Pediatric surgery workforce: population and economic issues

doi:10.1016/j.jpedsurg.2008.02.081

Journal of Pediatric Surgery

Volume 43, Issue 8, August 2008, Pages 1426-1431

https://doi.org/10.1016/j.jpedsurg.2008.02.081 Get rights and content

Abstract

Background

Whether a shortage of pediatric surgeons exists in the United States, such as those observed in the total physician and general surgical workforces, is an important issue that will affect decisions regarding training, credentialing, and reimbursement. Our goal was to update information regarding the demand and supply of pediatric surgeons.

Methods

Online American Pediatric Surgical Association (APSA) membership directory gave numbers of pediatric surgeons and their residence by metropolitan statistical areas (MSA), defined by the US census. Population and economic data were obtained from appropriate US government agencies.

Results

There were 835 APSA members and 375 MSA. Eliminated were 86 MSA (with 12 APSA members) with incomplete data, 14 MSA (0 members) with populations less than 100,000, and 25 members with listed locations outside an MSA. The remaining 798 members and 275 MSA comprised the study. The number of APSA members in an MSA correlated closely with MSA population (R² = 0.836) and 2006 births (R² = 0.767). Metropolitan statistical areas without an APSA member had a smaller population and birth rate than those with one or more members (P = .0001). An MSA with 1 APSA member had a higher population (P = .0003) and births per APSA member ratios (P = .0014) than MSA with 2 and 3 or more members. The presence of a medical school or a pediatric training program had no effect on population or births-to-APSA member ratios. There was no correlation between numbers of APSA members and state GDP or state GDP per capita. We used a low, medium, and high threshold to predict the need for pediatric surgeons based upon population per APSA member ± 1 SD (272,466 ± 163,386) to predict a need of 82 to 1344 pediatric surgeons, an increase in the APSA membership by 10% to 168%.

Conclusion

Based on population estimates and APSA membership, a current shortage of pediatric surgeons exists. Measures should be taken to address this workforce issue.

Section snippets

Materials and methods

The APSA member directory (http://www.eapsa.org/) identified APSA members' locations by city and state. The December 2006 US Census Bureau Metropolitan Statistical Areas and Components defined MSA (http://www.census.gov/) for the purposes of the study. The surgeon's office address given in the directory was used as to assign the surgeons' MSA. The most recent iteration of MSA is a refinement of previous versions, combining large geographic regions into a single unit that covers more than one

Results

There were 835 APSA members and 375 MSA. Eliminated were 86 MSA (with 12 APSA with listed locations there) with incomplete data, 14 MSA (0 APSA) with populations less than 100,000, and 25 APSA members with listed locations outside an MSA. The remaining 798 APSA and 275 MSA comprised the study.

The number of APSA members in an MSA correlated closely with MSA population (R² = 0.836; Fig. 1). Metropolitan statistical areas falling above the regression line had relatively more APSA members than

Discussion

The fundamental weakness of our study is the use of APSA membership as a first estimate for the numbers of pediatric surgeons in full-time practice. There are pediatric surgeons in active practice who have just finished training and not completed APSA requirements and those who have chosen not to join APSA or who are ineligible. We do not count the 20 to 30 surgeons who will be inducted as new APSA members (May 2008) as the membership and roster are updated at the annual APSA conference. We

References (11)

G.F. Sheldon et al.
Supply and demand—surgical and health workforce
Surg Clin N Am
(2004)
J.A. O'Neill et al.
An analysis of the need for pediatric surgeons in the United States
J Pediatr Surg
(1980)
J.A. O'Neill et al.
Update on the analysis of the need for pediatric surgeons in the United States
J Pediatr Surg
(1995)
E.S. Wiener et al.
Hernia survey of the section on surgery of the American Academy of Pediatrics
J Pediatr Surg
(1996)
M.I. Rowe et al.
An analysis of the operative experience of North American pediatric surgical training programs and residents
J Pediatr Surg
(1997)

There are more references available in the full text version of this article.

