Vertical Integration Versus Physician Owners: Trends in Practice Structure Among Breast Cancer Surgeons.

OBJECTIVE: The objective of this study was to document changes in physician practice structure among surgeons who treat women with breast cancer. DESIGN: We merged cancer registry records from 5 large states with Medicare Part B claims to identify each surgeon who treated women with breast cancer. We added information from SK&A surveys and extensive internet searches. We analyzed changes in breast surgeons' practice structure over time. MEASURES: We assigned each surgeon-year a practice structure type: (1) small single-specialty practice; (2) single-specialty surgery or multispecialty practice with ownership in an ambulatory surgery center (ASC); (3) physician-owned hospital; (4) multispecialty; (5) employed. RESULTS: In 2003, nearly 74% of breast cancer surgeons belonged to small single-specialty practices. By 2014, this percentage fell to 51%. A shift to being employed (vertical integration) accounted for only a portion of this decline; between 2003 and 2014, the percentage of surgeons who were employed increased from 10% to 20%. The remainder of this decline is due to surgeons opting to acquire ownership in an ASC or a specialty hospital. Between 2003 and 2014, the percentage of surgeons with ownership in an ASC or specialty hospital increased from 4% to 17%. CONCLUSIONS: Dramatic changes in surgeon practice structure occurred between 2003 and 2014 across the 5 states we examined. The most notable was the sharp decline in the prevalence of the small single-specialty practice and large increases in the proportion of surgeons either employed or with ownership in ACSs or hospitals.

Uneven Progress in Gender Equality at Plastic Surgery Conferences: Lessons from a Decade of Meetings.

BACKGROUND: The demographics of plastic surgeons and plastic surgery trainees are changing, reflecting an increase in the diversity of medical school graduates. The authors investigated the gender diversity of speakers at several plastic surgery conferences and evaluated temporal trends over a 10-year period. METHODS: The following societies' conferences and years were included based on the conference agendas available for review: American Society for Aesthetic Plastic Surgery, Plastic Surgery Research Council, American Association of Plastic Surgeons, Northeastern Society of Plastic Surgeons, and American Society for Reconstructive Microsurgery. Differences in the average amount of time spoken were analyzed using an independent one-tailed t test. RESULTS: The number of female speakers and the time allotted to speak increased for all conferences. There was not a consistent difference in the amount of time individual men and women were allotted to speak. Across the five conferences, there was no consistent relationship found between years since board certification and female participation in conference. Gender diversity among speakers at plastic surgery conferences has not kept pace with the increase in female plastic surgery trainees because those who are selected to speak are overwhelmingly men. The hypothesis that a paucity of female speakers reflects the relatively shorter duration of career experience of female plastic surgeons was not supported by these findings. CONCLUSION: It is imperative that conferences increase the participation of women and strive toward more accurately reflecting the burgeoning role that female surgeons have in the field at present and will have in the future.

The evolving role of endovascular therapy in the management of arterial thoracic outlet syndrome.

OBJECTIVE: Over the past two decades, vascular surgeons have successfully incorporated endovascular techniques to the routine care of patients with arterial thoracic outlet syndrome (ATOS). However, no reports have documented the impact of endovascular therapy. This study describes the trends in management of ATOS by vascular surgeons and outcomes after both endovascular and open repair of the subclavian artery. METHODS: We queried a single-institution, prospectively maintained thoracic outlet syndrome database for ATOS cases managed by vascular surgeons. For comparison, cases were divided into two equal time periods, January 1986 to August 2003 (P-1) vs September 2003 to March 2021 (P-2), and by treatment modality, open vs endovascular. Clinical presentation, outcomes, and the involvement of vascular surgeons in endovascular therapy were compared between groups. RESULTS: Of 2200 thoracic outlet syndrome cases, 51 were ATOS (27 P-1, 24 P-2) and underwent 50 transaxillary decompressive operations. Forty-eight cases (92%) presented with ischemic symptoms. Thrombolysis was done in 15 (29%). During P-1, vascular surgeons performed none of the catheter-based interventions. During P-2, vascular surgeons performed 60% of the angiograms, 50% of thrombolysis, and 100% of stent grafting. Subclavian artery pathology included 16 aneurysms (31%), 15 stenoses (29%), and 19 occlusions (37%). Compared with open aneurysmal repair, endovascular stent graft repairs took less time (241 vs 330 minutes; P = .09), incurred lower estimated blood loss (103 vs 150 mL; P = .36), and had a shorter length of stay (2.4 vs 5.0 days; P = .10). Yet the endovascular group had decreased primary (63% vs 77%; P = .481), primary assisted (75% vs 85%; P = .590), and secondary patency rates (88% vs 92%; P = .719), at a mean follow-up time of 3.0 years for the endovascular group and 6.9 years for the open group (P = .324). These differences did not achieve statistical significance. Functionally, 84% of patients were able to resume work or school. A majority of patients (88%) had a good to excellent functional outcome based on their Derkash score. Somatic pain scores and QuickDASH (disabilities of the arm, shoulder, and hand) scores decreased postoperatively, 2.9 vs 0.8 (P = .015) and 42.6 vs 12.6 (P = .004), respectively. CONCLUSIONS: This study describes the evolving role of endovascular management of ATOS over the past two decades and documents the expanded role of vascular surgeons in the endovascular management of ATOS at a single institution. Compared with open repair, stent graft repair of the subclavian artery may be associated with shorter operative times, less blood loss, but decreased patency, without changes in long-term functional outcomes.

