Physician Workforce Data Suggest Epochal Change

In late January, the Association of American Medical Colleges (AAMC) released the 2023 US Physician Workforce Data Dashboard,¹ the organization’s latest dataset on the medical workforce. The dashboard provides detailed data, current to December 31, 2022, on active physicians in all practice specialties with more than 2,500 active physicians.

As with previous AAMC reports, this data release combines US Census and AAMC information with the American Medical Association Physician Professional Data™—a historical database of the education and professional certifications of more than 1.4 million physicians. Uniquely among AAMC reports, however, the new dashboard is an interactive display that allows users to generate bar graphs and maps on physicians in specified specialties, geographic locations, and demographic groups.

The dashboard is the one of the first physician workforce datasets released by the AAMC since its 2021 report, The Complexities of Physician Supply and Demand: Projections from 2019 to 2034.² The two reports are not directly comparable, as the dashboard provides current granular data on subsets of physicians while the 2021 report used data modeling to predict future workforce numbers. But combining the 2021 predictions with the current dashboard, additional data from the AAMC, ACS data, and other information, enables examining the surgical workforce today and generate insights into current and future surgeon supply, demand, and distribution in the US.

Losing Ground

In its 2021 report, the AAMC quantified the supply of surgeons across all surgical disciplines in 2019 at 152,700. It also projected a shortage by 2034 of 15,800 to 30,200 surgeons relative to demand, a large part of a shortfall of 37,800 to 124,000 physicians overall in the same period. In a just-released 2024 report,³ the AAMC updated the total projected shortage to 13,500 to 86,000 physicians by 2036, including a predicted shortfall of 10,000 to 19,900 surgeons (in other words, as much as 74% of the total).

In the shorter term, the 2021 and 2024 reports both projected that in 2024, the US public would need the services of approximately 160,000 surgeons, an increase of approximately 4.8% over the number in 2019, provided the status quo (of various aspects of the surgical workforce, including retirement age) was maintained. Other scenarios mapped the workforce in conditions other than the status quo, all of which resulted in a similar approximate level of demand in 2024.

The just-released AAMC dashboard can be compared with separate AAMC ^data4 published in 2019, providing the number of surgeons in various specialties as of December 31, 2018—the timeliest match to the 2019 estimates in the 2021 report. In other words, can be roughly compared the recent predictions of surgeon supply^2,3 with the current reality.⁴ Has surgeon workforce growth, per the new dashboard, kept up with projected demand?

The news is not encouraging. Per the AAMC data,^1,4 the number of surgeons in a range of surgical specialties grew by an average of 3.0% between late 2018 and late 2022 (see Figure 1), while physicians in all medical specialties (surgical and nonsurgical) grew by 5.4% in the same period. This suggests that surgeons are experiencing larger-than-average shortfalls at present.

Notably, several surgical specialties are growing at large rates, particularly sports medicine-orthopaedic surgery, which increased its workforce by 15.2% since 2019. Vascular surgery (9.5%) and neurological surgery (6.9%) also gained surgeons in larger proportions than the overall physician and surgeon workforces did. All other specialties, however, gained less than 4.6% in this 4-year span, including one (orthopaedic surgery, a category listed separately from sports medicine-orthopaedic surgery) with an increase of just 1.2%. Although the total number of surgeons in late 2022 was 155,549—not very far from the projected demand^2,3 of approximately 160,000—these data suggest that much of surgery is currently losing ground relative to growing population needs.

Aging into a Surgeon Shortage

Of course, a period of 4 years is too brief a period to show the full manifestation of a long-term workforce shortage. While the declines to this point may be disheartening, the full extent of the predicted shift likely has not yet arrived.

Indeed, population pressures point to intriguing issues that will affect surgery greatly—despite their origination far beyond the field.

The US, like much of the world, is facing a rapidly aging population, with the percentage of elderly people increasing relative to the full population. The US is not yet facing a decline in population size, thanks to lengthening lifespans and net gains from immigration. Nonetheless, every available statistic on population growth shows flat or declining rates.⁵ The US joins the two-thirds of the global population in experiencing a national fertility rate below the threshold population replacement rate;⁶ the US birth rate has been below replacement since 2007.⁵ In sum, the workforce is aging overall, with many people approaching retirement, relatively few younger people replacing them, and an expectation that the pattern will only increase in intensity in the future. This shift is slowing labor pool growth throughout much of the world.

