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Ann Thorac Surg 2006;82:1152
© 2006 The Society of Thoracic Surgeons
a St. Christopher's Hospital for Children, Drexel University College of Medicine, Philadelphia, Pennsylvania
b Children's Memorial Hospital, Northwestern University, Chicago, Illinois
c Congenital Heart Institute of Florida, University of South Florida, St. Petersburg, Florida
d Montreal Children's Hospital, McGill University Health Center, Montreal, Quebec, Canada
* Address correspondence to Dr Marshall L. Jacobs, Section of Cardiothoracic Surgery, St. Christopher's Hospital for Children, Erie Ave at Front St, Philadelphia, PA 19134 (Email: marshall.jacobs{at}tenethealth.com).
Presented at the Forty-second Annual Meeting of The Society of Thoracic Surgeons, Chicago, IL, Jan 30–Feb 1, 2006.
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Abstract |
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 Top Abstract IntroductionMaterial and MethodsResultsCommentDiscussionFootnotesAcknowledgmentsReferences |
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METHODS: Preliminary research of websites and databases revealed a potential target group of 263 congenital heart surgeons, including 248 surgeons at 121 US centers and 15 at eight Canadian sites. Surveys were sent to these, plus any additional individuals who listed an interest in congenital or pediatric heart surgery on CTSNet or STS websites. Responders include active congenital heart surgeons, inactive, or retired surgeons, adult cardiac surgeons, and surgeons in training. Analysis is based exclusively on the responses of 217 active congenital heart surgeons (>80% of target).
RESULTS: Average age was 48.3 ± 8.3 years (range, 33 to 78). Ten were female (5%), 207 male (95%). American Medical School graduates were 170 (79%), with 9.2 ± 1.6 years of postgraduate training. Eighty-five percent are Thoracic Board certified. Congenital heart surgery training outside the United States or Canada was obtained by 29 (14%). One hundred twenty-eight (59%) do exclusively congenital heart surgery. One third perform fewer than 100 congenital cases per year, one third perform 100 to 199, and one third perform 200 or more. Congenital heart surgeons have been in their current positions for 9.5 ± 8.2 years. Eleven are in their first year of practice. Mean anticipated years to retirement is 15.7 ± 7.5 (range, 1 to 34). Three anticipate retirement within 1 year. At the same time, 39 fellows will complete postgraduate training at 28 centers this year, and 19 will seek positions in North America.
CONCLUSIONS: These data should help to facilitate rational plans to meet manpower needs, including evolving policies concerning training and certification.
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Introduction |
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TopAbstractIntroductionMaterial and MethodsResultsCommentDiscussionFootnotesAcknowledgmentsReferences |
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The project was approved and supported by the STS Council on Education and Member Services and the Council on Health Policy and Relationships. The methodology and results of previous STS/American Association for Thoracic Surgery (AATS) practice surveys were studied, and the organizers and principal investigators of those previous studies served as advisors to the Workforce, in hopes of maximizing the yield of this first-time subspecialty survey with respect to both response rates and data quality. This report summarizes the results of the first STS Congenital Heart Surgery Practice and Manpower Survey.
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Material and Methods |
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TopAbstractIntroductionMaterial and MethodsResultsCommentDiscussionFootnotesAcknowledgmentsReferences |
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Initial efforts to identify a "target group" of practicing congenital heart surgeons took several forms: (1) An electronic mailing was directed to all members of the Congenital Heart Surgeons Society requesting the identification of any and all individuals within the members' state and contiguous states who were known to be engaged in the practice of congenital heart surgery. (2) The American Hospital Association 2002 Guide to the Health Care Field [4] was reviewed searching for all institutions that had any of the following departments: cardiac catheterization laboratory, neonatal intensive care unit, pediatric intensive care unit, open heart surgery, and transplant services. (3) Then, each institution identified in step 2 above was located on the Worldwide Web or contacted directly to obtain a listing of pediatric and congenital cardiothoracic surgeons, and to obtain available information concerning the number of operations performed per year and the existence of residency or fellowship training programs. (4) A complete listing of Canadian Health Service congenital heart surgery programs and congenital heart surgeons was obtained and cross-referenced by two Canadian Workforce members.
A subcommittee of the Workforce for Congenital Heart Surgery designed a comprehensive self-administered questionnaire detailing demographic and geographic practice characteristics (Appendix *). Having a similar format, the complexity of the survey instrument was approximately equivalent to that of the survey instrument used in 1999 for the AATS/STS Thoracic Surgery Workforce Survey. The estimated time for completion was judged to be between 10 and 20 minutes. The survey instrument could be completed without reference to any other source material, but respondents were urged to refer to their own institutional databases as appropriate to ensure accuracy of case numbers.
