CHAPTER 9
Thoracic Surgery Practice Surveys Richard J. Shemin, MD Division of Cardiothoracic Surgery, Ronald Reagan UCLA Medical Center, Los Angeles, California
P
rofessional workforce surveys performed periodically provide a series of snapshots to follow broad demographic and practice trends as well as attitudes of the physician workforce. National concern about the physician workforce has resulted in studies and projections by several professional societies and the Association of American Medical Colleges (AAMC) as well as the federal government. The changing demographics and the disease burden of the United States population have resulted in predicted shortages in many specialties over the next few decades [1–19]. In the early 1970s, long before other specialty societies began to survey their members, The Society of Thoracic Surgeons (STS) and the American Association for Thoracic Surgery (AATS) established a joint ad hoc committee to survey their respective memberships. Chairs of the Manpower Committee (now the Thoracic Surgery Practice and Access Task Force) have included Lyman A. Brewer, III, MD, Paul C. Adkins, MD, Richard J. Cleveland, MD, Floyd D. Loop, MD, Lawrence H. Cohn, MD, Richard J. Shemin, MD, and John S. Ikonomidis, MD, PhD. Survey snapshots were to be repeated from time to time (every 5 to 10 years) to better understand demographics, practice patterns, caseloads, and other trends in cardiothoracic surgery practice. Surveys of the combined STS and AATS membership began in the early 1970s, with the first results published in 1974, followed by periodic surveys using similar questions and analytical methodology [20–27]. As the survey instrument became more standardized, important trends were documented.
Survey Evolves With Specialty In the 1970s, most cardiothoracic surgeons had primarily a general thoracic (GT) and vascular practice. The incorporation of increasing numbers of cardiac surgical procedures into practice significantly changed the specialty and increased the clinical case volume. The cardiac procedures performed expanded from those involving primarily congenital, vascular, and valvular conditions to ever-increasing numbers of myocardial revascularization procedures for coronary artery occlusive disease. As the specialty changed, the content of the survey instrument was expanded. The additional data accrued provided more detailed insights and identified a number of existing and emerging trends. This information was invaluable and enabled STS and AATS to better represent Address correspondence to Dr Shemin, Ronald Reagan UCLA Medical Center, Division of Cardiothoracic Surgery, 10833 Le Conte Ave, Los Angeles, CA 90095; e-mail: [email protected].
Ó 2014 by The Society of Thoracic Surgeons Published by Elsevier Inc
the specialty and respond to the increasing demands for information from governmental agencies and third-party payers in the arenas of advocacy and health policy. Survey questions also sought information on length of training, educational debt, malpractice insurance premiums, career satisfaction, retirement projections, workload, case distribution, the adoption and effect of new technology, and participation in Medicare. Over the years, survey publication has alternated between the STS and AATS journals, The Annals of Thoracic Surgery and the Journal of Thoracic and Cardiovascular Surgery, respectively. The most recent survey results were published simultaneously in both journals [27, 28].
Surveys Track Changes in Scope of Practice Attempts at using surveys to predict the retirement rate of practicing cardiothoracic surgeons and the number of residency positions required to achieve an optimally sized workforce have been unsuccessful. One reason is that demand for cardiothoracic surgeons, as determined by cardiac and GT diseases requiring surgical treatment, is difficult to measure, principally because of inadequate data and imprecise methodology. The number of procedures performed by thoracic surgeons for lung and pericardial diseases was relatively flat during the 1970s, whereas the number of procedures for cardiac disease, particularly valve surgery and myocardial revascularization, increased substantially [20–27]. The problematic issue of general surgeons performing thoracic procedures remains an area of concern. In the early surveys, the number of GT surgical procedures (lung and esophageal) that were performed by general surgeons was estimated to be 40%, whereas cardiac surgical procedures, such as coronary artery bypass grafting (CABG) and valve procedures, were performed exclusively by board-eligible or board-certified cardiothoracic surgeons. Data gathered by the Dartmouth Health Policy Group [30] and later by the STS/AATS manpower surveys demonstrated that general surgeons continued to perform lung resections, although the volume of procedures was lower. Trends in the practice of vascular surgery have resulted in a significant reduction in the number of peripheral vascular surgical procedures performed by cardiothoracic surgeons, a change at least partly due to vascular surgery having moved from a subspecialty to a distinct specialty in its own right. The most recent STS/AATS survey results indicated that endovascular aortic procedures were performed by 36% of adult cardiac (AC) surgeons. Peripheral vascular Ann Thorac Surg 2014;97:S40–S43 0003-4975/$36.00 http://dx.doi.org/10.1016/j.athoracsur.2013.10.008
Ann Thorac Surg 2014;97:S40–S43
surgical procedures were performed by 33% of surgeons (AC surgeons, 41%; congenital heart [CH] surgeons, 10%; and GT surgeons, 22%). The Southwest (63%) and Mountain (49%) regions were areas where performance of peripheral vascular procedures predominated. At that time, only 8.5% of cardiothoracic surgeons (8.2% of AC surgeons, 0% of CH surgeons, and 7.5% of GT surgeons) were certified in vascular surgery; this figure is similar to 2005 survey findings of 9.0%. Survey results track and reinforce findings that cardiologists, especially those in the subspecialty of cardiac electrophysiology, have largely replaced cardiothoracic surgeons for the placement of cardiac pacemakers. The development of less invasive technology, such as percutaneous coronary intervention and endovascular grafting for thoracic aortic disease, has reduced the number of procedures performed by AC surgeons. This reduction in volume has occurred despite increased numbers of appropriately insured elderly patients who require interventions for cardiac and vascular disease.
