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PEDIATRICS Vol. 102 No. 2 August 1998, pp. 418-427
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ABSTRACT |
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Top
Abstract
Conclusion
References
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This statement reviews current physician workforce projections, and identifies the factors that will have the most impact on future pediatric workforce projections. It discusses the key issues relating to the pediatric workforce: utilization of services, provision of care by both pediatricians and nonpediatricians, pediatric subspecialization, ethnic composition of the population and of the pediatric workforce, indebtedness, and geographic distribution. In a concluding series of recommendations, the statement addresses the steps that must be taken to ensure that all of America's infants, children, adolescents, and young adults have access to appropriate pediatric health care.
Developing accurate forecasts of the physician workforce is
a difficult task. To understand physician workforce forecasting, one
must appreciate that various analytic approaches are used, including
demand-based forecasting (measuring productivity against actual demand
for services), needs-based and adjusted needs-based forecasting (which
estimate requirements at least partly on the basis of population
morbidity rather than observed use of services), and the extrapolation
method (based on managed care staffing patterns and cross-national
comparisons of physician-to-population ratios). As analytic approaches
vary between studies, so too do many measures and assumptions.
One of the seminal works in the area of physician workforce
forecasting was a comprehensive workforce study undertaken by the
Graduate Medical Education National Advisory Committee (GMENAC) and
completed in 1980. Using an adjusted needs-based approach (ie,
estimation of need for physician services based on projected population
morbidity), GMENAC concluded that the aggregate US physician supply
would, by 1990, exceed requirements by 70 000 physicians, and that
supply would exceed requirements by 145 000 in the year
2000.1
In 1992, the Council on Graduate Medical Education (COGME) published a
report that emphasized a growing shortage of practicing generalists
(ie, general pediatricians, general internists, and family physicians)
and called for an increase in the percentage of residents who complete
training in the generalist specialties.2 In 1995, COGME
predicted a net oversupply of 105 000 physicians in the year 2000 (comprised of a surplus of 125 000 specialists and a modest shortage
of 20 000 generalists).3
In 1993, Feil et al4 reviewed eight forecasts of physician
supply and requirements undertaken or published during the 1980s and
concluded that seven of the eight studies predicted an aggregate physician surplus by the year 2000. The size of the oversupply predicted in these studies ranged from <50 000 to >300 000. The single exception cited in the review by Feil and associates was a study
by Schwartz et al,5 which predicted a supply nearly in
balance with requirements. Feil et al aptly pointed out that the
discrepancies in magnitude between existing studies largely stem from
differing inputs or assumptions, that assumptions about requirements
are especially ambiguous, and that even small differences in
assumptions can result in large discrepancies over time.
A widely cited 1994 study by Weiner6 used extrapolation
from managed care organizations' staffing patterns. The key
assumptions of this work were that all Americans would be insured by
the year 2000, and that 40% to 65% of Americans would be enrolled in
managed care plans. Based on these assumptions, Weiner concluded that in the year 2000 there would be an aggregate surplus of approximately 165 000 physicians (representing 30% of patient care physicians), with virtually all of this surplus consisting of specialists (supply and requirements of generalists being in relative balance). Weiner noted that, despite his use of an entirely different forecasting approach from GMENAC, his projection was remarkably similar to that of
the earlier study.6 The most optimistic of the recent forecasts has been that by Cooper7 who projected a surplus of only 31 000 physicians (5% of patient care physicians) in the year
2000. Cooper's projections were built on assumptions of population projections, health maintenance organizations' staffing patterns, geographic distribution of physicians, and physician productivity that
diverge from those used by other authors. On the other hand, recent
cross-national comparisons have suggested that the supply of generalist
physicians in the United States is currently adequate, and that efforts
to expand the generalist workforce significantly are
ill-conceived.8
Based on estimates of growth of the number of pediatricians,
GMENAC predicted an excess of 7500 general pediatricians by 1990, growing to a greater surplus by the year 2000.1 The
American Academy of Pediatrics (AAP) studied the report and issued a
response in 1981 that questioned many elements in the
model.9 Concerned, however, that an excess number of
pediatricians would be produced by the 1990s, the Academy published a
statement in 1985, which it later revised in 1987, recommending
government and academic policies that would ensure the production of
fewer pediatricians, and at the same time, ensure production of
pediatricians of the highest quality.10
Subsequent to the 1987 statement, some evidence pointed to shortages of
pediatricians, rather than the projected surplus, in many regions of
the country. This view continued to be reflected in Academy workforce
policy statements. In 1993, it was noted that, although the absolute
number of physicians caring for children was increasing, significant
unmet health needs in the pediatric population existed. The Academy
called for the support of recruitment efforts to increase the number of
pediatricians and to encourage medical students of the highest caliber
to select pediatrics as a career.11
Throughout the early 1990s, a number of studies and reports were
promulgated that had important implications for pediatrics. A 1990 survey of residency program directors provided the strongest empirical
evidence to date that the supply of new pediatricians did not
significantly exceed the demand.12 More recent data from a
study of medical journal recruitment advertisements for pediatricians
indicate that the number of positions advertised for general
pediatricians peaked in 1990, and has steadily declined since then. For
pediatric subspecialists, the number of positions advertised remained
steady.13
In 1990, COGME contracted with the consulting firm of Abt Associates,
Incorporated to reexamine the adequacy of physician workforce supply.
