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a Department of Pediatric and Congenital Heart Surgery, Cleveland Clinic, Cleveland, Ohio
b Division of Congenital Heart Surgery, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas
c The Congenital Heart Institute of Florida, Saint Petersburg and Tampa, Florida
d Division of Cardiothoracic Surgery, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
e Department of Cardiac Surgery, The Children's Hospital, Harvard Medical School, Boston, Massachusetts
f Montreal Children's Hospital, McGill University, Montreal, Quebec, Canada
g Division of Cardiac Surgery, Johns Hopkins University, Baltimore, Maryland
Accepted for publication March 28, 2011.
* Address correspondence to Dr Jacobs, 6019 Goshen Rd, Newtown Square, PA 19073 (Email: marshall.jacobs{at}comcast.net).
Presented at the Forty-seventh Annual Meeting of The Society of Thoracic Surgeons, San Diego, CA, Jan 31–Feb 2, 2011.
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Abstract |
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Methods: Preliminary research suggested a potential target group of 273 congenital heart surgeons, including 258 at 125 US centers and 15 at 8 Canadian centers. The web-based survey was sent to these surgeons, plus all individuals listing pediatric cardiac surgery on CTSNet.
Results: Two hundred forty-six responders included 213 active congenital heart surgeons, 16 retired congenital heart surgeons, and 17 surgeons in training. Retirement age was 63.5 ± 7.5 years. Two hundred thirteen active congenital heart surgeon responders represent 78% of the original estimate. Their responses generated the following data: The mean age was 49.2 ± 8.5 (range, 35 to 75 years). American medical school graduates included 159 of 201 respondents (79%). Years of postgraduate training was 9.7 ± 1.7. One hundred ninety-seven (92%) respondents were certified in thoracic surgery by the American Board of Thoracic Surgery (ABTS). Twenty-eight of 200 (14%) received their congenital heart surgery training outside the United States or Canada. One hundred forty-three of 190 respondents (75%) perform exclusively congenital heart operations; 31 (16%) perform exclusively pediatric heart operations. Of 186 respondents, 54 (29%) perform fewer than 100 major congenital heart operations per year, 78 (42%) perform 100 to 199 procedures, and 54 (29%) perform 200 procedures or more. Active congenital heart surgeons have been in their current positions for 9.3 ± 8.6 years. Eight respondents are in their first year of practice. For 203 respondents, mean anticipated years to retirement is 16.1 ± 7.6. Twenty-eight anticipate retirement within 5 years; 31 in 6 to 10 years.
Conclusions: These data should help facilitate rational plans to meet workforce needs for an expanding patient population.
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Introduction |
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TopAbstractIntroductionMaterial and MethodsResultsCommentDiscussionReferences |
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The 2010 Congenital Heart Surgery Practice and Manpower Survey was undertaken to obtain contemporary data that may help to anticipate and address workforce needs to serve an expanding patient population.
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Material and Methods |
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These preliminary investigations suggested a potential target group of 273 practicing congenital heart surgeons, including 258 at 125 US centers and 15 at 8 Canadian centers. Finally, to ensure that no practicing congenital heart surgeon was overlooked, the list was expanded using data available on the Internet at CTSNet (www.CTSNet.org), which was searched by state/Canadian province. Names found on CTSNet, but not identified by the earlier methods, were added to the distribution list.
A self-administered questionnaire was created, similar in format to the 2005 survey instrument. New questions were included in sections for trainees and retirees and in a module related to adult congenital heart disease. Estimated time for completion of the survey was 20 minutes. Respondents were urged to refer to institutional databases to ensure accuracy of case volume numbers. Questions were designed to distinguish individuals actively engaged in the practice of congenital heart surgery from those in training and retirees. Responses from individuals not meeting these criteria were excluded from analysis. The initial broad inclusion, followed by these exclusions, was intended to achieve the closest approximation to the target group of active cardiothoracic surgeons who perform congenital heart operations.
