Vascular surgery in the United States

Transcription

1 SPECIAL ARTICLE Vascular surgery in the United States Report of the Joint Society for Vascular Surgcry-- International Society for Cardiovascular Surgery Committee on Vascular Surgical Manpower Calvin B. Ernst, M.D., Ira M. Rutkow, M.D., MPH, Dr.PH, Richard J. Cleveland, M.D., J. Roland Boise, M.D., George Johnson, Jr., M.D., and James C. Stanley, M.D. The Joint Committee on Vascular Surgical Manpower was established in 1985 by the Society for Vascular Surgery and the North American Chapter of the International Society for Cardiovascular Surgery. It was charged to provide recommendations regarding vascular surgical manpower requirements for the next 15 years. Analysis of National Center for Health Statistics vascular operative rate data and 1690 questionnaire responses from vascular surgeons documented that vas~atlar surgeons performed 235,400 (41%) of the total of 571,000 vascular operations undertaken in Vascular surgeons performed 87% of 30,000 aortolliofemoral reconstructions, 77% of 72,000 peripheral vessel bypasses, 75% of 33,000 abdominal aortic aneurysm repairs, 59% of 55,000 angioaccess procedures, and 50% of 107,000 carotid endarterectomies. However, lack of accurate data on caseloads of surgeons who were not vascular specialists precludes precise prediction of manpower requirements for vascular surgery. It is important that surgical leaders and policy makers define the types of vascular surgical procedures that may be undertaken by vascular and other surgeons. Ongoing analyses must include such determinations to establish accurate data for the prediction of future manpower needs for vascular surgery. Furthermore, future manpower studies should be linked to outcome studies to assess not only numbers of surgeons and operations but quality of care as well. (J VAsc SURG 1987;6: ) Among many socioeconomic questions that confront this country's surgeons, those concerning vascular surgical manpower and vascular surgical rates have been widely discussed.l-s Who performs vascular surgical operations, how many of these operations are performed annually, and whether vascular surgical hospital privileges should be restricted to a defined cadre of surgeons remain controversial issues. In addition, since general vascular surge D, has become a recognized specialty by the American Board of Surgery (ABS) and training programs have bccn defined and approved by the Residency Review Committee (RRC) for Surgery, the question of how many vascular surgeons should be trained annually Presented at the Thirty-fifth Scientific Meeting of the North American Chapter, International Sociew for Cardiovascular Surgeu, Toronto, Canada, June 8-9, Reprint requests: Calvin B. Ernst, M.D., Henry Ford Hospital, 2799 West Grand Blvd., Detroit, MI has become more relevant. To this end and because vascular surgery is a relatively young and dynamic branch of medicine, it would seem that the principal currcnt health planning need is for data gathering, monitoring, and analysis rather than implementation of arbitrary or bureaucratic controls. To address these important manpower issues, in 1985 Drs. James A. DeWeese and Anthony M. Imparato, Presidents of the North American Chapter of the International Society for Cardiovascular Surgery (ISCVS) and the Society for Vascular Surgery (SVS), respectively, appointed Dr. Calvin B. Ernst to chair and organize a Joint Committce on Vascular Surgical Manpower with representation from both societies. Society members accepting this charge were Drs. Richard J. Cleveland, J. Roland Folse, George Johnson, Jr., and James C. Stanley. Dr. Ira M. Rutkow served as consultant to the committee. The committee was charged with determining the proportion of vascular surgical operations performed by vascular 611

