Real-world persistence of multiple sclerosis disease-modifying therapies.

BACKGROUND AND PURPOSE: Treatment persistence is the continuation of therapy over time. It reflects a combination of treatment efficacy and tolerability. We aimed to describe real-world rates of persistence on disease-modifying therapies (DMTs) for people with multiple sclerosis (pwMS) and reasons for DMT discontinuation. METHODS: Treatment data on 4366 consecutive people with relapse-onset multiple sclerosis (MS) were pooled from 13 UK specialist centres during 2021. Inclusion criteria were exposure to at least one MS DMT and a complete history of DMT prescribing. PwMS in blinded clinical trials were excluded. Data collected included sex, age at MS onset, age at DMT initiation, DMT treatment dates, and reasons for stopping or switching DMT. For pwMS who had received immune reconstituting therapies (cladribine/alemtuzumab), discontinuation date was defined as starting an alternative DMT. Kaplan-Meier survival analyses were used to express DMT persistence. RESULTS: In 6997 treatment events (1.6 per person with MS), median time spent on any single maintenance DMT was 4.3 years (95% confidence interval = 4.1-4.5 years). The commonest overall reasons for DMT discontinuation were adverse events (35.0%) and lack of efficacy (30.3%). After 10 years, 20% of people treated with alemtuzumab had received another subsequent DMT, compared to 82% of people treated with interferon or glatiramer acetate. CONCLUSIONS: Immune reconstituting DMTs may have the highest potential to offer a single treatment for relapsing MS. Comparative data on DMT persistence and reasons for discontinuation are valuable to inform treatment decisions and in personalizing treatment in MS.

An Updated Physician Workforce Model Predicts a Shortage of Vascular Surgeons for the Next 20 Years.

BACKGROUND: Concern regarding the adequacy of the vascular surgery workforce persists. We aimed to predict future vascular surgery workforce size and capacity using contemporary data on the US population and number, productivity, and practice patterns of vascular surgeons. METHODS: The workforce size needed to maintain current levels of access was estimated to be 1.4 vascular surgeons/100,000 population. Updated population estimates were obtained from the US Census Bureau. We calculated future vascular surgery workforce needs based on the estimated population for every 10 years from 2020 to 2050. American Medical Association Physician Masterfile data from 1997 to 2017 were used to establish the existing vascular surgery workforce size and predict future workforce size, accounting for annual rates of new certificates (increased to an average of 133/year since 2013), retirement (17%/year), and the effects of burnout, reduced work hours, transitions to nonclinical jobs, or early retirement. Based on Medical Group Management Association data that estimate median vascular surgeon productivity to be 8,481 work relative value units (wRVUs)/year, excess/deficits in wRVU capacity were calculated based on the number of anticipated practicing vascular surgeons. RESULTS: Our model predicts declining shortages of vascular surgeons through 2040, with workforce size meeting demand by 2050. In 2030, each surgeon would need to increase yearly wRVU production by 22%, and in 2040 by 8%, to accommodate the workload volume. CONCLUSIONS: Our model predicts a shortage of vascular surgeons in the coming decades, with workforce size meeting demand by 2050. Congruence between workforce and demand for services in 2050 may be related to increases in the number of trainees from integrated residencies combined with decreases in population estimates. Until then, vascular surgeons will be required to work harder to accommodate the workload. Burnout, changing practice patterns, geographic maldistribution, and expansion of health care coverage and utilization may adversely affect the ability of the future workforce to accommodate population needs.

The Impact of Burnout on the Obstetrics and Gynecology Workforce.

Although there has been discussion of a shortage of surgical specialties including OB/GYN, consensus is difficult because of the multiple variables involved in estimating both supply and demand. In addition, burnout has become more recognized as a variable that has not been taken into account in estimating a shortage of OB/GYNs. We estimate OB/GYN physician shortages of 17%, 24%, and 31% by 2030, 2040, and 2050, respectively. Here, we examine the impact of burnout on the OB/GYN workforce. Specifically, we address the associations of burnout, reduction in clinical productivity as well as early retirement. We also discuss the implications of the substantial increase of female OB/GYNs to ∼66% of workforce over the next 10 years and how this may impact the impending OB/GYN shortage. Finally, we briefly consider possible solutions to workforce issues causing burnout.