The survey questionnaire was reviewed and approved by the STS Executive Committee and the Institutional Review Board of the Cleveland Clinic. It was converted to a web-based instrument. Invitation to participate was by e-mail to the entire distribution list. E-mail communication identified the study as an STS survey and included an introductory description explaining the research and how the information would be used. The e-mail also included a link to the online survey instrument at www.surveymonkey.com. E-mail solicitation commenced in January 2010. The survey was announced at the 46th Meeting of the STS during Congenital Heart Surgery sessions. Repeat solicitations went by e-mail to nonresponders through April 2010. The final portion of the survey requested names of professional associates and other congenital heart surgeons in the same geographic region. When a survey was returned listing names not previously included in the distribution list, the e-mail invitation to participate was sent to those additional surgeons. Before the dataset was considered complete, at least 2 e-mails were sent to every name on the original distribution list and 3 additional batch e-mails went to nonresponders and newly acquired names.
This approach yielded a total of 246 eligible completed surveys. The secondary group identified through CTSNet was made up mostly of "ineligible" individuals not actively engaged in the practice of congenital heart surgery. Some were physician/scientists not practicing surgery. Some were from outside the United States and Canada. The web-based survey instrument featured skip logic; those who identified themselves as retirees or trainees were directed to specific modules and not to the remainder of the survey questions. The 246 eligible completed surveys were all from surgeons in the United States or Canada, including 213 from active congenital heart surgeons (representing 78% of the initial target group), 16 from retirees, and 17 from individuals in training. Further responses were not pursued after May 2010. Responses were checked for inconsistencies and errors. Only data entered into the survey instrument by respondents in the United States or Canada actively engaged in the practice of congenital heart surgery, in training, or retired were extracted and analyzed. No information from other sources, including the preliminary investigations to identify congenital heart surgeons, was analyzed. Data were downloaded to Microsoft Excel spreadsheets (Microsoft, Seattle, WA) and imported into SPSS (SPSS Inc, Chicago, IL) for analysis. Percentages are reported as the percent of the actual number of respondents, which varied from question to question.
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Results |
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Education and Postgraduate Training
Of 201 active congenital heart surgeons who provided responses, 159 (79.1%) graduated from medical schools in the United States, 10 (5.0%) graduated from medical schools in Canada, 10 (5.0%) graduated from medical schools in Europe, 12 (6.0%) graduated from medical schools in Asia, and 10 (5.0%) graduated from medical schools elsewhere. The average years of training after medical school graduation was 9.7 ± 1.7 years (range, 6 to 15 years; median, 9 years). Of the 200 active congenital heart surgeons who responded, 152 (76%) undertook the major portion of their congenital heart surgery training in the United States; 23 (11.5%) in Europe, and 20 (10%) in Canada. The remaining 2.5% listed Asia, Australia, or New Zealand.
One hundred ninety-seven of the 213 actively practicing congenital heart surgeons reported certification by the ABTS. One hundred six (53.5%) have recertified 1 or more times, 39 (19.7%) 2 or more times, and 11 (5.6%) 3 or more times. (No alternative choice was offered to indicate certification in cardiothoracic surgery by the Royal College of Physicians and Surgeons of Canada). Of 198 respondents, 17 (8.6%) held the ABTS Certificate of Specialization in Congenital Heart Surgery. Thirty-one (15.7%) indicated that they were not yet certified but had taken the examination and were awaiting results, 100 (50.5%) indicated that they plan to take the examination, and 50 (25.3%) indicated that they did not plan to take the examination.
Current Practice
Years in practice
The number of years that respondents (n = 202) have been engaged in the practice of congenital heart surgery is: 0 to 5 years, 43 (21%) respondents; 6 to 10 years, 36 (18%) respondents; 11 to 15 years, 42 (21%) respondents; and greater than 15 years, 81 (40%) respondents, of which 22 individuals have practiced for greater than 25 years. Active congenital heart surgeons have been in their current positions for 9.3 ± 8.6 years. Eight respondents were in their first year of practice.