2 612 Ernst et al. 7oum~ o5 VASCULAR SURGERY ,0~ TOTAL OPERATIONS ON 5 ~ THE VASCULAR SYSTEM 553, ;[ o_ J L O L 125" 360,000~ n uj , ,000 PERIPHERAL ; OPERATIONS 15S,000~ t;n nnn " ' ~ HEAD AND NECK ' ~ ~ OPERATIONS... ~'~131,00,O~--.~ 8 INTRA-ABDOMINAL 134,u~~ 4r_~ 149, ,000 OPERATIONS 97, 000~ 118, ' ~ 38,000 41,000 50,000 55,000 ANGlO-ACCESS e A OPERATIONS 19' ' YEARS Fig. 1. Overall vascular surgical operations, through Absolute numbers are noted. age-sex standardized surgical rates from 1979 and nonvascular surgeons, the 1985 rates of vascular surgery in the United States, and recommendations regarding vascular manpower requirements for the next 15 years. This report summarizes the findings of the Joint Committee on Vascular Surgical Manpower. SOURCES OF DATA AND METHODS Surgical rates. The National Center for Health Statistics (NCHS), through its National Hospital Discharge Survey, has compiled data on surgical rates in the United States since These data were gathered from face sheets of medical records of inpatients discharged from an approximate 5% sample of nonfederal short-stay hospitals in the 50 states and the District of Columbia. Through a complex system of weighting measures, the sample data were expanded to produce national estimates of the absolute numbers of operations performed by age and sex in a given year. 4 As in all surveys, results of this study were subject to nonsampling and sampling errors. Approximate relative standard errors of estimated mtmbers of procedures in this report are 18% for 10,000 operations, 11% for 100,000 operations, and 7% for 1,000,000 operations. Two major rubrics were used from the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) in this analysis: rubric 38 (incision, excision, and occlusion of vessels) and rubric 39 (other operations on vessels). Within these two rubrics were some codes that did not define a vascular operation (38.5, 38.85, 38.9, 39.0, 39.6, 39.91, 39.92, and through 39.97) and these were excluded. Once appropriate macrodata wer c identified, vascular operations were stratified into four major components: peripheral operations, head and neck operations, intra-abdominal operations, and angioaccess operations. Angioaccess has the following ICD-9-CM codes: 39.27, 39.42, 39.43, 39.93, and Information was also obtained for several specific vascular reconstructive procedures. Included among the peripheral operations were shunt or bypass including axillofemoral, femorofemoral, and femoropopliteal (39.29); suture and repair of laceration of blood vessel (39.3 and through 39.5); embolectomy (38.00, 38.03, 38.08, and 38.09); and endarterectomy (38.18). Among head and neck operations were carotid endarterectomy (38.12) and aorta-subclavian-carotid bypass (39.22). Within the intra-abdominal category were aortic aneurysm

3 Volume 6 Number 6 December 1987 Vascular surgical manpower LOWER EXTREMITY 115,000 AMPUTATION 114,000 ~ (TOE, FOOT, BKA AND AKA) 45-.J L 0 %,r. Ill O , ~ 46,000 52,000 54,000 (AXILLARY-FEMORAL 74,000 72,000 BYPASS. ~ FEMOnA'-~EMORAL, FEMORA" ~- POPLITEAL, ETC.) / 58.00o REPAIR OF.//~",.JUREO VESSEL / ~*-...~.~8,ooo / / ~ EMBOLECTOMY :t 28, ,000 17,000 12,000 ~ ENDARTERECTOMY 10, O'-'---"~ e---'--"" YEARS Fig. 2. Vascular surgical operations on peripheral blood vessels, age-sex standardized surgical rates from 1979 through Lower extremity amputations are also displayed. Absolute numbers are noted. (38.44 and 38.64); aortoiliofemoral bypass (39.25); endarterectomy (38.14 and 38.16); aneurysm other than aortic (38.46 and 38.66); plication ofvena cava by either filter or ligation (38.7); venous shunts (39.1); embolectomy (38.06); aorta-celiac-superior mesenteric bypass (39.26); and aortorenal bypass (39.24). Vascular surgical procedures performed at federal institutions, such as Armed Forces Hospitals and Veterans Administration Hospitals, were not included in this analysis. Therefore, it should be recognized that the absolute numbers recorded represent an underestimate of somewhat less than 5% of the total numbers of vascular operations performed in the United States. Regardless, the establishment of trends and comparison of absolute figures remain valid. In a comparison of annual vascular surgical rates, operative procedure data can be affected considerably by the age-sex composition of the population studied. To compensate for these differences, a standardized surgical rate has been employed. The surgical rates of varying age-sex groupings in 1979, 1981, 1983, and!985 were calculated and applied to a common standard population, that of the 1972 population of the United States. These summarized total rates define what the rates in a given year would be if each year included an equivalent in age-sex population distribution instead of actual differing populations. The age groups birth to 14 years, 15 to 44 years, 45 to 64 years, and 65 years and over were used in the standardization process. Therefore it is important to recognize that the object throughout was only comparison; a standardized surgical rate standing alone has no meaning. Vascular surgeons questionnaire. A questionnaire concerning vascular surgical manpower was developed by the Joint SVS-ISCVS Committee on Vascular Surgical Manpower (see boxed material on page 620). The goal of this portion of the study was to determine the volume of vascular surgical procedures performed by vascular surgeons as defined by the committee. This information would serve as a base for calculation of the numbers of vascular surgical procedures performed by general surgeons and other surgical specialists not defined as vascular surgeons. A vascular surgeon was defined as one who was a member of either the SVS, the ISCVS, North