The impending shortage and cost of training the future plastic surgical workforce.

An expanding US population with increasing demand for aesthetic surgery, growing competition from other specialties, a constant rate of retiring plastic surgeons, and a static number of residents places increasing demands on the plastic surgical workforce in the coming years. Without certain changes, the plastic surgical workforce will be unable to meet their demand, and other specialties will increasingly encroach on aesthetic and reconstructive procedures. Given Census Bureau predictions for the US population, the numbers of residents allotted by the Balanced Budget Act of 1997, The American Board of Plastic Surgery data on the current plastic surgical workforce, and using a population-based analysis to predict future shortages in plastic surgery residents, the workforce shortage can be estimated as 800 residents in 2020 and up to 3223 residents in 2050. Based on previously reported figures, the additional cost in training these residents by 2050 is more than $1.5 billion.

How We Solved the Shortage of Cardiothoracic Surgeons: Train More or Work Longer.

BACKGROUND: In the early 2000s, a significant shortage of cardiothoracic surgeons was predicted. We sought to evaluate our specialty's progress and to update the predicted needs of cardiothoracic surgeons in the coming decades. METHODS: To assess the supply of cardiothoracic surgeons, the evolution of cardiothoracic surgery training was reviewed. The cardiothoracic surgery workforce and future supply and demand were obtained from the National Center for Health Workforce Analysis. Based on these data, predictions from the early 2000s were compared with the current status, and future supply of cardiothoracic surgeons was modeled. RESULTS: The number of cardiothoracic surgery trainees increased from 230 in 2008-2009 to 519 in 2022-2023. In 2022-2023, 174 trainees underwent the American Board of Thoracic Surgery Certification Exam, with 129 certificates awarded. From 2005 to 2021, the total number of practicing cardiothoracic surgeons in the United States increased from 4000 to 5200, which contradicts all projections from the early 2000s. The average attrition of 31 cardiothoracic surgeons per year was significantly less than predictive models from the early 2000s. Predictive models project a need of 7000 cardiothoracic surgeons by 2050, which can be met if we continue to fill our available training spots with 173 graduates per year. CONCLUSIONS: The predicted shortage of cardiothoracic surgeons by midcentury has been overcome by training more cardiothoracic surgeons as well as by a reduction in cardiothoracic surgeon attrition. Future increasing demand can be met by filling our available training positions. Continual assessment of cardiothoracic surgeon supply and demand will help achieve the optimal number of cardiothoracic surgery training positions.

Assessing Neurofilaments as Biomarkers of Neuroprotection in Progressive Multiple Sclerosis: From the MS-STAT Randomized Controlled Trial.

BACKGROUND AND OBJECTIVES: Improved biomarkers of neuroprotective treatment are needed in progressive multiple sclerosis (PMS) to facilitate more efficient phase 2 trial design. The MS-STAT randomized controlled trial supported the neuroprotective potential of high-dose simvastatin in secondary progressive MS (SPMS). Here, we analyze serum from the MS-STAT trial to assess the extent to which neurofilament light (NfL) and neurofilament heavy (NfH), both promising biomarkers of neuroaxonal injury, may act as biomarkers of simvastatin treatment in SPMS. METHODS: The MS-STAT trial randomized patients to 80 mg simvastatin or placebo. Serum was analyzed for NfL and NfH using Simoa technology. We used linear mixed models to investigate the treatment effects of simvastatin compared with placebo on NfL and NfH. Additional models examined the relationships between neurofilaments and MRI and clinical measures of disease severity. RESULTS: A total of 140 patients with SPMS were included. There was no evidence for a simvastatin treatment effect on NfL or NfH: compared with placebo, NfL was 1.2% lower (95% CI 10.6% lower to 9.2% higher; p = 0.820) and NfH was 0.4% lower (95% CI 18.4% lower to 21.6% higher; p = 0.969) in the simvastatin treatment group. Secondary analyses suggested that higher NfL was associated with greater subsequent whole brain atrophy, higher T2 lesion volume, and more new/enlarging T2 lesions in the previous 12 months, as well as greater physical disability. There were no significant associations between NfH and MRI or clinical variables. DISCUSSION: We found no evidence of a simvastatin treatment effect on serum neurofilaments. While confirmation of the neuroprotective benefits of simvastatin is awaited from the ongoing phase 3 study (NCT03387670), our results suggest that treatments capable of slowing the rate of whole brain atrophy in SPMS, such as simvastatin, may act via mechanisms largely independent of neuroaxonal injury, as quantified by NfL. This has important implications for the design of future phase 2 clinical trials in PMS. TRIAL REGISTRATION INFORMATION: MS-STAT: NCT00647348. CLASSIFICATION OF EVIDENCE: This study provides class I evidence that simvastatin treatment does not have a large impact on either serum NfL or NfH, as quantified in this study, in SPMS.