Practice characteristics and case volume
Concerning the makeup of their current practice (congenital heart surgery, pediatric, adult, and other), 190 active surgeons provided responses. The data is summarized in Figure 1
. One hundred forty-three of 190 respondents (75.3%) perform exclusively congenital heart surgery. A total of 161 (84.7%) respondents perform exclusively or mostly congenital heart surgery.
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Of 188 respondents, 84 (45%) indicated that their overall caseload of congenital heart operations (pediatric and adult) was smaller than they would like. Another 96 (51%) thought it was just right, and 8 (4%) said it was too large. Ninety-eight of 185 (53%) respondents said their caseload of congenital heart operations was relatively stable from year to year. Twenty-two (12%) said it was declining because of the growth of interventional procedures, whereas 65 (35%) said it was growing despite the growth of interventional procedures. A significant majority (134 of 187 [72%]) reported that the number of congenital heart surgery cases per year for which they serve as first assistant to another attending surgeon is fewer than 50. Only 17 respondents (9%) served as first assistant to another attending congenital heart surgeon for 100 or more cases per year. Participants were asked to indicate who most often serves as first assistant when they are the surgeon of record for congenital heart operations. Responses (n = 190) are summarized in Table 2.
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Pattern of referrals
Most surgeons operate primarily on patients from within their own state or province. Fifty-five of 185 respondents (30%) report that greater than 10% of their cases were from contiguous states or provinces. Twenty (11%) report that greater than 10% of their cases were from noncontiguous states or provinces or from foreign countries.
Miscellaneous
Most respondents work in groups of 2 or 3 congenital heart surgeons. Thirty-three (17%) are solo practitioners of congenital heart surgery. Twenty-five (16%) work in groups of 4 or more congenital heart surgeons. The vast majority of respondents reported using minimally invasive techniques for less than 5% of congenital heart operations. Twenty-six (14%) respondents used minimally invasive techniques for 5% to 10% of cases, and 13 (7%) respondents used such techniques for greater than 10% of cases. Five respondents (2.7%) used robotic techniques: 4 surgeons for 1% or less of cases and 1 surgeon for 1% to 5% of cases.
Academics and Teaching
One hundred fifty-four respondents (75%) have a full-time academic appointment. One hundred sixty-two of 189 respondents (86%) engage in clinical research, with 85 (45%) reporting that they participate in clinical trials or protocol-driven investigations. Sixty-two (33%) engage in laboratory research, whereas 11 (6%) report no participation in any research. Compensation was primarily fee for service for just 21 of 196 respondents (11%); it was primarily salary for 109 (56%) respondents, and it was salary plus incentives for 66 (34%) respondents.
Of 213 surgeons who responded, 116 participate in training of residents in an ACGME-accredited ABTS-approved cardiothoracic surgery residency (or Canadian equivalent). Thirty-three participate in training of congenital heart surgery subspecialty residents in an ACGME-accredited congenital heart surgery training program, and 50 participate in the training of postgraduate fellows who have not completed an ABTS-approved cardiothoracic residency (or the Canadian equivalent).
Retirement
Two hundred two active congenital heart surgeons indicated an estimated number of years until their anticipated retirement. Data are summarized in Table 3. Mean anticipated years to retirement is 16.1 ± 7.6 (range, 1 to 40 years).
