Health care reform is forcing “alignment” between hospitals and physicians. The acceleration of employment of physicians by hospitals is bringing into focus contractual terms where compensation is ...tied to clinical productivity. Physician productivity is being almost entirely defined by work relative value units (WRVUs). However, vascular surgeons may bring value to a health system in ways that are unique and separate from clinical revenue as measured by WRVUs. Incentives for physicians should also be tied to behaviors that are desired, such as quality of care, efficiency, patient outcomes, patient satisfaction scores, teaching, and research, depending on the specific environment. Vascular surgeons must be aware of proper use and misuse of WRVUs and have access to the most appropriate benchmarks in negotiations for employment. With increasing employment of physicians by hospitals and focus on “alignment,” a more comprehensive measure of physician productivity is necessary.
Talent management and leadership development is becoming a necessity for health care organizations. These leaders will be needed to manage the change in the delivery of health care and payment ...systems. Appointment of clinically skilled physicians as leaders without specific training in the areas described in our program could lead to failure. A comprehensive program such as the one described is also needed for succession planning and retaining high-potential individuals in an era of shortage of surgeons.
Objective To estimate the size of the future workforce in vascular surgery (VS) and the added cost associated with addressing the projected shortage in the United States. Methods The net supply ...(number of Vascular Surgeons VSN currently practicing, new graduates entering the workforce, and those retiring) for each decade was calculated. The projected population for each decade was determined by U.S. Census Bureau figures. Some assumptions of this model included: (1) In 2008, the population was 300,000,000; (2) There were 2783 board certified VSN in 2008; (3) VSN will practice 30 years from board certification to retirement; (4) There will be 105 board certifications and 93 retirements per year; (5) Vascular operations will remain at 284 per 100,000 population; (6) Salaries of trainees will be $50,000 with benefits of 30% and $15,000 of additional direct medical education costs. Results Population and workload analysis suggests that there will be a shortage of 330 surgeons (9.8%) and 399 surgeons (11.6%) by 2030, respectively. The cost of training enough VSN (in a six-year program) by 2030 will be between $1,166,400,000 and $1,199,520,000. Conclusions A conservative estimate by both population and workload analysis, disregarding aging of the population, lifestyle choices of future VSN, and increasing demand for services, indicates a shortage of VSN in the future. Unless the Balanced Budget Act of 1997 is revised by Congress, the cost to train the additional VS workforce remains a significant barrier.
Background The potential impact of shortages of the surgical workforce on both urban and rural hospitals is undefined. There is a predicted shortage of 30,000 surgeons by 2030 and the need to train ...and hire more than 100,000 surgeons. The aim of this study is to estimate the average recruitment needs in our nation’s hospitals for 7 surgical specialties to ensure adequate access to surgical care as the U.S. population grows to 364 million by 2030. Methods We used the census figure of 309 million in 2010 for U.S. population. Currently there are estimated to be 3,012 urban hospitals and 1,998 rural hospitals in the U.S. (American Hospital Association’s Trend Watch report, 2009). At 253 million people (82 % of the population of 309 million in 2010) receive healthcare in urban hospitals; 56 million people receive healthcare in rural hospitals (18%). We assumed a work force model based on our previous publications, equal population growth in all geographic areas, recruitment by rural hospitals limited to Ob-Gyn, General Surgery, and Orthopedics, and that the percentage of the population receiving care at urban and rural hospitals will stay constant. Results Rural hospitals will have to recruit an average of 3.4 OBGYN’s, and an average of 1.6 Orthos, and 2.0 GS for a total of 7 full-time equivalents in the period from 2011 to 2030. Urban hospitals which have to recruit surgical specialists will have to recruit ten Ob-Gyns, about 5 Orthos, 6 GS’s, 5 ear, nose, and throat surgeons (ENT’s), an average of 2.5 urologists, a neurosurgeon, and a thoracic surgeon to meet the recruiting goals for the surgical services for their hospitals. Conclusion Rural hospitals will be in competition with urban hospitals for hiring from a limited pool of surgeons. As urban hospitals have a socioeconomic advantage in hiring, surgical care in rural areas may be at risk. It is imperative that each rural hospital analyze local future healthcare needs and devise strategies that will enhance hiring and retention to optimize access to surgical care.
