Thomas E. Williams Jr. M.D. PH.D., E. Christopher Ellison M.D., Bhagwan Satiani M.D. M.B.a. - The Coming Shortage of Surgeons - Why They Are Disappearing and What That Means For Our Health (The Pra

THE COMING SHORTAGE
OF SURGEONS
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THE COMING SHORTAGE
OF SURGEONS
Why They Are Disappearing and
What That Means for Our Health
Thomas E. Williams, Jr., M.D., Ph.D.; FACS,

Bhagwan Satiani, M.D., M.B.A.; FACS,
and E. Christopher Ellison, M.D.; FACS
Foreword by Thomas R. Russell, M.D.; FACS

Executive Director, American College of
Surgeons
The Praeger Series on Contemporary Health and Living

Julie Silver, M.D., Series Editor
PRAEGER
An Imprint of ABC-CLIO, LLC
Copyright 2009 by Thomas E. Williams, Jr., Bhagwan Satiani, and E. Christopher Ellison
All rights reserved. No part of this publication may be reproduced, stored in a retrieval
system, or transmitted, in any form or by any means, electronic, mechanical, photocopying,
recording, or otherwise, except for the inclusion of brief quotations in a review, without
prior permission in writing from the publisher.
Library of Congress Cataloging-in-Publication Data
Williams, Thomas Edwards, 1935–
The coming shortage of surgeons : why they are disappearing
and what that means for our health / Thomas E. Williams, Jr.,
Bhagwan Satiani, and E. Christopher Ellison ; foreword
by Thomas R. Russell.
p. ; cm. — (Praeger series on contemporary health and living)
Includes bibliographical references and index.
ISBN 978-0-313-38070-9 (hard copy : alk. paper) ISBN 978-0-313-38071-6 (ebook)
1. Surgeons—Supply and demand—United States. I. Satiani, Bhagwan.
II. Ellison, E. Christopher. III. Title. IV. Series: Praeger series on
contemporary health and living.
[DNLM: 1. General Surgery—manpower. 2. Education, Medical,
Graduate—trends. 3. Specialties, Surgical—trends. WO 21 W727c 2009]
RD27.42.W55 2009
338.4'7617—dc22 2009027608
13 12 11 10 09 1 2 3 4 5
This book is also available on the World Wide Web as an eBook.

Visit www.abc-clio.com for details.
ABC-CLIO, LLC
130 Cremona Drive, P.O. Box 1911
Santa Barbara, California 93116-1911
This book is printed on acid-free paper
Manufactured in the United States of America
To my beloved wife, Margaret Barton Williams, to our daughters, Beth,
Peggy, and Catherine.
And to my best friend and wife, Mira Satiani.
And to my beloved wife, Mary Pat Borgess, to our sons, Jonathan and Eric,
and daughter-in-law Hillary Dorwart, and
to the memory of my father, Edwin H. Ellison, M.D., and
Robert M. Zollinger Sr., M.D.
This page intentionally left blank
Contents
List of Figures ix
List of Tables xiii
Series Foreword by Julie K. Silver, M.D. xv
Foreword by Thomas R. Russell, M.D., FACS Executive Director,
American College of Surgeons xvii
Preface xix
Acknowledgments xxi
Acronyms xxiii
1. The Problem 1
2. Demand for a Surgical/Medical Workforce 10
3. Surgical Supply: Residents—The Future Surgeons 22
4. Constraints to Supply: Pertinent Issues 32
5. Calculating Physician Supply: The Model—Assumptions,
Relevant Parameters, and the Algorithm 54
6. Orthopedic Surgery 67
7. Cardiothoracic Surgery 72
8. Otolaryngology 78
9. Obstetrics and Gynecology 85
10. General Surgery 93
11. Neurosurgery 103
12. Urology 108
viii Contents
13. The Last Hurdle: The Balanced Budget Act of 1997

and Graduate Medical Education Funding 114
14. Is There a Solution? Numerical Projections,
and Improving Physicians’ Productivity 127
15. Challenges and Consequences 144
Epilogue 156
Appendix 159
Notes 165
Index 187
About the Authors 193
About the Series Editor 195
List of Figures
1.1 U.S. Medical School Applicants 3

1.2 U.S. Population and First-Year Medical School Enrollments, 1980–2005 4
1.3 Fourth-Year Medical Students Selecting General Surgery as
Their Top Choice Specialty 6
2.1 Staying Alive 12
2.2 Heart Failure Hospitalizations 13
2.3 The Nation’s Health Dollar, Calendar Year 2007: Where It Went 14
2.4 The Nation’s Health Dollar, Calendar Year 2007: Where It Came From 15
2.5 Balance Sheet 16
2.6 Population Growth of People over age 65 Years, 2000–2020 17
2.7 Relationship of GDP and Physician Ratio 18
2.8 Physicians per 1,000 People, 1991 and 2001 19
3.1 National Resident Matching Program, 2008 25
3.2 Residencies 27
3.3 American Board Surgical Certificates Awarded 29
4.1 Median Medical Education Debt 34
4.2 Projected Loan Payments as a Percentage of Projected Physician
After-Tax Income 35
4.3 Report Finds Physician Income “Losing Ground” to other Professions 39
4.4 Physician Income 40
4.5 Reimbursements for Open Surgery 41
4.6 Hospital versus Physician Reimbursement 42
4.7 Average CV Physician Compensation per Physician Work RVU,
2002–2006 43
4.8 Ohio Closed Claims in 2006 Outcome of Malpractice Claims 45
4.9 Annual Physician Premium Payments for Selected Specialties 47
x List of Figures
4.10 Where Malpractice Dollars Go 48

4.11 First-Year M.D. Enrollment per 100,000 Population 49
4.12 Source of Physicians Entering Training, 2005 51
4.13 Physician Morale 52
5.1 U.S Medical Student Enrollment 56
5.2 Medical School Applicants and Matriculants 57
5.3 Relationship of GDP and Physician Ratio: Active Physicians
per 100,000 of Population and Gross Domestic Product per Capita
(1996 Dollars) in the United States, 1929–2000 58
5.4 U.S. Population Growth 59
5.5 Population Growth of People over age 65 Years, 2000–2020 60
5.6 Retiring Doctors 61
5.7 New Medical School Graduates 62
5.8 Total of Doctors Practicing Each Year 64
5.9 Illustration of Methodology Used in Calculating Physician Supply 65
7.1 Thoracic Surgeons 76
7.2 Applications for First-Year Posts: Thoracic and Cardiovascular Surgery 77
8.1 Cochlear Implant Device 79
8.2 Tracheostomy 80
8.3 Supply of Otolaryngologists 82
9.1 Numbers of ART Cycles Performed, Live-Birth Deliveries,
and Infants Born through ART, 1996–2004 86
9.2 Populations and Numbers of Obstetrics and Gynecologists 88
9.3 Caesarian Rates for First Births, for All Women and Low-risk Women:
United States, 1990–2003 91
10.1 Surgical Incision for Radical Mastectomy in 1960 94
10.2 Breast Cancer Now 95
10.3 Gallbladder Incisions—1960 96
10.4 Incisions for Minimally Invasive Gallbladder Surgery 97
10.5 Forecasted Increases in Work by Specialty 100
10.6 Decreasing General Surgical Workforce with Increasing Population
of the United States 101
12.1 Production Rates of Urologists and General Surgeons 112
13.1 Traditional Pathway for Residency Training 115
14.1 Shortages 128
14.2 Medical School Enrollments and Forecasted Medical School Additions
by State, 2006 129
14.3 Physicians Working Part Time, 2005–2006 131
14.4 GME Graduates Pursuing Additional Training 135
List of Figures xi
14.5 Residents “Significantly Concerned” about Availability of Free Time

in Future Practice Setting 136
14.6 Hospitals Extending Information Technology Benefits to Physicians 141
14.7 Physicians Over 55 Years and Retirement 142
15.1 Median Wait Times for Patients from Referral by General Practitioner
for Treatment by Specialty 153
List of Tables
1.1 Physician Shortages 4

2.1 Leading Causes of Death 11
2.2 Incidence of New Cancer Cases and Deaths 12
2.3 Physician Requirements by Medical Specialty 20
3.1 Years in Training 23
3.2 Demographics of the Emerging Surgical Workforce 23
3.3 First-Year Positions 24
3.4 U.S. Physician and International Medical Graduates
Population Overview 26
3.5 The American Boards of Medical Specialties Certificates Issued
in Surgical Specialties 28
3.6 The American Board of Thoracic Surgery Certification Data:
1996–2008 30
3.7 Mean Stipends for Residents, 2007 30
3.8 Comparison of Resident Salary with other Occupations from
May 2007 National Occupational Employment and Wage Estimates 31
4.1 Medical School Tuition, First-Year Students, 2008–2009 33
4.2 Tuition and Fees: Current Dollars and Constant 2004 Dollars 33
4.3 Single Greatest Source of Professional Frustration 37
4.4 Choice of Specialty and Lifestyle 38
4.5 Surgical Compensation 40
4.6 Hospital Reimbursements 41
4.7 Surgeon Reimbursements 42
4.8 Medical Malpractice Claim Disposition and Defense Costs, 2007 44
4.9 Rising Premiums after One Year of Capping Jury Award in Ohio 46
5.1 Physicians Needed by Decade 61
xiv List of Tables
5.2 Retiring Doctors 62

5.3 New Physicians Added 63
5.4 Total of Practicing Doctors 64
5.5 Shortage Estimates 65
6.1 35 Years to Retirement for Orthopedic Surgeons 69
6.2 30 Years to Retirement for Orthopedic Surgeons 69
7.1 35 Years to Retirement for Thoracic Surgeons 74
7.2 30 Years to Retirement for Thoracic Surgeons 74
8.1 35 Years to Retirement for ENT 81
8.2 30 Years to Retirement for ENT 82
9.1 35 Years to Retirement for OB/GYN 88
9.2 30 Years to Retirement for OB/GYN 89
10.1 35 Years to Retirement for General Surgeons 98
10.2 30 Years to Retirement for General Surgeons 98
11.1 35 Years to Retirement for Neurosurgeons 105
11.2 30 Years to Retirement for Neurosurgeons 106
12.1 35 Years to Retirement for Urologists 109
12.2 30 Years to Retirement for Urologists 110
13.1 Changes in the Add-on Percentage of Indirect Medical
Education Adjustment as Set by BBA-1997, BBRA-1999,
and MPDIMA-2003, 1997 to 2008 119
13.2 Graduate Medical Education Costs for Training Residents 122
13.3 Present Costs for Surgical Residents 124
13.4 Specialists, Shortages, and Cost of Training 125
14.1 Increasing First Enrollment to 22,000 Places 130
14.2 45 Years to Retirement for Doctors 133
A.1 Retiring Doctors 159
A.2 New Physicians Added 161
A.3 Total of Practicing Doctors 163
Series Foreword
CONTEMPORARY HEALTH AND LIVING

Over the past 100 years, there have been incredible medical breakthroughs
that have prevented or cured illness in billions of people and helped many
more improve their health while living with chronic conditions. A few of the
most important 20th century discoveries include antibiotics, organ transplants
and vaccines. The 21st century has already heralded important new treat-
ments including such things as a vaccine to prevent human papillomavirus
from infecting and potentially leading to cervical cancer in women. Polio is on
the verge of being eradicated worldwide, making it only the second infectious
disease behind smallpox to ever be erased as a human health threat.
In this series, experts from many disciplines share with readers important
and updated medical knowledge. All aspects of health are considered includ-
ing subjects that are disease specific and preventive medical care. Disseminat-
ing this information will help individuals to improve their health as well as
researchers to determine where there are gaps in our current knowledge and
policy makers to assess the most pressing needs in healthcare.
Series Editor Julie K. Silver, M.D.

Assistant Professor
Harvard Medical School
Department of Physical Medicine and Rehabilitation
Foreword
The Coming Shortage of Surgeons provides a comprehensive look at one of

the major ailments afflicting the U.S. health care system: a potential surgical
workforce shortage that may leave many Americans with limited access to ap-
propriate and necessary surgical services. The authors are to be commended
for tackling this complex issue and for communicating the related problems
clearly and forcefully.
This book offers a detailed overview of how the government, economists,
and nonsurgeon academics have miscalculated the number of surgeons who
will be able to care for the growing and aging U.S. citizenry. An older popu-
lation means more people with chronic medical conditions, and, therefore,
a greater demand for health care services. Other developments that the au-
thors identify as drivers of an increasing demand for medical and surgical
services include economic expansion and technological innovations. A sig-
nificant segment of this country’s population, who are either economically
comfortable or wealthy, will want and will pay for the latest procedures, even
if our economy should remain on shaky ground for the foreseeable future
and years beyond.
The authors also pinpoint the reasons why patient demand is steadily out-
pacing physician supply. One explanation is a growing reluctance among medi-
cal students to enter surgical training because of concerns about the level of
debt, the unbalanced lifestyle, the decreases in reimbursement, and the mal-
practice worries they will experience in surgical practice. Meanwhile, many
international medical school graduates are returning to their native countries
and more established physicians are retiring, largely due to the same payment
and liability issues that trouble prospective surgeons. These elements combine
to yield a shrinking pool of surgeons.
In addition, the authors offer an in-depth look at the workforce issues for
seven specialties of surgery, probing the potential demand for each specialty’s
services in the coming years. They also explore the effects of the Balanced
Budget Act of 1997 on residency programs and the problems besetting the
xviii Foreword
nation’s emergency departments (EDs) due to a dearth of physicians willing

and able to take call.
Most importantly, the authors do more than outline the symptoms of the
workforce shortfalls. They also address the causes and effects of our current
condition.
Determining how many physicians the United States will need 10, 20, or
40 years from now requires more than number crunching; it also calls for
foresight. For instance, workforce analysts need to take into account the fact
that continued innovation in pharmacology and technology will make some
of the practices, procedures, and operations performed today obsolete tomor-
row. Consequently, the workforce will need to evolve and adapt and become
more nimble and malleable. Most likely, surgeons will be performing fewer
operations and will need to expand their practices to include other treatment
options that have been uncovered through comparative effectiveness research
and other types of evidence-based medicine.
The surgical profession and our training programs also need to respond to
the wants and needs of a new generation that considers having a balanced life-
style to be of paramount importance. In addition, we must reevaluate where
and how residents are being trained. As the authors note, many physicians
train in major urban areas under the supervision of highly specialized sur-
geons. As a result, fewer surgeons are able to perform the broad range of
procedures needed to treat conditions they are likely to see in an ED or a rural
hospital, further complicating the maldistribution of physicians.
I particularly appreciate the authors’ “letter to all surgical residents,” which
really emphasizes the need to focus on developing competencies and becom-
ing board certified. As long as surgical residents center their attention on these
goals, they will have plenty of opportunities to enjoy future success in the
surgical profession.
In all, the authors have done a remarkable job of drawing attention to the
vicissitudes of today’s workforce and to their implications. Furthermore, The
Coming Shortage of Surgeons lays out sensible goals for creating a sustainable,
reliable, and competent surgical workforce that will be capable of providing
high-quality care to an evolving patient population.
Thomas R. Russell, M.D., FACS

Executive Director,
American College of Surgeons, Chicago, IL
Preface
In the research for Consumer Driven Health Care, we realized that we would
be facing a shortage of physicians in the next 45 years. We set out to estimate
what the shortages of surgeons will be.
Although physician extenders, nurse practitioners, nurse midwives, physi-
cian assistants, and nurse anesthetists can extend health care ably to many
patients, nonetheless, there remain some specialties of medicine for which
trained physicians are required. Pathology and radiology are two examples in
which the image interpretation abilities of the pathologist or radiologist are
critical.
The same is true of surgeons. Not only are their surgical skills in the operat-
ing rooms essential, so also is their judgment of when, or when not, to conduct
a surgical procedure on a patient. We will elaborate on some of the factors
affecting the supply of surgeons and what must be done about this.
Acknowledgments
The authors wish to thank the many people who have been so helpful to us, par-
ticularly Chris Paul, Bernadine Healy, Richard Cooper, Roger Blackwell, Steven
Scheiber, Michael Pine, Don Fry, Wiley “Chip” Souba, Steven Gabbe, Benjamin
Sun, Dick Briggs, Allen Damschroder, Steve Dutton, Michelle Keith, Gerald
Medlin, Alan Ayers, Gary Bos, John Makley, Chris Copeland, Walter Hull, Jerry
Kakos, Bill Gay, Rob Michler, Bill Winnenberg, Mary Jo McElroy, Melanie Ken-
nedy, Dave Kelly, Molly Feuer, Steve Moon, Jerrry Johnson, Ron Ferguson, Rob-
ert Beran, Harry Siderys, Bob Falcone, Melinda Willis, Renee Troyer, Sueann
Treiber, Steve Cotter, Varsha Krishnasamy, Sylvia Kolbes, Andrew Thomas,
Kamal Pohar, Garth Essig, Atul Grover, and E. Antonio Chiocca.
This effort was partially supported by a grant from the Columbus Medical
Association Foundation for “Utilization of Operations Research Techniques in
Clinical Medicine.”
Acronyms
FACS Fellow American College of Surgeons

GDP Gross Domestic Product
OB/GYN Obstetrician and Gynecology
ENT Otolaryngologist
FMG Foreign Medical Graduate
IMG International Medical Graduate
MHA Merritt, Hawkins, and Associates
ABTS American Board of Thoracic Surgery
ACGME Accreditation Council for Graduate Medical Education
GME Graduate Medical Education
FTE Full-Time Equivalent
HIPAA Health Insurance Portability and Accountability Act
AAMC Association of American Medical Colleges
AMGA American Medical Group Association
AAOS American Association of Orthopedic Surgeons
AATS American Association for Thoracic Surgery
STS Society of Thoracic Surgeons
MGMA Medical Group Management Association
CMS Centers for Medicare and Medicaid Services, formerly known
as the Health Care Financing Administration (HCFA)
1
The Problem
Early one afternoon in the year 2030 your daughter calls. She is crying. You’re
afraid it’s related to her breast cancer.
“What happened?” you ask.
“I called the surgeon’s office for an appointment.”
“What happened?”
They said, “Do you belong to our SAM’s club?”
“What?”
“SAM’s club is their Surgical Access Management business. I’m not a mem-
ber and therefore I could not get an appointment for three months.”
The era of doctors working 60 to 80 hours per week and being at the
mercy of the telephone, 24 hours per day, 365 days per year, is over. Medi-
cal students are looking for a more scheduled lifestyle that will allow them to
coordinate activities for two income families.
The authors are surgical educators. We see a time, not too many years
away, when people will face the rationing of surgical care. This will result in
long waiting times to obtain a doctor’s appointment, or pay access fees to get in
line for surgical care. In fact, these things are already happening in primary
care. It is called concierge or boutique care.
What do we mean by this? How have we arrived at this conclusion? It is
increasingly hard to get a doctor’s appointment. Medical recruiting firms find it
difficult to recruit surgeons, both in the cities and in rural locations. Hospitals
try to employ surgeons to meet the demands of their communities for trauma
care and to deliver babies. The baby boomers want service; how will they get it
if we don’t have enough surgeons? Somebody will think of a market solution.
How did we get to this point? How can we get out of it? How do we recover
from this situation? Let’s start at the beginning—medical school.
HAVE WE BEEN OUTSOURCING OUR DOCTORS OF MEDICINE?

In the late 1960s and early 1970s, many members of the medical commu-
nity believed that more physicians were needed to serve America’s growing
2 The Coming Shortage of Surgeons
health care needs. In response, states rushed to open new medical and osteo-
pathic schools and increased class sizes in existing schools. At the Ohio State
University College of Medicine, for example, freshman class enrollment in-
creased from 150 students in 1963 to 225 students in 1973. By the 1980s,
enrollment levels in existing schools and construction of new schools leveled
off due to a projected oversupply of physicians and has remained at the same
level for 25 years. In 2008, Ohio State’s medical school freshman class
enrollment is 210, slightly lower than its peak.
In addition to opening new medical schools and increasing enrollment,
America also found another way to solve its physician shortage—by export-
ing medical education to the poorer, emerging economies of the world and in
turn permitting international medical graduates (IMGs) to practice medicine
in the United States. Out of necessity these tactics were employed to deal with
workforce shortages in rural and underserved areas in the United States. It was
certainly cheaper to have other countries pay for medical education than to
fork out millions of dollars ourselves.
The United States has already debated and witnessed the offshore out-
sourcing of its auto and textile manufacturers, data processors, computer pro-
grammers, and financial analysts. The question for policy makers, Congress,
and the public is whether to persist in importing IMGs or ramp up both U.S.
medical school and graduate medical education funding, or a combination of
both.
The total enrollment of first year medical students in the United States has
not changed over the past 25 years at about 17,000 (Figure 1.1).
There are over 42,000 applicants, or more than 2½ for every avail-
able seat in medical school classes, which means that many qualified and
well-intentioned American college graduates never get a chance at a medi-
cal career.1 At the same time, hospitals and other health care institutions
hire physicians trained overseas, filling more than 25 percent of the nation’s
100,000 available residency posts with IMGs.2
This number could get even higher in the future because of the inability
to recruit enough U.S. medical graduates into primary care areas such as
pediatric and internal medicine programs.3 It is not as much a matter of
IMGs being foreigners, as of the 4,563 international medical school par-
ticipants in the national resident matching program who obtain residency
training positions, more than 50% are actually U.S. citizens.4 In fact, one of
the Caribbean medical schools has an entering class of 400 students, more
than any U.S. medical school, composed largely of American and Canadian
citizens.
Eighty-five percent of Post-graduate Year One matches in the National
Resident Matching Program are U.S. citizens,5 but 15 percent are not. A case
can be made for matching an American-educated pool of available medical
school applicants who are going to receive a standardized medical school
education that is geared towards diseases and illnesses treated in the United
States.
The Problem 3
Figure 1.1
U.S. Medical School Applicants
50,000
45,000
40,000
35,000
30,000
25,000
20,000
15,000
10,000
5,000
0
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
Applicants Matriculants
Source: Copyright © 2005, Association of American Medical Colleges http://www.aamc.org/
data/facts/2008/2008school.htm, accessed July 2, 2009.
Future Demand
While the supply of physicians remains constant or even declines, demand
on physicians’ time is likely to increase in the next few decades, especially
with the epidemics of lifestyle-associated illnesses such as heart disease and
cancer—America’s two most common causes of death. Medical science has
provided us with new treatments and cures for some of these diseases and
other treatments that prolong life, but such advances come at the expense
of ongoing care. Demand for these services is likely to increase, especially in
critical care areas such as cardiac disease, including chronic congestive heart
failure, and cancer.
In 1980 400,000 patients were hospitalized for heart failure. By 2000,
this rose to almost 1,000,000.6 In addition, these patients require continuing
care at least every six months and probably every three months for optimum
control of heart failure.
In 2004, cancer overtook heart disease in age-adjusted death rates, and
is now the leading killer of Americans under the age of 85.7 More cases of
cancer are being discovered, and the cancer five-year survival rates have risen
from 50 percent to 64 percent in the last 25 years. As a result of advances
in science and patient care by oncologists and surgical specialists, there were
10,000,000 living cancer patients in the United States in 2000, each needing
follow-up visits at least every year.8
Steady medical school enrollment levels also ignore the fact that the popu-
lation of the United States has increased from 227 million in 1980 to 300
million in 2005—an increase of over 73 million people (Figure 1.2).
The Census Bureau predicts that the population of the United States will
reach 420 million by 2050, an increase of 40 percent from 2006.9
These and other trends lead us to project a shortage of 500,000 physicians
by the year 2050, shown below in Table 1.1.10
Figure 1.2
U.S. Population and First-Year Medical School Enrollments, 1980–2005
300
250
16,000
200
11,000 150
100
6,000
50
1,000 0
# first-year enrollments U.S. population
1980 2005
Source: AAMC, “U.S. Census Bureau and Medical School Graduates 2005,” Copyright © 2005,
Association of American Medical Colleges. http://www.aamc.org/data/facts/2008/2008school.
htm, accessed July 2, 2009.
Table 1.1
Physician Shortages
Physicians Physicians
Decade Population Needed Practicing Shortage
2010 309,000,000 883,740 787,600 96,140

2020 336,000,000 960,960 757,400 203,560
2030 364,000,000 1,041,040 727,200 313,840
2040 392,000,000 1,121,120 697,000 424,120
2050 420,000,000 1,201,200 697,000 504,200
Source: Roger D. Blackwell, Thomas E. Williams, and Alan Ayers, Consumer Driven Health Care
(Ashland, OH: Book Publishing Associates, 2005), 89–96.
The Problem 5
The standard method for measuring physician supply or demand in the

United States is calculating the physician-to-population ratio. Currently there
are 286 active physicians per 100,000 people in the United States. Based on
the increasing population, by 2050 we will need 1.2 million doctors in the
United States to maintain this ratio. Assuming that the average physician prac-
tices for 40 years from internship to retirement, and that American medical
schools will not increase their enrollment, our American medical schools will
be able to supply only 58 percent of the physicians needed in 2050. As stated
above, this will leave American citizens with a shortage of 500,000 doctors.
Who will fill this void? The calculations for these projections will be further
explained in chapter 5. Using his own methodology, Dr. Richard Cooper, for-
mer Dean of the Medical College of Wisconsin in Milwaukee, arrived at simi-
lar conclusions for projected physician shortages. In his paper, published in
November, 2004, he estimates the deficit of physicians will be approximately
200,000 by 2025.11
Changing retirement ages adds to the problem. The average age for
retirement for a general surgeon was 71 years of age.12 By 2000, it was 58.
A survey conducted by Merritt, Hawkins & Associates reported that among
physicians who are 50 years old, almost 50 percent of them are planning to
retire, limit their practices, or seek other nonclinical opportunities within the
next three years.13
How can a doctor limit his or her practice? Performing fewer procedures
or seeing fewer patients would allow a more manageable workload for an
aging physician. However, in today’s environment of skyrocketing malpractice
insurance premiums, a lower volume of procedures or patients seen would not
generate enough income to cover a physician’s malpractice cost. For instance,
a thoracic surgeon’s malpractice premium of, say, $110,000 is not dependent
on the surgeon’s volume of cases. For each open-heart surgery, the surgeon
is paid $2,200 and therefore must perform over 50 operations a year just to
pay his or her malpractice insurance premiums. Meeting these costs makes it
difficult for a surgeon to reduce the number of surgical procedures he or she
performs as retirement draws near.
Economically, it is nearly impossible to become a part-time physician or
surgeon unless the doctor’s entire overhead is covered by a health care institu-
tion. Because aging doctors do not want the long hours and overnight call that
is demanded of today’s physicians, yet cannot afford to reduce their practices,
many feel forced to retire prematurely or choose alternative careers.
With rapidly increasing demand, why don’t more people seek admission
to medical school?14 Debt is one reason. The average medical school debt for
the graduating class of 2007 was $139,517, an almost seven percent increase
from the previous year.15 Residents complete their training in general surgery
at about the age of 31, and earn approximately $200,000 over the course
of their residency. Attempting to pay off a debt of over $139,000 during
that time period is not feasible, as it leaves the resident only about $60,000
to survive on over five years. In contrast, a 21-year-old staff nurse who has
a four-year diploma or associate degree, as a licensed RN, can start at over

$40,000 per year and probably be earning $60,000 a year or more by the
age of 25 to 30. Part of the problem, of course, is that the current third-party
payer system doesn’t provide for medical education. Rather than invest more
than $100,000 in the education of a U.S.-trained physician, it is cheaper to
outsource the problem and hire a physician trained elsewhere. In periods of
shortages of nonphysician healthcare workers there has also been a reliance
on international trainees to increase the workforce for nurses, technicians, and
other medical personnel.
It’s time that the United States gets serious about helping individuals prepare
for healthcare careers, which involves innovative training programs, forgive-
ness of student debt, and greater utilization of “physician extenders,” including
nurse practitioners and physician assistants. Otherwise the United States will
be resigned to outsourcing its medical education to developing nations.
In the United States the number of applicants from medical school gradu-
ates for general surgery residencies dropped 30 percent between 1996 to
2002 (Figure 1.3).16 Will this happen to America’s entire surgical workforce?
Figure 1.3
Fourth-Year Medical Students Selecting General Surgery as Their Top Choice
Specialty
12
10
0
1996 1997 1998 1999 2000 2001 2002
% of students
Source: Brotherton SE, Rockey PH, Etzel SI.U.S Graduate Medical Education, 2002–2003. JAMA.
290:1197–1202, 2003. Copyright © American Medical Association. All rights reserved.
JAMA
The Problem 7
Lawyers versus Doctors

This comparison is not about malpractice or malpractice premiums; it is
about numbers. Stephen T. Schreiber, Executive Vice President and Chief Op-
erating Officer Law School Admission Council, and the Director of the Law
School Admissions Test, referred us to the American Bar Association’s Web
site.17 In 2004, the first year enrollment in law schools in the United States
was 48,239 and between 75,000 and 100,000 people apply to law school
each year. If you examine the statistics, since 1990, law school enrollment for
the first year is almost three times that of medical school enrollment. By way
of comparison, there are nine law schools and seven allopathic and osteopathic
medical schools in the state of Ohio. The lawyer versus doctor comparison
serves to demonstrate just how severe this numerical disparity has become.
Based on current trends, which forecast a growing demand for physicians of all
types, especially surgeons, it is increasingly clear that at present rates of physi-
cian training demand will vastly outstrip supply in the near future.
A striking similarity, however, is the growing number of professionals in
both professions who are dispirited and considering retiring or changing
occupations. The number of law school applicants has dropped from 98,700
in 2004 to 83,500 in 2006, a 6.7 percent drop. Forty-four percent of lawyers
would not recommend their profession to younger people.18
Why It Matters
We are facing the “perfect storm” gathering in the shadows of the health
care profession. That is a rationing of health care services brought about by
an inadequate supply of doctors graduating from medical schools to fill the
100,000—110,000 residencies in the United States. The number of trained
surgical specialists needs to be increased but the Balanced Budget Act of 1997
fixed the number of residencies in the United States at 1996 levels.
Patients will face the rationing of health care services. That rationing will
be either by waiting for a long time or failing to get an appointment for
an appropriate surgical specialist. If the United States doesn’t have enough
surgeons to perform operations, patients will face massive lines waiting for
surgical services all over the country, and particularly in rural areas.
This could also be an unsolvable problem both for employers and their
employees. It could result in more access fees, in addition to hospital fees and
surgical fees. Hospital administrators will find it difficult to recruit some if not
all of the surgical specialists they need. To do so, administrators must offer a
fair salary and all the benefits, including a pension plan, perhaps educational
debt forgiveness, a signing bonus, and in highly competitive areas even consid-
ering paying for the education of the specialists’ children.
Certainly, this is a problem with no quick or cheap solution. If we have
universal insurance with all doctors salaried, there is no incentive to take care
of patients after 40 hours of work a week. We cannot solve the problem
of access to surgical specialists without an appropriate and adequate surgical

workforce.
One of the biggest factors contributing to a shortage of surgeons is the issue
of work/life balance. Many of these students will be married and part of a two
income family. They have to have some time for family life. They will not work
the 60 to 80 hours a week worked by the previous generations of surgeons.
In fact, one parent must be home to meet the kids, take them to their music
lessons, take them to athletic practices, and be there for them through the nor-
mal stresses of growing up. Another alternative is to hire a nanny, but to do
so is very expensive and denies parents the pleasure of raising their children.
Work/life balance is the most meaningful consideration for medical students
when selecting their residencies, as we will see later in the book.
OUTLINE OF THE BOOK

As you see, the thrust of this book is medical demand, physician supply,
and, above all, access to your doctor or surgeon.
In chapter 2, we discuss Medical/Surgical Demand as it applies to the physi-
cian workforce.
Chapter 3 is titled “Surgical Supply: Residents—The Future Surgeons.”
In chapter 4, we discuss some of the pertinent issues that constrain the
future medical/surgical workforce and the decision to apply for a residency.
These issues include malpractice insurance premiums, reimbursements of
surgical procedures, medical students’ debt, controllable lifestyle, culture,
gender, and retirement.
In chapter 5, we outline the assumptions and relevant parameters of the
model we have proposed for calculating physician shortages. We will also
discuss the algorithm, or the model, and take you through the steps we
took in calculating the original model for the shortages of doctors. You will
see how by using the model we can estimate the future supply of surgical
specialists.19
In chapter 6, we apply the same technique to orthopedic surgeons. Ortho-
pedic surgeons take care of bones and joints and perform hip replacements,
knee replacements, and reconstructive surgery for arthritis.
Thoracic and cardiovascular surgeons are the surgeons who treat lung can-
cer, heart disease, and diseases of the esophagus. They treat all the surgical
diseases in the chest. In chapter 7, we discuss thoracic and cardiovascular
surgery, including workforce estimates derived from the model.
Otolaryngologists (ENT surgeons), or head and neck surgeons, treat cancer
of the tongue and larynx and perform radical neck dissections. They also put
tubes in childrens’ ears. We cover their work estimates in chapter 8.
In chapter 9, we discuss obstetrics and gynecologists, the doctors who
deliver your babies.
General surgeons treat breast cancer, colon cancer, and diseases of the
abdomen. In chapter 10, we apply the same technique to general surgeons.
The Problem 9
Neurosurgeons treat brain tumors, brain trauma, and cervical (neck) spine
problems and are covered in chapter 11. Urologists treat both men and women
for incontinence and urinary problems and treat prostate cancer in men. Our
projections for this specialty are covered in chapter 12.
In chapter 13, we discuss the Balanced Budget Act of 1997; one of its
provisions capped the residencies available in the United States. This Act func-
tions like a valve to prevent the needed increase in training positions to meet
the demands of the future medical/surgical workforce. Every state requires
one or more years of postgraduate training for a resident to be eligible for a
medical license in that state.
In chapter 14, we attempt to synthesize this information and recommend
steps to increase the numbers of physicians in this country.
Finally, in chapter 15, we discuss the challenges and examine the conse-
quences if we fail to act.
2
Demand for a Surgical/Medical
Workforce
The scene is East Florida; there is a shortage of neurosurgeons; somebody

has to take trauma call—to be on hand for all sudden emergencies, includ-
ing potential neurological injury. A hospital employs two neurosurgeons for
$1 million a year each. The hospital then pays for their malpractice and
health insurance and gives them retirement benefits, and in return they
agree to be on call. Why can neurosurgeons command this salary and these
benefits? It is a case of high risk and little reward. Many patients in large
hospitals are uninsured, the reimbursement for doctors’ fees is very low,
and—perhaps even more importantly—there are more malpractice suits. So
why don’t the neurosurgeons go into private practice? The reimbursements
in private practice do not provide the same financial benefits.
Previous projections of the need for physicians have relied on various sce-
narios estimating the demand for their services.1 Although there is no ideal
measure, demand has been inferred by using population-to-physician ratios,
work hours, and procedural or office visit time studies for typical illnesses or
similar issues. The stakes are high in being able to correctly predict public
demand for these services as there is a substantial lag, often a decade or more,
between changing the number of physicians permitted in residency programs
and completion of training programs allowing the trainee to enter practice and
be counted as part of the available supply of doctors. Chronic illnesses such
as cancer and atherosclerotic cardiac and vascular disease will continue to re-
quire significant resources in the foreseeable future and therefore make it ex-
ceedingly difficult to accurately predict the demand for physicians’ services.
SETTING THE STAGE

As shown in Table 2.1, of the top 10 leading causes of death, surgeons treat
the following: heart disease, circulatory disorders such as peripheral arterial
disease (vascular disease in diabetes causing gangrene, for example), cancer
(malignant neoplasms), cerebrovascular disease (carotid artery disease causing
Demand for a Surgical/Medical Workforce 11
Table 2.1
Leading Causes of Death
Heart disease: 652,091

Cancer: 559,312
Stroke (cerebrovascular diseases): 143,579
Chronic lower respiratory diseases: 130,933
Accidents (unintentional injuries): 117,809
Diabetes: 75,119
Alzheimer’s disease: 71,599
Influenza/Pneumonia: 63,001
Nephritis, nephrotic syndrome, and nephrosis: 43,901
Septicemia: 34,136
Source: CDC, National For Vital Statistics Deaths: Final Data for 2005, Tables C, 7, 30, http://
www.cdc.gov/nchs/FASTATS/deaths.htm (accessed June 30, 2008).
strokes), and some of both intentional (suicidal) and unintentional accidents

with injuries.2
The Scourge of Cancer

Cancer overtook heart disease as the leading killer of Americans under the
age of 85 in 2004.3 In the United States, half the men and one-third of the
women will have cancer in their lifetimes.
Table 2.2 shows the incidence and estimated number of deaths on an
annual basis caused by some of the most common forms of cancer.4 In the
digestive system, the most common cancer is cancer of the large intestine, the
colon. With regard to the respiratory system, the most common form of cancer
is carcinoma of the lung. Breast cancer is the most common cancer in women.
There has been a tremendous effort on the part of oncologists and surgeons to
try to cure those women afflicted with breast cancer, as shown in the five-year
survival rates in chapter 10.
The Burden of Chronic Disease

Are we winning the war on cancer?
Not yet. We are making tremendous progress in the treatment of cancer.
Five-year survival rates have improved, and Americans who have had cancer
are living longer. With regard to cancer, in the years since 1975 there has
been an extraordinary increase in life expectancy and five-year survival rates,
from 50 percent to 64 percent.5 As you can see in Figure 2.1, there are now
more than 10,000,000 people who have had cancer and survived in the
American population.6 These people must see their physicians at least once or
Table 2.2
Incidence of New Cancer Cases and Deaths
Estimated New Cases Estimated Deaths

Both Sexes Both Sexes
All Sites 1,437,180 565,650
Oral Cavity and Pharynx 35,310 7,590
Digestive System 271,290 135,130
Respiratory System, Including Lungs 232,270 161,840
Breast 184,450 40,480
Genital System, Including Prostate 274,150 57,820
Endocrine, Including Thyroid 39,510 2,430
Source: American Cancer Society, Cancer Facts and Figures, 2008, http://www.cancer.org/down
loads/STT/2008CAFFfinalsecured.pdf (accessed January 29, 2009).
Figure 2.1
Staying Alive
The number of living Americans who have had cancer diagnoses

has more than tripled since 1975.
10
Millions of Americans with
8
cancer diagnoses
0
1975 1980 1985 1990 1995 2000
Source: National Cancer Institute, http://seer.cancer.gov/statfacts/html/all.html (accessed July 3,
2009).
twice a year just to make sure their cancer has not recurred. It takes more and
more medical manpower, perhaps 5,000 doctors, to fill this need.
Heart Failure
Eugene Braunwald, in his Presidential Address to the American College of
Cardiology, used this graph (Figure 2.2) to emphasize the impact of congestive
Figure 2.2
Heart Failure Hospitalizations
600,000
500,000
400,000
Discharge
300,000
200,000
100,000
0
81 83 85 87 89 91 93 95 97 99 00
Women Men
Source: Reprinted from Braunwald, E. “Cardiology: the Past, the Present, and the Future.” Journal
of the American College of Cardiology, 42 (2003): 2031–2041, with permission from Elsevier.
heart failure on the utilization of resources in the American heath care sys-
tem.7 Hospitalizations due to heart failure for both men and women totaled
about 400,000 in 1980. By 2000, this had increased to about 1,000,000
hospitalizations. All these people must be seen regularly in their doctors’
offices to manage their condition and to eliminate or minimize the number of
hospitalizations for these patients, both for their health and to save money.
WHAT DOES IT COST?

In 2004, the total health care bill for the United States of America was
$1.9 trillion, 16 percent of Gross Domestic Product; by 2005 it had increased
to $2 trillion, and by 2007 more than $2.2 trillion, almost $7,000 for every
person.8
Let us dissect our health care expenditures. In Figure 2.3, we can see how
the health dollar for 2007, $2.2 trillion, was spent.
About $682 billion was spent on hospital services, $462 billion for physi-
cians services, and $220 billion for prescription drugs.
Who paid for this? You the taxpayer, you the employee, and you the citizen.
As shown in Figure 2.4, the total bill for Medicare, Medicaid, and SCHIP was
about $748 billion, one-third of health care costs for 2004. Including all other
public spending you, the taxpayer, spent $1.012 trillion. You, the individual or
employee, through your insurance, spent $770 billion, or three-quarters of a
trillion dollars. Finally you, the citizen, paid about $264 billion—12 percent—
out of your own pocket.
Figure 2.3
The Nation’s Health Dollar, Calendar Year 2007: Where It Went
Other
Spending
Program
25%
Administration
and Net Cost
7%
Prescription Hospital
Drugs Care
10% 31%
Nursing Home
Care Physician
6% and Clinical
Services
21%
Note: Other Spending includes dentist services, other professional services, home health, durable
medical products, over-the-counter medicines and sundries, pubic health, other personal health
care, research, and structures and equipment.
Source: Center for Medicare & Medicaid Services, Office of the Actuary, National Health Statis-
tics Group. http://www.cms.hhs.gov/NationalHealthExpendData/downloads/PieChartSources
Expenditures2007.pdf (accessed July 3, 2009).
Trauma is one of the nation’s most expensive surgical problems. Trauma

care now exceeds $70 billion annually.9 Our nation today faces a serious lack
of specialists—neurosurgeons, orthopedic surgeons, and general surgeons—
who see trauma victims. There are several causes for this: (1) Many patients
who visit emergency rooms are uninsured, yet they will sue specialists for
malpractice; (2) Malpractice premiums are very high for surgical specialists
including trauma surgeons; and (3) Being on call for trauma does not allow for
a controllable scheduled lifestyle.
WORKFORCE ISSUES
There are pro and con arguments about whether the state of the economy
drives demand for health care services or whether demand is physician in-
duced.10 Nevertheless, in order to have a rational approach to undertaking a
decision that involves billions of dollars and serious public health issues over
the next few decades, reviewing supply and demand of physicians at a basic
level seems warranted. If one views the supply and demand of physicians as
one would an accounting balance sheet, the assets side of the sheet would
include input into the health care market, such as new doctors from within the
United States, IMGs, and nonphysician personnel (Figure 2.5).
Figure 2.4
The Nation’s Health Dollar, Calendar Year 2007: Where It Came From
Other Public1 Other Private2

12% 7%
Medicaid and
SCHIP
15%
Private
Insurance
Medicare 35%
19%
Out-of-pocket
12%
Note: The numbers shown may not add up to 100.0 because of rounding.
Source: Center for Medicare & Medicaid Services, Office of the Actuary, National Health Statistics
Group. http://www.cms.hhs.gov/NationalHealthExpendData/downloads/PieChartSourcesExpen
ditures2007.pdf, accessed July 3, 2009.
On the liability side of the balance sheet, entries such as early retirements,
death, disability, and those changes that lead to a reduced work output would
be listed. However, similar to a balance sheet there are contingencies that
have to be disclosed to the reader that may materially affect the future value
of a company, such as uncertain liabilities, commitments, or other items. In
our scenario, the factors that may affect future projections of demand include
population growth, the country’s economic growth, productivity, technology,
trends in specialty choice, geographic distribution, and drastic changes in the
delivery of health care, such as universal insurance. Let us briefly review these
contingencies that may influence the demand for surgical specialties.
Population growth & aging. As we have previously discussed, the estimated
growth of the U.S. population according to the Census Bureau will be 309 mil-
lion by 2010, 336 million by 2020, and 420 million by the year 2050. What
has a significant impact on the demand side of the equation is the growth of the
population of people over the age of 65 years. The population growth curves
comparing people over age 65, about 50 percent, and those under 65, less
than 10 percent, diverge strikingly even in the next 10 years (Figure 2.6).
This difference is important because of the disproportionate utilization of ser-
vices by those over 65. The 54 million people over 65 in 2020 and the 70 mil-
lion by 2030 are likely to visit doctors twice as often as those under age 65.11
The mean number of diagnoses per visit and the mean number of drugs
Figure 2.5
Balance Sheet
Current Physician Supply
‘‘Asset’’ ‘‘Contingencies’’ ‘‘Liability’’

side of side of
balance balance
sheet sheet
Population
# of currently active physicians growth & # retiring
aging
Demand
# of new U.S. medical graduates for services # dying or disabled
Trends in
specialty
choice
# of IMGs # career change
Economic
growth
Technology
# of and role of physician extenders Productivity # reduced work hours/gender/lifestyle
Change in
health care
disruptive technology Delivery length of training & debt
model
Future Physician Supply

Legend: IMGs (International Medical Graduates)
mentioned at visits increased by 13 percent and 18 percent, respectively, in pa-

tients over the age of 45.12 The aged will require joint replacements (orthopedic
surgeons), coronaries and peripheral blood vessels bypasses or repairs (cardio-
thoracic surgeons or vascular surgeons), vision corrections (ophthalmologists),
and other common abdominal ailments attended to (general surgeons).
Productivity. An important contingency is the almost certain decline in
the physician work effort, which will occur due to several reasons. First, the
physician population is aging, as evidenced by the fact that one-third of cur-
rently practicing physicians are over 55 years old. Between 1982 and 2001,
the proportion of physicians 65 years and older increased from 8 percent
to 11 percent.13 Second, 48.3 percent of medical students14 and 28 percent
of practicing physicians15 are women. Women physicians work an average
of 20–25 percent less than men, particularly in surgical specialties.16 It is
estimated that gender distribution will reduce the effective supply of physi-
cians by 5 percent in 2010 and 7 percent in 2020.17 Third, both men and
women (particularly women) are opting for controllable lifestyles. In a survey
of medical students from 1996–2003, the percentage of women who chose
specialties with controllable lifestyles increased from 18 percent in 1996 to
Figure 2.6
Population Growth of People over age 65 Years, 2000–2020
60%
Percent Growth in Population
50%
Age 65+
40%
30%
20%
Age <65
10%
0%
2005 2010 2015 2020
Year
Source: U.S. Department of Health and Human Services Health Resources and Services Administra-
tion Bureau of Health Professions, “Physician Supply and Demand: Projections to 2020,” (Health
Resources and Services Administration, Department of Health & Human Services, October 2006).
36 percent in 2003.18 What makes the impact of lifestyle on any future calcu-
lations about supply and demand difficult is the fact that in the same survey,
the percentage of men who chose controllable lifestyles grew from 28 percent
in 1996 to 45 percent in 2003.
Economic growth. It is postulated that economic growth leads to expansion
of medical insurance coverage and therefore increases the demand for physician
services. In a series of cross-sectional analyses using regression with data from
all 50 states and several other countries, Cooper et al found a correlation be-
tween the number of physicians per capita and economic growth (Figure 2.7).19
Starting from an assumption that the existing historical ratio of physicians to
population reflects actual demand, the aforementioned researchers concluded
that every 1 percent increase in GDP per capita results in a 0.75 percent in-
crease in demand for physicians’ services. Some serious objections have been
raised based on the assumptions used, data limitations, and the possibly nonlin-
ear correlation between economic growth and physician demand.20
Technology. Advances in technology drive demand. The discovery of CAT
scans, MRI scans, PET scans, color-flow ultrasound, less riskier techniques
to biopsy breast lumps, and minimally invasive methods to remove diseased
organs such as gallbladders influence consumers to agree to interventions they
might have refused in the past. In addition, diagnostic scans frequently reveal
Figure 2.7
Relationship of GDP and Physician Ratio
350
300
250
200
#
150
100
50
0
1929 1960 1970 1980 1990 2000
Year
GDP Per Capita ($100s) Physicians/100,000 Population
Source: “Active Physicians per 100,000 of Population and Gross Domestic Product per Capita
(1996 dollars) in the United States, 1929–2000,” Health Serv Res 38(2) (April, 2003): 675–696,
http://www.pubmedcentral.nih.gov/articlerender.fegi?artid=1360909 (accessed July 2, 2008).
abnormal findings that lead to more procedures, often on a preventative basis.

