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.

"Diversity in Surgery-How Do We Change the Narrative: Pipeline to Professor?"

The goal of our paper is to provide our perspectives on why there is a need to change the narrative in academic surgery to improve health equity by increasing the pipeline of pre-med students to professors. It is well documented that Health disparities hurt many different people, but they especially hurt Black, Indigenous, and People of color. Black men and women have a decreased life expectancy. Differences in care are associated with greater mortality among minority patients and that care provided to black patients by black physicians can lead to improved compliance with medications and care plans. The lack of black diversity in the medical profession proportional to the societal ethnic distribution is alarming. We have opportunities for improvement for recruitment, retention and promotion within the field of surgery.

Trends in Number of Women Speakers at the American Head and Neck Society Meetings, 2007-2019.

Importance: The number of female speakers at American Head and Neck Society (AHNS) conferences should ideally be consistent with the number of women entering head and neck surgery fellowships to ensure gender equity in the field. Yet the presence of women speakers at the annual AHNS meetings, which is specific to the field of head and neck cancer, endocrine and microvascular reconstructive surgery, has yet to be studied. Objective: To determine whether the proportion of female speakers at the AHNS has increased in a manner consistent with the numbers of women entering fellowships since 2007. Design, Setting, and Participants: This qualitative study assessed 13 final meeting programs from AHNS national/international conferences from 2007 to 2019. The number of male and female participants in different roles throughout the meeting were retrospectively tracked. Participants were male and female speakers at AHNS national/international conferences who took part in the roles of scientific session presenter, scientific session moderator, expert panelist, miscellaneous moderator, and named lecturers/keynote speaker. Gender of the speaker was determined by searching names on the internet and using available published pronouns. Main Outcomes and Measures: Number of speaking opportunities for men and women in different roles from 2007 to 2019 as well as number of men and women entering AHNS fellowships since 2007 and new active AHNS members since 2012. Results: In this qualitative study, from 2007 to 2019, 4059 speakers were identified. Of these speakers, 902 (22%) were women and 3157 (78%) were men. Overall, there was a strong correlation between increasing years and number of women speakers from 2007 to 2019 (ρ = 0.75; 95% CI, 0.72-0.78). There were 2096 invited speaking roles that excluded research presentations, of which 400 were offered to female participants (19.1%) across the study period. There were 131 different women that made up all 400 of the opportunities that were offered to women in the years surveyed. There was a strong correlation in the proportion of women as presenters for oral abstracts, expert panelists, and miscellaneous moderators between the years but no correlation in scientific session moderators and named lecturers/keynote speakers. Of the 45 named lecturers/keynote speakers in the programs tracked, only 2 were women. Conclusions and Relevance: In this study, from 2007 to 2019, the presence of women at ANHS has increased overall, reflecting the changing demographic characteristics of those entering in head and neck oncology and microvascular surgery fellowships. However, a strong disparity continues to exist for preeminent speaking opportunities.

Gender Disparity in Surgical Society Leadership and Annual Meeting Programs.

INTRODUCTION: Prior work suggests women surgical role models attract more female medical students into surgical training. We investigate recent trends of women in surgical society leadership and national conference moderator and plenary speaker roles. METHODS: Gender distribution was surveyed at 15 major surgical societies and 14 conferences from 2014 to 2018 using publicly reported data. Roles were categorized as leadership (executive council), moderator, or plenary speaker. Data were cross-checked from online profiles and by contacting societies. Logistic regression with Huber-White clustering by society was utilized to evaluate proportions of women in each role over time and determine associations between the proportion of women in executive leadership, and scientific session moderators and plenary speakers. RESULTS: The proportion of leadership positions held by women increased slightly from 2014 to 2018 (20.6%-26.6%, P = 0.23), as did the proportion of moderators (26.2%-30.6%, P = 0.027) and plenary speakers (26.2%-30.9%, P = 0.058). The proportion of women in each role varied significantly across societies (all P < 0.001): leaders (range 0.0%-52.0%), moderators (12.5%-58.8%), and plenary speakers (11.3%-60.0%). Three patterns of change were observed: eight societies (53.3%) demonstrated increases in representation of women over time, four societies (26.6%) showed stable moderate-to-good gender balance, and three societies (20.0%) had consistent underrepresentation of women. CONCLUSION: There is significant variability in the representation of women at the leadership level of national surgical societies and participating at national surgical conferences as moderators and plenary speakers. Over the past 5 years some societies have achieved advances in gender equity, but many societies still have substantial room for improvement.

Surgical subspecialists in West Africa: Workforce size, training opportunities, and contributing factors.