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Comment |
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TopAbstractIntroductionMaterial and MethodsResultsCommentDiscussionReferences |
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Our research suggests that the majority of congenital heart operations are performed by approximately 273 surgeons at 125 centers in the United States and 15 surgeons at 8 centers in Canada, with 54% doing 150 or more index cases per year. The estimated survey response rate (213 of 273 [78%]) is similar to the 80% rate for the 2005 survey. Our overall numbers of surgeons and centers are very similar to those in another recent report [5]. Although survey results can never be assumed to be completely representative, the response rates of close to 80% are encouraging. Using case numbers provided by respondents (based on midpoint of ranges) and multiplying by a factor of 273/186 = 1.47 (186 respondents provided index case volume estimates) yields an overall annual congenital heart surgical procedure case volume estimate for the United States and Canada of approximately 40,000. A different model, based on yearly average numbers of congenital heart operations in both the STS Congenital Heart Surgery Database [6] and the STS Adult Cardiac Database [7], yields a similar overall estimate of around 40,000 per year. These must be considered very rough estimates. Both are based on assumptions that are simple but not validated. The precise number of surgeons doing these operations is unknown, as our methods cannot determine the number doing occasional operations for congenital heart disease, particularly in adults.
Comparison of the results of the current survey to those of the initial survey in 2005 reveal that the percentage of respondents doing fewer than 100 index congenital heart operations per year has trended downward. The first survey report indicated that 37% of responding surgeons had annual congenital heart operation case volumes of less than 100. In the current report, 29% of responding surgeons had annual congenital case volumes of less than 100. We do not feel however that these data lend themselves to rigorous statistical comparisons.
Studies that predict an overall workforce shortage in cardiothoracic surgery in the coming decades did not include analyses specific to congenital heart surgery. It is important however to consider the statement from Dr. Richard Jonas' 2010 Presidential Address to the Congenital Heart Surgeons Society [8] that "congenital cardiac surgeons are at the end of this training pipeline, so our supply of potential recruits is likely to be seriously affected." Our ability to project and meet the needs of a growing population of patients with congenital heart disease should ultimately be enhanced by awareness of current trends and numbers describing flux into and out of the workforce. The 2005 and 2010 survey respondents included 11 and 8 individuals, respectively, in their first year of practice. Responses to the 2010 survey suggest that a minimum of 59 practicing congenital heart surgeons plan to retire over the next 10 years, and a total of 106 plan to retire over the next 15 years, for an average of about 7 per year. This is a minimum estimate that does not consider those who did not respond to the survey or did not answer the specific question. It also does not include projections of unplanned retirement for reasons of health, which were cited by 7 of 16 retired congenital heart surgeons who participated in the 2010 survey. The 2005 Survey Report indicated that at that time, 65 practitioners anticipated leaving the workforce through retirement during the coming decade [1].
We reported previously that in 2005 there were 39 fellows who anticipated completing congenital heart surgery training within the following 12 months. Of those, 19 were expecting to seek practice positions in North America [1]. At present, there are 10 ACGME-accredited training programs in the United States, which may graduate 1 congenital heart surgeon per year. In April 2010, the Thoracic Surgery Directors Association In-Service Training Examination Survey was taken by 299 thoracic surgery residents as a prerequisite to the mandatory Thoracic Surgery Directors Association In-Service Training Examination [9]. Twelve residents expressed intent to pursue a congenital heart surgery residency for 2010 to 2011, and 11 additional residents for 2011 to 2012 [10]. In the 2009 American Board of Surgery In-Service Examination Survey, 11 of 1,034 (1.1%) fifth-year general surgery residents indicated an intent to pursue careers in congenital heart surgery [11].
In years past, there was a general tendency to equate surgery for congenital heart disease with pediatric cardiac surgery. The expanding population of patients with congenital heart disease surviving into adulthood and the increasing recognition of the frequency and breadth of surgical needs of those patients has led to a more general consideration of congenital heart surgery from infancy to adulthood. A limitation of the present study is the difficulty in determining the number of surgeons who perform operations for congenital heart disease infrequently, particularly in adult patients. In responses to the 2010 American Association for Thoracic Surgery/STS Practice Survey (for all branches of cardiothoracic surgery), more than 500 respondents indicated that they performed at least 1 operation per year for congenital heart disease in either adults or infants and children. Clearly congenital heart operations, often in small numbers, continue to be performed by surgeons who do not specialize in the treatment of congenital heart disease, despite the recognition by the ACGME and ABTS that congenital heart surgery is a specialty for which dedicated training with a specialized curriculum is appropriate. It is likely that over time, the fraction of adult congenital heart surgical cases performed by surgeons not formally trained as congenital heart surgeons will diminish.