Amid this global sea change, US surgeons face a triple burden of aging.

First, the population of physicians is more aged than that of the country overall. Per the AAMC dashboard, by the end of 2022, 23.2% of active physicians were age 65 or older,⁷ a percentage nearly 40% greater than that of the same age group in the full US population (16.8%).⁸ Among surgeons alone, the AAMC dashboard showed that 39,759 of 155,549, or 25.6%, were older than 65 years. For five surgical specialties (ophthalmology, orthopaedic, plastic, thoracic, and urology), the percentage older than 65 years is even higher (see Figure 2). Just one specialty (sports medicine-orthopaedic) has a percentage of surgeons under age 40 that is larger than the percentage over age 65. All other surgical specialties have smaller populations in the younger generation than the older generation.

Statistical tests suggest the growth in surgeon specialties between late 2018 and late 2022 is partly attributable to the ability of a specialty to retain surgeons younger than 40. The Spearman ranked correlation coefficient between the percentage of surgeons older than 65 years and the growth in surgeon population is -0.64—a moderately strong negative correlation. Similarly, the percentage difference between surgeons older than 65 and those younger than 40 is negatively correlated with surgeon population growth (correlation coefficient, -0.55). Most growth, in other words, is coming from recruiting surgeons under 40; only this statistic had a positive association with change in surgeon population (correlation coefficient, 0.45).

The surgeon shortage means that, as surgeons over age 65 retire, surgery likely will face widespread workload challenges. The decline may have already begun, and it will certainly speed up over the next 5 to 10 years.

Meanwhile, population-wide aging will further complicate the balance of workers. The 2021 AAMC projections suggest offsetting a surgeon shortage by increasing the number of other surgical team members, such as nurse practitioners. But the aging of the broader workforce⁹ means this may prove challenging, as workers may simply not be present for recruitment.

Finally, many surgical specialties will face a higher workload as surgical needs increase with age across the entire population. The smaller workforce won’t face today’s surgical demands, in other words, but rather, in many specialties, significantly increased needs.

The 2021 AAMC report projects small shifts in surgeon shortages based on the retirement age of the existing surgical workforce. Factoring in a pattern of retirement 2 years earlier or later than the current typical age (65 years) contributes to the range in their estimated shortfall of 10,000 to 19,900 surgeons by 2036. The current dashboard, helpful in illuminating the overall issue, offers no further insight into these possible changes over time.

How Many, How Old, and Where?

Belying the AAMC workforce predictions, some have espoused that the problem is simply not about shortage at all, but rather maldistribution of surgeons across the US. The idea is that surgeons may favor living and working in urban areas, not least of all because they tend to attend surgical residencies clustered within one of several US cities. Some surgeons have posited that this is why surgeons in rural areas are often in critically short supply. Read more about this issue in the March 2024 Bulletin.

Can the new AAMC dashboard shed more light on the maldistribution and shortage as the primary surgical workforce issues?

The dashboard offers state-level maps of surgeon distributions, which show dramatic differences between some rural and urban places. Take New Hampshire, one of the most rural states in the US, versus Washington, DC, for instance. Washington, DC, with an entirely urban population of 689,545, has 167 general surgeons, or 24.1 for every 100,000 people. New Hampshire, with a population of 1,402,054 (41.7% of them rural), has 136 general surgeons, or 10.0 per 100,000 population—less than half the amount in the District of Columbia. (See more data in Figure 3).

But the pattern is not absolute. Some states are both largely urban and relatively underserved. California, with a population of 39.37 million people (just 5.8% of whom are rural) and 2,923 general surgeons,¹ has 7.1 general surgeons per 100,000 people—notably fewer than much more rural New Hampshire.

The real difference in rural versus urban areas may lie in surgical demand, rather than supply. This is because some rural populations have a notably higher median age than the national population, and increased age often correlates with increased surgical needs. Comparing states by their percentages of rural population and population older than 65 through non-AAMC data^10-12 shows a correlation coefficient of 0.27—indicating a weak-to-moderate connection between dwelling in a rural area and being in this older age group.

Comparing these population-level data with a 2021 AAMC state-by-state physician workforce report13 reveals similar correlations between the percentage of a state dwelling in rural areas and general surgeons per 100,000 people (correlation coefficient, 0.25) or the elderly percentage of the population and the number of general surgeons (correlation coefficient, 0.36).

