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Aging population creating higher demand for surgery

A UCLA study predicts surgeon shortages in ophthalmology and cardiology and urges doctors to work even more efficiently.

By Myrle Croasdale, amednews staff. Aug. 25, 2003.

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An expanding aging population will create a shortage of physicians in most surgical specialties, according to the author of a new study published in the August Annals of Surgery.

By 2020 primary care doctors may find it hard to get their patients in to see an ophthalmologist or cardiothoracic surgeon if the predictions of David Etzioni, MD, hold true.

Those performing the surgeries and managing surgical facilities will need to find ways to work more efficiently, he said, since it takes eight to 14 years to train a surgeon.

"Over the next 20 years it will become increasingly difficult to find a surgeon," Dr. Etzioni said. "There will be an increase in demand greater in scale than whatever increases in supply may be occurring."

Dr. Etzioni, a general surgeon at University of California, Los Angeles, and lead author of the study, "The Aging Population and Its Impact on the Surgery Workforce," predicts the sharpest increases in demand will be in ophthalmology and cardiothoracic surgery, which will see 47% and 42% increases in demand respectively by 2020, compared with 2001.

He based his findings on U.S. Census Bureau expectations that the number of people older than 65 will jump 13.3% by 2010 and 53.2% by 2020 to 53.7 million, as baby boomers age and life expectancies lengthen.

Data on age-specific surgery rates came from the 1996 National Hospital Discharge Survey and the National Survey of Ambulatory Surgery.

A lot can happen in 10 years

Still, Richard Cooper, MD, director and professor of the Medical College of Wisconsin's Health Policy Institute in Milwaukee, says even though he, too, anticipates a shortage of physicians, forecasts based on existing surgical rates have an inherent weakness.

"You just can't extrapolate a lot from surveys that way," Dr. Cooper said. "Who knows what will happen next year, let alone in 10 years? It's a given an aging population will need more hips and knees and things. You only know they'll need more, but you don't know what it will be."

Dr. Cooper suggested that technological advances could make some surgeries faster, make current procedures obsolete or increase demand in unanticipated areas.

For example, technologies such as the cardiac valve stent may push back a patient's need for bypass surgery. Less-invasive surgery could mean some procedures are done more frequently. Today gastroenterologists, cardiologists and interventional radiologists are doing procedures previously handled by general surgeons, he said. In the future more doctors will be needed to treat diseases that aren't treated effectively today, such as lung cancer and multiple sclerosis.

As a result, there are too many variables to accurately predict demand by specialty, Dr. Cooper said.

Dr. Etzioni acknowledged such challenges in his study. Citing research indicating the stent has not reduced the number of coronary artery bypasses, he emphasized that new technologies over the long run have meant more procedures, not less.

Ophthalmologist Paul Lee, MD, who has analyzed work force demand within his specialty, said the report's prediction of a 47% increase in demand for ophthalmologic surgery doesn't necessarily mean that he and his colleagues would become overwhelmed with cataract patients.

"An increase in demand for surgical services doesn't necessarily translate into a shortage of surgeons to do the work," Dr. Lee said.

Surgery is a significant part of ophthalmologists' work but not the bulk of their daily routine, he said. One past work force study showed ophthalmologists spend 17% of their time on surgery. An increase in surgery would mean restructuring the work load, he said, and might even include allowing optometrists to take over more tasks.

"We don't need 47% more time or 47% more doctors to take on a 47% increase in demand," he said. "People won't have to put up with a Canadian waiting list to get cataract surgery."

Industry estimates pegged cataract surgeries at 2.3 million in 2002, up substantially from the mid-1990s when there were 1.6 million to 1.8 million surgeries every year.

Work force shortages are notoriously difficult to predict accurately.

The Graduate Medical Education National Advisory Committee of 1981 predicted an oversupply of physicians by 2000. Specifically, this report called for an oversupply of specialists, with a shortage of primary care physicians developing. Dr. Cooper's physician work force model contends that the opposite is taking place. There now are enough primary care physicians, but the number of specialists is short, he said.

State and specialty societies have weighed in on the issue as well.

Anesthesiologists, cardiologists and geriatricians are among specialists who noted shortages in their fields, often marked by an increase in average salaries for the specialty. State medical societies have reported increases in the number of retirees, suggesting population increases are outpacing the ability to maintain an adequate physician framework and further underscoring the potential for deepening shortages in the future.

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