shortage of doctors and other health care workers exists. The United States needs to develop self-sufficiency in educating health professionals and lessen its dependency on immigration of health workers from less-advantaged countries.

A shortage of surgeons exists and is becoming a limitation to optimal health care of the public. The shortage involves all surgical fields and will worsen if not addressed. Although many imponderables exist, the academic surgical community and surgery at large should exert efforts to find solutions to these issues. The issue of immediacy is the removal of the ill-conceived arbitrary cap limiting the number of Medicare-funded graduate medical education residency positions established by the Balanced Budget Act of 1997 and/or develop some alternative funding mechanism for the education of residents.

© 2007 Lippincott Williams & Wilkins, Inc.