Demand for imaging services is also often driven by patients pressuring physi-
cians or by defensive medicine. The estimated cost for imaging in the United
States is estimated at $100 billion.21 Similarly, total prescription sales in the
United States were estimated at $216.4 billion in 2003.22 While technology
often leads to shorter hospital stays and less pain for the patient, it also opens
the door to an increase in the volume of procedures or newer, more expensive
prescription drugs. It is impossible to look into the future and predict what
impact new technology will have on the demand for health care services.
Geographic distribution and specialty choice. A general accounting office
study in 2002 concluded that the physician population in the United States
between 1991 and 2001 increased 26 percent, which was twice the rate of
the general population.23 However, disparities between metropolitan and non-
metropolitan areas persisted (Figure 2.8).
Twelve percent of the physician increase went to nonmetropolitan areas
and 88 percent of the increase went to metropolitan areas. Demand for sur-
gical specialists may change as the issue of lifestyle makes it more accept-
able for physicians’ families to settle in rural areas even though it generally
takes a large population base to support a specialist. However, since the rural
Figure 2.8
Physicians per 100,000 People, 1991 and 2001
300
267
250 239 242
214
200
150
122
99
100
50
0
U.S. Metropolitan Nonmetropolitan
areas areas
1991
2001
Source: PHYSICIAN WORKFORCE. Physician Supply Increased in Metropolitan and Nonmet-

ropolitan Areas but Geographic Disparities Persisted. Report to the Chairman, Committee on
Health, Education, Labor, and Pensions, U.S. Senate October 2003. http://www.gao-gov/new-
items/d04124.pdf (accessed June 20, 2008).
population is aging much more rapidly than the general population, there is
likely to be faster growth in percentage terms for specialist services compared
to demand for primary care physician services.24 For this reason, specialties
with the highest percentage growth are cardiology (33%) and urology (30%),
as shown in Table 2.3. Historically, 68 percent of graduates entered special-
ties.25 Factors usually considered in making a choice include lifestyle, income
potential, intellectual stimulation, family situation, prestige, and age/gender or
ethnic background of the physician.
Change in reimbursement and the health care delivery model. There is
no question that the type of insurance and the type of insurance plan a person
has determines his or her frequency of usage of the health care system.
The Health Resources and Services Administration, Department of Health &
Human Services has estimated per capita use of physician services under different
insurance scenarios after controlling for age and sex.26 Managed care plans and
exclusive HMO plans, for instance, were projected to use fewer of these services
Table 2.3
Physician Requirements by Medical Specialty
Base
Year Projected
Percent
Change from
Specialty 2000 2005 2010 2015 2020 2005–2020
Medical
Specialties 86,400 93,000 100,700 109,800 119,800 29%
Cardiology 20,600 22,200 24,200 26,700 29,600 33%
Other Internal
Medicine 65,900 70,800 76,500 83,100 90,200 27%
Surgical
Specialties 159,400 169,000 179,900 192,000 205,100 21%
General Surgery 39,100 41,700 44,800 48,400 52,200 25%
Obstetrics/
Gynecology 41,500 43,100 44,800 46,000 47,200 10%
Ophthalmology 18,400 19,700 21,200 23,100 25,200 28%
Orthopedic
Surgery 24,100 25,600 27,300 29,300 31,600 23%
Other Surgery 16,200 17,400 18,800 20,300 22,000 26%
Otolaryngology 9,800 10,300 11,000 11,600 12,400 20%
Urology 10,400 11,100 12,000 13,200 14,400 30%
Source: Adapted from U.S. Department of Health and Human Services. Health Resources and
Services Administration Bureau of Health Professions, “Physician Supply and Demand: Projec-
tions to 2020,” (Health Resources and Services Administration, Department of Health & Human
Services, October 2006).
compared to traditional fee-for-service plans. In theory, part of the reason that

recent estimates of physician oversupply were significantly off the mark is that
some experts projected that demand for services would be severely curtailed
with managed care. The public simply refused to buy into a delivery system
where their choice of their physician was dictated by an insurer or surrogate.
Demand for Nonphysician Services

In our book Consumer Driven Health Care, we noted a shortage of nurs-
ing personnel, physical therapists, speech therapists, and X-ray technicians.27
Peter Buerhaus, a nurse and a health economist, suggests that the supply of
nurses will peak in 2015, but the demand will exceed supply by 2–3 percent
per year, resulting in a shortage of 285,000 RNs by 2020 and a shortage of
500,000 by 2025.28 There is a huge shortage of pharmacists as well. The
Tennessee legislature has already approved the formation (the state’s second)
of a pharmacy school to be located at the University of Eastern Tennessee
in Johnson City.29 By 2020, Ohio will have 1,400 fewer pharmacists than
it needs. Nationally, the number is even more startling, with a shortfall of
157,000 pharmacists predicted.30 Nonphysician clinical occupations such as
pharmacists and nurse practitioners continue to grow in numbers and expand
their scope of practice. If physicians are more productive or focused on the
more complicated cases, then the number of these nonphysician clinicians is
important in any equation that tries to predict future demand for specialists.
Public Reaction
The general public is learning in a variety of media about an impending
shortage of both primary care and specialist physicians. Here is a sample of
what has been presented in the news media recently:
• “The shortage of surgeons is a particular threat to the health care of 54 million

rural Americans, medical specialists say. The impact often is most severe in
rural America, where only 9,334 of 211,908 physicians are general sur-
geons, according to AMA data. The Census Bureau defines rural as open
country or small towns with fewer than 2,500 residents.”31
• “You could be waiting weeks or months for a doctor’s appointment, travel-
ing further to get there and spending less time with your doc when you
do & that’s if you get to even see a physician! The reason—experts say we’re
headed for a doctor shortage in this country.”32
• “Michigan medical students getting slammed by mounting postgraduate debt
are shying away from areas of medicine that are in high need and demand,
but rank low on the doctor pay scale, a state association asserts.”33
• “The country needs to train 3,000 to 10,000 more physicians a year—up
from the current 25,000—to meet the growing medical needs of an aging,
wealthy nation, the studies say. Because it takes 10 years to train a doctor,
the nation will have a shortage of 85,000 to 200,000 doctors in 2020 un-
less action is taken soon.”
• “The nation now has about 800,000 active physicians, up from 500,000 20
years ago. They’ve been kept busy by a growing population and new proce-
dures ranging from heart stents to liposuction.”34 The supply of physicians
will shrink in about 10 years when doctors from the baby boom generation
retire in large numbers. Today, new physicians roughly equal the numbers
of doctors retiring.
Finally, from the previous article in USA Today is a quotation by Dr. Richard
Cooper, a former medical school dean, that sums up the picture: “It’s foolish to
limit doctors as a way to control health care costs . . . doctors don’t drive medi-
cal costs. . . . sickness does . . . we face at least a decade of severe physician
shortages because a bunch of people cooked numbers to support a position
that was obviously wrong.” Cooper continues, “This is a desperate situation.
And we need to act now because it takes a long time to train a doctor.”35
3
Surgical Supply: Residents—The
Future Surgeons
The scene is New York in the mid 1990s; a resident makes a mistake and sub-
sequently the state laws change and the American residency systems change
to enforce an 80 hour residency work week. Before that residents in surgery
worked 100 to 150 hours a week. Mistakes were made when they were tired.
What does this have to do with the supply and demand of surgeons? Plenty,
as we shall see.
RESIDENCIES
Internships and residencies can begin as soon as a doctor graduates from
medical school. In the senior year of medical school, medical students inter-
view at selected residency programs and enter the National Residency Match-
ing Program (NRMP), which matches applicants with training institutions. Most
residencies are three to five years in duration. The period of residency extends
from four years in obstetrics and gynecology (OB/GYN) to seven years in tho-
racic and cardiovascular surgery. Otolaryngology (ENT, ear, nose, and throat),
orthopedic surgery, general surgery, and urology take five years (Table 3.1).
Neurosurgeons train for six years. These are the surgery specialties we will
cover in this book. A fellow is a doctor who takes one or more years of post
graduate training after completing his or her residency, such as a fellowship in
plastic or vascular surgery.
Demographics of the resident workforce. In 2007, there were a total of
17,359 (51.7% male and 48.3% female) medical school graduates in the
United States.1 The demographics of the surgical workforce are shown in
Table 3.2. The table shows the following specialties: obstetrics and gynecology,
orthopedic surgery, otolaryngology (ear, nose, and throat), general surgery,
thoracic surgery, neurosurgery, and urology. The total number of programs
for each of those specialties is shown in column 2; that is, 250 in OB/GYN,
104 in otolaryngology, 152 in orthopedic surgery, 251 in general surgery,
118 in urology, 97 in neurosurgery, and 85 in thoracic surgery. The total
Surgical Supply 23
number of resident positions available is shown in column 3 and range from

282 in thoracic surgery to 7,651 in general surgery. The number of females
in each residency varies from 33 in thoracic surgery to 3,596 in OB/GYN.
In fact, females comprise almost 75 percent of the resident workforce in OB/
GYN. U.S. medical graduates, Canadian graduates, and osteopaths who select
Table 3.1
Years in Training
Specialty Years in Residency
OB/GYN 4
ENT 5
ORTHO 5
GENERAL 5
UROLOGY 5
NEURO 6
THORACIC 7
Source: http://www.abms.org/Who_We_Help/Consumers/About_Physician_Specialties/orthopae
dic.aspx; www.abns.org, www.abog.org, www.aboto.org, www.abos.org, www.absurgery.org, www.
abu.org, www.abts.org
Table 3.2
Demographics of the Emerging Surgical Workforce
Total Number of
Number of USMDs,
Total Residents’ Number of Canadians, and Number of
Number of Positions Females Osteopaths IMGs
Specialty Programs Available % % %
OB/GYN 250 4,739 3,596 75.9 3,735 78.8 1,004 21.2

ENT 104 1,292 352 27.5 1,256 97.2 36 2.8
ORTHO 152 3,187 367 11.5 3,114 97.7 73 2.3
GENERAL 251 7,651 2,275 29.7 6,189 80.9 1,462 19.1
UROLOGY 118 992 212 21.4 956 96.4 36 3.6
NEURO 97 881 95 10.8 789 89.6 92 10.4
THORACIC 85 282 33 11.7 221 78.4 61 21.6
Source: “Resident Physicians on Duty in ACGME-Accredited and in Combined Specialty Medical

Education (GME) Programs December 1, 2006.” Journal of the American Medical Association
(September 5, 2007): Appendix II, Table 2. (3).
these residencies comprise close to 80 percent in OB/GYN, general surgery,

and thoracic surgery to almost 98 percent in otolaryngology, orthopedic, and
urologic surgery; around 20 percent of the surgeons who train in OB/GYN,
general surgery, and thoracic surgery are IMGs (international medical school
graduates).
Table 3.3 shows the number of first-year positions in Accreditation Council
for Graduate Medical Education (ACGME) accredited programs in 2007–8.
As an example, 118 first year positions in thoracic surgery, 152 positions in
neurosurgery, and 2,363 in general surgery were offered in 2007–2008.
Thoracic surgery requires a resident to be board certified in general surgery
before assuming thoracic surgery residency.
Origin of residency applicant pool. Of the entire current physician
workforce, 11 percent are osteopathic graduates, five percent are U.S.-born
IMGs; and 20 percent are foreign-born IMGs.2 So, approximately 65 percent
of the workforce graduated from a Liaison Committee on Medical Educa-
tion (LCME) school. The LCME is the national accrediting authority for
medical education training programs leading to the M.D. degree in U.S. and
Canadian medical schools. The LCME is sponsored by the Association of
American Medical Colleges (AAMC) and the American Medical Association
(AMA).3
U.S.-born IMGs
Typically, the U.S.-born IMG leaves the United States to go to a foreign
medical school because he or she is not able to gain admission to an ac-
credited medical school. These students subsequently return to the United
Table 3.3
First-Year Positions
Total Number of Residents’ Number of First-Year

Specialty Positions Available Positions
OB/GYN 4,739 1,225

ENT 1,292 262
ORTHO 3,187 637
GENERAL 7,651 2,363
UROLOGY 992 178
NEURO 881 152
THORACIC 282 118
Source: “Total Program Size and Number of First Year Positions Available in ACGME-Accredited
and Combined Special Programs for the Next Academic Year (2007–2008) as Projected by Pro-
gram Directors.” Journal of the American Medical Association (September 5, 2007): Appendix II,
Table 10. (3).
Surgical Supply 25
States and have to take ECFMG (Educational Commission for Foreign Medical
Graduates) certification in order to apply for an ACGME accredited residency
position.4 According to ECFMG data, there were 9,759 IMG applicants in the
NRMP for residency positions in 2007. Of these 6,992 were non-U.S. citizens
and 2,694 were U.S. citizens. Fifty percent of the U.S. citizens and 46 percent
of the non-U.S. citizens were eventually matched with an educational institu-
tion for residency training (Figure 3.1).5
Foreign-born IMGs
U.S. medical graduates generally apply to 5–10 programs, whereas the
non-U.S. IMGs submit their applications to a minimum of 25 programs.6 Only
14 percent of IMG applicants are granted interviews, and only 8 percent
Figure 3.1
National Resident Matching Program, 2008
12,000
10,000
8,000
6,000
4,000
2,000
0
Total Non U.S. U.S. Citizen
Participants Citizen IMG IMG
Participants Participants
# Participants # Matched
Source: National Resident Matching Program, Results and Data: 2008 Main Residency Match.
National Resident Matching Program, Washington, DC., 2008, http://www.nrmp.org/data/result
sanddata2008.pdf (accessed March 11, 2009).
of the entire applicant pool will be employed by an institution.7 Once ac-

cepted, successful applicants apply for an H-1B or a J-1 visa. The J-1 visa
is a temporary nonimmigrant educational visa reserved for participants in
the Exchange Visitor Program. Once recipients of J-1 visas complete train-
ing they are required to return home for at least two years before they
can apply for re-entry on another visa. A waiver from this requirement can
be obtained by seeking employment through a medically underserved area
(MUA) or Health Professions Shortage Area (HPSA) in the United States.8
IMGs comprise close to 40 percent of the physician workforce in inner city
areas in large metropolitan cities.9 However, there is concern among leaders
in academic medicine about the inconsistent quality of medical education
in international schools. In addition, as Dr. Fitzhugh Mullan, contributing
editor for Health Affairs puts it, “Rather than relying on foreign medical
school graduates to complete residency classes, the United States should
increase its output to fill the gap.”10 Most hospital credentials committees
will accept proof of an IMG’s board certification upon successful completion
of a residency training program in the United States and passing a certifying
examination administered by the appropriate board. The IMG can then be
approved for the hospital staff. An overview of the U.S and IMG population
is shown in Table 3.4. and is illustrated in Figure 3.2.
The proportion of IMGs who research and teach as academic faculty in U.S.
medical schools has remained fairly constant at 17 percent in 1981 and 18 per-
cent in 2000.11
American Board Certification

The number of board certificates given over the last 10 years in the spe-
cialties of obstetrics and gynecology, thoracic surgery, orthopedics, general
surgery, otolaryngology, urology, and neurosurgery is listed in Table 3.5. The
Table 3.4
U.S. Physician and International Medical Graduates Population Overview
Number of physicians in U.S. 902,053

Number of international medical graduates 228,665
(from 127 countries)
% of international medical graduates in U.S. 25.3%
% of international medical graduates in residency programs 28.2%
% of international medical graduates in primary care 37.6%
% of U.S. medical graduates in primary care 31.9%
% of international medical graduates in patient care 80.1%
% of international medical graduates in academics 16.2%
Source: Physician Characteristics and Distribution in the U.S., 2007 edition; AMA, Chicago, Ill.
Surgical Supply 27
Figure 3.2
Residencies
Graduates of Foreign and U.S. Medical Schools in

Residency Programs in the U.S. | 1985–2002
Number of graduates per year:
80,000
70,000
60,000
50,000
40,000
30,000
20,000
10,000
0
85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 00 01 02
U.S. schools Foreign schools
Graduates of Canadian medical schools and graduates of
osteopathic schools are included in the data for U.S. schools
Source: Blumenthal D. “New Steam from an Old Cauldron—The Physician-Supply Debate.” The
New England Journal of Medicine, 1533–4406, April 22, 2004, Vol. 350, Issue 17. Copyright ©
2004 Massachusetts Medical Society. All rights reserved.
average number of certificates awarded in the last 10 years ranges from less
than 150 per year in thoracic surgery and neurosurgery to 1200 in obstetrics
and gynecology. In orthopedic surgery, the number ranges from 625 to 650
board certified surgeons a year. In general surgery, it is about 1,000, and in
otolaryngology and urology, it is between 250 and 300.
The trend shows a level or decreasing number of certificates awarded each
year except in general surgery (Figure 3.3).12
A review of the American Board of Thoracic Surgery Certification Data
from 1996 to 2008 provides an example of how IMGs filled the gap in this
specialty (Table 3.6). During this time period, an average of 16 percent of
certificates were awarded to IMGs, with 25 percent awarded in 2008.
Work Hours
Probably the single greatest impact on training residents is the limitation on
the hours surgical trainees can work. A typical intern’s schedule in the 1960s
was more than 100 hours a week. The event that started legislative action
in New York State was in response to the death of a patient, Libby Zion, in
which resident physician fatigue was suspected as a factor. The state enacted
Table 3.5
The American Boards of Medical Specialties Certificates Issued
in Surgical Specialties
Year OB/GYN Eent Ortho General Urology Neuro Thoracic
1997 1,201 284 640 947 244 119 121

1998 1,220 282 645 1,001 261 137 168
1999 1,291 305 623 976 247 128 135
2000 1,214 321 639 1,043 290 124 126
2001 1,174 303 621 994 288 120 120
2002 1,119 310 631 995 262 143 162
2003 1,225 250 563 920 245 152 118
2004 1,049 274 594 1,068 255 139 152
2005 1,128 281 645 1,124 249 145 112
2006 1,105 259 593 1,266 211 128 134
Ten Year
Total 11,338 2,869 6,194 11,191 2,559 1,335 1,348
MEAN 1,171 288 628 1,028 255 134 139
Source: The American Boards of Medical Specialties, Member Boards, General Surgery Certificates
Issued 1995–2002; Available at http://www.abms.org/ (accessed July 4, 2009).
legislation limiting resident work hours to 80 hours per week. Following this, in
July 2003 the ACGME instituted standards for all accredited training programs
and introduced the same limitation. The average 80 hour work week applies to
all time spent in a hospital, including the clinic, operating room, and teaching
conferences. A resident can be on call no more than every third day on average
and must have at least 24 hours off a week.13 These restrictions are expensive
and difficult to enforce, and violations are frequent and not always reported.
The data on the impact of the new paradigm on mortality and morbidity
among patients is still not clear. A study of 3000 Medicare hospital admis-
sions compared mortality rates prior to and after the new standard showed no
difference in mortality.14 Another report on patient care in a Level 1 Trauma
Center noted a significant increase in total, preventable, and nonpreventable
complications after the 80 hour work week was instituted. No difference in
mortality was recorded. The authors of the Trauma Center study blamed the
higher complication rate in part on the reduced work hours for various rea-
sons, including poor communication or hand off between resident teams.15
In terms of the impact on the workforce, the fewer ‘man’ hours roughly
translate to a 20 percent reduction in work hours of the nation’s approximately
112,000 medical residents and fellows, which is equivalent to losing the work-
load of about 15,000 to 22,000 full-time positions.16
Surgical Supply 29
Figure 3.3
American Board Surgical Certificates Awarded
Certificates Per Year

1,500
1,200
900
600
300
0
1997 1999 2001 2003 2005 2007
ENT OB/GYN Ortho Urology

General Neuro Thoracic
Source: The American Boards of Medical Specialties Certificates Issued in Surgical Special-
ties. The American Boards of Medical Specialties, Member Boards. Available at http://
www.abms.org/ (Accessed July 4, 2009) and at http://www.abms.org/Who_We_Help/
Consumers/About_Physician_Specialties/orthopaedic.aspx, accessed 6/27/2009.
Source: www.abns.org, www.abog.org, www.aboto.org, www.abos.org, www.absurgery.org,
www.abu.org
Compensation of Residents
Residents’ salaries range from $40,000 to about $55,000 (Table 3.7).17
At 80 hours each week for 50 weeks of the year, a resident works 4,000
hours in a year. The average resident is therefore paid about $10.00 to $14.00
per hour for his or her time. Table 3.8 compares these wages with some skilled
labor wages as well as the wages of some comparable professions as published
by the Bureau of Labor Statistics.18
When trainees finish their residencies, they are between 28 and 35
years old. The typical career path includes 12 years of primary/secondary
school with a GPA that exceeds 3.5 and SAT scores greater than 1300,
four years of college premed courses, again with a GPA 3.5 or higher, and
four years of medical school. Three to five years of residency training is
often followed by one to two years of an additional subspecialty fellow-
ship. Doctors then look forward to paying down a median debt of between
$145,000 and $180,000, with 23 percent of students reporting a debt
principle in excess of $200,000.19
Table 3.6
The American Board of Thoracic Surgery Certification
Data: 1996–2008
Total No. of
Year Certifications U.S. & Canada Fmg/Img
1996 160 150 10

1997 121 108 13
1998 168 154 14
1999 135 119 16
2000 126 111 15
2001 120 97 23
2002 162 132 30
2003 118 104 14
2004 152 112 40
2005 112 86 26
2006 134 102 32
2007 116 94 22
2008 126 101 25
Total 1,750 1,470 (84%) 280
Source: Patricia Watson. American Board of Thoracic Surgery http://www.abts.org/sections/
Contact%20Us/index.html (accessed June 24, 2008).
Table 3.7
Mean Stipends for Residents, 2007
PGY – 1 Intern $44,000

PGY – 2 $46,000
PGY – 3 $48,000
PGY – 4 $52,000
PGY – 5 $54,000
PGY – 6 $54,000
Note: These are means based on a national survey by the AAMC; the actual figures can vary by
$3,000 to $4,000 on either side of the mean, and at times by more. Chief Residents may receive
an additional stipend of $2,000 to $3,500 a year.
Source: http://mdsalaries.blogspot.com/2005/10/residency-salaries.html (accessed June 23,
2008).
Surgical Supply 31
Table 3.8
Comparison of Resident Salary with other Occupations from May 2007
National Occupational Employment and Wage Estimates
Occupation Code Occupation Title Mean Hourly

Surgical Residents $10–14
51–4111 Tool and Die Makers $22.36
47–2041 Carpet Installers $19.21
47–2031 Carpenters $19.84
53–2021 Air Traffic Controllers $51.82
47–4021 Elevator Installers
and Repairers $31.89
47–2111 Electricians $23.12
23–1011 Lawyers $56.87
Source: http://www.bls.gov/oes/current/oes_nat.htm (accessed June 23, 2008).
CONCLUSIONS
Surgical residency training is long and arduous. In general, the compensa-
tion for residents at $10–14 an hour is lower than most occupations that
require comparable education. Certainly, a resident’s future income level is
higher compared to the occupations listed in Table 3.8 when they go into
practice. The debt burden is high. The reduced work hours for residents
reduce manpower by almost 20 percent. The number of board certified
surgeons is on a downward trend for U.S. and Canadian medical graduates.
The percentage of IMGs in U.S. surgical residencies has been gradually in-
creasing. With these demographics and the considerations of a “controllable
lifestyle,” as we will see in chapter 4, some authorities think we will need
1.3 full-time medical graduates to replace one medical graduate in today’s
workforce.
In addition to these implications, we must also increase residencies to serve
a population that will almost grow 40 percent by 2050. At the same time, the
implications of the figures with regard to American Board of Thoracic Surgery
(Table 3.6) suggest there will be even more IMGs with certificates granted
by the various American Boards. Therefore, the surgical workforce will be
increasingly populated by international medical school graduates.
What happens if the professional opportunities and/or the job market
for IMGs start to improve in their own countries? Will a larger percentage
decide to return to their cultures? We have already some evidence that they
will.
It behooves our policy makers and our government to make preparations to
deal with the crisis that is headed our way.
4
Constraints to Supply:
Pertinent Issues
A young surgeon graduates from her surgical residency. What does she face?
Well, let’s see: (1) Over $150,000 of debt; (2) malpractice premiums that
range from $75,000 to more than $200,000 per year; (3) reimbursement
rates that continuously go down; and (4) an uncertain work and call schedule,
in part, due to her partners’ early retirements.
Among the most pertinent issues we discuss in this chapter are factors that
influence potential applicants to consider medical school, such as medical stu-
dent debt and graduate medical education funding (covered in a later chapter),
which are both barriers to potential students. We consider issues that lead to
reduced workload during doctors’ careers, such as lifestyle and gender issues,
the influence of decreased reimbursement, and professional liability (malprac-
tice) on the choice of nonsurgical careers, some outside of clinical practice.
We review an alternative source of doctors, international medical graduates
(IMGs). Finally, we examine the potential of early retirement and its effect on
any projections for future manpower.
MEDICAL STUDENTS’ DEBT

The mean tuition and fees for first year medical students in both private
and public medical schools are shown in Table 4.1.1 In the public sector, the
mean tuition and fees for a medical student who is a resident of the state in
which the school is located is $18,748.00. For a nonresident of that state, it is
$37,984.00. With regard to private medical schools, the average tuition for a
resident is $37,869.00 and $38,337.00 for a nonresident.
The Association of Academic Medical Centers (AAMC) has determined that
between 1984 and 2004 the median private medical school tuition increased
by 50 percent (real dollars adjusted for inflation) and the median public school
tuition by 133 Percent (Table 4.2).
S— For the class of 2007, the average educational debt of those medical students
E— was $139,517, an increase of 6.9 percent over the previous year (Figure 4.1).2
L—
Constraints to Supply 33
Table 4.1
Medical School Tuition, First-Year Students, 2008–2009
Status Public Private

Resident $18,784 $37,869
Non-Resident $38,082 $38,337
Source: AAMC, “Tuition and Students Fees Reports. Table 1—U.S. Medical Schools Tuition and
Students Fees—First Year Students, 2008–2009 and 2007–2008,” http://services.aamc.org/tsfre
ports/report_median.cfm?year_of_study=2009 (accessed March 28, 2009).
Table 4.2
Tuition and Fees: Current Dollars and Constant 2004 Dollars
40,000
Private Schools
30,000
20,000
Public Schools
10,000
0
1984–85 1989–90 1994–95 1999–00
Constant dollars Constant dollars

Current dollars Current dollars
Source: AAMC, “Tuition and Students Fees Reports. Table 1—U.S. Medical Schools Tuition and
Students Fees—First Year Students, 2008–2009 and 2007–2008,” http://services.aamc.org/
tsfreports/report_median.cfm?year_of_study=2009 (accessed March 28, 2009).
Although only 23 percent of medical graduates are more than $200,000

in debt, with inflation-adjusted incomes for physicians falling, the anxiety level
of those who incur high debt burdens is palpable.3
It is therefore useful to look at repayment of this large debt from the point
of view of future practitioners. If a medical school graduate amortizes his or
her debt, say $130,000, after residency with the monthly payment spread
Figure 4.1
Median Medical Education Debt
Thousands of dollars per year:
$150,000
$120,000
$90,000
$60,000
$30,000
0
’84 ’86 ’88 ’90 ’92 ’94 ’96 ’98 ’00 ’02 ’04
Private Numbers have not been adjusted for inflation

Public No data available for 1991
Source: Median Medical Education Costs and Student Debt, Association of American Medical
Colleges, p. 5. Copyright © 2004.
over 10 years,4 his or her payment would be $1,827.00 per month with a
total interest cost of $104,257.00 and a total repayment of $219,258.00.
The maximum interest rate on these debts is 8.25 percent.5 Looking at the
projected loan repayments as a percentage of the physician’s after tax income
over the next 20 years, the debt service will account for 20 percent or more
(Figure 4.2). One of the general rules of family finance is that about 20–25
percent of income should be devoted to housing. A physician’s debt burden is
equivalent to an extra house payment every month until the debt is repaid.
Steve Dutton is the chief financial officer, and a partner, in the Don Casto
organization, a real estate firm in Columbus, Ohio, that develops properties
nationally. After reviewing a draft copy of this book he wrote the following in
an e-mail with regards to medical student debt:6
The thought that we discussed last night dealt with the idea of how to subsidize
the financing cost medical students incur, as an alternative to an outright forgive-
ness of the debt, which might have complicating negative political overtones.
Figure 4.2
Projected Loan Payments as a Percentage of Projected Physician After-Tax
Income
70%
60%
50%
40%
30%
20%
10%
0%
2003 2007 2011 2015 2019 2023 2027 2031
Public Assumptions: Indebtedness grows at historic rate of 8.3%

Private for public school students and 8.9% for private school
students; physician income grows at 0.6%; average tax
rate 33.4%; 30-year loans
Source: Medical School Tuition and Young Physician Indebtedness (An update to the 2004 Report),
Copyright © 2004, Association of American Medical Colleges, p. 6. AAMC.
Another way around the issue would be to lengthen maturities and lower the
interest rates on the debt. I thought that maybe this could be done by providing
a guarantee or other credit enhancement from a governmental agency—similar
to the way municipal bonds work. This would provide an investor with a tax free
return, hence a lower rate requirement. Also, the government backing should
cause the investor to be more comfortable with a longer term, and the ultimate
collectivity. Clearly, providing the city, county, state or nation with more compe-
tent doctors would be seen to serve the public purpose, and thus be a worthwhile
use of the agencies credit enhancing ability.
The legislature of the state of Pennsylvania passed such a bill in 2007.

Clearly the prospect of this enormous debt has an impact on the number of
people who choose to become doctors, particularly in attracting primary care
physicians and medical school applicants from less privileged backgrounds. The
debt crisis harms both medical students and patients. Some graduates want to
take shorter residencies (three years), like those for primary care physicians
(family doctors, internists, or pediatrics), in order to commence paying their

debt. Some others want, instead, to either seek specialties that offer higher
incomes or more leisure time. The problem of debt also compounds itself in
the decreased diversity of the physician workforce, which can prevent students
from low-income or minority families from attending medical school. Debt has
mental health implications as well. In an already exhausting training program,
the likelihood of having to moonlight (work for extra pay) is real and can be
extremely stressful. The level of a person’s debt correlates with symptoms of
depression and cynicism.7
Controllable Lifestyle and Gender: In Search

of Work /Life Balance
In today’s hustle and bustle world, which seems to leave little time for the
most important things, employees across industries seek to have greater con-
trol over their work/life balance. It’s one of the dominant themes found among
the cohort of young people of the baby boom echo currently in its teens and
20s, described by marketers as “generation X” or the Xers and “generation
Y” or the Millennials (born between 1984 and 1994). College students are
increasingly abandoning undergraduate premedical studies, often citing disil-
lusionment with the physician lifestyle. However, the choice of a career based
on concerns about lifestyle is true of professions other than medicine also.8
Unlike the days of old, when physicians owned their own practices and thus
set their own hours, hired their own staff, and built enduring relationships of
loyalty and trust with patients, physicians today, in a sense, are employees
of a third-party payer. The proportion of physicians with an ownership stake
in their practice decreased from 61.6 percent to 54.4 percent as physicians
opted for employment over the 10 year period from 1996 to 2005.9
Studies of physicians’ complaints include workload, administrative paper-
work, limitations on referring patients to specialists of a physician’s choosing,
financial incentives to curb medical work-ups, and the physician’s role as an
agent for insurers, government agencies, and courts (Table 4.3).
In a survey taken from Medical Economics in November 2005, the average
work hours per week were the highest, 60 hours, for cardiologists, general sur-
geons, OB/GYNs, neurosurgeons, and thoracic surgeons.10 The average work
week for orthopedic surgeons was 50 hours. Work hours were up and patient
visits were reported down in a recent survey.11 Why? Because of increased
paperwork.
Over 80 percent of part-time physicians work at least half a work week;
69 percent of female physicians and 11 percent of male physicians who
practiced part-time indicate family responsibilities as the reason for cutting
back.12 Male physicians also give unrelated professional or personal pursuits
(31%) and preparing for retirement (29%) as the predominant reasons for
working part time.
Facing these issues, why would anyone expect physicians to put in longer
hours than corporate lawyers, accountants, or other well-educated professionals?
Table 4.3
Single Greatest Source of Professional Frustration
2007 2004 2000
Long hours 15% 10% 4%

Malpractice worries 18% 28% 6%
Reimbursement issues* 33% 16% 56%
Medicare/Medicaid regulations** 13% 15%
Patient attitudes today 8% 5% 8%
Pressure of running a business 11% 10% 6%
Other 15% 9% 5%
N/A 9%
Source: 2007 Survey of Physicians 50 to 65 Years Old http://www.merritthawkins.com/pdf/
mha2007olderdocsurvey.pdf (accessed July 5, 2008).
Even when the income, working hours, and years of required training for a
medical career are considered, none approaches the impact of a controllable
lifestyle and the time to meet family responsibilities. In a 2003 study of spe-
cialty choices by U.S. medical students, the findings suggested a significant shift
in specialty preference between 1996 and 2002 (Table 4.4).13
In analyzing the second column (lifestyle) and the fourth column (average
work hours per week) in Table 4.4, it is obvious that the practitioners of special-
ties classified as uncontrollable work over 10 percent longer hours per week
with fewer scheduled hours than other specialists. The specialty preferences
of U.S. senior medical students reflect these lifestyle variables, particularly in
family practice and general surgery. For general surgery, the decline was from
10.4 to 7.6 percent, representing 300 fewer general surgeons training each
year and raising concerns about an adequate general surgery workforce. The
concern is even greater for family practice, with residency programs declining
from a 73 to 43 percent fill rate from 1996 to 2002.14
It is important to understand that a controllable lifestyle and professional
satisfaction do not necessarily go together. In a survey of Canadian physicians,
some specialties, such as radiation oncology and urology (which are perceived
as allowing for a better lifestyle), were actually specialties in which physician
groups were the least satisfied.15
Gender also plays a role in the choice of a specialty. However, both men
and women are choosing specialties with a more predictable and controllable
lifestyle.16 With regard to gender, this same survey showed the median num-
ber of hours worked per week by female doctors is 45, while the median
number of hours worked per week by male practicing doctors was 54. As you
can see, both sexes work more than 40 hours per week. When you have a two
income family, someone has to take the kids to basketball practice and music
lessons, and pick them up from school.
Table 4.4
Choice of Specialty and Lifestyle
Years of
Graduate
Average Average Medical
Income, $ in Work Hours Education
Specialty Lifestyle Thousands per Week Required
Anesthesiology Controllable 225 61.0 4

Dermatology Controllable 221 45.5 4
Emergency medicine Controllable 183 46.0 4
Family practice Uncontrollable 132 52.5 3
Internal medicine Uncontrollable 158 57.0 3
Neurolgy Controllable 172 55.5 4
Obstetrics and gynecology Uncontrollable 224 61.0 4
Ophthalmology Controllable 225 47.0 4
Orthopedic surgery Uncontrollable 323 58.0 5
Otolaryngology Controllable 242 53.5 5
Pathology Controllable 202 45.5 4
Pediatrics Uncontrollable 138 54.0 3
Psychiatry Controllable 134 48.0 4
Radiology (diagnostic) Controllable 263 58.0 4
Surgery (general) Uncontrollable 238 60.0 5
Urology Uncontrollable 245 60.5 5
Average for the above
specialties Not applicable 208 53.9 4
Source: E. Ray Dorsey, M.D., MBA, David Jarjoura, PhD, and Gregory W. Rutecki, M.D., “Influence
of Controllable Lifestyle on Recent Trends in Specialty Choice by US Medical Students,” JAMA, 290
(2003), http://jama.ama-ssn.org/cgi/content/full/290/9/1173/TABLEJOC30309T1 (accessed
July 16, 2008). Copyright © American Medical Association, All rights reserved.
How much will lifestyle and gender issues affect choice of surgical special-
ties, and what will that do to physician workforce supply?
REIMBURSEMENTS
The constant negativity projected by private practitioners and academic
physicians about declining reimbursement is bound to influence all potential
physicians as well as their relatives, friends, and neighbors and current medical
students and residents.
In 2008, according to Medical Group Management Association (MGMA),

specialists’ income unadjusted for inflation rose 3.16 percent in 2007, but
with a 2.85 percent rise in the Consumer Price Index, the increase in real dol-
lars was 0.31 percent. Primary care physicians’ incomes increased by 6.3 per-
cent unadjusted and 3.35 percent adjusted for inflation.17 A telephone survey
of over 6000 physicians by the Center for Studying Health System Change in
2006 showed that the average net income adjusted for inflation for all physi-
cians dropped 7 percent from 1995 to 2003 (Figure 4.3). In contrast, profes-
sional and technical workers saw a 6.9 percent increase in inflation-adjusted
income in the same period.
In comparison, income for nonphysician professionals increased 7 per-
cent during the same period.18 In the same survey it was noted that Medicare
reimbursements to physicians increased by 13 percent between 1995 and
2003—compared with a general inflation rate of 21 percent—and that reim-
bursements from private health insurers increased by less than 13 percent.
According to The American Medical Association (Figure 4.4), in 1984 physi-
cian income was reported as $165,000 in current dollars. In 2000 physicians
were making about $175,000 a year, again in current dollars, but purchasing
power of the 2000 dollars was only 50 percent of that of the 1984 dollars. In
other words, physicians had less disposable income in 2000 than they did in
1984.
The American Medical Group Association published these figures in 2007
for surgeons’ salaries (Table 4.5).19 There is no question that physicians are in
Figure 4.3
Report Finds Physician Income “Losing Ground” to other Professions
Change in inflation-adjusted income Study methodology

1995–2003
6.9% • Results of 1996–1997 telephone
survey of 12,000 physicians
compared against results from
2004–2005 survey of 6,600
All Medical Surgical
physicians PCPs specialists specialists physicians
Professional, • Physician income trends pitted
(2.1%) technical against U.S. Bureau of Labor
workers Statistics Employment Cost
Index data for professional,
specialty, and technical
(7.1%) workers.
(8.2%)
(10.2%)
Source: “Physician Income: Study Shows dip as CMS Proposes Reimbursement Changes,” © The
Advisory Board Company. All rights reserved. Reprinted with permission. http://www.advisory.
com/members/default.asp?contentID=60277&collectionID=798&program=5&filename=602
77.xml (accessed January 10, 2009).
Figure 4.4
Physician Income
$250,000
$200,000
$150,000
$100,000
$50,000
0
1984 1986 1988 1990 1992 1994 1996 1998 2000
Current dollars
Constant dollars
Source: Medical Educational Costs and Student Debt, p. 4. Copyright © 2004, Association of
American Medical Colleges.
Table 4.5
Surgical Compensation
Surgical Specialty Median
Orthopedics $436,481
Otolaryngology $327,399
Obstetrics and Gynecology $297,887
General Surgery $327,902
Thoracic and Cardiovascular Surgery $460,000
Neurological Surgery $530,000
Urology $365,999
Source: American Medical Group Association–2007. American Medical Group Association
Compensation Survey Data 2007 Report. Available at http://www.cms.hhs.gov/AcuteInpatient
PPS/Downloads/AMGA_2007%20Report.pdf (accessed June 27, 2009).
the top 10 percent of earners and at least half of all physicians earned more
than $170,000 in 2003.20 Nevertheless, when nurse anesthetists, who have
much less education, no primary responsibility, little overhead, and flexible
work hours earn more than physicians, the impact on budding physicians is
undeniable.21
Jack Matloff, M.D., presented this figure on reimbursement for cardiothoracic

surgeons for coronary bypasses in his presidential address to the Society of
Thoracic Surgeons in 2001 (Figure 4.5).22 The figure shows that reimburse-
ments have decreased 50 percent since 1987 without correction for the Con-
sumer Price Index, and with correction for the Consumer Price Index, more
than 75 percent.
Consider physician income relative to hospital reimbursements. As an
example, for an aortic valve replacement performed in the year 2000, a large
teaching hospital received about $35,000. By 2005, the hospital received
almost $45,000, an increase of about 26 Percent (Table 4.6). Similarly, for a
Figure 4.5
Reimbursements for Open Surgery
$4,000
$3,600
$3,200
$2,800
$2,400 -50%
$2,000
$1,600
-77.5%
$1,200
$800
1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002
Amount Amount
Corrected for Consumer Corrected for Consumer
Price Index Price Index
Source: Jack M. Matloff, “The Practice of Medicine in the Year 2010: Revisited in 2001,” Annals
of Thoracic Surgery 72 (2001): 1105–1112.
Table 4.6
Hospital Reimbursements
2000 2005 Increase Percent Increase
Aortic Valve Replacement $35,324.99 $44,506.89 $9,181.90 26.0%

CABGx3 including LIMA $25,213.06 $28,206.83 $2,993.77 11.9%
Source: Finance Office, Ohio State University Hospitals.
triple coronary bypass the hospital received $25,000 in 2000 and by 2005,
the reimbursement increased by $3,000, an almost 12 percent increase.
Now consider the reimbursement for the surgeon performing this very deli-
cate and life saving procedure (Table 4.7).
In 2000, the surgeon who performed the aortic valve replacement was
paid about $2,200. By 2005, that number had been reduced by almost $60
or 2.6 percent. Similarly, the surgeon that performed the coronary revascu-
larization got $2,300 in 2000, and by 2005 received about $2000 or about
9 percent less. When we graph the reimbursements shown in Tables 4.6 and
4.7 these decreases become even more vivid (Figure 4.6).
Decreasing reimbursement is one reason that more and more specialists are
becoming employees of hospitals and hospital systems. Specialists employed by
hospitals can make more money and are free of the hassles of administrating
Table 4.7
Surgeon Reimbursements
2000 2005 Decrease Percent Decrease
Aortic Valve Replacement $2,221.42 $2,162.96 ($58.46) 2.6%

CABGx3 $2,344.29 $2,132.77 ($211.52) 9.0%
Source: Executive Director 1986–2009, Ray Manley, OSU Surgery LLC.
Figure 4.6
Hospital versus Physician Reimbursement
51,000
41,000
31,000
21,000
11,000
1,000
CABG CABG AVR AVR
Hospital MD Hospital MD
2000 2005
Source: Chief Financial Officer Ray Manley, OSU Surgery LLC.

Figure 4.7
Average CV Physician Compensation per Physician Work RVU, 2002–2006
Nominal Dollars
CAGR: 1.3%
$54.27
$53.53 $53.78
$51.96
$51.01
$52.34
Real Dollars2
$49.99
$49.48 CAGR: 1.5%
$47.99
2002 2003 2004 2005 2006

Source: Physician-Hospital Alignment, p. 17. Advisory Board Company. All rights reserved.
Reprinted with permission. http://www.advisory.com/members/default.asp?contentid=74287&
program=2&collectionid=763 (accessed July 26, 2008).
an office and, of course, because they are in short supply, their actual wages are
more than what they could make in private practice.
The amount of work performed by physicians is measured by work units
called “work relative value units,” or WRVUs. The remuneration for cardiovas-
cular specialists has not kept pace with inflation (Figure 4.7). In the specialty of
thoracic surgery, physicians’ reimbursement has decreased nearly 50 percent
since 1991.23
This quote on current Medicare reimbursement projections was taken from
The Society of Thoracic Surgeons Web page March 14, 2006: “The Society of
Thoracic Surgeons . . . is seeking to institute a fair Medicare physician payment
formula. The Medicare payment freeze will only apply to 2006. In 2007, . . .
physicians could see a five percent payment cut. . . . Medicare trustees predict
six straight years of payment cuts ultimately totaling 26 percent.”24 And it
keeps on coming.
As an aside, an article in the Columbus Dispatch reported that, in New York
City, equity law partners took home nearly $770,000 in 2004.25 That is two
times what the average surgeon makes, according to the American Medical
Group Association figures. Now, would you trust your life to a lawyer? Only
on a capital offense.
The Medical Malpractice Problem

A constant concern for young people contemplating a medical career is the
threat of getting sued. Every time a patient has an operation, a sizeable part
of the patient’s bill goes to pay for malpractice insurance. Check the financial
statements of your hospital, and you will find the hospital is paying more,
often much more, for malpractice insurance than all of its utilities—electricity,
gas, and water—combined. Skyrocketing malpractice insurance premiums are
driving specialists out of some high-risk specialties, forcing part-time or semi-
retired physicians completely out of practice, and leaving some states without
critical specialties
Although some consumers perceive malpractice to be when a physician
is unable to bring about a cure for a patient, in actuality it is defined by
Merriam-Webster as “dereliction from professional duty or a failure to exer-
cise an accepted degree of professional skill or learning by a person (such as
a physician) rendering professional services, which results in injury, loss or
damage.”26 From the patient’s perspective, malpractice is a two-dimensional
problem.
First, the occurrence of actual malpractice is detrimental to a patient’s
health. Second, the increased cost of health care attributed to alleged or real
malpractice affects a patient’s costs.
About half of malpractice suits are regarded as nuisance suits that result
in no finding of fault and no award (although legal fees are still incurred).
More than 90 percent of cases are settled prior to trial, and only a very small
percentage are decided in favor of the plaintiff (Table 4.8).27
In Ohio, for example, of 4,004 claims closed in 2006, 80 percent were
closed with no indemnity payment; two-thirds of these were dropped or dis-
missed, and another 8.5 percent were dismissed by summary judgment or di-
rected verdict (Figure 4.8).28 Of the 20 percent that resulted in some payment,
18 percent were settled and only 1% ended with a verdict for the plaintiff.
The actual costs to the health care system are much greater because of
costs associated with “defensive medicine”—tests and procedures based on the
threat of litigation rather than medical need. In a poll of physicians by Harris
Interactive about the effect of liability issues on the quality of care, 79 percent
say they order unnecessary tests for this reason.29 “One dollar in litigation
costs corresponds to more than four dollars of unnecessary hospital costs re-
lated to defensive medicine.”30
Table 4.8
Medical Malpractice Claim Disposition and Defense Costs, 2007
Claim Disposition Share of Claims Mean Expense Payment
Dropped or dismissed 73% $15,246

Settled 22% $46,209
Trial verdict: for defense 4% $110,346
Trial verdict: for plaintiff 1% $114,787
Source: Adapted from Physician Insurers Association of America, “PIAA Data Sharing Project,”
PIAA (Washington, D.C., 2007).
Figure 4.8
Ohio Closed Claims in 2006 Outcome of Malpractice Claims
0.6% Disposed 55.5% Claim Suit

of by Trial Verdict Abandoned without
Jury Verdict— Indemnity Payment,
0.2% Dismissed by
with Indemnity Including Dismissed
Court Summary
without Prejudice
Judgment Directed
Verdict—with
Indemnity
0.2% Disposed
of by Alternative 8.5% Dismissed by
Dispute Resolution— Court Summary
1.2% Disposed Judgment Directed
without Indemnity of by Settlement Verdict—without
Agreement— Indemnity
1.4% Disposed
without Indemnity
of by Alternative
Dispute Resolution—
with Indemnity 17.6% Disposed 4.8% Disposed of
of by Settlement by Trial Verdict
Agreement— Jury Verdict—
with Indemnity without Indemnity
65.5% dismissed without indemnity payment

8.5% dismissed by court summary judgment or directed verdict, no indemnity
4.8% disposed of by jury verdict
Source: Ohio 2006 Medical Liability Closed Claim Report. January 2008, Available at www.ohio
insurance.gov/Legal/REPORTS/MedMal_Closed_Claim_2008.pdf (accessed July 4, 2009).
The severity of the malpractice problem is summarized in testimony before

the National Conference on Medical Malpractice held by the Subcommittee on
Health and the Environment of the U.S. House of Representatives. How does
malpractice affect health care? Physicians face these major problems:
1. The skyrocketing costs of malpractice insurance are forcing some physicians

to retire early and new, young physicians to consider malpractice costs when
deciding on their specialties and where to open their practices.
2. The system by which malpractice claims are settled is extremely costly to
physicians and subsequently to their patients as rates continue to escalate.
3. They are forced to practice defensive medicine.