In other words, surgeons are neither systematically avoiding more rural states (which would yield a negative correlation coefficient) nor gravitating toward them (a larger positive correlation coefficient than the correlation of rurality and old age). A maldistribution of surgeons in urban versus rural areas may not be discoverable via state-level data. Nonetheless, these data suggest surgeons may not be selecting a state for practice based on the elderly population of that state.

What the AAMC Data Can and Cannot Tell Us

Examining the AAMC data makes it clear that the full pattern of surgeon supply and demand across geographic locations, surgical specialties, and age groups is complex, challenging, and in the midst of pivotal change.

The long-term outlook for surgery appears to include large-scale workforce changes for most surgical specialties. As most of the world faces a generational shift in the labor pool, the US must consider how best to meet the needs of more patients with fewer surgeons. This may include advocating for more surgeons to practice in rural areas where patient needs are particularly strong—an effort the ACS is already spearheading through its Division of Advocacy and Health Policy. Read more on those efforts in the February 2022 Bulletin article, “Data Reveal the Details about the Surgeon Workforce Shortage.”

What is less clear is what this epochal change may mean for ensuring optimal care for surgical patients. This is in part because dynamic, complex changes will affect surgical workforce needs as technological innovation, shifting lifestyles, international migration (including of international medical graduates), and other factors reshape epidemiology and the surgical workforce, potentially altering how many surgeons a population needs and how surgeons work.

M. Sophia Newman is the Medical Writer and Speechwriter in the ACS Division of Integrated Communications in Chicago, IL.

References

1. Association of American Medical Colleges. 2023 US Physician Workforce Data Dashboard. February 2024. https://www.aamc.org/data-reports/data/2023-us-physician-workforce-data-dashboard.
2. Association of American Medical Colleges. The Complexities of Physician Supply and Demand: Projections From 2019 to 2034. June 2021.
3. Association of American Medical Colleges. The Complexities of Physician Supply and Demand: Projections From 2021 to 2036. March 2024. https://www.aamc.org/media/75236/download?attachment.
4. Association of American Medical Colleges. Physician Specialty Data Report: Active Physicians in the Largest Specialties by Major Professional Activity, 2021. Published 2021. Accessed February 12, 2024. https://www.aamc.org/data-reports/workforce/data/active-physicians-largest-specialties-major-professional-activity-2021.
5. Hamilton BE, Martin JA, Osterman MJK. Births: Provisional Data for 2022. Vital Statistics Rapid Release, Report No. 28. Published June 2023. Accessed February 9, 2024.
6. Ijaz S. 24 Countries with Biggest Population Decline. Published December 19, 2023. Accessed February 9, 2024. https://finance.yahoo.com/news/24-countries-biggest-population-decline-114914844.html.
7. Association of American Medical Colleges. 2023 US Physician Workforce Data Dashboard: 2023 Key Findings and Definitions. Published February 1, 2024. Accessed February 9, 2024. https://www.aamc.org/data-reports/data/2023-key-findings-and-definitions.
8. Kaplan Z. US Older Population Grew From 2010 to 2020 at Fastest Rate Since 1880 to 1890. Published May 25, 2023. Accessed February 9, 2024. https://www.census.gov/library/stories/2023/05/2020-census-united-states-older-population-grew.html.
9. Elvery JA, Isabel Brizuela I. Demographic Trends Are Major Factors in Today’s Weak Labor Force Growth. Published April 21, 2022. Accessed February 27, 2024. https://www.clevelandfed.org/publications/cleveland-fed-district-data-brief/2022/cfddb-20220421-demographic-trends-weak-labor-force-growth.
10. Kilduff L, Population Reference Bureau. Which US States Are the Oldest? Published December 22, 2021. Accessed February 9, 2024. https://www.prb.org/resources/which-us-states-are-the-oldest/.
11. DC Health Matters. 2023 Demographics: Age Data for City: District of Columbia. Accessed February 27, 2024. https://www.dchealthmatters.org/demographicdata?id=130951&sectionId=942.
12. World Population View. Most Rural States. Accessed February 26, 2024. https://worldpopulationreview.com/state-rankings/most-rural-states.
13. Association of American Medical Colleges. 2021 State Physician Workforce Data Report, January 2022. Accessed February 27, 2024. https://store.aamc.org/2021-state-physician-workforce-data-report.html.