The Neurosurgeon Shortage: Are Subspecialties a Cause?

The U.S. faces a projected deficit of 1,200 neurosurgeons by 2025, and it won’t be an easy problem to solve. Although approximately 1,200 residents a year go through 102 accredited neurosurgery residency programs in the U.S. and produce 160 graduates a year, it can take up to 18 years from the start of medical school to produce a board-certified neurosurgeon. That slow replenishment rate only guarantees that the neurosurgeon shortage will grow over time.

A 1975 U.S. government report recommended one neurosurgeon per 100,000 people, although a more recent analysis puts it around 1:61,000. Add a growing and aging population and this proportion may still be inadequate to meet current healthcare needs.

A Scarcity of Neurosurgeons in the U.S.

According to Physicians Thrive and the American Association of Neurological Surgeons, two main reasons for the shortage of neurosurgeons in the U.S. are demographics and subspecialization.

Specifically, the U.S. population is projected to grow by 10% by 2032, and the population is aging. The number of people over age 65 is expected to rise 48% by 2032, meaning more patients of advanced age requiring care, but also more professionals retiring. In fact, a 2016 report from AANS Neurosurgeon noted that almost half of practicing neurosurgeons were at least 55 years old.

There are fewer than 3,700 neurosurgeons who work in more than 5,700 hospitals in the U.S. What’s more, neurological services tend to be clustered in large population areas, leaving many rural areas without coverage. In general, there are more trained physicians in the East, while states with the largest aging populations in the Midwest and South face significant shortages and try to lure physicians with higher salaries and higher bonuses. Rural and low-income urban areas are expected to face the greatest physician shortages.                                                                                                 

At the same time, major scientific breakthroughs and advanced surgical techniques mean that U.S. neurosurgeons are more likely to choose a subspecialty—from neurotrauma and neurocritical care to stroke and brain tumors. That subspecialization not only adds one or two years to residency, but also makes it more difficult to stay abreast of all of the changes across the discipline.

COVID-19’s Effect on Neurosurgeon Training

An April 2020 study of 379 medical students and foreign medical graduates considering or pursuing a career in neurosurgery in the U.S. found that the pandemic had a significant effect on the neurosurgery pipeline, and thus, the impending neurosurgeon shortage.

Survey participants reported:

• • 92% stopped in-person didactic education
  • 43% experienced basic science delays and 44% experienced clinical research delays
  • 60% cited a negative impact on academic productivity
  • Among first year students, 18% said they were less likely to pursue a career in neurosurgery
  • More than 50% of second year and third year students were likely to delay taking the U.S. Medical Licensing Examination Steps I and II
  • Among third year students, 77% reported indefinite postponement of sub-internships and 43% were unsatisfied with communication from external programs

Researchers hoped that such a survey would highlight the need to mitigate disruption to medical education because, they note, “the future of surgical fields, such as neurosurgery, depends on continuous recruitment of strong medical students.”

Optimizing Neurosurgery Residency Programs

Some believe one way to address the neurosurgeon shortage is to shorten neurosurgery residency programs by creating a four-year residency program to produce a general neurosurgeon, then dedicate the mandatory remaining neurosurgeon training time of up to three years for subspecialty training.

Those who complete the four years to become a general neurosurgeon would learn neurotrauma and the most common neuro procedures and be obligated to work in an underserved area before pursuing subspecialty neurosurgeon training. Patients would benefit because they would be stabilized by general neurosurgeons, then referred to tertiary care centers for more complex pathologies.

Another potential solution is private funding such as the $10 million gift from one patient to create an endowed fund to train neurosurgery residents in perpetuity and bypass limits on the number of federally-supported residency training slots.

In Florida, this happened after a man named John Sonnentag nearly lost the ability to walk due to a rare spinal tumor. He was successfully treated by a neurosurgeon at the Mayo Clinic’s Florida campus. To show his gratitude, he and his wife funded a program that will educate seven residents in various stages of their seven-year training for a career in neurosurgery. As one graduates, another will enter the program.

“There’s a tremendous need for training neurosurgeons in this country,” says Dr. Robert Wharen, Jr., chair of neurosurgery at the Mayo Clinic in Florida, in a news release. “There is now a shortage of neurosurgeons, and that shortage is actually going to get worse, because there are more neurosurgeons retiring over the next 10 years than we are able to train.”