A contemporary reassessment of the US surgical workforce through 2050 predicts continued shortages and increased productivity demands.

BACKGROUND: We aimed to predict practicing surgeon workforce size across ten specialties to provide an up-to-date, national perspective on future surgical workforce shortages or surpluses. METHODS: Twenty-one years of AMA Masterfile data (1997-2017) were used to predict surgeons practicing from 2030 to 2050. Published ratios of surgeons/100,000 population were used to estimate the number of surgeons needed. MGMA median wRVU/surgeon by specialty (2017) was used to determine wRVU demand and capacity based on projected and needed number of surgeons. RESULTS: By 2030, surgeon shortages across nine specialties: Cardiothoracic, Otolaryngology, General Surgery, Obstetrics-Gynecology, Ophthalmology, Orthopedics, Plastics, Urology, and Vascular, are estimated to increase clinical workload by 10-50% additional wRVU. By 2050, shortages in eight specialties are estimated to increase clinical workload by 7-61% additional wRVU. CONCLUSIONS: If historical trends continue, a majority of surgical specialties are estimated to experience workforce deficits, increasing clinical demands substantially.

The continued urbanization of American surgery: A threat to rural hospitals.

BACKGROUND: In 2011, we predicted that surgeon shortages for rural hospitals would contribute to closures of rural hospitals. Here, we update population trends, the distribution of rural and urban hospitals, and surgeon supply to estimate surgeon demand for rural and urban hospital settings by 2040. METHODS: Surgeon supply was based on new certifications for general surgery, orthopedic surgery, and obstetrics and gynecology adjusted for retirement. Surgeon demand from 2020 to 2040 was projected based on the US Census and published practice ratios: general surgery 10.7/100,000, orthopedic surgery 7.9/100,000, and obstetrics and gynecology 13.0/100,000. RESULTS: The US population grew from 309 million in 2011 to 327 million in 2017 with rural populations unchanged at 56 million. By 2040, the US population will be 374 million (urban 85% and rural 15%) creating shortages of general surgery (-31.5%), orthopedic surgery (-34.3%), and obstetrics and gynecology (-25.3). Future hiring needs for urban hospitals will be 5 times greater than rural hospitals. Urban hospitals will likely recruit most newly certified surgeons. CONCLUSION: Increases in surgery trainees will not meet the demand. The continued urbanization of American surgery may push rural hospitals into a vicious financial cycle leading to additional closures of rural hospitals and worsening issues of access. An alternative training paradigm for the rural surgeon is recommended to meet the unique demands of rural hospitals.

The impending shortage and the estimated cost of training the future surgical workforce.

OBJECTIVES: To estimate the workforce needed by 2030 in 7 surgical specialties to serve a population of 364 million people and to quantify the cost associated with training additional surgeons. MATERIALS AND METHODS: A review of the certificates granted in otolaryngology, orthopedic surgery, thoracic surgery, obstetrics and gynecology, neurosurgery, urology, and general surgery was conducted. Using a population-based algorithm, we extended the results of Richard Cooper's pioneering work to these fields of surgery. The assumptions were unchanged physician to population ratio, 30 years in practice from completion of residency to retirement, and no revision of the Balanced Budget Act of 1997, and therefore no additional residency positions offered. Per resident expenses were estimated annually at $80,000, including salaries, benefits, and other direct medical education costs. RESULTS/CONCLUSIONS: (1) There will not be enough surgeons in the 7 surgical specialties studied. (2) We will have to train more than 100,000 surgeons by 2030 to maintain access for our citizens at an annual cost of almost $2 Billion and total cost of about $37 billion. (3) To train the extra needed surgical workforce will cost an additional $10 Billion. (4) To do this, the Balanced Budget Act of 1997 must be revised to permit more residents to be trained in the United States or other alternatives explored.

