The General Surgery Workforce

Francis Kwakwa, MA
Olga Jonasson, MD, FACS

Abstract

Background: The workforce in general surgery has been the subject of studies in 1975 and 1994, as has the input of residency program graduates, their subsequent subspecialization, and the retirement pattern of practicing general surgeons. This study analyzes the distribution of general surgeons in the United States.

Data Sources: Certified general surgeons were identified from files of the American Board of Medical Specialties (ABMS). Included were general surgeons with no additional certificates except for Surgical Critical Care. Excluded were surgeons certified only by an osteopathic board, non-certified surgeons, retirees, missionaries, federal employees and military surgeons. The Area Resource File of the Bureau of Health Professions was used to classify metropolitan and rural areas, and primary care health professions shortage areas (PC-HPSA).

Conclusions: General surgeons are well distributed in the various states. More general surgeons are located in metropolitan than in rural areas, and few general surgeons practice in counties in which the whole county is designated as a PC- HPSA. The ratio of general surgeons to the population is similar to that found in 1975.

Beginning in 1970, a study of surgical services in the United States in the modern era was conducted as a joint effort of the American Surgical Association and the American College of Surgeons.1 This landmark study, popularly known as the SOSSUS report (Study on Surgical Services for the United States), was completed in 1975. The report observed that "... we have failed to identify large or small areas of this country that are significantly undersupplied with personnel suitably qualified to carry out surgery." Based on population estimates and workload calculations, the SOSSUS subcommittee on Surgical Manpower estimated that 1,600-2,000 surgeons should complete residency education and enter the workforce each year between 1976 and 2012, in order to fill the needs for surgical services in the United States.

Since 1982 the American College of Surgeons has conducted an annual comprehensive survey of surgical residents. This study, the Longitudinal Study of Surgical Residents,2 has reported that 4,200 surgeons completed core residency programs in surgery in 1994. Core surgical specialties are those offering primary certification by an American Board of Medical Specialties (ABMS) board. This number is more than twice that predicted to be needed through the year 2008 by the model used in the SOSSUS study. Why the discrepancy, and does this larger number mean that an excess supply of surgeons is now being produced by core surgical programs?

We recently determined that the number of practicing general surgeons in the US in 1994 was between 17,289 and 23,502, or a ratio of 7.1 practicing general surgeons per 100,000 population.3 In 1974, the SOSSUS study found that this ratio was 6.93. The model used by the SOSSUS study to predict surgeon supply, seems to have underestimated the input of new general surgery graduates needed to maintain this ratio.

The input of general surgeons over the years since 1973 has been quite stable; since 1982, the number of graduates from general surgery residency programs has averaged 1,004 per year (range: 976-1,042).2 The average time in practice (practice-years) has risen slightly as general surgeons are retiring later (mean age of retirement in 1995: 62.9; median: 64), but this increase in productivity has been offset by the large-scale diversion of general surgery graduates into advanced surgical specialty residency programs leading to subspecialization.4 Thus, the actual number of practice-years by each graduating cohort of general surgeons is declining. Fewer general surgeons are available each year to supply the necessary surgical services traditionally provided by the broad-based general surgeon, given a stable graduation rate from residencies and input into practice. On the other hand, input into the general surgery-based specialties of colon and rectal, thoracic, pediatric, vascular, and plastic surgery has been increasing.2 This trend to specialization beyond general surgery was not foreseen in the SOSSUS model for general surgery.

The SOSSUS study also found that surgeons were generally well distributed throughout communities with at least 50,000 population, and that rural counties average fewer surgical specialists than do large cities. We report here our recent study of the distribution of certified general surgeons throughout the country, with special emphasis on the number of general surgeons in rural and metropolitan areas in 1996, seeking to confirm that the 1975 SOSSUS finding that surgeons in all specialties were fairly well distributed throughout the nation, applies to general surgeons in 1996.

Materials and Methods

We defined active general surgeons as certified allopathic trained general surgeons aged 63 years and under who have no subspecialty certification except Surgical Critical Care. General surgeons who are primarily engaged in teaching, research, and administration were included. Not included are surgeons certified only by an osteopathic board who provide a small contribution to the general surgery workforce, and the surgical procedures performed by non-surgeons which we also assume is a small number. (Hospital credentialing processes, managed care organization (MCO) policies, medicolegal issues, and other factors combine to limit these practices in recent years.) The 63 year age limit was based on the fact that the average age of retirement from practice among the general surgery Fellows of the American College of Surgeons (approximately two-thirds of all general surgeons) was 62.9 years in 1995.4 The median age of retirement was 64 years. Practicing general surgeons aged 64 years were examined separately.