4 614 Ernst et al. 3ourn± of VASCULAR SURGERY ,000 CAROTID ENDARTERECTOMY Z 30- _.q.j ~ 25-0 L ~ 20-1= ul ~ ,000. e"~ 14,000 ~--e--.~o ~ SYMPATHECTOMY-LUMBAR 2000 e-""""~-- - -~ ~ AORTA-SUBCLAVIAN-CAROTID 0 i I I I BYPASS YEARS Fig. 3. Vascular surgery operations on head and neck blood vessels, age-sex standardized surgical rates from 1979 through Absolute numbers are noted. American Chapter, any one of 18 regional or local vascular societies (see boxed material on page 619), or having passed either part of the American Board of Surgery (ABS) Examination for Certification of Special Qualifications in General Vascular Surgery. To provide a data base for the United States alone, Canadian surgeons were excluded. Membership rosters of the SVS and ISCVS were combined, excluding duplicatc names, and this list served as the crossindexing base. Against this base, regional vascular society membership rosters and ABS-qualified and certificd vascular surgeons were cross-indexed to exclude duplicate names. A total of 2414 vascular surgeons were identified. Questionnaires were mailed to vascular surgeons in June and July In all instances anonymity was assured. Second and third mailings were sent to nonrespondents from September through December Each individual surgeon was asked to provide the total number of specified vascular operations they performed in These included arterial reconstructions, cmbolectomies, endarterectomies, vascular injury repairs, and angioaccess procedures, portosystemic shunts, and venous reconstructions. In addition, exact numbers were requested for five specific vascular procedures for which they were surgeons of record. Included were peripheral arterial bypass, carotid endartcrectomy, abdominal aortic aneurysm repair, aortoiliofemoral bypass, and angioaccess. The following explanations describe calculations used to evaluate the raw questionnaire data. There were 16 numeric categories regarding the total number of vascular operations. The median of cach category (20-29 = 25; = 112~ wa~multiplied by the number of respondents in that category, and the sum of these 16 products was considered the total number of vascular operations pcrformed by all the respondents. To calculate the total number of vascular procedures performed bv all vascular surgeons as defined by the committee, an assumption was made that nonrespondents carried a similar caseload as respondents. There was an actual response of 65% to question 2 (the number of vascular operations performedl Accordingly, the calculated number of reported vascular operations was expanded to equate to 100% to account for the unreported data from the 35% of nonresponding vascular surgeons. This calculation defined the total number of vascular operations performed by all cohort vascular surgeons in the United States. This

5 Volume 6 Number 6 December 1987 Vascular surgical manpower ,000 ~ ABDOMINAL AORTIC ANEURYSM REPAIR o % 12-19,00/ 18,000 / ~.~/~'~ 0,0"~0 2 7, ~ -28'000 AORTA-iLIAC-FEMORAL 00 BYPASS 3- ~ VENA CAVA (INCLUDING FILTERS) 4000 ENDARTERECTOMY 400-~ pofltosystemic SHUNT EMBOLECTOMY <2000~r~ < 00-- < ~2g OTHER AORTA-CELIAC-MESENTERIC ANEURYSM REPAIR BYPASS <2oooe <1000~ <tgoo= < lo0o~.