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The Continued Urbanization Of American Surgery: A Threat To Rural Hospitals
E Christopher Ellison, Bhagwan Satiani, *David P Way, Thomas E Williams
The Ohio State University, Columbus, OH

OBJECTIVES: In 2011, we predicted surgeon shortages for rural hospitals (RH) which could contribute to RH closures. We reevaluate current RH status and surgeon need by updating population trends, rural and urban hospital (UH) distribution, surgeon supply and needs.
METHODS: We used the US Census Bureau reports to estimate population trends. Distributions of UH and RH were obtained from the American Hospital Association. The baseline number of surgeons was obtained from the AMA Master File (2017). We estimated surgeon supply using the American Board of Medical Specialties (ABMS) certifications for: General Surgery (GS), Orthopedic Surgery (OS), and OB-GYN (2006-2016). We used a stock and flow model adjusted for retirement attrition to project surgeons in practice for the years 2020-2040. Surgeon need was projected using published practice ratios (Merritt-Hawkins 2012) - GS 10.7/100,000, OS 7.9/100,000, and OB-GYN 13.0/100,000.
RESULTS: The US population grew from 309M in 2011 to 327M in 2017. Growth was restricted to the 300 largest metropolitan statistical areas (MSA): 253 to 271M; while rural populations remained unchanged at 56M. From 2011 to 2017 the number of UH grew from 3,012 to 3,387 (+375), whereas the number of RH declined: 1,998 RH to 1,875 RH (- 123). In 2017, there were GS (20,606 in practice, 687 retirements, 982 new); OS (16,977 in practice, 566 retirements, 671 new); OB-GYN (34,274 in practice, 1142 retirements 1,229 new). By 2040, the US population will be 374 M (MSA 85% and Rural 15%) creating shortages of GS (31.5%), OS (34.3%), and OB-GYN (25.3%). Respectively, UH and RH will need to hire 5016 and 885 surgeons per year to meet the demand exceeding the annual supply of 2,882 new surgeons for these specialties.
CONCLUSIONS: Surgical workforce shortages probably contributed to the 6% decrease in RH since 2011. Urban US population is growing compared to rural areas. Future UH demand for surgeons will exceed supply and necessitate policymakers' efforts to maintain RH staffing for surgical services and avoid further closures.

Population Based Recruitment Needs for Urban and Rural Hospitals 2020-2040
HospitalsSpecialtyNumber of SurgeonsTotal
Needed*
Surgeons
Trained/Yr
Hires
Per Year
Hires
Per Hospital
In PracticeShortage
Urban (n=3,387)GS23,28510,68733,972169910
OS16,4838,59925,08212547
OBGYN30,82410,45041,274206412
Totals70,59229,736100,328501630
Rural (n=1,875)GS4,1091,8865,9953003
OS2,9091,5174,4262212
OBGYN5,4401,8447,2843644
Totals12,4585,24717,7058859
Total (n=5,262)GS27,39412,57339,96798219988
OS19,39210,11629,50867114756
OBGYN36,26412,29448,5581,22924289
Totals83,05034,983118,0332,882590222
Notes:
*Recruitment Needs Based on Urban areas (MSA) representing 85% and Rural 15% of the US Population.
†Allocation of new trainees to urban or rural hospitals is indeterminate.


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