BACKGROUND: The global burden of disease treatable by surgical subspecialists remains an outstanding area of need, and yet little is known about the subspecialist workforce worldwide, especially in sub-Saharan Africa. This study aims to quantify the subspecialty surgical workforce and number of subspecialty training programs in West Africa and to identify socioeconomic factors predicting the number of subspecialists in West African countries. METHODS: West African subspecialists and accredited fellowship training programs in 17 West African countries were quantified using membership data from the West African College of Surgeons and compared with publicly available workforce data from the United States, the United Kingdom, and East, Central, and Southern Africa. Spearman's coefficients were calculated to identify socioeconomic predictors of subspecialist surgical workforce. RESULTS: Of 2,181 surgeons, 712 (32.6%) were surgical subspecialists. Three (18%) of 17 West African countries had greater than 11 subspecialists. There were 174 subspecialty training programs in the region, though 13 countries (76%) had no programs. The number of subspecialists correlated most strongly with the number of subspecialty training programs (rS = 0.68, P = .003) but also correlated significantly with gross population and number of medical schools (rS = 0.50-0.52, P ≤ .05). CONCLUSION: Subspecialist surgeons represent one third of surgeons in West Africa, though most countries have fewer than 12 providers. The number of subspecialists is significantly correlated with the number of subspecialty training programs, and yet many West African countries lack accredited programs. These results suggest that investing in training programs is the most valuable potential strategy to address the shortage of surgical subspecialists in West Africa.

Asian American Pacific Islander Representation in Outcomes Research: NSQIP Scoping Review.

BACKGROUND: If Asian American and Pacific Islanders (AAPIs) are not recognized within patients in health services research, we miss an opportunity to ensure health equity in patient outcomes. However, it is unknown what the rates are of AAPIs inclusion in surgical outcomes research. STUDY DESIGN: Through a scoping review, we used Covidence to search MEDLINE, EMBASE, PsycINFO, Web of Science, Scopus, and CINAHL for studies published in 2008-2018 using NSQIP data. NSQIP was chosen because of its national scope, widespread use in research, and coding inclusive of AAPI patients. We examined the proportion of studies representing AAPI patients in the demographic characteristics and Methods, Results, or Discussion section. We then performed multivariable logistic regression to examine associations between study characteristics and AAPI inclusion. RESULTS: In 1,264 studies included for review, 62% included race. Overall, only 22% (n = 278) of studies included AAPI patients. Of studies that included race, 35% represented AAPI patients in some component of the study. We found no association between sample size or publication year and inclusion. Studies were significantly more likely to represent AAPI patients when there was a higher AAPI population in the region of the first author's institution (lowest vs highest tercile; p < 0.001). Studies with a focus on disparities were more likely to include AAPI patients (p = 0.001). CONCLUSIONS: Our study is the first to examine AAPI representation in surgical outcomes research. We found < 75% of studies examine race, despite availability within NSQIP. Little more than one-third of studies including race reported on AAPI patients as a separate group. To provide the best care, we must include AAPI patients in our research.

Virtual Interviews May Fall Short for Pediatric Surgery Fellowships: Lessons Learned From COVID-19/SARS-CoV-2.

BACKGROUND: As a result of the coronavirus disease 2019 pandemic, many Pediatric Surgery Fellowship programs were forced to convert their normal in-person interviews into virtual interviews. This study sought to determine the perceived value of virtual interviews for Pediatric Surgery Fellowship. METHODS: An anonymous survey was distributed to the applicants and faculty at a university-affiliated, free-standing children's hospital with a Pediatric Surgery fellowship program that conducted one of three interview days using a virtual format. RESULTS: All applicants who responded to the survey had at least one interview that was converted to a virtual interview. Faculty (75%) and applicants (87.5%) preferred in-person interviews over virtual interviews; most applicants (57%) did not feel they got to know the program as well with the virtual format. Applicants and faculty felt that virtual interviews could potentially be used as a screening tool in the future (7/10 Likert) but did not recommend they be used as a complete replacement for in-person interviews (3.5-5/10 Likert). Applicants were more likely than faculty to report that interview type influenced their final rank list (5 versus 3/10 Likert). CONCLUSIONS: Faculty and applicants preferred in-person interviews and did not recommend that virtual interviews replace in-person interviews. As the coronavirus disease 2019 pandemic continues, more virtual interviews will be necessary, and innovations may be necessary to ensure an optimal interview process. TYPE OF STUDY: Survey. LEVEL OF EVIDENCE: N/A.

Evaluation of a Managed Surgical Consultation Network in Malawi.