4. They fear that in a profession that depends upon the trust and confidence
of their patients, medical malpractice is contributing to erosion of the
relationship.
5. The contingent fee system of paying lawyers is an incentive for lawyers to
aim for high settlements from physicians.
The Ohio Department of Insurance published data recently tracking premiums

shortly after tort reform legislation passed in Ohio (Table 4.9).
As shown in Figure 4.9, the data confirms that the surgical specialties have
the highest premiums.
According to the Washington Post, December 29, 2005, the insurance in-
dustry reports huge losses from malpractice suits, now running more than
7 billion dollars a year, and says they have been forced to hike malpractice
premiums.31 But, at the same time, insurance companies collect 9.4 billion
dollars a year in premiums for malpractice insurance. The premiums, for the
most part, are passed on to the consumer/patient in the form of higher health
insurance premiums and cost of services at all levels.
Mlive.com is an association of Michigan newspapers. They ran an article
titled “Four in 10 malpractice cases groundless.” on their Web site on May 10,
2006.32 The Web site reviewed a New England Journal of Medicine medical
article titled “Claims, Errors, and Compensation Payments in Medical Malprac-
tice Litigation.”33 The investigators commented as follows: “For 3 percent of the
claims, there were no verifiable medical injuries, and 37 percent did not involve
errors. Most of the claims that were not associated with errors (370 of 515
[72%]) or injuries (31 of 37 [84%]) did not result in compensation.” Overall,
claims not involving errors accounted for 13 to 16 percent of the system’s total
monetary costs. For every dollar spent on compensation, 54 cents went to ad-
ministrative expenses (including those involving lawyers, experts, and courts).”
A study by Tillinghast Towers Perrin in 2003 showed that only 22 cents of
a dollar moving through the U.S. tort system goes to a plaintiff (and 54 percent
of that dollar never even reaches the victim because of lawyers and other
Table 4.9
Rising Premiums after One Year of Capping Jury Award in Ohio
Insurance Company 2002 2003 2004
Medical Protective 22% 28% 40%

Medical Assurance 44% 19% 13–18%
OHIC 24% 17% NA
American Physicians 29% 88% NA
The Doctors 49% 18% 10%
Source: Ohio Department of Insurance, http://www.ohioinsurance.gov/Legal/REPORTS/
MedMal_Closed_Claim_2008.pdf (accessed June 27, 2009).
Figure 4.9
Annual Physician Premium Payments for Selected Specialties
$0 $50,000 $100,000 $150,000
Neurosurgery Anesthesiology Family Practice

OB/GYN Gastroenterology
Orthopedic Surgeon Internal Medicine
Source: Courtesy Berwanger Overmyer Associates.
expenses).34 A similar study found 60 to 70 percent of malpractice claims to be

without merit and only 38 percent of the dollars flowing through the litigation
system to the plaintiffs (Figure 4.10).35
One of the ways to solve the malpractice problem is compulsory arbitration,
a contract between a physician and/or hospital and patients that if anything
negative were to happen to the patient, or the patient perceived an adverse
outcome, a compulsory arbitration could be arranged by medical experts and
lawyers to protect the patient’s rights and the provider’s rights without need
for a trial by jury. If either party wanted to sue after the claim had been final-
ized, they could sue, perhaps, with the loser paying both the plaintiff’s and the
defendant’s legal fees, a system such as they have in Great Britain. When we
buy stocks or bonds we agree to this compulsory arbitration.
Tort reform can have a significant influence on professional liability premi-
ums. In Ohio, for instance, four of the state’s five largest medical malpractice
insurers have filed rate changes indicating an average decrease of 1.7 percent
in 2006. This, after rate “increases of 30 percent in each of 2002 and 2003,
20 percent in 2004, and 6.7 percent increase in 2005.”36
Figure 4.10
Where Malpractice Dollars Go
A recent report by the Employment Policy Foundation of Washington, D.C.,

indicates that plaintiffs receive less than half of the total number of dollars
that flow through the malpractice litigation system. Here’s a breakdown of
malpractice dollars spent. The number of malpractice claims eventually
found to be without merit? Sixty to seventy percent.
to defense, claims
adjustment, and
investigation to plaintiffs
30% 38%
to plaintiffs’
32%
lawyers and
expert witnesses
Source: Physicians Practice and http://overlawyered.com/2003/08/employment-policy-foundation

finds-med-mal-system-lacking (accessed July 30, 2008).
Are there any other solutions for the malpractice situation? Perhaps. One
might consider the health courts described in this letter from Philip K. Howard,
Chairman, Common Good, located in New York, to the Wall Street Journal,
published February 28, 2006 and titled “Juryless Health Courts Could Stabi-
lize ‘Crisis’”:37
According to studies by the Institute of Medicine and others, nearly universal

distrust of American justice is causing American health care to suffer a kind of
nervous breakdown. Doctors squander tens of billions of dollars in unnecessary
“defensive medicine.” Professional interaction is chilled by legal fears, leading to
tragic errors. Getting rid of inept doctors is, literally, a trial—the doctors invari-
ably hire a lawyer and threaten to sue the hospital.
To begin to restore order to health care, a broad coalition of patient advo-
cates, consumer groups and providers, has come together behind the idea of
creating pilot projects for special health courts. These health courts, developed
by a joint venture of Common Good and the Harvard School of Public Health,
would have judges focused on health care, neutral experts, incentives for prompt
compensation, and written opinions to offer guidance on good practices. As with

other administrative courts, health courts would have no juries. In a public sur-
vey conducted by Harris Interactive and released by Common Good, 63% of
people supported medical lawsuits being tried in special health courts when
asked “Specifically, would you favor or oppose having medical malpractice cases
tried in special courts presided over by medical professionals and other experts
to review and decide injury cases?”38
America has a long tradition of specialized courts for areas needing special
expertise, including admiralty courts, bankruptcy courts, and workers com-
pensation systems. Several bi-partisan bills have been brought up and passed
in the House of Representatives, but because of heavy lobbying by plaintiff
attorneys, the legislation has never made it to the Senate floor.
We will talk a lot more about malpractice premiums when we discuss the
malpractice problem in obstetrics and gynecology.
Foreign Medical Graduates, the “Brain Gain/Drain,” and Culture

Until the recent recommendations made by AAMC and the expansion
that has started towards producing more medical graduates, the number of
future M.Ds enrolled per 100,000 population had been steadily decreasing
(Figure 4.11).
For years the hospitals in the United States have been training foreign medical
graduates along with American medical school graduates. A majority of these
Figure 4.11
First-Year M.D. Enrollment per 100,000 Population
7.5
7.3
7.0
Number of Enrollees
6.8
6.5
6.4
6.0 6.2
5.8
5.5 5.6
5.4
5.0 5.2
5.0
4.5
4.0
1980 1985 1990 1995 2000 2005 2010 2015 2020
Source: U.S. Census Bureau, Prepared for Center of Workforce, AAMC, Feb 2006, AAMC Center
for Workforce Studies, Public Opinion Strategies, Voter Survey, June 2006. Copyright © 2006,
Association of American Medical Colleges. http://www.aamc.org/workforce/workforcecharts.pdf
(accessed July 11, 2008).
foreign medical graduates go into practice in the United States, sometimes serv-
ing in rural areas or small cities. Some go to academic medical centers where
they have distinguished academic medical careers. What has happened in these
35 years or so has been a brain gain on the part of American medicine.
The Metrics of Physician Brain Drain

Between 23 and 28 percent of the physicians in the United States, the
United Kingdom, Australia, and Canada come from lower income countries.39
In 2007, there were 227,665 IMGs from 127 countries practicing in the
United States, about 25 percent of the physician workforce.40 India, the Philip-
pines, and Pakistan are the leading sources of foreign medical graduates here.
This medical migration is called “brain drain” from the foreign countries and
“brain gain” in the United States.
The New York Times published an article titled “Stealing from the Poor to
Care for the Rich.”41 Norman Wall, the author, was Chief of Medicine and
Director of Medical Education at a small Catholic hospital in a small Pennsyl-
vania town. All of the residents were IMGs, mainly from Asia, and they filled
all of the residency spots at the hospital. They tended to stay in his community,
where they worked hard. “By luring and keeping large numbers of medical
immigrant doctors, the American medical establishment is reducing medical
care where it is needed the most, really in the developing countries. In a very
real sense, it would be immoral to deprive those developing countries of their
educated people—doctors who are educated at the developing countries’ ex-
pense,” Hall said. As an example, one of the authors (BS) completed five years
of medical school without incurring any expense at all. In fact, he was awarded
merits scholarship money each year with which to buy books, even though his
parents were wealthy and able to afford tuition and books.
Twenty-five percent of U.S. residencies are occupied by IMGs (Figure 4.12).
They do a good job and they are well trained by the time they finish their
residencies. There is another side to the brain gain, however, and that when
IMGs decide to go back to their home countries after finishing medical resi-
dencies in the United States. What if many more doctors return to their na-
tive countries—as many engineers and PhDs return to India and China after
receiving graduate degrees in the United States? We would have an immense
problem in servicing our hospitals, clinics, and research institutions.
Those foreign countries that have been robbed of their best people are be-
coming increasingly prosperous with good economies and GDP growth rates
better than ours. One can obtain a world class medical or surgical residency in
the United States and then go home to India or the Philippines and lead a life
in one’s own culture, where the net rewards for practicing medicine outnumber
those in the United States. These physicians would be in their own cultures, prob-
ably do better in terms of standard of living, and be free of all the hassles that
plague American medicine. When the combination of professional opportunities
and support systems is better in their native countries, where will they go?
Figure 4.12
Source of Physicians Entering Training, 2005
IMGs U.S. M.D.

6,436 (26%) Graduates
15,411 (62%)
D.O.
Graduates
2,888* (12%)
Total 24,735
*All M.D.s, IMGs, and one-half of the D.O. graduates (1,478) enter Accreditation
Council for Graduate Medical Education (ACGME) residency programs.
Source: AAMC Center for Workforce Studies, Public Opinion Strategies, Voter Survey, June 2006.
Copyright © 2006, Association of American Medical Colleges. http://www.aamc.org/workforce/
workforcecharts.pdf (accessed July 11, 2008).
It is happening. At the Ohio State University, two graduates of the thoracic

and cardiovascular training program in five years have gone back to their na-
tive countries. In Pakistan, by 2004, of the 1100 medical graduates produced
by Pakistan’s Aga Khan University, 900 went on to higher-level training in the
United States. Of these, 40 have so far returned to Pakistan.42
If this continues to be the case, we could become a net exporter of U.S.-trained
foreign medical graduates to their own nations. In so doing, the brain gain that
we have had for so many of the last 50 years will become a brain drain for
this country as well.
What’s wrong with this picture? The problem is that we have to have
enough residents to train and to manage the care of patients in large teach-
ing hospitals and be the source of future physicians. If a there is a reversal of
the current trends of IMGs staying in the U.S. then this will contribute to the
future shortage of physicians as there are insufficient numbers of Americans
interested in careers as physicians. Some countries are making efforts to re-
verse this brain drain with special programs such as the McKenzie Medical
and Surgical Repatriation University of Otago Fellowship in New Zealand

established through private donations.43
The solution to this problem looming ahead of us is to admit more medical stu-
dents to our medical schools in the United States.
RETIREMENT
The effects of retirement of senior physicians also has a major impact on
the physician supply. Many of these are work horse doctors, who have worked
many, many hours per week, and whose retirement from medicine will lead to
greater difficulties for patients in getting appointments or surgical evaluations.
A Merritt Hawkins Survey indicates that about 38 percent of all physicians
in the United States are 50 years old or older.44
In a report given to the American Association of Medical Colleges in May
2006, Yamagata presented a survey of the retirement behaviors of 5,330 phy-
sicians between 50 and 79 years of age.45 The mean age of retirement was 64,
and the median age was 63.5 years. Over 60 percent of physicians had retired
from clinical practice of medicine by the age of 65. Female surgeons retired
earlier, at an average of about 61 years. The study also included physicians
who worked part time and retired later at an average age of 68.
In a 2007 survey of physicians aged 50–65 years, 49 percent indicated
they planned to make a change in their practices within the next one to three
years, and of these 14 percent planned to retire, 7 percent were going to seek
Figure 4.13
Physician Morale
Other
5.8% Loss of
MMP autonomy
10.5% 21.2%
Loss of
respect
11.8%
Low
Patient
reimbursement
overload
21.9%
12.1%
Red tape
16.8%
Note: MMP means medical malpractice in this figure.
Source: Adapted from American College of Physician Executives 2006 Morale Survey
a job in a nonclinical setting, 3 percent were going to pursue a nonmedical

job, 12 percent planned to work part time, and 4 percent planned locum ten-
ens, a temporary job substituting for another surgeon in the surgeon’s town.46
Based on this survey, should 20 percent of this age group follow through with
retirement or to nonclinical roles in the next one to three years, about 59,650
physicians would leave the clinical workforce. As Merritt and colleagues point
out, even if 10 percent of the 50–65 age group follow through with retirement
(estimated at 25,000 physicians), about 52 million patient visits (based upon
an average of 2100 patient visits yearly) will have to be picked up by other
physicians.47 The workload would have to be absorbed by generation Y or the
remaining older physicians. Is that realistic given the lifestyle issues we have
discussed? Not likely.
All of the above factors, such as loss of autonomy, reimbursement issues,
and red tape, play a role when physicians are asked about their morale
(Figure 4.13).
Many physicians we know have chosen to leave medical practice for the
reasons stated. Some have chosen fields related to medicine, while others have
broken away completely. As an example, recent switches have been made to
clinical pharmacology research studies, hospital administration, noninvasive
lab directorship, new product development, underwater photography, and
medical fiction writing. Many were probably getting ready to retire before
the dot-com disaster. When the retirement funds are replenished we may see
many more of the middle-aged physicians retiring. It is certainly possible that
while many physicians indicate on surveys that they plan to retire, they may
get cold feet and stick to something they know. In any case, even in the most
optimistic scenario, for all the reasons mentioned, we believe a big enough
void will exist to severely affect patient care.
5
Calculating Physician Supply: The
Model—Assumptions, Relevant
Parameters, and the Algorithm
In this chapter we will attempt to calculate the needs for the entire physician
work force. In later chapters, we will consider the surgical workforce for six
specialties. Finally, in chapter 14, we will come back to the entire physician
workforce.
MODELS
There are at least four algorithms or models for assessing physician supply.
They include (1) the Work Per Capita Analysis by Etzione; (2) Cooper’s Trend
Analysis; (3) the Physicians Supply Model (PSM) and Physicians Requirement
Model (PRM); and (4) our simplified Population Analysis.
The Work Per Capita Analysis by Etzione et al uses age specific rates of
current surgical procedures and relative work units expended to estimate the
amount of surgical work per capita.1 In that study the authors separate the
population into several age groups: patient age group (less than 15 years old,
15–44 years old, 45–64 years old, and 65 years and older). They use age-
specific incidence rates for each procedure, and multiply these by the cor-
responding work related value units (RVUs). All 214 procedures included in
the study were analyzed by specialty to allow for forecasting in the various
surgical specialties (ENT, Ortho, etc.) based upon population growth in various
age groups. Etzioni and colleagues speculate growth of 14–47 percent for the
individual surgical specialties by 2020. Their projections are limited because
they did not take into account changes in surgical procedural demand due to
aging, technology, or other factors.
Cooper hypothesizes an economic trend model to measure adequacy of
physician supply. Four factors are considered in this macro-analysis: national
economic expansion, population growth, physician work effort, and volume of
nonphysician clinical services.2 Cooper reports a linear relationship between
physician supply, per 100,000 of population, and real (inflation adjusted) per
capita gross domestic product (GDP) per capita over a 70 year period between
Calculating Physician Supply 55
1929 and 2000. The authors in that report also show that for every 1 percent
increase in GDP, the physician supply increases by 0.75 percent. A greater
shortage of specialists is suggested as compared to primary care physicians.
Some, including Weiner, have disagreed with Cooper’s model. They, instead,
point to specialist physicians driving up the volume of care rendered.3
The PSM & PRM were developed by the Bureau of Health Professions
from the Health Resources and Services Administration (HRSA).4 The PSM
measures the number of active physicians and the number of full-time equiva-
lents (FTEs) by age, sex, country of medical education, type of degree, medical
specialty, and whether the physician is in patient care or nonpatient care. The
model then takes the number of physicians in the preceding year, adds the
number of U.S. and international medical graduates, and subtracts attrition
due to retirement, death, and disability to calculate future supply. The accu-
racy is limited to the large picture and may not be reliable over the long-term.
The PRM utilizes population projections, medical insurance category trends,
and physician-to-population ratio.
If the gross domestic product remains the same, then population is the
greatest predictor for surgical services. We have elected to use a simplification
of the Population Analysis model. Rather than slice and dice active physician
numbers, we have elected to use gross numbers by specialty, add the number
of physicians entering the workforce, subtract those leaving medical practice,
and come up with the future demand and supply. In our book Consumer
Driven Health Care, our population analysis estimate for the total medical
workforce in 2020 was 960,960.5 That compares favorably with the HRSA
2006 model of 951,800 and with the Council of Graduate Medical Educa-
tion (COGME) model published in 2005, which arrives at physician supply
of 971,817.6 The three estimates differ by less than 1.25 percent. In addition,
our estimate of a shortage of about 200,000 physicians in 2020 is also in line
with Cooper’s shortage figure of about 200,000. We believe that our physician
population algorithm has been corroborated by the aforementioned studies.7
Assumptions
There are some critical assumptions relevant to the algorithm that have to
be discussed in order to understand the limitations of our model.
Assumption #1: The ratio of physicians to population will be constant.
286 physicians for each 100,000 people in the United States (for a total of
806,520) is assumed.8 The HRSA estimate that 756,000 physicians under
the age of 75 practiced in 2000, and their physician supply model projected
817,000 in 2005.9 Implicit in this assumption is that the 286/100,000 ratio
is actually what is needed to care for our future population. We will therefore
assume 800,000 practicing doctors for our calculations.
Assumption #2: Medical school enrollments will not increase. As demon-
strated in Figure 5.1 first year medical school enrollments of about 16,000 to
17,000 remained constant from 1980 to 2005.10
Figure 5.1
U.S. Medical Student Enrollment
80,000
70,000
60,000
50,000
40,000
30,000
20,000
10,000
0
1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005
Source: B. Barzansky, H. S. Jonas, S. I. Etzel, JAMA, September 1, 282(9): 840–846; JAMA,
September 3, 290(9): 1190–1196: JAMA, September 7, 294(9): 1068–1074.
Following recommendations to increase medical school enrollment, recent

projections by AAMC seem to indicate that there will be about 19,909 enroll-
ments by 2012.11 Whether these increased enrollments materialize remains
to be seen. We have therefore chosen to use the current number of medical
school enrollments, as shown in Figure 5.2, in our calculations.
Assumption #3: Gross domestic product per capita will not decrease, and,
therefore, we will maintain our standard of living as the population of the United
States increases. Cooper has published extensively on the linear relationship
between gross domestic product (GDP) and the number of active physicians
per capita (Figure 5.3).12 In the 1960s, the GDP per capita was between
$11,000 or $12,000, and the number of physicians was about 140 to 150
per 100,000 population. By the year 2000, the GDP was about $33,000 per
capita and there were about 286 physicians per 100,000 people. Weiner and
Grumbach have argued against this concept and have interpreted the data to
imply that physicians create their own demand and therefore we should not
expand medical school enrollment.13
However, as we get older and become more affluent, people care more
about their health and can do something about it. There are two sides to de-
mand: 1) Physicians increase demand by their very existence, or 2) consumers
increase the demand because of affluence and education.
Assumption #4: Census Bureau estimates for the population are accurate.
The United States Census Bureau estimates that there will be an increase in
Figure 5.2
Medical School Applicants and Matriculants
50,000
45,000
40,000
35,000
30,000
25,000
20,000
15,000
10,000
5,000
0
2000
2001
2002
2003
2004
2005
2006
2012
1996
1997
1998
1999
(est)
Applicants Matriculants
Source: AAMC, Medical School Applicants and Matriculants by School and Sex. Copyright ©
2005, Association of American Medical Colleges. https://services.aamc.org/Publications/show
file.cfm?file=versionl111pdf&prd_id=229&pdf_id=111 (accessed July 2, 2008).
the population in the United States by almost 50 percent between 2000 and
2050 (Figure 5.4).
If these figures are accurate, and we remain an affluent society, demand
for health care will increase with the growth of the population. Even more
important is the aging of the population, which will place further demands on
the health care system (Figure 5.5).
Assumption #5: Years to retirement will remain constant. In our model
regarding the supply of physicians, we estimate that physicians practice for
about 40 years from the time they graduate from medical school until they
retire. For surgeons, we estimate 30–35 years from board certification to
retirement because the training for any given surgical program lasts between
five and seven years. Our definition of retirement also includes leaving the
surgical workforce because of disability or death of the physician.
Assumption #6: The funding for graduate medical education—GME—will
remain constant. GME is funding from the government to support residency
training programs. Despite pressure from the academic teaching community,
think tanks, and some policy experts for more funding, Congress has not yet
Figure 5.3
Relationship of GDP and Physician Ratio: Active Physicians per 100,000 of
Population and Gross Domestic Product per Capita (1996 Dollars) in the United
States, 1929–2000
350
300
250
200
#
150
100
50
0
1929 1960 1970 1980 1990 2000
Year
GDP Per Capita ($100s) Physicians/100,000 Population
Source: Health Serv Res, (April 2003): 38(2): 675-696, http://www.pubmedcentral.nih.gOv/arti

clerender.fegi?artid=1360909 (accessed July 7, 2008).
seriously evaluated various proposals for increased funding. With budget defi-
cits as far into the future as one can see, the prospect of a major infusion of
dollars seems slim.
We make no adjustments or assumptions for gender or controllable life-
style for physicians. Yet, these factors will affect the supply of practicing
physicians. As we mentioned in chapter 3, based on the difference between
work hours for men and women, it is estimated that we will need 1.3
full-time equivalents (FTE’s) for every practicing doctor now, if doctors
decrease their working hours.14 So, if anything, our estimates may be fairly
conservative.
We make no adjustments for malpractice effects or malpractice premiums
and what they will do, or will not do, in the next 45 years. Yet, malpractice
continues to be a concern. It is very difficult to be a part-time surgeon in
most states in the United States In most states, malpractice premiums are not
adjusted to a physician’s level of practice; in a sense, it is one size fits all. This
discourages physicians from practicing surgery part time as they cannot afford
the full-time premiums.
Figure 5.4
U.S. Population Growth
419,854
450,000
335,805
400,000
350,000
300,000
250,000
200,000
150,000
100,000
50,000
0
2000 2008 2010 2020 2030 2040 2050
Millions
Source: U.S. Census Bureau, Statistical Abstract of the United States: 2008.
We also make no adjustments for reimbursements from either the gov-

ernment or private insurers, which we expect to decrease and consequently
affect physicians’ income and possibly attract fewer medical students into the
profession or hasten retirement at an even earlier age.
And finally, we make no adjustments in this algorithm for chronic disease.
As patients afflicted with cancer live longer, there will be a greater necessity
for follow-up appointments for the rest of their lives. Similarly, those who have
heart disease and survive require the same sort of follow-up to be provided
for them.
Relevant Parameters
The total physician workforce is estimated at 800,000 for this example.
Similarly, we estimate the general surgeon workforce at 7.1/100,000 (total
21,000), orthopedic surgeons at 6.5/100,000 (total 18,000), and thoracic
and cardiovascular surgeons at 1.4 per 100,000 (total 4,000). The otolaryn-
gology workforce is estimated at about 3.2/100,000 (total 8900). In obstetrics
and gynecology, we estimate 27.1 physicians for each 100,000 women (total
34,000). For neurosurgeons, we use 1.06/100,000; there are about 3,100
Figure 5.5
Population Growth of People over age 65 Years, 2000–2020
60%
Percent Growth in Population
50%
Age 65+
40%
30%
20%
Age <65
10%
0%
2005 2010 2015 2020
Source: U.S. Department of Health and Human Services Health Resources and Services Admin-
istration Bureau of Health Professions, “Physician Supply and Demand: Projections to 2020,”
(Health Resources and Services Administration, Department of Health & Human Services, Octo-
ber 2006).
practicing at the time of this writing. For urology we use 3.31/100,000, with
10,000 of them in active practice.
Calculation
Estimating Physicians Needed
To arrive at the number of physicians needed by a specific year, we started
with the current number of physicians for each 100,000 (286/100,000)
of population and multiplied that by the estimated population based upon
the census for 2010, 2020, 2030, 2040, and 2050 (Table 5.1). In round
numbers, that means the United States will need almost 880,000 physicians
by 2010, 960,000 by 2020, 1.0 million by 2030, 1.1 million by 2040, and
1.2 million by 2050. In other words, we have a need to produce 80,000
more physicians per decade.
Retiring Physicians
Our definition of retiring includes those who have retired as well as deaths
and disabilities in the physician workforce. The number of physicians who are
retiring in a given year is subtracted from the number of physicians who are
practicing in that year. Our baseline is the number of physicians who practiced
in the preceding year. The result equals the number of practicing physicians
for the next year (Figure 5.6).
We repeat this calculation until all of the physicians at the beginning of the
time period have retired. As an illustration, let us assume there were 800,000
physicians in the year 2000. Assuming an even distribution of our estimates,
20,000 would retire each year. Based on assumption #5, by 2040 none of
these physicians would remain in practice (Table 5.2).
New Medical School Graduates

We must add new medical school graduates to the pool of practicing phy-
sicians each year. From that number we must subtract physicians who have
completed 40 years in practice. Similar to the previous calculation, this is
repeated until the current crop is retired by 2041 (Figure 5.7).
Table 5.1
Physicians Needed by Decade
Year Population # Physicians Needed
2010 309,000,000 883,740

2020 336,000,000 960,960
2030 364,000,000 1,041,040
2040 392,000,000 1,121,120
2050 420,000,000 1,201,200
Figure 5.6
Retiring Doctors
Number of Old Physicians Practicing
Subtract Old Physicians Retiring Each Year
Equals Old Practicing Doctors

Table 5.2
Retiring Doctors
Year Old Physicians Retiring Each Year Number of Old Physicians Practicing
2000 800,000
2001 20,000 780,000
2002 20,000 760,000
2003 20,000 740,000
2004 20,000 720,000
2005 20,000 700,000
2038 20,000 40,000
2039 20,000 20,000
2040 20,000 0
2041 0 0
Note: This table is an abbreviated version of Table A.1 in the Appendix.
Figure 5.7
New Medical School Graduates
Total of New Graduates
Subtract New Graduates Who Have Retired
Equals Total of New Graduates Practicing
Table 5.3 shows that if the number of medical school graduates stays
constant (assumption #2) at 17,000, and none of the graduates retire, the
number of practicing physicians increases to 85,000 by 2005. As we go on
in this scenario, by 2035 there are 595,000 practicing physicians, because,
again, none of them retire. However, in 2040, the first year of retirement
for this group, the number of new medical school graduates stabilizes to
680,000.
Table 5.3
New Physicians Added
New Graduates Total of New

Present Total of New Who Have Graduates
Year Graduating Class Graduates Retired Practicing
2000
2001 17,000 17,000 0 17,000
2002 17,000 34,000 0 34,000
2003 17,000 51,000 0 51,000
2004 17,000 68,000 0 68,000
2005 17,000 85,000 0 85,000
2035 17,000 595,000 0 595,000
2036 17,000 612,000 0 612,000
2037 17,000 629,000 0 629,000
2038 17,000 646,000 0 646,000
2039 17,000 663,000 0 663,000
2040 17,000 680,000 0 680,000
2041 17,000 697,000 17,000 680,000
2042 17,000 714,000 34,000 680,000
The Total Number of Physicians Practicing Each Year

To estimate the total number of physicians practicing in a given year, we
start with the number of physicians who were practicing the previous year,
subtract those who have retired, and add the number of new medical school
graduates. In any given year, this equals the grand total of practicing physi-
cians (Figure 5.8).
To illustrate the methodology, let us assume that we have 800,000 physi-
cians in the year 2000. 20,000 retire in 2001, leaving a total of 780,000
still in practice (Table 5.4). To this we add 17,000 new medical school gradu-
ates for a grand total of 797,000 practicing physicians in 2001. This pattern
repeats itself because we have a fixed retirement rate of 20,000 and a fixed
incoming rate of 17,000. Therefore, by 2040 we end up with a fixed supply
of 680,000 practicing doctors.
The results of these calculations are illustrated in Figure 5.9. The complete
tables are included in the Appendix; Tables 5.2, 5.3, and 5.4 in this chapter
are presented in an abbreviated form.
Figure 5.8
Total of Doctors Practicing Each Year
Number of Old Physicians Practicing
Add Total of New Graduates Practicing
Equals Grand Total of Practicing Doctors
Table 5.4
Total of Practicing Doctors
Number of Old Total of New Grand Total of

Year Physicians Practicing Graduates Practicing Practicing Doctors
2000 800,000 800,000

2001 780,000 17,000 797,000
2002 760,000 34,000 794,000
2003 740,000 51,000 791,000
2004 720,000 68,000 788,000
2005 700,000 85,000 785,000
2038 40,000 646,000 686,000
2039 20,000 663,000 683,000
2040 0 680,000 680,000
2041 0 680,000 680,000
2042 0 680,000 680,000
Shortage
Estimating the shortage of physicians involves deducting the grand total
of practicing physicians (last column of Table 5.4) from the number of phy-
sicians needed (Table 5.1) for any year. To estimate the percent shortage,
divide the shortage by the number of physicians needed and multiply by 100
(Table 5.5). For instance, in our assumptions for physician retirement we use
20,000/year (800,000 physicians divided by 40 years). We also use 17,000
per year as the number of graduating medical class members. This means
Figure 5.9
Illustration of Methodology Used in Calculating Physician Supply
1,000,000
900,000
800,000
700,000
600,000
500,000
400,000
300,000
200,000
100,000
0
1990 2000 2010 2020 2030 2040 2050 2060
Year
Old New Total
Table 5.5
Shortage Estimates
Physicians Grand Total of Percent

Year Population Needed Practicing Physicians Shortage Shortage
2010 309,000,000 883,740 770,000 113,740 13%

2020 336,000,000 960,960 740,000 220,960 23%
2030 364,000,000 1,041,040 710,000 331,040 32%
2040 392,000,000 1,121,120 680,000 441,120 39%
2050 420,000,000 1,201,200 680,000 521,200 43%
that according to our calculations, there is a net deficit of 3,000 physicians

every year.
Our methodology is straightforward and is based upon population analysis.
The projected shortages are very close to the other models cited. Like all other
models, ours relies on many assumptions, any one of which, if altered signifi-
cantly, would result in widely divergent findings.
CONCLUSION
Many previous studies of forecasted workforce needs have proved com-
pletely erroneous. Relying on factors such as relative value units produced
or number of procedures/visits performed, and allowing for lifestyle changes
or trying to guess how many physicians will be working full or part time
may be akin to guessing wind direction years from now. Population growth
projections have a lower margin of error, and physician-population ratios and
fairly standard terms of practice seem to us a better foundation to base our
calculations upon.
6
Orthopedic Surgery
For the next seven chapters we will talk about various surgical specialties and
our projections on their workforce issues.
ORTHOPEDIC MIRACLES
Many Americans fear death, but death comes when it comes. A greater
fear for most Americans is incurring a significant disability. One of the medi-
cal miracles in the last 50 years is the development of reconstructive surgery
for arthritis. But, orthopedic care runs the gamut from early childhood (think
broken bones), to spine surgery, to joint replacements in older citizens. Two-
thirds of hip replacements are performed on people over the age of 65. Hips,
knees, and even shoulders and ankles are cared for by orthopedic surgeons.
In 2005, the American Academy of Orthopedic Surgeons reported over one
million joint replacements.1 Patients who undergo joint replacement surgery
do so because they feel that they are so disabled they cannot live their lives
the way they desire.
In 2005, the number of first-time and revision total knee replacements was
about 570,000, and hip replacements (new, partial, and revisions) numbered
almost 500,000.2 According to the American Academy of Orthopedic Sur-
geons, the number of first-time total knee replacements is predicted to jump
673 percent to 3.48 million by the year 2030. Similarly, primary total hip re-
placements will increase by 174 percent. Knee and hip revisions will increase
by 522 percent and 237 percent, respectively, as patients’ longevity increases
and joints wear out and need to be replaced again.3 Think about all the baby
boomers reaching the age when their joints wear out and this fact will increase
the need for these services. Famous sports celebrities such as Jack Nicklaus,
Mary Lou Retton, and Jimmy Connors are spokespersons for joint replacement
hardware manufacturers. The boomers are not likely to sit in their chairs or
quietly head off to rest in nursing homes to live with arthritic joints!
Will there be enough orthopedic surgeons to meet their needs?
ORTHOPEDIC SURGEON PROJECTIONS

Several studies since the 1970s have predicted a surplus of orthopedic sur-
geons over the next 30 or 40 years until the mid-21st century.4 In 1995, The
RAND Corporation was commissioned by the American Academy of Orthope-
dic Surgeons to project the workforce in orthopedic surgery. RAND employed
the usual factors in the supply side such as number of residents, number of
retiring surgeons, changing practice patterns, new technology, number of female
and minority surgeons, and the number of subspecialists. On the demand side,
they considered population increase, aging of the population, number of visits
by the elderly, and new technology and came up with a new methodology to
determine the demand side of the equation. Lee et al used utilization data from
national inpatient and outpatient datasets to convert factors related to demand
to work time. Based on the RAND data and population growth, they projected
demand in 1998 to be 14,750 full-time equivalents and a supply of 18,296
surgeons. They further projected a surplus of 3,546 orthopedic surgeons by
2010 and therefore proposed a reduction in residency training positions. In
contrast, the Council on Graduate Medical Education (COGME) in 2005 pro-
jected a deficit of about 12,000 to 15,000 orthopedic surgeons by 2020.5
The Dartmouth Atlas provides a method of calculating the number of spe-
cialists in each community taking into account the prevalent practice style.6
Heckman and Weinstein, in their estimates of need for orthopedic surgeons,
suggest that seven orthopedic surgeons per 100,000 population is excessive
and suggests as low a number as five per 100,000 population.7 The American
Academy of Orthopedic Surgeons estimates that in 2006 the density of ortho-
pedic surgeons was 6.1 per 100,000 population.8 For our projections, we use
the following baseline numbers:
1. 6.5 orthopedic surgeons for 100,000 population

2. 650 newly board-certified orthopedic surgeons each year
Our assumption with regard to longevity in practice is 35 years (524 retiring

each year) for this estimate. In Table 6.1, one can see that in 2010 20,085
orthopedic surgeons will be needed, but only 18,960 will be in practice, a
shortage of 1,125. Similarly, for 2030, 23,660 orthopedic surgeons will be
needed, but only 21,480, according to this estimate, will be in practice, for
a shortage of 2,180 or about 9 percent. Similarly, in 2050, around 27,000
orthopedic surgeons will be needed, but only about 23,000 will be available,
resulting in a shortage of more than 15 percent.
If we make the same assumption for the number of board certified surgeons
but change the length of practice to 30 years and assume a retirement age
somewhere between age 60 and 65, there will be an even greater shortage
(see Table 6.2). By 2030, as we said before, 23,660 orthopedic surgeons will
be needed, but only 19,305 will be available, resulting in a shortage of 4,355
or 18 percent. By 2050, the shortage will equal 7,800 or almost 30 percent.
Orthopedic Surgery 69
Table 6.1
35 Years to Retirement for Orthopedic Surgeons
Orthopedic Orthopedic
Projected Surgeons Surgeons Percent
Year Population Needed in Practice Shortage Shortage
2000 282,000,000 18,330
2010 309,000,000 20,085 18,960 1,125 6%
2020 336,000,000 21,840 20,220 1,620 7%
2030 364,000,000 23,660 21,480 2,180 9%
2040 392,000,000 25,480 22,750 2,730 11%
2050 420,000,000 27,300 22,750 4,550 17%
Table 6.2
30 Years to Retirement for Orthopedic Surgeons
Orthopedic Orthopedic
2000 282,000,000 18,330

2010 309,000,000 20,085 18,525 1,560 8%
2020 336,000,000 21,840 18,915 2,925 13%
2030 364,000,000 23,660 19,305 4,355 18%
2040 392,000,000 25,480 19,500 5,980 23%
2050 420,000,000 27,300 19,500 7,800 29%
Workforce Issues
According to Gary Bos, M.D., former chairman of the Department of
Orthopedic Surgery at Ohio State University, the shortage of orthopedic sur-
geons is so profound that sometimes there are 18 pages of classified advertise-
ments for these jobs in the orthopedic journals.9 This is particularly the case in
small towns. In view of the 80-hour work week limitations and the demand for
orthopedic surgeons, the Residency Review Committee has recently increased
training positions by 9–10 percent. We must also point out that 29 accredited
osteopathic residency programs turned out about 84 surgeons in 2008.10
Is there an emerging star system for orthopedic surgeons? Advertisements
such as “Orthopedic Surgeon, Idaho, one hour from Spokane, $600,000+,
hospital managed, no malpractice concerns, beautiful area, great schools” are
not uncommon. The salary in this advertisement is about two times what the
average orthopedic surgeon earns in the United States, according to the Medi-
cal Group Management Association. The surgeon who accepts this position
will be a hospital-based employee with no office expenses and will have health
insurance as well. Why does a rural hospital need to spend so much for a sur-
geon? There is only one orthopedic surgeon on the staff. What does the hospital
do when the orthopedic surgeon has to take his or her daughter to college, go
on a family vacation, or becomes disabled? Why would the hospital offer so
much for an additional surgeon? An orthopedic surgeon will add $3,000,000
to the hospital’s top line; that is, the revenue line.11 The contribution profits
for the hospital industry in 2006 for orthopedic care were over $11 billion.12
That’s why. The hospital has to keep its orthopedic presence in their small
town or city in which the hospital is located. It cannot afford to refer all its
orthopedic patients out of town or to other hospitals.
A survey by Merritt, Hawkins, & Associates (MHA) showed that 46 percent
of physicians would not choose a career in medicine again, and 56 percent cited
managed care as the biggest source of professional frustration.13 The percentage
of orthopedic surgeons over the age of 50 increased from about 41 percent in
1994–5 to 51 percent in 2004–5, and early retirements will have a significant
impact on the available workforce in the next decade.14 The mean age of mem-
bers and fellows of the American Academy of Orthopedic Surgeons (AAOS)
was 59 years in 2005, well below the retirement age of 65.15
According to the August, 2001 AAOS Bulletin, almost 25 percent of
its active members were contemplating retirement from orthopedic practice
within the next five years. In 2006, one in 10 orthopedic surgeons in the
AAOS member survey had retired and about 8 percent were considering retir-
ing within the next two years.16
Recent high managed-care penetration with low payments, coupled with
high malpractice costs have forced 5 of 15 orthopedists in the Ogden Ortho-
pedic and Neurosurgical Specialists group in Ogden, Utah, to leave. In Penn-
sylvania, these same issues have forced orthopedists to move out of the state
or the operating room.
According to Carlos Lavernia, M.D., chief of orthopedics at Cedars Medical
Center in Miami, “Many orthopedic surgeons are leaving hospital-based care
and going to outpatient surgery centers due to demanding hours and lack of
pay for on-call hospital services.”17 Malpractice premiums are a part of the
problem as well. Regulatory issues, such as those outlined in the Emergency
Medical Treatment and Active Labor Act (EMTALA), affect an orthopedic
surgeon’s practice. If an emergency patient comes into the hospital, the hospital
is required by law to accept the patient. The surgeons who are on call can be
liable for malpractice suits without any protection from the hospital. Many
hospitals do not pay their surgeons for on-call hours. In a survey by Sullivan-
Cotter of physician on-call pay, out of 35 organizations reporting, the average
hourly compensation for orthopedic surgery was $44.29 at trauma centers
and $30.65 for nontrauma surgeons.18 Hence, being on call is a no-win
situation for the orthopedic surgeon.
Based on available trends in the workforce and the above-mentioned fac-
tors that influence both supply and demand, there is likely to be a shortage of
Orthopedic Surgery 71
orthopedists who are willing to practice in hospitals and multi-specialty clinics

by 2020. In an effort to recruit orthopedists to these centers, salaries have
skyrocketed. The MHA study found that the average orthopedic income offer
rose from $241,000 in 1997–98, to $287,000 in 2000–01, to more than
$350,000 in 2004.19 These larger salaries are attractive to residents who
have accumulated large amounts of medical education debt. Currently, ortho-
pedic surgery residency positions are very much sought after, with 0.7 posi-
tions available for each applicant who lists the specialty as his or her preferred
specialty.20
Unless there is salary support from hospitals or academic centers, most or-
thopedic specialty groups may not have the financial resources to compete for
additional associates without cutting their own compensation.
7
Cardiothoracic Surgery
Cardiothoracic (CT) surgery (sometimes referred to as Thoracic or Cardiovas-

cular Surgery) deals with the operative treatment of diseases as well as injuries
of the heart, lungs, mediastinum, esophagus, chest wall, diaphragm, and great
vessels.
MEDICAL MIRACLES
Heart Disease
Early efforts in this field were made to correct congenital heart disease.
Robert Gross of Boston repaired the first patent ductus of the aorta in the
1930s. A patent ductus is a congenital communication between the aorta
and the pulmonary artery; it causes high blood pressure in the pulmonary
artery. Craaford, in Sweden, was the first to repair coarctation of the aorta. A
coarctation is a congenital narrow spot in the descending thoracic aorta that
also causes high blood pressure in the aorta. The mean life expectancy for
patients with either of these conditions was less than 40 years until the early
1940s. Alfred Blalock and Helen Taussig of Johns Hopkins Hospital designed
an operation to palliate or extend the life of cyanotic blue babies. In this same
period, cardiac catheterization was successfully performed.
John Gibbon of Philadelphia conducted the first open heart procedure in
1953. He invented the open heart pump. Cardiac valves were repaired and
later replaced in the 1960s. Also in the 1960s coronary artery bypass grafts
were performed to repair coronary artery disease at the Cleveland Clinic and
in Milwaukee, Wisconsin. The first cardiac transplant was performed by Chris-
tian Barnard in South Africa in 1967. The first percutaneous transluminal
coronary angioplasty (PTCA) for dilating blood vessels was performed in the
1970s; stents came along in the late 1980s.
At the same time, in the late 20th century, other devices such as pacemak-
ers and automatic implantable cardiac defibrillators found their places in the
Cardiothoracic Surgery 73
cardiac armamentarium. At first these devices had to be implanted surgically.