The resulting report, commonly referred to as the Abt report, concluded
that there would be an even greater oversupply of pediatricians than
the projections outlined in the 1980 GMENAC report.14 The
Academy's concerns with this report's methodology and conclusions
were strongly voiced to the COGME and in the
literature.15,16
The Academy, along with other members of the pediatric community, is
currently participating in the Future of Pediatric Education II
Project. This is a multifaceted effort that seeks to address the health
care needs of children and the workforce necessary to meet those needs
in the next millennium. A final report from the Future of Pediatric
Education II Project, with conclusions and recommendations, is expected
in mid-1999. The Academy anticipates that the findings in this report
will have far-reaching implications for the specialty of pediatrics and
the development of future policy positions pertinent to both the
pediatric workforce and the lifelong pediatric education process.
The Academy believes that it is important to support efforts to assure
that adequate, but not excessive, numbers of well-trained pediatricians
enter the labor market in accordance with the needs and numbers of US
children. Given that the studies referenced above concur that the
supply of physicians overall either has or will soon reach a surplus,
it is likely that all specialties, including those in primary care,
will be called on by policymakers, both within the federal government,
as well as within the medical community, to consider carefully the
reduction of training capacity. The Academy has, therefore, supported
the establishment of an independent, national health care workforce
commission or policy body with regulatory authority, which would be
insulated from the political process and have broad representation from
the primary care community, including pediatrics. Among its several
charges, the policy body would be called on to project the aggregate
need for the medical care workforce for the health care delivery
system; to determine the necessary number of residency positions on a national basis (including the number of international medical graduates
[IMGs]), while maintaining the appropriate number of generalists and
subspecialists; to allocate residency positions by specialty and
subspecialty; to implement appropriate incentives to reinforce the
selection of primary care; and, finally, to conduct ongoing research
that will ensure the availability of appropriate data on which to base
workforce decisions.17
The underpinning of these workforce considerations and decisions must
be the acquisition of reliable data and the development of realistic,
scientifically sound workforce models for both primary and subspecialty
pediatric care. The Academy recognizes that insurance reform and market
forces (including the influence of managed care organizations and the
provision of care delivered by nonpediatricians, such as family
practice physicians and nurse practitioners) make it virtually
impossible to state with precision the workforce requirements for
pediatricians. Notwithstanding the uncertainties involved in workforce
forecasting and the conflicting prior assessments, it is appropriate
that the Academy issue a current statement on pediatric workforce and
recommend which steps must be taken to ensure that all of America's
infants, children, adolescents, and young adults have access to
appropriate pediatric health care.
Trends in Pediatric Workforce Supply
According to the most recent data collected by the American
Medical Association, in 1996 there were 53 369 self-designated active
pediatricians (both board-certified and non-board-certified) in the
United States. The main professional activity of approximately 93% of
these pediatricians was the provision of patient care in office- and
hospital-based settings. The remainder were engaged in other
professional activities, such as administration, medical teaching, or
research.18 The total number of active pediatricians represents a slightly >30% increase from the 40 893 pediatricians accounted for in 1990. From 1970 to 1996, the total number of US
physicians more than doubled. The largest percentage increase in the
primary care specialties was in family practice (411.4%), followed by
pediatrics (191.1%). Between 1980 and 1996, the pediatric population
(0-20 years old) increased by 5.4%.18,19
In 1996, 25% of all pediatricians were younger than 35 years of age,
and another 33% were between the ages of 35 and 44 years, which makes
pediatricians, on average, younger than other physicians.18 The implication of this age structure on the current pediatric workforce is that retirement would not be expected to affect the workforce significantly until 2015 to 2025, when large numbers of
pediatricians reach the age of 65 years.