The preliminary research endeavors described above yielded a list of 248 individuals practicing congenital heart surgery at 121 centers throughout the United States, and 15 individuals practicing congenital heart surgery at 8 Canadian centers. Recognizing the possibility of having failed to identify virtually all practicing congenital heart surgeons, every member home page on CTSNet and the STS website was reviewed, and 120 additional individuals who had listed "congenital heart surgery" or "pediatric cardiac surgery" among their activities or interests were added to the survey target list.
The first mass mailing of the survey instrument was in mid January 2005. The survey was sent through the US mail. The envelope was identified on the outside as containing an STS survey instrument. The envelope contained a cover notification, the 6-page survey instrument, and a final identification page that requested the names of each individual's professional associates also engaged in the practice of congenital heart surgery, and the names of other individuals in the state or geographic region who were engaged in the practice of congenital heart surgery. Any time a survey was returned listing the names of congenital heart surgeons that had not been included in the initial distribution list, a survey instrument was mailed to those additional surgeons. The second mass mailing to all remaining nonrespondents from the now enlarged target list of surgeons took place in April 2005. By August 2005 there remained a group of 61 individuals who had been identified with a reasonable degree of certainty as practitioners of congenital heart surgery, and remained as nonrespondents. A third mailing of the survey instrument to the offices of these individuals was accompanied by fax communication of an electronic transmittal copy of the survey instrument to the same offices. In a few instances, telephone communication was used to confirm receipt of the survey instrument.
This cumulative effort yielded a total of 235 completed survey instruments. During the time that had transpired since the initial mass mailing, most of the secondary target group identified through the CTSNet and STS websites was eventually determined to be made up of individuals not actively involved in the practice of cardiothoracic surgery. Some were physician/scientists not engaged in the practice of surgery. Some were from countries other than the United States and Canada. Many turned out to be residents or fellows in training who responded by returning the survey instrument, but without completing the data. In September 2005, with 235 completed surveys, including 217 from active congenital heart surgeons from within the United States and Canada (representing greater than 80% of the initial target group), a decision not to pursue further responses was made. Each survey response was checked for inconsistencies and errors. The data were carefully entered using quality control and verification measures into a comprehensive database. The survey data were downloaded and rigorously analyzed using STATview statistical software.
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Results |
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Age and Sex
Active congenital heart surgeon respondents ranged in age (as of December 31, 2004) from 33 years to 78 years (mean, 48.3 ± 8.3). Ninety-five percent (207) were male, and 5% (10) were female. The median age of male and female respondents was 48.0 years and 43.5 years, respectively. Figure 1
depicts the age distribution of practicing congenital heart surgeons in the United States and Canada; 76% are between 40 and 59 years of age. This is quite similar to data reported for the entire Thoracic Surgery Workforce by the AATS/STS Workforce Committee in 2002 [2]. That data included a mean age of 50 years, with 74% between 40 and 59 years of age.
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Figure 2 depicts the duration of postgraduate training of respondents. The mean duration of postgraduate training is 9.2 ± 1.6 years (median, 9). This includes both clinical training (residency and fellowships) and research activities preceding initial employment as a "trained" congenital heart surgeon. That compares with a mean of 8.3 years and median of 8 years, which was the average duration of training for the entire thoracic surgical workforce in the AATS/STS 2002 report [2]. It appears that the majority of individuals entering the practice of congenital heart surgery have completed general surgical training (5 years), plus the 2 to 3 years of required cardiothoracic surgical training, and then in addition, an average of 1 more year of supplemental clinical or research or combined fellowship training. Of the 217 active congenital heart surgeons whose responses were analyzed, 168 (77%) indicated that they undertook the major portion of their congenital heart surgery training in the United States; 16 (7%) listed Canada and 21 (10%) listed the United Kingdom as the site where their major (most significant) congenital heart surgery training had taken place. Four individuals listed United States plus other countries, and 1 individual listed both Canada and United Kingdom. A total of 9 individuals listed Australia, New Zealand, or other. In all, 186 (86%) are certified by the American Board of Thoracic Surgery (ABTS) or the Royal College of Physicians and Surgeons of Canada.