Data on board certification and practice location for all living board-certified general surgeons in the United States in May 1996 were obtained from the American Board of Medical Specialties (ABMS) (Personal communication, Ronald S. Cornick, ABMS). From the Area resource File (ARF) of the Bureau of Health Professions we obtained the United States Department of Agriculture's (USDA) 1995 Rural/Urban Continuum Codes for Metropolitan and Nonmetropolitan counties.5 These codes form a classification scheme that distinguishes metropolitan counties by size and nonmetropolitan counties by the degree of urbanization or proximity to metropolitan areas (Table I). By combining these codes, we provide analyses of the number of general surgeons in metropolitan and adjacent areas (0-4,6) compared to completely rural and areas not adjacent to metropolitan counties (5, 7-9).

Table I. United States Department of Agriculture 1995 Rural/Urban Continuum Codes for Metropolitan and Nonmetropolitan Counties.

Code Metropolitan Counties (0-3)
00 Central counties of metro areas of 1 million population or more
01 Fringe counties of metro areas of 1 million population or more
02  Counties in metro areas of 250,000 - 1,000,000 population
03 Counties in metro areas of less than 250,000 population
  Nonmetropolitan Counties (4-9)
04 Urban population of 20,000 or more, adjacent to a metro area
05 Urban population of 20,000 or more, not adjacent to a metro area
06 Urban population of 2,500-19,999, adjacent to a metro area
07 Urban population of 2,500-19,999, not adjacent to a metro area
08 Completely rural (no places with a population of 2,500 or more) adjacent to a metro area
09 Completely rural (no places with a population of 2,500 or more) not adjacent to a metro area
99 Missing value (Alaska is carried as one total area on the ARF, and was given a missing value code )

The US Census Bureau provided data on the 1995 population estimates for all counties in the United States and data on the Primary Care Health Profession Shortage Areas (PC-HPSA) were provided by the Bureau of Health Professions.5 The PC-HPSA file, originally created by the Bureau of Primary Health Care, contains the primary care HPSA designation status (whole county is a PC- HPSA, part of the county is a PC-HPSA or no PC-HPSA in county) of all US counties as of June 1996. With the exception of the ABMS file which contained zip codes, our sources provided county level data. Hence, it was necessary to link the zip codes to counties in order to merge the ABMS file with other files.

Results

We found 19,791 active certified general surgeons ages 63 and under in the United States in 1996, including those in research, teaching, and administration and excluding retirees, missionaries, federal employees and military surgeons. This is a ratio of 7.5 certified general surgeons per 100,000 population. The age distribution is shown in Figure 1. The number of general surgeons in each state, the ratio of general surgeons/100,000 population, and the mean and median ages of the general surgeons is given in Table II.

Table II. Distribution of General Surgeons in Each State

State Population
Certified GS*
GS*/100,000
  Age (mean; median)
Alabama 4,252,982 331 7.8 46.7; 45
Alaska 603,617 39 6.5 48; 49
Arizona 4,217,940 289 6.8 48.1; 47
Arkansas 2,483,769 191 7.7 47.7; 47
California 31,589,153 2,014 6.4

48.5;48
Colorado 3,746,585 306 8.2 46.6; 45
Connecticut 3,274,662 319 9.7 47.4; 46
Delaware 717,197 56 7.8 47.6; 46
District of Columbia 554,256 106 19.1 47.6; 46
Florida 14,165,570 1,066 7.5 48.2; 48
Georgia 7,200,882 564 7.8 46.9; 45
Hawaii 1,186,815 84 7.0 48.1; 47
Idaho 1,163,261 77 6.6 47.8; 47
Illinois 11,829,940 846 7.2 47.9; 48
Indiana 5,803,471 352 6.1 47; 45
Iowa 2,841,764 195 6.9 47.6; 47
Kansas 2,565,328 183 7.1 47.3; 47
Kentucky 3,860,219 314 8.1 46.7; 45
Louisiana  4,342,334 373 8.6 47.1; 46
Maine 1,241,382 101 8.1 49.4; 50
Maryland 5,042,438 501 9.9 47.4; 47
Massachusetts 6,073,550 600 9.9 47.5; 47
Michigan 9,549,353 621 6.5 47.8; 47
Minnesota 4,609,548 330 7.2 47; 46
Mississippi 2,697,243 148 5.5 47.8; 47
Missouri 5,323,523 394 7.4 47.1; 45
Montana 870,281 72 8.3 48.6; 47
Nebraska 1,637,112 116 7.1 47.7; 46
Nevada 1,530,108 99 6.5 47.7; 46
New Hampshire 1,148,253 86 7.5 49.9; 50
New Jersey 7,945,298 614 7.7 48.3; 48
New Mexico 1,685,401 113 6.7 45.9; 45
New York 18,136,081 1,627 9.0 47.7; 47
North Carolina 7,195,138 593 8.2 47.1; 46
North Dakota 641,367 57 8.9 46.1; 46
Ohio 11,150,506 829 7.4 47; 46
Oklahoma 3,277,687 176 5.4 48.4; 49
Oregon 3,140,585 249 7.9 48.4; 49
Pennsylvania 12,071,842 1,097 9.1 46.9; 46
Rhode Island 989,794  88 8.9 49.6; 52
South Carolina 3,673,287 279 7.6 47.2; 47
South Dakota 729,034 65 8.9 47.2; 46
Tennessee 5,256,051 434 8.3 47; 46
Texas 18,723,991 1,263 6.7  46.4; 45
Utah 1,951,408 120 6.2 47.9; 47
Vermont 584,771 47 8.0 47.4; 46
Virginia 6,618,358 485 7.3 47.6; 47
Washington 5,430,940 352 6.5 47; 46
West Virginia 1,828,140 150 8.2 48.8; 49
Wisconsin 5,122,871 357 7.0 46.9; 46
Wyoming 480,184 23 4.8 46.5; 45
US Total 262,755,270 19,791 7.53 47.5; 47

