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Purpose: To evaluate the gender distribution of first and last authors with Brazilian surgical affiliations in PubMed-indexed surgical journals., Methods: Data from eligible surgical journals were retrieved using Scimago Journal & Country Rank 2021 and manually reviewed. Manuscripts published from 2018 to 2022 were included if at least one author was affiliated with a Brazilian institution and a surgical specialty., Results: Data from 340 eligible surgical journals were included. We analyzed first and last authors' forenames of 1,881 manuscripts. Women comprised 16.7% of the first and 12.4% of the last authors. Analyzing the differences in gender trends in authorship across the five Brazilian regions, we found that the South had the highest representation, while the Midwest and North showed the lowest, respectively. Obstetrics and gynecology featured the highest percentage of women-first authors, whereas orthopedics had the lowest. For the last authorship, pediatric surgery showed the highest, with hand surgery having the lowest representation. Male first authors were 1.9 times more likely to engage in international collaborations., Conclusions: This study suggests the persistent underrepresentation of Brazilian women in surgical journal authorship. Local policy changes should be considered to encourage greater diversity and inclusivity in surgical research.

Objective: Previous studies have identified significant gender discrepancies in grant funding, leadership positions, and publication impact in surgical subspecialties. We investigated whether these discrepancies were also present in academic vascular surgery., Methods: Academic websites from institutions with vascular surgery training programs were queried to identify academic faculty, and leadership positions were noted. H-index, number of citations, and total number of publications were obtained from Scopus and PubMed. Grant funding amounts and awards data were obtained from the National Institutes of Health (NIH) and Society for Vascular Surgery websites. Industry funding amount was obtained from the Centers for Medicare and Medicaid Services website. Nonsurgical physicians and support staff were excluded from this analysis., Results: We identified 177 female faculty (18.6%) and 774 male faculty (81.4%). A total of 41 (23.2%) female surgeons held leadership positions within their institutions compared with 254 (32.9%) male surgeons (P = .009). Female surgeons held the rank of assistant professor 50.3% of the time in contrast to 33.9% of men (P < .001). The rank of associate professor was held at similar rates, 25.4% vs 20.7% (P = .187), respectively. Fewer women than men held the full professor rank, 10.7% compared with 26.2% (P < .001). Similarly, women held leadership positions less often than men, including division chief (6.8% vs 13.7%; P < .012) and vice chair of surgery (0% vs 2.2%; P < .047), but held more positions as vice dean of surgery (0.6% vs 0%; P < .037) and chief executive officer (0.6% vs 0%; P < .037). Scientific contributions based on the number of each surgeon's publications were found to be statistically different between men and women. Women had an average of 42.3 publications compared with 64.8 for men (P < .001). Female vascular surgeons were cited an average of 655.2 times, less than half the average citations of their male counterparts with 1387 citations (P < .001). The average H-index was 9.5 for female vascular surgeons compared with 13.7 for male vascular surgeons (P < .001). Correcting for years since initial board certification, women had a higher H-index per year in practice (1.32 vs 1.02; P = .005). Female vascular surgeons were more likely to have received NIH grants than their male colleagues (9.6% vs 4.0%; P = .017). Although substantial, the average value of NIH grants awarded was not statistically significant between men and women, with men on average receiving $915,590.74 ($199,119.00-$2,910,600.00) and women receiving $707,205.35 ($61,612.00-$4,857,220.00; P = .416). There was no difference in the distribution of Society for Vascular Surgery seed grants to women and men since 2007. Industry payments made publicly available according to the Sunshine Act for the year 2018 were also compared, and female vascular surgeons received an average of $2155.28 compared with their male counterparts, who received almost four times as much at $8452.43 (P < .001)., Conclusions: Although there is certainly improved representation of women in vascular surgery compared with several decades ago, a discrepancy still persists. Women tend to have more grants than men and receive less in industry payments, but they hold fewer leadership positions, do not publish as frequently, and are cited less than their male counterparts. Further investigation should be aimed at identifying the causes of gender disparity and systemic barriers to gender equity in academic vascular surgery., (Copyright © 2020 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Introduction: Over the past three decades, there has been a recognised need for emergency surgery (ES). Studies of ES have demonstrated variation in patient outcomes depending on admission time or day. ES as a subspecialty is still under consideration in Europe despite being recognised as such in the US. This article reviews this need and addresses the issues required to develop ES as a separate surgical subspecialty in Europe., Method: A survey on ES was developed by the Educational Committee of the European Society for Trauma and Emergency Surgery (ESTES) and sent to all ESTES members with 102 responses received. Results: Of the responses, 93.1% had completed training. 75.3% of respondents report that ES should be a recognised subspecialty and 79% report that ES is capable of offering a rewarding career. 90% report that ES should have dedicated post-graduate training programme with 69.8% in agreement that dedicated emergency surgeons have improved outcomes following ES., Conclusion: Developing ES as a subspecialty in Europe would improve patient outcomes and facilitate resource allocation. This advancement is, however, still in its infancy and its evolution would require overhaul of our current European system, training methods and understanding of the role of emergency surgeons in ES., (Celsius.)