Cited by (31)

The Canadian Pediatric Surgery Workforce: A 10-year Prospective Assessment
2024, Journal of Pediatric Surgery
The Canadian Association of Paediatric Surgeons launched a 10-year prospective assessment of the Canadian pediatric surgery workforce and training environment, beginning in 2013. The results of the first 5 years (2013–2017) were previously published. Here, we present the results of the last 5 years (2018–2022), and the cumulative results of the past decade.
With IRB approval, a web-based survey was sent to all pediatric surgery division chiefs in Canada each year (2013–2022). The survey gathered workforce data on pediatric surgery practices, as well as data regarding fellowship graduates from Canadian training programs.
Complete responses were received from all 18 divisions (100% response rate). Over the decade studied, the number of pediatric surgeons and full-time equivalent positions increased from 73 to 81, and 65 to 82, respectively. Thirty positions were vacated (15 retirement, 6 new Canadian practice, 8 leaving Canada, 1 other), and 38 were filled (20 new Canadian fellowship graduates, 8 Canadian surgeons moving from other sites in Canada, 10 surgeons coming from outside Canada). Seventy-five fellows completed training eligible for North American certification, including 34 Canadians, 31 Americans, and 10 non-North American foreign nationals (9 of whom left North America after training). The proportion of Canadian graduates who desired, but could not find, a Canadian position improved from 44% in the first 5 years to 20% in the second 5 years.
The Canadian pediatric surgery workforce has experienced a modest increase over a decade. A mismatch still exists between Canadian pediatric surgery graduates and attending staff positions, but the situation has improved during the last 5 years.
Survey.
5.
Location of Treatment Among Infants Requiring Complex Surgical Care
2023, Journal of Surgical Research
Rural children have worse health outcomes compared to urban children. One mechanism for this finding may be decreased access to specialized care at children's hospitals. The objective of this study was to evaluate the hospital types where complex surgical care in infants is performed nationally.
This study examined infants (<1 y old) in the Kids' Inpatient Database from 2009 to 2019 who underwent surgery for one of the following conditions: esophageal atresia, gastroschisis, omphalocele, Hirschsprung disease, anorectal malformation, pyloric stenosis, small bowel atresia, congenital diaphragmatic hernia, and necrotizing enterocolitis. The relationship between patient residence (rural versus urban) and location of surgical care (children's hospital versus other) was compared in relation to other covariates using multivariable logistic regression models.
Among 29,185 infants undergoing these operations, 16.0% lived in a rural area. Rural infants were more frequently White (64.8% versus 43.4% P < 0.001), from the lowest two income quartiles (86.5% versus 52.0%, P < 0.001), and from the South or Midwest regions (P < 0.001). Surgical care was predominantly (94.1%) provided at urban teaching hospitals but frequently not at children's hospitals, especially among rural infants. After adjusting for other covariates, rural infants were significantly less likely to undergo care at a children's hospital for both 2009 (adjusted odds ratio 0.66, P < 0.001) and 2012-2019 (adjusted odds ratio 0.78, P < 0.001).
A sizable portion of complex surgical care in infants is performed outside children's hospitals, especially among those from rural areas. Further work is necessary to ensure adequate access to children's hospitals for rural children.
The Pediatric Surgical Team: a Model for Increased Surgeon Index Case Exposure
2019, Journal of Pediatric Surgery
Citation Excerpt :
These findings are not remarkable of themselves: in an isolated setting with a fixed population such as Hawai‘i, it would be predicted that the region would need 3–5 pediatric general surgeons. Workforce models would predict, as we found, that individual surgeon case volume would be sufficient and likely above average even without a team approach [11]. Nevertheless, as a model for improved surgical volume and systems improvement, it may be worthy of consideration in select settings.
High surgical volume for both surgeons and hospital systems has been linked to improved outcomes for many surgical problems, yet case volumes per pediatric surgeon are diminishing nationally in complex pediatric surgery. We therefore sought to review our experience in a geographically isolated setting where a surgical team approach has been used to improve per-surgeon exposure to index pediatric surgical cases.
As a surgical group, we incorporated a surgical team approach to complex pediatric surgical cases in 2010. We obtained institutional review board approval to review our pediatric surgeon index case volume experience. We then compared our surgeon experience to published surgical volumes for complex pediatric surgical cases.
A surgical team approach (2 or 3 board certified pediatric surgeons/urologists working as co-surgeons or assistant surgeon) was used in the majority of cases for tracheoesophageal fistula/esophageal atresia (77%), congenital pulmonary airway malformation (73.5%), cloaca (75%), anorectal malformation (43.6%) biliary atresia (77.8%), Hirschsprung's disease (51.9%), congenital diaphragmatic hernia (67.6%), robotic choledochal cyst (100%), and complex oncology (adrenal tumors, neuroblastoma, Wilms tumor and Hepatoblastoma surgery) (85–100%). Over the 5-year period, surgeon index case exposure for all index pediatric surgical cases was above the published national median for pediatric surgeons, except for in splenic operations when contrasted to published experience.