BACKGROUND: Access to surgery is a challenge for low-income countries like Malawi due to shortages of specialists, especially in rural areas. District hospitals (DH) cater for the immediate surgical needs of rural patients, sending difficult cases to central hospitals (CH), usually with no prior communication. METHODS: In 2018, a secure surgical managed consultation network (MCN) was established to improve communication between specialist surgeons and anaesthetists at Queen Elizabeth and Zomba Central Hospitals, and surgical providers from nine DHs referring to these facilities. RESULTS: From May to December 2018, DHs requested specialist advice on 249 surgical cases through the MCN, including anonymised images (52% of cases). Ninety six percent of cases received advice, with a median of two specialists answering. For 74% of cases, a first response was received within an hour, and in 68% of the cases, a decision was taken within an hour from posting the case on MCN. In 60% of the cases, the advice was to refer immediately, in 26% not to refer and 11% to possibly refer at a later stage. CONCLUSION: The MCN facilitated quick access to consultations with specialists on how to manage surgical patients in remote rural areas. It also helped to prevent unnecessary referrals, saving costs for patients, their guardians, referring hospitals and the health system as a whole. With time, the network has had spillover benefits, allowing the Ministry of Health closer monitoring of surgical activities in the districts and to respond faster to shortages of essential surgical resources.

Developing Research Potential and Building Partnerships: A Report of the Fundamentals of Surgical Research Course at the College of Surgeons of East, Central, and Southern Africa.

BACKGROUND: Approximately a decade after the inaugural Fundamentals of Surgical Research Course (FSRC) at the West African College of Surgeons meeting (2008), the Association for Academic Surgery expanded the course offering to the annual meeting of the College of Surgeons of East, Central and Southern Africa (COSECSA). After the second annual offering of the course in 2019, participants were surveyed to assess the impact of the course. METHODS: A survey was distributed to the attendees of the 2019 second COSECSA FSRC course, held in December 2019 in Kampala, Uganda. Approximately 80 people attended at least a portion of the full-day course. Forty-nine participants completed the voluntary survey questionnaire distributed to assess each session of the course at course completion. RESULTS: Ten different countries were represented among the attendees. Of the 49 evaluations, 35 respondents were male and six were female. Eight respondents did not identify a gender. Surgical residents comprised 19 of the 49 attendees, and one of the 49 attendees was a medical student. Thirty-five respondents indicated that their views of surgical research had changed after attending the course. CONCLUSIONS: The second annual FSRC at COSECSA confirmed significant interest in building research skills and partnerships in sub-Saharan Africa. A wide variety of learners attended the course, and a majority of the sessions received overwhelmingly positive feedback. Multiple conference attendees expressed interest in serving as faculty for the course moving forward, highlighting a viable path for sustainability as the Association for Academic Surgery develops an international research education platform.

Personalized Graduate Medical Education and the Global Surgeon: Training for Resource-Limited Settings.

PROBLEM: The World Health Organization and the World Bank have identified improvement in access to surgical care as an urgent global health challenge and a cost-effective investment in public health. However, trainees in standard U.S. general surgery programs do not have adequate exposure to the procedures, technical skills, and foundational knowledge essential for providing surgical care in resource-limited settings. APPROACH: The Michael E. DeBakey Department of Surgery at Baylor College of Medicine (BCM) created a 7-year global surgery track within its general surgery residency in 2014. Individualized rotations equip residents with the necessary skills, knowledge, and experience to operate in regions with low surgeon density and develop sustainable surgical infrastructures. BCM provides a formal, integrated global surgery curriculum-including 2 years dedicated to global surgery-with surgical specialty rotations in domestic and international settings. Residents tailor their individual experience to the needs of their future clinical practice, region of interest, and surgical specialty. OUTCOMES: There have been 4 major outcomes of the BCM global surgery track: (1) increased exposure for trainees to a broad range of surgeries critical in resource-limited settings, (2) meaningful international partnerships, (3) contributions to global surgery scholarship, and (4) establishment of sustainable global surgery activities. NEXT STEPS: To better facilitate access to safe, timely, and affordable surgical care worldwide, global surgeons should pursue expertise in topics not currently included in U.S. general surgical curricula, such as setting-specific technical skills, capacity building, and organizational collaboration. Future evaluations of the BCM global surgery track will assess the effect of individualized education on trainees' professional identities, clinical practices, academic pursuits, global surgery leadership preparedness, and comfort with technical skills not encompassed in general surgery programs. Increasing availability of quality global surgery training programs would provide a critical next step toward contributing to the delivery of safe surgical care worldwide.