Longitudinal analysis of National Institutes of Health funding for academic thoracic surgeons.

OBJECTIVE: National Institutes of Health (NIH) funding for academic (noncardiac) thoracic surgeons at the top-140 NIH-funded institutes in the United States was assessed. We hypothesized that thoracic surgeons have difficulty in obtaining NIH funding in a difficult funding climate. METHODS: The top-140 NIH-funded institutes' faculty pages were searched for noncardiac thoracic surgeons. Surgeon data, including gender, academic rank, and postfellowship training were recorded. These surgeons were then queried in NIH Research Portfolio Online Reporting Tools Expenditures and Results for their funding history. Analysis of the resulting grants (1980-2019) included grant type, funding amount, project start/end dates, publications, and a citation-based Grant Impact Metric to evaluate productivity. RESULTS: A total of 395 general thoracic surgeons were evaluated with 63 (16%) receiving NIH funding. These 63 surgeons received 136 grants totaling $228 million, resulting in 1772 publications, and generating more than 50,000 citations. Thoracic surgeons have obtained NIH funding at an increasing rate (1980-2019); however, they have a low percentage of R01 renewal (17.3%). NIH-funded thoracic surgeons were more likely to have a higher professorship level. Thoracic surgeons perform similarly to other physician-scientists in converting K-Awards into R01 funding. CONCLUSIONS: Contrary to our hypothesis, thoracic surgeons have received more NIH funding over time. Thoracic surgeons are able to fill the roles of modern surgeon-scientists by obtaining NIH funding during an era of increasing clinical demands. The NIH should continue to support this mission.

The Shortage of Trauma Surgeons in the US.

BACKGROUND: As the United States (US) population increases, the demand for more trauma surgeons (TSs) will increase. There are no recent studies comparing the TS density temporally and geographically. We aim to evaluate the density and distribution of TSs by state and region and its impact on trauma patient mortality. METHODS: A retrospective cohort analysis of the American Medical Association Physician Masterfile (PM), 2016 US Census Bureau, and Centers for Disease Control and Prevention (CDC's) Web-based Injury Statistics Query and Reporting System (WISQARS) to determine TS density. TS density was calculated by dividing the number of TSs per 1 000 000 population at the state level, and divided by 500 admissions at the regional level. Trauma-related mortality by state was obtained through the CDC's WISQARS database, which allowed us to estimate trauma mortality per 100 000 population. RESULTS: From 2007 to 2014, the net increase of TS was 3160 but only a net increase of 124 TSs from 2014 to 2020. Overall, the US has 12.58 TSs/1 000 000 population. TS density plateaued from 2014 to 2020. 33% of states have a TS density of 6-10/1 000 000 population, 43% have a density of 10-15, 12% have 15-20, and 12% have a density >20. The Northeast has the highest density of TSs per region (2.95/500 admissions), while the Midwest had the lowest (1.93/500 admissions). CONCLUSION: The density of TSs in the US varies geographically, has plateaued nationally, and has implications on trauma patient mortality. Future studies should further investigate causes of the TS shortage and implement institutional and educational interventions to properly distribute TSs across the US and reduce geographic disparities.

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.

Analysis of authorship trends in vascular surgery demonstrates a sticky surgical floor for women.