--~ Z --<2000 AORTA-RENAL BYPASS 1 I I I YEARS Fig. 4. Vascular surgical operations on intra-abdominal blood vessels, age-sex standardized surgical rates from 1979 through Absolute numbers are noted. figure was then contrasted with the actual number of vascular surgical procedures provided by NCHS data in In regard to the five index operations, peripheral vessel bypass, carotid endarterectomy, abdominal aortic aneurysm repair, aortoiliofemoral bypass, and angioaccess, actual numbers for each category were totaled. As in question 2, the actual response to question 3 on index cases was 65%. Therefore, the totaled respondents' data were expanded to equate to 100% to account for the unreported data from the 35% of nonresponding vascular surgeons. This provided the total numbers of five vascular surgical procedures performed by the defined cohort of vascular surgeons. The percentage of the total operative caseload represented by vascular operations and the percentage if any of vascular operations performed at either an Armed Forces Hospital or a Veterans Administration Hospital was determined for the vascular surgeon cohort from questions 4 and 5. The respondents' percentages were totaled and this figure was divided by the number of respondents to yield an average that was assumed to be representative of the entire cohort. RESULTS NCHS vascular surgery data. In 1985, on the basis of NCHS data, a total of 571,000 vascular operations were performed in the United States (Fig. 1). It should be noted that data in subsequent figures of surgical rates do not agree with the totals in Fig. 1 because each figure includes only selected operations within each category delineated in Fig. 1. The 204,000 operations on peripheral blood vessels represented 36% of the total and was the most common of the four major subdivisions of vascular surgical procedures, Head and neck vascular operations numbering 168,000 accounted for 29% of the total, with the 143,000 intra-abdominal operations representing an additional 25 %. Angioaccess procedures (55,000) accounted for another 10% of the total reported vascular operations. The changes between 1979 and 1985 in specific vascular surgical rates are shown in Fig. 2. The trend in rates of operations on peripheral blood vessels paralleled amputations. A total of 72,000 peripheral bypasses were performed in Extremity amputations numbering 115,000, although not counted among vascular procedures, included 31,000 aboveknee, 29,000 below-knee, 12,000 foot, and 43,000

6 616 Ernst et al. 5oumed o( VASCULAR SURGERY A (22%) 296(19%) 0 k (16%) ; [9(16 (n uj a ;Z 0 1. u) (9% 129(8%) d z (6%) 61<1%) 7(<1%1 ( ' I ' ; Prior to t YEAR Fig. 5. Year in which questionnaire respondents completed surgical training. Sixty-five percent have completed training within the past 20 years. Table I. Portion of vascular operations performed by vascular surgeon cohort in 1985 Portion of national total NCHS Actual cohort Ex~and~d to include Operation totals response entire cohort" % All operations 571, , , Aortoiliofemoral 30,000 17,000 26, Peripheral vessel bypass 72,000 36,000 55, Abdominal aortic aneurysm 33,000 16,000 24, Angioaccess procedures 55,000 21,000 32, Carotid endarterectomy 107,000 35,000 53, NCHS = National Center for Health Statistics. *See text for definition. toe amputations. Among peripheral blood vessel operations, significant growth from previous years' volume was identified only for repair of injured vessels. Embolectomies declined and endarterectomies remained relatively unchanged at 39,000 and 17,000, respectively, The most common arterial reconstructive procedure in 1985 was carotid endarterectomy, which was performed on 107,000 occasions (Fig. 3). However, the rate of increase in performance of this operation appears to have declined. Abdominal aortic aneurysm repairs totaled 33,000 in 1985 (Fig. 4). There were 30,000 aortoiliofemoral bypasses in the same year. Other intraabdominal procedures, both venous and arterial, were performed much less frequently. Vascular surgeon questionnaire data. The first mailing to vascular surgeons included a total of 2414 questionnaires with 1155, or 48%, returned. The second mailing (1259) had 341, or 27%, returned. The third and last mailing (918) had 194 returned for a 21% response. The overall response rate was 1690 of 2414 or 70%. A total of 237 questionnaires were marked "deceased, retired, performing only cardiac procedures, or no longer operating." These were excluded from analysis, leaving 2177 as the corrected total questionnaire distribution, which served as the denominator in computation of percentages. Approximately 65% of respondents completed their training within the past 20 years (Fig. 5). Less than 10% had been practicing for more than 30 years. There were 1415 surgeons who reported their cumulative number of vascular operations (question 2), with a total of i53,000 procedures reported. This number was expanded to compensate for nonrespondents to yield 235,400 operations (Table I).