Is the relative value of surgeon effort equal across surgical specialties?

BACKGROUND: Although relative value units are used to measure physician productivity, research has demonstrated incongruencies between relative value units and actual surgeon work effort. We sought to determine whether this variation extends across surgical specialties. METHODS: A retrospective review of surgical cases was conducted using the 2017 American College of Surgeons National Surgical Quality Improvement Program database. For each case, we identified the primary Current Procedural Terminology, surgical specialty, total relative value units, and 5 alternative measures of work effort. We then examined the correlation between a Current Procedural Terminology's mean total relative value unit and work effort. Finally, we constructed a multivariable linear regression model to evaluate the association between surgical specialty and the expected mean total relative value unit adjusting for work effort and patient characteristics. RESULTS: A total of 876,515 cases met the inclusion criteria. Overall, median operative time correlated well with mean total relative value unit (R = 0.85), though it was lowest for cardiac surgery (R = 0.51) and highest for otolaryngology (R = 0.97). Neurosurgery had the greatest increase in mean total relative value unit per hour of operative time (12.9/h). Mean total relative value unit correlated modestly with length of stay (R = 0.58) and serious adverse events (R = 0.61) and weakly with readmission (R = 0.42) and mortality (R = 0.29). When holding these metrics constant, the multivariable model showed mean total relative value units differed according to surgical specialty alone. Compared with general surgery, neurosurgery and cardiac surgery earned 3.41 to 3.61 additional mean total relative value units (P < .05), while orthopedics, otolaryngology, thoracic, urology, and vascular surgery received fewer mean total relative value units (-1.84 to -4.43, P < .05). CONCLUSION: Surgeon productivity is increasingly measured using relative value units. While mean total relative value units correlate well with operative time, they may not reflect other aspects of work effort. Differences in mean total relative value units by surgical specialty demonstrate potential inequities in the determination of physician productivity.

Patient complexity by surgical specialty does not correlate with work relative value units.

BACKGROUND: Understanding the differences in how patient complexity varies across surgical specialties can inform policy decisions about appropriate resource allocation and reimbursement. This study evaluated variation in patient complexity across surgical specialties and the correlation between complexity and work relative value units. STUDY DESIGN: The 2017 American College of Surgeons National Surgical Quality Improvement Program was queried for cases involving otolaryngology and general, neurologic, vascular, cardiac, thoracic, urologic, orthopedic, and plastic surgery. A total of 10 domains of patient complexity were measured: American Society of Anesthesiologists class ≥4, number of major comorbidities, emergency operation, major complications, concurrent procedures, additional procedures, length of stay, non-home discharge, readmission, and mortality. Specialties were ranked by their complexity domains and the domains summed to create an overall complexity score. Patient complexity then was evaluated for correlation with work relative value units. RESULTS: Overall, 936,496 cases were identified. Cardiac surgery had the greatest total complexity score and was most complex across 4 domains: American Society of Anesthesiologists class ≥4 (78.5%), 30-day mortality (3.4%), major complications (56.9%), and mean length of stay (9.8 days). Vascular surgery had the second greatest complexity score and ranked the greatest on the domains of major comorbidities (2.7 comorbidities) and 30-day readmissions (10.1%). The work relative value units did not correlate with overall complexity score (Spearman's ρ = 0.07; P < .01). Although vascular surgery had the second most complex patients, it ranked fifth greatest in median work relative value units. Similarly, general surgery was the fifth most complex but had the second-least median work relative value units. CONCLUSION: Substantial differences exist between patient complexity across specialties, which do not correlate with work relative value units. Physician effort is determined largely by patient complexity, which is not captured appropriately by the current work relative value units.

Development and Validation of the Data Instrument for Surgical Global Outreach.

Countless efforts have been made by global surgery outreach organizations to provide care to individuals in low- and middle-income countries; however, there is a paucity of data on these interventions. The authors created the Data Instrument for Surgical Global Outreach to collect basic program, cost, and clinical data on surgical outreach efforts using the literature and the experience of our team. The authors performed a two-round modified Delphi technique to build content validity on the instrument and establish consensus. Experts engaged in global health or global surgery as a health care provider, researcher, or policymaker participated in the validation. In addition, the authors calculated Cronbach's alpha to determine the degree of agreement among experts. A total of 22 experts in global health participated in the validation of the data tool. Changes were made to reword, combine, remove, add, clarify, and simplify data points. There was a unanimous decision to accept the revised data collection instrument among the experts after the second Delphi round. Cronbach's alpha was 0.86 for the first round and 0.95 for the second round, indicating a high degree of internal consistency. The global surgery outreach community must define a set of strategies to collect more robust data on surgical outreach efforts to low- and middle-income countries. Such data will permit policymakers to identify shortfalls in programs and researchers to pursue sustainable treatment modalities and processes of care. Quality collaboratives for surgical outreach organizations may serve as a tool to overcome variation, reduce cost, and improve the quality of care for patients.