Cardiothoracic Surgery Sees Shifts in Supply and Demand Now the specialty faces the effect of another “disruptive” new technology, transcatheter aortic valve replacement, which is reducing the volume of open aortic replacements. Transcatheter approaches to mitral valve disease are rapidly evolving and will soon be more widely available. Future surveys will need to follow these trends. The supply side of the workforce can be accurately determined by the number of filled residency positions and by the number of practicing American Board of Thoracic Surgery (ABTS) diplomates; however, recent surveys have found that the number of positions available to competent cardiothoracic surgeons—the demand side—is unpredictable. Estimates on the attrition rate from the cardiothoracic surgery workforce as a result of retirement or other reasons, such as family leave, disability, or assuming nonoperating positions (eg, full time research, administration), have not been as predictable as assumed in some studies. Survey results from 1999 found that most cardiothoracic surgeons wanted to retire between the ages of 61 and 65 years. Findings in the 2009 survey, however, showed a significant deferral of retirement to an older age, driven mainly by unfavorable economic conditions. Surgeons are remaining in practice longer because of a downturn in the financial markets and the overall economy, both of which affected the value of retirement and pension funds. Early retirement today is more unusual and driven principally by disability or by practice environments that are no longer financially viable. Although the number of surgeons who have assumed “nonoperating” positions, such as health executives or administrators, has increased, this has had little impact on the total number of clinically active cardiothoracic surgeons. A “perfect storm” was created by the deferral of early retirement and reduced case volume, a situation then
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compounded by reduced reimbursement—all of which led to a tight market for available positions. This “perfect storm” had a profound effect on residents who had completed their training. The attractiveness of cardiothoracic surgery as a specialty has been negatively affected, and consequently, the number of applicants to cardiothoracic surgery training programs has declined considerably.
Practice Settings Also Change According to survey results, practice settings have varied among the cardiothoracic surgery subspecialties. The typical CH surgeon is most likely to practice only CH surgery as part of an academic group in a major metropolitan center. The typical GT surgeon is located in or around a major city, working in a multispecialty or academic group practice. AC surgeons have the widest geographic distribution and the most diverse practices. Even though their focus is on cardiac surgery, approximately 80% of these surgeons perform GT procedures, 33% perform vascular procedures, and a few perform CH procedures. Only 8.5% are board-certified in vascular surgery, and 6% are certified in critical care. Most work in single-specialty private group practices or in large multispecialty groups, in both private and academic settings. The solo practice, so common in the early surveys, has virtually disappeared. Hospital or health maintenance organization full-time employment models are now the most prevalent forms of practice. Health care reform and the reorganization into Accountable Care Organizations make these models attractive from the economic standpoint [29]. Results from the 1999 and 2009 surveys documented the effect of the changing economic conditions and practice patterns, which partly contributed to the significant reduction in applications to cardiothoracic surgery residency programs. Another factor contributing to the decline in applications is the relative unattractiveness of the specialty of cardiothoracic surgery to women. Women currently compose 3% of the cardiothoracic surgery workforce; however, women represent more than 50% of the current medical school enrollment and fill more than 25% of the residency training positions in general surgery.
Specialty Sees Declining Surgical Volume The 2009 survey results showed that operative volume declined over the previous 12 months for 30% of surgeons. The greatest decrease was 34% for AC surgeons, followed by 20% for GT surgeons, and 13% for CH surgeons. AC surgeons experienced the greatest reductions in reimbursement as well as case volume, reporting an average of 155 AC cases per year. Those AC surgeons doing GT procedures reported performing 92 pulmonary and 22 esophageal procedures on average each year. GT surgeons reported an average of 174 pulmonary and 40 esophageal cases per year. The CH surgeons reported 191 pediatric and 28 adult congenital cases per year. There
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was very little variation in these figures among the various geographic areas.