Predicted shortage of vascular surgeons in the United States: population and workload analysis.

OBJECTIVE: To estimate the size of the future workforce in vascular surgery (VS) and the added cost associated with addressing the projected shortage in the United States. METHODS: The net supply (number of Vascular Surgeons [VSN] currently practicing, new graduates entering the workforce, and those retiring) for each decade was calculated. The projected population for each decade was determined by U.S. Census Bureau figures. Some assumptions of this model included: (1) In 2008, the population was 300,000,000; (2) There were 2783 board certified VSN in 2008; (3) VSN will practice 30 years from board certification to retirement; (4) There will be 105 board certifications and 93 retirements per year; (5) Vascular operations will remain at 284 per 100,000 population; (6) Salaries of trainees will be $50,000 with benefits of 30% and $15,000 of additional direct medical education costs. RESULTS: Population and workload analysis suggests that there will be a shortage of 330 surgeons (9.8%) and 399 surgeons (11.6%) by 2030, respectively. The cost of training enough VSN (in a six-year program) by 2030 will be between $1,166,400,000 and $1,199,520,000. CONCLUSIONS: A conservative estimate by both population and workload analysis, disregarding aging of the population, lifestyle choices of future VSN, and increasing demand for services, indicates a shortage of VSN in the future. Unless the Balanced Budget Act of 1997 is revised by Congress, the cost to train the additional VS workforce remains a significant barrier.

Fill in the blanks. 8 steps to make your practice competitive in the physician hiring game.

A swelling U.S. population and a shrinking supply of physicians to care for it means trouble for medical groups seeking to recruit doctors. But forewarned is forearmed: Use these tips to put your practice in the best possible position to attract new hires.

Providing cardiothoracic services in 2035: Signs of trouble ahead.

OBJECTIVE: As the population ages, we will present the reality around being able to meet the health care needs of our population. In particular, we will present that providing cardiothoracic services in 2035 with a shortage of surgeons and an unknown caseload may be an impossibility. METHODS: By using data from the American Board of Thoracic Surgery, we estimate that in 2010, 4000 cardiothoracic surgeons performed more than 530,000 cases. Additionally, cardiothoracic residency programs train and certify on average 90 new surgeons every year. To estimate the number of cases for 2035, we consulted the Census Bureau figures for 2010 and population projections for 2035. We then estimated the expected caseload for cardiothoracic surgeons relative to heart surgery, as well as lung and esophageal surgery. We found that among 2010 cardiothoracic surgeons in the United States, they completed more than 530,000 cases. RESULTS: We project that by 2035 there will be 853,912 cases to perform, representing an increase from 2010 to 2035 of approximately 61% nationally. The cases per surgeon, per year, in 2010 averaged 135 for almost each of the 4000 surgeons. In 2035, the average caseload per surgeon will be 299 cases, representing an increase of 121% for the individual surgeon. CONCLUSIONS: We conclude that by 2035, cardiothoracic surgeons will be responsible for more than 850,000 patients requiring surgery. This represents a 61% increase in the national case load and a potential for a 121% increase for each cardiothoracic surgeon. We believe this is not feasible and a sign of trouble ahead.

Ten-year reassessment of the shortage of general surgeons: Increases in graduation numbers of general surgery residents are insufficient to meet the future demand for general surgeons.