Now they can be implanted by a short subcutaneous (under the skin) incision.
Laman Gray, a surgeon from Louisville, Kentucky, implanted an artificial heart
in 2001. Mr. Tools, the first recipient of an artificial heart, lived four months
and was preparing to go home when he developed complications. Dr. Gray
implanted a second patient who lived for 13 months in his own home.
The pharmaceutical industry introduced many families of drugs over sev-
eral decades, including the beta-blockers to control blood pressure and heart
rate, calcium channel blockers to control heart rate and blood pressure, and
ACE inhibitors, a new class of drugs, which are also used to treat high blood
pressure. Another significant family of drugs is called the statins. These help
keep blood cholesterol in balance and reduce the likelihood of developing
arteriosclerosis or hardening of the arteries, which give rise to symptomatic
coronary artery disease, the cause of heart attacks.
WHAT TO EXPECT IN CARDIAC SURGERY

Almost all of the hospitals in America that operate open-heart surgical
programs subscribe to the National Database of the Society of Thoracic Sur-
geons for comparison with other hospitals. In 2000, approximately 200,000
open-heart procedures were performed. By 2006, almost 260,000 proce-
dures were done. In the last 10 years, a little over 2.4 million open-heart
surgeries were performed. About 1.65 million of those cases were coronary
artery bypass procedures (CABG).1
The mortality rate for an isolated coronary bypass operation is about 2.3 to
2.5 percent. In other words, the patient’s odds of survival are between 97 and
98 percent. With regard to aortic valve replacement, the mortality figures
are about 3.4 percent, a little better than 96 percent of patients who undergo
aortic valve replacement will live. A mitral valve replacement has about a 6
percent mortality rate, or a 94 percent survival rate. The average length of
stay between surgery and discharge for a coronary artery bypass grafting pro-
cedure is about five to six days.
Thoracic Surgery Projections

The assumptions for our projections are, again, that gross domestic product
per capita will not change, that medical school enrollments will not change,
and that the ratio of physicians to population will not change; that is, that there
are 1.42 thoracic and cardiovascular surgeons per 100,000 population.2
In this projection, we are going to assume 35 years to retirement, 114 retire-
ments, and 100 board-certified surgeons produced each year. Table 7.1 indi-
cates that the shortage of thoracic and cardiovascular surgeons will probably not
be significant until 2020, when there will be a shortage of about 21 percent. By
2030 we will have a shortage of more than 1,500 thoracic and cardiovascular
surgeons. That shortage will be almost 2,500 by 2050, or 41 percent.
Table 7.1
35 Years to Retirement for Thoracic Surgeons
Thoracic Thoracic
2000 282,000,000 4,004

2010 309,000,000 4,388 3,930 458 10%
2020 336,000,000 4,771 3,790 981 21%
2030 364,000,000 5,169 3,650 1,519 29%
2040 392,000,000 5,566 3,510 2,056 37%
2050 420,000,000 5,964 3,500 2,464 41%
Table 7.2
30 Years to Retirement for Thoracic Surgeons
Thoracic Thoracic
2000 282,000,000 4,004

2010 309,000,000 4,388 3,835 553 13%
2020 336,000,000 4,771 3,505 1,266 27%
2030 364,000,000 5,169 3,175 1,994 39%
2040 392,000,000 5,566 3,000 2,566 46%
2050 420,000,000 5,964 3,000 2,964 50%
Assuming 30 years to retirement (the surgeon’s retirement age between 60

to 65 years), 133 retirements, and 100 board certified surgeons each year, by
2020, the shortage will be more than 25 percent, and by 2050 the shortage
will be about 3,000, or 50 percent (Table 7.2).
In summary, given our assumptions and our projections, we predict that
there will be a shortage of between 2,500 to 3,000 practicing thoracic and
cardiovascular surgeons by 2050. These projections are consistent with the
Shermin report as well as the recent AATS/ STS/AAMC estimates of future
CT workforce.3
WORKFORCE STUDIES OF CT SURGERY

There have been several workforce studies detailing the workload in
thoracic and adult cardiac surgery. A study by the Thoracic Surgery Workforce
in 1995 showed the respondents to be predominantly male with 45 percent
practicing in single-specialty private practice.4 The mean age had increased

from previous surveys to 52 years in the 1995 survey. The study concen-
trated on workforce demographics and procedural volumes and did not in-
quire about retirement plans. The responses indicated that 2,103 respondents
performed a mean of 151 cases for a total caseload of about 317,000. The
next important study was by The Workforce Committee of the American As-
sociation for Thoracic Surgery and The Society of Thoracic Surgeons (AATS/
STS), which was charged with conducting a membership survey to determine
membership demographics, work volume, and practice patterns in thoracic
surgery.5 Between August and December of 1999, the AATS/STS designed
and sent a comprehensive seven-page questionnaire to all of its members over
the course of three separate mass mailings. At the completion of the third mass
mailing they had a response rate of 62.6 percent (2,515 of 4,018), which
provided a statistically significant sample. The mean age of practicing surgeons
had decreased to 50 compared to a peak of 52 years in the 1992 survey. The
workload had increased to a mean of 237 cases, and respondents worked
67 hours a week on average. Career satisfaction was highest among retired
thoracic surgeons at 85 percent. Career satisfaction also correlated with the
number of hours worked per week.
The AATS/STS survey gathered data on retirement plans for the first time.
Most surgeons were projected to retire by or prior to age 65, and the authors
estimated that 50 percent of practicing CT surgeons would retire by 2010.
They also pointed out that the increasing female medical class enrollment,
lifestyle considerations, length of training, educational debt, medico-legal envi-
ronment, declining income, and work hours were all factors in a decline in the
applicant pool for residency training.
The same report also correctly noted the comparative growth in primary
care physicians by 25 percent, all specialists by 35 percent, and the number
of cardiologists from 6,000 to 15,500 between 1975 and 1995 as compared
to a relatively stable pool of 4000 CT surgeons. The report suggested that the
CT specialty needed to focus on the recruitment of outstanding talent that it
had attracted in the past. CT surgeons were advised to become more proactive
in reaching out to and mentoring medical students to demonstrate the unique
role that thoracic surgeons play in the healthcare system. Although the spe-
cialty appeared to be right-sized in 2002, the report projected a scenario that
predicted a likely shortage of CT surgeons in the coming years.
According to William Gay, Executive Director of the American Board of
Thoracic Surgery, “Fewer than 4,000 physicians are actively practicing thoracic
surgery. While the number of candidates for certification has remained stable
over the last five to ten years, the number of applicants to thoracic surgery
residencies has declined over that period. In fact, last year (2003), there were
about the same number of applicants as there were residency positions.”6
Recently, the American Association for Thoracic Surgery (AATS) and the
Society of Thoracic Surgeons (STS) commissioned a workforce analysis of CT
surgery by the American Association of Medical Colleges (AAMC).7 The boom
era of coronary revascularization resulted in a peak of about 4,900 surgeons

from 1996 until 2002. The number of active CT surgeons then declined from
approximately 5,100 surgeons in 2003 to about 4,000 in 2005.
The Dartmouth Atlas investigators hypothesize that the number of CT sur-
geons would be stable between 1.1 to 1.3 per 100,000 population between
1995 and 2005, followed by a decline to 0.9 per 100,000 by 2020.8 The
study conducted by Atul Grover for the AAMC estimates that if 75 residents
complete training each year and demand stays at 2005 levels, there will be a
shortage of about 3000 CT surgeons by the year 2025.9 The graph in Figure 7.1
represents our estimate, a deficit of almost 2000 by 2030 increasing to about
3000 by 2050.
An additional consideration is the fact that a large number of CT surgeons
are over 50 years old and expected to retire over the next 10 years.
CURRENT THORACIC SURGICAL WORKFORCE

It takes an average of 8.3 years of training after graduation from medical
school for a CT surgeon to start practicing their craft. CT surgery residency
training is generally two to three years in length. However, 33 percent of CT
surgeons train nine years or longer.10 The National Resident Matching Program
Figure 7.1
Thoracic Surgeons
Demand versus Supply

7,000
6,000
5,000
Surgeons
4,000
3,000
2,000
1,000
0
1990 2000 2010 2020 2030 2040 2050 2060
Years
Demand Supply
Legend: Demand is taken from column 3 (Thoracic Surgeons Needed) of Table 7.2 and supply is
taken from column 4 (Thoracic Surgeons in Practice) of that table.
Figure 7.2
Applications for First-Year Posts: Thoracic and Cardiovascular Surgery
200
160
120
80
40
0
’93 ’94 ’95 ’96 ’97 ’98 ’99 ’00 ’01 ’02 ’03 ’04 ’05 ’06 ’07
Total number of applicants

Active positions available
U.S. medical school graduate applicants
Source: American Board of Thoracic Surgery.
(NRMP) conducts the annual matching of training programs with potential ap-
plicants. In 2007, of the 92 certified programs in the match and 130 positions
available, only 61 percent (56) were filled, leaving 39 percent unfilled. From
the applicant’s perspective, 87 (91%) of the 96 certified applicants matched.
Of the 87 who matched, 62 were U.S. graduates and the remaining were inter-
national graduates, U.S. foreign graduates, and osteopaths. Some of the most
prestigious programs in the United States did not fill their first-year residency
positions (Figure 7.2).11
Based on these data, the number of applicants for CT surgery training
dropped approximately 47 percent between 1997 and 2007. In contrast,
the number of active positions available in the same decade dropped only
13.7 percent. For the past five years, from 2004–2008, fewer than 100
American medical school graduates applied in each year. Grover points out
that anesthesiology went through a similar decrease in the applicant pool
and it took about six years to return to stability.12 Will this happen with CT
surgery? Perhaps.
8
Otolaryngology
Otolaryngology (OL)—head and neck or ear, nose, and throat (ENT) consists
of physicians that specialize in the diagnosis and treatment of ear, nose, throat,
and head and neck disorders. Common disorders treated by these specialists
include chronic ear infection, sinusitis, snoring and sleep apnea, hearing loss,
allergies and hay fever, swallowing disorders, nosebleeds, hoarseness, dizziness,
and head and neck cancer.1 These surgical specialists train for five years, includ-
ing at least one year in general surgery. Various subspecialties include head and
neck surgery, facial plastics, otology, neuro-otology, laryngology, sleep medi-
cine, sinus diseases, and pediatric ENT.
MEDICAL MIRACLES
Cochlear Implants
What is a cochlear implant? A cochlear implant is a small, complex
electronic device that can help provide the sense of sound to a person who is
profoundly deaf. It is very different from a hearing aid,2 which amplifies sound,
but cochlear implants compensate for damaged or nonworking parts of the
inner ear. The cochlear implant bypasses damaged cells and converts speech
and environmental sounds into electrical signals, which are sent to the hearing
nerve (Figure 8.1).
According to the Food and Drug Administration in their 2006 data, approx-
imately 112,000 people worldwide have received implants.3 In the United
States alone, about 13,000 adults have cochlear implants and nearly 10,000
children have received them. In a recent Johns Hopkins study of 35 school age
children, about 75 percent were in mainstream classes full time.4
Laryngeal Cancer
Laryngeal cancer is cancer of the voice box or Adam’s apple and occurs
in approximately 10,000 Americans per year with a five year survival rate
Otolaryngology 79
Figure 8.1
Cochlear Implant Device
External
Components
Internal
Components
Source: Courtesy of Molly Feuer.
of 65.1 percent.5 A total laryngectomy (complete removal of the voice box)

means that a person will have to have a hole in the front part of his or her neck
(a permanent tracheostomy) just above the breast bone (Figure 8.2). Most
people who have undergone this operation can learn to speak with a speech
therapist’s help.
Prognosis for cancers involving the glottis (true vocal cords) is much bet-
ter, with a five year survival of almost 85 percent compared to cancers af-
fecting the supra-glottic area (area above the vocal cords).6 New techniques
include transoral endoscopic removal of cancers, robotic assisted endoscopic
Figure 8.2
Tracheostomy
Source: Courtesy of Catherine Williams.
surgery, microvascular techniques for covering large defects from cancer

removal, and concurrent administration of radiation and chemotherapy for
malignancies.
ENT Projections
In 2004, C. Ron Cannon and his associates re-assessed the ENT workforce
and made recommendations for a future national practice model.7 The num-
ber of practicing ENT increased from 8,514 in 1995 to 9,252 in 2002. The
number of residents entering the workforce was also discussed in this study.
Cannon, et al estimated a fairly stable number of about 300 residents graduat-
ing each year, although they noted an overall decline in the number of training
positions, an increase in female residents, and a clear desire for family priori-
ties expressed by newer graduates.
These figures were utilized to prepare the following estimates: We esti-
mated that there were about 8,900 ENT surgeons in the United States in
2000, or a ratio of 3.2 for every 100,000 people. These figures project the
ENT workforce with regard to 35 years of service (Table 8.1).
Otolaryngology 81
Table 8.1
35 Years to Retirement for ENT
ENT ENT
2000 282,000,000 8,911

2010 309,000,000 9,764 9,136 628 7%
2020 336,000,000 10,618 9,586 1,032 10%
2030 364,000,000 11,502 10,036 1,466 13%
2040 392,000,000 12,387 10,500 1,887 15%
2050 420,000,000 13,272 10,500 2,772 21%
It is anticipated that about 255 ENTs will retire each year and that there
will be about 300 new board-certified ENT surgeons per year as mentioned.
By 2030, the ENT surgeons required for the U.S. population will be about
11,500 (Figure 8.3). Our projections with regard to 2030 indicate a 13 per-
cent shortage. By 2050, the number of ENT surgeons that will be needed to
service our patients’ needs is about 13,000, with an estimated shortage of
21 percent or 2,772 ENTs.
If ENT surgeons retire after 30 years of service, again using the 3.2 per
100,000 number, 297 would retire each year (and 300 new board-certified
ENTs would enter the specialty each year) (Table 8.2). In that case, by 2030,
there would be about a 22 percent shortage compared to the 11,502 sur-
geons needed. It becomes even more alarming in 2050 when 13,272 ENTs
will be required to give patient care and the United States will be about 4,272
(32%) short of this number.
ENT WORKFORCE ISSUES

In one of the first studies to look at future workforce in the specialty, Miller
in 1992 attempted to predict the future workforce in the year 2010 based
upon a model that included the number of residents in training, age distribu-
tion of currently practicing specialists, and death rates of doctors.8 He esti-
mated that there would be a 21 percent increase in practicing ENTs between
1995–2010 and that the ratio of ENTs to population would climb from 2.5
to 2.8 per 100,000 population. Fully 49 percent of practitioners at the time
of the study were less than 45 years of age. In 1996, Jafek et al reported an
increase in the supply of ENTs from 2.38 to 3.1 per 100,000 population over
a 20-year period.9 In 1994, Anderson and co-authors, , relying on data from
three health maintenance organizations and other sources, reported an under-
supply of ENTs.10 However, based on the number of trainees and requirement
Figure 8.3
Supply of Otolaryngologists
10
0
1980 1990 2000 2020
Number (thousands) Per/100,000 population
Source: American Medical Association, Chicago, Illinois. Copyright, 2007. Physician characteristics
and distribution in the U.S. annual. Projections for 2020 based upon our analysis as shown in
Table 1.
Table 8.2
30 years to retirement for ENT
ENT ENT
2000 282,000,000 8,911

2010 309,000,000 9,764 8,926 838 9%
2020 336,000,000 10,618 8,956 1,662 16%
2030 364,000,000 11,502 8,986 2,516 22%
2040 392,000,000 12,387 9,000 3,387 27%
2050 420,000,000 13,272 9,000 4,272 32%
Otolaryngology 83
of ENTs, they also suggested an oversupply by 2010 with a ratio between

2.69 and 3.77 per 100,000 population. The first major study on workforce
issues in OL was commissioned by the American Academy of Otolaryngology-
Head and Neck Surgery and reported in 2000.11 The study collected informa-
tion on practice patterns, geographic distribution, and supply and demand for
ENTs between 1993 and 1995. In this study the workforce had aged, and
with 47.6 percent were more than 50 years old and only 37 percent were
younger than 45 years of age. According to this report based on the AMA
master file, there were 3.240 ENTs per 100,000 population in 1995. Their
actuarial supply model was based upon base supply, retirements, deaths, and
entrance of new graduates. The formula they used was:
Supply N+1 = Supply N - Retirements N+1 —Deaths N+1 + Graduates N+1

where N represented the current year.
Their conclusions, which were based upon administrative claims data, noted
that 50–60 percent of charges were for office or evaluation and management
services rather than procedural codes. This algorithm is similar to ours.
In 1996, Jafek and his co-authors observed that market forces, rather than
the political process and government, would dictate practice patterns for the
immediate future.12 They posited that perceived problems would then nega-
tively affect the number of applicants for otolaryngology residencies. Addi-
tionally, they raised concerns about the health care market’s commitment to
quality, teaching, academia, and research. Lastly, the lack of predictability in
the medical practice was considered responsible for much of the stress and
frustration felt by many otolaryngologists.
There are several other trends that bear watching that may change our
models for supply and demand in this specialty. Although the number of new
residents entering training remains stable at roughly 300 per year, the num-
ber of applicants for these training slots has decreased by 30 percent over the
past five years. In addition to allopathic residency programs, the American
Osteopathic Association reports that 19 programs in ENT have 100 available
training slots, of which only 76 were filled in 2007.13 The priorities of these
residents are changing as well. In 1984, a study reported that practice poten-
tial and quality of the medical community were considered important priori-
ties in a resident trainee’s choice of a specialty.14 In a recent study about the
influence of lifestyle and income on medical students’ career specialty choices,
both lifestyle (p = .018) and income (p = .011), both very significant, were
found to increasingly influence medical students’ career choices.15
Gender issues are also an important part of any specialty’s effort to under-
stand its workforce and attempt to change recruitment and training methods.
In a 1996 report, the OL specialty was 93.5 percent male and 6.5 percent
female; however, in 2000 the figures showed that 91.9 percent of physicians
were male and 8.13 percent were female.16 Thus, there was an increase in
the number of women entering the workforce, especially between the ages
of 30 and 49. Other surgical specialties have also documented an increase in

the number of women. The increased presence of women does present some
interesting scenarios. Female surgeons tend often to marry other professionals,
which can lead to two physician families and complicated work schedules.17
The result is that female ENTs may not practice as many hours per week or as
long as their male counterparts. In a 2006 Association of American Medical
Colleges survey, 28 percent of female physicians worked part time compared
with 4 percent of male physicians.18 The survey results indicate that the most
common type of practice is that of a specialty practice, with the median size of
the practice being 3.1 full-time equivalent (FTE) otolaryngologists per group.
Results also indicated that otolaryngologists spent an average of 27.1 hours
per week in the office and 11.3 hours per week in the OR. The general trend
to earlier retirement has been observed across all specialties. When asked about
retirement, the average age of planned retirement for ENTs was 64 years. In
a 2002 survey conducted by the American Academy of Otolaryngology-Head
and Neck, the following factors influenced retirements: finances (61%), practice
hassle (59%), age (49%), lack of enjoyment (43%), health concerns (40%), loss
of autonomy (32%), and decreasing Medicare reimbursement rates (31%).19
As is true for many of the specialties, the main marketplace concern for
this specialty lies with flat or reduced reimbursement in the face of increased
practice expenses (particularly malpractice expenses). In addition, there will be
more of a demand for geriatric ENT services as the population ages. When
coupled with declining Medicare reimbursements, it is not clear who will pro-
vide these services for patients over the age of 65. Because Medicare has
become the gold standard on which all payers base their fees, physicians are
currently faced with inadequate payment to sustain their practices. As a result,
many are in fact closing their practices or declining to accept new Medicare
patients. This creates a constant challenge for physicians trying to sustain their
practices while providing quality patient care.
In the final analysis, flat and decreasing reimbursements in the face of
increased office expenses, regulatory mandates such as HIPAA, changing
priorities, and the liability insurance crisis are factors that are likely to make
an ENTs survival a daunting task. And while it is impossible to predict how
each of these factors will come to bear on the profession as a whole, it is safe
to say that all will have a substantial impact on the specialty.
9
Obstetrics and Gynecology
An obstetrician/gynecologist (OB/GYN) specialist is a physician who provides

medical and surgical care to women and has particular expertise in pregnancy,
childbirth, and disorders of the reproductive system. This includes preventative
care, prenatal care, detection of sexually transmitted diseases, Pap test screen-
ing, and family planning.1 A minimum of four years of training after medical
school is required for a physician to be eligible to take the board certification
examination prior to becoming a specialist. An OB/GYN is often a primary
care physician for many women in addition to acting as a specialist in his or
her own area. Subspecialties within OB/GYN include female pelvic medicine
and reconstructive surgery, gynecologic oncology, maternal-fetal medicine and
reproductive endocrinology/infertility.
OB/GYN MIRACLES
In Vitro Fertilization
Who will help us to conceive? Who will help us get pregnant? One of the
miracles of obstetrics and gynecology in the last 30 years is that of in vitro
fertilization and assisted reproductive technology (ART). Of the approximately
62 million women of reproductive age in 2002, about 1.2 million, or 2 per-
cent, had had an infertility-related medical appointment in 2001 or 2002,
and 10 percent had had an infertility-related medical visit at some point in
the past.2 The 134,260 ART cycles with eggs implanted performed at these
reporting clinics in 2005 resulted in 38,910 live births (deliveries of one or
more living infants) and 52,041 infants (Figure 9.1).3
Ovarian Cancer
Ovarian cancer is the fifth most common cancer among women, excluding
skin cancers. Ovarian cancer accounts for about 3 percent of all cancers in
Figure 9.1
Numbers of ART Cycles Performed, Live-Birth Deliveries, and Infants Born
through ART, 1996–2004
140,000
120,000
100,000
Number
80,000
60,000
40,000
20,000
0
1996 1997 1998 1999 2000 2001 2002 2003 2004
Year
Number of ART cycles
Number of infants born
Number of live-birth deliveries
Source: CDC, “2004 Assisted Reproductive Technology (ART) Report: Section 5—Trends in ART,”
1996–2004.
women.4 The American Cancer Society estimates that about 21,550 new cases
of ovarian cancer will be diagnosed in the United States during 2009.5 It is esti-
mated that there will be about 14,600 deaths from ovarian cancer in the United
States during 2009. The overall five-year survival rate for ovarian cancer is 45
percent. Although only 20 percent of ovarian cancers are found at an early stage,
the five-year survival after treatment for these early cancers is 92 percent!
Other major advances in this field include robotic surgery, minimally inva-
sive procedures for ectopic pregnancy, infertility, uterine fibroids, and urinary
incontinence, as well as the exciting frontier that is fetal surgery and placental
surgery.
A WORD TO THE WISE

The Threat of Premature Delivery
One in eight babies is born prematurely. That is over 500,000 babies a
year. The cost of the effort to save their lives is about $26 billion per year,
Obstetrics and Gynecology 87
according to the Institute of Medicine.6 Full-term pregnancy lasts from 38

to 42 weeks. Babies born before the completion of week 37 are premature.
Those babies born before 32 weeks have the greatest risk of death; at least
one-fifth don’t survive.
Who is at risk? Previous preterm delivery doubles the risk of delivering
prematurely, and carrying twins increases the prematurity risk by 40 percent.
Women younger than 16 or older than 35 are more at risk as well. Close su-
pervision of these pregnancies by an obstetrician, early in the prenatal period,
can reduce the incidence of premature births.
OB/GYN WORKFORCE PROJECTIONS

The need for obstetrics and gynecologists is based on the number of women
in the United States. The number of females in the United States as of Octo-
ber 1, 2007, was 153.6 million.
The female population is projected to be 157 million in 2010, 170 mil-
lion in 2020, and 213 million in 2050.7 The reported trend of OB/GYNs per
100,000 women has increased from 23.0 in 1978, 25.0 in 1988, 27.0 in
1993, to 27.2 in 1997.8 We have used 27.2 per 100,000, which translates
to 39,000 OB/GYNs, as the estimate of the number of specialists practicing
in 2000. This is consistent with the ABOG actual number of OB/GYNs in
practice, about 40,241 in 2000 (Figure 9.2).9
There was a significant decline in the number of U.S. medical graduates
electing to practice OB/GYN between 1997 and 2004.10 In 2006, women
represented only 27 percent of active physicians in the United States, but
42 percent of all residents/fellows in ACGME accredited programs.11 Women
represent about 23–24 percent of graduates of surgical graduate medical edu-
cation. The proportion of female residents increased every year between 1997
and 2004 in primary care and surgery, but the highest proportion of first year
female graduates entered OB/GYN. For the years 1997–2004, 73.3 percent
of residents who chose OB/GYN were female in contrast to 21.6 percent who
chose surgery and 47 percent who chose primary care.12
Assuming board certification of 1,200 each year (see chapter 2), and retire-
ment after practicing for 35 years, in 2010, about 42,000 OB/GYN special-
ists will be needed to take care of our women’s’ needs. In 2050, that number
will increase to almost 58,000. Unfortunately, with the present rate of 1,200
board- certified OB/GYNs entering the new workforce, the number in practice
will be constant at 42,000 from 2040 to 2050 (Table 9.1). By 2030, there
will be a shortage of about 18 percent (9,000) OB/GYNs compared to the
estimated 50,000 needed. By 2050, that shortage will increase to 25 percent
or 15,723 OB/GYNs.
Now let’s examine the projections based on 30 years of clinical practice.
The 30-year horizon may be more relevant than 35 years to retirement since
female physicians may take time off from their practices in their childbearing
years. It also may be in the practitioners’ interest to have shorter work weeks
Figure 9.2
Populations and Numbers of Obstetrics and Gynecologists
250
200
150
100
50
0
2010 2020 2030 2040 2050
Projected female population (hundreds of thousands)
Projected number OB/GYN in practice (hundreds)

Source: http://www.census.gov/ipc/www/usinterimproj/natprojtab02a.pdf (accessed June 3, 2008).
Table 9.1
35 Years to Retirement for OB/GYN
OB/GYN OB/GYN
2000 144,000,000 39,024

2010 157,000,000 42,547 39,449 3,098 7%
2020 171,000,000 46,341 40,299 6,042 13%
2030 185,000,000 50,135 41,149 8,986 18%
2040 200,000,000 54,200 42,000 12,200 23%
2050 213,000,000 57,723 42,000 15,723 27%
Table 9.2
30 Years to Retirement for OB/GYN
OB/GYN OB/GYN
2000 144,000,000 39,024

2010 157,000,000 42,547 38,519 4,028 9%
2020 171,000,000 46,341 37,509 8,832 19%
2030 185,000,000 50,135 36,499 13,636 27%
2040 200,000,000 54,200 36,000 18,200 34%
2050 213,000,000 57,723 36,000 21,723 38%
during that particular time of their lives. In this scenario, after 30 years of
practice, there will be about 1,300 obstetricians retiring each year, and with
1,200 new board certified surgeons, there will be a net shortage of 100 OB/
GYNs each year. By 2030, the OB/GYNs actively in practice will total 36,499;
that shortage will amount to more than 25 percent of the workforce needed.
By 2050, with 36,000 OB/GYNs in practice, the shortage will be more than
35 percent (Table 9.2).
OB/GYN WORKFORCE ISSUES

One of the few studies on the future workforce in the specialty was con-
ducted by Jacoby and associates.13 They predicted slow or no growth in OB/
GYN-to-population ratio until 2014 based upon an actuarial supply model
and analysis of practice patterns. The authors also expressed concern about an
oversupply based on implementation of managed care staffing models through-
out the country. In addition, they noted a higher attrition rate for female OB/
GYNs due to slow downs in childbearing years.
Based upon American Medical Association data on the number of Board
Certified OB/GYNs, their number per 100,000 population has increased
from 11.4 in 1975 to 14.1 in 2006.14 Almost 20 percent of OB/GYNs do
not practice obstetrics and quit doing so at an average age of 48, which obvi-
ously will influence any forecasting of manpower needs.15 Therefore, there
are multiple factors that may influence the accuracy of any projection of the
future need for OB/GYNs. One issue that may alter projections for the future
need for OB/GYNs is the error in estimation of workload if these specialists
provide more or less primary or generalist care than is generally calculated in
most workforce studies. Some female Medicare beneficiaries, about 13 per-
cent based on relative value units billed, received more than half of all their
medical and surgical care from an OB/GYN. Yet, for instance, Jacoby and
associates observed that only 7.5 percent of female Medicare beneficiaries

were ever seen by an OB/GYN.16
Another factor in projecting the need for OB/GYNs in the future is the issue
of lifestyle and the fact that OB/GYN is one of the uncontrolled lifestyle spe-
cialties.17 Most OB/GYNs currently work about 60 hours per week. In chapter
4 in the section on “Controllable Lifestyle and Gender: In Search of Work/
Life Balance” we indicated that the average female physician works about
45 hours per week. Based on a 45-hour work week, the figures for female
obstetricians have to be multiplied by 1.3. Twenty-three percent of female
OB/GYNs under 40 years of age reduce or cease practice for family reasons
compared to only 5 percent of male OB/GYNs in the same age group.18 In a
survey of work hours, the aggregate productivity of female OB/GYNs is about
85 percent that of their male counterparts.19 Recall that about 73 percent of
the obstetrician residencies are occupied by female residents. The number of
residency training positions has stayed stable at about 4700 annually (1,225
first year positions) since a high of 5000 in 1993.20 In OB/GYN News in April
2004, there was a report stating that the number of OB/GYN residency spots
filled by U.S. senior medical students dropped. The fill rate by seniors was only
61.5 percent of the total number of available residencies.21 Despite a declin-
ing proportion of U.S. medical graduates entering OB/GYN programs, current
training programs are maintained due to an increase of U.S. osteopathic, Cana-
dian, and non-U.S. citizens filling the positions.
Escalation of medical liability premiums and a sharp uptick in the aver-
age payment per case has had an impact on the potential choice of career
specialty among doctors. The average annual liability premium for an OB/
GYN has increased dramatically from $30,682 in 1996 to $92,834 in
2006.22 Medical liability premium prices have gone from the second most
to the most serious problem for people going into OB/GYN. A recent survey
assessing professional liability of 2,185 American Academy of Obstetrics
and Gynecology fellows found that one in seven have stopped practicing
due to the risk of liability claims, and that more than 76 percent had a li-
ability claim filed against them, half of these within the past 10 years.23 Five
percent of these respondents have stopped performing major gynecological
surgery.
Another report shows that, as of 2004, Florida had the highest liability
premiums in the United States, at more than $175,000 annually.24 The states
with the lowest premiums, at $17,000 on the average, included Oklahoma,
Nebraska, South Dakota, Indiana, Idaho, and North Dakota. In Dade County,
Florida, which includes Miami, premiums went from $149,000 in 2003 to
$207,000 in 2004. In the same period, in Cook County, Illinois, the premiums
jumped from $138,000 to more than $230,000. In Wayne County, Detroit,
they went up from $164,000 to nearly $194,000.
OB/GYN malpractice premiums are so high because “the statute of limita-
tions for malpractice claims by a minor ends one year after the minor reaches
18” years old, as opposed to the two year statute of limitations for a practicing
surgeons in other specialties.25 Would it be difficult to get a delivery in some

of the major cities in the United States? Perhaps.
According to one of the authors of a very good paper on OB/GYN working
issues, “As a specialty we are threatened by rising malpractice premiums, lower
job satisfaction, intrusion of policymakers, and insurance companies demand-
ing better service and access while providing few resources, and decreased
interests in obstetrics and gynecology among senior medical students are for-
midable challenges.”26
Who Will Deliver Our Babies?

Midwives and obstetricians deliver babies, but midwives cannot perform
caesarean section deliveries. This presents a problem (Figure 9.3). Approxi-
mately 4 million women were hospitalized for delivery in 2005, and their
average stay was 2.6 days.27 Caesarean sections per 100 deliveries increased
from 20.8 in 1995 to 31.3 in 2005, and the rate of primary cesareans per
100 deliveries without a previous caesarean increased from 15.5 to 21.7 dur-
ing this period. Caesarean section rates rose 6 percent in 2004 and have gone
up 46 percent since 1996.
Figure 9.3
Caesarian Rates for First Births, for All Women and Low-risk Women: United
States, 1990–2003
30%
25%
20%
15%
10%
5%
0%
1990 1992 1994 1996 1998 2000 2003
All women Note: Data for 1990 excludes data from

Low-risk women Oklahoma, which did not report method
of delivery on the birth certificate.
Source: National vital statistics reports: from the Centers for Disease Control and Prevention,
National Center for Health Statistics, National Vital Statistics System.
What will happen in 2050 when we have an estimated population of 420

million people? If this trend continues, there will be 1.8 million babies or more
delivered by cesarean section. There are several reasons for the increase in
caesarean sections. Experts point to several factors, particularly malpractice. If
a baby has birth difficulties, the obstetrician is liable for 18 to 21 years of the
baby’s life in most states and so would perform a caesarean section to comply
with the standard of care.
Obstetrics Hospitalists: Laborists—an Emerging Field

Walter Hull, who spent 20 years of his life as a missionary in Zaire, is an
obstetrician and gynecologist. Walter has returned to the United States as an
OB/GYN faculty staff member at The Ohio State University Hospital. He says
that the way that we deliver babies in the United States is inefficient. He says
this is because, sometimes, in one hospital in one day, 12 babies are delivered
by 10 to 12 obstetricians.
Perhaps it would be better to assign two obstetricians to deliver babies over
a 24-hour period so that the other obstetricians could get some rest and pro-
vide prenatal care to expecting mothers and their fetuses. That would make
for a scheduled or controllable lifestyle. This may well be the case as time goes
on, considering that 75 percent of OB/GYN residents are female.
Laborists are OB/GYNs who work in hospitals delivering babies.28 They can
be hospital employees or independent contractors. They work seven or eight
24-hour shifts per month. Part of the job is delivering babies for uninsured
women who appear in the emergency room. Besides improving patient care,
laborists can lower a hospital’s malpractice liability and insurance premiums.
Laborists also reap rewards, too—predictable schedules, relief from running
a practice, and competitive compensation. With the hospitals paying for mal-
practice coverage, as employees, laborists can afford to deliver babies.
A FINAL NOTE
What do all of these considerations do to the relationship between a mother
and her obstetrician? What does this mean to the private practice of obstetrics and
gynecology?
10
General Surgery
WHAT IS GENERAL SURGERY?

The American Board of Surgery defines general surgery as “. . . a discipline
encompassing the following essential content areas: Alimentary Tract, Abdo-
men and its Contents, Breast, Skin and Soft Tissue, Endocrine System, Head
and Neck Surgery, Pediatric Surgery, Surgical Critical Care, Surgical Oncol-
ogy, Trauma/Burns and Vascular Surgery.”1 In other words, general surgery
encompasses the core of all surgical training, and practitioners are taught to
care for common surgical problems relating to and ranging from accidents and
injuries to cancers.
Medical Miracles
Advances in the field of general surgery have benefited the entire spectrum
of surgical specialties from plastic surgery to gynecology. Some examples of
recent progress in this specialty are discussed in the following sections.
Breast Cancer
One of the real miracles, with regard to cancer, is what is happening in
breast surgery. In the 1960s and before, the standard curative surgical pro-
cedure for breast cancer was a radical mastectomy, which involved very long
scars and prolonged recovery (Figure 10.1).
This disease in the 1960s was associated with a mortality rate of 30 to
40 percent within five years, or a five-year survival rate of 60 to 70 percent.
The five-year survival is now almost 88 percent, the 10-year survival rate
80 percent, the 15-year rate 71 percent, and the 20-year rate 63 percent.2
Here are many factors that have contributed to the improved statistics for
breast cancer. The most important thing in the last 25 years, perhaps, is the
increased awareness of the disease among women. The Komen Race for the
Cure has made more and more women aware of the seriousness of this cancer
Figure 10.1
Surgical Incision for Radical Mastectomy in 1960
that could await them.3 At the same time, improved techniques for diagnosis,
mammography, and needle biopsy have been developed. Improved surgical
techniques such as lumpectomy, perhaps with ‘sentinel’ lymph node biopsy, as
well as marked advances in radiation methods and new chemotherapy drugs
have all played a part in the goal toward eliminating breast cancer. Mono-
clonal antibodies such as Herceptin have been approved as immunotherapy
for breast cancer, and various other specific antigen vaccines are also on the
horizon (Figure 10.2).
Gallbladder
In the past, before the development of minimally invasive surgery, a six- to
eight-inch incision along the ribs or a paramedian incision from the ribs to the
belly button was made to remove a diseased gallbladder (Figure 10.3).
A remarkable innovation in general surgery is the minimally invasive ap-
proach of introducing a laparoscope through four one-inch openings (ports)
through which a gallbladder can be removed with much less pain and disfig-
urement and a quick recovery (Figure 10.4). In the new era, only 10 percent
of all cholecystectomies (gallbladder removals) are done with open surgery,
General Surgery 95
Figure 10.2
Breast Cancer Now
Woman with lumpectomy

A = Tumor (dark area)
B = Tissue removed at lumpectomy (lighter area)
Five year survival rate—88%
and almost 750,000 laparoscopic cholecystectomies are performed annually

in the United States.4 In most cases, cholecystectomy is a same-day procedure
with discharge from the hospital the next day.
NOTES PROCEDURE (NATURAL ORIFICE

TRANSLUMENAL ENDOSCOPIC SURGERY)
Incisionless surgery through an endoscope performed via a natural orifice
in the body is the next frontier in minimally invasive procedures. Approach-
ing intra-abdominal organs through natural orifices such as the mouth, anal
canal, and vagina leads to less pain, quicker recovery, and fewer or no external
scars even compared to laparoscopic surgery. Several venture capital firms are
investing hundreds of millions of dollars into new technology that promises to
Figure 10.3
Gallbladder Incisions —1960
alter the landscape of minimally invasive surgery even more dramatically than
laparoscopic procedures.
Will there be enough general surgeons to perform these procedures and
lead the way to even further innovation directed towards making procedures
less invasive, painless, and safe?
General Surgery Projections and Scenarios

General surgery is facing a shortage similar to that of other surgical special-
ties. There has been a decrease in the relative number of general surgeons of
about 26 percent since 1981, from 7.6 to 5.6/100,000 population.5 Until
recently, the number of applicants for general surgery residency had dropped
30 percent. In 1987, about 7.8 percent of medical school graduates elected
General Surgery 97
Figure 10.4
Incisions for Minimally Invasive Gallbladder Surgery
general surgery residencies.6 By 2002, the figures were down to about 5.8
percent. One of the workforce studies projected that by 2005, only 4.8 per-
cent of U.S. medical school graduates would be interested in general surgery.
The number of applicants for the National Residency Matching Program in
general surgery declined from 2,000 in 1994 to 1,500 in 2001; however,
in a recent turnaround, 83.1 percent of available categorical general surgery
positions in 2008 were filled by U.S. medical school seniors.7
At the present time, the American Board of Surgery awards approximately
1,000 certificates each year. About 150 of these recipients will take other
residencies, such as thoracic surgery, vascular surgery, and pediatric surgery.
For our estimates, we will assume that 850 newly board certified surgeons will
actually practice general surgery. The first projection assumes a career span-
ning 35 years with 604 retirees during the same period. Again, the relevant
surgeon-to-population ratio used is 7.5 per 100,000.8 Under this scenario, by
2050 we will have a shortage of 1,750 or about 6 percent of general surgeons
(Table 10.1).
If we change our assumption to a career of 30 years of service instead
of 35 years and 705 retiring surgeons by 2030, we will have a shortage of
about 2,500 surgeons or about 9 percent. By 2050, that shortage will have
increased to 6,000 or about 19 percent (Table 10.2).
General Surgery Workforce Issues

The landmark study on the surgical workforce was conducted in the 1970s
by the American Surgical Association and the American College of Surgeons
and is known as the SOSSUS (Study on Surgical Services for the United States).9
The study was completed in 1975 and was based on population estimates and
workload. The authors concluded that 1600–2000 surgeons completing their
Table 10.1
35 Years to Retirement for General Surgeons

2000 282,000,000 21,150

2010 309,000,000 23,175 22,380 795 3%
2020 336,000,000 25,200 24,840 360 1%
2030 364,000,000 27,300 27,300 0 0%
2040 392,000,000 29,400 29,760 (360) –1%
2050 420,000,000 31,500 29,750 1,750 6%
Table 10.2
30 Years to Retirement for General Surgeons

2000 282,000,000 21,150

2010 309,000,000 23,175 21,875 1,300 6%
2020 336,000,000 25,200 23,325 1,875 7%
2030 364,000,000 27,300 24,775 2,525 9%
2040 392,000,000 29,400 25,500 3,900 13%
2050 420,000,000 31,500 25,500 6,000 19%
residencies each year from 1976 to 2012 should satisfy the country’s need
surgical services. The ratio of general surgeons to the population was estimated
at 6.93/100,000. The authors of the study did not identify any particular
undersupply or oversupply within various parts of the United States. The next
influential report, called the GMENAC (Graduate Medical Education National
Advisory Committee) report, is considered one of the most comprehensive at
evaluating physician workforce, although it continues to receive criticism for
its methodology, modeling, and analysis.10 The GMENAC report evaluated
the physician workforce in 1978, issued its findings in 1980, and predicted
an oversupply of 145,000 physicians by the year 2000. In regard to sur-
gery, the predicted manpower need for 1990 was estimated between 23,000
and 24,000 general surgeons, and this was projected to be between 9.4 to
9.8/100,000 population. The GMENAC report also documented 30,700
general surgeons in 1978 and predicted an increase of 15 percent to 35,300
general surgeons by 1990. Therefore, the report concluded that there would
be an oversupply of surgical specialists in the years following 1978.
General Surgery 99
The Council on Graduate Medical Education (COGME) was created under

the Consolidated Omnibus Budget Reconciliation Act of 1983 (COBRA) to
monitor physician supply and demand.11 COGME recommendations included
training 50 percent specialists and 50 percent generalists with total gradu-
ate medical and surgical positions fixed at 110 percent of all U.S. medical
graduates; international medical graduates, often from foreign nations, com-
prised the other 10 percent. A reduction in the number of residency train-
ing positions followed as policy makers relied upon recommendations of the
GMENAC report as well as the COGME report.
One of the few earlier assessments to have predicted an undersupply of
general surgeons was an AMA report in 1986.12 This study, which used the
AMA master file as a basis, calculated that there were 32,100 general sur-
geons, including 8,900 surgical residents prior to 1986. In the later 1980s,
only 1000 residents graduated compared to the 1600 to 2000 that SOSSUS
had predicted. The AMA concluded that the workload for surgeons would
go up by almost 20 percent, but that the workforce would increase by only
6 percent.
Using different databases, the American Board of Medical Specialties had
the number of general surgeons in the U.S. as 22,470 and the American
Board of Surgery came up with 19,917 general surgeons. However, as George
Sheldon, the former chair of the department of surgery at the University of
North Carolina points out, board-certified active general surgeons probably
numbered between 17,829 and 19,520, which was about half the number
used by the AMA and other planning committees.13 COGME was to later com-
pletely reverse its earlier stance and state its position as being in favor of ex-
panding undergraduate and graduate medical education programs in 2003.14
One of the first thoughtful challenges to the GMENAC and COGME reports
was a 1991 study that employed modified needs-based models updated with
population projections.15 This study predicted a 33 percent (37,022 general
surgeons) increase in needs between 1990 and 2010 and only a 10 percent
increase in the supply of general surgeons, with a resulting shortage of about
5000 general surgeons by 2010.
In 1996, Kwakwa and Jonasson reported that board certifications in gen-
eral surgery had been stable at 1000 for 12 years.16 In addition, the ratio of
7.1 general surgeons/100,000 population observed in 1994 was less than the
population ratio predicted by GMNEC and the revised update. The number of
general surgeons decreased, according to the AMA master file, from 27,509
in 1998 to 24,902 in 2002.17 Sheldon opines that even though the number
of osteopathic general surgeons (1,037 in 2007) is not considered in many
estimates of the workforce, their small numbers do not substantially alter his
view that the shortage is significant.
Academia has been persuaded by a steady flow of data confirming the
future undersupply of general surgeons. The decline in the relative number of
general surgeons from 6.93/100,000 in the SOSSUS study, and 7.1/100,000
in Sheldon’s report to 6/100,000 or lower has received attention.18 A survey
of 70 responding deans of medical schools showed that 89 percent could cite

shortages in at least one specialty, 17 percent in general surgery and 21 per-
cent in surgical subspecialties.19
The total percentage of U.S. medical school graduates matching to gen-
eral surgery or one of its subspecialties stayed steady from 1987–2002 at
around 11–12 percent.20 During the same time frame, the number of medical
students who chose general surgery declined from 7.8 percent in 1987 to
5.8 percent in 2002. An attrition rate of about 20 percent based on lifestyle
issues has also been documented.21 There is declining interest in general sur-
gery among medical students because of the long years of training, the difficult
work hours, the lifestyle, the debt, and professional liability issues, as well as
other factors such as declining reimbursement. In a presidential address at
the annual meeting of the Western Surgical Association in November 2002,
J. David Richardson delivered a talk entitled “Work Force Issues in Surgical
Figure 10.5
Forecasted Increases in Work by Specialty
50%
45%
40%
35%
30%
25%
20%
15%
10%
5%
0%
2001 2010 2020
U.S. Population Neurosurgery Otolaryngology

Cardiothoracic Ophthalmology Urology
General Surgery Orthopedics
Note: General surgery includes vascular, breast, hernia, abdominal, gastrointestinal, and pediatric
procedures.
Source: D. Etzioni, J. Liu, M. Maggard, et al., “The Aging Population and Its Impact on the Surgery
Workforce,” Annals of Surgery 238 (2003): 170–176.
General Surgery 101
Training and Practice.” He said that lifestyle issues remain at the forefront of
students concerns:22
I posed . . . this question to the students. Do you view your medical career as a
job or a profession? Eighty percent of the women stated it is a job while 50%
of the men had the same response. Women usually state that the all-consuming
commitment to the profession is not what they want. Before rushing to judge
me as an anti-woman, let me tell you that I have a daughter in medicine who
has made me sensitive for a need to have life away from our patients. The bal-
ance of work with home and family is a feeling stated by virtually all students
regardless of gender. The need for a balanced life is crucial and should be
encouraged.23
International medical graduates have stepped in to fill about 15 percent

of ACGME-approved general surgical residency positions. Approximately half
of general surgical residents have previously sought advanced training. The
Figure 10.6
Decreasing General Surgical Workforce with Increasing Population of the
United States
20,000
17,394 17,757 17,922
18,000
16,662
7.68
16,000
7.04
14,000 7
6.29
12,000
5.69
10,000 5
8,000
6,000 3
4,000
1 1,000 995 1,064 1,124
2,000
0
1981 1991 2001 2005
# General Surgeons
#/100,000 Population
# ABS Certificates Awarded
Source: F. Kwakawa and O. Jonasson, “The General Surgery Workforce,” Advisory Council for Gen-
eral Surgery, http://www.facs.org/about/councils/advgen/gstitlpg.html (accessed May 17, 2008);
D. C. Lynge, E. H. Larson, M. Thompson et al., “A Longitudinal Analysis of the General Surgery
Workforce in the United States, 1981–2005,” Archives of Surgery 143 (2008): 345–350. Copy-
right © 2008 American Medical Association. All rights reserved.; Census bureau.
proportion of general surgical trainees going on to further specialty training

has recently increased from 55 percent to 70 percent.24 Surgical oncology,
colorectal surgery, vascular surgery, pediatric surgery, and cardiac surgery are
among the specialties they choose.
Another concern with regard to the general surgery workforce is an earlier
age of retirement. Kwakwa and Jonasson noted an increase in retirement age
from 60 to 63 years in the years 1984–1995.25 In 1990, general surgeons
retired at about the age of 71. By 2000, general surgeons were retiring at the
age of 58.
Etzioni and co-authors have examined the impact of the aging popula-
tion on the demand for surgical services.26 Based on estimated population
increases of 7.9 percent by 2010 and 17 percent by 2020, they predict
a 31 percent growth in procedure-based work in general surgery (Figure
10.5).
Why is there such great disparity in attempts by serious and well-informed
individuals to ascertain the approximate number of general surgeons required
to serve our communities? There are multiple reasons, most of which are
articulated by Cooper.27 One basic reason stands out: the models commonly
used for predicting demand were probably in error. Most studies used patient
visits or procedures and physician full-time equivalents for estimating demand.
Methodologies having to do with estimation of workloads and then computa-
tion of demand for surgical services have been inconsistent. Cooper used a
trend model which took into account economic expansion (gross domestic
product), population growth, physician work effort, and a trend of increas-
ing services provided by physician extenders such as nurse clinicians. In our
projections, we have not taken into account the increased surgical workload
forecasted by most experts. However, it is now clear that despite a new desire
to train more general surgeons for the future, we may find ourselves behind
the curve (Figure 10.6).
11
Neurosurgery
Neurosurgery is the specialty that involves the surgical treatment of diseases of

the nervous system. A more comprehensive definition of neurosurgery is that
it is a specialty that involves the operative and nonoperative management in-
volved in the diagnosis, treatment, and rehabilitation of a patient with disorders
of the central and peripheral nervous system.1 The training of a neurosurgeon
involves a rigorous five to seven year program with the first year consisting of
general surgery/rotating internship and one to two later years gaining research
experience in the top tier programs. Subspecialty programs within neurosurgery
include cerebrovascular surgery, neurocancer, pediatric neurosurgery, skull-base
surgery, stereotactic surgery, complex spine surgery, and epilepsy surgery.
NEUROSURGICAL MIRACLES
Brain Trauma—Two Cases
Neurosurgeons treat brain trauma. Whenever any tissue gets injured, swell-
ing occurs. If that swelling is confined to a narrow space, for instance the skull,
and there is no relief for the pressure, the brain herniates down towards the
spinal column through the opening connecting it with the skull. This can cause
death or severe disability. One of the current miracles of neurosurgery is the
management of severe brain trauma.
In 2005, Peter Jennings, the news anchor for the ABC evening news, died
of lung cancer. Bob Woodruff was appointed to be his successor. In the course
of the first months of his reporting he went to Baghdad, where he was injured
by an improvised explosive device. He suffered severe head and brain trauma.2
Because of the swelling of his brain, the doctors removed a large piece of his
skull to relieve the swelling. Over the course of a year, Woodruff recovered to
the point where he is now reporting again for ABC news.
The same techniques have been brought into general use as well. In Wor-
thington, Ohio, in the Halloween season of 2006, some teenage girls wanted
to visit what they thought was a haunted house. As they entered the yard of
the haunted house on a dare, the owner shot one of the girls from the window
of the house with a rifle.3 She had severe brain trauma, and the technique
of removing a piece of her skull to control the brain swelling was used. For
several months she had to wear a helmet in order to protect her brain. Even-
tually her skull was reconstructed. She was well enough to attend her high
school graduation.
SELECTIVE BRAIN SURGERY

Bernadine Healy, M.D., and her husband, Fred Loop, M.D., are a distin-
guished medical couple. She is a cardiologist, former director of the National
Institutes of Health, and dean of the Ohio State University Medical School.
Fred is a heart surgeon and retired head of the Cleveland Clinic.
Bernadine was right handed, what she calls “a left brain,” and so the speech
center was on the left side of her brain. In 1999 she learned that she had a
malignant brain tumor. The brain tumor was close to the speech center on the
left side. This passage is taken from her book, Living Time, Faith and Facts to
Transform Your Cancer Journey with her permission:4
I was clearly harnessed to the operating table with my head immobilized by

some kind of paraphernalia. I had no pain medically or physically. Dr. Barnett
had already numbed my scalp with a local anesthetic and opened up a 4–5”
window into the left side of my skull to expose the tumor. . . . My brief reverie
was interrupted when neurologist, Hans Luders, an expert on brain geography
appeared before me in full surgical garb. . . . He now stood over me holding my
neurosurgical homework, a literary passage I was to read again and again during
the operation. This was strangely satisfying: I was a part of the team, aware of
what was going on, able to influence my own outcome, never entirely relinquish-
ing whatever meager control over my fate I can muster.
Like a third grader reading aloud in front of the class, I tried to pronounce
each word perfectly, though the words seemed odd. I asked Dr. Luders if this
passage made a lot of sense to him, and he laughed. To me it seemed out of
context and very flowery, not at all a passage I would have chosen for this criti-
cal moment in my life. But hey, who was I to be choosy. Just as I was feeling
comfortable about my ability to handle this strange experience, Dr. Barnett told
me he was finishing up and all was well.
Dr. Healy is an nine-year survivor of this malignant tumor. She is the health
care correspondent for U.S. News and World Report.
NEUROSURGICAL ADVANCES
1. Image-guided surgery and radiosurgery, including neuronavigation with
preoperative/intraoperative guidance.5 Neuronavigation uses computer as-
sisted technologies to navigate within the skull or vertebral column during
surgery.
Neurosurgery 105
2. Intracranial and spinal minimally invasive and/or endoscopic assisted surgery

with small incisions using endoscopes (small tubes used to look inside the
body).6
3. Complex spinal instrumentation used in surgical procedures to implant ma-
terials like titanium alloys or steel into the spine with the use of rods, hooks,
plates, screws, and threaded interbody cages to stabilize the spine.7
4. The management of brain trauma.
PROJECTIONS FOR NEUROSURGERY