7 Volume 6 Number 6 December 1987 Vascular surgical manpower " %~ " / 5~\ 91 80' 60" 40' 20' qr ~ 4% 4% 4% 4% 3% " 0"9 I 20"29 I 40"49 I 60"69 I 80-'89 h00" " '2' >251 NO. OF OPERATIONS Fig. 6. Number of vascular operations for which questionnaire respondents were surgeon of record in Fifty-one percent performed more than 100 operations. On the average, 107 operations were performed annually. This represents 41% of all vascular operations performed in the United States during 1985, on the basis of NCHS data. Conversely, 59% of vascular surgical procedures in this country were performed by general surgeons or other surgical specialists not defined as vascular surgeons. Approximately 50% of respondents had performed more than 100 vascular operations, and another 28% had performed 50 to 100 procedures in 1985 (Fig. 6). Of note is that among the defined cohort of vascular surgeons, 11% performed more than 200 procedures and 21% performed fewer than 50. On the average, 107 vascular procedures were performed annually by vascular surgeon respondents to the questionnaire. The response to performance of specific operations (question 3) allowed further insight into the practice of vascular surgery (Table I). Aortoiliofemoral reconstruction. The combined experience of the vascular surgeon respondents totaled 17,000, which when expanded represented 26,200 operations, or 87% of all 1985 aortoiliofemoral bypass procedures. Peripheral vessel bypass. The combined experience of the respondents in this category totaled 36,000. When expanded, 55,400 operations, or 77% of all peripheral vessel operative procedures, were performed by the vascular surgeon cohort. Abdominal aortic aneurysm. The combined experience of the vascular surgeon respondents was 16,000, which when expanded represented 24,600 operations, or 75% of all abdominal aortic aneurysm repairs performed in that year. Table II. Number of vascular operations a surgeon should perform per year to be designated a vascular specialist: Summary of vascular surgeon cohort responses No. of vascular operations No. of respondents (% of total) At least (13) At least (35) At least (24) At least (19) Greater than (9) Angioaccess. The reported experience of vascular surgeon respondents totaled 21,000, which when expanded represented 32,300 operations, or 59% of all 1985 angioaccess procedures. Carotid endarterectomy. The combined experience of respondents was 35,000, which when expanded represented 53,800 operations performed by vascular surgeons. This represented 50% of all carotid endarterectomies performed in The average portion of the vascular surgeon respondents' total caseload comprising vascular operations was 51% (Fig. 7). Only 13% of surgeons had practices exclusively limited to vascular surgery. Five percent of the vascular surgeon respondents' total caseload was from either Veterans Administration or Armed Forces Hospitals. Given this fact and with recognition that relatively few vascular procedures are performed in these institutions by surgeons not included in the respondent pool, then any expansion

8 618 Ernst et al. ~o,jx~a[ 05 VASCULAR SURGERY %) Z Z %) I ill III 87(6%1 9817%1 9817%) I I 207(13%) 140(10%)~[ [ ~ PERCENT OF CASELOAD Fig. 7. Percentage of vascular operations comprising questionnaire respondents' total surgical caseload in Average respondents' total caseload was 51%. of the NCHS data base to include these cases should be limited, and in no case should this reflect more than a 5% increase in the total numbers noted in this report. Fifty-two percent of the questionnaire respondents thought that to be considered a vascular specialist, performance of at least 75 vascular operations annually was required. Eighty-seven percent thought at least 50 procedures should be performed (Table II). Fifty-eight percent of respondents thought vascular surgical privileges should be restricted to vascular specialists defined by criteria reflecting the vascular caseload. DISCUSSION Commenting in 1984 on an analysis of the Graduate Medical Education National Advisory Committee report, Dr. Francis D. Moore noted, "No matter how we express it or rationalize it, there will be severe overcrowding of the surgical profession." He concluded, "And we can hope that the voluntary national surgical organizations will see this as a realistic problem and face it squarely rather than adopting the juvenile view that surgeons are such wonderful people that one can never imagine a situation in which there are actually too many of them. ''6 The study reported herein attempts to address these important manpower issues and provide a reasoned response to Moore's challenge. This study provides key data needed for determining future vascular surgical manpower needs. It establishes the role of vascular surgeons in the total surgical effort in treating patients with vascular disease. For instance, in 1985 approximately 41% of vascular operations in the United States were performed by surgeons with a recognized credibility in vascular surgery. Furthermore, four fifths of specific vascular operanons ~peripheral vessel bypass, abdominal aortic aneurysm repair, and aortoiliofemoral bypass) were performed by these vascular surgeons. Most of the balance of the 1985 vascular operations were performed by general surgeons and others not defined as vascular surgeons whose ranks total approximately 42,000.