BACKGROUND: In 2008, we projected that a deficit in the general surgical workforce would grow to 19% by 2050. We reexamined population-based general surgical workforce projections to determine the impact of recent changes in population estimates and trends in certification and General Surgery Residency. METHODS: We reviewed the Census Bureau data and the potential pool of general surgeons defined by American Board of Surgery certificates, residents completing Accreditation Council for Graduate Medical Education-approved General Surgery Residency and combined American Board of Surgery and osteopathic certificates averaged from 2007-2016. The model included removal of 150 surgeons/year who subspecialize and 729 retirements/year. RESULTS: Updated census projections estimate a 2050 U.S. population of 439 million, a 19 million increase over prior census projections. From 2007-2016, the American Board of Surgery granted 10,173 certificates, averaging 1,017/year; General Surgery Residency graduations were 10,088, averaging 1,088/year; combined American Board of Surgery and osteopathic (American Osteopathic Association) certificates were 10,084, averaging 1,084/year. General surgical workforce shortage in 2050 is projected to be 7,047 (21%) based on American Board of Surgery certificates; 4,917(15%) based on General Surgery Residency completions; 5,037 (15%) based on combined American Board of Surgery and American Osteopathic Association certificates; and 57 (0%) based on hypothetical expansion of general surgeons training by 75 positions by 2021. CONCLUSIONS: Without increasing future general surgeons training numbers, the projected future general surgical workforce shortage will continue to grow.

The impact of the aging population and incidence of cancer on future projections of general surgical workforce needs.

BACKGROUND: Assessments of the future general surgery workforce continue to project substantial shortages of general surgeons. The general surgery workforce is targeted currently to maintain a surgeon/population ratio of 6.5-7.5/100,000. METHODS: We examined population and age-associated incidence of cancer to estimate the number of general surgeons needed for initial surgical treatment of the patient with cancer in the year 2035 compared with 2010. We hypothesized that the number of general surgeons needed to provide future cancer care will exceed the projections of available general surgeons based on current training numbers, as well as on population-based ratios alone. RESULTS: The total number of new patients with cancers treated by general surgeons is projected to increase 56% (511,450 in 2010 to 798,070 in 2035). To maintain the same patient census per surgeon, it is estimated that 34,698 general surgeons will be needed. This is an increase of 9,198 over that based on current training numbers and 5,300-7,400 greater than the need projected by population growth alone. CONCLUSION: The analysis supports the hypothesis that an increasing incidence of cancer in the future will exceed the potential capacity of the general surgeon workforce. Regionalization of cancer care may be one solution to projected access issues.

Big conductance calcium-activated potassium channel openers control spasticity without sedation.

BACKGROUND AND PURPOSE: Our initial aim was to generate cannabinoid agents that control spasticity, occurring as a consequence of multiple sclerosis (MS), whilst avoiding the sedative side effects associated with cannabis. VSN16R was synthesized as an anandamide (endocannabinoid) analogue in an anti-metabolite approach to identify drugs that target spasticity. EXPERIMENTAL APPROACH: Following the initial chemistry, a variety of biochemical, pharmacological and electrophysiological approaches, using isolated cells, tissue-based assays and in vivo animal models, were used to demonstrate the activity, efficacy, pharmacokinetics and mechanism of action of VSN16R. Toxicological and safety studies were performed in animals and humans. KEY RESULTS: VSN16R had nanomolar activity in tissue-based, functional assays and dose-dependently inhibited spasticity in a mouse experimental encephalomyelitis model of MS. This effect occurred with over 1000-fold therapeutic window, without affecting normal muscle tone. Efficacy was achieved at plasma levels that are feasible and safe in humans. VSN16R did not bind to known CB1 /CB2 /GPPR55 cannabinoid-related receptors in receptor-based assays but acted on a vascular cannabinoid target. This was identified as the major neuronal form of the big conductance, calcium-activated potassium (BKCa ) channel. Drug-induced opening of neuronal BKCa channels induced membrane hyperpolarization, limiting excessive neural-excitability and controlling spasticity. CONCLUSIONS AND IMPLICATIONS: We identified the neuronal form of the BKCa channel as the target for VSN16R and demonstrated that its activation alleviates neuronal excitability and spasticity in an experimental model of MS, revealing a novel mechanism to control spasticity. VSN16R is a potential, safe and selective ligand for controlling neural hyper-excitability in spasticity.

American Board of Thoracic Surgery examination: fewer graduates, more failures.