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The average number of years in the current practice situation was 9.5 ± 8.2 years. When broken down into 5-year intervals (Figure 5), the largest group (86, 40%) had been in their current practice situation for 1 to 5 years. For 6 surgeons in their current practice situation for less than 1 year, the average number of years in their previous practice situation was 5. Eleven respondents were in their first year of practice. For 99 surgeons (45%), the practice was primarily at a designated children's hospital, for 79 surgeons (36%), it was primarily at a combined adult and pediatric medical center, and for 34 surgeons (16%) the practice was divided between two or more hospitals. The mean number of active congenital heart surgeons in a practice group was 2.3 ± 1.3. Forty-three individuals (20%) were solo practitioners of congenital heart surgery; 97 individuals (45%) worked in a group of two, 52 (24%) in a group of 3, and 20 (9%) in groups of 4 or more congenital heart surgeons. Most surgeons operate primarily on patients from within their own state and contiguous states. For more than 80% of surgeons (n = 177), patients from noncontiguous states account for less than 10% of their total case volume. More than one third operate on some patients from foreign countries, but this generally accounts for less than 10% of the total case volume.
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Retirement
The survey instrument requested that the respondents estimate the number of years until their anticipated retirement from active clinical surgery, and their expected age at the time of retirement (Figure 7). Three surgeons anticipated retirement within 1 year of completing the survey. The mean number of years to anticipated retirement is 15.7 ± 7.5 years. Twenty-five surgeons anticipate retirement within the coming 5-year period, and 40 more anticipate retirement during the subsequent 5 years. Thus, 65 practitioners anticipate leaving the work force through retirement during the coming decade. More than 80% of currently active congenital heart surgeons anticipate working until they are at least 60 years old, and 26% beyond age 65.
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Comment |
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TopAbstractIntroductionMaterial and MethodsResultsCommentDiscussionFootnotesAcknowledgmentsReferences |
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We believe that the present study does allow us to estimate with reasonable accuracy the number of active congenital heart surgeons in the United States and Canada. Two mass mailings of the survey instrument took place in early 2005. As stated earlier, after responses to the second mass mailing were in, there remained a group of 61 individuals who the investigators believed with reasonable certainty consisted of active congenital heart surgeon nonresponders. With the final campaign of electronic facsimile communications, phone calls and e-mails, 34 additional responses from this group were obtained before the decision to close the data set for analysis was taken, with the total number of responses from active congenital heart surgeons being 217. This would leave a remainder of 27 individuals thought to be active congenital heart surgeons who are nonresponders. Given the extent to which the investigators sought to identify all active congenital heart surgeons, it seems likely that the additional number of those missed entirely (ie, never identified or never targeted by the survey) is not larger than the group of nonresponders. If this assumption is accepted, then the estimate of the active congenital heart surgery workforce in the United States and Canada would be approximated by the sum of the responders (n = 217), the nonresponders (n = 27), and the hypothetical remainder, never identified during the course of the investigation (n = 27); the theoretical sum is 271. This figure is strikingly close to our initial target assumption, which was 248 (United States) plus 15 (Canada); that sum being 263. . Using target estimates of either 263 or 271, then the responses to this survey would represent 83% or 80% of the workforce, respectively. It would clearly be desirable to have data from the entire workforce, but the likelihood that inferences would be significantly altered given the estimated response rate is not great.
In an earlier Thoracic Surgery Workforce study by the AATS and STS published in 1995 [1], a survey questionnaire had been sent to 3,487 thoracic surgeons and there were 3,049 responses (87%). Data were reflective of 1992 practice: 51 respondents (1.9%) did only pediatric cardiac surgery; 237 respondents (7.8%) did pediatric cardiac surgery in addition to adult cardiac surgery plus or minus general thoracic surgery, plus or minus peripheral vascular surgery. A total of 320 respondents (10.5%) did some pediatric cardiac surgery. For these individuals self-designated as pediatric cardiac surgeons, the number of pediatric cardiac cases per surgeon was low, with a mean of 27 cases per year and a median of 26 cases per year: Fully one half (50%) of these surgeons did fewer than 25 pediatric cases per year. There was speculation as to incompleteness of the data, as the total number of pediatric cardiac cases accounted for by the survey fell short of contemporary government agency estimates. Nonetheless, it is apparent that a feature of the maturation of the subspecialty of congenital heart surgery over the past decade has been a degree of centralization of congenital heart surgery. By centralization, we refer not to geography, but to the fact that a larger fraction of congenital heart surgery cases are being performed by subspecialists. The percentages of practitioners performing more than 100 cases per year and more than 200 cases per year in 1992 were 22% and 7%, respectively. Those figures from the current survey are 60% and 26%. Respondents to the current survey were asked to respond "true" or "false" with respect to the statement, "Though I maintain my skills, my interest, and my knowledge base, I currently (past two years) perform fewer than 25 major congenital heart operations per year." There were 25 responses of true, and 2 nonresponders. Thus, the percentage currently doing fewer than 25 congenital cases per year (11.5%) is considerably different than the 50% in the 1992 practice profile. It must be acknowledged that part of this difference may be attributable to methodology, as the target audiences of the two surveys are not the same.