Background: Several surgeon characteristics are associated with the use of sentinel lymph node biopsy (SLNB) for breast cancer. No studies have systematically examined the relative contribution of both surgeon and hospital factors on receipt of SLNB., Objective: To evaluate the relationship between surgeon and hospital characteristics, including a novel claims-based classification of hospital commitment to cancer care (HC), and receipt of SLNB for breast cancer, a marker of quality care., Data Sources/study Design: Observational prospective survey study was performed in a population-based cohort of Medicare beneficiaries who underwent incident invasive breast cancer surgery, linked to Medicare claims, state tumor registries, American Hospital Association Annual Survey Database, and American Medical Association Physician Masterfile. Multiple logistic regression models determined surgeon and hospital characteristics that were predictors of SLNB., Results: Of the 1703 women treated at 471 different hospitals by 947 different surgeons, 65% underwent an initial SLNB. Eleven percent of hospitals were high-volume and 58% had a high commitment to cancer care. In separate adjusted models, both high HC (odds ratio [OR] 1.53, 95% confidence interval [CI] 1.12-2.10) and high hospital volume (HV, OR 1.90, 95% CI 1.28-2.79) were associated with SLNB. Adding surgeon factors to a model including both HV and HC minimally modified the effect of high HC (OR 1.34, 95% CI 0.95-1.88) but significantly weakened the effect of high HV (OR 1.25, 95% CI 0.82-1.90). Surgeon characteristics (higher volume and percentage of breast cancer cases) remained strong independent predictors of SLNB, even when controlling for various hospital characteristics., Conclusions: Hospital factors are associated with receipt of SLNB but surgeon factors have a stronger association. Since regionalization of breast cancer care in the U.S. is unlikely to occur, efforts to improve the surgical care and outcomes of breast cancer patients must focus on optimizing patient access to SLNB by ensuring hospitals have the necessary resources and training to perform SLNB, staffing hospitals with surgeons who specialize/focus in breast cancer and referring patients who do not have access to SLNB to an experienced center.