We use the same assumptions in this chapter that we have used throughout
the book, which are that the ratio of physicians to population will not change,
that medical school enrollments and the number of board certifications will
not change, that the gross national product will not change, and that popula-
tion estimates are accurate. The relevant parameter for neurosurgeons we
have used for our assumptions is 1.06 per 100,000 population. The number
of practicing neurosurgeons in 2003 was 3,080 according to a press release
by the American Academy of Neurosurgery (AANS), with about 125 neuro-
surgeons being newly certified each year.8
In Table 11.1 we assume 35 year projections to retirement and 88 retir-
ees. According to these projections, by 2030 there will be a surplus of 147
neurosurgeons. By 2050, we project that there will be a shortage of about
77 neurosurgeons or two percent.
If we assume 30 years as an average time of a neurosurgeon’s medical ca-
reer, from entering practice to retirement (103 retire each year), the shortage is
projected at only six percent or 228 neurosurgeons in 2030 (Table 11.2). It be-
comes worse by the year 2050 with a shortage of 700 or about 16 percent.
NEUROSURGERY WORKFORCE
In this book we have tried to keep our estimates of the shortages of physi-
cians at a minimum instead of a maximum. As you can see, the estimates we
Table 11.1
35 Years to Retirement for Neurosurgeons
Projected Neurosurgeons Neurosurgeons Percent

2000 282,000,000 3,080

2010 309,000,000 3,275 3,265 10 7%
2020 336,000,000 3,562 3,635 (73) –2%
2030 364,000,000 3,858 4,005 (147) –4%
2040 392,000,000 4,155 4,375 (220) –5%
2050 420,000,000 4,452 4,375 77 2%
Table 11.2
30 Years to Retirement for Neurosurgeons
Projected Neurosurgeons Neurosurgeons Percent
2000 282,000,000 3,080

2010 309,000,000 3,275 3,190 85 3%
2020 336,000,000 3,562 3,410 152 4%
2030 364,000,000 3,858 3,630 228 6%
2040 392,000,000 4,155 3,750 405 10%
2050 420,000,000 4,452 3,750 702 16%
have given for the neurosurgical workforce might not seem significant in terms
of total numbers. The Health Resources Services Administration (HRSA) has
projected a total supply of 5,570 neurosurgeons in 2010, and 5,670 in 2020.9
However, in terms of clinical full time equivalents, after excluding residents
and those not in clinical practice, these numbers show that there will be 4,490
neurosurgeons available to practice in 2010 and 2020. This, we believe, is an
overestimate. Compare the numbers used by HRSA with the numbers based
on the AANS data.10
A recent paper by Gottfried et al approaches the workforce issue from a
different angle.11 The study attempted to evaluate the neurosurgical workforce
by reviewing journal advertisements for available positions from 1994–2003.
The number of practicing neurosurgeons declined after 1998, and by 2002 it
was less than it had been in 1991, whereas the number of incoming and ma-
triculating residents remained stable. The study noted that from 1999—2001,
25 percent of the board-certified neurological surgeons retired and concluded
that the number of positions advertised had increased significantly in the face
of the declining number of neurosurgeons and a static supply of residents.
Merritt, Hawkins & Associates confirmed this demand for neurosurgeons in
their “Summary Report, 2005 Review of Physician Recruitment Incentives.”12
The report said that neurosurgeons were in the “top 15 most recruited
specialties, the first time it has been on the list.” In Merritt, Hawkins & As-
sociates’ 2007 report of the 20 most recruited specialties, the average salary
offer for neurosurgeons was the highest at $530,000 (range $350,000 to
$850,000).13
The most publicly identified need for neurosurgeons, particularly in smaller
communities, is about availability of neurosurgeons who can take trauma call
for brain injuries.14 Here is increasing specialization in neurosurgery, as in
other fields. Neurosurgeons who specialize in spinal disease and other kinds of
specialized neurosurgery may feel unable to take trauma calls because of their
inexperience, as the years go on, in head and brain trauma. Small communi-
ties are feeling a severe shortage of neurosurgeons capable of handling brain
Neurosurgery 107
trauma patients. General guidelines call for 1.1 brain surgeons to 100,000
population, and business newspaper columns are full of recruiting pitches for
these specialists.15 A previous study has suggested, based upon time and
distance factors, that a distance of 100 miles and ground travel time of two
hours may be acceptable when a neurosurgeon is needed.16 However, even
with air ambulance transportation, press reports of inadequate care for brain
injuries put pressure on politicians to address the issue.17 South Carolina has
approximately 83 neurosurgeons, but six are residents and 22 are retired,
which leaves 53 neurosurgeons to care for a population of 4.3 million.18
There is also some evidence that the wave of retiring neurosurgeons is a
result of the malpractice insurance situation that has occurred in the last 10
years.19 Neurosurgeons pay some of the highest annual malpractice premiums
of any specialty, with an average of over $100,000 and up to $300,000 per
year in some states.20
The evidence shows that the liability crisis may not affect the number
of neurosurgeons practicing in plaintiff-friendly states. However, in those
plaintiff-friendly states some neurosurgeons restrict their practices to low-risk
procedures; there may be a need for two neurosurgeons to care for the popu-
lation instead of one for every 100,000 people.21
Opinion polls in the 1970s indicated that almost 45 percent of neuro-
surgeons felt that there were too many neurosurgeons, and that 50 percent
considered the numbers adequate.22 Most neurosurgical program directors
currently think that they are training too few neurosurgeons. Although the
total number of applicants is large enough to fill the positions, there is a signifi-
cant downward trend in the number of applications. Again, one of the things
that program directors conclude is that their field, particularly with respect to
trauma, is precluded from having a regular work schedule.23
12
Urology
Urologists deal with the diagnosis and treatment of diseases of the urinary tract
and genital systems in both males and females. Generally, in order to be eli-
gible for board certification, residency training consists of one year of general
surgery rotations plus another four years of urologic surgery. Some trainees
elect to do a year of research or alternatively train for another one to two years
to subspecialize in one of several highly specialized areas such as:
andrology (diseases of men and of the male sexual organs)

infertility and urologic prosthetics
endourology, laparoscopy, and robotic surgery
neurourology, urodynamics, and incontinence
pediatric urology
oncologic (cancer) urology
UROLOGY MIRACLES
Robotic Urology. We never expected to see a symphony conducted in the
operating room. Nonetheless, we were treated to just such an experience in
the operating room that morning. The conductor was seated at the robotic
console while the players were scrubbed, playing robotic arms as was appro-
priate. It was a seamless performance that was conducted in about two hours
and 15 minutes. The patient had six one-inch incisions to accommodate the
operative ports, and the bladder was joined with the urethra with the preci-
sion of detail that is only possible with a binocular 3-D magnifying system.
After the operation, the patient was returned to the recovery room and then
later to his room. He walked later that day. A student who is a pilot, was ob-
serving the operation and commented, “This is like a flight simulator.” Most
patients go home after one day in the hospital.1 The blood loss in these op-
erations is less than 150 cubic centimeters or five ounces. Patients return to
Urology 109
have their urinary catheters out within a week of their surgery. The surgeon
who sits at the console can do a meticulous dissection of the prostate such
that about 75 percent of those who undergo the operation will have their
sexual function intact.
Penile prosthesis. When pharmacological methods (oral medication or
penile injections) to address erectile dysfunction fail, mechanical prostheses
can be inserted with a five year mechanical failure-free rate of up to 93.6
percent.2
Neurourology is a highly specialized subspecialty that is involved in the
diagnosis and treatment of conditions such as neurogenic bladder (urine leak-
age, retention, or incontinence), multiple sclerosis, spinal cord injury, spinal
bifida, strokes, brain or spinal cord tumors, and herniated discs. Sophisticated
urodynamic testing is now available to accurately diagnose these conditions.
WORKFORCE PROJECTION
The demand for urologists was illustrated in a recent news report enti-
tled “Is There a Urologist in the House, Maybe Not For Long” in the Urology
Times.3 The report stated that 45 percent of urologists are 55 years, and older,
that urologists are among the 15 most sought out specialists, and that they
command a salary of over $300,000 often with a substantial signing bonus.4
Why is this? Aging of the baby boomers and relief for previously untreatable
conditions such as large kidney stones, paralyzed bladders, and impotence
has created an increasing demand for urology services. The early detection
of prostate cancer with the Prostate Specific Antigen or PSA test has meant
earlier diagnosis and therefore earlier surgery for these patients.
The number of currently active urologists is taken from the AAMC Spe-
cialty Chart Book.5 The ratio to population used is 3.31/100,000. A projec-
tion for urologists practicing for an average of 35 years is shown in Table 12.1.
There were fewer than 10,000 urologists in the year 2000, but 282 surgeons
will retire each year and only 260 will be newly board certified. Because the
Table 12.1
35 Years to Retirement for Urologists
Projected Urologists Urologists Percent

2000 282,000,000 9,864

2010 309,000,000 10,228 9,754 474 7%
2020 336,000,000 11,122 9,534 1,588 14%
2030 364,000,000 12,048 9,314 2,734 23%
2040 392,000,000 12,975 9,100 3,875 30%
2050 420,000,000 13,902 9,100 4,802 35%
Table 12.2
30 Years to Retirement for Urologists
Projected Urologists Urologists Percent

2000 282,000,000 9,854

2010 309,000,000 10,228 9,524 704 7%
2020 336,000,000 11,122 8,844 2,278 20%
2030 364,000,000 12,048 8,164 3,884 32%
2040 392,000,000 12,975 7,800 5,175 40%
2050 420,000,000 13,902 7,800 6,102 44%
population will increase, there will be a demand for about 12,000 in 2030
and almost 14,000 by 2050. This will lead to shortages of more than 2,500
in 2030, and almost 5,000 by 2050. The number of urologists in practice sta-
bilize at 9,100 in 2040, resulting in a shortage of urologists of about 23 per-
cent in 2030, 30 percent in 2040, and 35 percent in 2050.
Projections for the supply of urologists assuming 30 years of service before
retirement are even more alarming. In this situation 328 will retire each year
and only 260 will be board certified annually, so that only 7,800 will be
practicing between the years 2040 and 2050. There will be a shortage of
almost 4,000 in 2030 or 32 percent, and by the year 2050 the shortage will
be greater than 6,000 or 44 percent (see Table 12.2).
In similar projections, the Department of Health & Human Services proj-
ects a full-time equivalent physician supply of about 8400 urologists in 2020,
or a shortage of 9 percent compared to the 9,200 urologists in the base year
(2000) number.6
WORKFORCE ISSUES
One of the earliest assessments of urologic manpower was in 1977,7 fol-
lowed subsequently by a survey of 154 training programs in 1979.8 The
survey concluded that there were too many urologists being trained. This opin-
ion was based on the fact that the ratio of urologists to the population was
projected to increase from 1:32,416 in 1978 to 1:25,972 by the year 2000.
Subsequently, several other publications supported the idea of an oversupply
of urologists. In 1978, based upon a population of approximately 218 million
and a ratio of 1:35,000, the existing supply of 7,242 urologists was seen as
being far in excess of the stated need for 6,229 urologists.9 Fraley et al, assum-
ing a population increase of about 1% per year and an attrition rate of 2% per
year, suggested that the 386 urologists being trained in 1979 were in excess
of the estimated need.10 The authors noted that the number of board certifi-
cates granted had increased by 90 percent (four times more than the average
Urology 111
for all surgical specialties) from 1969–1973 to 1974–1978. Furthermore, 69

percent of program directors in the survey opined that there were too many
residents being trained. The authors recommended a drastic 50 percent cut
in resident trainees. Similarly, Gee and his associates published a telephone
survey of academic urologists in which half of respondents thought that too
many new residents were being trained.11As a result, the number of training
programs gradually declined from 153 to 120 in the early 1980s.12 At the
same time, the number of residency positions declined from 253 to 220 in a
three year period. Later, in the mid 1980s, the number of programs increased
to 131 with a total of 260 residents trained per year.
The earlier dire predictions of an oversupply appear not to have come
true. The ideal ratio of urologists to the general population has been a matter
of debate. Allen and associates pegged the ideal ratio as between 1:35,000
to 1:40,000.13 The ratio has varied from 1:35,000 in 1975 to 1:30,000 or
31,000 in 1995 to the current 1:30,200.14 While the number of urologists
added to the pool has varied over the years, data from the American Urologic
Association indicates that the average is 260 trainees entering the workforce
annually.15
The number of international medical graduates in the urology workforce
ranged from 2–4 percent in the 1980s and 1990s and has not been a factor
in manpower estimates in the past. However, data from the AAMC show that
international graduates represented almost 17 percent of practicing urolo-
gists in 2006.16 Despite this additional manpower, the trend or percentage
change (increase) in the number of active urologists between 1995–2004
was only about 8 percent, one of the lowest positive growths among special-
ties.17 As an example, vascular surgery increased 41 percent, plastic surgery
20 percent, and neurologic surgery 10 percent during the same period.18 In
addition, if one looks at the ratio of board certifications to active physicians
in accredited programs, urology is the one of the lowest (2.5%). Urologists
would have to practice for 40 years to keep the numbers constant (see
Figure 12.1).
The study by Gee et al also noted that the average urologist plans to retire
at a mean age of 64 years.19 Urology happens to have the fourth highest num-
ber of active physicians aged 55 years or older, at approximately 45 percent
compared to the 33.3 percent for the average specialty.20 Urologists in the
younger age group (37–45 years of age) tended to indicate an even earlier
retirement age.
According to David L. McCullough, “The market forces, program directors,
and economics had resulted in the decreasing number of training programs,
decreasing from 153 to 120.”21 McCullough was probably the first to realize
that by 2020 there would not be enough urologists to treat the people.
Aging of the population has a particular impact on the demand side of the
urology equation because of prostatic hyperplasia (enlargement) and prostatic
cancer, which occur in the aging male. The 65-plus age group accounts for
about 44 percent of visits to the urologist.22 Despite new pharmacological
Figure 12.1
Production Rates of Urologists and General Surgeons
5.00%
4.50%
4.00%
3.50%
3.00%
2.50%
2.00%
1.50%
1.00%
0.50%
0.00%
Urology General Surgery
Production Rate %
Legend: Comparison of % production rates of urologists and general surgeons legend; Assumption
of 280 new urologists joining workforce annually and approximately 9,864 urologists in practice.
Assumption of 1,027 general surgeons joining the workforce annually and 21,150 already in
practice.
medications for prostatic pathology and new less invasive technology to treat
the prostate gland, the need for increasing urologic consultation or interven-
tion seems a certainty.
Steers and Shaeffer, in an editorial in the Journal of Urology, declared that
there were not enough urologists to meet the demands of the aging popula-
tion.23 In response, Allison Stewart and John Bolton, who are practicing urolo-
gists in the United Kingdom, recommended a curriculum change in urologic
residencies.24 Stewart and Bolton related their experience in the United King-
dom, where a modification of the training curriculum was necessary. The
Senior Urological Registrars Group in England, analogous to our residents,
has stated that more than 95 percent of their members were not happy to
go to a shorter training program. So, there are both supply issues and cur-
riculum issues as urologic training programs take on the new sciences and
Urology 113
new operative techniques. In addition, a factor not to be dismissed in the con-

tinuing supply of manpower is medical students. Medical students are a vital
link in recruitment to understaffed specialties. A recent investigative report
showed alarming trends in exposure to urology for medical students.25 The
major finding was that training program directors felt that urology was not
being taught in the medical schools. In the last five decades there has been a
decline in medical student exposure to urology.
There were required rotations in urology in almost all of the medical schools
in the United States in the mid-1950s; by the late 1970s these rotations were
optional, and only 40 percent of medical schools required urology rotation.
Although 97 percent of the medical schools offered some urology rotation
during the clinical years, now only 20 percent require it. Loughlin, in a survey
of 118 residency program directors, found that in almost one-third of medical
schools no urology lectures were given in the preclinical years. Additionally,
50 percent of schools lacked lectures in the physical diagnosis course, and two-
thirds of program directors stated that it was possible for a student to gradu-
ate without any clinical exposure to urology.26 The author of this report was
particularly concerned with the management of urinary tract infections and
urinary incontinence in women and men, let alone the management of benign
hypertrophy of the prostate gland and its consequences, and the management
of cancer of that gland.27
In summary, based upon current supply, anticipated future supply of urolo-
gists , and population growth, particularly in the aged, a significant shortage of
urologists is predicted.
13
The Last Hurdle: The Balanced
Budget Act of 1997 and Graduate
Medical Education Funding
THE BALANCED BUDGET ACT OF 1997

AND GRADUATE MEDICAL EDUCATION FUNDING
Graduate medical education (GME) or residency training after medical school

in a program approved by the American Council of Graduate Medical Educa-
tion, the ACGME, or AOA (American Osteopathic Association) is necessary
for licensure to practice medicine in the United States. The term “resident”
implies that a physician has completed his or her medical school and is prac-
ticing medicine under supervision while learning a specialty. Even though
the term “intern” is used in the media and refers to graduates in their first
year of training postmedical school, first-year trainees are now referred to as
postgraduate year one residents (PGY-1). Fellows are usually trainees pursu-
ing subspecialization following residency training but are also included under
GME (Figure 13.1). For example, a fellow in gastroenterology is in his or her
first year of specialty training after three years of internal medicine residency
and is a PGY-4 resident.
THE EARLY HISTORY OF GME

From its inception in 1965, Medicare has served as the major source of
GME funding. Other sources of revenue for funding medical education
include Medicaid in some states, patient care revenues from commercial pay-
ers, the Veterans Administration, and nonprofit foundations. Disproportionate
Share Payments (DSP) also compensate teaching hospitals for serving low-
income patients outside the GME funding mechanism.
Prior to 1984, Medicare simply paid expenses allocated to medical training
programs under an open ended, cost based, retrospective reimbursement sys-
tem. In an oversimplification, if Medicare utilization of a hospital was 35 per-
cent, the GME reimbursement was 35 percent of GME costs of the hospital.
In 1986, the Consolidated Omnibus Budget Reconciliation Act (COBRA)
The Last Hurdle 115
Figure 13.1
Traditional Pathway for Residency Training
Medical School:
MD or DO Degree
(Four Years)
“Match”
Through National Residency
PGY1 Matching Program
or Internship
Licensure
Examination
PGY2
Practice of Family Practice,

PGY3
General Medicine, General Pediatrics
Fellowships in Subspecialties
PGY4 Gastroenterology, Cardiology, etc.
Practice Fellowships in Subspecialties
PGY5 OB/GYN Infertility, etc.
General Surgery
PGY6 Orthopedics Extra Training in Subspecialties
PGY7 Laparoscopy, etc.
Cardiac Surgery
Neurosurgery
Vascular Surgery
Plastic Surgery
further modified GME reimbursement from a system of pass throughs to a

“per- resident amount” (PRA) for reimbursing GME costs. COBRA left the
decision relevant to GME funding policies to Congress rather than the Health
Care Financing Administration (HCFA).
Under COBRA, the measurement of full-time equivalents (FTE) of residency
positions was determined by the initial residency period (IRP), the shortest
amount of time required for a trainee to become board certified. For instance,
internal medicine was allotted three years and general surgery was allotted
five years. The training program was only allowed funding for the specified
IRP, with complicated formulas for residents who changed their minds about
their final specialty or decided to obtain two certificates. HCFA (later to be
called Health & Human Services or HHS) set up the Intern & Resident In-
formation System (IRIS) to monitor the accuracy of the trainees’ information,
since reimbursement was based on exactly how they were counted. Congress
also established the Council On Graduate Medical Education (COGME) as the
official advisor to Health & Human Services.
Medicare was subsidizing GME programs by $7 billion a year for physi-

cian and nurse training. The main focus of revamping GME funding was to
encourage market forces to curb costs, encourage private sector support of
GME, standardize payment for training, encourage primary care growth, and
promote training in ambulatory care.
Pre Balanced Budget Act (BBA) of 1997

The prospective payment system instituted in 1983 allowed payments to
hospitals for each discharge. Teaching hospitals were also reimbursed for
additional costs incurred teaching and training residents. GME was subsidized
by two mechanisms.
Direct Medical Education (DME) Reimbursement. DME costs were for
Medicare’s share of direct expenses associated with resident and intern train-
ing, such as salaries and benefits of residents and teaching faculty, GME
administrative office costs, laboratory, and teaching space costs. In addition
to Medicare, other payers included the Department of Veterans Affairs, the
Department of Defense, appropriations from state and local governments,
faculty practice plans, and charitable organizations.1
The baseline PRA for each hospital was based on 1984 levels and updated
each year depending on changes in the consumer price index (CPI). Medicare
DME payments were calculated by multiplying the PRA (per-resident amount)
by the weighted number of full-time equivalent (FTE) residents working in all
areas of the hospital (and nonhospital sites, when applicable), and the Medi-
care share of total inpatient days for each hospital.2
The formula used was (number of Medicare inpatient days) × (number of
FTE residents) × PRA (total inpatient days).
As an example, let us assume that there were 200 resident FTEs in the
1984 base year and 230 in the current year. Let us also assume that hospital
audited costs were $12 million in 1984. The hospital PRA would be calcu-
lated as $12,000,000/200 FTEs = $60,000 PRA.
Then using the CPI, the base year PRA would be updated to the current
year. Let us assume that the adjusted PRA amount after CPI adjustment was
$85,000. To determine the aggregate DME payment, the PRA would be
multiplied by the number of resident FTEs. If total Medicare inpatient days
were 45,000 out of a total of 150,000, the Medicare share would have been
30 percent. The aggregate DME amount is multiplied by 30 percent to give
the final DME payment.
Hospital DME payment = $85,000 × 230 × .30 = $5,865,000
It is important to understand the financial consequences for a teaching
hospital related to the initial residency period referred to earlier. For example,
a general surgery resident is counted as one FTE for the five-year period of
general surgery training for purposes of DME reimbursement under Medicare.
Any training after this period may only be counted as 0.5 FTE. There are
a few programs, such as preventive medicine and geriatrics, that have been
The Last Hurdle 117
excluded from this limitation. However, this limitation only applies to reim-
bursement under DME, not to Indirect Medical Education (IME) adjustment
payments. In other words, if a surgery resident pursues a two year vascular or
plastic surgery fellowship (PGY-6 and 7), the position is one FTE for purposes
of IME adjustment. It is also relevant to note that payment for IME adjust-
ments are generally larger than DME payments, so the impact of additional
trainees for most hospitals may be limited depending on circumstances, such
as number of inpatient Medicare days or PRAs.
Indirect Medical Education (IME) reimbursement. The IME is intended
to reimburse teaching hospitals for higher costs incurred because of extra test-
ing, new technology, indigent care, research, and higher costs due to expenses
associated with teaching residents. The basis for this reimbursement is the
correlation between the hospital’s intern and resident-to-bed ratio and hospital
costs. The higher the ratio, the greater the hospital’s costs.
The IME payment was established in 1982 by The Tax Equity and Fiscal
Responsibility Act (TEFRA). It was initially estimated that “Medicare inpa-
tient operating cost per case increased approximately 5.79 percent with each
10 percent increase in the number of residents per hospital bed.”3 Soon after
TEFRA was introduced, because of projections showing serious financial con-
sequences for hospitals, the adjustment was increased to 11.59 percent for
each 10 percent increase in the resident-to-bed ratio. This was later reduced
to 8.1 percent in 1986 and to 7.7 percent prior to the BBA of 1997.
The IME is paid by Medicare as a percentage add-on to the amount
Medicare pays the hospital for each beneficiary under the PPS (prospec-
tive payment system). Again, the amount paid is proportional to the ratio
of interns and residents to the number of hospital beds. Because IME pay-
ments are only approximate for actual costs, there is a wide variation among
payments, with some hospitals receiving Medicare mark-ups in excess of
40 percent, although the median mark-up is less than eight percent.4
For calculating IME payment the formula used is:
IME = C × [ (1 + r) .405—1]
where r is the residents-to-bed ratio and C is a multiplier set by Congress.
Medicare payments under both DME and IME in 1997 were $6.8 billion,
with IME constituting two-thirds of the payments. In fiscal year 2006, it is
estimated by the Congressional Budget Office that IME payments amounting
to $5.6 billion were paid out to 1,100 teaching hospitals.5 In 2007, the Con-
gressional Budget Office estimated that IME expenses were $5.7 billion and
DME costs were $2.8 billion, with DSP totaling another $9.4 billion.6 Some
hospitals, such as psychiatric, children’s or cancer hospitals, are paid on a cost
basis and excluded from IME adjustment payments.
Academic Medical Centers (AMC) derive enough of their revenues from
Medicare’s GME funding that any small decrease has a significant impact on
their bottom lines. Thirty percent of total revenues of AMC hospitals were a
result of Medicare funds, and DME/IME represented about 10 percent of that
amount.7
Because of the large amount of funds paid to teaching hospitals, and with
no end in sight for yearly positive adjustments and decent hospital margins,
Congress began to look at this program for some savings.
The Balanced Budget Act (BBA) of 1997. For the most part, reforms en-
acted by the Balanced Budget Act of 1997 were intended to curb Medicare
expenditures rather than truly base Medicare GME policy on workforce require-
ments for the next few decades. The BBA included changes that drastically
altered GME funding to reduce the growth and number of intern/resident
training positions while attempting to maintain primary care positions.
Congress had several reasons for reducing funding for medical education.
Congress wanted to reduce hospitals’ incentives for profiting by adding more
residents at a time when health care experts were expressing the opinion that
there was an adequate supply of physicians, particularly specialists.8
Basically, the legislation halted the open-ended financial support of GME.
The intent was to force teaching hospitals to deal with the true costs of the
residency programs. It set the December 31, 1997, cost reporting period to
cap the number of FTE trainees to calculate DME and IME payments. After
this date, a three year rolling average was to be used. Essentially, the number
of residents that could be claimed by hospitals for reimbursement was fixed
as of that date.
The BBA also split payments to hospitals for patient care and medical edu-
cation into separate pots. Subsidies to teaching hospitals were reduced by
5.6 billion dollars for IME over five years (1998–2002). In addition, dispro-
portionate share and IME adjustments for outlier cases of $2.2 billion were
also decreased over five years. As mentioned previously, an adjustment of
7.7 percent for each 10 percentage point increase in the intern/resident-to-
bed ratio was made. This was now decreased every year from 7.7 percent to
7% in fiscal year 1998, 6.5 percent in fiscal year 1999, 6 percent in fiscal
year 2000, and to 5.5 percent by 2001, for a cumulative payment reduction
of 28.5 percent (Table 13.1).
There were some positive aspects of the BBA for GME. The BBA changed
the funding of GME as related to managed care plans. Instead of paying the
managed care companies for the care of Medicare managed care enrollees,
Medicare would now pay teaching hospitals directly. This significant change
in GME funding of $4 billion over four years somewhat offset the large BBA
cuts. Another positive step was to allow teaching hospitals to include residents
rotating off-site in calculating IME reimbursement in order to allow ambula-
tory experiences in primary care training.
A new outpatient prospective payment system (OPPS) similar to the Di-
agnosis Related Group (DRG) was instituted for out patient care based on a
mix of cost and charge payments. Hospitals were encouraged to reduce their
residency training programs by 20–25 percent in general except for primary
care residents. To encourage primary care programs, the BBA also expanded
the type of facilities that could receive funds to include rural health clinics and
community health centers, Medicare managed care plans, and others.
The Last Hurdle 119
Table 13.1
Changes in the Add-on Percentage of Indirect Medical Education
Adjustment as Set by BBA-1997, BBRA-1999, and MPDIMA-2003,
1997 to 2008
Period IME% IME Multiplier
Balance Budget Act FY 1997 7.50% 1.83

FY 1998 7.00% 1.71
Balance Budget
Refinement Act FY 1999 6.50% 1.59
2000 6.50% 1.59
FY 2002 5.50% 1.35
Medicare, Prescription
Drug Improvement,
and Modernization Act FY 2003 5.50% 1.35
Jan-Mar 2004 5.50% 1.34
Mar-Sept 2004 6.00% 1.47
FFY 2005 5.80% 1.42
FFY 2006 5.55% 1.37
FFY 2007 5.35% 1.32
FFY 2008 & beyond 5.50% 1.35
Source: Otero, H. J., Parra, S. O., Erturk, S. M., Ros, P. R., adapted from “Financing Radiology Gradu-
ate Medical Education: Today’s Challenges,” ( J Am Coll Radio: 2006), 3: 207–212.
Post BBA
The period following BBA was followed by several legislative victories as
a result of intense lobbying efforts by academic medical centers. As can be
expected, there was a loud chorus of protest from academic institutions that
led to some relief in the form of the passage of the Medicare, Medicaid and
SCHIP Balanced Budget Refinement Act of 1999 (BBARA). The BBARA
delayed the schedule for reducing the IME and DSP payments, maintained
the IME factor at 6.5 percent, and postponed the 5.5 percent goal until 2002.
In addition to this, changes were made that somewhat softened the OPPS and
physician payment methodologies.
The Medicare, Medicaid, and SCHIP Benefits Improvement and Protection
Act of 2000 (BIPA) passed in December 2000 and further increased Medi-
care outlays by approximately $36 billion over five years. BIPA again froze
IME payments at 6.5 percent in fiscal years 2001 and 2002 before reducing
them to 5.5 percent in fiscal year 2003 and thereafter allowing teaching hos-
pitals another $700 million over five years. In addition, BIPA increased the
inflation update adjustment to Medicare reimbursements for inpatient services
and eliminated Medicaid DSP payment reductions. The DSP allotment provi-
sions alone translated to $1.25 billion in increased reimbursement for GME
over five years in payments to hospitals from Medicaid.
The Medicare Prescription Drug, Improvement, and Modernization Act
(MMA) of 2003 included a program to redistribute Medicare resident caps
between hospitals with below-cap resident counts and hospitals seeking
to expand their caps. This basically allowed for a trading system of resident
counts. MMA changed resident numbers and the process by which the slots
could be increased. The legislation also increased IME adjustment to 6 percent
in April 2004 and scheduled for it to decrease to 5.5 percent in fiscal year
2008. These changes cumulatively increased payments for teaching hospitals
by about $400 million over five years.
The changes outlined above have forced teaching hospitals to come to
depend on clinical income as their chief source of revenue. This has had far
reaching consequences related to town and gown competition, a re-evaluation
of the previous emphasis on research and teaching as the pillars of academia,
and the types of faculty recruited for academic medical centers. Time for
teaching, research, and the weighting given to academic publications, for
example, has fallen victim to relative value units and clinical productivity. In
a study of radiology residency training, one-on-one teaching was estimated to
reduce productivity (examination volume, RVUs, and dollars billed) by almost
50 percent.9 Teaching hospitals typically take on a large number of uninsured
patients and use the clinical experiences offered by these patients for teaching
purposes. If productivity suffers as a result of the time that is expended by
faculty for teaching instead of producing work units, it follows that someone
has to subsidize these nonrevenue producing but necessary activities.
In total, it is estimated that Medicare contributes $7.5 billion (DME &
IME), Medicaid from several states $3 billion, and the Veterans Administration
$1.1 billion for a sum of $11.6 billion in total governmental support for teach-
ing hospitals annually.10
Several experts have proposed all-payer funding of GME without much
success.11 The proposed plan includes a per capita assessment on health plan
enrollees in addition to contributions from Medicare and other federal payers.
However, payers have argued that they are already subsidizing GME through
higher payments that are made as a result of inflated charges by hospitals due
to decreasing margins from Medicare and Medicaid. In a broader context, the
PEW Commission has suggested a public-private partnership and identified
seven major issues that have to be addressed:12
1. Lack of a mechanism to ensure that private beneficiaries contribute to subsi-

dization of GME
2. Insufficient incentives to permit market forces to regulate the training of phy-
sicians, particularly international medical graduates (IMGs)
3. Illogical variation in reimbursement for direct medical education (DME)
expenses
The Last Hurdle 121
4. Insufficient incentives for training physicians in generalist disciplines (family

practice, general internal medicine, and general pediatrics)
5. Insufficient incentives for training residents in nonhospital settings
6. Lack of incentives for cost control and sound cost accounting and
7. Inadequate support for advanced clinical education of advanced practice
nurses (APNs) and physician assistants (PAs)
Beyond just the financial implications for teaching hospitals, the BBA attempted
to slow the growth of the physician workforce by freezing the FTE resident
cap at 1996 levels and creating incentives to reduce resident positions. The
effect of the BBA on the number of residents trained in the United States has
recently been reported. Immediately after passage of the BBA, the number
of physicians trained in GME programs declined. However, after 2002 the
number of trainees gradually increased. New entrants into the system have
increased over the past decade by 7.6 percent due primarily to IMGs.13
As Salsberg et al have pointed out, even though the growth in residents was
8 percent between 1997–2007, the U.S. population increased 12.6 percent
during the same period. This resulted in a net decrease in the ratio of resident
physicians from 36.7/100,000 to 35.1/100,000 population in 2007.14
In the face of projected physician shortages, how does the big ship (of physi-
cians training) get turned around 180 degrees?
GRADUATE MEDICAL EDUCATION FUNDING

There were about 105,000 residency positions listed in ACGME approved
programs in 2007.15 Richard Cooper has suggested that Congress should
increase the residency slots in graduate medical education by 1,000 a year
for 10 years.16 We accept his recommendations and therefore by 2020 we
will increase the available residency posts to 115,000 in each training year.
If we assume salaries at $50,000 per year between 2011 and 2030, we will
have to spend almost $113 billion just for residents’ salaries (Table 13.2).17 If
we include benefits at 30 percent, that figure increases by almost $34 billion.
The total figure for resident salaries and benefits at $65,000 per year (not
adjusted for inflation and with no other direct medical education costs) for the
20 year period 2011 to 2030 would be almost $150 billion. The additional
funding required would be about $10 billion for the 20-year period, or 500
million dollars per year.
In Table 13.3, we list each of the specialties under discussion, the years of
training, and the board certifications for obstetrics and gynecology, otolaryn-
gology, orthopedic surgery, general surgery, neurosurgery, and thoracic sur-
gery. If certifications in the surgical specialties remain constant over the next
20 years, we will train between 100 surgeons a year in thoracic surgery and
1,200 in OB/GYN. The cost for training these individuals is about $1.1 billion
for each class with a total of about $22 billion for the cost of training from
2011 to 2030 (Table 13.3).
Table 13.2
Graduate Medical Education Costs for Training Residents
Additional Funding
Year Residents Positions Salaries at $50,000 Benefits at 30% Total Required
2010 105,000
2011 106,000 $5,300,000,000 $1,590,000,000 $6,890,000,000 $65,000,000
2012 107,000 $5,350,000,000 $1,605,000,000 $6,955,000,000 $130,000,000
2013 108,000 $5,400,000,000 $1,620,000,000 $7,020,000,000 $195,000,000
2014 109,000 $5,450,000,000 $1,635,000,000 $7,085,000,000 $260,000,000
2015 110,000 $5,500,000,000 $1,650,000,000 $7,150,000,000 $325,000,000
2016 111,000 $5,550,000,000 $1,665,000,000 $7,215,000,000 $390,000,000
2017 112,000 $5,600,000,000 $1,680,000,000 $7,280,000,000 $455,000,000
2018 113,000 $5,650,000,000 $1,695,000,000 $7,345,000,000 $520,000,000
2019 114,000 $5,700,000,000 $1,710,000,000 $7,410,000,000 $585,000,000
2020 115,000 $5,750,000,000 $1,725,000,000 $7,475,000,000 $650,000,000
2021 115,000 $5,750,000,000 $1,725,000,000 $7,475,000,000 $650,000,000
(Continued )
Additional Funding
Year Residents Positions Salaries at $50,000 Benefits at 30% Total Required
2022 115,000 $5,750,000,000 $1,725,000,000 $7,475,000,000 $650,000,000

2023 115,000 $5,750,000,000 $1,725,000,000 $7,475,000,000 $650,000,000
2024 115,000 $5,750,000,000 $1,725,000,000 $7,475,000,000 $650,000,000
2025 115,000 $5,750,000,000 $1,725,000,000 $7,475,000,000 $650,000,000
2026 115,000 $5,750,000,000 $1,725,000,000 $7,475,000,000 $650,000,000
2027 115,000 $5,750,000,000 $1,725,000,000 $7,475,000,000 $650,000,000
2028 115,000 $5,750,000,000 $1,725,000,000 $7,475,000,000 $650,000,000
2029 115,000 $5,750,000,000 $1,725,000,000 $7,475,000,000 $650,000,000
2030 115,000 $5,750,000,000 $1,725,000,000 $7,475,000,000 $650,000,000
Totals 2011 to 2030 $112,750,000,000 $33,825,000,000 $146,575,000,000 $10,075,000,000
Note: All estimates are in nominal dollars unadjusted for inflation.
Table 13.3
Present Costs for Surgical Residents
Number
Certifi- of Trainee Cost of Training
Years in cations Per Years Per Per Class Cost of Training
Specialty Residency Year Class at $65,000 2011 to 2030
OB/GYN 4 1,200 4,800 $312,000,000 $6,240,000,000

ENT 5 300 1,500 $97,500,000 $1,950,000,000
ORTHO 5 650 3,250 $211,250,000 $4,225,000,000
GENERAL 5 1,000 5,000 $325,000,000 $6,500,000,000
UROLOGY 5 260 1,300 $84,500,000 $1,690,000,000
NEURO 6 125 750 $48,750,000 $975,000,000
THORACIC 7 100 200 $13,000,000 $260,000,000
TOTAL 3,635 16,800 $1,092,000,000 $21,840,000,000
A formidable task lies before us. Our problem is that we will have a
shortage of surgeons. The most severe shortage will occur in obstetrics and
gynecology, at almost 14,000. In Table 13.4, we review the seven special-
ties, the years to train specialists, the present number of certifications per
year, and the total number trained if we maintain the certifications at the
present level. We note the shortage of surgeons as a result of our calcula-
tions in the previous chapters. If we assume 30 years from board certifica-
tion to retirement, the shortage for all specialties totals more than 29,000
doctors. We total the number of surgical specialists to be trained between
2011 to 2030, including the shortage in each of the specialties and then
divide that by 20 to obtain the number per class in column 7. We calculate
the trainee years per class by multiplying the years to train in column 2 by
number per class.
We then calculate per class cost assuming $50,000 income and 30 percent
benefits for a total of $65,000 per trainee per year. In the last column, we
calculate the training cost for each specialty to get the appropriate costs of the
surgeons to be trained by 2030 to take care of the needs of our population.
At the date of publication of this book, there are about 100,000 surgeons,
or fewer, practicing in the United States. In essence, we have to train an entire
new surgical workforce (101,838) to manage our increasing population.
The total annual cost for this will be $1.6 billion (column 9), amounting
to more than $31 billion by 2030 (column 10). The greatest costs will be in
OB/GYN, orthopedic surgery, and general surgery. The cost of training the
surgeons we need is slightly less than 500 million dollars per year. This is a
formidable task.
Table 13.4
Specialists, Shortages, and Cost of Training
Total to Be
Total Trained Trained Trainee Per Class Cost Total Cost 2011
Years to Certifications 2011 to 2011 to Number Per Years at $65,000 to 2030
Specialty Train Per Year 2030 Shortage 2030 Class Per Class Millions Millions
OB/GYN 4 1,200 24,000 13,636 37,636 1,882 7,527 $489 $9,785

ENT 5 300 6,000 2,516 8,516 426 2,129 $138 $2,768
ORTHO 5 650 13,000 4,355 17,355 868 4,339 $282 $5,640
GENERAL 5 1,000 20,000 2,525 22,525 1,126 5,631 $366 $7,321
UROLOGY 5 260 5,200 3,884 9,084 454 2,271 $148 $2,952
NEURO 6 125 2,500 228 2,728 136 818 $53 $1,064
THORACIC 7 100 2,000 1,994 3,994 200 1,398 $91 $1,817
TOTAL 3,635 72,700 29,138 101,838 5,092 23,115 $1,567 $31,348
In this chapter we have traced the history of graduate medical education

and the role of the government as the major payer. Funding for GME was
altered significantly with passage of the BBA of 1997. Besides other changes,
the major impact of this legislation was a cap on funding the number of resi-
dency positions regardless of population changes. We have illustrated, as an
example, the nominal costs associated with an increase in 1000 residency
positions annually. We believe there will be a profound shortage in surgical
specialties in future years.
It is entirely relevant to run “what if” simulation scenarios related to the
cost of funding a number of residency positions depending on the severity of
the impending shortage.
To provide education for our future surgical workforce, without any ques-
tion, we have to revise the Balanced Budget Act of 1997. Otherwise, we will
have to ration surgical services!
14
Is There a Solution? Numerical
Projections, and Improving
Physicians’ Productivity
While there is no magic bullet to improve the impending shortage in the

immediate future, there are multiple factors that have to be considered in
coming up with a comprehensive solution.
It has become clear to all stakeholders that the shortage of physicians is
real. In a survey of 400 hospital CEOs, 82 percent agreed that the United
States has too few physicians, and greater than 66 percent agreed that the
physician shortage is a serious problem (Figure 14.1).1
This has directly impacted hospitals’ and physician groups’ ability to recruit
new physicians. In a Health Care Advisory Board survey of almost 400 hos-
pital administrators, 49 percent indicated that recruiting new physicians was
“extremely challenging” and 55 percent felt that it had become more difficult
in the last two years.2
Let us return to the subject of the whole physician workforce including
surgeons.
It is clear from our discussion in the chapters on supply and demand that
a shortage of physicians, including surgical specialists, is on the horizon. Both
sides of the supply and demand equation, much like the energy crisis in our
nation, have to be addressed in a comprehensive and thoughtful fashion taking
into account budgetary implications.
We will now attempt to analyze the possible solutions being considered to
forestall the impending shortage.
PRODUCE MORE DOCTORS

This story entitled “University of Maine’s President Wants the School to
Offer a Medical Degree” appeared in the Portland, Maine Press Herald in late
September, 2005. It was a pointed effort at keeping Maine students in Maine
to practice medicine. The University of Maine’s President was told by Robert
Edwards, former Bowdoin College president and member of the University of
Figure 14.1
Shortages
“The U.S. Has Too “Physician Shortage

Few Physicians” Is a Serious Problem”
400 Hospital CEOs 400 Hospital CEOs
82% >66%
Agree Agree
Source: Advisory Board, “Physician Recruitment: Attracting Talent in a Competitive Market,”

(Washington, DC: The Advisory Board Company, May 1, 2008), http://www.advisory.com/mem
bers/default.asp?contentID=77362&collectionID=1720&program=7&filename=77362.xml
(accessed May 27, 2008). © 2006 The Advisory Board Company. All rights reserved. Reprinted
with permission.
Maine’s Board of Visitors, that “they will face several challenges including try-
ing to raise money to offset declining state support.”3
A similar headline in the Orlando Business Journal, November 16, 2005,
read “University of Central Florida Makes Pitch for Medical School.” After
years of planning, talking, and fundraising, the University of Central Florida
President, John Hitt, made the case for a new medical school in Orlando.4
There are currently 126 medical schools in the United States, to reach 130
by late 2009. The average first year enrollment is about 130. Shortly after
the American Association of Medical Colleges (AAMC) publicized its recom-
mendations for more medical schools, plans were made for an additional 14
medical schools (Figure 14.2). In March 2008, three new schools opened their
doors. Texas Tech University’s Paul L. Foster School of Medicine at El Paso (El
Paso, Texas), Florida International University College of Medicine (Miami, Flor-
ida), and University of Central Florida College of Medicine (Orlando, Florida)
were accredited by the Liaison Committee on Medical Education (LCME).5
Class Size
Jordan J. Cohen, M.D., the President of AAMC, said in February 2005 that
AAMC supports a 15 percent increase in medical school enrollments because
of a projected shortage in the number of physicians needed to serve the na-
tion’s growing population. Subsequently in November of 2005, Dr. Cohen
revised his estimate to a 30 percent increase translating to roughly 5,000
Is There a Solution? 129
Figure 14.2
Medical School Enrollments and Forecasted Medical School Additions by State,
2006
Washington
University of Washington
(Spokane) Montana North Dakota Maine
Michigan
Oregon Idaho Minnesota Vermont
New Hampshire
South Dakota Beaumont Hospital &
Wisconsin Mass. Massachusettes
Oakland University Northeastern
New York Pennsylvania
Wyoming
(Auburn Hills) Education Development R.I.Rhode Island
Conn.
Consortium
Pennsylvania
(Scranton)
Connecticut
Iowa
Nebraska
Nevada Ohio New Jersey
Indiana Touro University
Utah Illinois
(Florham Park) Delaware
Colorado Maryland
California West
Kansas Virginia Virginia
Virginia Tech University
Missouri Kentucky & Carilion Health Systems
University of California
(Roanoke)
(Merced & Riverside) North Carolina
Oklahoma Tennessee
Arizona
Arkansas South
New Mexico Carolina University of North Carolina
& Carolina Medical Center
Arizona State University Mississippi Georgia (Charlotte)
& University of Arizona University of Texas Alabama
(Phoenix) (El Paso) Texas Mercer University Number of
(Savannah)
Texas Tech University
Louisiana
matriculants
Health Sciences Center
(El Paso)
Florida
Over 1,000
University of Houston, University of Central
Methodist Hospital, & Florida (Orlando) 800–899
Cornell University
(Houston)
600–699
Alaska Florida International 400–499
University (Miami) 300–399
200–299
Hawaii
100–199
0–99
Source: http://www.teachinghosp.org/pdf/pwchealthstaffingshortage.pdf (accessed August 5, 2008).
Used with permission of PriceWaterhouseCoopers.
new positions. He cited two factors for revising his opinion. They were (1) the
looming shortage of physicians, and (2) to reduce the unacceptably high num-
ber of U.S. students flocking to foreign medical schools.6
The entering class of 2005–6 cracked the 17,000 mark for the first
time with a 2.1 percent increase over the previous year and marked the
third consecutive year of an increase in applications for medical school. The
2007 class topped 17,800 students, a 2.3 percent increase over 2006.
The 2007 class had the highest MCAT (Medical College Admission Test)
scores and cumulative grade point averages on record.7 A large number of
medicals schools (86%) have expanded their class size or intend to within
five years.8 A recent AAMC survey suggests that first year student enrollment
is expected to grow to 19,900 students by 2012, an increase of 3400 stu-
dents or 21 percent.
We have estimated the effect of increasing first-year medical enrollments
by 30 percent to 22,000 positions in Table 14.1. Again, we are using our
Table 14.1
Increasing First Enrollment to 22,000 Places
Grand Total
Doctors of Practicing Shortage
Year Population Needed Doctors Shortage Percent
2010 309,000,000 883,740 775,000 108,740 12%

2020 336,000,000 960,960 795,000 165,960 17%
2030 364,000,000 1,041,040 815,000 226,040 22%
2040 392,000,000 1,121,120 835,000 286,120 26%
2050 420,000,000 1,201,200 880,000 321,200 27%
usual algorithm of 286 physicians per 100,000 population, a starting number

of 800,000 doctors practicing in 2000, and 40 years from graduation from
medical school to retirement.
In other words, raising the initial medical class enrollment to 22,000 would
result in almost 200,000 more doctors by 2050. However, this still leaves us
with a shortage of more than 300,000 doctors.
The barriers to expansion of medical school enrollments have to do with
both financial investments and investments in our youth. New clinical sites,
laboratory space, medical education buildings, support services, and additional
faculty will all require additional resources.
REVERSE GRADUATE MEDICAL EDUCATION

(GME) MORATORIUM
We discussed in detail the history, mechanisms, and roadblocks to fund-
ing of GME in chapter 13. It is clear that some of the wounds related to the
cap on the number of residency training positions are self-inflicted. Almost all
major medical societies or organizations supported, indeed, actively pushed
the federal government to limit funding due to the perceived future oversupply
of physicians. The same organizations, including AAMC and the AMA, have
now completely reversed course and called for elimination of the cap and an
increase in entry level training positions. One wonders how policymakers will
react to these organizations now asking for a 180 degree reversal.
Some of the severe consequences of the BBA were blunted somewhat by
subsequent legislative remedies sought by various academic medical organi-
zations. However, the basic restriction or cap on funding of the number of
residents is still in place. Our estimates in Table 13.2 for additional funding
for 1000 additional physicians per year from 2011 to 2020 unadjusted for
inflation would amount to roughly $10 billion over a 20-year period start-
ing in 2011. Despite budget deficits and unfunded liabilities in the Social
Security system, we believe this relatively modest investment would partially
address the physician shortage. In return for accommodating the need to

adjust the cap and increasing entry level positions, there are likely to be de-
mands for much greater accountability.9 While Iglehart and others have used
the momentum to change direction to produce more physicians and also to
promote shifting even more dollars away from specialists to primary care, it is
not clear that the American public will tolerate further shortages in surgical
specialists.
TAKE ADVANTAGE OF RETIREES: PART-TIME WORK

The percentage of part-time physicians increased from 13 percent in
2005 to 20 percent in 2007, shown in Figure 14.3.10 Another survey by
the Advisory Board shows similar numbers, with more than a 50 percent
increase in part-time physician staff over a one year period (2005–6).11
More than 80 percent of physicians who practice part time are at least 0.5
FTE, and expectedly the workforce in this category consists mostly of pre-
retirement males and early career females. Interestingly, there is a higher
turnover rate among part-time physicians of either gender as opposed to full
time physicians.
There are many reasons to consider utilizing those recently retired or con-
sidering retirement as a valuable resource in addressing a potential shortage
Figure 14.3
Physicians Working Part Time, 2005–2006
12%
Senior and mid- Over 50 percent

life physicians increase in part-
most interested 8% 8% time staff over
in part-time work one-year period
5%
2005 2006
Male Female
Source: http://www.advisory.com/members/defauIt.asp?contentlD=73082&program=14&collec
tionid=1021 (accessed August 6, 2008). © 2006 The Advisory Board Company. All rights re-
served. Reprinted with permission.
of specialists. When one sets out to appraise the capability of surgeons, there
are four things that must considered. The first thing a surgeon must have
is the physical capability to perform operations. Secondly, he or she must
have the technical ability, and thirdly, a surgeon must have the ability to
plan an operation. But the fourth consideration, and the most important, is
the judgment to select the patients for whom the goals of an operation and
the operation itself will be a complete success. For instance, it may not be
wise to perform an open heart procedure on an 80-year-old patient who has
Alzheimer’s disease or cancer. Even if the problem is technically fixable, an
alternative approach might be to counsel the family against an aggressive
approach due to a higher risk of death and limited life expectancy. Further
discussions may involve a second opinion. Since every patient is different
and each family has unique dynamics, it takes time to develop sound surgical
judgment. The problem is that sometimes young surgeons view patients as
surgical or technical problems that need to be solved. More mature surgeons
views patients as people, and therefore take into account all relevant factors,
including technical problems, and, in so doing, can act as counselors to pa-
tients’ families.
With the large numbers of physicians retiring or planning to retire, part of
the solution may lie in tapping what should be a fairly large pool of experi-
enced physicians to work part-time hours on terms suitable to them. These
physicians have wisdom and judgment accumulated over years of practice.
Their experience is invaluable both to the patients and to young surgeons.
While this solution may not be practical for some specialties because of con-
tinuity of care or the necessity of sharing call, for other specialties it may
provide needed relief. The principle barrier to this course of action in many
states is the malpractice premium ,particularly for part-time independent sur-
gical practitioners. Until comprehensive tort reform is enacted, one way for
hospitals to take advantage of the older doctors’ experience is to employ them
under hospital malpractice programs.
An Estimate Based on Raising the Retirement Age to 70

With increasing longevity, another option is to consider raising the retire-
ment age to 70 barring health issues that may prevent the practice of a physi-
cian’s surgical specialty.
Using the same algorithm as we used in Table 14.1 but with 45 years in
practice instead of 40 years, we have estimated the additional workforce re-
quirements and the effect on the shortage in Table 14.2.
In this table, we have combined increasing initial medical school enroll-
ments to 22,000 and lengthened the time of the average practice to 45 years.
These would result in an additional 290,000 doctors from American medical
schools in practice by 2050.
The point of all these numbers is to show that some of the deficit could be
met by “function shifting.” Function shifting is a business term for giving the
Table 14.2
45 Years to Retirement for Doctors
Grand Total
Doctors of Practicing Shortage
Year Population Needed Doctors Shortage Percent
2010 309,000,000 883,740 797,220 86,520 10%

2020 336,000,000 960,960 839,440 121,520 13%
2030 364,000,000 1,041,040 881,660 159,380 15%
2040 392,000,000 1,121,120 923,880 197,240 18%
2050 420,000,000 1,201,200 970,000 231,200 19%
appropriate job to the appropriate person in any given business environment.