While others have made theoretical suggestions concerning the appropriate caseload per surgeon, and ideal number of centers based upon population estimates [6], it is difficult to truly determine the size and characteristics of an optimal congenital heart surgery workforce. What the current survey does provide is contemporary and previously unavailable information concerning the flux of manpower into and out of the workforce. Eleven congenital heart surgeons were in their first year of practice at the time of the survey. Three others anticipated retirement within a year of the survey. In all, 25 anticipated retirement within 5 years, and a total of 65 anticipated retirement within 10 years. The number that may leave the work force for other reasons (unanticipated health problems, involuntary replacement, death, and so forth) is unknown, but certainly small compared with the number retiring. At the same time, 39 individuals are expected to complete postgraduate fellowship training in congenital heart surgery in the United States and Canada in the year after the survey, with 19 of them committed to finding jobs in North America. The survey does not tell us the extent to which these 1-year figures are representative of either the recent past or the immediate future, but clearly we can anticipate being faced with a potentially significant mismatch if the number of individuals seeking career positions as congenital heart surgeons continues to significantly exceed the number leaving the workforce. To some extent, the magnitude of the discrepancy may be lessened by the steadily increasing number of individuals with complex congenital heart disease surviving to adulthood and needing life-long care, a phenomenon that will be of increasing importance as we try to anticipate future congenital heart surgery needs with respect to both workforce and resources [7].
It is the hope and intent of the authors, and the Society of Thoracic Surgeons Workforce on Congenital Heart Surgery, that the data from this study will help to facilitate rational plans to meet future workforce needs, including evolving policies regarding training and certification of congenital heart surgeons.
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Appendix |
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Directions: Please take the time necessary to complete this very important questionnaire on the characteristics of your practice. Read each question carefully and complete as many questions as possible to the best of your knowledge by checking the box that best represents your answer(s). Please consult your institutional data base to ensure maximal accuracy. Results from this survey will only be reported in the aggregate. The request for identification is to ensure as complete a field of respondents as possible, and to avoid duplication, as there is likely to be a need for more than one distribution of this survey instrument. The same reasons apply to the request for identification of your colleagues and practitioners in neighboring areas. In no way will any practice, group, or affiliation be identified in the analysis of these data or in subsequent reports.
Return your completed survey to:
_________________________________________________________________________________
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Discussion |
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TopAbstractIntroductionMaterial and MethodsResultsCommentDiscussionFootnotesAcknowledgmentsReferences |
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Doctor Jacobs and his coauthors undertook the difficult task of gathering information about the current workforce in congenital heart surgery in North America in an effort to estimate the total number of surgeons and characterize those performing the majority of the cases. Any survey of this nature is bound to be incomplete, but the relatively small numbers involved and the exhaustive search techniques employed by the authors would indicate that their results are likely to be accurate and strongly representative of the target audience as a whole. The authors' estimate of 80% completeness seems entirely reasonable.
Their research identified 248 individuals at 121 US centers and 15 individuals at 8 Canadian centers, and their findings are based on the responses of 217 active congenital heart surgeons. The results show interesting if not predictable trends, some of the most interesting of which I would like to summarize here.
First, the workforce is overwhelmingly male. Second, the average age of 48 years reflects, at least in part, the long length of training, with a median duration of 9 postgraduate years. Third, only 128 do exclusively congenital heart surgery, a little more than half of the group. Fourth, and perhaps the most stunning finding of the survey, only 97 respondents do more than 150 congenital cases per year and another 36 do fewer than 50. Fifth, a third of the respondents would be in violation of an 80-hour workweek, which we know is coming. Sixth, nearly half were at their current practice location for less than 5 years. And finally, disturbingly, while only 3 anticipate retirement within the next year, 39 fellows will complete postgraduate training in congenital heart surgery this year, and 19 are seeking employment in North America.