* GS, General Surgeons

The distribution of general surgeons in metropolitan and adjacent areas and strictly rural areas were compared (Table III). The distribution of general surgeons among part, whole or no PC-HPSA counties shows that the largest number of general surgeons practice in counties designated as part PC-HPSA. This is because most of the large urban counties fall into this category. Only 1.9% of general surgeons practice in counties that are wholly PC-HPSA designated.

Table III.Distribution of General Surgeons in Metropolitan and Rural Areas and in Primary Care Health Professions Shortage Areas.

 

General Surgeons No. (% of GS)

Age Mean; Median
Metropolitan and Adjacent Areas 18,382 (92.8) 47.5; 47
Strictly Rural Areas 1,370 (6.9) 48.6; 49
No PC-HPSA* in County 4,985 (25.1) 47.3; 46
Part County PC-HPSA* 14,417 (72.8) 47.6; 47 
 Whole County PC-HPSA* 380 (1.9) 48.5; 49

* PC-HPSA indicates Primary Care Health Professions Shortage Area

The age of general surgeons in metropolitan and adjacent areas is, on average, less than that of surgeons in strictly rural areas.(47.5 and 48.6 respectively) (Table III). When a subset of 407 active surgeons 64 years of age is analyzed, 37 (9.1%) are located in strictly rural areas.

Discussion

Although more general surgeons are located in metropolitan than in strictly rural areas, their distribution throughout the states is fairly even, averaging approximately 7.5 general surgeons per 100,000 population (range 19.1 in the District of Columbia to 4.8 in Wyoming). Most states have ratios between 7 and 9 general surgeons/100,000. As noted in the SOSSUS report1, surgical services follow hospital bed availability. We assume that this remains the case in 1996, and that the whole counties designated as primary care health professions shortage areas are likely to have few hospital facilities, consistent with the low number of general surgeons who practice in these areas.

The mean age of active general surgeons in 1996 is 47.5 years, or approximately 15 years following completion of a general surgical residency.2 General surgeons practicing in rural areas are somewhat older, averaging over 48 years; in some states (New Hampshire, Maine) the median age is 50. The lesser number of general surgeons in rural areas and the higher age of these surgeons may indicate that new graduates from residency programs may find that practice opportunities are greater in rural than in metropolitan areas.

The lower than average ratio of general surgeons to population found in California (6.4/100,000), a state with a high penetration of managed care, may indicate that managed care organizations are more efficient in their utilization of physicians and require a lesser number of general surgeons.6 Alternatively, more surgical specialists such as vascular or colon and rectal surgeons may practice in California, and provide some of the services provided by general surgeons in other areas. We have not studied this possibility.

General surgeons provide a vital component of basic health services. Through association of the number of approved resident positions in surgical programs with the resources available and the quality of the educational program, growth in the input of new general surgeons into the workforce has been contained and the number of practicing general surgeons has expanded slowly. Increasing diversion of general surgery graduates into surgical specialties has further contained the growth of the workforce of general surgeons.4 Whether the current workforce in general surgery is appropriate to the needs for surgical services has yet to be determined, but it is essentially the same in 1996 as found in 1975 in the SOSSUS study.

References

1. Surgery in the United States: a summary report of the Study on Surgical Services for the United States(SOSSUS), Baltimore, American College of Surgeons and the American Surgical Association; 1975

2. Kwakwa F, Jonasson O: The Longitudinal Study of Surgical Residents, 1993-1994. JACS 1996;(in press)

3. Jonasson O, Kwakwa F, Sheldon GF: Calculating the workforce in General Surgery. JAMA 1995;274:731-734.

4. Jonasson O, Kwakwa F: Retirement age and the workforce in general surgery. Ann Surg 1996;224:574-582.

5. Bureau of Health Professions: Area Resource File. Rockville, MD: DHHS; February, 1996

6. Kronick R, Goodman DC, Wennberg JE, Wagner E: The marketplace in health care reform: the demographic limitations of managed competition. N Engl J Med 1993;328:148-152.

Revised June 11, 2001


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