Will There Be Enough Cardiothoracic Surgeons in the Future? The most recent attempt by STS and AATS to project future workforce needs was done in conjunction with the AAMC in 2009. This investigation concluded that the combination of the burden of heart disease in the United States, the diabetes epidemic, the aging of the population, and the marked reduction in the number of practicing cardiothoracic surgeons could represent another “perfect storm.” The study predicted that the shortage of cardiothoracic surgeons could be critical by 2025. It is estimated that the demand for cardiothoracic surgeons could increase by 46% over this time period. Corrective action would be difficult in the short-term because of the long “pipeline” of 6 to 9 years required to train cardiothoracic surgeons. The study acknowledged the steps that have been taken to reduce the time to train cardiothoracic surgeons, with the new integrated 6-year programs now accepting residents directly from medical school. Parenthetically, there appears to be great enthusiasm and interest among medical students for this shortened pathway. The subspecialized areas of cardiothoracic surgery currently include organ transplantation and the implantation of cardiac-assist devices. In the 2009 survey, organ transplantation was performed by only 18% of surgeons (AC, 17%; CH, 61%; GT, 13%). Implantation of cardiacassist devices was performed by 27% of surgeons (AC, 35%; CH, 57%; GT, 2.1%).
Cardiothoracic Surgery and Critical Care Critical care has always been an integral part of cardiothoracic surgery. However, since the inception of a separate accrediting board in critical care, few cardiothoracic surgeons have obtained certification in this specialty. In the 2009 survey, certification in critical care was reported by 6.4% of surgeons (AC, 5.9%; CH, 6.1%; GT, 8.4%). Certification was most prevalent in the East–South Central region (11%). Sixty percent of AC surgeons reported that they practiced in hospitals that had a dedicated cardiac surgery intensive care unit (ICU). In 6% of these units, the director was a cardiac surgeon certified in critical care; in 33% of the units, a cardiac surgeon not certified in critical care was director; and in 23%, a director who was not a cardiac surgeon served in the director role. Survey results revealed that 70% of hospitals where CH surgeons practiced had a dedicated pediatric ICU. In 60% of those pediatric ICUs, the unit director was not a cardiac surgeon. Twenty percent of GT surgeons reported that their hospitals had a dedicated GT ICU, with the director being a GT surgeon certified in critical care in 2% and not certified in 7%. Shared responsibility for postoperative care has involved cardiologists, pulmonologists, and intensivists, in addition
Ann Thorac Surg 2014;97:S40–S43
to cardiothoracic surgeons. This is currently the predominant practice model in heart transplantation, lung transplantation, circulatory support, and pediatric ICU care.
ABTS and Residency Issues Data from workforce surveys indicate that AC surgeons continue to perform GT and CH procedures, and this conclusion has affected ABTS policies regarding maintenance of certification. In addition, such data have helped STS and AATS provide appropriate educational programs for their members. ABTS and STS/AATS will jointly conduct surveys of surgeons presenting for the secure examination in the 10th year of the maintenance of certification cycle. This survey will provide more accurate information annually regarding issues and trends affecting individual surgeons who have been in practice 10, 20, or 30 years after their initial ABTS certification. As noted previously, the specialty of cardiothoracic surgery has faced a constrained job market in recent years. The cardiothoracic surgery workforce is aging (the average age of the practicing surgeon was 53 years in 2009 and 50 years in 1999), and half of the practicing surgeons questioned in 2009 projected retirement at age 65. The number of Accreditation Council for Graduate Medical Education-accredited cardiothoracic surgery residency programs declined from a peak of 92 programs in 2003–2004 to 66 independent programs in 2012–2013 (43 2-year and 23 3-year programs) and 18 integrated programs. According to the National Resident Matching Program, only 80 of the 102 first-year positions at independent programs were filled in 2012–2013. The current projection is that the supply of new surgeons will not adequately replace the surgeons who are retiring. A further concern is that the failure rate on the oral portion of the ABTS qualifying examination has risen in recent years to approximately 33%. Clearly, providing an adequate and qualified workforce is the responsibility of the profession and the expectation of the public. The increased failure rate on the ABTS qualifying oral examination has caused concern about the knowledge base of new surgeons entering practice. The Thoracic Surgery Residency Review Committee, the Thoracic Surgery Directors Association, and the Joint Council