A noteworthy trend in both the overall physician workforce, and
specifically, in the pediatric workforce, is the growing number of
women physicians. Between 1970 and 1996, the total number of women in
medicine increased over fivefold. Since 1970, pediatrics has been on
the leading edge of the percentage increase of women in medicine. In
1996, 24 271, or nearly 45%, of all pediatricians in practice, were
women, compared with approximately 25% of physicians in internal
medicine and 21% of all physicians.18
With the significant increase in the number of women in pediatrics, and
with the increase of dual-career marriages, lifestyle and childrearing
considerations greatly influence employment decisions of both women and
men. Unpublished data from the AAP Department of Research (1994)
indicate that female pediatricians in direct patient care work 82.8%
as many hours per week (46.5 vs 56.1) and see 76.5% as many patients
(82.9 vs 108.4 per week) as male pediatricians. In light of the fact
that 62.4% of current pediatric residents are women,20
this may be pertinent to productivity considerations in the future. On
the other hand, other data have suggested that there are no significant
differences in productivity among primary care physicians when measures
appropriate to managed care are used.21 It is very
difficult to predict the effect of increasing the numbers of women
practicing pediatrics during a period in which many variables are
changing simultaneously. These variables include: the elusive
definition of a "full-time equivalent", the numbers of women in
training, the average age of the women practicing pediatrics, and
growth in managed care irrespective of gender issues.22 The
COGME concluded that "calculations based on current knowledge of
practice patterns and trends in the gender balance in the workforce
suggest that effects of gender-based adjustments are
minimal."23 It is possible, but unproven, that given the
very large percentage of women pediatricians entering the workforce,
the implications of gender-based differences in productivity may be
greater for pediatrics than for other specialties.
The number of IMGs in pediatrics has grown by >300% between 1970 and
1996.18 In 1996, IMGs comprised nearly 29% of the
pediatrician workforce, compared with 23% of the total physician
workforce. The immigration status of IMGs, along with fluctuations in
the US birth rate, variations in practice patterns, and market changes (discussed in following sections), are four factors that are likely to
have the most impact on future pediatric workforce projections.
Pediatric Training
During the 1980s, interest in primary care specialties declined
among US medical students. Unlike the other primary care specialties, however, pediatrics did not experience a significant decline during this period in the percentage of US medical students choosing pediatric
residency programs,24 in part because of the large number of women selecting pediatric residencies. More recently, US
medical school graduates have shown increasing interest in generalist
training, including training in joint programs, such as internal
medicine/pediatrics, an area in which the numbers of programs and
positions offered have increased significantly.25
Between 1988 and 1993, approximately 10% of US medical school
graduates participating in the National Resident Matching Program (NRMP) chose pediatrics.24 This percentage increased
slightly between 1994 and 1996. In 1998, 11.9% of matching US medical
school graduates (1766) filled 80.4% of the pediatric postgraduate
year 1 (PGY-1) positions (2196) offered through the NRMP.25
The IMGs filled 16.1% of the positions offered through the NRMP, which also reports that 6.3% of the pediatric PGY-1 offered were filled by
"others" (which, according to the NRMP, includes Canadian, osteopathic, fifth pathway, and US physicians), while 1.1% of pediatric positions remained unfilled.25 A significant
number of additional pediatric positions are usually filled outside of the "match," largely by IMGs. These positions filled outside the match, along with several other factors used in counting residents, account for discrepancies between the number of residents reported by
the NRMP and data from residency training directors and the American
Board of Pediatrics (ABP).
Currently, there are 215 accredited pediatric training programs in the
United States. According to the ABP, approximately 7644 pediatricians
were in residency training in 1997, a 14% increase from the 6731 residents reported in 1991. Of pediatric residents in 1997, 64% were
women, while 25% were IMGs.26
Current immigration policy makes it difficult to predict the number of
IMGs in training who will be able to enter the pediatric workforce. The
number and types of visa categories available to IMGs have become more
complex in recent years. Some categories require the physicians to
return to their countries of origin after training is completed, while
others provide for extensions of the visa if, upon completion of
training, the IMG agrees to practice in a designated medically
underserved area. Other exceptions under US immigration policies are
sometimes granted, thereby allowing additional extensions under various
circumstances. In 1996, slightly >36% of all IMGs were "exchange
visitors" and were not expected to remain in the US. Thus, the number
of IMG pediatricians entering practice after training in the US, based
on IMG visa status, can be expected to be modestly smaller than the
number of IMGs counted at the time of entry into pediatric graduate
medical education (GME) programs.20 Many proposals have
been put forward in an effort to reduce the production of physicians in
the US by reducing the available number of GME positions. The Academy
endorses reducing first year GME positions in number to correspond more
closely to the number of US medical school graduates.
