1. The Estimated Cost of Training the Future Surgical Workforce Thomas E. Williams, Jr., MD,PHD, Bhagwan Satiani, MD,MBA, Andrew Thomas, MD,MBA, and E. Christopher Ellison, MD The Ohio State University Medical Center Departments of Surgery and Internal Medicine DISCLOSURE: This effort was partially supported by a grant from Columbus Medical Association Foundation

2. HISTORY – 1910 Flexner – 1959 Bane – 1975 SOSSUS [ Rural Shortage] – 1981 GMENAC – 1986 COGME, IOM, PEW, AAMC, AMA – 1994 COGME – 1995 PEW – 2004 Cooper – 2006 HRSA – 2008 Dill & Salsberg, AAMC Surplus Shortage

3. PHYSICIAN SHORTAGES

4. MEDICAL SCHOOL ENROLLMENTS PER 100,000 POPULATION 227,000,000300,000,000 Medical School Enrollments – no increases between 1980 and 2005

5. BALANCED BUDGET ACT Post Graduate Positions capped in 1997 by BBA No revision of the BBA so far

6. SUPPLY AND DEMAND Aging Population

7. INCREASED WORK LOAD FOR THESE SEVEN SPECIALTIES OBGYN also

8. Objectives To estimate the workforce needed by 2030 in seven surgical specialties to serve a population of 364 million people To quantify the cost associated with training additional surgeons.

9. Assumptions Unchanged physician to population ratio 30 years in practice from completion of residency to retirement, No revision of the Balanced Budget Act of 1997 and therefore no additional residency positions offered. Per resident expenses were estimated at $80,000 including salaries, benefits, and other direct medical education costs.

10. Methods A review of the certificates granted in otolaryngology, orthopedic surgery, thoracic surgery, obstetrics and gynecology, neurosurgery, urology, and general surgery was conducted. Population estimates of U.S Census bureau Population-based algorithm Baseline Supply + New Entrants (U.S & IMG’s) - Attrition

11. RESULTS: UROLOGY WORKFORCE

12. RESULTS SHORTAGES SPECIALTYYEARSCERTIFIC-TOTAL SHORTAGE TOATIONS/TRAINED NEEDED 2011 TO TRAINYR 2011 TO 2030 OB-GYN41,20024,00037,63613,636 ENT53006,0008,5162,516 ORTHO565013,00017,3554,355 GENERAL51,00020,00022,5252,525 UROLOGY52605,2009,0843,884 NEURO61252,5002,728228 THORACIC21002,0003,9941,994 TOTAL3,63572,700101,83829,138

13. Cost of training surgical specialists at present certification levels SPECIALTYYEARS IN RESIDENCY CERTIFICATIONS PER YEAR TOTAL TO BE TRAINED 2011 TO 2030 TOTAL TRAINEE YEARS TOTAL COST AT $80,000 PER TRAINEE YEAR OB-GYN41,20024,00096,000$7,680,000,000 ENT53006,00030,000$2,400,000,000 ORTHO565013,00065,000$5,200,000,000 GENERAL51,00020,000100,000$8,000,000,000 UROLOGY52605,20026,000$2,080,000,000 NEURO61252,50015,000$1,200,000,000 THORACIC21002,0004,000$320,000,000 Total3,63572,700336,000$26,880,000,000

14. Cost of training surgical specialists at certification levels needed SPECIALTY TOTAL TO BE TRAINED 2011 TO 2030 NUMBER PER CLASS TRAINEE YEARS PER CLASS PER CLASS COST AT $80,000 TOTAL COST 2011 TO 2030 OB-GYN37,6361,8827,527602,176,00012,043,520,000 ENT8,5164262,129170,320,0003,406,400,000 ORTHO17,3558684,339347,100,0006,942,000,000 GENERAL22,5251,1265,631450,500,0009,010,000,000 UROLOGY9,0844542,271181,680,0003,633,600,000 NEURO2,72813681865,472,0001,309,440,000 THORACIC3,99420039931,952,000639,040,000 TOTAL101,8385,09223,1151,849,200,00036,984,000,000 Incremental Cost: $10B

15. LIMITATIONS Validity of US Census numbers Surgical demand of the aged Shortened training programs Specialization Misdistribution of surgeons Impact of the economy Disruptive technology

16. CONCLUSION There will not be a sufficient number of trained surgeons to care for the American people as early as 2030. The shortage will grow to almost 30,000 surgeons by 2030. Cost of $ 36.9 B –Current cost $ 26,8B –Incremental cost $ 10.1B

17. CHALLENGES - CREATING THE RESIDENCIES GOAL – REVISION OF BBA OF 1997

18. CHALLENGES Convince policymakers of consequences of shortages –Revise the BBA of 1997 Find alternative funding – Apply H.R 2583 The Physician Work Enhancement Act of 2008 to Surgery –Non-governmental Recruitment –Life style –Rural Practice

19. IMPACT OF SHORTAGE ACCESS TO CARE WILL PORTSMOUTH, OHIO HAVE THESE SERVICES ??? –APPENDECTOMY –BROKEN ARMS –DELIVERY of BABIES INCREASES IN –TIME TO APPOINTMENTS –TRAVEL TIMES

20. WILL IT COME TO THIS ?? RATIONING OF SURGICAL SERVICES SOURCE: NEJM

22. SHORTAGES # Job solicitations Recruiting hard Salary/bonus offers Hospital employment Source: Advisory Board (2007)

23. THORACIC SURGERY

24. HEALTH CARE $$$ Source: Modern Healthcare

25. LIMITATIONS OF STUDY POPULATION BASED VARIABLES NOT CONSIDERED: –WORKLOAD –GENDER, –AGING OF POPULATION & SURGEONS –NON-PHYSICIAN CLINICIANS –LIFESTYLE –EARLY RETIREMENTS –EFFICIENCY & DISRUPTIVE TECHNOLOGY –SALARIED PRACTICE ?? TIME BIDDING WARS COST FIGURES ‘NOMINAL’ (UNADJUSTED FOR INFLATION)

26. COOPER

27. % Growth in surgical residents Source: AAMC

28. SURGICAL WORKFORCES SPECIALTYPRESENTSURGEONS WORK FORCEPER 100,000IN PRACTICEPER 100,000 IN 2030 OB-GYN34,00027.1036,49919.73 ENT8,9003.168,9862.47 ORTHO18,0006.5019,3055.30 GENERAL21,0007.5024,7756.81 UROLOGY10,0003.498,1642.24 NEURO3,1001.093,6301.00 THORACIC4,0001.423,1750.87 TOTAL99,000104,534

29. GENERAL SURGERY 7.5 6.81 24,775 21,000 340M 364M

30. NEEDED VERSUS SUPPLY THORACIC SURGEONS

31. RESULTS: UROLOGY WORKFORCE

32. SUMMARY Possible Cure for the Shortage Increase training positions –Funding Interest trainees in small town USA –Role models –Rural tracking or training programs –Incentives for rural practice Increase interest of X and Y generation and women in surgery