on Thoracic Surgery Education are actively addressing the quality of cardiothoracic surgery residency programs and the quality of the educational materials and clinical experience provided to residents, who must work within the constraints imposed by the reduction in permissible working hours. Some consider the number of hours worked and the intensity of effort expended by cardiothoracic surgeons to be excessive compared with other specialties. That has had a disproportionate effect on older surgeons and on the ability to attract more women into the specialty. An excessive workload clearly affects the balance between the time devoted to personal and professional activities. To date there have been sincere, but only partially effective, attempts to address these issues. The surveys have also shown that the cost of malpractice insurance and the need for tort reform
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remain important issues for cardiothoracic surgeons. A few states that have adopted tort reform have seen a reduction or stabilization of liability premiums; however, there is significant regional variation. The length of training of the cardiothoracic surgeon also has been a major concern; however, it differs little from that of other surgical specialties, which require 5 years of general surgery and additional training for subspecialization, often necessitating an additional 1 to 3 years of training. The not insignificant educational debt accumulated by medical school graduates is compounded during the subsequent years of residency training. In 2009, the cumulative average educational debt was $56,000 at the time the cardiothoracic surgery resident completed training and entered practice. This figure was similar for AC ($59,000), CH ($59,000), and GT surgeons ($54,000). The average level of debt has increased compared with previous surveys. The average educational debt was reported as $24,930 in the 1999 survey. One-third of residents completing training after 2000 reported educational debt of more than $100,000. Uncertainty about the ability to repay the debt in the setting of the uncertain job market and declining reimbursement has discouraged applications to training programs in cardiothoracic surgery.
Career Satisfaction Despite the many challenges facing the specialty of cardiothoracic surgery, the 2009 survey results revealed that more than 46% of practicing cardiothoracic surgeons were extremely or very satisfied with their careers. This was an improvement from the 39% in the 1999 survey. The advances in transplantation, circulatory support, arrhythmia surgery, endovascular approaches to the thoracic aorta and valvular heart disease, thoracic oncology, and critical care are a few of the areas that have expanded the scope of practice and provided increased opportunities for professional growth and satisfaction. This renewed enthusiasm, combined with new training paradigms and innovations in teaching, has resulted in a more positive perception of the future of cardiothoracic surgery. Future workforce surveys will continue to document the evolution of our specialty and provide the background for decisions to improve the quality and professional satisfaction of future cardiothoracic surgeons and the quality of care delivered to patients.
References 1. Cooper RA. Seeking a balanced physician workforce for the 21st century. JAMA 1994;272:680–7. 2. Schroeder SA. Managing the US health care workforce: creating policy amidst uncertainty. Inquiry 1994;28:266–75. 3. Kaufman JL. Who will pay for graduate medical education? N Engl J Med 1998;339:52. 4. Cooper RA, Getzen TE, McKee HJ, Laud P. Economic and demographic trends signal an impending physician shortage. Health Aff 2002;21:140–54. 5. Cooper RA. Perspectives on the physician workforce to the year 2020. JAMA 1995;274:1534–43.
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6. Cooper RA, Getzen TE, Laud P. Economic expansion is a major determinant of physician supply and utilization. Health Serv Res 2003;38:675–96. 7. Barer M. New opportunities for old mistakes. Health Aff 2002;21:169–71. 8. Brown MM, Brown GC, Sharma S, et al. Physician manpower and health care expenditures in the United States: a thirty-year perspective. J Health Care Finance 2001;27:55–64. 9. Tarlov AR. Estimating physician workforce requirements: the devil is in the assumptions. JAMA 1995;274:1558–60. 10. Oransky I. Report finds shortage of US physicians by 2020. Lancet 2003;362:1291. 11. Salsberg E, Grover A. Physician workforce shortages: implications and issues for academic health centers and policymakers. Acad Med 2006;81:782–7. 12. Cooper RA. There’s a shortage of specialists: is anyone listening? Acad Med 2002;77:761–6. 13. Sheldon GF. Great expectations: the 21st century health workforce. Am J Surg 2003;185:35–41. 14. Snyderman R, Sheldon GF, Bischoff TA. Gauging supply and demand: the challenging quest to predict the future physician workforce. Health Aff 2002;21:167–8. 15. Grumbach K. The ramifications of specialty-dominated medicine. Health Aff 2002;21:155–7. 