Abstract Objective Whereas duplex ultrasound parameters for predicting internal carotid artery (ICA) stenosis are well defined, the use of common carotid artery (CCA) Doppler characteristics to ...predict ICA stenosis when the ICA cannot be insonated directly or accurately because of anatomy, calcification, or tortuosity has not been studied. The objective of this study was to identify CCA Doppler parameters that may predict ICA stenosis. Methods We reviewed all patients at our institution who underwent carotid duplex ultrasound (CDU) from 2008 to 2015 and also had a comparison computed tomography, magnetic resonance, or catheter angiogram. We excluded patients whose CDU examination did not correlate with the comparison study, those whose arteries were not visualized on the comparison study, and those with complete occlusion of the CCA. We collected CCA peak systolic velocity (PSV), end-diastolic velocity (EDV), and acceleration time (AT) in addition to CDU and comparison imaging interpretation of degree of stenosis. A multivariate model was used to identify predictors of ICA stenosis. Results There were 99 CDU examinations with corresponding comparison imaging included. For every increase of 10 cm/s in EDV in the CCA, the odds of a >50% ICA stenosis being present vs a ≤50% ICA stenosis decreased by 37% (odds ratio OR, 0.63; 95% confidence interval CI, 0.41-0.97; P = .03). For every increase of 10 cm/s in EDV in the CCA, the odds of a 70% to 99% ICA stenosis being present vs a ≤50% ICA stenosis decreased by 48% (OR, 0.52; 95% CI, 0.28-0.94; P = .03). A CCA EDV of 19 cm/s or below was associated with a 64% probability of a 70% to 99% ICA stenosis. For every 50-millisecond increase in AT in the CCA, the odds of a >50% stenosis being present vs a ≤50% ICA stenosis increased by 56% (OR, 1.56; 95% CI, 1.03-2.35; P = .04). A CCA AT of 80 milliseconds or above was associated with a 69% probability of a >50% ICA stenosis. There was no correlation between CCA PSV and ICA stenosis. Conclusions CCA EDV and AT are independent predictors of ICA stenosis and may be used in the setting of patients whose ICA cannot be directly insonated or when standard duplex ultrasound parameters of ICA PSV, EDV, or ICA/CCA ratio conflict.
Noninvasive vascular diagnostic testing is efficient and cost-effective, and it is an integral part of vascular surgery practice. Integration of the laboratory into the practice can add significant ...income to a practice as well as increase the quality of the patient's experience. Maintaining a successful vascular laboratory is a key component of the practice's remaining competitive in an ever-changing health care system. Attention must be paid to staffing, operations, financial performance, revenue cycle, and patient and referring physician satisfaction to grow the business.
Background The trend for choosing to work part-time (PT) in medicine is increasing. We hypothesize that strategies to employ PT surgeons and prolong the duration of practice might reduce the surgeon ...shortage considerably. We calculated the effects of PT employment on the surgical workforce. Study Design We estimated the surgical workforce in obstetrics and gynecology, general surgery, thoracic surgery, ENT, orthopaedic surgery, urology, and neurosurgery to be 99,000 in 2005. We assumed 3,635 Board Certificates would be granted each year and surgeons will practice for 30 years, with 3,300 retiring each year. Scenarios were constructed with one-quarter (scenario 1), one-half (scenario 2), or three-quarters (scenario 3) of potential retirees working half-time for an additional 10 years. Results By 2030, with other variables unchanged, the United States would have 4,125; 8,250; and 12,375 additional PT surgeons under scenario 1 (4% increase), scenario 2 (8% increase), and scenario 3 (12% increase), respectively, with a corresponding reduction in the shortage of surgeons. Conclusions An opportunity exists to reduce the shortage of surgeons by offering models for PT employment particularly to mid-career women and retiring surgeons. Employment models should address flexible work schedules, malpractice premium adjustments, academic promotion, maintenance of certification and licensure, and employment benefits.
Background Our aim was to compare trends in retention of academic surgeons by reviewing surgical faculty attrition rates (leaving academic surgery for any reason) of 3 cohorts at 5-year intervals ...between 1996 and 2011. Study Design The Association of American Medical Colleges' Faculty Administrative Management On-Line User System database was queried for a retention report of all tenure/clinical track full-time MD faculty within our academic medical center on July 1, 1996 (group 1), July 1, 2001 (group 2), and July 1, 2006 (group 3). Retention was tracked for 5 years post snapshot. The individual 5-year cohort attrition rates (observed frequencies) were compared with combined attrition rates for all 3 groups (expected frequencies). Results Overall, attrition trends for groups 2 (lower) and 3 (higher) were significantly different than the trends for all groups combined. Minorities and professors at the full or associate rank in group 3 contributed to this difference. Faculty in group 3 leaving our academic medical center were significantly more likely to transition into nonacademic practice compared with the other 2 groups. Conclusions Greater attrition in the last 5-year cohort, despite the increase in faculty positions, is worrisome. A continuous retention life cycle is critical if academic medical centers hope to compete for talent. Retention planning should include on-boarding programs for enculturation, monitoring of professional satisfaction, formalized mentoring of younger surgeons, retaining academic couples and a part-time workforce, leadership and talent management, exit interviews, and competitive financial packages.
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