Background: Carotid endarterectomy (CEA) is currently performed by various surgical specialties with varying outcomes. This study analyzes different surgical practice patterns and their effect on perioperative stroke and cost., Methods: This is a retrospective analysis of prospectively collected data of 1000 consecutive CEAs performed at our institution by three different specialties: general surgeons (GS), cardiothoracic surgeons (CTS), and vascular surgeons (VS)., Results: VS did 474 CEAs, CTS did 404, and GS did 122. VS tended to operate more often on symptomatic patients than CTS and GS: 40% vs 23% and 31%, respectively (P < .0001). Preoperative workups were significantly different between specialties: duplex ultrasound (DUS) only in 66%, 30%, and 18%; DUS and computed tomography angiography in 27%, 35%, and 29%; and DUS and magnetic resonance angiography in 6%, 35%, and 52% for VS, CTS, and GS, respectively (P < .001). The mean preoperative carotid stenosis was not significantly different between the specialties. The mean heparin dosage was 5168, 7522, and 5331 units (P = .0001) and protamine was used in 0.2%, 19%, and 8% (P < .0001) for VS, CTS, and GS, respectively. VS more often used postoperative drains; however, no association was found between heparin dosage, protamine, and drain use and postoperative bleeding. Patching was used in 99%, 93%, and 76% (P < .0001) for VS, CTS, and GS, respectively. Bovine pericardial patches were used more often by CTS and ACUSEAL (Gore-Tex; W. L. Gore and Associates, Flagstaff, Ariz) patches were used more often by GS (P < .0001). The perioperative stroke/death rates were 1.3% for VS and 3.1% for CTS and GS combined (P = .055); and were 0.7% for VS and 3% for CTS and GS combined for asymptomatic patients (P < .034). Perioperative stroke rates for patients who had preoperative DUS only were 0.9% vs 3.3% for patients who had extra imaging (computed tomography angiography/magnetic resonance angiography; P = .009); and were 0.9% vs 3% for asymptomatic patients (P = .05). When applying hospital billing charges for preoperative imaging workups (cost of DUS only vs DUS and other imaging), the VS practice pattern would have saved $1180 per CEA over CTS and GS practice patterns; a total savings of $1,180,000 in this series., Conclusions: CEA practice patterns differ between specialties. Although the cost was higher for non-VS practices, the perioperative stroke/death rate was somewhat higher. Therefore, educating physicians who perform CEAs on cost-saving measures may be appropriate., (Copyright © 2014 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Length of training (LOT), lifestyle, and decreasing reimbursement have been credited with contributing to the decline in applications to thoracic surgery (TS). Other surgical specialties share similarities in LOT and lifestyle; however, trends in applications for these specialties have not been compared. One cannot look at applications to TS without examining concurrent changes in the pool of residents finishing general surgery. To clarify the relative impact of LOT, lifestyle, applicant pool, and reimbursement on applications to TS, we analyzed these trends concurrently., Methods: National Resident Matching Program residency and fellowship match placement data (1997 to 2012) for general, TS, pediatric, transplant, and vascular surgery, including integrated TS and vascular surgery, were analyzed. Corresponding trends in reimbursement were analyzed from Medical Group Management Association data (1996 to 2010)., Results: During the study period, percentage of medical students matching into general surgery has remained relatively constant (4.9% to 5.5%). Applications for TS have declined since 1997. Applications for pediatric and transplant surgery have increased. Vascular surgery has remained relatively constant, with an applicant to position ratio approximately 1:1. Integrated programs (thoracic and vascular) have been popular; 3 to 7.4 applicants per position and 2 to 3.47 applicants per position, respectively. Cardiovascular surgery median salaries have remained largely the same; salaries for general thoracic, pediatric, transplant, and vascular surgery have increased (1.95% to 7.13% per year) although cardiovascular surgeons continue to have the highest median salary., Conclusions: Given the above data, it does not appear that LOT is the critical issue associated with the decline in fellowship applications for TS. The increased demand for integrated training programs may be reflective of other factors rather than LOT. The success of abbreviated programs in training competent thoracic surgeons has not yet been determined. Given that LOT does not appear to affect applications to surgical specialty, we may be able to maintain applications to the specialty without compromising LOT., (Copyright © 2014 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Scholarly activity is expected of program directors of Accreditation Council for Graduate Medical Education (ACGME)-accredited residency training programs. Anesthesiology residency programs are cited more often than surgical programs for deficiencies in academic productivity. We hypothesized that this may in part reflect differences in scholarly activity between program directors of anesthesiology and surgical trainings programs. To test the hypothesis, we examined the career track record of current program directors of ACGME-accredited anesthesiology and surgical residency programs at the same institutions using PubMed citations and funding from the National Institutes of Health (NIH) as metrics of scholarly activity., Methods: Between November 1, 2011 and December 31, 2011, we obtained data from publicly available Web sites on program directors at 127 institutions that had ACGME-accredited programs in both anesthesiology and surgery. Information gathered on each individual included year of board certification, year first appointed program director, academic rank, history of NIH grant funding, and number of PubMed citations. We also calculated the h-index for a randomly selected subset of 25 institution-matched program directors., Results: There were no differences between the groups in number of years since board certification (P = 0.42), academic rank (P = 0.38), or years as a program director (P = 0.22). However, program directors in anesthesiology had less prior or current NIH funding (P = 0.002), fewer total and education-related PubMed citations (both P < 0.001), and a lower h-index (P = 0.001) than surgery program directors. Multivariate analysis revealed that the publication rate for anesthesiology program directors was 43% (95% confidence interval, 0.31-0.58) that of the corresponding program directors of surgical residency programs, holding other variables constant., Conclusions: Program directors of anesthesiology residency programs have considerably less scholarly activity in terms of peer-reviewed publications and federal research funding than directors of surgical residency programs. As such, this study provides further evidence for a systemic weakness in the scholarly fabric of academic anesthesiology., Competing Interests: Name: Deborah J. Culley, MD Contribution: This author helped design the study, conduct the study, analyze the data, and write the manuscript Attestation: Deborah J. Culley has seen the original study data, reviewed the analysis of the data, approved the final manuscript, and is the author responsible for archiving the study files Conflicts of Interest: Deborah J. Culley received honoraria from American Board of Anesthesiology Dr. Culley is a Director of the American Board of Anesthesiology and a member of the ACGME Anesthesiology RRC Name: Brenda G. Fahy, MD Contribution: This author helped design the study, conduct the study, and write the manuscript Attestation: Brenda G. Fahy has seen the original study data and approved the final manuscript Conflicts of Interest: Brenda G. Fahy received honoraria from American Board of Anesthesiology Dr. Fahy is a Director of the American Board of Anesthesiology and a member of the ACGME Anesthesiology RRC. Name: Zhongcong Xie, MD, PhD Contribution: This author helped write the manuscript Attestation: Zhongcong Xie has seen the original study data and approved the final manuscript Conflicts of Interest: The author has no conflicts of interest to declare. Name: Robert Lekowski, MD Contribution: This author helped conduct the study and write the manuscript Attestation: Robert Lekowski has seen the original study data and approved the final manuscript Conflicts of Interest: The author has no conflicts of interest to declare. Name: Sascha Buetler, MD, PhD Contribution: This author helped conduct the study and write the manuscript Attestation: Sascha Buetler has seen the original study data and approved the final manuscript Conflicts of Interest: The author has no conflicts of interest to declare. Name: Xiaoxia Liu, MS Contribution: This author helped with statistical support and rewriting of the manuscript Attestation: Xiaoxia Liu has seen the original study data and approved the final manuscript Conflicts of Interest: The author has no conflicts of interest to declare. Name: Neal H. Cohen, MD Contribution: This author helped design the study and write the manuscript Attestation: Neal H. Cohen has seen the original study data and approved the final manuscript Conflicts of Interest: Neal H. Cohen Former Chairman of the ACGME Anesthesiology RRC. Name: Gregory Crosby, MD Contribution: This author helped design the study, analyze the data, and write the manuscript Attestation: Gregory Crosby has seen the original study data, reviewed the analysis of the data, and approved the final manuscript Conflicts of Interest: The author has no conflicts of interest to declare.

