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 evolution of surgical virtual education and telementoring: One surgeon's journey.

The first era of the global proliferation of surgical advancements involved surgical infection rate and technique breakthroughs by Lister, Halsted, and others. This was propagated by letters, academic papers, and international visits. While success was achieved, it was at a suboptimal pace. In the current era of minimally invasive surgical approaches, these methods are inadequate. This paper chronicles the development and application of virtual learning and telementoring as force multipliers to speed procedural adoption and proliferation.

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.

Paediatric surgical response to an 'adult' COVID-19 pandemic.

INTRODUCTION: The Coronavirus Disease 2019 (COVID-19) has dramatically affected global healthcare systems. We aimed to determine the response of our paediatric surgical fraternity to a disease that overwhelmingly affects adults. MATERIALS AND METHODS: We conducted a cross-sectional questionnaire-based study over 6 weeks during a federally mandated lockdown. Using snowball sampling, we recruited paediatric surgeons, trainees and medical officers from paediatric surgical units in Malaysia. The anonymous online questionnaire covered sociodemographic information, changes in patient care, redeployment, concerns regarding family members, and impact on training. Mental well-being was assessed using the Depression, Anxiety and Stress Scale (DASS-21). Kruskal-Wallis, ANOVA and multiple regression analysis was used, with significance level 0.05. RESULTS: Of the 129 eligible participants, 100(77%) responded. Junior doctors had clinically higher levels of depression, anxiety, and stress. Age <30 years was significantly associated with anxiety. Junior doctors believed that redeployment led to loss of surgical skills (p<0.001) and trainees felt that clinical application of knowledge had reduced (p<0.020). CONCLUSION: Specific to our paediatric surgical community, this study highlights areas of concern, particularly among junior doctors. It is likely that recurrent cycles of the pandemic will occur soon. These issues must be addressed to preserve the mental and emotional well-being of all health care workers.

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.

The evolving sex, race, and ethnic composition of the surgical workforce: North Carolina is a bellwether of national change.

BACKGROUND: North Carolina, as a state with a significant Black population and fast-growing Hispanic population, serves as bellwether of demographic changes nationally and the challenges facing the nation to recruit and retain a general surgery workforce that mirrors the population. METHODS: Annual licensure data from the North Carolina Medical Board were analyzed between 2004 and 2019. Physicians self-reporting a specialty of abdominal surgery, critical care surgery, colon and rectal surgery, general surgery, trauma surgery, proctology, and surgical oncology were categorized as general surgeons. RESULTS: Female surgeons made the most gains from 2004, at just 8% of the workforce in 2004 to 26% of the workforce in 2019. Over the same period, Black surgeons increased from just 5% to 6% of the workforce, with those gains largely represented by Black female surgeons. Almost half of North Carolina's Black physicians are aged 46 and 55 and will be nearing retirement in the coming decade. Nearly two-thirds (64%) of Hispanic general surgeons were 45 or younger, and one-third of these young surgeons were international medical graduates. CONCLUSION: Although the general surgery workforce in North Carolina is slowly diversifying, growth in the Black surgeon workforce has stagnated in the last 15 years at levels much lower than their representation in the population. More research is needed on the individual and life course phenomena that drive this underrepresentation.

NIH Funding for Surgeon-Scientists in the US: What Is the Current Status?

BACKGROUND: Recent literature suggests that the future of surgeon-scientists in the US has been threatened for the past several decades. However, we documented an overall increase in NIH funding for surgeon-scientists, as well as the number of NIH-funded surgeons, from 2010 to 2020. STUDY DESIGN: NIH-funded principal investigators (PIs) were identified for June 2010 and June 2020 using the NIH internal data platform iSearch Grants (version 2.4). Biographical sketches were searched for key terms to identify surgeon-scientists. Grant research types and total grant costs were collected. American Association of Medical Colleges data were used to determine total surgeon and physician populations. Bivariate chi-square analyses were performed using population totals and were corroborated using z-tests of population proportions using JMP (version 13.0.0). A 2-tailed p value <0.05 was considered significant. RESULTS: In June of 2020, a total of 1,031 surgeon-scientists held $872,456,710 in NIH funding. The percentage of funded surgeons significantly increased from 2010 (0.5%) to 2020 (0.7%) (p < 0.05), and the percentage of funded other physicians significantly decreased from 2.2% in 2010 to 1.6% in 2020 (p < 0.05). All surgeons sustained R grant funding at both time points (58% in 2020 and 60% in 2010), and specifically maintained basic science-focused R grants (73% in 2020 and 78% in 2010). CONCLUSIONS: Our study found surgeon-scientists are increasing in number and NIH funding and are becoming more diverse in their research efforts, while maintaining a focus on basic science.

Postgraduate Assessment Approaches Across Surgical Specialties: A Systematic Review of the Published Evidence.