It works very well in Toyota automobile manufacturing where every team
member is trained in multiple skills. The opposite was true of the Big Three
auto manufacturers in North America, where their contracts with the United
Auto Workers (UAW) did not allow for job rotations—thus making them less
flexible or adaptable to an ever-changing global marketplace.12
How could function shifting work to meet the deficit of doctors? We know
that a combat corps-man or corps-woman in the U.S. military has vast clinical
experience. We also know that there are nurse practitioners and physician as-
sistants who are experts in providing health care. Think of the Minute Clinic
in the Target stores or CVS pharmacies. We see this function shifting as one of
the ways to meet the demands caused by the coming shortage of doctors.
CASE STUDY OF HARRY SIDERYS

Harry Siderys called one of the authors one afternoon in 2005. After we passed the
time of day, I said, “Harry, what are you doing these days?”
He said, “Well, I am working part time in my group. I go to the operating room two
or three times a week to help the other partners, see some patients, and take care of the
Society of Thoracic Surgeons’ database for our group in the hospitals.”
I said, “Can you come and go as you please?”
He said “Sure.”
Harry Siderys is an accomplished cardiac surgeon who has been in surgical practice
between 35 and 40 years. He was one of the first cardiothoracic surgeons to perform
cardiac surgery in a private hospital—in the late 1960s. The practice is rewarding for
him clinically. He draws a small salary. The thing that is amazing about Harry is that
he is 79 years old, he lives in Indianapolis, Indiana, and he can practice because his
malpractice premiums there are $8,000 per year. Contrast that to one of our groups
in Columbus that at one time was paying $123,000 per surgeon. In Ohio, even if you
have a limited practice, it is one-size-fits-all malpractice premiums for every surgeon.
CASE STUDY OF AL DAMSCHRODER: WINE OR VINEGAR

Allen Damschroder, M.D., is a medical school classmate of one of the authors.
Dr. Damschroder practices in Petoskey, Michigan. These are his words:
It came as a complete surprise to me when, after 5 years of retirement following

30 years as an orthopedic surgeon, I was invited to return to part-time practice
with a very active orthopedic group. What an opportunity this was. This group
is well respected and consists of seven younger active orthopedic surgeons and
two consultants or senior surgeons. One was the chief of a major orthopedic
department at a major teaching institution in Michigan and the other senior was
one of the founders of the group. This mix of the new and the old may be part
of the success of the group. Last year and again this year we have been selected
as one of the top 5% of hospitals in the USA in the performance of total hip and
knee arthroplasty.
During those five years of retirement I had busied myself with travel, land
preservation interests and outdoor activities. In spite of all these activities I still
felt professionally unfulfilled. I did not miss the nights and weekends of a busy
call schedule or the worries that are part and parcel of caring for sick patients.
I did miss the personal contact and the immense satisfaction that comes from
challenging surgeries skillfully accomplished.
I was invited to return as a physician surgical assistant to help with joint re-
placement and technically demanding cases. I had kept in place my license and
CME requirements, but my professional corporation and credentialing had to
start from scratch. All of the hurdles were cleared, including malpractice insur-
ance (which was partially covered by the group).
About 1 year ago I re-entered the surgical suite. It has been an exhilarating
experience! The interface with younger surgeons has been an exceptional op-
portunity for me. I hope that it has been worthwhile for them, also, and that in
the final analysis patients and Medicine have benefited.
I have compared my medical career to the process of winemaking. First is
all of the preparation including planting, pruning, harvesting, pressing, barreling,
mixing and bottling. I compare the early product to Nuevo Beaujolais (French),
refreshing and new but lacking in complexity. Next in viniculture comes aging
with a gradual improvement in quality as with QBA, Kabinet and finally Spate-
lese (German). For me there was one final step—late harvest! I see many profes-
sionals who never have this opportunity and become cynical and critical of their
professions, especially of the younger people who are now practicing. Too bad, as
that has not been my experience working with my new colleagues.
I have chosen late harvest and not vinegar.
SHORTENING THE DURATION OF TRAINING

The duration of residency programs has gone from four to five years to six
or even eight years, delaying the entry of physicians into the workforce. The
Advisory Board estimates that the number of graduates pursuing additional
training increased from 27.2 percent in 1999 to 33.8 percent in 2005 (Fig-
ure 14.4).13
Figure 14.4
GME Graduates Pursuing Additional Training
34% 33.8
32.1
29.6
27.2
26%
1999 2001 2003 2005

Source: http://www.advisory.com/members/defauIt.asp?contentlD=7308 2&program=14&collec
tionid=1021 (accessed September 9, 2008). © 2006 The Advisory Board Company. All rights
reserved. Reprinted with permission.
The reasons for this increase include an increasing database of knowledge,

demand for subspecialization within specialties, cutting edge technology such
as laparoscopic, robotic, and minimally invasive procedures, and the desire of
graduates to become subspecialized and stand out in their own niches within the
broader specialty. Academic programs also use graduates for their own research
purposes by creating mandatory research years within residency programs or
chief administrative resident positions to allow for junior faculty-type positions
without the compensation that goes with regular faculty appointments.
There has been a recent movement to shorten surgical training programs
and enable those physicians who decide on their specialties early to spend
more time in their chosen specialties instead of training in general surgery. For
instance, the American Board of Plastic Surgery will now permit trainees with
three years of general surgery training followed by at least two years in plastic
surgery to appear for their board examinations. The traditional pathway of
five years of general surgery followed by two years of plastic surgery is still
available. Similarly, the thoracic surgery board now also allows an alternative
pathway of a six-year integrated thoracic surgery residency, which saves train-
ees one year. As is the case with the 80-hour work week, we do not yet have
solid evidence of any deleterious effects of shortened training programs.
IMPROVING PHYSICIANS’ PRODUCTIVITY

Perhaps the most significant change in attitudes is reflected by the change
in priorities of recent graduates looking for jobs. For those over the age of 41,
compensation and practice setting were among the top five factors when
choosing a job, and spouse/family consideration ranked last.14 For those be-
tween ages 36 and 40 years, geographic location was first and spouse/family
consideration was again last. But, for those younger than 35 years, geographic
location and call schedule were the top two factors, while compensation and
professional growth opportunity were last. In addition, the percentage of cur-
rent Generation Y residents who are significantly concerned about available
free time in a future practice has increased from 13 percent in 1999 to 63 per-
cent (Figure 14.5).
This generation has therefore changed the rules of the game somewhat.
The new roles for physicians are partly the result of the demand for sub-
specialization and improvement in the quality of care, but acceptance has
come because younger physicians see these new roles as a better fit with the
lifestyle they have in mind. Many of these changes have a profound effect on
productivity as well. We will now discuss these new roles and their impact on
productivity.
Hospitalists
The trend to training and employment of hospitalists started about a de-
cade ago, when, because of declining reimbursement, primary care physicians
significantly curtailed their inpatient load to focus on outpatient care. Initially
Figure 14.5
Residents “Significantly Concerned” about Availability of Free Time in Future
Practice Setting
Recent resident corps

significantly more
63% lifestyle-oriented
51%
13% 15%
1999 2001 2003 2005

Source: http://www-advisory.com/merribers/default-asp7contentlD=73082&coHectionlD=1021
&program=14&filename=73082.xml (accessed August 7, 2008). © 2006 The Advisory Board
Company. All rights reserved. Reprinted with permission.
they handed off the care of their patients to other internists who had inpatient
consultative practices. An increasing number of internists realized that out-
patient evaluation and management services were being rewarded with bet-
ter reimbursement, and this led to a demand for hospital-based primary care
physicians. Current estimates of the need for 30,000 hospitalists by 2010 are
due to fewer graduates choosing primary care.15 Hospitals have also started
surgical hospitalist programs due to the delay in calling in general surgeons
and overcrowding of emergency rooms during evening and weekend hours.
The program at the University of California in San Francisco has reported that
85 percent of patients see a hospitalist surgeon within 45 minutes of arriving
in the emergency room.16
Emergency Medical Services

In the 1960s, every physician in every hospital was on call for emergen-
cies in the hospitals’ emergency rooms. As we went into the 1970s, it became
obvious that more effective emergency care could be delivered by emergency
physicians. Now almost every hospital in the United States has a corps of
emergency medical physicians who evaluate the patients presenting to their
emergency room, admit them to the hospital, if necessary, treat them for other
diseases in which they are experts, and call consultants to see them for emer-
gency operations, broken bones, and so forth. This is an evolution of the prac-
tice of medicine in the last 35 years. In many respects it is more efficient for all
physicians. Emergency physicians have regular hours and can therefore meet
the needs for emergency care readily and efficiently. This system also allows
for a predictable lifestyle and days off during the week to attend to personal
and family issues. Again, lifestyle issues and productivity are both front and
center.
The Grant Trauma Service

Robert Falcone, M.D., a surgeon, developed a trauma program at Grant
Hospital, Columbus, Ohio, in the early 1980s. It was one of the first hospi-
tals in which a group of surgeons were contracted as surgical hospitalists for
trauma care. One surgeon would give 24 hours, one day in five, to emergency
trauma surgery. Another surgeon would do the rounds on the trauma patients.
The surgeons were accompanied on their rounds by an associated staff of
RNs, which would today be called Nurse Practitioners, a social worker, and a
pharmacist.
It was an immensely successful effort that is still running as a very success-
ful Level I trauma facility. The Grant Trauma Service admits 3600 patients per
year. Dr. Falcone was appointed CEO of Grant Hospital and has retired from
that post. Trauma care has also evolved because it promises better quality of
care, highly specialized service, and, despite a very intensive call schedule, a
certain predictability of fixed days off.
Electronic Intensive Care Units

The scene is Riverside Methodist Hospital, Columbus, Ohio. Riverside is
the flagship of the Ohio Health system. In the south office building there is a
suite on the third floor that is similar to the suites of the other offices except
that it has four computers; one of them is assigned to Melanie Kennedy, RN.
On her computer there are five screens; one is for a patient’s history and aller-
gies, the second is for the patient’s drugs, the third is for laboratory results, the
fourth is for the vital signs, and the fifth is the monitor for a mini camera that
is focused on the patient’s bed. Melanie and her physician colleagues run an
electronic Intensive Care Unit, an e-ICU. The e-ICU rooms are outfitted with
microphones and call buttons to link the patient and the nurse to the remote
monitoring site. Each e-ICU room has a video camera that the intensivist nurse
can use to zoom in on the patients Also available on the computer are the
patient’s X-rays.
Mary Jo McElroy, R.N., one of the nursing directors, and Bill Winnenberg,
the Chief Information Officer of the system, show us around the room. The
e-ICU staff is monitoring 12 beds from Doctor’s West Hospital and 34 beds
from Riverside Methodist Hospital. Two years ago the Ohio Health Board
committed $6 million to an electronic ICU. By the time this is published, the
e-ICU unit will be monitoring almost 100 patients in five separate hospitals
from Delaware, Ohio, 30 miles away from Columbus, to the downtown Grant
Hospital.
This is one way to improve the productivity of physicians.17 Again, it ap-
peals to a lot of physicians because it is a highly specialized service and, in
most ICUs, offers predictability based on a rotating call schedule. There is
a nationwide shortage of intensivists, doctors who specialize in critical care
medicine.18 By improving the efficiency of an ICU’s operation and turning it
into an e-ICU, one intensive care nurse or doctor can serve multiple patients.
The technology holds the potential to improve care and shorten ICU stays by
catching complications and small changes in vital signs. The demand for inten-
sive care for the aging population is one of the reasons for this.
The original installation of an e-ICU was in the Sentara Healthcare in south-
eastern Virginia. According to Information Week, in May 2003, Cap Gemini,
Ernst & Young, a consulting firm, completed a study in two of the Sentara
Health e-ICUs in Norfolk, Virginia. The study showed a 25 percent drop in the
mortality rate. There was also a 17 percent shorter stay in the units, allowing
the units to treat 20 percent more patients. The study calculated a $3 million
net gain for the 16 ICU beds.
Visicu, Inc. is a company founded by two doctors from Johns Hopkins Uni-
versity who were seeking a way to better take care of patients in critical care
units.19 In a sense, they combined intensive care provided by hospitalists with
telemedicine. Many hospitals are using the Visicu system, including Sutter
Health in Sacramento, California, the Tripler Army Medical Center in Texas,
and Jewish Hospital in Louisville, Kentucky.
In its 1999 report “To Err Is Human: Building a Safer Health System,” the
National Academy of Sciences Institute of Medicine concluded that 44,000
to 98,000 patients died from medical errors each year. Many, if not most of
those, are admitted to an intensive care unit before they die.20
NIGHTHAWK AND TELERADIOLOGY—EXPORTING

AND IMPORTING
Naiyer Imam is a graduate of Brown University and its medical school.

He completed his training in radiology at the University of Southern Florida
and Johns Hopkins. He developed a fascination with telemedicine and formed
American Teleradiology, which later became Nighthawk Radiology Services, a
corporation that does teleradiology all over the world.21
Where do you get your emergency room film read, particularly if you are
in some places in rural America, where there are no radiologists in the com-
munities? What would you do if you had access by teleradiology to 125 board
certified American radiologists? With its team of U.S. board-certified, state-
licensed, and hospital-privileged physicians, NightHawk services over 1,350
hospitals and medical groups in the United States 24 hours a day, seven days
a week from centralized facilities located in the United States, Australia, and
Switzerland.
This is a case of exporting radiologic images—chest X-rays, CT scans, MRIs,
and so forth—and importing their interpretations by the Nightshawk staff of
American board certified radiologists.
Medical Tourism—Outsourcing or Exporting our Patients

This is the final chapter in increased physician efficiency—outsourcing our
surgery. Medical tourism now represents a $2.1 billion business. Probably more
than 6,000,000 Americans will go outside the country to get medical care,
especially surgical care, by 2010, according to Medical Economics.22 More
than 40 percent of Americans would consider traveling outside the country
for surgical care because it is cheaper. Uninsured U.S. citizens represent the
largest group of perspective medical tourists.
The Joint Commission for Accreditation for Hospitals, the certifying agency
for the United States, has already certified 250 hospitals in more than 30
countries. They think that figure will double by 2012. The American Medical
Association unveiled its first set of medical tourism guidelines in 2008.23 Blue
Cross and Blue Shield of South Carolina have already provided employers with
a medical tourism package.
According to the Wall Street Journal, in an article published September 30,
2008, some companies are paying their workers to go for surgery abroad.
There is a company in Maine that gives its employees the option to fly to Sin-
gapore for hip or knee replacements while “pocketing an extra $10,000”; in
essence, the company and the employee split the difference from the money
saved for not having such a procedure in the United States. That hip replace-
ment costs $12,000 in Singapore.24 A heart bypass procedure can be done
for less than $19,000 in Singapore, or for $10,000 to $12,000 in India or
Thailand. It would cost $30,000 to $40,000 in the United States.
Patients can get high quality care in these countries, and many of the doc-
tors who conduct the surgeries are certified by the American Board of Surgery
or other American boards, or have surgical certificates from the English health
care system. One of the difficulties one sees with medical tourism, however, is
getting appropriate postoperative follow-up in this country because of our fear
of potential malpractice situations, especially with an untoward result.
According to Wikipedia’s article on medical tourism, 750,000 Americans
went abroad for health care in 2007.25 People go to Costa Rico, Singapore,
Hong Kong, Thailand, and India. In the Union of South Africa, medical tourism
is known as “medical safaris.” In Singapore there is a multi-agency government—
industry partnership to facilitate medical tourism.
Fortune Magazine published a special advertising segment on Thailand two
years ago. One advertisement was from a Bangkok Heart Hospital. It men-
tioned a distinguished cardiovascular surgeon, Kit V. Arom, M.D., who had
practiced in the United States but returned to his native Thailand to lead the
hospital’s open heart surgery program, which attracts many medical tourists.
There are eight other cardiac surgeons on his staff.26
Dr. Arom practiced in Minneapolis, Minnesota, and had a distinguished
academic and clinical career. He founded the Minneapolis Heart Institute, one
of the most prestigious groups in cardiac surgery in the nation.
In a letter to the editor of the Wall Street Journal published Wednesday,
August 27, 2008, Ronald M. Becker wrote, “Aggressive harassment from
insurance companies, government agencies, hospital administrators, and ig-
norant nonmedical persons is doubtless a major factor in the early burnout
and decline of cardiac surgery as a “hot” specialty; residency slots, coveted a
generation ago, now go begging.” Less than 50 percent of these positions are
filled by American graduates.
Again, if the support systems and professional opportunities are better in
Thailand, Singapore, or India, where will our surgeons go? Can we export our
surgical cases to these countries?
OTHER RECOMMENDATIONS
• While PA’s and NP’s production may somewhat make up for a lack of enough
primary care physicians, there is no similar solution for all specialists. Spe-
cialization and subspecialization among future physicians will likely con-
tinue for the reasons stated earlier. Providing physicians with assistance in
the form of physician assistants and nurse practitioners may, however, im-
prove doctors’ productivity and decrease their stress level in busy practices.
Some specialties, such as cardiac surgery and vascular surgery, are ideal for
physician assistants, whereas specialties such as plastic surgery may not be
well suited.
• Reduce nonclinical duties of physicians: increase incentives and funding for

electronic medical records. The Department of Health and Human Services
(HHS) announced some rules in 2008 that addressed exceptions to Stark
laws and safe harbors for anti-kickback laws. These Stark law regulations
were the main hurdles that discouraged hospital assistance for physicians
in electronic prescribing and electronic medical records.27 The number of
hospitals extending information technology assistance to physicians has
increased due primarily to some relaxation of regulatory restrictions. For
example, in a recent survey 41 percent of hospitals already provided some
assistance, and another 29 percent were considering plans to do so within
two years (Figure 14.6).28 We still have a long way to go, however, because
the adoption rate by office-based physicians is only 12 percent. It is worse
for solo physicians (7%) because of the expense of implementing electronic
medical records in a private practice. It remains to be seen how the stimulus
plan of the current administration will actually improve efficiency.
• Decrease regulatory burdens by making coding/documentation requirements
easier. The complexity of coding and the byzantine rules for correctly billing
for services is a major source of frustration and inefficiency for physicians.
The Department of Justice, using fraud and abuse regulations, has aggres-
sively gone after billing errors by physician offices. The vast majority of
errors are clerical or unintentional due to the pressure of time, understaff-
ing, and an inadequate understanding of the complicated rules governing
coding. A recent study reported on five evaluation and management codes
that represented 70 percent of the codes utilized by emergency physicians
to bill for services.29 Five coding specialists reviewed the records and could
agree in only 15 percent of cases. They disagreed completely in 6 per-
cent. Furthermore, the disagreement in 29 percent of these was significant
Figure 14.6
Hospitals Extending Information Technology Benefits to Physicians
(survey of senior health executives)
NO 58.6% YES 41.4%
50% plan to do so in next

24 months
Source: Conn J.I.T. subsidies embraced. http://www.modernhealthcare.com/apps/pbcs.
dll/article?AID=/20080225/REO/60045 8706/-l/toc25.02.08&nocache=l (accessed
September 9, 2008).
enough that prosecution may have been considered against the physicians!
A public/private taskforce should be convened to vastly simplify the system
so as to allow physicians more face-to-face time with patients instead of wast-
ing it on deciphering an ever increasing number of diagnosis and procedure
codes.
FOCUS ON RETENTION OF YOUNGER

AND MIDDLE AGED PHYSICIANS
With 35 percent of physicians currently over the age of 55, attention should
focus on the middle aged and younger physicians. In the 55–65 age group, the
percentage of physicians planning to retire in the next three years has more
than doubled from 9 percent in 2004 to 20 percent in 2007 (Figure 14.7).30
The brunt of the work, will be performed by the middle aged and younger
physicians when older physicians retire or begin working part-time hours.
With the lifestyle choices they are making, is this group ready to assume the
burden of patient care with all the stresses that accompany a specialty prac-
tice? Given the lifestyle preference of this group, it is highly likely that full-time
Figure 14.7
Physicians Over 55 Years and Retirement
Percentage of Physicians Percentage of Physicians Age 55 to

over the Age of 55 65 That Plan to Retire in Next 3 Years
35%
24%
20%
9%
1985 2006 2004 2007

Source: Health Care Advisory Board, Physician Recruitment: Attracting Talent in a Competitive
Market (Washington, DC: The Advisory Board Company, May 1, 2008), http://www.advisory.com/
members/default.asp?contentID=77362&collectionID=1720&program=7&filename=77362.
xml (accessed May 27, 2008). © 2006 The Advisory Board Company. All rights reserved. Re-
printed with permission.
employment by hospitals will suit their goals. Newer alternative practice struc-
tures, such as joint practice ownership or partnership with hospital systems,
may be the trend of the future. Another tactic to increase retention in the
older group of physicians is to offer sabbaticals in order to avoid burnout and
provide intellectual stimulation. This may not be possible in small specialty
groups or health systems.
Mentoring programs to assist younger physicians to start on a positive note
are an important part of any large health system that wants to encourage lon-
gevity in the physician workforce. For instance, a surgeon fresh out of training
should have a senior surgeon available to assist on difficult or re-do cases or
give curbside consultations freely to develop confidence. The first few months
can be fairly traumatic for a young surgeon if a rash of unexpected complica-
tions occur and there is no one to counsel the young practitioner.
In summary, there are no simple solutions, and simply cycling more medical
students through the system without the infrastructure ready to receive them will
fail. We have shared some of many possible solutions that seem to us to be
within reach.
15
Challenges and Consequences
OUR LETTER TO ALL SURGICAL RESIDENTS

For the rest of your career you will be in demand. There is an emerging
shortage of surgeons that can only be dealt with by increasing the surgical
workforce in the next 40 years. This will be difficult to do, and for that reason,
you will be in demand.
You will enjoy your practice and we wish you much success. The key to
your practice will be the close patient relationships that you develop in your
career. They are meaningful for both you and your patients, and for your
patients’ families. Follow them for as long as they want to see you. As these
relationships develop, you will see, they will confide in you more and more.
That confidence is a sacred trust.
You will be successful financially. Most of you will be in two-income families
and will need a scheduled or a more controllable lifestyle. The employment
model in the surgical world is becoming more and more attractive to surgical
specialists, as well as hospitals and regional health care organizations. Hospi-
tals cannot deliver patient care without specialists. Some of you may go into
private practice, but others may not want the hassles of coding, the paperwork,
and all the administrative frustrations that come with the territory.
While insurance reimbursements for physician services may decrease, be-
cause you will be in demand and not supply, a salaried model of hospital
employment will pay you a fair rate for your services. Their motive will be to
minimize turnover in their surgical staffs. Remember, an operation cannot be
performed without a surgeon.
In your negotiations with your employer, think about these things: a fair
salary, perhaps a signing bonus or a contract that involves assistance in paying
off your medical school debt, and, certainly, payment of all of your malpractice
premiums. You should also arrange for disability insurance and life insurance.
Remember, the odds of your becoming disabled are far greater than the odds
of your dying. Save for retirement. Make sure that your employer has a good
Challenges and Consequences 145
retirement plan, but also save in your own name. Our advisors recommend
that you save $5,000 a year for your children’s education, if you can.
The hospital-physician relationship is evolving, perhaps into a clinic-based
model such as those in the Mayo Clinic and the Cleveland Clinic, where the
doctors have a significant say in running the business and the organization.
This model makes for a closer and more efficient relationship between hospi-
tals and the physicians who practice there and allows you to know the markets
wherever you are practicing. As a result of this evolution, more and more of
you will have administrative responsibilities later on in your careers. Certainly,
both the Mayo and the Cleveland Clinics were originated by doctors, and both
have had doctors for chief executive officers many times. The number of hos-
pitals that have physician chief executive officers is on the rise.1
Above all, pass your boards. Once you are board certified, all of these
opportunities lie before you. Good luck.
Thomas E. Williams, M.D.; Ph.D.

Bhagwan Satiani, M.D.; M.B.A
E. Christopher Ellison, M.D.
Future Doctors of America

Chris Paul, who did research for this book, is attending medical school. Chris
graduated from Middlebury College, was on the ski patrol at Alta, Utah, and
has an Emergency Medical Technician certificate. He wants to be an orthopedic
surgeon. The authors asked him to summarize his feelings after doing the
research. Here is his letter:2
An ancient Chinese proverb states, “May you live in interesting times,” and
for those of you in high school and college who are considering a career in
medicine no one line could be more appropriate. Over the past 15 years the
face of medicine has changed dramatically, and the one thing we know about
change is that it never ceases. The practice of medicine today is significantly
different from what it was when our grandparents practiced, and some might
argue that it has not changed for the better. But for those of you holding onto
the dream of becoming a physician, do not lose hope. Much of what we are see-
ing in medicine today is cyclic; meaning that bad times inevitably will give rise
to better ones. But before we address how things will improve for physicians in
the future it is imperative to identify what has gone haywire with medicine in
its current state.
Medicine today has undergone a fundamental change in that many of the
systems that have been put into place over the course of recent history have
changed the way medical care is being delivered and compensated for. For in-
stance, as the cost of medical care has increased over the years, private insurance
companies, which help to defer the expense of large medical bills by charging
reasonable monthly amounts (premiums), have been forced to increase the size
of premiums and scrutinize your medical bills more closely. The government also
provides its own form of medical coverage for persons over the age of 65 in the
form of Medicare. Medicare’s sister program, Medicaid, provides coverage for

low-income individuals and families.
This all seems reasonable so far, right? Well, not quite. Today there are
some 78 million baby boomers in the United States. Just to remind you, the
term “baby boomer” was affectionately given to those born between 1946 and
1964. This alone wouldn’t be a huge problem except that they are all reaching
the age of 65+ around the same time. Now let’s also remember that statistically,
persons aged 65 and over require almost 40 percent of all surgical services!
You can see that problems begin to arise when these roughly 78 million people
who require access to these medical services also need the government to help
pay for it all.
But how does this impact doctors today and in the future? Well, anticipating
this problem the federal government passed the Balanced Budget Act of 1997,
which in itself was a sweeping piece of legislation. However, a very important
part of that bill stated that from 1996 onward the amount that the government
would pay to physicians for services or procedures provided to patients who are
covered through Medicare would systematically decrease over time. Just recently
additional decreases in reimbursement rates have been approved through 2011.
Okay, so essentially you’ll be receiving less money. Not a big deal if you’re not
dealing with people on Medicare, which is why initially the Balanced Budget Act
of 1997 didn’t raise such a backlash. However, as more people have moved and
continue to move to Medicare, more doctors are finding that they are having to
see greater numbers of patients to compensate financially for the reduced fees.
This is resulting in longer waiting times for patients and less quality time be-
tween the patients and their physicians. As a result, some physicians have simply
stopped seeing Medicare patients, while others have decided to retire early. Not
an encouraging thought.
Yet Medicare alone might not drive these physicians from practice altogether.
In reality, a myriad of other factors have all worked to make the working en-
vironment less hospitable for today’s physicians. Here is what has happened.
Medicare in the insurance world acts as the gold standard. You know, the basis
for which all insurance companies adjust their rates of compensation. As Medi-
care reimbursements have dropped in recent years, other insurance companies
have taken notice and have lowered their rates of reimbursement as well. Why
should Blue Cross/Blue Shield® pay a physician $500.00 for a procedure that
Medicare pays only $300.00 for? From an economic standpoint this makes total
sense; however, it spells trouble for physicians.
FROM BAD TO WORSE

Okay, so physicians today don’t make as much as they used to; big deal.
Well, actually it is. Especially, because some of these physicians, such as those
in private practice, cannot afford to keep up with rising rates of malpractice pre-
miums and practice costs. What do I mean by this? Just like anyone else physi-
cians need insurance to protect themselves in the event that something should
go wrong and a patient decides to file a lawsuit. The problem is that some of
these lawsuits against physicians have awarded so much money to the patients
and their lawyers (through contingency fees) that insurance companies, afraid
of going bankrupt while paying out these settlements from these lawsuits, have
dramatically increased the amount of the premiums for physicians. For example,
in Columbus, Ohio, if you are a cardiothoracic surgeon (meaning you work on

the heart, lungs, and all major vessels in the chest), you pay over $100,000 per
year in malpractice insurance premiums.
To many surgeons, especially those who are nearing the end of their practic-
ing years and may wish to work on a part-time basis, the cost of remaining in
practice is just too great. Many are discovering that they cannot afford the costs
of practicing, even if they still find the practice of medicine rewarding, and so
are forced to retire.
The other piece of the puzzle here are the practice costs associated with run-
ning a private practice. But wait, don’t most doctors work at the hospital? Well,
some do and others do not. If you’re a hospitalist you see patients in the hospital
itself. However, if you have a clinic you may have an office and a practice in a
building that is not associated with a specific hospital. The problem today is that
practice expenses have been skyrocketing, particularly staffing expenses. Those
physicians who work in private practice act as employers and thus are feeling
the pinch of rising staffing expenses, lease agreements, and paper products—just
like any other business.
. . . AND THE HITS JUST KEEP ON COMING

The result of all of these changes is a net loss of doctors from not just the back
end of the workforce supply, but from the front end as well. What is meant by
this? Well, a loss of doctors reflects older surgeons who are choosing to retire.
The front-end losses are just as concerning, however, and refer to our generation
of medical students.
There are three principal reasons for this.
First, today more than ever, problems concerning the medical profession’s abil-
ity to adequately meet workforce demands are the subject of much speculation.
Much of this speculation revolves around the debate as to whether our medical
schools should be/could be producing more medical students per year. At pres-
ent, according to AMA medical school enrollment statistics, roughly 17,000 new
doctors enter the workforce each year. This number has remained more or less
constant over the past 25 years. Now, remembering that there are some 34,000
candidates applying to medical schools each year, this means that nearly one-
half of all U.S. applicants are required to seek their medical education elsewhere
(i.e., outside the United States), reapply the following year, or pursue an alternate
career. To most, this statistic may not seem alarming, but the reality is that it is quite
disconcerting given the current state of the medical workforce amidst a growing
and aging population. The good news, however, is that by acting now we can avert
future shortages in specific specialties and the physician workforce in general.
Second, in our time there has been a fundamental change in the priorities
of our generation. Where in the past the mentality was to work and save what
was earned, our generation has grown up in the wake of our historically affluent
parents, the baby boomers. As a result, our priorities regarding work, family, and
leisure have shifted as well. Many medical students today dream of practicing
medicine, of course, but not at the tremendous cost to family and leisure life
that has historically been indicative of life as a physician. This has created a shift
away from those medical specialties that place large time demands on the physi-
cian such as thoracic surgery, orthopedic surgery, and obstetrics, and towards
specialties with controllable lifestyles, like dermatology and radiology.
Third, there is the word-of-mouth dilemma that has been plaguing many of
these surgical specialties. Have you ever had a class, or maybe even a major, that
you were unsure about so you looked to older students for advice? Well, the same
thing happens with medical students. And believe it or not, these bad vibes often
start with the surgeons. Surgeons, upset and perhaps disenchanted with the cur-
rent reimbursement, malpractice situations, etc, etc, often talk to their colleagues
and residents about the hardships in their specialties. The residents, in turn, often
echo these sentiments to 3rd- and 4th- year medical students doing rotations
with them. These students then decide that whatever specialty they are rotating
through, let’s say its OB/GYN, is not for them. They then relay this same disen-
chanted theme to other students in turn. It is a brutal cycle that ultimately hurts
those specialties as a whole, because a negative impression of the specialty is cre-
ated before the students ever get a chance to see what the specialty is all about.
So far in this book we have tried to accurately portray the current state of
medicine and the challenges that face it. How will the numerous problems that
have been addressed play out and affect both patient and physician populations?
With regard to both patients and physicians, rest assured the climate under
which medicine is practiced will be different.
So how does this all play out in the future?
Well, for one, if current conditions persist, we will continue to see greater
numbers of physicians leaving the profession, opting instead for an early retire-
ment. The loss of these experienced physicians will place even greater pressure
on practicing physicians to pick up the slack in order to attend to a growing
patient population. In addition, losses not only from the back-end but from the
front-end of the surgical workforce, in the form of fewer medical students, will
occur as well. (Ironically, we are not seeing this trend develop. As of January of
2009, with the U.S. economy tanking, many new college graduates, unable to
secure a job, are applying to graduate schools in the hopes of making themselves
more competitive in the future. As a result, medical school applications have
risen, as have GPAs and MCAT scores, which are the basis of the medical school
admission criteria.) As students begin to assert their desire for career satisfac-
tion, the specialties that will be hardest hit will be the ones that cannot provide
a controllable overall lifestyle.
WHO WILL LOSE OUT?

Mainly it will be you, the consumer of health care, who will in all likelihood
suffer the most from these changes. You will lose out in the form of greater up-
front fees and longer waiting periods to see a physician. You will lose out in the
nature of your relationship with your physician; it may not be what it once was.
He or she will be unable to spend time attending to your needs and concerns due
to the amazing demands that will be placed on his or her time in the clinic or
operating room. Physicians will also lose out in that they will lose not only income,
but practice time. For some physicians, especially older ones, even part-time work
towards the end of one’s career is valuable and challenging. It also gives these
senior doctors a chance to pass on valuable knowledge to their successors.
As you can see, these are some issues that need to be ironed out in the coming
years. The solutions will be neither simple nor quick; in reality, a combination
of measures will need to be enacted to right this ship. The good news is that if
you’ve read this far then you’ve read the worst. In truth, medicine remains an
incredibly rewarding and invaluable profession. The amount of good that you
will be able to do on behalf of others will amaze you. There is no doubt that you
will have to work very hard to achieve your dream of becoming a physician, but
I believe that in the end, for all the flaws and imperfections that are associated
with practicing physicians today, medicine it is still one of the greatest journeys
you will ever undertake. I wish you all the best in your future endeavors.
Very respectfully yours,

Christopher M. Paul
Challenges
In this book, we have pointed out a number of challenges that face us.
These are all real challenges. They require a multi-pronged approach to a
complicated issue during a time when the financial health of our country is not
good. But, we have to invest in our youth, who are going to be taking care of
our health. At the same time, there is maybe an even more pressing challenge,
and that is to make the career of medicine or surgery appealing to all who wish
to make a commitment to helping the sick.
We must make the profession of medicine appeal to all high school gradu-
ates and college students. One example of promoting the profession to disad-
vantaged groups is close to home for us. At The Ohio State University there
is a M.D. camp for those who come from a racial or ethnic identity, such as
African American, Latino, and American Indian, that is underrepresented in
medicine.3 This could be expanded to every race and ethnicity. The camp
meets for three weeks in early summer. They meet from Monday to Friday,
from 8:00 A.M. to 5:00 P.M. The cost is $650.00, and scholarships are based
on need and academic merit. As you can see, this could be expanded and the
necessary scholarships could be provided by local industry, local manufactur-
ing companies, and local businesses.
In some colleges, there are premed clubs for those students interested
in the profession of medicine. We have to organize more of these clubs in
order to meet the demands that we will face in 2050. Local medical societies
should cooperate with high schools to assist them with ambassadors to speak
or host students on career day. Physicians who are excited about their profes-
sion should be on the front line to display their passion for service to fellow
citizens.
We also have to make surgical disciplines more attractive to medical stu-
dents, and particularly women. Part of the blame lies with current faculty and
practicing physicians. All residents and medical students hear the constant
whining about reimbursement, malpractice cost, endless paperwork, and a
promise (threat) of early retirement. There is no question that we have chal-
lenges, but every generation of physicians has had their own hills to climb.
No wonder our future physicians are apprehensive about their future. This
negativity is then conveyed to parents of prospective students and others con-
templating a career in medicine. Those of us who see the impending shortages
have to educate the younger generation about the opportunity that exists for
them among the many challenges.
There are surgery interest clubs in many medical schools. Perhaps we
should have more of them. We should introduce medical students to the con-
cepts and ideas of surgery early on in their medical school careers. One of the
authors (TEW) spent the summer of 1960 as a part-time scrub technician in
the operating rooms of University Hospital in Columbus, Ohio. By the end of
the summer he had determined that he would go into surgery. Another author
(BS) encouraged his operating room scrub technician to apply for medical
school and wrote a strong recommendation letter for the highly motivated
individual. The same author has also provided part-time research jobs to pro-
spective medical school applicants to assist them in building their resumes.
People enter medicine for different reasons. There are generational
differences, and we should take advantage of the motives of “generation Y” to
encourage them to serve humanity. While some in the older generation had
expectations of income and lifestyle that were consistent with better times, the
current generation may have lower expectations in terms of income levels. In
a recent survey by Kaplan Test Prep and Admissions of premed and pre-law
students regarding their reasons for future careers, less than one-half were
“very much” or “somewhat” influenced by earning potential as a reason for
choosing medicine.4 The prime motivation of 461 students taking the MCAT
was the desire to help others. In contrast, 71 percent of pre-law students gave
money as the main reason for choosing law as a career. Is there a better con-
trast between the two professions?
In a survey of women physicians 76 percent were either “very satisfied” or
“satisfied” with their choice of medicine as a career.5 Only 11 percent were
“dissatisfied” or “very dissatisfied” with their choice. The greater the number
of hours worked, the higher the rate of dissatisfaction. Interestingly, those
women with four children had the highest rate of satisfaction with work life
balance. Two-thirds said they would pick medicine as a profession if they had
to start all over again. This is encouraging news. Medical schools and residency
programs must have mentorship programs for women and minorities of vari-
ous ethnic backgrounds to aggressively encourage them to choose medicine as
a profession that will satisfy their personal needs as well as provide them with
opportunities to give back to their own communities. We also need many more
role models among women and minorities to be available to their communities
in order to attract future physicians.
In addition to the challenges to make surgery or medicine a more desirable
career for many people, there are other challenges as well. We have to do
something with regard to scheduled lifestyles and off hours. While the defini-
tive answer in terms of the safety of the 80-hour work week that is now man-
dated for residents is not in yet, there is little question that shorter hours fit
in with this generation’s preference for a more relaxed lifestyle. There is now
word that a 56-hour work week instead of the current 80-hour work week for
residents is under discussion.6 As we have pointed out, one answer may be the
intensivists and hospitalists in the hospitals for 24 hours in internal medicine,

for surgical hospitalists, and perhaps similar in-house obstetricians as well.
One thing educators can do to provide some comfort and decrease the
apprehension of prospective physicians is to give them the tools to deal with
the business side of medicine. The main reason for medical school residents
second guessing the choice of medicine as a career (25%) is the business side
of medicine. In an Epocrates future physician of America survey of 1000
medical students, only 12 percent were receiving a course in practice man-
agement and 78 percent said the course would be valuable.7 In 2003, when
residents were asked about their degree of concern in this regard, 47 percent
rate themselves “unprepared” for the business side of their medical career,
and 51 percent say they felt “somewhat prepared.” Over half stated they
had had no exposure to the business side of medicine in their training. In the
same survey in 2006, the “unprepared” number dropped significantly from
about 47 percent to only 15 percent. Only 30 percent of residents get any
formal training in the business or practice management issues they will be
deeply involved in when they graduate. Medical schools and residency train-
ing programs must restructure their programs and abandon the rut they are
in to address the changes in medicine to train our physicians to deal with the
future with confidence. At Ohio State, one of the authors (BS) has established
an 18-month curriculum of Practice Management Seminars for senior surgi-
cal residents, which has mandatory attendance requirements. Topics covered
include health care economics, contract negotiations, choosing a practice, how
to purchase insurances (life, disability, liability, and health), personal finance,
basic accounting, billing and coding, and fraud and abuse regulations. Resi-
dents from other specialties also attend when they hear about the monthly
sessions that are oriented to provide very practical information. When resi-
dents graduate they take with them an entire folder of valuable handouts that
serve as a reference book.
Something must also be done about medical school debt. There are several
programs that exist to assist graduating students, such as the First for Medi-
cal Education debt assistance program run by the Association of American
Medical Colleges (AAMC).8 We need more of these programs in order to get
the medical students interested, particularly in surgical careers with their long
residencies. A quarter of residents polled by Merritt Hawkins & Associates
stated that medical school debt was a concern.9 Almost 47 percent of residents
in the same survey said that a deal involving payoff of the debt would affect
their choice of a job.
Something has to be done about physicians’ malpractice premiums and
insurance options. Some states are making some progress, but the cost of the
malpractice premiums and the associated liability for 2 to 18 years in most
states will still discourage those who want to go into surgical and OB/GYN
residencies. In a survey of current residents by Merritt Hawkins & Associates,
two-thirds said that malpractice issues gave them the biggest reasons for
concern.10 Since liability reform was passed in Texas in 2003, malpractice
premiums have dropped 24 percent and medical license applications have

jumped 59 percent!11 Lowering premiums works. It can be done.
As we have discussed in detail, we must challenge our Congress and the
executive branch of our government to change funding for the required resi-
dency positions for post graduate medical education to accommodate the in-
creasing population.
Something must be done about residents’ salaries. First year salaries for
corporate attorneys in Baltimore, for instance, averaged $145,000 in 2008.12
That is about three times what a surgical resident makes. We estimated per
hour wages of residents to be in the $10–14 range and compared them to
other skilled labor wage profiles in chapter 3. That, combined with the debt
burden and the clear preference of all educators that all residents avoid any
moonlighting jobs, makes it imperative that we pay a fair wage to residents.
And, finally, something has to be done about reimbursement. As we have
discussed in previous chapters, hospitals are getting regular market basket up-
dates in reimbursement for the services they provide. For example, for the fiscal
year 2009, Congress has been asked to increase hospital payments by the pro-
jected rate of increase in the hospital market basket index, currently estimated at
3.0 percent.13 Contrariwise, physician reimbursement is always on the chopping
block each year until it receives a last minute reprieve by Congress. But, without
medical reimbursements for physicians that allow them to pay off their medical
school debts, and provide for retirement, and their children’s education, they will
not go into medicine. Medical private practice groups will not hire new physicians
and hospitals will be the only ones left with enough capital to hire physicians. Do
we want all physicians to be employed by large healthcare megasystems?
A BRIEF REVIEW OF HEALTHCARE IN CANADA

We are reviewing the Canadian health care system because some version
of that health care system might form the template of universal health care in
the United States. We want particularly to review the waiting times for surgical
services in Canada. A more complete review of the Canadian health care sys-
tem can be found in our book Consumer Driven Health Care and in the Sally C.
Pipes book Miracle Cure: How to Solve America’s Health Care Crisis and why
Canada Isn’t the Answer.14 Ms. Pipes is a Canadian citizen and former head of
the Fraser Institute in Vancouver, British Columbia.
In 2003, Canada’s health care spending was about $3,000 per citizen, about
half of what we spent in the United States.15 Now, Canada is beginning to
privatize some of its medical care. Even the European nations, including Great
Britain and Sweden, are advocating more and more private health care.16
There are about 220 doctors per 100,000 population in Canada, as opposed
to about 286 in the United States, split about evenly between primary care
and specialty care.17 About 1 in 12 Canadian doctors have immigrated to the
United States.
There are three levels of difficulty in negotiating the Canadian health care
system. The first is in getting an initial doctor’s appointment so that a primary
care doctor can diagnose your problem and refer you for tests or to the ap-
propriate specialist if, indeed, you need consultation. The second difficulty is
in getting appropriate diagnostic tests scheduled in a timely manner when the
general practitioner recommends it. The third difficulty is in getting consultant
appointments for their diagnoses and treatment.
In 2003, 15 percent of Canadians reported difficulties for routine health
care matters and 23 percent for minor health problems.18 Some of the lead-
ing critics of the Canadian health care systems are Canadians themselves. In
Investors Business Daily, David Gratzer, a Canadian doctor associated with the
Manhattan Institute, said that about 1.5 million people in Ontario, almost one-
eighth of the population of Ontario, cannot find family physicians. That results
in overcrowded emergency rooms.19
According to the Fraser Institute, in 2005 the median waiting time after a
patient’s initial visit to a general practitioner to provision of treatment was almost
18 weeks or 4½ months. For cardiovascular surgery, it is eight weeks from
initial visit to completion, in general surgery it is 10.4 weeks or 2½ months, in
orthopedic surgery, it is nine months. In chest surgery, abdominal surgery, and
hip surgery there is usually another three months after the operation to com-
plete rehabilitation (Figure 15.1).20
Figure 15.1
Median Wait Times for Patients from Referral by General Practitioner for Treat-
ment by Specialty
Canada (median)
OB/GYN
Specialty
Ortho
Uro
Cardiovascular
Plastics
GenSurg
0 10 20 30 40 50
Weeks
Wait times from GP to Specialist