Vascular surgery is a subspecialty that attracts future surgeons with challenging technical procedures and complex decision making. Despite its appeal, continued promotion of the field is necessary to recruit and retain the best and brightest candidates. Recruitment of medical students and residents may be limited by the lifestyle inherent to vascular surgery and the length of residency training. The young adults of the current applicant and resident pool differ from prior generations in their desire for hands-on mentoring, aspirations to affect change daily, a penchant for technology, and strong emphasis on work-life balance. Furthermore, the percentage of women pursuing careers in vascular surgery is not representative of the eligible workforce. Women are now the majority of graduates in all of higher education, and thus, vascular surgery may need to make a concerted effort to appeal to women in order to attract the most talented young professionals to the field. Recruiting strategies for both men and women of Generation Y should target a diverse group of potential candidates with an awareness of the unique characteristics and needs of this generation of rising surgeons., (Copyright © 2013 Society for Vascular Surgery. All rights reserved.)

Objectives: To explore trends in the clinical activity of hospital specialists in English National Health Service (NHS) hospitals, and test the effect of contract reform., Design: Retrospective secondary analysis of hospital episode statistics, describing trends and testing for a contract effect using multilevel interrupted time series analysis., Setting: Ten surgical and medical specialties in English NHS hospitals from 1999 to 2009. Participants Hospital consultants on full time or maximum part-time English NHS hospitals., Intervention: A new contract offered to NHS consultants in October 2003, with higher pay alongside job planning and appraisal., Main Outcome Measures: Inpatient finished consultant episodes (FCEs) per consultant per month, with and without accounting for case-mix differences., Results: In most specialties there was a statistically significant downward trend in FCEs per consultant per month. On average in the surgical specialties, FCEs reduced by 0.14 per month (95% CI -0.16 to -0.11) and in medicine there was a smaller reduction of 0.08 FCEs per month (95% CI -0.1 to -0.06). NHS patients symptoms have increased in severity over time, and the downward trend is reduced after case-mix-adjustment, and reversed in general and geriatric medicine. The effect of the contract on clinical activity was minimal. In five specialties there was no statistically significant effect, but in five specialties there was a statistically significant negative effect., Conclusions: Consultant clinical activity, as measured by FCEs per month, has shown a general downward trend from 1999 to 2009. The consultant contract was not associated with an increase in consultant clinical activity rates.