PURPOSE: Ensuring competence for surgical trainees requires holistic assessment of the qualities and competencies necessary to practice safely and effectively. To determine the next steps toward achieving this aim, the authors conducted a systematic review to summarize and appraise the available evidence related to any assessment approach to postgraduate surgical training and to identify the dominant themes for assessment approaches across different specialties or countries. METHOD: Medline and Embase were searched on January 10, 2019, without language or time restrictions. Any peer-reviewed study that described an assessment framework (in practice or novel) throughout postgraduate surgical training globally was included. An iterative review and thematic analysis were performed on full-text articles to determine assessment themes. Studies were then grouped by assessment themes. A tailored quality assessment of the studies included in the final analysis was conducted. Assessment themes and validity were compared across surgical specialties and countries. RESULTS: From an initial 7,059 articles, 91 studies (evaluating 6,563 surgical trainees) were included in the final analysis. Ten defined assessment themes were extracted. Ten studies (11.0%) were deemed low risk of bias based on the quality assessment tool used and thus were determined to be high quality. Minor differences in assessment themes were observed between specialties and countries. Assessment themes neglected by individual surgical specialties and assessment themes that need validated assessment tools were identified. CONCLUSIONS: This review highlights the low quality of evidence and fragmented efforts to develop and optimize surgical assessments. The minor differences observed demonstrate a common approach, globally and across specialties, related to surgical assessments. A paradigm shift in assessment approaches, which will require national and international collaboration, is required to optimize design and validation so that a comprehensive assessment of surgical competence can be implemented.

Representation of women in speaking roles at annual surgical society meetings.

BACKGROUND: Women are disproportionately underrepresented in American academic surgery and surgical society leadership; we investigated the proportion of speaking roles held by women across a wide variety of surgical society meetings. METHODS: Publicly-available data on invited speakers, panelists, and moderators at 23 national surgical societies' annual meetings from 2002 to 2019 were collected. Mixed effects logistic regression was used to evaluate the adjusted trend of gender representation over time for each role. RESULTS: 15.9% of invited speakers were women. Adjusted analysis showed an 8% increase in odds of having female speakers per year (OR1.08, p = 0.002, 95%CI 1.03-1.14). 24.4% of moderators and 22.5% of panelists were female; there was increasing trend in adjusted analysis for both moderators (OR1.09, p < 0.001, 95%CI 1.07-1.11) and panelists (OR1.13, p < 0.001, 95%CI 1.11-1.43). CONCLUSIONS: There is a wide range in speaking roles held by women at surgical society meetings, but an encouraging trend towards greater parity was seen overall.

Longitudinal Survey of Trainee Case Log Entry for Carotid Endarterectomy: Trends in Neurologic, General, and Vascular Surgery.

BACKGROUND: Multiple surgical specialties perform carotid endarterectomy (CEA). As indications for CEA narrows, neurosurgery residents are less exposed to this procedure. This study aims to determine trends in CEA training among graduating trainees in neurosurgery and compare these to general and vascular surgery. METHODS: ACGME case log reports were retrospectively reviewed from 2013 to 2019 for neurologic, general, and vascular surgery residencies and vascular surgery fellowship. These annual reports contain the mean number of logged cases for graduating trainees and their level of participation. We analyzed trends in logged cases over the study period and compared mean number of logged cases between specialties and their respective required minimum numbers. RESULTS: Neurosurgery residents (13.5 ± 0.76) performed significantly more CEAs than their counterparts in general surgery (9.4 ± 0.34, P < 0.01) but less in integrated vascular surgery (57.7 ± 0.88) and vascular surgery fellowship (47.9 ± 0.79, both P < 0.001). The only statistically significant change over the study period was a decline in mean number of cases logged by general surgery residents at -0.4 cases/year (P < 0.001). Trainees in all specialties reported around twice as many cases as the respective Accreditation Council for Graduate Medical Education required minimum numbers. Neurosurgery residents demonstrated increasing participation as lead surgeons by 0.7 cases/year (P = 0.04) and a concurrent decline as senior surgeons by 1.4 cases/year (P < 0.01). CONCLUSIONS: Neurosurgery residents exceeded their minimum requirements for CEA, with increasing trend in higher level of participation. But neurosurgery residents' exposure to this procedure was far less significant than their colleagues in vascular surgery, a gap that may widen over time and should be addressed proactively.

Impact of the COVID-19 Pandemic on Surgical Training and Learner Well-Being: Report of a Survey of General Surgery and Other Surgical Specialty Educators.

