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Tomorrow’s Healthcare Challenges: Will the Neurosurgical Workforce Measure up?

Guest Post From Ann R. Stroink, MD, FAANS
Central Illinois Neuro Health Sciences
Bloomington, Illinois

Like other neurosurgeons, I maintain a busy practice, take call, train residents and work with hospital administrators and members of the healthcare team to ensure that my patients receive the highest quality care. Days start early and end late. Time is a valuable commodity, but we make the most of every day by anticipating problems, creating efficiencies, and making informed decisions.

With demands on our time that require careful planning, I’ve grown increasingly frustrated with what I see as a big problem for this country: chronic, irresponsible procrastination. We have allowed our leaders to kick the can down the road, time and again ignoring looming issues with clear, predictable and significant impact.

This is true, too, of medicine.

In 1997, when President Bill Clinton signed the Balanced Budget Act of 1997 capping the number of Medicare funded residency positions, the baby boomers were 33-51 years of age – the oldest of them only 14 years from Medicare eligibility and retirement. Seventy-five million aging people would eventually engage the healthcare system as a natural part of the life cycle, yet no forethought was given to the workforce needed to care for them. Today, the (AAMC) forecasts a shortage of 63,000 physicians by 2015, growing to 130,000 by 2025. The anticipated workforce shortage has long been predicted and yet our leaders delay instituting practical solutions for addressing the problem.

Neurosurgery is not immune to the challenges that lie ahead, as demonstrated by the AAMC in its and physician specialty data books. Our workforce is aging – in 2010, 43 percent of the neurosurgical workforce was age 55 or older – and growth has slowed. From 2007-2010, the number of active neurosurgeons increased by 2.6 percent; however, the number of neurosurgeons specializing in patient care only increased by 0.6 percent. Meanwhile, U.S. population growth is outpacing that of the neurosurgical workforce. During the same time period, the number of people per patient-care neurosurgeon increased 1.9 percent. The slow growth of our patient-care neurosurgeons relative to the total population, coupled with the impending increase in healthcare users, will increase workload demands and negatively impact patient care.

The (ACGME) resident duty hour restrictions instituted in 2003 also impact workload practice demands. While this was done in the name of patient safety, there has been no definitive evidence to show that the limits achieved their intended goals. In fact, many believe that limiting resident work hours has impeded the resident’s growth as a physician. The work hour restrictions not only limit resident exposure to neurosurgical cases and patient care, but exacerbate the problems of an aging physician population by forcing older physicians to work longer hours.

Addressing concerns about the future of the neurosurgical workforce is not a can we can kick down the road. As older neurosurgeons retire, we need to proactively plan for workforce replenishment, particularly in a modern healthcare environment that stresses work-life balance and encourages hospital employment. It takes seven years to train a neurosurgery resident; replacing someone cannot be done overnight. We need to act now – especially if we want to grow the profession – to avoid an even greater crisis in the future. Expanding the number of residents could alleviate this problem by providing more assistance to older physicians, extending their careers, and fighting the physician shortage until more residents become independently practicing physicians.

To that end, I recently had the opportunity to introduce Representative Aaron Schock (R-IL-18) at the March 19, 2013, policy roundtable on GME and physician workforce put on by the .  Just days earlier, Rep. Schock, along with Rep. Allyson Schwartz (D-PA-13), introduced the Training Tomorrow’s Doctors Today Act (H.R. 1201), a piece of legislation intended to address physician workforce issues by expanding funding for Medicare sponsored residency positions.

Expanding Residency Training
Over the next five years, the Training Tomorrow’s Doctors Today Act would expand Medicare funding for residency training by 15,000 slots – 3,000 positions for each year. The slots will be divided into two groups. One-third of all available positions will be reserved for a “cap-relief pool.”  These positions will be allocated to hospitals that already train residents in excess of their Medicare funded positions.  Hospitals receiving assistance through this pool must train at least 30% of their residents in primary care and general surgery.  The legislation distributes the remaining two thousand slots under the “priority pool.”  The order of priority for disbursement is:

  • Hospitals with at least 40% of their graduates in primary care over the previous 5 years
  • Hospitals in states with medical schools that have opened since 1997
  • Hospitals eligible for electronic health record (EHR) incentive payments
  • All other hospitals

The U.S. Department of Health and Human Services must distribute slots to higher priority facilities before lower priority facilities.  Hospitals may apply for positions in both pools; however, they may not be awarded more than seventy-five total positions in a given year.  Overall, 50% of new residency positions must be awarded to primary care.  The other 50% must be awarded to a designated “shortage specialty” as determined by the 2008 Health Resources and Services Administration workforce report until a new report is completed.

In addition to expanding available residency slots, the Training Tomorrow’s Doctors Today Act commissions a variety of studies that examine GME and the physician workforce.  The studies include:

  • Health and Human Services is to examine Medicare GME payments utilizing hospital reported data on how they use GME funding.
  • The Government Accountability Office (GAO) will report on the physician workforce by January 1, 2014. This report is to provide an update on medical specialties facing a physician shortage.
  • The GAO will investigate strategies for increasing the diversity of healthcare professionals.
  • The GAO will study and report on how well physicians are caring for older adults.

At the same time that Representatives Schock and Schwartz introduced H.R. 1201, Senator Bill Nelson (D-FL) and his co-sponsors Sens. Charles Schumer (D-NY) and Harry Reid (D-NV) introduced similar legislation in the U.S. Senate. Though there are differences, at its core, Senator Nelson’s legislation, S. 577, the Resident Physician Shortage Reduction Act of 2013, is similar to the bills in the House of Representatives, as it also provides for 15,000 additional residency positions over the next five years.

Contact Your Representatives
At the Alliance of Specialty Medicine policy roundtable on GME and physician workforce, Rep. Schock noted that the looming physician shortage is an avoidable crisis and that constituent support is needed for this legislation.  Though he believes that support will come, especially as people experience the consequences of the Affordable Care Act and limits on access to physicians, this is an issue on which neurosurgery needs to be a leader. In that spirit, I hope that you will take the time to contact your senator or representative and ask them to support H.R. 1201, the Training Tomorrow’s Doctors Today Act and S. 577, the Resident Physician Shortage Reduction Act.

With your help, we can prevent tomorrow’s physician workforce shortage crisis today!

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