Does Vertical Integration Improve Access to Surgical Care for Medicaid Beneficiaries?

BACKGROUND: Vertical integration is increasingly common among surgical specialties in the US; however, the effect of vertical integration on access to care for low-income populations remains poorly understood. We explored the characteristics of surgical practices associated with vertical integration and the effect of integration on surgical access for Medicaid populations. STUDY DESIGN: Using a survey of US office-based physician practices, we examined characteristics of 15 surgical subspecialties from 2007 to 2017, including provider sex and specialty, practice payer mix, surgical volume, and county socioeconomic status. Using multivariable logistic regression and time-series analysis, we evaluated practice and provider characteristics associated with vertical integration-our primary outcome-and practice Medicaid acceptance rates-our secondary outcome. RESULTS: Our analysis included 84,795 unique surgical practices (303,903 practice-years). The rate of vertical integration during the 10-year period was 18.0%, with 72.1% of surgical practices never integrating. Practices that integrated were more likely to accept Medicaid patients than practices that did not (81.0% vs 60.8%, p < 0.001). Accepting Medicaid increased the likelihood of vertical integration relative to practices that did not (odds ratio [OR] 4.20, 95% CI 3.93 to 4.49). Practices that integrated were more likely to accept Medicaid in the future (OR 2.61, 95% CI 2.40 to 2.83), even after adjusting for previous Medicaid acceptance and hospital and time fixed effects. CONCLUSIONS: Surgical practices caring for the underinsured are more likely to join larger health care systems, driven by market characteristics. Vertical integration is associated with future increased rates of Medicaid acceptance among practices, allowing for increased access to surgical care for vulnerable, low-income patients. The potential benefit of increased surgical access for low-income beneficiaries from vertical integration must be balanced with the potential for increased prices.

Filling the gap: Objective data to guide pediatric surgery applicants who do not match on the first attempt.

PURPOSE: Acquiring a pediatric surgery fellowship is an arduous process, with less than half of applicants matching each year. For those who fail to match initially but remain steadfast in their goal to become a pediatric surgeon, choosing a valuable postresidency path can be challenging. Furthermore, objective data to evaluate the utility of pediatric surgical subspecialty fellowships (PSSF) are lacking. METHODS: PSSF training programs were identified on the APSA website. Names and contact information of PSSF graduates between 2014 and 2018 were obtained from individual training programs. Each graduated fellow was then contacted to participate in a voluntary 14-question survey. RESULTS: Names of 47 graduated fellows were obtained from programs listed on the APSA website. Among them, 30 (64%) ultimately matriculated into a pediatric surgery fellowship, 11 (37%) of whom matched at the same institution they completed their PSSF. The type of PSSF was not predictive of matriculation into a pediatric surgical fellowship (p = 0.43). Thirty-two (68%) of the 47 study participants completed a satisfaction survey. While all but two graduates found their fellowships to be at least satisfactory, those who matched were more likely to recommend their PSSF compared to those who did not (100% vs 67%, respectively, p = 0.02). Within the cohort of fellows who did not ultimately match into pediatric surgery (n = 17) and completed a survey (n = 9), all who completed a critical care fellowship (4/4) currently use/or plan to use the skills obtained during their PSSF while only two of five (40%) completing other PSSFs use them. CONCLUSION: The matriculation rate from a PSSF into a pediatric surgery fellowship was 64% with no significant difference among subspecialties. Of fellows who did not match, those completing a critical care PSSF were more likely to use their fellowship training than those completing a different PSSF. TYPE OF STUDY: Clinical research paper. LEVEL OF EVIDENCE: III.

Stanford's Biodesign Innovation program: Teaching opportunities for value-driven innovation in surgery.

The Stanford Biodesign Innovation process, which identifies meaningful clinical needs, develops solutions to meet those needs, and plans for subsequent implementation in clinical practice, is an effective training approach for new generations of healthcare innovators. Continued success of this process hinges on its evolution in response to changes in healthcare delivery and an ever-increasing demand for economically viable solutions. In this article, we provide perspective on opportunities for value-driven innovation in surgery and relate these to value-related teaching elements currently integrated in the Stanford Biodesign process.