BACKGROUND: The COVID-19 pandemic disrupted the delivery of surgical services. The purpose of this communication was to report the impact of the pandemic on surgical training and learner well-being and to document adaptations made by surgery departments. STUDY DESIGN: A 37-item survey was distributed to educational leaders in general surgery and other surgical specialty training programs. It included both closed- and open-ended questions and the self-reported stages of GME during the COVID-19 pandemic, as defined by the ACGME. Statistical associations for items with stage were assessed using categorical analysis. RESULTS: The response rate was 21% (472 of 2,196). US stage distribution (n = 447) was as follows: stage 1, 22%; stage 2, 48%; and stage 3, 30%. Impact on clinical education significantly increased by stage, with severe reductions in nonemergency operations (73% and 86% vs 98%) and emergency operations (8% and 16% vs 34%). Variable effects were reported on minimal expected case numbers across all stages. Reductions were reported in outpatient experience (83%), in-hospital experience (70%), and outside rotations (57%). Increases in ICU rotations were reported with advancing stage (7% and 13% vs 37%). Severity of impact on didactic education increased with stage (14% and 30% vs 46%). Virtual conferences were adopted by 97% across all stages. Severity of impact on learner well-being increased by stage-physical safety (6% and 9% vs 31%), physical health (0% and 7% vs 17%), and emotional health (11% and 24% vs 42%). Regardless of stage, most but not all made adaptations to support trainees' well-being. CONCLUSIONS: The pandemic adversely impacted surgical training and the well-being of learners across all surgical specialties proportional to increasing ACGME stage. There is a need to develop education disaster plans to support technical competency and learner well-being. Careful assessment for program advancement will also be necessary. The experience during this pandemic shows that virtual learning and telemedicine will have a considerable impact on the future of surgical education.

Women in Academic Surgery: A Double-Edged Scalpel.

Women continue to be underrepresented in academic surgery, especially at the leadership level. Surgical culture has been historically male dominated and recently received negative attention for higher rates of mistreatment, sexual harassment, and attrition of women compared with other medical specialties. The authors examine factors that contribute to challenges in academic surgery, making it a potentially difficult environment for women and underrepresented minorities; these include surgical culture, work-life balance, and historic promotion timelines. Efforts to change social norms and structural biases are critical to improving gender parity in academic surgery.

Gender disparities in academic vascular surgeons.

OBJECTIVE: Previous studies have identified significant gender discrepancies in grant funding, leadership positions, and publication impact in surgical subspecialties. We investigated whether these discrepancies were also present in academic vascular surgery. METHODS: Academic websites from institutions with vascular surgery training programs were queried to identify academic faculty, and leadership positions were noted. H-index, number of citations, and total number of publications were obtained from Scopus and PubMed. Grant funding amounts and awards data were obtained from the National Institutes of Health (NIH) and Society for Vascular Surgery websites. Industry funding amount was obtained from the Centers for Medicare and Medicaid Services website. Nonsurgical physicians and support staff were excluded from this analysis. RESULTS: We identified 177 female faculty (18.6%) and 774 male faculty (81.4%). A total of 41 (23.2%) female surgeons held leadership positions within their institutions compared with 254 (32.9%) male surgeons (P = .009). Female surgeons held the rank of assistant professor 50.3% of the time in contrast to 33.9% of men (P < .001). The rank of associate professor was held at similar rates, 25.4% vs 20.7% (P = .187), respectively. Fewer women than men held the full professor rank, 10.7% compared with 26.2% (P < .001). Similarly, women held leadership positions less often than men, including division chief (6.8% vs 13.7%; P < .012) and vice chair of surgery (0% vs 2.2%; P < .047), but held more positions as vice dean of surgery (0.6% vs 0%; P < .037) and chief executive officer (0.6% vs 0%; P < .037). Scientific contributions based on the number of each surgeon's publications were found to be statistically different between men and women. Women had an average of 42.3 publications compared with 64.8 for men (P < .001). Female vascular surgeons were cited an average of 655.2 times, less than half the average citations of their male counterparts with 1387 citations (P < .001). The average H-index was 9.5 for female vascular surgeons compared with 13.7 for male vascular surgeons (P < .001). Correcting for years since initial board certification, women had a higher H-index per year in practice (1.32 vs 1.02; P = .005). Female vascular surgeons were more likely to have received NIH grants than their male colleagues (9.6% vs 4.0%; P = .017). Although substantial, the average value of NIH grants awarded was not statistically significant between men and women, with men on average receiving $915,590.74 ($199,119.00-$2,910,600.00) and women receiving $707,205.35 ($61,612.00-$4,857,220.00; P = .416). There was no difference in the distribution of Society for Vascular Surgery seed grants to women and men since 2007. Industry payments made publicly available according to the Sunshine Act for the year 2018 were also compared, and female vascular surgeons received an average of $2155.28 compared with their male counterparts, who received almost four times as much at $8452.43 (P < .001). CONCLUSIONS: Although there is certainly improved representation of women in vascular surgery compared with several decades ago, a discrepancy still persists. Women tend to have more grants than men and receive less in industry payments, but they hold fewer leadership positions, do not publish as frequently, and are cited less than their male counterparts. Further investigation should be aimed at identifying the causes of gender disparity and systemic barriers to gender equity in academic vascular surgery.

Learning health systems and the future of clinical research.

Pediatric surgeons are collectively passionate about prioritizing the healthcare needs of children. We contend that this passion is deeply ingrained in how we drive clinical care and influence scientific discovery. Thus, the future of clinical research in our field will be deeply embedded in our history as a "patient-centric" profession. Service to pediatric patients requires an understanding of their needs and expectations, and designing research that acknowledges both. In this article we detail how future pragmatic clinical research will look in the evolving and learning health system.