BACKGROUND: The American Board of Thoracic Surgery (ABTS) has noted a yearly decrease in the number of examination certificates being awarded, with only 93 certificates awarded in 2011. In 2003, the Accreditation Council for Graduate Medical Education required all programs to implement the 80-hour residency workweek. We hypothesized that this requirement has resulted in trainees being less capable of becoming successfully certified. METHODS: We examined the ABTS board scores, both written and oral, from 2000 to 2011. We divided the interval into 2 periods: 2000 to 2005, representing the 6-year, pre-80-hour workweek, and 2006 to 2011, the 6-year period post-80-hour workweek implementation. We analyzed whether a significant difference would be present in the pass rate before and after the 80-hour workweek for both the written and the oral boards. RESULTS: An inflection point of examination failures was found that started in 2006, correlating with the first examination year the 80-hour workweek would have affected. The written examination failure rates increased from 2006 to 2009 but have since decreased. The actual percentage failing the written component was less than the percentage failing the oral examinations in both periods. The oral examination failure rates have continued to increase at an alarming rate. CONCLUSIONS: An increase has occurred in the failure of the ABTS board examinations that has been significantly greater after implementation of the 80-hour workweek. The failure rate for the written examination was not as significant as that for the oral examination. Because we are now training fewer, and perhaps less successful, cardiothoracic surgeons, it is our duty to develop strategies to improve and promote innovation in the methods of training.

A review of trends in attrition rates for surgical faculty: a case for a sustainable retention strategy to cope with demographic and economic realities.

BACKGROUND: Our aim was to compare trends in retention of academic surgeons by reviewing surgical faculty attrition rates (leaving academic surgery for any reason) of 3 cohorts at 5-year intervals between 1996 and 2011. STUDY DESIGN: The Association of American Medical Colleges' Faculty Administrative Management On-Line User System database was queried for a retention report of all tenure/clinical track full-time MD faculty within our academic medical center on July 1, 1996 (group 1), July 1, 2001 (group 2), and July 1, 2006 (group 3). Retention was tracked for 5 years post snapshot. The individual 5-year cohort attrition rates (observed frequencies) were compared with combined attrition rates for all 3 groups (expected frequencies). RESULTS: Overall, attrition trends for groups 2 (lower) and 3 (higher) were significantly different than the trends for all groups combined. Minorities and professors at the full or associate rank in group 3 contributed to this difference. Faculty in group 3 leaving our academic medical center were significantly more likely to transition into nonacademic practice compared with the other 2 groups. CONCLUSIONS: Greater attrition in the last 5-year cohort, despite the increase in faculty positions, is worrisome. A continuous retention life cycle is critical if academic medical centers hope to compete for talent. Retention planning should include on-boarding programs for enculturation, monitoring of professional satisfaction, formalized mentoring of younger surgeons, retaining academic couples and a part-time workforce, leadership and talent management, exit interviews, and competitive financial packages.

A comparison of future recruitment needs in urban and rural hospitals: the rural imperative.

BACKGROUND: The potential impact of shortages of the surgical workforce on both urban and rural hospitals is undefined. There is a predicted shortage of 30,000 surgeons by 2030 and the need to train and hire more than 100,000 surgeons. The aim of this study is to estimate the average recruitment needs in our nation's hospitals for 7 surgical specialties to ensure adequate access to surgical care as the U.S. population grows to 364 million by 2030. METHODS: We used the census figure of 309 million in 2010 for U.S. population. Currently there are estimated to be 3,012 urban hospitals and 1,998 rural hospitals in the U.S. (American Hospital Association's Trend Watch report, 2009). At 253 million people (82 % of the population of 309 million in 2010) receive healthcare in urban hospitals; 56 million people receive healthcare in rural hospitals (18%). We assumed a work force model based on our previous publications, equal population growth in all geographic areas, recruitment by rural hospitals limited to Ob-Gyn, General Surgery, and Orthopedics, and that the percentage of the population receiving care at urban and rural hospitals will stay constant. RESULTS: Rural hospitals will have to recruit an average of 3.4 OBGYN's, and an average of 1.6 Orthos, and 2.0 GS for a total of 7 full-time equivalents in the period from 2011 to 2030. Urban hospitals which have to recruit surgical specialists will have to recruit ten Ob-Gyns, about 5 Orthos, 6 GS's, 5 ear, nose, and throat surgeons (ENT's), an average of 2.5 urologists, a neurosurgeon, and a thoracic surgeon to meet the recruiting goals for the surgical services for their hospitals. CONCLUSION: Rural hospitals will be in competition with urban hospitals for hiring from a limited pool of surgeons. As urban hospitals have a socioeconomic advantage in hiring, surgical care in rural areas may be at risk. It is imperative that each rural hospital analyze local future healthcare needs and devise strategies that will enhance hiring and retention to optimize access to surgical care.