Wait times from Specialist to treatment
Source: R. Steinbrook, “Private Healthcare in Canada,” New England Journal of Medicine 354:16
(2006) 1661–1664.
Dr. Gratzer’s article compares the five-year survival rate obtained in Ameri-
can medicine to European results. For leukemia, the American survival rate is
almost 50 percent; in Europe it is 35 percent. For esophageal carcinoma, one
of the most lethal of cancers, the five year survival rate is 12 percent in the
United States and six percent in Europe. The survival rate of prostate cancer
is more than 80 percent in the United States, just over 60 percent in France,
and just 40 percent in England.21
In fact, there is a firm headed by a Canadian who describes himself as a
medical broker; that is, Canadians pay him to set up surgical procedures, diag-
nostic testing, and specialist consultations privately and quickly.22 A prominent
doctor from British Columbia, head of the Canadian Medical Association, said,
“This is a country in which dogs can get a hip replacement in under a week
and in which humans can wait for two to three years.”23
The issue of private insurance, which was banned in the province of
Quebec, resulted in a lawsuit filed by a patient and his doctor against the
province. The patient was placed on a waiting list for his hip replacement to
have the operation in one year. The judges in the Supreme Court of Canada
found for the patient, saying that “access to a waiting list is not access to
health care.”24
The purpose of this section on Canadian medical care is not to criticize
it, but to emphasize that if we don’t have the doctors, we will ration surgical
care by both the doctor’s time to see patients, but more importantly, the
patient’s time.
Consequences
Finally, let’s talk about consequences. In the face of increasing demand
and decreasing supply, we will have a four-tier health care system. Let us
explain.
The wealthy can afford anything that modern health care can provide. So
they will make up the first class of health care. They will have no rationing
at all. The second class will be those who have advocates in the health-
care fields; people who have an inside track to arrange for their medical
appointments and procedures. They will face rationing only in terms of the
time it takes to get a medical or surgical appointment. The third class will
be the rest of the insured. They will face rationing by time. They will not
be able to get a prompt medical appointment and will have long wait times,
particularly for surgical appointments. And finally, the fourth class will be
the under insured or uninsured. This is a problem for 45,000,000 or more
Americans. If we don’t do something about it, it will be a problem for about
70,000,000 Americans by 2050.
If we fail to increase medical school enrollments, fail to create the residen-
cies, and fail to meet these other challenges, we will be in a position where
every practice could become a boutique practice. That is, we will sell access
to physicians for their opinions, and the access fee will not be included in the
physicians’ fees. In other words, we will be operating like a Sam’s Club, selling
access to the store. Merchandise fees will apply after you gain entry to the
store. There is much that needs to be fixed in our current system of delivering
health care, but we doubt that the American public is ready for a Sam’s Club
approach.
Epilogue
A LETTER TO OUR PATIENTS

Multiple surveys of our citizens have shown areas of dissatisfaction with our
health care system. In a 2009 CNN/Opinion Research Corporation survey
more than 8 in 10 were satisfied with the quality of care they received, nearly
3 of every 4 expressed satisfaction with their overall health coverage but as ex-
pected, 3 of 4 people were dissatisfied with the cost of healthcare in the United
States. We may have the best “sick care” system in the world but the inefficien-
cies, including excess litigation, are a burden we cannot pay for anymore.
You can render primary care with primary care physicians and other pro-
fessionals such as nurse practitioners and physician assistants. Unfortunately,
you cannot provide hospital care without medical and surgical specialists. Sur-
geons are unique in being able to deliver life-saving interventions that no
other health care professional can provide. But, to render surgical care, we
must have an adequate surgical workforce. That is the point of this book. As a
patient, you must understand that if we don’t increase medical school enroll-
ments and amend the Balanced Budget Act of 1997 to allow enough surgical
trainees, we will not have enough surgeons to meet the increasing needs of
our population.
There are many stakeholders at the table discussing ways to reform the
healthcare system in the United States. Who would you trust the most in look-
ing out for you? In a recent Gallup poll, 73 percent of people polled expressed
confidence that physicians would recommend the right thing when reforming
the system. This high vote of confidence exceeded that of all other parties in-
cluding the President, Congress, researchers, insurers, or pharmaceutical compa-
nies. Physicians hold the patient-doctor relationship sacred. But, would you trust
doctors to write law or to engineer legislation or foreign policy? You would not.
So, why would you entrust the responsibility to enact reform to so-called experts
who have never delivered health care? Together, we must speak up and insist on
a health policy that has the patient at the heart of any change.
Epilogue 157
You, as citizens and taxpayers of the United States, must make sure that our
government does not make fatal mistakes that will result in rationing of health
care to all of you. Witness the waiting times in Canada and the five-year sur-
vival rate for cancers in Europe, as we alluded to in chapter 15.
Very respectfully submitted,

Thomas E. Williams, Jr.
Bhagwan Satiani
E. Christopher Ellison
Appendix
The tables (A.1, A.2, and A.3) contained in this Appendix are the original
tables from which shorter tables in chapter 5 were taken. The table titles are
the same.
Table A.1
Retiring Doctors
Old Physicians Number of Old

Year Retiring Each Year Physicians Practicing
2000 800,000
2001 20,000 780,000
2002 20,000 760,000
2003 20,000 740,000
2004 20,000 720,000
2005 20,000 700,000
2006 20,000 680,000
2007 20,000 660,000
2008 20,000 640,000
2009 20,000 620,000
2010 20,000 600,000
2011 20,000 580,000
2012 20,000 560,000
2013 20,000 540,000
2014 20,000 520,000
2015 20,000 500,000
2016 20,000 480,000
(continued )
160 Appendix
Table A.1
Retiring Doctors (continued )
Old Physicians Number of Old

Year Retiring Each Year Physicians Practicing
2017 20,000 460,000
2018 20,000 440,000
2019 20,000 420,000
2020 20,000 400,000
2021 20,000 380,000
2022 20,000 360,000
2023 20,000 340,000
2024 20,000 320,000
2025 20,000 300,000
2026 20,000 280,000
2027 20,000 260,000
2028 20,000 240,000
2029 20,000 220,000
2030 20,000 200,000
2031 20,000 180,000
2032 20,000 160,000
2033 20,000 140,000
2034 20,000 120,000
2035 20,000 100,000
2036 20,000 80,000
2037 20,000 60,000
2038 20,000 40,000
2039 20,000 20,000
2040 20,000 0
2041 0 0
2042 0 0
2043 0 0
2044 0 0
2045 0 0
2046 0 0
2047 0 0
2048 0 0
2049 0 0
2050 0 0
Appendix 161
Table A.2
New Physicians Added
New Graduates
Present Total of New Who Have Total of New
Year Graduating Class Graduates Retired Graduates Practicing
2000
2001 17,000 17,000 0 17,000
2002 17,000 34,000 0 34,000
2003 17,000 51,000 0 51,000
2004 17,000 68,000 0 68,000
2005 17,000 85,000 0 85,000
2006 17,000 102,000 0 102,000
2007 17,000 119,000 0 119,000
2008 17,000 136,000 0 136,000
2009 17,000 153,000 0 153,000
2010 17,000 170,000 0 170,000
2011 17,000 187,000 0 187,000
2012 17,000 204,000 0 204,000
2013 17,000 221,000 0 221,000
2014 17,000 238,000 0 238,000
2015 17,000 255,000 0 255,000
2016 17,000 272,000 0 272,000
2017 17,000 289,000 0 289,000
2018 17,000 306,000 0 306,000
2019 17,000 323,000 0 323,000
2020 17,000 340,000 0 340,000
2021 17,000 357,000 0 357,000
2022 17,000 374,000 0 374,000
2023 17,000 391,000 0 391,000
2024 17,000 408,000 0 408,000
2025 17,000 425,000 0 425,000
2026 17,000 442,000 0 442,000
2027 17,000 459,000 0 459,000
2028 17,000 476,000 0 476,000
2029 17,000 493,000 0 493,000
2030 17,000 510,000 0 510,000
2031 17,000 527,000 0 527,000
(continued )
162 Appendix
Table A.2
New Physicians Added (continued )
New Graduates Total of New

Present Total of New Who Have Graduates
Year Graduating Class Graduates Retired Practicing
2032 17,000 544,000 0 544,000

2033 17,000 561,000 0 561,000
2034 17,000 578,000 0 578,000
2035 17,000 595,000 0 595,000
2036 17,000 612,000 0 612,000
2037 17,000 629,000 0 629,000
2038 17,000 646,000 0 646,000
2039 17,000 663,000 0 663,000
2040 17,000 680,000 0 680,000
2041 17,000 697,000 17,000 680,000
2042 17,000 714,000 34,000 680,000
2043 17,000 731,000 51,000 680,000
2044 17,000 748,000 68,000 680,000
2045 17,000 765,000 85,000 680,000
2046 17,000 782,000 102,000 680,000
2047 17,000 799,000 119,000 680,000
2048 17,000 816,000 136,000 680,000
2049 17,000 833,000 153,000 680,000
2050 17,000 850,000 170,000 680,000
Appendix 163
Table A.3
Total of Practicing Doctors
Number of Old Physicians Total of New Graduates Grand Total of

Year Practicing Practicing Practicing Doctors
2000 800,000 800,000

2001 780,000 17,000 797,000
2002 760,000 34,000 794,000
2003 740,000 51,000 791,000
2004 720,000 68,000 788,000
2005 700,000 85,000 785,000
2006 680,000 102,000 782,000
2007 660,000 119,000 779,000
2008 640,000 136,000 776,000
2009 620,000 153,000 773,000
2010 600,000 170,000 770,000
2011 580,000 187,000 767,000
2012 560,000 204,000 764,000
2013 540,000 221,000 761,000
2014 520,000 238,000 758,000
2015 500,000 255,000 755,000
2016 480,000 272,000 752,000
2017 460,000 289,000 749,000
2018 440,000 306,000 746,000
2019 420,000 323,000 743,000
2020 400,000 340,000 740,000
2021 380,000 357,000 737,000
2022 360,000 374,000 734,000
2023 340,000 391,000 731,000
2024 320,000 408,000 728,000
2025 300,000 425,000 725,000
2026 280,000 442,000 722,000
2027 260,000 459,000 719,000
2028 240,000 476,000 716,000
2029 220,000 493,000 713,000
2030 200,000 510,000 710,000
2031 180,000 527,000 707,000
(continued )
164 Appendix
Table A.3
Total of Practicing Doctors (continued )
Number of Old Physicians Total of New Graduates Grand Total of

Year Practicing Practicing Practicing Doctors
2032 160,000 544,000 704,000
2033 140,000 561,000 701,000
2034 120,000 578,000 698,000
2035 100,000 595,000 695,000
2036 80,000 612,000 692,000
2037 60,000 629,000 689,000
2038 40,000 646,000 686,000
2039 20,000 663,000 683,000
2040 0 680,000 680,000
2041 0 680,000 680,000
2042 0 680,000 680,000
2043 0 680,000 680,000
2044 0 680,000 680,000
2045 0 680,000 680,000
2046 0 680,000 680,000
2047 0 680,000 680,000
2048 0 680,000 680,000
2049 0 680,000 680,000
2050 0 680,000 680,000
Notes
CHAPTER 1—THE PROBLEM

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JAMA 290 (2003): 1190–1196.
2. S. E. Brotherton, P. H. Rockey, and S. I. Etzel, “U.S. Graduate Medical Educa-
tion, 2002–2003,” JAMA 290 (2003): 1197–1202; American Medical Association,
“International Medical Graduates in the U.S. Workforce. October 2007,” http://www.
ama-assn.org/ama1/pub/upload/mm/18/img-workforce-paper.pdf (accessed June 16,
2008).
3. American Medical Association, “International Medical Graduates in the U.S.
Workforce,” October 2007, http://www.ama-assn.org/ama1/pub/upload/mm/18/
img-workforce-paper.pdf (accessed June 16, 2008).
4. ECFMG, “Fact Card—Summary Data—2006 2007,” http://www.ecfmg.org/
cert/factcard.pdf (accessed June 15, 2008).
5. “Charting Outcomes in the Match.” National Resident Matching Program,
http://www.nrmp.org/data/chartingoutcomes2007.pdf (accessed July 3, 2009).
6. Eugene Braunwald, “Cardiology: The Past, the Present, and the Future,” Journal
of the American College of Cardiology 42 (2003): 2031–2041.
7. “Public Enemy No. 1,. Fortune, March 22, 2004.
8. “Living Longer,” Wall Street Journal, June 9, 2004; “Staying Alive,” New York
Times, June 1, 2004.
9. “USA in 2050: Population projected over five decades,” USA Today, March
18, 2004.
10. Roger D. Blackwell, Thomas E. Williams, and Alan Ayers, Consumer Driven
Health Care (Ashland, OH: Book Publishing Associates, 2005) 89–96.
11. Richard A. Cooper, “Weighing the Evidence for Expanding Physician Supply,”
Annals of Internal Medicine 141 (2004): 705–714.
12. “Demands on Surgeon Work Force to Grow Rapidly through 2020,” Physician
Compensation Report, September 2003, http://findarticles.com/p/articles/mi_m 0FBW/
is_9_4/ai_106954764?tag=content;col12/19/2009 (accessed February 5, 2009).
13. Merritt Hawkins and Associates, “White Paper: An Analysis of the Emerging
Physician Shortage in the United States,” October, 2004, http://www.mhagroup.com/
(accessed June 16, 2008).
166 Notes
14. AAMC, “Table 1: U.S. Medical School Applications and Matriculants by

School, State of Legal Residence, and Sex, 2007,” http://www.aamc.org/data/facts/
2007/2007school.htm (accessed June 16, 2008).
15. Emily Lee, “UW Study Finds a Decline in General Surgeons,” The Daily of
University of Washington, May 28, 2008, http://thedaily.washington.edu/2008/5/28/
uw-study-finds-decline-general-surgeons/ (accessed June 15, 2008).
16. D. A. Newton and M. S. Grayson, “Trends in Career Choice by U.S. Medical
School Graduates,” Journal of the American Medical Association 290 (2003): 1179–
1182; “National Residency Matching Program. Advance Data Tables—2008 Main Resi-
dency Match,” http://www.nrmp.org/data/advancedatatables2008.pdf (accessed May
16, 2008).
17. The American Bar Association, www.abanet.org (accessed November 5, 2005).
18. Alex Williams, “YOU can’t say Law Firms aren’t Trying,” New York Times, Janu-
ary 6, 2008, http://www.nytimes.com/2008/01/06/fashion/06professions.html?pa
gewanted=1&_r=1 (accessed June 16, 2008).
19. T. E. Williams, B. Satiani, A.Thomas, and E. C. Ellison, “The Impending Short-
age and the Estimated Cost of Training the Future Surgical Workforce,” Annals of
Surgery. In press.
CHAPTER 2—DEMAND FOR A SURGICAL/

MEDICAL WORKFORCE
1. American College of Surgeons and the American Surgical Association, “Sur-
gery in the United States: A Summary Report of the Study on Surgical Services for the
United States (SOSSUS),” (Baltimore: 1975); R. A. Cooper, T. E. Getzen, H. J. McKee,
P. Laud, “Economic and Demographic Trends Signal an Impending Physician Short-
age,” Health Affairs 21 (2002): 140–154; Council on Graduate Medical Education,
“Physician Workforce Policy Guidelines for the U.S. for 2000–2020,” (Rockville, MD:
U.S. Department of Health and Human Services: 2005).
2. CDC, “National For Vital Statistics Deaths: Final Data for 2005,” http://www.
cdc.gov/nchs/data/nvsr/nvsr56/nvsr56_10.pdf (accessed June 18, 2008).
3. C. Leaf, “Why We’re Losing The War on Cancer [and How to Win It],” Fortune
Magazine, March 22, 2004, http://www.healingcancernaturally.com/conventional-
cancer-treatment.html (accessed June 18, 2008).
4. ACS, “Cancer Facts & Figures—2007,” http://www.cancer.org/downloads/
STT/caff2007PWSecured.pdf (accessed June 19, 2008).
5. “Living Longer,” Wall Street Journal, June 9, 2004.
6. “Staying Alive,” New York Times, June 1, 2004.
7. Eugene Braunwald, “Cardiology: The Past, the Present, and the Future,” Journal
of the American College of Cardiology 42 (2003): 2031–2041.
8. “Health Care Spending Slows in 2004,” Modern Health Care’s Daily Dose, January
10, 2006; Cynthia Smith, Cathy Cowan, Stephen Heffler, Aaron Catlin, and the National
Health Account Team, “National Health Spending In 2004 Recent Slowdown Led by
Prescription Drug Spending,” Health Affairs 25 (2006): 186–196; “U.S. Spending Rose,”
Modern Health Care Alert, February 22, 2006; Alex Berenson and Reed Abelson, “Weigh-
ing the Costs of a CT Scan’s Look Inside the Heart,” New York Times, June 29, 2008.
9. “Trauma now Nation’s Costliest Medical Problem,” Modern Health Care’s Daily
Dose, January 25, 2006.
Notes 167
10. R. A. Cooper, T. E. Getzen, H. J. McKee, P. Laud, “Economic and Demographic

Trends Signal an Impending Physician Shortage,” 2002; M. Barer, “New Opportunities
for Old Mistakes,” Health Affairs 21 (2002): 169–171.
11. United States Census Bureau. http://www.census.gov/ipc/www/usinterimproj/
natprojtab02a.xls (accessed June 18, 2008); Federal Interagency Forum on Aging Re-
lated Statistics, “Aging Stats 2008 Report,” http://www.agingstats.gov/agingstatsdot net
/Main_Site/Data/Data_2008.aspx (accessed June 18, 2008).
12. D. K. Cherry, C. W. Burt, and D. A. Woodwell, “National Ambulatory Medical
Care Survey: 2001 Summary. Advance Data from Vital and Health Statistics; no. 337,”
(Hyattsville, MD: National Center for Health Statistics, 2003).
13. Council on Graduate Medical Education, “Physician Workforce Policy Guide-
lines for the U.S. for 2000–2020,” 2005.
14. AAMC, Data Warehouse, Total U.S. Medical School Enrollment by Race and Eth-
nicity within Sex, 2003–2008. “Applicant Matriculant File as of September 25, 2007.”
15. statehealthfacts.org, “Distribution of Nonfederal Physicians by Gender, 2007,”
http://www.statehealthfacts.org/comparetable.jsp?ind=430&cat=8 (accessed July 3rd,
2009).
Trends Signal an Impending Physician Shortage,” 2002; S. Evans and B. Sarani, “The
Modern Medical School Graduate and General Surgical Training. Are They Compat-
ible?” Archives of Surgery 137 (2002): 274–277.
Trends Signal an Impending Physician Shortage,” 2002.
18. E. M. Lambert and E. M. Holmboe, “The Relationship Between Specialty
Choice and Gender of U.S. Medical Students, 1990–2003,” Academic Medicine 80
(2005): 791–796.
Trends Signal an Impending Physician Shortage,” 2002.
20. M. Barer, “New Opportunities for Old Mistakes,” 2002; K. Grumbach, “The
Ramifications of Specialty-Dominated Medicine,” Health Affairs 21 (2002): 155–157.
21. Hamilton DP, “Overtreatment in Action: $30 Billion Wasted on Unnecessary
MRI, CT Scans,” BNET Healthcare, http://industry.bnet.com/healthcare/1000138/
overtreatment-in-action-30-billion-wasted-on-unnecessary-mri-ct-scans/ (accessed July
3, 2009).
22. J. Merritt, J. Hawkins, and P. B. Miller, “Will the last physician in America please
turn off the lights?” 3rd ed. (Irving, TX: Practice Support Publisher, 2006), 18.
23. United States General Accounting Office, “Physician Workforce—Physician Sup-
ply Increased in Metropolitan and Nonmetropolitan Areas but Geographic Disparities
Persisted,” http://www.gao.gov/new.items/d04124.pdf (accessed June 20, 2008).
24. U.S. Department of Health and Human Services Health Resources and Ser-
vices Administration Bureau of Health Professions, “Physician Supply and Demand:
Projections to 2020,” (Health Resources and Services Administration, Department of
Health & Human Services, October 2006).
25. Council on Graduate Medical Education, “Physician Workforce Policy Guide-
lines for the U.S. for 2000–2020.” 2005.
26. U.S. Department of Health and Human Services Health Resources and Services
Administration Bureau of Health Professions, 2006.
Health Care, (Ashland, Ohio: Book Publishing Associates, 2005), 86–89.
168 Notes
28. Marquette Tribune, “Nursing Shortage to Worsen, 500,000 will be Needed by

2025,” http://media.www.marquettetribune.org/media/storage/paper1130/news/
2008/04/03/News/Nursing.Shortage.To.Worsen-3298458.shtml (accessed June 20,
2008).
29. East Tennessee State University College of Pharmacy, http://www.pharmcas.
org/collegesschools/schoolETSUpage.htm (accessed June 21, 2008).
30. Public Broadcasting Systems, transcript of “Bill of Health-Pharmacist Shortage,”
http://www.pbs.org/nbr/site/onair/transcripts/080327c/ (accessed June 20, 2008).
31. Robert Davis, “Shortage of Surgeons Pinches U.S. Hospitals,” USA Today,
February 26, 2008, http://www.usatoday.com/news/health/2008–02–26-doctor-
shortage_N.htm (accessed June 20, 2008).
32. Margot Kim, “Doctor Shortage,” February 29, 2008, http://abclocal.go.com/kfsn/
story?section=news/health/health_watch&id=5931876 (accessed June 20, 2008).
33. Christina Rogers, “Doctor Shortage Worsens as Student Debt Rises,” The De-
troit News June 18, 2008, http://www.detnews.com/apps/pbcs.dll/article?AID=
2008806180336 (accessed June 21, 2008).
34. Dennis Cauchon, “Medical Miscalculation Creates Doctor Shortage,” USA
Today, March 3, 2005, http://www.usatoday.com/educate/college/healthscience/ar
ticles/20050306.htm (accessed June 21, 2008).
35. Dennis Cauchon, “Medical Miscalculation Creates Doctor Shortage,” USA
Today, March 3, 2005.
CHAPTER 3—SURGICAL SUPPLY: RESIDENTS—THE

FUTURE SURGEONS
1. AAMC, “Table 1: U.S. Medical School Applications and Matriculants by
School, State of Legal Residence, and Sex, 2007,” http://www.aamc.org/data/facts/
2007/2007school.htm (accessed June 30, 2008).
2. The Liaison Committee on Medical Education, http://www.lcme.org/ (accessed
June 25, 2008).
3. The Liaison Committee on Medical Education.
4. “A Word from the President: Filling the Workforce Gap,” AAMC Reporter (April 2005),
http://www.aamc.org/newsroom/reporter/april05/word.htm (accessed June 24, 2008).
5. ECFMG, “Fact Card—Summary Data—2006 2007,” http://www.ecfmg.org/
cert/factcard.pdf (accessed June 23, 2008).
Workforce. A discussion paper.” October 2007. http://www.ama-assn.org/ama1/pub/
upload/mm/18/img-workforce-paper.pdf (accessed June 25, 2008).
Workforce. A discussion paper.” October 2007.
Workforce. A discussion paper.” October 2007; Fitzhugh Mullan, “The Case for More
U.S. Medical Students,” New England Journal of Medicine 343 (2000): 213–217.
Notes 169
12. The American Boards of Medical Specialties, Member Boards, General Sur-
gery Certificates Issued 1995–2002. Available at http://www.abms.org/, (accessed
July 4, 2009) and at http://www.abms.org/Who_We_Help/Consumers/About_Physi
cian_Specialties/orthopaedic.aspx, accessed 6/27/2009. Source: www.abns.org,www.
abog.org, www.aboto.org, www.abos.org, www.absurgery.org, www.abu.org.
13. Christopher L. Skelly, “Medical Student Education and the 80 Hour Work
Week,” http://www.facs.org/education/gs2003/gs26skelly.pdf (accessed June 23,
2008).
14. K. G. Volpp, A. K. Rosen, P. R. Rosenbaum, P. S. Romano, et al., “Mortality
Among Hospitalized Medicare Beneficiaries in the First 2 Years Following ACGME
Resident Duty Hour Reform,” JAMA 298 (2007): 975–983.
15. A. Salim, P.G.R. Texeira, L. Chan, D. Oncel, et al., “Impact of the 80-Hour Work-
week on Patient Care at a Level I Trauma Center,” Archives of Surgery 142 (2007):
708–714.
16. J. Merritt, J. Hawkins, and P. B. Miller, “Will the last physician in America please
turn off the lights?” 3rd ed. (Irving, TX: Practice Support Publisher Inc., 2006), 18.
17. MD Salaries, “Residency Salaries in the United States,” http://mdsalaries.blog
spot.com/2005/10/residency-salaries.html (accessed June 23, 2008).
18. Bureau of Labor Statistics, “May 2007 National Occupational Employment and
Wage Estimates,” http://www.bls.gov/oes/current/oes_nat.htm (accessed June 23, 2008).
19. Robert Steinbrook, “Medical Student Debt—Is There a Limit,” New England
Journal of Medicine 359 (2008): 2629–2632.
CHAPTER 4—CONSTRAINTS TO SUPPLY:

PERTINENT ISSUES
1. AAMC, “Tuition and Students Fees Reports. Table 1—U.S. Medical Schools
Tuition and Students Fees—First Year Students, 2004–2005 and 2003–2004,”
https://services.aamc.org/Publications/showfile.cfm?file=version103.pdf&prd_
id=212&prv_id=256&pdf_id=103 (accessed January 20, 2008).
2. AAMC, “Medical School Tuition and Young Physician Indebtedness An Update
to the 2004 Report. October, 2007.”
3. Robert Steinbrook, “Medical Student Debt—Is There a Limit?” New England
4. Association of American Medical Colleges, “Congratulations to the Class of
2005,”from The AAMC MEDLOANS Program.
5. AAMC, “Medical School Tuition and Young Physician Indebtedness An Update
to the 2004 Report.
6. S. Dutton, personal communication.
7. American Medical Association, “Figure 1 –Medical Education Debt Has
Outpaced Inflation,” http://www.ama-assn.org/ama1/pub/upload/mm/15/debt_
figures_1_2.pdf (accessed July 10, 2008).
8. J. Bond, E. Galinsky, and J. S. Wanberg, National Study of the Changing Work-
force, (New York: Families and Work Institute, 1998); J. Lang, “It’s Time Over Money
for this Generation,” Journal Commerce 1 (2000): 7.
9. A. Liebhaber and J. M. Grossman, “Physicians Moving to Mid-Sized, Single-Specialty
Practices,” http://www.hschange.org/CONTENT/941/ (accessed July 4, 2008).
10. Gail Garfinkel Weiss, “Productivity Takes a dip,” Medical Economics 18 (2005):
86–94.
170 Notes
11. Gail Garfinkel Weiss, “Exclusive Survey—Productivity: Work Hour up, Patient
Visits down,” Medical Economics, (2006), http://www.memag.com/memag/Medical+
Practice+Management%3A+Productivity/Exclusive-SurveymdashProductivity-Work-
hours-up-pa/ArticleStandard/Article/detail/382220?contextCategoryId=38712,
(accessed December 16, 2007).
12. American Medical Group Association, “Media Alerts,” http://www.amga.org/
MediaAlerts/article_mediaAlerts.asp?k=267 (accessed July 25, 2008).
13. E. Ray Dorsey, David Jarjoura, and Gregory W. Rutecki, “Influence of Control-
lable Lifestyle on Recent Trends in Specialty Choice by U.S. Medical Students,” Journal
of American Association 290 (2003): 1173–1178.
14. National Resident Matching Program, Tables 10–11, NRMP Data, (Washing-
ton, DC: National Resident Matching Program, March 1996): 14–15.; National Resi-
dent Matching Program, Tables 10–11, Results and Data 2002 Match (Washington,
DC: National Resident Matching Program, April 2002): 20–21.
15. B. Satiani, The Smarter Physician, Vol. 3, (Englewood, CO: Medical Group Man-
agement Association, 2007; M.O. Baerlocher, “Happy Doctors? Balancing Professional
and Personal Commitments,” Canadian Medical Association Journal 174 (2006): 1070.
16. E. M. Lambert and E. S. Holmboe, “The Relationship Between Specialty Choice
and Gender of U.S. Medical Students, 1990–2003,” Academic Medicine 80 (2005):
797–802; E. Ray Dorsey, David Jarjoura, and Gregory W. Rutecki, “Influence of Control-
lable Lifestyle on Recent Trends in Specialty Choice by U.S. Medical Students,” 2003.
17. fiercehealthcare, “Specialty physician compensation barely keeps up with in-
flation,” http://www.fiercehealthcare.com/press-releases/specialty-physician-compensa
tion-barely-keeps-inflation-primary-care-physicians-repor (accessed March 20, 2009);
18. D. Adams, “Physician income not rising as fast as other professional pay,”
http://www.ama-assn.org/amednews/2006/07/24/prsc0724.htm (accessed March
20, 2009).
19. Physician Compensation, “Physician Pay, Doctor Salary, Doctor Pay,” http://
www.cejkasearch.com/conpensation/amga_physician_compensation_survey.htm (ac-
cessed May 20, 2008).
20. D. Adams, “Physician Income not Rising as Fast as Other Professional Pay.
2006/2007.
21. “Some Nurses Land Higher Salaries Than Primary Care Doctors,” Wall Street
Journal, http://blogs.wsj.com/health/2008/06/18/some-nurses-land-higher-salaries-
than-primary-care-doctors/ (accessed July 25, 2008).
22. Jack M. Matloff, “The Practice of Medicine in the Year 2010: Revisited in
2001,” Annals of Thoracic Surgery 72 (2001): 1105–1112.
23. STS Urgent Action Alert, “Take Action Now to Stop Medicare Cuts,” email to
Thomas E. Williams M. D., November 10, 2005.
24. American Medical Association, “Ask your federal representatives to stop the
Medicare payment cuts,” http://www.ama-assn.org/ama1/pub/upload/mm/15/i05_
cola_news.pdf (accessed February 20, 2009); “Physician Payment Cut Reversed,”
Society of Thoratic Surgeons, e-mail to Thomas E. Williams, M.D., March 14, 2006.
25. “Law-firms partnerships harder to get, survey says,” Columbus Dispatch,
March 1, 2005, http://abovethelaw.com/2008/05/ (accessed February 20, 2009).
26. Merriam-Webster, “Definition,” http://medical.merriam-webster.com/medical/
malpractice (accessed July 30, 2008).
27. B. Satiani, “Demystifying the Business of Medicine in your Practice,” The Smarter Phy-
sician, Vol. 1 (Englewood, CO: Medical Group Management Association, 2007) 166–167.
Notes 171
28. Ohio Department of Insurance, “Ohio 2006 Medical Liability Closed Claim Re-
port January 2008,” http://www.ohioinsurance.gov/Legal/Reports/MedMal_Closed_
Claim_2008.pdf (accessed March 20, 2009).
29. Commongood, “Fear of Litigation: The Impact on Medicine,” http://common
good.org/healthcare-reading-cgpubs-polls-6.html (accessed July 26, 2008).
30. D. P. Kessler and M. McClellan, “How Liability Law Affects Medical Productiv-
ity,” National Bureau of Economic Research, (February 2000), http://www.nber.org/
digest/aug00/w7533.html (accessed July 30, 2008).
31. D. Starkman, “Calculating Malpractice Claims- Study by Consumers Group
Suggests Insurers Set Premiums Based Market, Not Their Losses,” Washington Post,
http://www.washingtonpost.com/wp-dyn/content/article/2005/12/28/AR2005122
801490.html (accessed July 30, 2008).
32. Alicia Chang, “Four in 10 malpractice cases groundless,” http://www.high
beam.com/doc/1P1–123318675.html (accessed February 20, 2009).
33. D. M. Studdert, M. M. Mello, A. A. Gawande, et al., “Claims, Errors, and Com-
pensation Payments in Medical Malpractice Litigation,” New England Journal of Medi-
cine 354 (2006): 2024–2033.
34. Tillinghast Towers Perrin, “U.S. Tort Costs, 2003 Update,” (December
2003) 17.
35. “Employment policy foundation finds medical malpractice system lacking,”
Physicians Practice, http://overlawyered.com/2003/08/employment-policy-founda
tion-finds-med-mal-system-lacking (accessed July 30, 2008).
36. State of Ohio, Department of Insurance, “Medical Liability Insurance Rates for
2006 Decrease by 1.7 Percent,” http://www.ohioinsurance.gov/newsroom/scripts/
Release.asp?ReleaseID=3963 (accessed March 20, 2009).
37. Phillip K. Howard, “Juryless Health Courts Could Stabilize Crisis,” letter to the
editor, Wall Street Journal, February 28, 2006, http://commongood.org/learn-reading-
cgpubs-opeds-47.html (accessed July 30, 2008).
38. Common Good, “Majority of Americans Support Creating Special Health
Courts,” http://commongood.org/healthcare-reading-cgpubs-polls-7.html (accessed July
26, 2008).
39. Fitzhugh Mullan, “The Metrics of the Physician Brain Drain,” New England
40. American Medical Association, “International Medical Graduates In the U.S.
Workforce. A Discussion Paper October 2007,” http://www.ama-assn.org/ama1/pub/
upload/mm/18/img-workforce-paper.pdf (June 25, 2008).
41. Norman M. Wall, “Stealing From the Poor to Care for the Rich,” New York
Times, December 14, 2005, http://www.nytimes.com/2005/12/14/opinion/14walln.
html (accessed July 30, 2008).
42. S. Shafqat and A. K. Zaidi, “Pakistani Physicians and the Repatriation Equa-
tion,” New England Journal of Medicne 356 (2007): 442–443.
43. News-Medical.Net, “Reversing Medical Brain Drain in New Zealand,” http://
www.news-medical.net/?id=1814 (accessed July 26, 2008).
44. Merritt, Hawkins & Associates, “Summary Report 2004 Survey Of Physicians
50 to 65 Years Old,” http://www.merritthawkins.com/pdf/Survey_2004_survey_of_
physicians_50–65.pdf (accessed July 30, 2008).
45. H. Yamagata, “Retirement Behaviors of Physicians Based on the Physicians
Over 50 Survey Preliminary Findings,” (paper presented at the 2006 AAMC Physician
Workforce Research Conference, Washington DC, May 5, 2006).
172 Notes
46. Merritt, Hawkins & Associates. “2007 Survey of Physicians 50 to 65 Years Old,”
http://www.merritthawkins.com/pdf/mha2007olderdocsurvey.pdf (accessed July 5, 2008).
47. J. Merritt, J. Hawkins, and P. B. Miller, Will the Last Physician in America Please
Turn the Lights Off? 3rd ed. (Irving, Texas: Practice Support Publisher, 2006).
CHAPTER 5—CALCULATING PHYSICIAN SUPPLY:

THE MODEL—ASSUMPTIONS, RELEVANT PARAMETERS,
AND THE ALGORITHM
1. D. Etzioni, J. Liu, M. Maggard, C. Y. Ko, “The Aging Population and Its Impact
on the Surgery Workforce,” Annals of Surgery 238 (2003): 170–176.
2. Richard A. Cooper, “There’s a Shortage of Specialists: Is Anyone Listening?”
Academic Medicine 77 (2002): 761–766; R. A. Cooper, T. E. Getzen, and P. Laud,
“Economic Expansion Is a Major Determinant of Physician Supply and Utilization,”
Health Services Research 38 (2003): 675–696; R.A. Cooper, T. E. Getzen, H. J. McKee,
and P. Laud, “Economic and Demographic Trends Signal an Impending Physician
Shortage,” Health Affairs 21 (2002): 140–154.
3. J. P. Weiner, “A Shortage of Physicians or a Surplus of Assumptions?” Health
Affairs (Millwood) 21 (2002): 160–162.
Administration Bureau of Health Professions, Physician Supply and Demand: Projec-
tions to 2020 (Health Resources and Services Administration, Department of Health &
Human Services, October 2006), ftp://ftp.hrsa.gov/bhpr/workforce/PhysicianFore
castingPaperfinal.pdf (accessed July 11, 2008).
5. Roger D. Blackwell, Thomas E. Williams, and Alan Ayers, “Consumer Driven
Health Care,” (Ashland, Ohio: Book Publishing Associates, 2005) 127–130.
6. Council On Graduate Medical Education, “Physician Workforce Policy Guide-
lines for the United States, 2000—2020, January 2005,” Sixteenth Report, https://ser
vices.aamc.org/Publications/showfile.cfm?file=version111.pdf&prd_id=229&prv_
id =279&pdf_id=111 (accessed July 2, 2008).
7. Richard A. Cooper, “There’s a Shortage of Specialists: Is Anyone Listening?”
2002; R. A. Cooper, T. E. Getzen, and P. Laud, “Economic Expansion Is a Major De-
terminant of Physician Supply and Utilization,” 2003; R. A. Cooper, T. E. Getzen, H. J.
McKee, and P. Laud, “Economic and Demographic Trends Signal an Impending Physi-
cian Shortage,” 2002; Council On Graduate Medical Education, “Physician Workforce
Policy Guidelines for the United States, 2000–2020, January 2005.
8. D. Scalise, “2005 Physician Supply. The Physician Workforce,” November 17,
2005, http://www.hhnmag.com/hhnmag_app/hospitalconnect/search/article.jsp?dcrpath
=HHNMAG/PubsNewsArticle/data/0511HHN_FEA_gatefold&domain=HHNMAG
(accessed March 19, 2008).
Administration Bureau of Health Professions, “Physician Supply and Demand: Projec-
tions to 2020,” 2006.
10. AAMC, “Questions and Answers About the AAMC’s New Physician Workforce Po-
sition,” http://www.aamc.org/workforce/workforceqa.pdf (accessed March 20, 2009).
11. AAMC. “U.S. Medical School Enrollment Projected to Rise 21 Percent by 2012.
Both New and Existing Schools Will Fuel Growth,” http://www.aamc.org/newsroom/
pressrel/2008/080501.htm (accessed March 20, 2009).
Notes 173
12. R. A. Cooper, T. E. Getzen, H. J. McKee, and P. Laud, “Economic and Demo-

graphic Trends Signal an Impending Physician Shortage,” 2002.
13. J. P. Weiner, “A Shortage of Physicians or a Surplus of Assumptions?” 2002.
K. Grumbach, “The Ramifications of Specialty-Dominated Medicine,” Health Affairs
(Millwood) 21 (2002): 155–157.
14. Gail Garfinkel Weiss, “Productivity Takes a dip,” Medical Economics 18 (2005):
86–94.
CHAPTER 6—ORTHOPEDIC SURGERY

1. American Academy of Orthopedic Surgeons, “Patient Demographics—Information
about Orthopaedic Patients and Conditions,” http://www.aaos.org/Research/stats/patient
stats.asp (accessed May 4, 2008).
2. American Academy of Orthopedic Surgeons, “Patient Demographics—Information
about Orthopaedic Patients and Conditions.”
3. “Replaceable You—Can the System Keep Up with Demand for New Hips and
Knees?” http://stanmeddev.stanford.edu/2008spring/replaceable_you.html (accessed
May 9, 2008).
4. P. Lee, C. A. Jackson, D. A. Relles, “Demand-Based Assessment of Workforce
Requirements for Orthopaedic Services,” Journal of Bone and Joint Surgery 80 (1998):
313–326; J. D. Heckman, P. P. Lee, J. N. Weinstein, et al., “Orthopaedic Workforce in
the Next Millennium,” Journal of Bone and Joint Surgery 80 (1998): 1533–1551.
5. Frances A. Farley, James N. Weinstein, Gordon M. Aamoth, et al., “Workforce
Analysis in Orthopaedic Surgery: How Can We Improve the Accuracy of Our Predic-
tions?” Journal of American Academy of Orthopedic Surgeons 15 (2007): 268–273.
6. Wennberg J. E., Cooper M., The Dartmouth Atlas of Healthcare, (Chicago, Ill:
American Hospital Publishing, 1998).
7. J. D. Heckman, P. P. Lee, J. N. Weinstein, et al., “Orthopaedic Workforce in the
Next Millennium,” Journal of Bone and Joint Surgery 80 (1998): 1533–1551.
8. American Academy of Orthopaedic Surgeons, “Density of Orthopaedic Sur-
geons 2000 to 2004 by State,” http://www.aaos.org/Research/stats/Density.pdf (ac-
cessed May 4, 2008).
9. Gary Bos M.D., personal communication.
10. American Osteopathic Academy of Orthopedics, http://www.aoao.org/aoao/
Residencies/FAQ.html#Q2 (accessed May 13, 2008).
11. “Why Hospitals Love You,” Medical Economics, November 5, 2004.
12. Innovations Center Future Database, Future of Orthopedics, Page 2, The Ad-
visory Board Company, http://www.advisory.com/members/default.asp?contentid=
72712&collectionid=1188&program=14&contentarea=606583 (accessed July 3,
2009).
13. Merritt Hawkins & Associates, “Survey Report, 2004 Survey of Physicians
50–65 Years of Age, Based on 2003 Data,” www.merritthawkins.com/pdf/2004_phy
sician50_survey.pdf (accessed July 25, 2006).
14. American Academy of Orthopaedic Surgeons, “Orthopaedic Practice in the
U.S. 2005–2006 Final Report,” http://www.aaos.org/Research/stats/2006opus.pdf
(accessed May 10, 2008).
15. American Academy of Orthopaedic Surgeons, “Orthopaedic Practice in the U.S.
2005–2006 Final Report.”
174 Notes
16. S. W. Castillo, “Orthopedic practice in the U.S. 2005–2006. Final report. June
2006,” American Academy of Orthopedic Surgeons.
17. Carlos Lavernia M.D., personal communication.
18. SullivanCotter Associates, ‘2006 On Call Survey Report,” http://www.sullivan
cotter.com/ (accessed April 26, 2007).
19. Merritt, Hawkins & Associates, “2007 review of Physicians and CRNA recruit-
ing incentives,” www.merritthawkins.com (accessed February 9, 2008).
20. E. S. Salsberg, A. Grover, M. A. Simon et al., “An AOA Critical Issue. Future
Physician Workforce Requirements: Implications for Orthopaedic Surgery Education,”
Journal of Bone and Joint Surgery 90 (2008): 1143–1159.
CHAPTER 7—CARDIOTHORACIC SURGERY

1. “Executive Summary of the Society of Thoracic Surgeons, Fall Report 2007,”
http://www.sts.org/documents/pdf/ndb/Fall_2007_Executive_Summary.pdf (accessed
May 11, 2008).
2. William Gay, personal communication.
3. R. J. Shemin, S. W. Dziuban, L. R. Kaiser et al., “Thoracic Surgery Workforce:
Snapshot at the End of the Twentieth Century and Implications for the New Millen-
nium,” The Annals of Thoracic Surgery 73 (2002): 2014–32; A. Grover, American As-
sociation of Medical Colleges Workforce Analysis for Cardiothoracic Surgery, personal
communication, 2008.
4. L. H. Cohn, R. P. Anderson, F. D. Loop et al., “Thoracic Surgery Workforce Re-
port,” The Journal of Thoracic and Cardiovascular Surgery 110 (1995): 570–585.
nium,” 2002.
6. William Gay, personal communication.
7. A. Grover, American Association of Medical Colleges Workforce Analysis for
Cardiothoracic Surgery, personal communication, 2008.
8. Wennberg D. E., Birkmeyer J. D, Eds., The Dartmouth Atlas of Cardiovascular
Care, (Chicago: AHA Press, 1999), http://www.dartmouthatlas.org/atlases/atlas_se
ries.shtm (accessed May 8, 2008).
9. A. Grover, personal communication, 2008.
nium,” 2002.
11. National Residents Matching Program, “Match Results Statistics Thoracic
Surgery Fellowship,” http://www.nrmp.org/fellow/match_name/thoracic/stats.html
(accessed May 7, 2008): 2.1.
12. Frederick L. Grover, “The Bright Future of Cardiothoracic Surgery in the Era
of Changing Health Care Delivery: An Update,” The Annals of Thoracic Surgery 85
(2008): 8–24.
CHAPTER 8—OTOLARYNGOLOGY
1. American Academy of Otolaryngology, “Head and Neck Surgery,” http://www.
entnet.org/ (accessed May 19, 2008).
Notes 175
2. Federal Drug Administration, “Cochlear Implants—Center for Devices and Ra-

diological Health,” http://www.fda.gov/cdrh/cochlear/index.html (accessed May 11,
2008); ENT Link, “Cochlear Implants,” http://www.entnet.org/healthinfo/ears/cochle
ar-implant.cfm (accessed May 18, 2008); “Cochlear Implants,” http://www.nidcd.nih.
gov/health/hearing/coch.asp (accessed May 18, 2008).
3. National Institute on Deafness and Other Communication Disorders, “Cochlear
Implants,” http://www.nidcd.nih.gov/health/hearing/coch.asp (accessed May 19,
2008).
4. “Cochlear Implant Increases Access To Mainstream Education,” http://www.
hopkinsmedicine.org/press/1999/APRIL99/990429.HTM (accessed May 19,
2008).
5. American Cancer Society, “Cancer Facts and Figures, 2005,” (Atlanta: Ameri-
can Cancer Society, 2005).
6. “Laryngeal Cancer,” http://www.origin8.nl/medical/alaryngea2.htm (accessed
May 19, 2008).
7. C. R. Cannon, E. M. Giaimo, T. L. Lee et al., “Special Report: Reassessment of
the ORL-HNS Workforces: Perceptions and Realities,” Otolaryngology—Head and Neck
Surgery 131 (2004): 1–15.
8. Robert H. Miller, “Otolaryngology Manpower in the Year 2010,” Laryngoscope
103 (1992): 750–753.
9. B. W. Jafek, N. Slenkovich, S. Sheikali, “Physician Workforce in Otolaryngol-
ogy,” Otolaryngology—Head and Neck Surgery 115 (1996): 306–311.
10. G. F. Anderson, K. C. Han, R. H. Miller et al., “A Comparison of Three Methods
for Estimating the Requirements for Medical Specialists: The Case of Otolaryngolo-
gists,” Health Services Research 32 (1997): 139–53.
11. H. C. Pillsbury, R. C. Cannon, S. E. Sedory Holzer et al., “The Workforce in Otolaryn-
gology—Head and Neck Surgery: Moving into the Next Millennium,” Otolaryngology – Head
and Neck Surgery 123 (2000): 341–56.
12. B. W. Jafek, N. Slenkovich, S. Sheikali, “Physician Workforce in Otolaryngol-
ogy,” Otolaryngology—Head and Neck Surgery, 1996.
13. “Osteopathic Otolaryngology/Facial Plastic Surgery Residencies,” (Rev. Octo-
ber, 2006), http://www.aocoohns.org/pdf/ENT_RESIDENCY_LISTrev_10_2006.pdf
(accessed May 14, 2008).
14. B. W. Pearson, J. D. Osguthorpe, “What Our Residents Think,” Otolaryngology—
Head and Neck Surgery 94 (1986): 139–142.
15. D. A. Newton, M. S. Grayson, L. F. Thompson, “The Variable Influence
of Lifestyle and Income on Medical Students’ Career Specialty Choices: Data
from Two U.S. Medical Schools, 1998–2004,” Academic Medicine 80 (2005):
809–14.
the ORL-HNS Workforces: Perceptions and Realities,” 2004; H. C. Pillsbury, R. C. Can-
non, S. E. Sedory Holzer et al., “The Workforce in Otolaryngology—Head and Neck
Surgery: Moving into the Next Millennium,” 2004.
17. F. Kwakawa, O. Jonasson, “The Longitudinal Study of Surgical Residents,
1993–1994,” Journal of the American College of Surgeons 183 (1996): 425–433.
18. D. G. Kirch, E. Salsberg, “The Physician Workforce: Response of the Academic
Community,” Annals of Surgery 246 (2007): 535–540.
the ORL-HNS Workforces: Perceptions and Realities, 2004.
176 Notes
CHAPTER 9—OBSTETRICS AND GYNECOLOGY