16. Feil EC, Welch HG, Fisher ES. Why estimates of physician supply and requirements disagree. JAMA 1993;269:2659–63. 17. Romano M. Workforce report 2005. Doc shortage gets noticed. Mod Healthc 2005;35:26–8. 18. Weiner JP. Forecasting the effects of health reform on US physician workforce requirement: evidence from HMO staffing patterns. JAMA 1994;272:222–30. 19. Blumenthal D. Toil and trouble? Growing the physician supply. Health Aff 2003;22:85–7. 20. Brewer LA, Ferguson TB, Langston HT, Weiner JM. National Thoracic Surgery Manpower Study: final report. Los Angeles: Cunningham Press; 1974. 21. Adkins PC, Orthner HF. The Society of Thoracic Surgeons manpower survey for 1976: a summary. Ann Thorac Surg 1979;28:407–12. 22. Feldstein PJ, Viets HP. Forecasting health manpower requirements: the case of thoracic surgeons. Ann Thorac Surg 1979;28:413–22. 23. Loop FD, Wilcox BR, Cunningham JN, et al. Thoracic surgery manpower. The fourth manpower study of thoracic surgery: 1985 report of the Ad Hoc Committee on Manpower of The American Association for Thoracic Surgery and The Society of Thoracic Surgeons. Ann Thorac Surg 1987;44:450–61. 24. Cohn LH, Anderson RP, Loop FD, et al. Thoracic Surgery Workforce Report: the fourth report of the Thoracic Surgery Workforce Committee of the American Association for Thoracic Surgery and The Society of Thoracic Surgeons. J Thorac Cardiovasc Surg 1995;110:570–85. 25. Shemin RJ, Dziuban SW, Kaiser LR, et al. Thoracic Surgery Workforce: snapshot at the end of the twentieth century and implications for the new millennium. Ann Thorac Surg 2002;73:2014–32. 26. Grover A, Gorman K, Dall TM, et al. Shortage of cardiothoracic surgeons is likely by 2020. Circulation 2009;120:488–94. 27. Shemin RJ, Ikonomidis JS. Thoracic Surgery Workforce: report of STS/AATS Thoracic Surgery Practice and Access Task Force—snapshot 2010. Ann Thorac Surg 2012;93: 348–55. 28. Shemin RJ, Ikonomidis JS. Thoracic Surgery Workforce: report of STS/AATS Thoracic Surgery Practice and Access Task Force—snapshot 2010. J Thorac Cardiovasc Surg 2012;143:39–46. 29. Fisher ES, Shortell SM. Accountable Care Organizations: accountable for what, to whom, and how. JAMA 2010;304: 1715–6. 30. Wennberg DE, Birkmeyer JD, eds. The Dartmouth atlas of cardiovascular health care. Chicago: AHA Press; 1999.
Thoracic Surgery Practice Surveys Richard J. Shemin, MD Division of Cardiothoracic Surgery, Ronald Reagan UCLA Medical Center, Los Angeles, California
P
rofessional workforce surveys performed periodically provide a series of snapshots to follow broad demographic and practice trends as well as attitudes of the physician workforce. National concern about the physician workforce has resulted in studies and projections by several professional societies and the Association of American Medical Colleges (AAMC) as well as the federal government. The changing demographics and the disease burden of the United States population have resulted in predicted shortages in many specialties over the next few decades [1–19]. In the early 1970s, long before other specialty societies began to survey their members, The Society of Thoracic Surgeons (STS) and the American Association for Thoracic Surgery (AATS) established a joint ad hoc committee to survey their respective memberships. Chairs of the Manpower Committee (now the Thoracic Surgery Practice and Access Task Force) have included Lyman A. Brewer, III, MD, Paul C. Adkins, MD, Richard J. Cleveland, MD, Floyd D. Loop, MD, Lawrence H. Cohn, MD, Richard J. Shemin, MD, and John S. Ikonomidis, MD, PhD. Survey snapshots were to be repeated from time to time (every 5 to 10 years) to better understand demographics, practice patterns, caseloads, and other trends in cardiothoracic surgery practice. Surveys of the combined STS and AATS membership began in the early 1970s, with the first results published in 1974, followed by periodic surveys using similar questions and analytical methodology [20–27]. As the survey instrument became more standardized, important trends were documented.
Survey Evolves With Specialty In the 1970s, most cardiothoracic surgeons had primarily a general thoracic (GT) and vascular practice. The incorporation of increasing numbers of cardiac surgical procedures into practice significantly changed the specialty and increased the clinical case volume. The cardiac procedures performed expanded from those involving primarily congenital, vascular, and valvular conditions to ever-increasing numbers of myocardial revascularization procedures for coronary artery occlusive disease. As the specialty changed, the content of the survey instrument was expanded. The additional data accrued provided more detailed insights and identified a number of existing and emerging trends. This information was invaluable and enabled STS and AATS to better represent Address correspondence to Dr Shemin, Ronald Reagan UCLA Medical Center, Division of Cardiothoracic Surgery, 10833 Le Conte Ave, Los Angeles, CA 90095; e-mail: [email protected].
