Thomas E. Williams

Reoperative coronary artery bypass grafting without cardiopulmonary bypass.

Between June 1979 and January 1992, 46 men and 13 women aged 35 to 81 years (mean, 58 years) underwent reoperative coronary artery bypass grafting without cardiopulmonary bypass. Isolated reoperative circumflex bypass was performed through a left thoracotomy, and reoperative bypass to the right coronary artery and left anterior descending coronary systems was through a median sternotomy. Complete revascularization was the goal in all patients. Saphenous vein grafts were placed to the right coronary artery (n = 21), circumflex artery (n = 11), and left anterior descending artery (n = 24), and 14 internal thoracic artery to left anterior descending artery bypass grafts were performed. The overall mortality rate was 3.4% (2 deaths). Postoperative morbidity included myocardial infarction in 1 patient and pleuropulmonary complications in 6. No patient was reexplored for hemorrhage, and 19 patients required no blood products. Twenty patients underwent repeat coronary angiography, and 18 of 20 grafts placed without cardiopulmonary bypass were patent. At a mean follow-up interval of 42.2 months 35 of 50 evaluable patients were in functional class I or II. In selected patients, reoperative coronary artery bypass grafting can be performed without cardiopulmonary bypass with a low perioperative morbidity and mortality rate, satisfactory graft patency rates, and good long-term symptomatic improvement.

Population analysis predicts a future critical shortage of general surgeons

BACKGROUNDnThe nations population grew from 227,000,000 to 282,000,000 between 1980 and 2000. By 2050, the population will be 420,000,000, an increase of 50%. Between 1980 and 2005, there was no increase in medical school enrollments. The funding of all postgraduate positions including general surgery was capped at 1996 levels, and so there have been few additional residency positions added. Based on a population analysis, we predict there will be a shortage of general surgeons in the United States by 2010.nnnMETHODSnCalculations were made with regard to the net supply of surgeons for each decade. The projected population for each decade was determined by US Census Bureau figures. The assumptions for these calculations were as follows: (1) the ratio of general surgeons per 100,000 population will remain the same as the year 2000 (7.53/100,000); (2) the number of postgraduate training positions will remain constant; (3) general surgeons will practice 30 years from board certification to retirement; (4) there will be 1000 board certifications a year; and (5) these projections are restricted to allopathic training programs.nnnRESULTSnAs early as 2010, we predict a potential shortage of 1,300 general surgeons growing to 1,875 in 2020 and 6,000 in 2050.nnnCONCLUSIONSnAccording to simple population calculations, if the number of surgical trainees is not increased and the care model remains constant, there will not be a sufficient number of allopathic-trained general surgeons to care for the American people. The government must take proactive steps to increase the funding for surgery trainees to prevent this shortage and maintain the level of access and service to continue the provision of high quality care for the US population.

Predicted shortage of Vascular Surgeons in the United States: Population and workload analysis

OBJECTIVEnTo 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.nnnMETHODSnThe 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

The Impact of Employment of Part-Time Surgeons on the Expected Surgeon Shortage

50,000 with benefits of 30% and

A formidable task: Population analysis predicts a deficit of 2000 cardiothoracic surgeons by 2030.

15,000 of additional direct medical education costs.nnnRESULTSnPopulation 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

Treatment of acute and chronic traumatic rupture of the descending thoracic aorta

1,166,400,000 and

A Review of Trends in Attrition Rates for Surgical Faculty: A Case for a Sustainable Retention Strategy to Cope with Demographic and Economic Realities

1,199,520,000.nnnCONCLUSIONSnA 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.

Current indications for left thoracotomy in coronary revascularization and valvular procedures.

BACKGROUNDnThe 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.nnnSTUDY DESIGNnWe 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.nnnRESULTSnBy 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.nnnCONCLUSIONSnAn 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.

A comparison of future recruitment needs in urban and rural hospitals: The rural imperative

OBJECTIVEnTo estimate the cardiovascular workforce needed by 2030 to meet the needs of our population and to quantify its costs. Our field is changing. The volume of surgery and the nature of the surgery are changing. The nations population grew from 227,000,000 to 282,000,000 between 1980 and 2000, and by 2030 the population is estimated to be 364,000,000. At the same time, the applications for fellowship in our specialty are decreasing at an alarming rate. The American Board of Thoracic Surgery has certified 4500 cardiothoracic surgeons since 1975, but only 1300 in the last 10 years. The US Department of Health and Human Services predicts only 3620 full-time cardiothoracic surgeons in 2020. Will we have enough cardiovascular and thoracic surgeons?nnnMETHODSnRetrospective examination of the pertinent literature and with a modified Richard Coopers economic trend analysis, a population algorithm with a ratio of physicians to population of 1.42 per 100,000. Each thoracic surgeon is predicted to practice 30 years from Board certification to retirement. The Balanced Budget Act will not be revised; therefore, we will certify 100 graduates from our programs per year. The assumed salaries will be 50,000 dollars with benefits of 30% and 15,000 dollars of additional Direct Medical Education costs.nnnRESULTSnThe population in 2030 will be 364,000,000 with 5169 cardiothoracic surgeons needed at that time. Unfortunately, there will be approximately only 3200 cardiothoracic surgeons in practice with a shortage of approximately 2000. To maintain our current status per 100,000 population from 2011 to 2030, we will have to train 4000 residents. The total person years would be approximately 28,000. The cost for this is more than 2,000,000,000 dollars. The annual cost for this training prorated over 20 years would be more than 110,000,000 dollars.nnnCONCLUSIONnWe must train approximately 4000 surgeons, an extra 100 per year, in our specialty to meet the needs of the population by 2030. That will cost approximately 2,250,000,000 dollars. To do this, the Balanced Budget Act of 1997 must be revised to permit more residents to be trained in the United States.

Simplified Management of Chylothorax in Neonates and Infants

Techniques have undergone much change since the first successful repair of an acute traumatic rupture of the descending thoracic aorta was performed by Klassen at our hospital in 1959. It is interesting that we are returning to the techniques which worked so well in that case. Using this approach, which involves virtual elimination of the use of cardiopulmonary bypass, and evaluating each patient individually for the use of a shunt, we have reduced our mortality rate from 61% (8 deaths among 13 patients) during the period 1959–1974, to 6% (1 death among 17 patients) in the last 5 years. We believe that these data confirm the validity of this approach in the management of acute blunt descending thoracic aortic rupture. Prevention of spinal cord ischemia has become the primary concern for continuing clinical and laboratory investigation.RésuméLes techniques de réparation de ruptures traumatiques aigües de laorte thoracique descendante ont subi de nombreuses modifications depuis la première opération réussie par Klassen dans notre hôpital en 1959. Il est intéressant de constater quon revient progressivement à la technique appliquée avec succès dans ce premier cas et qui nutilise presque jamais la circulation extracorporelle. Nous lavons employée, en analysant soigneusement chaque cas en vue de lutilisation dun bypass. Nous avons ainsi réduit notre mortalité de 61% entre 1959 et 1974 (8 décès sur 13 cas) à 6% pour les 5 dernières années (l décès sur 17 cas). Ces résultats confirment la valeur de cette méthode de traitement des ruptures aigües par traumatisme fermé de laorte descendante. La clinique et les examens de laboratoire doivent sintéresser surtout à la prévention des ischémies médullaires.