Nowadays, general surgery is considered as a tiring and uninteresting specialty. It is believed that the advent of new technologies, the internet, videosurgery, robotics, telemedicine, specialization and the indifference of recently graduated for the general surgery may be factors that had contributed to this change. In this article the changes of general surgery practice in Brazil, in the world an their consequences in the general surgeon professional development are being discussed.

Introduction: Information about the education, training and future employment prospects of Icelandic surgeons has not been available., Materials and Methods: The study included all Icelandic surgeons, in all subspecialties, educated at the Faculty of Medicine at the University of Iceland. Information on specialty training, higher academic degrees and in which country these were obtained was collected. Future employment prospects were analysed by calculating supply and demand until the year 2025. Approximations, such as sustained demand for surgeons per capita, were used., Results: Out of 237 licensed surgeons, two thirds were living in Iceland and 36 were retired. Majority (69.2%) had been trained in Sweden and orthopaedic (26.9%) and general surgery (23.9%) were the most common subspecialties. The average age of surgeons in Iceland was 52 years and 44 years for surgeons abroad. Females were 8% of surgeons in Iceland while being 17.4% among 36 doctors in surgical training overseas. Over 19% had received a PhD degree. Predictions suggest that supply and demand for surgeons in Iceland will be equal in the year 2025, not taking into account the prospects for the working market outside Iceland., Conclusion: A third of Icelandic surgeons live outside Iceland. The proportion of female surgeons is low but it is increasing. Our predictions indicate a balanced work market for surgeons in Iceland for the next 15 years. However, there are many uncertainty factors in the calculations and they do not predict the prospects for individual subspecialties.

Vascular surgery has emerged as an independent speciality in India. The growth and development of vascular surgery in India has been slow, yet steady. It is a matter of concern that almost a quarter century down the line this speciality is faced with several problems. This article examines the issue of whether it is feasible for vascular surgery to exist as an independent subspeciality. Does one follow a conciliatory or a confrontational approach with the 'competing specialities'?, (Copyright (c) 2010 European Society for Vascular Surgery. All rights reserved.)

Laparoscopy is considered today the highlight of modern surgery, the forerunner of the fascinating world of video and robotic surgery, both of them derived from the sophisticated areas of aeronautic industry. Remarkably, Romanian specialists keep up with the pace of worldwide technological developments, assimilating one by one each and every video endoscopic procedure. In the early 90s, the Romanian laparos-copic school was founded with the contribution of many important personalities; their activities and achievements have been an inspiration for the following generation of laparoscopic surgeons. In this last decade, the newest branch of laparoscopic surgery in our country, pediatric laparoscopy, managed to evolve from its "shy" beginnings to become an important method of improving the quality of surgical procedures, to the benefit of our "small patients". The purpose of this article is to encourage and promote minimally invasive video endoscopic surgery training, emphasizing its crucial role in the education and professional development of the next generation of pediatric surgeons, and not only. The modem concept of laparoscopic training includes experimental scientific practices, as well as the newest technical acquisitions such as virtual reality video-electronic simulation.

Background: Data envelopment analysis (DEA) is an established technique that hospitals and anesthesia groups can use to understand their potential to grow different specialties of inpatient surgery. Often related decisions such as recruitment of new physicians are made promptly. A practical challenge in using DEA in practice for this application has been the time to obtain access to and preprocess discharge data from states., Methods: A case study is presented to show how results of DEA are linked to financial analysis for purposes of deciding which surgical specialties should be provided more resources and institutional support, including the allocation of additional operating room (OR) block time on a tactical (1 yr) time course. State discharge abstract databases were used to study how to perform and present the DEA using data from websites of the United States' (US) Healthcare Cost and Utilization Project (HCUPNet) and Census Bureau (American FactFinder)., Results: DEA was performed without state discharge data by using census data with federal surgical rates adjusted for age and gender. Validity was assessed based on multiple criteria, including: satisfaction of statistical assumptions, face validity of results for hospitals, differentiation between efficient and inefficient hospitals on other measures of how much surgery is done, and correlation of estimates of each hospital's potential to grow the workload of each of eight specialties with estimates obtained using unrelated statistical methods., Conclusions: A hospital can choose specialties to target for expanded OR capacity based on its financial data, its caseloads for specific specialties, the caseloads from hospitals previously examined, and surgical rates from federal census data.