Ó 2014 by The Society of Thoracic Surgeons Published by Elsevier Inc
the specialty and respond to the increasing demands for information from governmental agencies and third-party payers in the arenas of advocacy and health policy. Survey questions also sought information on length of training, educational debt, malpractice insurance premiums, career satisfaction, retirement projections, workload, case distribution, the adoption and effect of new technology, and participation in Medicare. Over the years, survey publication has alternated between the STS and AATS journals, The Annals of Thoracic Surgery and the Journal of Thoracic and Cardiovascular Surgery, respectively. The most recent survey results were published simultaneously in both journals [27, 28].
Surveys Track Changes in Scope of Practice Attempts at using surveys to predict the retirement rate of practicing cardiothoracic surgeons and the number of residency positions required to achieve an optimally sized workforce have been unsuccessful. One reason is that demand for cardiothoracic surgeons, as determined by cardiac and GT diseases requiring surgical treatment, is difficult to measure, principally because of inadequate data and imprecise methodology. The number of procedures performed by thoracic surgeons for lung and pericardial diseases was relatively flat during the 1970s, whereas the number of procedures for cardiac disease, particularly valve surgery and myocardial revascularization, increased substantially [20–27]. The problematic issue of general surgeons performing thoracic procedures remains an area of concern. In the early surveys, the number of GT surgical procedures (lung and esophageal) that were performed by general surgeons was estimated to be 40%, whereas cardiac surgical procedures, such as coronary artery bypass grafting (CABG) and valve procedures, were performed exclusively by board-eligible or board-certified cardiothoracic surgeons. Data gathered by the Dartmouth Health Policy Group [30] and later by the STS/AATS manpower surveys demonstrated that general surgeons continued to perform lung resections, although the volume of procedures was lower. Trends in the practice of vascular surgery have resulted in a significant reduction in the number of peripheral vascular surgical procedures performed by cardiothoracic surgeons, a change at least partly due to vascular surgery having moved from a subspecialty to a distinct specialty in its own right. The most recent STS/AATS survey results indicated that endovascular aortic procedures were performed by 36% of adult cardiac (AC) surgeons. Peripheral vascular Ann Thorac Surg 2014;97:S40–S43 0003-4975/$36.00 http://dx.doi.org/10.1016/j.athoracsur.2013.10.008
Ann Thorac Surg 2014;97:S40–S43
surgical procedures were performed by 33% of surgeons (AC surgeons, 41%; congenital heart [CH] surgeons, 10%; and GT surgeons, 22%). The Southwest (63%) and Mountain (49%) regions were areas where performance of peripheral vascular procedures predominated. At that time, only 8.5% of cardiothoracic surgeons (8.2% of AC surgeons, 0% of CH surgeons, and 7.5% of GT surgeons) were certified in vascular surgery; this figure is similar to 2005 survey findings of 9.0%. Survey results track and reinforce findings that cardiologists, especially those in the subspecialty of cardiac electrophysiology, have largely replaced cardiothoracic surgeons for the placement of cardiac pacemakers. The development of less invasive technology, such as percutaneous coronary intervention and endovascular grafting for thoracic aortic disease, has reduced the number of procedures performed by AC surgeons. This reduction in volume has occurred despite increased numbers of appropriately insured elderly patients who require interventions for cardiac and vascular disease.
Cardiothoracic Surgery Sees Shifts in Supply and Demand Now the specialty faces the effect of another “disruptive” new technology, transcatheter aortic valve replacement, which is reducing the volume of open aortic replacements. Transcatheter approaches to mitral valve disease are rapidly evolving and will soon be more widely available. Future surveys will need to follow these trends. The supply side of the workforce can be accurately determined by the number of filled residency positions and by the number of practicing American Board of Thoracic Surgery (ABTS) diplomates; however, recent surveys have found that the number of positions available to competent cardiothoracic surgeons—the demand side—is unpredictable. Estimates on the attrition rate from the cardiothoracic surgery workforce as a result of retirement or other reasons, such as family leave, disability, or assuming nonoperating positions (eg, full time research, administration), have not been as predictable as assumed in some studies. Survey results from 1999 found that most cardiothoracic surgeons wanted to retire between the ages of 61 and 65 years. Findings in the 2009 survey, however, showed a significant deferral of retirement to an older age, driven mainly by unfavorable economic conditions. Surgeons are remaining in practice longer because of a downturn in the financial markets and the overall economy, both of which affected the value of retirement and pension funds. Early retirement today is more unusual and driven principally by disability or by practice environments that are no longer financially viable. Although the number of surgeons who have assumed “nonoperating” positions, such as health executives or administrators, has increased, this has had little impact on the total number of clinically active cardiothoracic surgeons. A “perfect storm” was created by the deferral of early retirement and reduced case volume, a situation then
STS 50TH ANNIVERSARY SHEMIN THORACIC SURGERY PRACTICE SURVEYS
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compounded by reduced reimbursement—all of which led to a tight market for available positions. This “perfect storm” had a profound effect on residents who had completed their training. The attractiveness of cardiothoracic surgery as a specialty has been negatively affected, and consequently, the number of applicants to cardiothoracic surgery training programs has declined considerably.