- Therefore 336,000 operations were performed by 42,000 nonvascular surgeons contrasted with the 235,000 performed by 2400 vascular surgeons. The validity of the protocol used to generate the study data can be assessed from the responses regarding carotid endarterectomy and angioaccess procedures. The questionnaire protocol might be suspect if the percentages of vascular surgeons performing the five specific operations delineated in question 3 (peripheral vessel bypass, carotid endarterectomy, abdominal aortic aneurysm repair, aortoiliofemoral reconstruction, and angioaccess) were equal or strikingly similar. Instead, the data documented that surveyed vascular surgeons performed 50% of all carotid endarterectomies. Although neurosurgeons and most cardiothoracic surgeons and general surgeons were not polled, it can reasonably be assumed that they performed meaningful numbers of these carotid artery operations. Indeed, this same data collection protocol has also been used by the Ad Hoc Committee on Manpower of the American Association for Thoracic Surgery and the Society of Thoracic Surgeons. Their study suggested that board-certified

9 Vo;ume 6 Number 6 December 1987 Vascular surgical manpower 619 thoracic surgeons perform approximately 15% of all vascular surgical operations (F. Loop, personal communication, 1987). Similarly, 59% of angioaccess operations were performed by vascular surgeons, a finding consistent with the fact that many angioaccess procedures are performed by transplant surgeons and general surgeons. In 1985 the total number of vascular operations performed showed the smallest increase (3%) compared with previous 2-year periods since 's'8'9 From 1970 through 1978, vascular surgical procedures increased 140%; from 1979 through 1981, vascular surgical procedures increased 24%; and another 24% increase was observed from 1981 through As with most surgical specialties it would appear that rates of vascular surgical procedures have not continued to increase as rapidly as in the past. 1 Whether this plateau effect is transient or is the beginning of a general trend remains uncertain. In this regard this study documented that for the individual respondent, surgical practice is currently 50% vascular in nature. Interestingly, for almost one fourth of the surveyed surgeons, their practice was greater than 90% vascular. Currently about half of the vascular surgeons perform a significant number of vascular operations. In the future this share may increase as more vascular surgeons are trained. Future percentages will depend on various factors, including numbers of surgeons and numbers of vascular operations performed. Determination of future vascular surgical manpower requirements demands knowledge of certain data bases. These are (1) past and current rates of vascular surgical operations, (2) determination of which surgeons perform or should perform vascular operations, (3) ability to predict future vascular surgical operative rates, and (4) establishment of competency levels regarding numbers and types of vascular operations that a surgeon should perform to be recognized mad certified as a vascular specialist. The current analysis provides insights into some of these issues. However, there is enough doubt regarding philosophical questions of who should or should not be performing vascular procedures, competency levels, and certification, that the process of determining future vascular surgical manpower requirements is still complicated with uncertainty. Among surgical specialies, it is particularly difficult to forecast the number of surgeons constituting an oversupply or shortage. However, data from our respondents suggest that more than 80% completed their training after 1960, and almost 50% finished their training after Thus vascular surgery is a relatively young branch of medicine, and it would REGIONAL VASCULAR SOCIETIES Allegheny Vascular Society Chesapeake Vascular Society Cleveland Vascular Society Delaware Valley Vascular Society Gateway Vascular Society Hawaiian Vascular Society Midwestem Vascular Surgical Society New England Society for Vascular Surgery Northern California Vascular Society Peripheral Vascular Surgery Society Portland Vascular Society Puget Sound Vascular Society Society for Clinical Vascular Surgery Southern Association for Vascular Surgery Southern California Vascular Society Upstate New York