The impact of employment of part-time surgeons on the expected surgeon shortage.

BACKGROUND: The trend for choosing to work part-time (PT) in medicine is increasing. We hypothesize that strategies to employ PT surgeons and prolong the duration of practice might reduce the surgeon shortage considerably. We calculated the effects of PT employment on the surgical workforce. STUDY DESIGN: We estimated the surgical workforce in obstetrics and gynecology, general surgery, thoracic surgery, ENT, orthopaedic surgery, urology, and neurosurgery to be 99,000 in 2005. We assumed 3,635 Board Certificates would be granted each year and surgeons will practice for 30 years, with 3,300 retiring each year. Scenarios were constructed with one-quarter (scenario 1), one-half (scenario 2), or three-quarters (scenario 3) of potential retirees working half-time for an additional 10 years. RESULTS: By 2030, with other variables unchanged, the United States would have 4,125; 8,250; and 12,375 additional PT surgeons under scenario 1 (4% increase), scenario 2 (8% increase), and scenario 3 (12% increase), respectively, with a corresponding reduction in the shortage of surgeons. CONCLUSIONS: An opportunity exists to reduce the shortage of surgeons by offering models for PT employment particularly to mid-career women and retiring surgeons. Employment models should address flexible work schedules, malpractice premium adjustments, academic promotion, maintenance of certification and licensure, and employment benefits.

A formidable task: Population analysis predicts a deficit of 2000 cardiothoracic surgeons by 2030.

OBJECTIVE: To estimate the cardiovascular workforce needed by 2030 to meet the needs of our population and to quantify its costs. Our field is changing. The volume of surgery and the nature of the surgery are changing. The nation's population grew from 227,000,000 to 282,000,000 between 1980 and 2000, and by 2030 the population is estimated to be 364,000,000. At the same time, the applications for fellowship in our specialty are decreasing at an alarming rate. The American Board of Thoracic Surgery has certified 4500 cardiothoracic surgeons since 1975, but only 1300 in the last 10 years. The US Department of Health and Human Services predicts only 3620 full-time cardiothoracic surgeons in 2020. Will we have enough cardiovascular and thoracic surgeons? METHODS: Retrospective examination of the pertinent literature and with a modified Richard Cooper's economic trend analysis, a population algorithm with a ratio of physicians to population of 1.42 per 100,000. Each thoracic surgeon is predicted to practice 30 years from Board certification to retirement. The Balanced Budget Act will not be revised; therefore, we will certify 100 graduates from our programs per year. The assumed salaries will be 50,000 dollars with benefits of 30% and 15,000 dollars of additional Direct Medical Education costs. RESULTS: The population in 2030 will be 364,000,000 with 5169 cardiothoracic surgeons needed at that time. Unfortunately, there will be approximately only 3200 cardiothoracic surgeons in practice with a shortage of approximately 2000. To maintain our current status per 100,000 population from 2011 to 2030, we will have to train 4000 residents. The total person years would be approximately 28,000. The cost for this is more than 2,000,000,000 dollars. The annual cost for this training prorated over 20 years would be more than 110,000,000 dollars. CONCLUSION: We must train approximately 4000 surgeons, an extra 100 per year, in our specialty to meet the needs of the population by 2030. That will cost approximately 2,250,000,000 dollars. To do this, the Balanced Budget Act of 1997 must be revised to permit more residents to be trained in the United States.