Practice Settings Also Change According to survey results, practice settings have varied among the cardiothoracic surgery subspecialties. The typical CH surgeon is most likely to practice only CH surgery as part of an academic group in a major metropolitan center. The typical GT surgeon is located in or around a major city, working in a multispecialty or academic group practice. AC surgeons have the widest geographic distribution and the most diverse practices. Even though their focus is on cardiac surgery, approximately 80% of these surgeons perform GT procedures, 33% perform vascular procedures, and a few perform CH procedures. Only 8.5% are board-certified in vascular surgery, and 6% are certified in critical care. Most work in single-specialty private group practices or in large multispecialty groups, in both private and academic settings. The solo practice, so common in the early surveys, has virtually disappeared. Hospital or health maintenance organization full-time employment models are now the most prevalent forms of practice. Health care reform and the reorganization into Accountable Care Organizations make these models attractive from the economic standpoint [29]. Results from the 1999 and 2009 surveys documented the effect of the changing economic conditions and practice patterns, which partly contributed to the significant reduction in applications to cardiothoracic surgery residency programs. Another factor contributing to the decline in applications is the relative unattractiveness of the specialty of cardiothoracic surgery to women. Women currently compose 3% of the cardiothoracic surgery workforce; however, women represent more than 50% of the current medical school enrollment and fill more than 25% of the residency training positions in general surgery.
Specialty Sees Declining Surgical Volume The 2009 survey results showed that operative volume declined over the previous 12 months for 30% of surgeons. The greatest decrease was 34% for AC surgeons, followed by 20% for GT surgeons, and 13% for CH surgeons. AC surgeons experienced the greatest reductions in reimbursement as well as case volume, reporting an average of 155 AC cases per year. Those AC surgeons doing GT procedures reported performing 92 pulmonary and 22 esophageal procedures on average each year. GT surgeons reported an average of 174 pulmonary and 40 esophageal cases per year. The CH surgeons reported 191 pediatric and 28 adult congenital cases per year. There
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was very little variation in these figures among the various geographic areas.
Will There Be Enough Cardiothoracic Surgeons in the Future? The most recent attempt by STS and AATS to project future workforce needs was done in conjunction with the AAMC in 2009. This investigation concluded that the combination of the burden of heart disease in the United States, the diabetes epidemic, the aging of the population, and the marked reduction in the number of practicing cardiothoracic surgeons could represent another “perfect storm.” The study predicted that the shortage of cardiothoracic surgeons could be critical by 2025. It is estimated that the demand for cardiothoracic surgeons could increase by 46% over this time period. Corrective action would be difficult in the short-term because of the long “pipeline” of 6 to 9 years required to train cardiothoracic surgeons. The study acknowledged the steps that have been taken to reduce the time to train cardiothoracic surgeons, with the new integrated 6-year programs now accepting residents directly from medical school. Parenthetically, there appears to be great enthusiasm and interest among medical students for this shortened pathway. The subspecialized areas of cardiothoracic surgery currently include organ transplantation and the implantation of cardiac-assist devices. In the 2009 survey, organ transplantation was performed by only 18% of surgeons (AC, 17%; CH, 61%; GT, 13%). Implantation of cardiacassist devices was performed by 27% of surgeons (AC, 35%; CH, 57%; GT, 2.1%).
Cardiothoracic Surgery and Critical Care Critical care has always been an integral part of cardiothoracic surgery. However, since the inception of a separate accrediting board in critical care, few cardiothoracic surgeons have obtained certification in this specialty. In the 2009 survey, certification in critical care was reported by 6.4% of surgeons (AC, 5.9%; CH, 6.1%; GT, 8.4%). Certification was most prevalent in the East–South Central region (11%). Sixty percent of AC surgeons reported that they practiced in hospitals that had a dedicated cardiac surgery intensive care unit (ICU). In 6% of these units, the director was a cardiac surgeon certified in critical care; in 33% of the units, a cardiac surgeon not certified in critical care was director; and in 23%, a director who was not a cardiac surgeon served in the director role. Survey results revealed that 70% of hospitals where CH surgeons practiced had a dedicated pediatric ICU. In 60% of those pediatric ICUs, the unit director was not a cardiac surgeon. Twenty percent of GT surgeons reported that their hospitals had a dedicated GT ICU, with the director being a GT surgeon certified in critical care in 2% and not certified in 7%. Shared responsibility for postoperative care has involved cardiologists, pulmonologists, and intensivists, in addition
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to cardiothoracic surgeons. This is currently the predominant practice model in heart transplantation, lung transplantation, circulatory support, and pediatric ICU care.