Vascular Society Vascular Society of New Jersey Western Vascular Society seem that the principal health planning need today is for data gathering, momtoring, and analvsis of this rapidly changing cohort. An oversimplification of the vascular manpower equation can be provided by assuming that all vascular operations should be performed bv vascular surgeons, and that a vascular surgeon must perform at least 75 vascular procedures per year, the number suggested by more than 50% of study respondents when defining a vascular specialist (Table II). With these data, in 1985 the United States would have required 7600 vascular surgeons (571,000 divided by 75). If we acknowledge that 107 vascular procedures per year constitute the average caseload of a vascular specialist (Fig. 6) and 571,000 is a conservative estimate of the total number of procedures performed annually, then approximately 5400 vascular surgeons are required. Furthermore, recogmzing that approximately 2400 vascular surgeons comprise the current manpower pool, then there appears to be need for approximately 3000 additional vascular surgeons to achieve the total of Again, this assumes that all vascular operations will be performed by vascular surgeons, whereas in fact general surgeons and other surgical specialists now perform 59% of all vascular operations. That all vascular operations should be performed by vascular specialists by restricting vascular surgical privileges to such persons was not strongly supported by the study respondents, since only 58% thought vascular surgical privileges should be restricted (Table II). Because many surgeons, such as general surgeons, cardiothoracic surgeons, neurosurgeons,

10 At At Regional > Ernst et al. Journal of VASCULAR SURGERY VASCULAR SURGICAL MANPOWER QUESTIONNAIRE 1. When did you complete your surgical training? In 1985, for how many "vascular operations" (arterial reconstructive procedures, embolectomies, endarterectomies, vascular injury repairs, angioaccess procedures, portosystemic shunts, and venous reconstructions) were you the surgeon of record? Insert number No longer perform vascular operations Only perform cardiac and thoracic surgery 3. In 1985, for how many of the five following operations (exact number) were you the surgeon of record? Peripheral vessel bypass Carotid endarterectomy Abdominal aortic aneurysm Aortoiliofemoral bypass A_ngioaccess 4. What percentage of your total operative caseload were vascular operations as defined in question 2? % 5. What percentage, if any, of your vascular operations were performed at either a Veterans Administration or military hospital? % 6. In your opinion, how many "vascular operations" (defined in question 2) should a surgeon perform per year to be termed a "vascular specialist"? least 25 At least 75 Greater than 100 least 50 At least Should vascular surgical privileges be restricted to those surgeons who fulfill your above criterion of a "vascular specialist"? Yes No 8. Member of SVS or ISCVS vascular society Certified by ABS in General Vascular Surgery urologists, transplant surgeons, and osteopaths, perform vascular procedures, any reasonable attempt at precisely predicting future manpower needs must include their operative rates. This analysis has documented that there is a cohort of approximately 2400 surgeons in the United States who may be justifiably labeled vascular surgeons. Considering this group, and assuming completion of training at 32 years of age with retirement from practice at 62 years of age, then these surgeons have an effective practice span of 30 years. To maintain the existing group size, 80 to 100 newly trained vascular surgeons, at most, will be required each year from vascular training programs (Fig. 5). If 5400 vascular surgeons are required, then 180 newly trained vascular surgeons per year will be necessary. In 1987 approximately 74 vascular fellows were trained in 52 programs approved by the Accrediting Council on Graduate Medical Education. In addition, of the 687 general surgery initiates into Fellowship of the American College of Surgeons in 1985, 12i or 18% noted that more than 40% of their practice was devoted to vascular surgery, n Acknowledging that these two groups may overlap,