1. “What Is an Obstetrician/Gynecologist (OB/GYN)?” http://www.womenshealth
channel.com/obgyn.shtml (accessed May 28, 2008).
2. Centers for Disease Control and Prevention, “Assisted Reproductive Technol-
ogy: Home,” http://www.cdc.gov/ART/ (accessed May 28, 2008).
3. Centers for Disease Control and Prevention, “Assisted Reproductive Technology
Surveillance—United States, 2005,” http://www.cdc.gov/mmwr/preview/mmwrhtml/
ss5705a1.htm?s_cid=ss5705a1_e/ (accessed May 28, 2008).
4. “Ovarian Cancer,” http://www.cancer.org/docroot/CRI/content/CRI_2_4_1X_
What_are_the_key_statistics_for_ovarian_cancer_33.asp?sitearea=(accessed May 28,
2008).
5. “Ovarian Cancer,” What are the key statistics for ovarian cancer.
6. Institute of Medicine, “Preterm Birth: Causes, Consequences, and Prevention,”
Released on July 13, 2006 http://www.iom.edu/CMS/3740/25471/35813.aspx,
(accessed June 27, 2009); Institute of Medicine, “Preterm Birth: Causes, Consequences,
and Prevention. Report Brief, July 2006.”
7. United Census Bureau, http://www.census.gov/ipc/www/usinterimproj/nat-
proj tab02a.pdf (accessed June 3, 2008).
8. W. H. Pearse, W.H.J. Haffner, and A. Primack, “Effect of Gender on the Obstetric-
Gynecologic Workforce,” Obstetrics & Gynecology 97 (2001): 794–97.
9. ACOG Resource Center, “Manpower Statistics,” (Washington DC, 2004),
resources@acog.org May 30, 2008).
10. M. Signer, “National Residency Matching Program: results and data 2004
match,” Report of the National Resident Matching Program (Washington, DC: National
Resident Matching Program, 2004).
11. Association of American Medical Colleges, “A Chart Book. Center for work-
force studies. August 2006,” Physician Specialty Data.
12. R. P. McAlister, D. A. Andriole, S. E. Brotherton et al., “Are Entering Obstet-
rics/Gynecology Residents More Similar to the Entering Primary Care or Surgery Resi-
dent Workforce?” American Journal of Obstetrics and Gynecology 197 (2007): 536.
e1–536.e6.
13. I. Jacoby, G. S. Meyer, W. Haffner et al., “Modeling the Future Workforce of
Obstetrics and Gynecology,” Obstetrics and Gynecology 92 (1998): 450–456.
14. ACOG Resource Center, “Manpower Statistics,” (Washington DC, 2004).
15. ACOG Resource Center, “Manpower Statistics,” (Washington DC, 2004).
16. I. Jacoby, G. S. Meyer, W. Haffner et al., “Modeling the Future Workforce of
Obstetrics and Gynecology,” Obstetrics and Gynecology, 1998.
17. E. M. Lambert and E. S. Holmboe, “The Relationship between Specialty Choice
and Gender of U.S. Medical Students, 1990–2003,” Academic Medicine 80 (2005):
797–802.
Gynecologic Workforce,” Obstetrics & Gynecology 97 (2001).
21. P. Robinson, X. Xu, K. Keeton et al., “The Impact of Medical Legal Risk on
Obstetrician-Gynecologist Supply,” Obstetrics and Gynecology 105 (2005): 1296–1301.
Notes 177
23. J. Silverman, “Malpractice crisis blamed; Fewer U.S. seniors match to ob. gyn
residency slots: the fill rate for this group falls to 65.1%,” OB GYN News, April 01,
2004.
24. M. D. Pearlman and P. A. Gluck, “Medical Liability and Patient Safety: Setting
the Proper Course,” Obstetrics and Gynecology 105 (2005): 941–943.
25. Robert C. Preston, J. D., personal communication.
26. Katie Gazella, “High cost of malpractice insurance threatens supply of ob/gyns,
especially in some urban areas,” http://www.med.umich.edu/opm/newspage/2005/
obgyn.htm (accessed June 27,2009).
27. Centers for Disease Control and Prevention, “National Hospital Discharge Sur-
vey: 2005 Annual Summary With Detailed Diagnosis and Procedure Data,” Vital
and Health Statistics, http://www.cdc.gov/nchs/data/series/sr_13/sr13_165.pdf
(accessed May 28, 2008); T. Zwillich, “Preterm Birth and C-Section Rates Up Sur-
gical Deliveries Continue Rapid Rise, CDC says,” WebMD Medical News, Nov. 15,
2005, http://www.webmd.com/content/Article/115/111635.htm (accessed June 9,
2008).
28. “Some health systems explore laborists idea,” USA TODAY, August 8, 2005.
CHAPTER 10—GENERAL SURGERY

1. American Board of Surgery, “Specialty of General Surgery Defined,” http://
home.absurgery.org/default.jsp?aboutsurgerydefined&ref=about (accessed May 14,
2008).
2. American Cancer Society, “Breast Cancer Facts and Figures, 2005–2006,”
http://www.cancer.org/docroot/STT/content/STT_1x_Breast_Cancr_Facts__
Figures_2005–2006.asp (accessed January 21, 2008); SEER, “5-Year Relative Survival
Rates by Race,” http://seer.cancer.gov/faststats/sites.php?site=Breast=Cancer&stat=
Survival (accessed January 21, 2008).
3. Susan G. Komen Race for the Cure, http://ww5.komen.org/ (accessed June
28, 2009).
4. M. J. Mack, “Minimally Invasive and Robotic Surgery,” Journal of the American
Medical Association 285 (2001): 568–572; Up to Date, “Laparoscopic Cholecystec-
tomy,” http://www.uptodate.com/patients/content/topic.do?topicKey=biliaryt/6036&
title=Gallstones (accessed May 16, 2008).
5. D. C. Lynge, E. H. Larson, M. Thompson et al., “A Longitudinal Analysis of the
General Surgery Workforce in the United States, 1981–2005,” Archives of Surgery 143
(2008): 345–350.
6. D. A. Newton, and M. S. Grayson, “Trends in Career Choice by U.S. Medical School
Graduates,” Journal of the American Medical Association 290 (2003): 1179–1182.
7. National Residency Matching Program, “Advance Data Tables—2008 Main
Residency Match,” http://www.nrmp.org/data/advancedatatables2008.pdf (accessed
May 16, 2008).
8. D. A. Newton, and M. S. Grayson, “Trends in Career Choice by U.S. Medical
School Graduates,” 2003; F. Kwakawa and O. Jonasson, “The General Surgery Work-
force,” Advisory Council for General Surgery, http://www.facs.org/about/councils/adv
gen/gstitlpg.html (accessed May 17, 2008).
178 Notes
9. American College of Surgeons and the American Surgical Association, “Surgery

in the United States: a Summary Report of the Study on Surgical Services for the United
States (SOSSUS),” (Baltimore: 1975).
10. Graduate Medical Education National Advisory Committee, “Summary Report
to the Secretary,” Department of Health and Human Services (HRA 81–653), Health
Resources Administration, Hyattsville, MD (1980) III.
11. Council on Graduate Medical Education (COGME), “Patient care physician sup-
ply and requirements: Testing COGME recommendations,” 8th Report, (Washington,
DC: Department of Health and Human Services, 1996).
12. AMA Council on Long Range Planning and Development, “The Future
of General Surgery,” Journal of the American Medical Association 262 (1989):
3178–3183.
13. G. F. Sheldon and A. T. Schroen , “Supply and demand—surgical and health
workforce,” (Surgical Clinics of North America, September 2004).
14. Council on Graduate Medical Education, “Statement on the physician work-
force,” (Washington, DC: Council on Graduate Medical Education, 2003).
15. Abt Associates, “Re-examination of the adequacy of physician supply
made in 1980 by the Graduate Medical Education National Advisory Committee
for selected specialties: Final Report,” HRSA 240–89–0041, (Springfield, VA:
National Technical Information Service, United States Department of Commerce,
1991).
16. F. Kwakawa and O. Jonasson, “The Longitudinal Study of Surgical Residents,
1993–1994,” Journal of the American College of Surgery 183 (1996): 425–433.
17. G. F. Sheldon, “Surgical Workforce Since the 1975 Study of Surgical Services in
the United States; An Update,” Annals of Surgery 246 (2007): 541–545.
18. North Carolina IOM Task Force on Primary Care and Specialty Supply, “Exam-
ining Provider Need by Specialty Area,” http://www.nciom.org/projects/supply/chap
ter4.pdf (accessed May 17, 2008).
19. R. A. Cooper, S. J. Stoflet, and S. A. Wartman, “Perceptions of Medical School
Deans and State Medical Society Executives about Physician Supply,” Journal of the
American Medical Association 290 (2003): 2992–2995.
20. D. A. Newton, and M. S. Grayson, “Trends in Career Choice by U.S. Medical
School Graduates,” 2003.
21. L. A. Neumayer, A. Cochran, S. Melby, et al., “The State of General Surgery
Residency in the United States: Program Director Perspectives, 2001,” Archives of Sur-
gery 137 (2002): 1262–1275.
22. J. D. Richardson, “Workforce and Lifestyle Issues in General Surgery Training,”
Archives of Surgery 137 (2002): 515–520.
23. J. D. Richardson, “Workforce and Lifestyle Issues in General Surgery Training.”
24. K. B. Stitzenberg and G. F. Sheldon, “Progressive Specialization within General
Surgery: Adding to the Complexity of Workforce Planning,” Journal of the American
College of Surgeons 201 (2005): 925–932.
25. F. Kwakawa and O. Jonasson, “The General Surgery Workforce,” Advisory
Council for General Surgery.
26. D. Etzioni, J. Liu, M. Maggard, et al., “The Aging Population and Its Impact on
the Surgery Workforce,” Annals of Surgery 238 (2003): 170–176.
27. R. A. Cooper, T. E. Getzen, H. J. McKee et al., “Economic and Demo-
graphic Trends Signal an Impending Physician Shortage,” Health Affairs 21
(2002): 140–154.
Notes 179
CHAPTER 11—NEUROSURGERY
1. C. Watts, “Neurosurgical Manpower,” Surgical Neurology 18 (1982): 241–245.
2. ABC News, “Woodruff, Cameraman Seriously Injured in Iraq,” January 29, 2006.
3. Encarnation Pyle, “What Now?” Columbus Dispatch, July 17, 2007.
4. Bernadine Healey, Living Time, Faith and Facts to Transform Your Cancer Jour-
ney, (New York, New York: Bantam Dell, 2007): 10.
5. E. Chiocca, personal communication, May 28, 2008.
8. American Academy of Neurosurgeons, “Relative Shortage of Neurosurgeons in
the U.S. Alarms the Medical Society,” Press Release: May 3, 2004.
Health & Human Services, October 2006), ftp://ftp.hrsa.gov/bhpr/workforce/Physi
cianFore castingPaperfinal.pdf (accessed June 2, 2008).
10. Medical News Today, “Study Analyzes How The Malpractice Environment Im-
pacts Practicing Neurosurgeons,” http://www.medicalnewstoday.com/articles/105599.
php (accessed June 2, 2008).
11. O. N. Gottfried, R. L. Rovit, A. J. Popp et al., “Neurosurgical Workforce Trends
in the United States,” Journal of Neurosurgery 102 (2005): 202–208.
12. Merritt, Hawkins & Associates, “Summary Report: 2005 Review of Physician
Recruitment Incentives,” http://www.merritthawkins.com/pdf/2005_incentive_sur
vey.pdf (accessed June , 2009).
13. “MD Salaries,” http://mdsalaries.blogspot.com/2007/10/2007-usa-physician-
salaries-survey.html (accessed June 2, 2008).
14. The Sun News, http://www.myrtlebeachonline.com/101/story/466769.html
(accessed June 2, 2008); “Hospitals risk losing specialists in Ers,” Dayton Business
Journal, November 18, 2005; “Rising fees for on-call specialists have hospitals seeing
red,” San Jose Business Journal, October 24, 2005.
15. News Day, “Special Report: Saving Bobby,” http://www.newsday.com/news/
local/ny-bobby-main,0,4964596.story?page=3 (accessed June 2, 2008).
16. C. Watts, W. Adelstein, “Access to Neurosurgical Care,” Surgical Neurology 17
(1982): 223–226.
17. News Day, “Special Report: Saving Bobby.”
18. News Day, “Special Report: Saving Bobby.”
19. C. Cassels. Aggressive Malpractice Environments Dictate How, Not Where,
Neurosurgeons Practice. Available at Medscape, http://www.medscape.com/view
article/573903 (accessed June 2, 2008); Todd C. Hankinson, Leif Bohman, Monique
Vanaman, et. al. “Geographical Workforce Analysis from 1990–2005 Improves Our
Understanding of the Role of Market Factors,” Clinical Neurosurgery 55 (2008):
145–149.
20. Medical News Today, “Study Analyzes How The Malpractice Environment Im-
pacts Practicing Neurosurgeons,” http://www.medicalnewstoday.com/articles/105599.
php (accessed June 2, 2008).
21. C. Cassels. Medscape, http://www.medscape.com/viewarticle/573903; Medi-
cal News Today, “Study Analyzes How The Malpractice Environment Impacts Practic-
ing Neurosurgeons,”
180 Notes
22. W. K. Clark and Ransohoff J. Wrenn, “Summary. Neurosurgical manpower

monitoring committee. 1976 Report,” American Association of Neurological Surgeons,
(Chicago: 1976).
23. L. D. Lunsford, A. Kassam, Y. F. Chang et al., “Survey of United States Neurosur-
gical Residency Program Directors,” Neurosurgery 54 (2004): 239–245.
CHAPTER 12—UROLOGY
1. V. R. Patel, R. Thaly, and K. Shah, “Robotic Radical Prostatectomy: Outcomes
of 500 Cases,” BJU International 99 (2007): 1109–1112; K. Baduani, S. Kaul, and
M. Menon, “Evolution of Robotic Radical Prostatectomy: Assessment after 2776 Pro-
cedures,” Cancer 100 (2007): 1951–1958.
2. “Contemporary Aspects of Penile Prosthesis Implantation,” Urologia Interna-
tionalis, http://content.karger.com/ProdukteDB/produkte.asp?Doi=68189 (accessed
June 11, 2008).
3. Urology Times, “Is There a Urologist in the House, Maybe Not For Long,” http://
urologytimes.modernmedicine.com/urologytimes/News=Feature/Is-there-a-urologist-
in-the-house-Maybe-not-for-lo/ArticleStandard/Article/detail/423954 (accessed May
27, 2008).
4. Urology Times, “Is There a Urologist in the House, Maybe Not For Long.”
5. Association of American Medical Colleges, Physician Specialty Data: A Chart
Book, August 2006.
Health & Human Services, October 2006).
7. J. F. Glenn, “Urologic Manpower and Training Program Survey,” The Journal of
Urology 117 (1977): 137–142.
8. E. E. Fraley and E. Watkins, “Surgical and Urologic Manpower in the United
States 1969–1978,” The Journal of Urology 127 (1982): 218–223.
9. J. S. Ansell, “Trends in Urological Manpower in the United States in 1986,” The
Journal of Urology 138 (1987): 473–476.
10. E. E. Fraley and E. Watkins, “Surgical and Urologic Manpower in the United
States 1969–1978,” 1982.
11. W. F. Gee, H. L. Holtgrewe, P. C. Albertsen et al., “Sub Specialization, Recruit-
ment and the Retirement Trends of American Urologists,” The Journal of Urology 159
(1998): 509–511.
ment and the Retirement Trends of American Urologists,” 1998.
13. T. D. Allen, J. F. Glenn, R. T. Plumb, and W. J. Staubitz, “Too Much of a Good
Thing. Editorial,” The Journal of Urology 120 (1978): 267.
Book 2006; D. L. McCullough, “Manpower Needs in Urology in the Twenty-first Cen-
tury,” Urologic Clinics of North America 25 (1998): 15–22.
15. D. M. Weiner, R. McDaniel, and F. C. Lowe, “Urologic Manpower Issues for the
21st Century: Assessing the Impact of Changing Population Demographics,” Urology
49 (1997): 335–342.
Book 2006.
Notes 181

Book 2006.
Book 2006.
ment and the Retirement Trends of American Urologists,” 1998.
Book 2006.
21. D. L. McCullough, “Manpower Needs in Urology in the Twenty-first Century,”
Urologic Clinics of North America 25 (1998): 15–22.
22. D. M. Weiner, R. McDaniel, and F. C. Lowe. Urology 49 (1997).
23. W. D. Steers andA. J. Schaeffer, “Is It Time to Change the Training of Urology
Residents in the United States?” The Journal of Urology 173 (2005): 1451.
24. A. Stewart and J. Bolton, “Re: Urology Residency Training: Time to Speed up or
Slow Down?” The Journal of Urology 175 (2006): 811–812.
25. Kevin B. Loughlin, “The Current Status of Medical Student Urological Educa-
tion in the United States,” The Journal of Urology 179 (2008): 1087–1091.
26. Kevin B. Loughlin. The Journal of Urology 2008.
27. Kevin B. Loughlin. The Journal of Urology 2008.
CHAPTER 13—THE LAST HURDLE: THE BALANCED

BUDGET ACT OF 1997 AND GRADUATE MEDICAL
EDUCATION FUNDING
1. AAMC, “Medicare Direct Graduate Medical Education (DGME) Payments”
http://www.aamc.org/advocacy/library/gme/gme0001.htm (accessed July 14, 2008).
2. Centers for Medicare and Medicaid Services, “Direct Graduate Medical Educa-
tion (DGME),” http://www.cms.hhs.gov/AcuteInpatientPPS/06_dgme.asp#TopOfPage
(accessed July 14, 2008).
3. AAMC, “Medicare Indirect Medical Education (IME) Payments,” http://www.
aamc.org/advocacy/library/gme/gme0002.htm (accessed July 14, 2008).
4. S. Nicholson and D. Song, “The Incentive Effects of the Medicare Indirect Medi-
cal Education Policy,” Journal of Health Economics 20 (2001): 909–33.
5. Congressional Budget Office, “CBO’s March 2008 Baseline: MEDICARE,”
http://www.cbo.gov/budget/factsheets/2008b/medicare.pdf (accessed September 12,
2008).
6. Congressional Budget Office, “CBO’s March 2008 Baseline: MEDICARE.”
7. J. A. Reuter, “The balanced budget act of 1997: Implications for graduate
medical education. The Balanced Budget Act of 1997 [executive summary],” The
Commonwealth Fund.
8. Council on Graduate Medical Education (COGME), “Patient Care Physician
Supply and Requirements: Testing COGME Recommendations,” 8th Report, (Washing-
ton, DC: Department of Health and Human Services, 1996).
9. D. A. Jamadar R. Carlos, et al., “Estimating the Effects of Informal Radiology
Resident Teaching on Radiologist Productivity: What is the Cost of Teaching?” HTAca-
demic Radiology 2 (2005): 123–128.
10. Richard A. Cooper, “It’s Time to Address the Problem of Physician Shortage:
Graduate Medical Education is the Key,” Annals of Surgery 246 (2007): 527–534.
182 Notes
11. Pew Commission Federal Policy Task Force, “Strengthening federal GME policy,”
http://futurehealth.ucsf.edu/press_releases/pewgme.htm (accessed July 13, 2008).
12. Pew Commission Federal Policy Task Force, “Strengthening federal GME
policy.”
13. E. Salsberg, “Medical School Expansion: On Track for a 30% Increase But Only
One Part of the Solution,” (paper presented at The Fourth Annual AAMC Physician
Workforce Research Conference, Crystal City, Virginia, May 1, 2008).
14. E. Salsberg, “Medical School Expansion: On Track for a 30% Increase But Only
One Part of the Solution.”
15. D. N. Burkhart and T. A. Lischka, “Osteopathic Graduate Medical Education,”
Journal of American Osteopathic Association 108 (2008): 127–137; Sarah E. Brother-
ton and Sylvia I. Etzel, “Appendix II, Table 1,” Journal of American Medical Association
298 (2007): 1081–1096.
16. Richard A. Cooper, “It’s Time to Address the Problem of Physician Shortage:
Graduate Medical Education is the Key,”2004; Richard A. Cooper, “The Coming Era of
Too Few Physicians,” Bulletin of the American College of Surgeons 93 (2008): 11–18.
17. AAMC, “AAMC survey of Housestaff Stipends, Benefits, and Funding. Autumn
2007 Report,” http://www.aamc.org/data/housestaff (accessed June 26, 2008).
CHAPTER 14—IS THERE A SOLUTION?

NUMERICAL PROJECTIONS, AND IMPROVING
PHYSICIANS’ PRODUCTIVITY
1. Health Care Advisory Board, “Physician Recruitment: Attracting Talent in a
Competitive Market,” (Washington, DC: The Advisory Board Company, May 1, 2008),
http://www.advisory.com/members/default.asp?contentID=73082&collectionID=
1021&program=14&filename=73082.xml (accessed May 27, 2008).
2. Health Care Advisory Board, “Physician Recruitment: Attracting Talent in a
Competitive Market.
3. “University of Maine’s President Wants the School to Offer a Medical Degree,”
Press Herald (Portland, Maine: September 24, 2005).
4. “UCF makes pitch for med school,” http://www.wesh.com/news/5341985/de
tail.html (accessed September 8, 2008).
5. Medical News Today, “Three New Medical Schools Join AAMC Membership,
USA,” http://www.medicalnewstoday.com/articles/99385.php (accessed Septmeber
8, 2008); PricewaterhouseCoopers’ Health Research Institute, “What works, Healing
the healthcare staffing shortage,” http://www.teachinghosp.org/pdf/pwchealthstaffing
shortage.pdf (accessed August 5, 2008).
6. “AAMC Head Calls for Increasing Enrollments by 30 Percent,” Chronicle of Higher
Education, November 7, 2005, http://chronicle.com/daily/2005/11/2005110702n.
htm (accessed September 8, 2008).
7. AAMC, “2007 U.S. Medical School Entering Class is Largest Ever.” http://www.
aamc.org/newsroom/pressrel/2007/071016.htm (accessed September 8, 2008).
8. AAMC, “U.S. Medical School Enrollment Projected to Rise 21 Percent by
2012,” http://www.aamc.org/newsroom/pressrel/2008/080501.htm (accessed Sep-
tember 8, 2008).
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gust 26, 2007.
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m=7&filename=77362.xml (accessed May 27, 2008).
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nID=1021&program=14&filename=73082.xml (accessed August 7, 2008).
15. The Hospitalist, “As need for hospitalists grows, recruiters sweeten the pot
to attract talent,” http://www.the-hospitalist.org/uploads/articles/THJuly2008Ar
ticle268.pdf (accessed September 7, 2008).
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features/patient_care/20070604_SurgicalHospitalists.aspx (accessed September 7,
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2006, http://www.modernphysician.com/Assets/DOC/2006MP/07MP2006.pdf (ac-
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19. “Virtual Intensive Care Unit—ICU of the Future,” press release, Visicu Inc.,
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20. “To Err Is Human: Building a Safer Health System,” Institute of Medicine, http://
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184 Notes
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Market,” (Washington, DC: The Advisory Board Company, May 1, 2008).
CHAPTER 15—CHALLENGES AND CONSEQUENCES

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Notes 185
Health Care (Ashland, Ohio: Book Publishing Associates, 2005) 39–42.; Sally Pipes,
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Index
Academic Medical Centers (AMC), 117 Assisted reproductive technology

Accidents, unintentional, 11 (ART), 85
Accreditation Council for Graduate Association of Academic Medical
Medical Education (ACGME), 24, 25, Colleges (AAMC), 32, 75 – 76, 84
28, 114
American Academy of Orthopedic Baby boom echo, 36
Surgeons (AAOS), 67, 70 Balanced Budget Act (BBA) of
American Academy of Otolaryngology- 1997, 7, 114 – 21; post, 119 – 21;
Head and Neck Surgery, 83 pre, 116 – 19
American Association for Thoracic Balanced Budget Refinement Act
Surgery (AATS), 75 (BBARA), 119
American Association of Medical Barnard, Christian, 72
Colleges (AAMC), 128 Becker, Ronald M., 140
American Bar Association, 7 Blalock, Alfred, 72
American board certification, 26 – 27 Bolton, John, 112
American Board of Medical Specialties, Bos, Gary, 69
99 Boutique care, 1
American Board of Surgery, 97 Brain drain, 49 – 52
American Board of Thoracic Brain gain, 49 – 52
Surgery, 27 Brain surgery, selective, 104
American Cancer Society, 86 Brain trauma, 103 – 4
American College of Cardiology, 12 Braunwald, Eugene, 12
American College of Surgeons, 97 Breast cancer, 93 – 94
American Medical Association (AMA), Buerhaus, Peter, 20
24, 39, 89
American Medical Group Association Caesarian section deliveries,
(AMGA), 39 91 – 92
American Osteopathic Association Canada, health care in,
(AOA), 114 152 – 55
American Surgical Association, 97 Cancer, 10 – 11
Arom, Kit V., 140 Cannon, C. Ron, 80
Arterial disease, 10 Cardiac defibrillators, 72 – 73
188 Index
Cardiothoracic surgeons: board Ear, nose and throat (ENT) surgeons. See
certification, 26–27; employment Otolaryngologists
outlook, 73 –74; graduate medical Economic growth, 17
education funding, 121; IMGs, 24; Educational Commission for Foreign
reimbursement, 43; residency program, Medical Graduates, 25
22 –23; retirement, 74; workforce Edwards, Robert, 127
issues, 74–77; work hours, 36 Electronic Intensive Care Units (e-ICUs),
Cardiothoracic (CT) surgery, 72 – 77; 138 – 39
heart disease, treatments for, 72 – 73 Emergency medical services, 137
Cardiovascular surgery. See Emergency Medical Treatment
Cardiothoracic (CT) surgery and Active Labor Act (EMTALA),
CAT scans, 17 70
Center for Studying Health System ENT surgeons. See Otolaryngologists
Change, 39 Exchange Visitor Program, 26
Cerebrovascular disease, 10
Cholecystectomies, 94 – 95 Falcone, Robert, 137
Chronic diseases, 11 – 12 Fee-for-service plans, 20
Circulatory disorders, 10 – 11 Foreign-born international
Class size of medical students, 128 – 30 medical graduates (IMGs), 25 – 26,
Cochlear implants, 78 49 – 50
Cohen, Jordan J., 128 Fraser Institute, 153
Color-flow ultrasounds, 17 Full-time equivalents (FTE’s), 58, 84,
Compensation, 29 – 31 115, 116
Complaints, physician, 36 Function shifting, 132 – 33
Concierge care, 1 Funding for graduate medical education
Connors, Jimmy, 67 (GME), 121 – 26
Consolidated Omnibus Budget
Reconciliation Act (COBRA), 99, Gallbladder, 94 – 95
114 – 15 General surgeons: board certification,
Consumer price index, 39, 41, 116 26 – 27; employment outlook,
Cooper, Richard, 5, 21, 121 96 – 97; graduate medical education
Cooper’s Trend Analysis, 54 – 55 funding, 121; medical student
Coronary artery bypass procedures statistics, fourth year, 6;
(CABG), 73 residency program, 22, 24;
Council of Graduate Medical Education retirement, 98; statistics, 59;
(COGME), 55, 68, 99, 115 workforce issues, 97 – 102;
work hours, 37
Dartmouth Atlas, 8, 76 General surgery, 93 – 102; breast
Death, treatment for leading causes of, cancer, 93 – 94; defined, 93;
10 – 11 gallbladder, 94 – 95; natural
Defensive medicine, 44 orifice translumenal endoscopic
Delivery model of health care, surgery, 95 – 96
19 – 20 Generation X (Xers), 36
Diagnosis Related Group (DRG), 118 Generation Y, 36
Direct medical education (DME) Gibbon, John, 72
reimbursement, 116 – 17 Graduate medical education (GME).
Disproportionate share payments See also Graduate medical education
(DSP), 114 funding: history of, 114 – 16; reverse,
Dutton, Steve, 34 130 – 31
Index 189
Graduate medical education funding, Imam, Naiyer, 139

121 – 26; cardiothoracic surgeons, Indirect medical education (IME)
121; general surgeons, 121; reimbursement, 117 – 18
gynecologists/obstetrics surgeons, Initial residency period (IRP), 115
121; Medicare, 114; neurosurgeons, Insurance, medical malpractice, 44
121; orthopedic surgeons, 121; Intern, defined, 114
otolaryngologists, 121 International medical graduates (IMGs),
Graduate Medical Education National 2, 24 – 26; cardiothoracic surgeons,
Advisory Committee (GMENAC), 98 24; foreign-born, 25 – 26, 49 – 50;
Graduate medical student statistics, statistics, 50; United States, 24 – 25
61 – 63, 161 – 62 Intern & Resident Information System
Grant Trauma Service, 137 (IRIS), 115
Gratzer, David, 153 – 54 In vitro fertilization, 85
Gross, Robert, 72
Gross Domestic Product (GDP), 13, 17, Jennings, Peter, 103
54, 56 Joint Commission for Accreditation for
Grover, Atul, 76 – 77 Hospitals, 139
Gynecologists/obstetrics surgeons: board Joint replacements, 16, 67
certification, 26 – 27; employment J-1 visa, 26
outlook, 87 – 89; graduate medical
education funding, 121; residency Knee replacement, 67
program, 22, 24; retirement, 88 – 89; Komen Race for the Cure, 93 – 94
statistics, 59; workforce issues, 89 – 91;
work hours, 36 Laborists, 92
Gynecology. See Obstetrics and Laryngeal cancer, 78 – 80
gynecology (OB/GYN) Lavernia, Carlos, 70
Law School Admission Council, 7
Harris Interactive, 44 Law School Admissions Test, 7
H-1B visa, 26 Lawyers vs. physicians, 7
Health care: Canada, 152 – 55; cost of, Left brain, 104
13 – 14; delivery model, 19 – 20; Liaison Committee on Medical Education
rural, 21 (LCME), 24
Health Care Advisory Board, 127 Loop, Fred, 104
Health Care Financing Administration Lumpectomy, 95
(HCFA), 115
Health & Human Services (HHS), 115 Malpractice. See Medical malpractice
Health Professions Shortage Area Malpractice insurance, 44
(HPSA), 26 Managed care plans, 19
Health Resources and Services Matloff, Jack, 41
Administration (HRSA), 19, 55, 106 McCullough, David L., 111
Healy, Bernadine, 104 McElroy, Mary Jo, 138
Heart disease, treatments for, 72 – 73 Medicaid, 13
Heart failure, 12 – 13 Medical broker, 154
Herceptin, 94 Medical College Admission Test
Hip replacement, 67 (MCAT), 129
Hospital: physician reimbursement vs., Medical College of Wisconsin, 5
42; reimbursement, 41 – 42 Medical Economics, 139
Hospitalists, 136 – 37 Medical Group Management Association
Howard, Philip K., 48 (MGMA), 39, 69
190 Index
Medical malpractice, 43 – 49; defensive funding, 121; residency program, 22;

medicine, 44; defined, 44; insurance, retirement, 105 – 6; statistics,
44; issues, current, 45 – 46; Michigan, 59 – 60; workforce issues, 105 – 7;
46; Ohio, 44 – 46; tort reform, 47 work hours, 36
Medical safaris, 140 Neurosurgery, 103 – 7; advances in,
Medical students: class size, 128 – 30; 104 – 5; brain surgery, selective, 104;
graduate statistics, 61 – 63, 161 – 62; brain trauma, 103 – 4
international graduates, 24 – 26; Neurourology, 109
statistics, 2 – 3, 4; tuition, 32 – 38 Nicklaus, Jack, 67
Medical tourism, 139 – 40 Nighthawk Radiology Services, 139 – 40
Medical workforce. See Surgical/medical Nonphysician services, demand for,
workforce 20 – 21
Medically underserved area (MUA), Nurse Practitioners, 137
26
Medicare, 13, 28; graduate medical Obstetric hospitals, 92
education funding, 114; indirect Obstetricians. See Gynecologists/
vs. direct medical education obstetrics surgeons
reimbursement, 117 – 18; Obstetrics and gynecology (OB/GYN),
reimbursement, 43, 84 85 – 92; ovarian cancer, 85 – 86;
Medicare, Medicaid and SCHIP Benefits premature delivery, 86 – 87; residency
Improvement and Protection Act program, 22; in vitro fertilization, 85
(BIPA), 119 – 20 Ohio Department of Insurance, 46
Medicare Prescription Drug, Ohio medical malpractice, 44 – 46
Improvement, and Modernization Act Ohio State University College of
(MMA), 120 Medicine, 2, 51, 104
Merritt, Hawkins & Associates (MHA), Ohio State University Hospital, 92
70 – 71, 106 Open surgery reimbursement, 41
Merritt Hawkins Survey, 52 – 53 Orthopedic surgeons: board certification,
Michigan medical malpractice, 26 – 27; employment outlook,
46 68 – 69; graduate medical education
Midwives, 91 – 92 funding, 121; residency program,
Millennials, 36 22, 24; retirement, 69; statistics, 59;
Moonlight hours, 36 workforce issues, 69 – 71
Morale, physician, 52 – 53 Orthopedic surgery, 67 – 71;
MRI scans, 17 reconstructive surgery, 67
Mullan, Fitzhugh, 26 Otolaryngologists: board certification,
26 – 27; employment outlook, 80 – 81;
National Academy of Sciences Institute graduate medical education funding,
of Medicine, 139 121; residency program, 22, 24;
National Conference on Medical retirement, 82; statistics, 59; workforce
Malpractice, 45 issues, 81 – 84; work hours, 36
National Institute of Health, 104 Otolaryngology (OL), 78 – 84; cochlear
National Residency Matching Program implants, 78; laryngeal cancer,
(NRMP), 2, 22, 76 – 77 78 – 80
Natural orifice translumenal endoscopic Outpatient prospective payment system
surgery (NOTES), 95 – 96 (OPPS), 118
Neurosurgeons: board certification, Outsourcing physicians, 1 – 8,
26 – 27; employment outlook, 105; 139 – 40
graduate medical education Ovarian cancer, 85 – 86
Index 191
Pacemaker, 72 Registered nurses (RNs), 20

Part-time physicians, 131 – 32 Reimbursement, 19 – 20; cardiothoracic
Paul, Chris, 145 surgeons, 43; direct medical
Penile prosthesis, 109 education, 116 – 17; hospital, 41 – 42;
Percutaneous transluminal coronary indirect medical education, 117 – 18;
angioplasty (PTCA), 72 Medicare, 43, 84; open surgery,
Per-resident amount (PRA), 115, 116 41; physician, 38 – 52; surgeon, 42;
Perrin, Tillinghast Towers, 46 surgical, 40
PET scans, 17 Residency program, 22 – 31; American
Pharmacists, 20 – 21 board certification, 26 – 27; applicants,
Physician reimbursement, 38 – 52; vs. origin of, 24; cardiothoracic
hospital, 42 surgeons, 22 – 23; compensation,
Physicians: complaints, 36; lawyers 29 – 31; general surgeons, 22, 24;
vs., 7; morale, 52 – 53; outsourcing, gynecologists/obstetrics surgeons,
1 – 8, 139 – 40; part-time, 131 – 32; 22, 24; IMG, 50; letter to surgical,
primary care, 35 – 36; productivity, 144 – 52; neurosurgeons, 22;
improving, 135 – 39; reimbursement, obstetrics and gynecology (OB/GYN),
38 – 52; retirement, 52 – 53, 60 – 61, 22; orthopedic surgeons, 22, 24;
132 – 34, 159 – 60; shortages, 4; otolaryngologists, 22, 24; surgical,
statistics, 63 – 65, 163 – 64; supply letter to, 144 – 52; surgical supply,
and demand, 3 – 6, 14 – 21, 60; work 22 – 31; training, shortening duration
force assessment models (See Physician of, 134 – 35; urologists, 22; workforce,
supply); work/life balance, importance demographics of, 22 – 24; work hours,
of, 36 – 38; younger generation, 27 – 29
retention of, 142 – 43 Residency Review Committee, 69
Physicians Requirement Model (PRM), Resident, defined, 114
54, 55 Retirement: cardiothoracic surgeons, 74;
Physicians Supply Model (PSM), 54, 55 general surgeons, 98; gynecologists/
Physician supply, 54 – 65; assumption obstetrics surgeons, 88 – 89;
models, 54 – 59; calculating, 60 – 65; neurosurgeons, 105 – 6; orthopedic
parameters, relevant, 59 – 60 surgeons, 69; otolaryngologists, 82;
Population aging, 15 – 16 physician, 52 – 53, 60 – 61, 132 – 34,
Population Analysis, 54 159 – 60; urologists, 109 – 10
Population growth, 15 – 16 Retton, Mary Lou, 67
Post Balanced Budget Act (BBA) of Reverse graduate medical education
1997, 119 – 21 (GME), 130 – 31
Postgraduate year one residents (PGY-1), Richardson, J. David, 100
2, 114 Robotic urology, 108 – 9
Pre Balanced Budget Act (BBA) of Rural health care, 21
1997, 116 – 19
Premature delivery, 86 – 87 SCHIP, 13
Prescriptions, 18 Schreiber, Stephen T., 7
Primary care physicians, 35 – 36 Senior Urological Registrars Group,
Private medical school tuition, 32 112
Public medical school tuition, 32 Sheldon, George, 99
Social workers, 137
Radical mastectomy, 94 Society of Thoracic Surgeons (STS), 41,
RAND Corporation, 68 73, 75
Reconstructive surgery, 67 Stewart, Allison, 112
192 Index
Study on Surgical Services for the United United States Food and Drug
States (SOSSUS), 97 Administration, 78
Suicide, intentional, 11 United States international medical
Supply and demand of physicians, 3 – 6, graduates (IMGs), 24 – 25
14 – 21, 60 University of California, 137
Surgeon reimbursement, 42 University of Central Florida, 128
Surgical/medical workforce: cancer, 11; University of Eastern Tennessee,
chronic diseases, 11 – 12; demand for, 21
10 – 21; employment outlook, 14 – 21; University of Maine, 127 – 28
heart failure, 12 – 13; workforce issues, University of North Carolina, 99
14 – 20 Urologists: board certification, 26 – 27;
Surgical reimbursement, 40 employment outlook, 109 – 10;
Surgical supply: constraints, 32 – 53; residency program, 22; retirement,
residencies, 22 – 31 109 – 10; statistics, 60; workforce
issues, 110 – 13
Taussig, Helen, 72 Urology, 108 – 13; neuro, 109; penile
Tax Equity and Fiscal Responsibility Act prosthesis, 109; robotic, 108 – 9
(TEFRA), 117
Technology advancement, 17 – 18 Veterans Administration, 114, 120
Teleradiology, 139 – 40 Visas, 26
Thoracic Surgery. See Cardiothoracic Visicu, Inc., 138
(CT) surgery Vision corrections, 16
Thoracic Surgery Workforce Committee,
74 – 75 Wall, Norman, 50
Tort reform, 47 Western Surgical Association, 100
Training, shortening duration of Woodruff, Bob, 103
residency, 134 – 35 Work force assessment models. See
Tuition, 32 – 38 Physician supply
Work horse doctors, 52
United Auto Workers (UAW), 133 Work hours, residency, 27 – 29
United States Bureau of Health Work/life balance, importance of,
Professionals, 55 36 – 38
United States Bureau of Labor Work Per Capita Analysis, 54
Statistics, 29 Work relative value units (WRVUs),
United States Census Bureau, 15, 56 43
United States Department of Health and
Human Services, 19, 110 Zion, Libby, 27 – 28
About the Authors
THOMAS E. WILLIAMS, JR., M.D., PH.D.; FACS, completed his surgical in-
ternship at The Presbyterian Hospital in New York City in 1964 and his resi-
dency at The Ohio State where he is Clinical Associate Professor of Surgery.
He won the Excellence in Teaching award for the Department of Surgery in
2004. He is author of Consumer Driven Health Care with Roger Blackwell and
Alan Ayers.
Dr. Williams has served on many boards and has contributed to more than
70 journal articles and presentations. Some of his professional affiliations
include the American Medical Association, the Society of Thoracic Surgeons,
and the American Association for Thoracic Surgery. Dr. Williams has also
served as a physician on missions in Vietnam, Cambodia, New Guinea,
Rwanda, Malawi, and the Dominican Republic.
BHAGWAN SATIANI, M.D., M.B.A; FACS, is a professor of clinical surgery

in the Division of Vascular Diseases & Surgery, and medical director of the
Non-Invasive Vascular Laboratory at The Ohio State University College of
Medicine in Columbus. He has practiced vascular surgery since 1978. He has
115 peer-reviewed publications and has been a speaker at numerous national
and international meetings. Dr. Satiani has an M.B.A. in Healthcare Manage-
ment and is a Fellow of the American College of Healthcare Executives. He
is president of Savvy Medicine Inc., which was formed to provide leadership
in the area of business education for physicians, and he lectures frequently
on business education/practice management to physicians. His three-volume
set The Smarter Physician, published by MGMA in 2007, is a comprehensive
resource for physicians to assist them in dealing with the economic, legal,
and personal finance challenges ahead. Dr. Satiani also teaches an 18-month
practice management curriculum for surgical residents in the Department of
Surgery. Dr. Satiani’s many community interests include serving on the board
194 About the Authors
of ASHA-Ray of Hope, a Columbus, Ohio, organization to prevent domestic

violence among South Asians.
E. CHRISTOPHER ELLISON, M.D.; FACS, is currently the Robert M. Zollinger

Professor of Surgery and Chairman of the Department of Surgery at Ohio State
University. He also serves as the Associate Vice President for Health Sciences
and Vice Dean of Clinical Affairs of the College of Medicine.
A Columbus, Ohio, native, Dr. Ellison received his undergraduate degree
from the University of Wisconsin and his medical degree from the Medical
College of Wisconsin. He returned to Columbus for general surgery residency
at Ohio State. Dr. Ellison then joined the university in 1984 as assistant profes-
sor, and also served for six years as director of the general surgery residency
program. His research interests include pancreatic disease, hepatic cancer,
wound healing, and Zollinger-Ellison Syndrome.
Dr. Ellison is a recent past president of the Central Surgical Association,
as well as a past chapter president and governor-at-large of the American
College of Surgeons (ACS) and currently serves on the ACS Advisory Council
for General Surgery. He is a past vice president of the American Association
of Endocrine Surgeons. He also serves on the editorial board of the American
Journal of Surgery. Dr. Ellison was elected in 2003 to the American Board of
Surgery as a representative of the ACS. For the past three years he has served
as chair of the ABS Examination Committee. He was elected this winter as
vice chair of the American Board of Surgery for 2009–2010. He will serve as
chair of the ABS in 2010–2011.
About the Series Editor
JULIE SILVER, M.D., is Assistant Professor, Harvard Medical School, Depart-

ment of Physical Medicine and Rehabilitation, and is on the medical staff
at Brigham & Women’s, Massachusetts General and Spaulding Rehabilitation
Hospitals in Boston, Massachusetts. Dr. Silver has authored, edited, or co-edited
more than a dozen books, including medical textbooks and consumer health
guides. She is also the Chief Editor of Books at Harvard Health Publications.
Dr. Silver has won many awards, including the American Medical Writers
Association Solimene Award for Excellence in Medical Writing and the presti-
gious Lane Adams Quality of Life Award from the American Cancer Society.
Dr. Silver is actively teaching health care providers how to write and publish,
and she is the founder and director of an annual seminar titled Publishing
Books, Memoirs and Other Creative Non-Fiction, facilitated by the Harvard Med-
ical School Department of Continuing Education.

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THE COMING SHORTAGE

Thomas E. Williams, Jr., M.D., Ph.D.; FACS,

Foreword by Thomas R. Russell, M.D.; FACS

The Praeger Series on Contemporary Health and Living

This book is also available on the World Wide Web as an eBook.

And to my best friend and wife, Mira Satiani.

13. The Last Hurdle: The Balanced Budget Act of 1997

1.1 U.S. Medical School Applicants 3

4.10 Where Malpractice Dollars Go 48

14.5 Residents “Significantly Concerned” about Availability of Free Time

1.1 Physician Shortages 4

5.2 Retiring Doctors 62

CONTEMPORARY HEALTH AND LIVING

Series Editor Julie K. Silver, M.D.

The Coming Shortage of Surgeons provides a comprehensive look at one of

nation’s emergency departments (EDs) due to a dearth of physicians willing

Thomas R. Russell, M.D., FACS

FACS Fellow American College of Surgeons

HAVE WE BEEN OUTSOURCING OUR DOCTORS OF MEDICINE?

2010 309,000,000 883,740 787,600 96,140

The standard method for measuring physician supply or demand in the

a four-year diploma or associate degree, as a licensed RN, can start at over

Lawyers versus Doctors

of access to surgical specialists without an appropriate and adequate surgical

OUTLINE OF THE BOOK

The scene is East Florida; there is a shortage of neurosurgeons; somebody

SETTING THE STAGE

 Heart disease: 652,091

strokes), and some of both intentional (suicidal) and unintentional accidents

The Scourge of Cancer

The Burden of Chronic Disease

Estimated New Cases Estimated Deaths

The number of living Americans who have had cancer diagnoses

WHAT DOES IT COST?

Trauma is one of the nation’s most expensive surgical problems. Trauma

Other Public1 Other Private2

Current Physician Supply

‘‘Asset’’ ‘‘Contingencies’’ ‘‘Liability’’

Future Physician Supply

mentioned at visits increased by 13 percent and 18 percent, respectively, in pa-

GDP Per Capita ($100s) Physicians/100,000 Population

abnormal findings that lead to more procedures, often on a preventative basis.

Source: PHYSICIAN WORKFORCE. Physician Supply Increased in Metropolitan and Nonmet-

compared to traditional fee-for-service plans. In theory, part of the reason that

Demand for Nonphysician Services

• “The shortage of surgeons is a particular threat to the health care of 54 million

number of resident positions available is shown in column 3 and range from

Specialty Years in Residency

OB/GYN 250 4,739 3,596 75.9 3,735 78.8 1,004 21.2

Source: “Resident Physicians on Duty in ACGME-Accredited and in Combined Specialty Medical

these residencies comprise close to 80 percent in OB/GYN, general surgery,

Total Number of Residents’ Number of First-Year

OB/GYN 4,739 1,225

of the entire applicant pool will be employed by an institution.7 Once ac-

American Board Certification

Number of physicians in U.S. 902,053

Graduates of Foreign and U.S. Medical Schools in

Year OB/GYN Eent Ortho General Urology Neuro Thoracic

1997 1,201 284 640 947 244 119 121

Certificates Per Year

ENT OB/GYN Ortho Urology

1996 160 150 10

PGY – 1 Intern $44,000

Heart disease: 652,091