Oversupply of Cardiothoracic Surgeons: Its Consequences and Correction

While the number of operations performed by our specialty in the USA is diminishing, the number of residents being trained for our specialty remains fairly constant. The supply of cardiothoracic surgeons, in my view, needs to be brought into balance with the demand for our services. In brief, too many cardiothoracic residents are being trained to do too few operations in practice, which is detrimental to all parties---the patients, the practitioners, and the residents.

Diminishing operations. The most common procedure performed by cardiothoracic surgeons as a group is coronary artery bypass grafting (CABG). The number of patients referred by cardiologists for CABG has declined at virtually all institutions, translating into fewer cardiac operations, overall, per surgeon. The obvious reason for the decrease in CABG referrals is the increase in percutaneous interventions to treat atherosclerosis. Vascular surgeons have experienced this phenomenon in nearly all operations for atherosclerosis. Open procedures are in decline. Closed procedures are on the rise.

Will the trend continue? Probably yes. Percutaneous interventions and medicines will improve and continue to dominant therapy for atherosclerosis. CABG will be applied more and more selectively in the future, for patients with advanced disease----probably after all percutaneous options have been exhausted.

Effect on patients. The diminishing number of operations in our specialty will impact our care of patients. The relation of surgeon volume and patient outcome was recently studied in a large sample of Medicare patients who underwent one of four cardiothoracic operations---CABG, aortic valve replacement, pulmonary resection, or esophagectomy (1). For each operation, higher surgeon volume was associated with lower operative mortality. For CABG, the mortality was 4.0% when the annual surgeon volume was >162 cases, and 5.4% when it was <101 cases.

A survey of cardiothoracic surgeons in 1999 showed that among adult cardiac surgeons also performing general thoracic surgery, the median number of cardiac cases was 174 per year (2). If the average adult cardiac surgeon performed, let's say, 150 cardiac operations last year, 125 this year, 100 next year, and so on as the CABG numbers diminish, patients face the probability of a higher operative risk, because of the surgeon's lower annual volume.

Effect on practitioners. While CABG numbers have declined, outcome expectations for all cardiothoracic operations have risen. Our surgical outcomes, especially for CABG, are feverishly analyzed, perhaps more so than any results in the history of surgery. To exceed national benchmarks in any complication category alarms our local critics. Red flags are raised. In this milieu, one year with a high complication numerator and a low volume denominator may be ruinous for a young surgeon, or even a seasoned one.

The decline in CABG numbers will affect all cardiothoracic surgeons, not just those whose practice is dominated by CABG procedures. The competition for valve referrals will increase, as will competition for general thoracic referrals. Vascular surgeons will also be impacted, as many cardiothoracic surgeons train their eyes on other vascular beds. The loss of concentration of valve, general thoracic, and vascular cases among subspecializing surgeons will ultimately mean higher rates of adverse outcomes.

Effect on residents. To train many residents for a specialty that has few openings in practice is unfair to trainees. Two "Situations Available" appeared in the January issue of the Annals of Thoracic Surgery this year, compared with 21 listings ten years ago; and yet, about 140 cardiothoracic residency positions remain available each year.

Medical students and general surgery residents have sensed the imbalance in our specialty and fewer apply each year for cardiothoracic positions. Fewer than 10% of applicants who attended American medical schools are rejected from cardiothoracic training (3), and this loss of competition to enter our specialty does not bode well for patients in the future.

The solution. The number of cardiothoracic training positions in the USA should be significantly decreased. Whether to decrease the number by a fourth, by a third, or by half, is debatable. The process of eliminating training positions is also debatable. Perhaps small training programs doing fewer than 400 adult cardiac operations per year, or some reasonable number, should phase out their programs. Perhaps large training programs with multiple slots should decrease the number of those slots by half. In the face of an unrelenting decline in CABG numbers, prompt correction of the oversupply of cardiothoracic surgeons is in the best interest of patients.

References

1. Birkmeyer JD, Stukel TA, Siewers AE, Goodney PP, Wennberg DE, Lucas FL. Surgeon volume and operative mortality in the United States. N Engl J Med 2003; 349: 2117-27
2. Shemin RJ, Dziuban SW, Kaiser LR, Lowe JE, Nugent WC, Oz MC, Turney DA, Wallace JK. Thoracic surgery workforce: snapshot at the end of the twentieth century and its implications for the new millennium. Ann Thorac Surg 2002; 73:2014-32
3. Orringer MB. Unity and participation: embracing counterintuitive survival skills. Ann Thorac Surg 2002; 74:3-12