ABTS and Residency Issues Data from workforce surveys indicate that AC surgeons continue to perform GT and CH procedures, and this conclusion has affected ABTS policies regarding maintenance of certification. In addition, such data have helped STS and AATS provide appropriate educational programs for their members. ABTS and STS/AATS will jointly conduct surveys of surgeons presenting for the secure examination in the 10th year of the maintenance of certification cycle. This survey will provide more accurate information annually regarding issues and trends affecting individual surgeons who have been in practice 10, 20, or 30 years after their initial ABTS certification. As noted previously, the specialty of cardiothoracic surgery has faced a constrained job market in recent years. The cardiothoracic surgery workforce is aging (the average age of the practicing surgeon was 53 years in 2009 and 50 years in 1999), and half of the practicing surgeons questioned in 2009 projected retirement at age 65. The number of Accreditation Council for Graduate Medical Education-accredited cardiothoracic surgery residency programs declined from a peak of 92 programs in 2003–2004 to 66 independent programs in 2012–2013 (43 2-year and 23 3-year programs) and 18 integrated programs. According to the National Resident Matching Program, only 80 of the 102 first-year positions at independent programs were filled in 2012–2013. The current projection is that the supply of new surgeons will not adequately replace the surgeons who are retiring. A further concern is that the failure rate on the oral portion of the ABTS qualifying examination has risen in recent years to approximately 33%. Clearly, providing an adequate and qualified workforce is the responsibility of the profession and the expectation of the public. The increased failure rate on the ABTS qualifying oral examination has caused concern about the knowledge base of new surgeons entering practice. The Thoracic Surgery Residency Review Committee, the Thoracic Surgery Directors Association, and the Joint Council on Thoracic Surgery Education are actively addressing the quality of cardiothoracic surgery residency programs and the quality of the educational materials and clinical experience provided to residents, who must work within the constraints imposed by the reduction in permissible working hours. Some consider the number of hours worked and the intensity of effort expended by cardiothoracic surgeons to be excessive compared with other specialties. That has had a disproportionate effect on older surgeons and on the ability to attract more women into the specialty. An excessive workload clearly affects the balance between the time devoted to personal and professional activities. To date there have been sincere, but only partially effective, attempts to address these issues. The surveys have also shown that the cost of malpractice insurance and the need for tort reform
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remain important issues for cardiothoracic surgeons. A few states that have adopted tort reform have seen a reduction or stabilization of liability premiums; however, there is significant regional variation. The length of training of the cardiothoracic surgeon also has been a major concern; however, it differs little from that of other surgical specialties, which require 5 years of general surgery and additional training for subspecialization, often necessitating an additional 1 to 3 years of training. The not insignificant educational debt accumulated by medical school graduates is compounded during the subsequent years of residency training. In 2009, the cumulative average educational debt was $56,000 at the time the cardiothoracic surgery resident completed training and entered practice. This figure was similar for AC ($59,000), CH ($59,000), and GT surgeons ($54,000). The average level of debt has increased compared with previous surveys. The average educational debt was reported as $24,930 in the 1999 survey. One-third of residents completing training after 2000 reported educational debt of more than $100,000. Uncertainty about the ability to repay the debt in the setting of the uncertain job market and declining reimbursement has discouraged applications to training programs in cardiothoracic surgery.
Career Satisfaction Despite the many challenges facing the specialty of cardiothoracic surgery, the 2009 survey results revealed that more than 46% of practicing cardiothoracic surgeons were extremely or very satisfied with their careers. This was an improvement from the 39% in the 1999 survey. The advances in transplantation, circulatory support, arrhythmia surgery, endovascular approaches to the thoracic aorta and valvular heart disease, thoracic oncology, and critical care are a few of the areas that have expanded the scope of practice and provided increased opportunities for professional growth and satisfaction. This renewed enthusiasm, combined with new training paradigms and innovations in teaching, has resulted in a more positive perception of the future of cardiothoracic surgery. Future workforce surveys will continue to document the evolution of our specialty and provide the background for decisions to improve the quality and professional satisfaction of future cardiothoracic surgeons and the quality of care delivered to patients.
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