Introduction: This paper describes the design, implementation and evaluation of a new professional role in surgery. The role of the perioperative specialist practitioner (PSP), conceived as a response to the Working Time Directive, provides integrated preoperative and postoperative care to patients undergoing surgery in hospital., Methods: A 1-year training programme was designed, dealing with a wide range of knowledge, skills and attitudes. Effective communication was a key component. Nine intensive 5-day modules at Imperial College London (London, UK) alternated with supervised experience of the surgical team at each participant's home trust. Detailed evaluation of the role and the training programme was provided by an independent research team, using an interview-based qualitative approach. Observational data were provided by the project team. Data were analysed using standard qualitative methods., Results: 27 PSPs across 12 National Health Service trusts took part in two PSP training programmes. A total of 124 interviews (94 individual and 30 group) were carried out with PSPs and their colleagues. Overall, the role was seen as successful and positive, with great potential for dealing with reductions in junior medical cover. Each site encountered different opportunities and problems. Lack of mentorship was a key issue, and the role provoked considerable opposition in trusts. The training programme was viewed as highly successful., Discussion: PSPs can provide high levels of expertise, but within clear limits. Our training programme has been effective and is perceived to be of high quality. However, introducing a new role requires time and sensitivity if opposition is to be minimised.

Background: The Calman-Hine Report in England and Wales and the Campbell Report in Northern Ireland initiated a major reorganization of cancer services with the aim of improving the provision and delivery of care to cancer patients. In this paper, breast cancer patients diagnosed in 1996 and those diagnosed in 2001 are compared in order to examine the extent of service change in Northern Ireland., Methods: Patients living in Northern Ireland with invasive breast cancer diagnosed in either 1996 or 2001 were identified from the Northern Ireland Cancer Registry database. Information relating to the delivery of cancer care to these patients was collected by retrospective review of their case notes., Results: Breast cancer surgery was performed in fewer hospitals (13 versus 21) by fewer surgeons (19 versus 40) with 98 percent of patients operated on by designated breast surgeons in 2001. Clinically relevant axillary node excision increased with 765 (87 percent) patients having six or more nodes excised in 2001 compared to 515 (67 percent) in 1996 (p < 0.001). Recording of oestrogen receptor (ER) status improved from 23 percent in 1996 to 91 percent in 2001 (p < 0.001) and 81 percent of patients received hormone therapy appropriate to their ER status in 2001 compared with 6 percent in 1996 (p < 0.001). Communication between hospitals and patients and their GPs also improved., Conclusion: A significant change in service provision and delivery has occurred in Northern Ireland in line with the recommendations of the Campbell report. Further work is underway to ascertain the extent to which these changes may have impacted on patient outcomes.

Objective: Records for all patients in Ontario who underwent elective repair of abdominal aortic aneurysms (AAAs) or repair of ruptured AAAs between 1993 and 1999 were studied to determine whether the profile of surgeons or patients changed and to determine whether postoperative mortality changed over time. The secondary objective was to describe long-term survival after AAA surgery., Methods: A population-based retrospective cohort was assembled from administrative data. Surgeon billing records were used to identify operations performed between 1993 and 1999. Chi(2) and linear regression analyses were used to determine whether variables changed over time. Kaplan-Meier survival curves were used to estimate long-term survival., Results: For patients undergoing elective AAA repair, average annual surgeon volume (P <.0001) and proportion of patients operated on by vascular surgeons (P =.02) increased over the study period; similar trends were noted for patients undergoing repair of ruptured AAAs. Surgeon volume was clearly correlated with mortality after both elective AAA repair and repair of ruptured AAAs; however, the benefit of this effect was modest beyond a surgeon volume of 6 to 10 ruptured AAA repairs per year or 20 to 30 elective AAA repairs per year. No change in crude 30-day mortality (4.5% for elective AAA repair and 40.4% for repair of ruptured AAAs) was noted during the study., Conclusion: Despite the finding that surgery to repair ruptured AAAs and elective repair of AAAs is being increasingly performed by high-volume vascular surgeons, there was no change in early mortality between 1993 and 1999. This may have been because average surgeon volume was already relatively high at the beginning of the study period, which translated into only modest benefit to further increases in surgeon volume.