OBJECTIVE: Prior research in vascular surgery has identified significant gender disparities in leadership positions, but few data exist regarding gender disparities in vascular publications. This study aims to evaluate authorship trends by gender in the three highest impact factor vascular surgery journals. METHODS: In this bibliometric analysis, PubMed was searched for articles published in the European Journal of Vascular and Endovascular Surgery, the Journal of Vascular Surgery, and Annals of Vascular Surgery from 2015 to 2019. The web-based application Genderize used predictive algorithms to classify names of first and last authors as male or female. Statistical analyses regarding trends in authorship were performed using Stata16. RESULTS: A total of 6457 articles were analyzed, with first author gender predicted with >90% confidence in 83% (4889/5796) and last author gender in 88% (5078/5796). Overall, 25% (1223/4889) of articles had women first authors, and 10% (501/5078) had women last authors. From 2015 to 2019, there was a slight increase in the proportion of articles written by women first authors (P = .001), but no increase in the proportion of articles written by women last authors (P = .204). The proportion of articles written by women last authors was lower than the proportion of active women vascular surgeons in 2015 (8% of articles vs 11% of surgeons; P = .015), 2017 (9% of articles vs 13% of surgeons; P < .001), and 2019 (11% of articles vs 15% of practicing surgeons; P < .001). The average number of last-author publications was higher for men (2.35 ± 3.76) than for women (1.62 ± 1.88, P = .001). The proportion of unique authors who were women was less than the proportion of active women vascular surgeons in 2017 (10% unique authors vs 13% surgeons; P = .047), but not in 2015 (9% unique authors vs 11% surgeons; P = .192) or 2019 (13% unique authors vs 15% surgeons; P = .345). Notably, a woman last author was associated with 1.45 higher odds of having a woman first author (95% confidence interval, 1.17-1.79; P = .001). CONCLUSIONS: Over the past 5 years, there has been no significant increase in women last authors among top-tier journals in vascular surgery. Women remain under-represented as last authors in terms of proportion of published articles, but not in terms of proportion of unique authors. Nevertheless, women last authors are more likely to publish with women first authors, indicating the importance of women-led mentorship in achieving publication gender equity. Support for women surgeons through grants and promotions is essential not only for advancing last authorship gender equity, but for advancing junior faculty and trainee academic careers.

Fifteen-year trends in participation of women in presentation and leadership positions in the Southern Association for Vascular Surgery, 2006 to 2020.

OBJECTIVE: The implementation of integrated vascular surgery training programs was recently shown to be associated with an increase in women entering the field. However, whether this has precipitated a subsequent increase in the active participation of women in academic vascular societies remains unclear. We sought to examine the trends of academic inclusion of women vascular surgeons and surgical trainees over the past 15 years at the Southern Association for Vascular Surgery (SAVS). METHODS: Scientific programs for annual meetings of the SAVS, and program matriculation statistics from the Accreditation Council for Graduate Medical Education, were reviewed for the period of 2006 to 2020. Yearly rates and 3-year averages of conference and society participation and vascular surgery training program matriculation rates were calculated and compared with proportion testing. Spearman correlation testing was used to compare trends, with ρ ≥0.600 defined as a strong correlation. RESULTS: Examining 3-year means, the average number of women authors per SAVS abstract increased from 0.78 to 1.42 over the course of the study period (P < .001), and the overall rate of women authors steadily increased from 12.8% to 21.5% (P < .001). Although this remains less than the proportion of women matriculating into vascular surgery programs in 2019 (29.3%; P = .007), the upward trend of women entering vascular surgery overall, and particularly vascular surgery fellowship, strongly correlates with the average number of women authors on abstracts at SAVS (ρ = 0.709 and ρ = 0.737, respectively). The percentage of women presenting authors increased from 9.7% to 28.4% (P = .004), but there was no increase in the percentage of women senior authors (10.1% to 9.6%; P = .92). In the 15-year period, only one abstract of 347 (0.3%) had full authorship by women vs 35.1% with full authorship by men (P < .001). Although the increase of women matriculating into vascular surgery programs over the study period did not correlate with the increase of women in senior leadership positions (ρ < 0.600), there was an increase in the number of women in committee chair positions (0.0% to 25.9%; P = .005), which correlated strongly with increasing society membership (ρ = 0.716). Additionally, there was an increase in women holding executive council positions from 0% to 10.0% (P = .08), although this was not statistically significant. CONCLUSIONS: Participation of women authoring and presenting papers at the SAVS has increased over the past 15 years at a rate that strongly correlates with the increasing rate of women entering vascular surgery training programs. It is important that society leadership opportunities continue to parallel this trend as we seek to further improve diversity in vascular surgery.

BJS commission on surgery and perioperative care post-COVID-19.

BACKGROUND: Coronavirus disease 2019 (COVID-19) was declared a pandemic by the WHO on 11 March 2020 and global surgical practice was compromised. This Commission aimed to document and reflect on the changes seen in the surgical environment during the pandemic, by reviewing colleagues' experiences and published evidence. METHODS: In late 2020, BJS contacted colleagues across the global surgical community and asked them to describe how severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) had affected their practice. In addition to this, the Commission undertook a literature review on the impact of COVID-19 on surgery and perioperative care. A thematic analysis was performed to identify the issues most frequently encountered by the correspondents, as well as the solutions and ideas suggested to address them. RESULTS: BJS received communications for this Commission from leading clinicians and academics across a variety of surgical specialties in every inhabited continent. The responses from all over the world provided insights into multiple facets of surgical practice from a governmental level to individual clinical practice and training. CONCLUSION: The COVID-19 pandemic has uncovered a variety of problems in healthcare systems, including negative impacts on surgical practice. Global surgical multidisciplinary teams are working collaboratively to address research questions about the future of surgery in the post-COVID-19 era. The COVID-19 pandemic is severely damaging surgical training. The establishment of a multidisciplinary ethics committee should be encouraged at all surgical oncology centres. Innovative leadership and collaboration is vital in the post-COVID-19 era.