11 Volume 6 Ntmaber 6 December 1987 Vascular surgical manpower 621 then approximately 200 new surgeons who perform vascular operations enter the manpower pool yearly. If, as noted earlier, 7600 vascular surgeons are required, the solution to the manpower equation changes. If one combines vascular fellowship trainees and general surgeons devoting a significant portion of their effort to vascular surgery', 30 additional surgeons above current training levels are needed annually to maintain the 7600 manpower pool. However, if only 5400 are needed, then we are currently training an excess of approximately 20 surgeons per year. What about future general surgeons who, although they have no vascular fellowship training, elect to perform vascular operations as part of their general surgical practice? This unknown variable particularly perturbs manpower planning. It is generally acknowledged that general surgery resident rotations on a vascular surgical service make such residents better general surgeons, but does this experience make them vascular surgeons? Recent data suggest that structured and concentrated vascular surgical training has made a positive impact on vascular surgical care. Requirements for general surgery training necessitates a reasonable experience in indexed (category I and II) operations for each finishing resident, and vascular surgery remains one of the seven principal components of general surgery according to the ABS. Although fully 50% of general surgery residents graduated in 1985 performed fewer than 10 indexed vascular procedures during the last years of their training, 12 the RRC national data for suggest a significant improvement in vascular training experiences with the average resident experience now greater than that expected by the RRC. But serious questions remain. Which surgeons should perform carotid endarterectomies and distal tibial or visceral arterial reconstructions? Should general surgeons provide only emergency vascular surgical care when a specially trained vascular surgeon is not available? To help solve this portion of the vascular surgical manpower dilemma, it is important that vascular and general surgery leaders and policy makers determine what type of vascular surgical procedures general surgeons should be trained to do, and subsequently what procedures they should perform when they enter practice. The many possible permutations and perturbations in vascular manpower analysis document the difficulty of rational planning. More accurate and ongoing refinement of data bases for vascular surgery should help to clarify issues relevant to such planning. Long-term projections must incorporate technical, scientific, epidemiologic, and demographic data into programs of vascular surgical care. Failure to do so may adversely affect quality and quantity of future vascular surgical care available to the United States populace. 13 On the one hand, the training of too many vascular surgeons raises concerns regarding possibility of unnecessary operations, loss of competence from inactivity, and ultimately poor-quality vascular surgical care. On the other hand, if too few vascular surgeons are trained, problems loom related to insufficient manpower, thereby limiting patient access to high-quality vascular surgical care, which in turn may increase morbidity and death from vascular disease, s,14 In particular regard to the latter, future manpower studies should be linked to outcome studies to assess not only numbers of surgeons and operations but quality of care as well. Studies such as this provide a logical step in the sequence of solving the manpower overproductionunderproduction dilemma. However, because known and unknown variables preclude an immediate establishment of the optimal number of vascular surgeons trained yearly, it is suggested that ongoing study and analysis be conducted by the SVS and the ISCVS to provide a constant and accurate data base for vascular surgical manpower planning. Evolution of a rational manpower policy and the future of vascular surgery in this country may depend in great measure on such action. REFERENCES 1. Bloom BS, Peterson OL. Changing the number of surgeons. N Engl J Med 1980;303: Moore FD. Surgical manpower: past and present reality, estimates for Surg Clin North Am 1982;62: Rutkow IM. Delivery of surgical health care in the United States. Arch Surg 1981;116: Rutkow IM, Ernst CB. Vascular surgical manpower. Too much? Enough? Too little? Unknown? Arch Surg 1982;117: Rutkow IM, Ernst CB. An analysis of vascular surgical manpower requirements and vascular surgical rates in the United States. J VASC SURG 1986;3: Moore FD. Medical and surgical manpower and economic phenomena. Surgery 1984;95: Physician characteristics and distribution in the U.S., 1986 ed. Chicago: Survey and Data Resources, Department of Data Release Services, American Medical Association, Rutkow IM, Zuidema GD. Surgical rates in the United States: 1966 to Surgery 1981;89: Rutkow IM. Rates of surgery in the United States: the decade of the 1970s. Surg Clin North Am 1982;62: I0. Rutkow IM. Surgical operations in the United States, 1979 to Surgery 1987;101: II. Johnson G Jr. Presidential address: the second-generation vascular surgeon. J VASC SURG 1987;5: Ernst CB. The impact of vascular surgical training on vascular surgical care. (Editorial) J VASC SURG 1987;5: Rutkow IM. Unnecessary surgery: what is it? Surg Clin North Am 1982;62: Rutkow IM. Surgical operations and manpower: an assessment of future quality. Health Affairs (In press.)