Objective: To predict the impact of the aging population on the demand for surgical procedures., Summary Background Data: The population is expanding and aging. According to the US Census Bureau, the domestic population will increase 7.9% by 2010, and 17.0% by 2020. The fastest growing segment of this population consists of individuals over the age of 65; their numbers are expected to increase 13.3% by 2010 and 53.2% by 2020., Methods: Data on the age-specific rates of surgical procedures were obtained from the 1996 National Hospital Discharge Survey and the National Survey of Ambulatory Surgery. These procedure rates were combined with corresponding relative value units from the Centers for Medicare and Medicaid Services. The result quantifies the amount of surgical work used by an average individual within specific age groups (<15 years old, 15-44 years old, 45-64 years old, 65+ years old). This estimate of work per capita was combined with population forecasts to predict future use of surgical services., Results: Based on the assumption that age-specific per capita use of surgical services will remain constant, we predict significant increases (14-47%) in the amount of work in all surgical fields. These increases vary widely by specialty., Conclusions: The aging of the US population will result in significant growth in the demand for surgical services. Surgeons need to develop strategies to manage an increased workload without sacrificing quality of care.

Background: The current status and future needs of peripheral endovascular utilization and training have not been well defined. This topic is particularly relevant to the future of four specialties: interventional cardiology, cardiothoracic surgery, interventional radiology, and peripheral vascular surgery. We attempt to analyze the current numbers of cardiovascular patients and procedures and the numbers of treating physicians and surgeons to make predictions and recommendations for the future., Methods: The numbers of cardiovascular patients and procedures were obtained from the Healthcare Cost and Utilization Project Trend Query web site. The number of endovascular abdominal aortic aneurysm repairs was obtained with telephone or e-mail contact with the aortic endograft manufacturers. The numbers of different cardiovascular specialists were obtained with contact with different cardiovascular professional societies and the American Board of Specialists via telephone, e-mail, or web site. The numbers of accredited US cardiovascular fellowship programs and first year spots were obtained from the Graduate Medical Education Directory 2000 to 2001. Finally, the numbers of endovascular fellowship programs and first year spots were obtained with contact with the individual programs., Results: The numbers of cardiovascular patients and procedures have risen from 1993 to 1997. This trend is expected to continue as the population ages. Despite the rapid rise of endovascular procedures, the number of open cases has continued to rise as well. However, the number of cardiovascular specialists is predicted to remain stable. Specific numbers and trends are depicted in the manuscript., Conclusion: Our analysis shows that a critical shortage of endovascular trained specialists will exist in the future. More surgeons need to receive endovascular training to meet these future needs.

Objectives: The Manitoba Centre for Health Policy and Evaluation worked in support of a provincial Physician Resource Committee to address questions pertinent to assessing Manitoba's supply of specialist physicians., Research Design: Because there was no direct method of determining whether the province's supply of specialists was adequate, three types of evidence were reviewed: the supply of specialists relative to recommended population/physician ratios; the supply of specialists relative to other Canadian provinces; and the level of care delivered by specialists in Manitoba relative to other provinces. Four additional questions were addressed: is a problem developing from the aging of Manitoba's specialist physicians? and will the supply of specialists be sufficient to keep up with the aging of the population? How well do specialists serve as a provincial resource? and how well do specialists serve high-need populations?

Medicine is entering an unprecedented era of provider abundance, including both physician and nonphysician providers. Over the next several decades, the projected number of primary care physicians will be more than adequate to meet national needs, although there is no assurance that any number of physicians will create an equitable distribution. At the same time, a growing surplus of specialists is projected. A balanced abundance in both primary care and specialty medicine will continue if approximately 33% of first-year residents ultimately practice primary care and 67% become specialists. In contrast, a shift to 50:50, as has been proposed by the Committee on Graduate Medical Education and others, will lead to a superabundance in primary care and a potential deficiency in specialty medicine later in the 21st century. Under either scenario, maintaining balance will be aided by those physicians with sufficient generalist skills to enable them to practice at the interface of primary care and specialty medicine, the domain of "middle care." The nation will be well served by educational policy that imparts such generalist expertise to medical students and that creates a workforce of highly skilled physicians capable of caring for patients in the technologically advanced clinical environment of the future.