A surgical team approach to complex pediatric surgery may help maintain exposure to adequate index case volumes. This model may be useful for maintaining competence in geographically-isolated practice settings and low-volume pediatric hospitals that provide surgical care; the model has implications for systems development and workforce allocation within pediatric surgery.
4
The Canadian pediatric surgery workforce: A 5-year prospective study
2019, Journal of Pediatric Surgery
In 2014, a survey study of the Canadian pediatric surgery workforce predicted a need for 2 new pediatric surgeons/yr. in Canada. We sought to assess these predictions and evaluate the status of the workforce.
With IRB approval, a web-based survey was sent to pediatric surgery division chiefs in Canada each year (2013–2017). The survey data included: number of practicing pediatric surgeons, full time equivalent (FTE) positions, and fellowship graduates.
There was a 100% response rate (18 divisions). From 2013 to 2017, the number of practicing pediatric surgeons and FTE positions increased (73 to 78, and 64.6 to 67.5, respectively). Eleven positions were vacated (4 retirement, 7 new practice), and 18 were filled. Eight were filled by new Canadian graduates, 7 by Canadians previously working in Canada or abroad, and 3 by European surgeons. Thirty-eight fellows completed training in Canada, including 24 non-Canadians who all left Canada. Nine Canadians who started practicing immediately after fellowship took positions in Canada (5) and the US (4).
Predictions made in 2014 were largely accurate. There has been modest growth in the Canadian pediatric surgery workforce over the last 5 years. A significant mismatch continues to exist between Canadian pediatric surgery graduates and attending staff positions.
Survey.
V
Partnership in fellowship: Comparative analysis of pediatric surgical training and evaluation of a fellow exchange between Canada and Kenya
2016, Journal of Pediatric Surgery
Citation Excerpt :
Chief among these is the profound lack of surgical workforce. Recent demographic data suggest that there are nearly the same number of practicing pediatric surgeons in the five largest metropolitan areas of the United States (serving approximately 3.3 million children) as there are serving the roughly 500 million children in sub-Saharan Africa [5,8]. The magnitude of the surgical need cannot be understated, particularly when considering estimates that nearly 85% of children will require some surgical intervention by their 15th birthday, and more than 10% of surgical admissions in Africa are for children [9,10].
In pediatric surgery, significant differences in education and practice exist between developed and developing nations. We compared the training of senior fellows in a Canadian and a Kenyan pediatric surgery training program, and evaluated a fellow exchange between the programs.
The study was performed six years after creation of the exchange program. Areas studied included case volume and distribution, length of training, curriculum, work hours, and an estimate of service to education ratio. Perceived strengths and challenges of the exchange were investigated using questionnaires.
Fellows at each site performed approximately 450 cases/year. Significant differences in case distribution were noted, with plastic surgery, urology and neurosurgery procedures being significantly more frequent in the Kenyan center, and neonatal, minimally invasive, and vascular access procedures being significantly more frequent in the Canadian center. All participants identified educational value in the exchange, although logistical challenges were significant.
Differences exist in the training experiences of pediatric surgical fellows in Canada and Kenya, reflecting the differences in health care environment, education, and surgical practice in the two countries. The exchange program of pediatric surgical fellows tapped into this rich diversity and may be applicable to other medical and surgical specialty training programs.
Global comparison of pediatric surgery workforce and training
2015, Journal of Pediatric Surgery
The number of pediatric surgeons and their distribution vary greatly throughout the world. The purpose of this study is to examine potential influential factors including the length of education and training, pediatric population, birth rate, and gross domestic product (GDP) per capita.
An internet search was conducted to determine the duration of education from grade school to pediatric surgery fellowship, number of pediatric surgeons, birth rate, GDP, and population under 15 years of age in 15 countries. The number of pediatric surgeons per million children was correlated with these factors.
The number of pediatric surgeons per million children varied from 0.51 to 29.3. The total length of education from grade school to completion of pediatric surgery training ranged from 23 to 29 years. There was no correlation between pediatric surgeons per million children with the duration of training. The number of pediatric surgeon per million children was inversely correlated with the birth rate. There was a positive correlation between the GDP per capita and pediatric surgeons per million children.
There is a tremendous variability in pediatric surgeons around the world. There appears to be a significant shortage of pediatric surgeons in countries with a high birth rate and low GDP per capita.

View all citing articles on Scopus

View full text

Original articlePediatric surgery workforce: population and economic issues

Abstract

Background

Methods

Results

Conclusion

Section snippets

Materials and methods

Results

Discussion

Surg Clin N Am

J Pediatr Surg

J Pediatr Surg

J Pediatr Surg

J Pediatr Surg

Original article
Pediatric surgery workforce: population and economic issues