How then do we use this information? The data from this manpower study crystallized what most of us have realized for some time: there are more congenital heart surgeons than there are positions, and too many do what is arguably an insufficient number of cases per year. Perhaps the real issue, then, is how many congenital heart surgeons should we train and how do we go about it?
At the fall 2005 meeting of the American Board of Thoracic Surgery, a proposal to establish a special certification of added qualifications in congenital heart surgery was approved. The requirements for this certification will be strict, and much discussion has gone into this still evolving process. Why now? Congenital heart surgery has evolved into its own specialty with unique techniques and skills. Current thoracic surgery residency programs do not adequately prepare the trainee to specialize in this field. Furthermore, fellowships in congenital heart surgery have lacked uniformity and control.
The following principles were established by the a ABTS: a 12-month fellowship during which candidates must perform 75 major cases as surgeon, including 25 key index cases; a written and an oral certification examination that will be available only to ABTS-qualified candidates.
As the authors acknowledge in their manuscript, it is difficult to extrapolate the data on retirement estimates as a predictor of the need for new individuals to enter the congenital heart surgery workforce. However, using the data from this survey, it is reasonable to estimate that there is a need to produce only about six or eight new congenital heart surgeons each year for all of North America. Frankly, I doubt that this number has substantially changed over many years. I would be interested in hearing Dr Jacobs' comments on this.
Doctor Jacobs and his colleagues should be congratulated on providing these important data, which represent the most accurate assessment to date of the congenital heart surgery workforce. Again, I thank the Society and Dr Jacobs for allowing me to comment on the paper.
DR JACOBS: Doctor Bove, thank you very much for your comments and for bringing us up to date with regard to the timely issues concerning the process by which we will achieve a plan for certification of subspecialty training in congenital heart surgery.
I think that we undertook this study with a number of hypotheses, only one of which I stated and the second of which was that there was probably an estimate we could determine of the number of congenital heart surgeons that would need to be trained in a given year. One of the things that prompted us to undertake this was the recent experience in the United Kingdom where based on the recognition that there were at any given time a dozen or more congenital heart surgery senior registrars seeking consultant posts, there were rarely in the United Kingdom more than one or two consultant posts opening up on a yearly basis. And of course, the National Health Service there and the medical societies have determined, for the time being, to limit training to only one multisite program.
I think we have to be thoughtful with regard to the number of congenital heart surgeons trained in any given year, for a variety of reasons. We don't have a very accurate estimate of the number of cases being done nationally on a total basis. The committee and I undertook about six different mechanisms of reaching this estimate, and you come up with figures from as low as 18,000 to as high as about 33,000; and Connie Haan on behalf of the STS Adult Cardiac Surgery Database was kind enough to share data indicating that surgeons who don't consider themselves congenital heart surgeons are doing about 2,000 ASDs a year as entered into the adult database and about 700 "other" congenital cases a year. So there may still be as much as 10% of the congenital volume that is being done by surgeons who don't consider themselves specialist congenital heart surgeons, and that is also worthy of consideration. But the mathematics certainly lead to the conclusion that you stated, that without accounting for other reasons for individuals to leave the workforce apart from retirement—and there are other reasons that account for much smaller numbers—yes, something in the ballpark of 6 to 8 individuals per year would probably fill the number of currently existing slots. The extent to which the field of adult congenital heart surgery is going to expand with an enlarging population of children surviving into adulthood will impact on this. I think the American Heart Association estimated 2 years ago that, for the first time, there were as many adults surviving with complex congenital heart disease as there were children being born with it. But I think the numbers that you calculated are a very accurate assessment based on the best data we could provide.
Thank you for your comments.
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Acknowledgments |
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TopAbstractIntroductionMaterial and MethodsResultsCommentDiscussionFootnotesAcknowledgmentsReferences |
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Footnotes |
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TopAbstractIntroductionMaterial and MethodsResultsCommentDiscussionFootnotesAcknowledgmentsReferences |
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References |
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TopAbstractIntroductionMaterial and MethodsResultsCommentDiscussionFootnotesAcknowledgmentsReferences |
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 K. F. Welke, B. S. Diggs, T. Karamlou, and R. M. Ungerleider Comparison of Pediatric Cardiac Surgical Mortality Rates From National Administrative Data to Contemporary Clinical Standards Ann. Thorac. Surg., January 1, 2009; 87(1): 216 - 223. [Abstract] [Full Text] [PDF]
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