The hope and intent of the authors and of the Society of Thoracic Surgeons Workforce on Congenital Heart Surgery is that data from this study will help to facilitate rational plans to meet future workforce needs, including evolving policies regarding training and certification of surgeons treating congenital heart disease.
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Discussion |
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Surgeons in training positions are really the major thing that has changed between these 2 surveys. In the last survey there were, I think, 39 congenital heart surgeons in training in that survey and now it is down to 17 in training in this survey and, as was just mentioned, the recently approved ACGME fellowship certification in congenital heart surgery has currently 10 approved programs, each with 1 resident in the program, so the number has decreased. Unfortunately that number of trainees is still higher than the anticipated number of open positions each year in congenital heart surgery, at least in the United States and Canada, so it is still a problem for us and will be an issue in the future.
I think of particular note is the relative underutilization of the current Congenital Heart Surgery Workforce. Almost a third of the practicing congenital heart surgeons perform fewer than 100 cases a year and 10% of practicing surgeons perform fewer than 25 cases a year. These are probably surgeons who are part of a larger adult practice. I am sort of predicting that, but I would assume that is the case. Fully 45% of the congenital heart surgeons that were surveyed felt that their caseload was inadequate, was too low for what they desired.
So I have 2 questions. One of these actually is a methodologic question. I am sure you can take care of that easily for me. However despite the rigorous follow-up that you used in trying to find all the congenital heart surgeons, I noted that only 40 of 50 states were represented in the survey, and I just wondered if you went back and looked at that 20% of states that did not have an identifiable congenital heart program whether that was truly accurate or you could find some that night have been lost in the survey?
DR JACOBS: Thank you, Dr Spray. It is a pertinent question, and while I had prepared a map with the distribution of survey respondents, it would not really have represented the entire workforce. It would have represented only the large percentage that responded. Of the states from which we had no respondents, we identified at least 3 in which we were quite certain that there were dedicated congenital heart surgeons practicing. In addition, we identified 4 states in which we were quite confident that there were not dedicated congenital heart surgeons. Those are states not all the way in the Pacific Northwest but in the northern central region, just south of the Canadian border. In general, the map showed that the distribution of congenital heart surgeons matched up quite closely with the density of population by states, which is not surprising.
DR SPRAY: One area of potential growth in case volume obviously is the adult congenital heart population, as you have already mentioned, and 81% of the congenital heart surgeons that were surveyed here do adult congenital surgery as part of their practice. However it is interesting that the American Board of Thoracic Surgery, when it set up the congenital heart surgery certification process, did not include adult congenital heart patients in the cases that are required for certification, and in fact they are specifically discriminated against. Surgeons who would have an interest and specific expertise in adult congenital heart surgery might even be excluded from taking the examination because they wouldn't have the index cases that are required for certification.
This I think is a real issue for the future, and I just wonder if you believe that the Residency Review Committee and the American Board of Thoracic Surgery should make adult congenital heart surgery a requirement for certification in the future and perhaps even adjust the case volume requirements to reflect this?
DR JACOBS: Well, it is an important and a provocative question, and I am going to resist being placed on the hot seat in terms of providing a response. I will say, Dr Spray, that you noted from the manuscript that 1 of the fundamental differences compared with 2005 was that we included a large module of questions related to adult congenital heart disease, and we did that specifically for the reason you stated. One of the major developments in the interim is the subspecialty training certification, and 1 of the major phenomena that we recognized is the expanding adult congenital heart surgery population. So as you suggested with the important question, we hope that the data we have provided from this survey may assist those who plan the training programs and certification requirements in our field in relation to that population. Thank you.
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