The financing of GME stands as the tool for reshaping the future supply
of physicians. Residency programs are federally supported at two
levels: direct medical education support, based on the number of
residents and per resident costs, and indirect medical education
support, which adjusts Medicare payments in recognition of higher costs
of patient care in teaching institutions. Additional primary care
training grants are provided through the health professions training
programs found in Title VII of the Public Health Service Act. Title VII
provides the principal federal support designated for primary care
training in diverse ambulatory settings. Title VII funds for
departments of pediatrics have been instrumental in the expansion of
services, the development of new programs, and training physicians who
have remained general pediatricians in inner-city underserved
communities. The Academy maintains that reauthorization and expansion
in funding for Title VII is crucial. Furthermore, the Academy believes
it is critical to insist on the inclusion of pediatrics and pediatric
training programs in all primary care incentive programs.27
Attempts are underway from many vantage points to implement changes in
the financing of Medicare GME to reduce the numbers of IMGs in training
programs.28 The future structure of GME financing will have
profound implications for pediatrics. The Academy will continue to
support changes in GME financing, which favor the training of primary
care physicians, including pediatricians, at levels adequate to meet
target requirements. The Academy endorses reforms that would entail an
all payer system to cover GME costs, and which would provide payments
directly to GME programs, thereby enhancing ambulatory training. The
Academy cautions, however, that the quality of primary care residency
training may be jeopardized soon, given current trends, which are
reducing numbers of patients seen by trainees in academic health
centers. Consequently, GME reform will need to address the unique
financial circumstances of the GME programs at academic health centers
(AHCs) and children's teaching hospitals. The funding mechanisms must
enable AHCs to develop and administer programs to educate pediatricians
in community settings where the AHC may not be the recipient of payment
for patient care.
The Academy has determined that the following factors are key issues
that must be considered when developing pediatric workforce policy:
utilization of services, provision of care by nonpediatricians (such as
nurse practitioners and family physicians), pediatric subspecialization, ethnic composition of the population and of the
pediatric workforce, indebtedness, and geographic distribution.
Utilization
Some evidence has revealed a growing demand for pediatricians.
Pediatric residency program directors reported a 96% placement rate
for program graduates in 1990, a year widely predicted to be one of
"pediatrician glut."12 In a 1993-1994 survey of
residency directors, only 2% of individuals completing pediatric
residency training were reported to have experienced difficulty finding a suitable position. However, these authors also reported that 11.4%
of program directors anticipated employment problems for their
1994-1995 cohort of senior residents, while 12.1% of directors indicated the possibility of reductions in numbers of positions during
the next 3 years.29 Projections of demand for pediatricians in the future are problematic. For example, the US Census Bureau predicted that there would be 3.7 million live births in 1990, whereas
the actual number of live births was 4.2 million.19,30 The
Bureau also predicted that by the year 2000 there would be 66 million
children <18 years old, a forecast that has now been called into
question.19 Fluctuations in the pediatric population have a
great impact on workforce needs and must be factored into workforce
models.
Trends indicate that utilization of pediatricians has increased in
recent years. For instance, data from the National Ambulatory Medical
Care Survey reveal that of the 13 largest specialties, pediatrics was
the only specialty showing a significant growth in percentage of all
office visits between 1985 and 1989, from 11.4% to
12.6%.31 During the 12-month period from January 1996 through December 1996, visits to pediatricians accounted for 96.8 million of the 734.5 million ambulatory care office visits made to
physicians in the United States, again, representing 13.2% of all
office visits.32 Possible explanations for increased visits
to pediatricians include the expansion in the number of children
enrolled in Medicaid and managed health care plans, both of which
generally cover ambulatory care services more than traditional indemnity plans, as well as a reduction in the number of office visits
to nonpediatricians.
Another explanation for the increase in visits to pediatricians is the
fact that pediatricians are more frequently providing health services
to all children, especially adolescents from 14 to 21 years of
age.33 According to AAP policy, the scope of pediatrics
includes infants, children, adolescents, and young adults. In many
settings (eg, college health centers, centers for treatment of chronic
illness), pediatricians actively participate in the care of young
adults beyond the age of 21 years. Successfully addressing the special
and unique needs of adolescents will continue to affect pediatric
workforce needs, as only 24% of adolescent care is now delivered by
pediatricians.33
The Academy believes that the need for pediatricians has
increased and will continue to expand, attributable in part to the growth and recognition of morbidities, such as, acquired
immunodeficiency syndrome, behavioral and learning problems, divorce,
child abuse, violence, homelessness, and the abuse of tobacco, alcohol,
and other substances. Additional factors that will influence the need for pediatricians include the impact of welfare reform; the relative lack of pediatricians practicing in low-income urban and rural communities; the continued underrepresentation of minority
pediatricians in the workforce; and the changing number of children who
are either uninsured or underinsured and the consequent changes in utilization that will occur. The impact of these issues on market demand for pediatricians' services is unclear. The Academy
believes these issues warrant immediate and ongoing attention, and that the development of accurate physician workforce models must take these
issues into account.
Allied Health Professionals
Workforce models have assumed that pediatric nurse practitioners
(PNPs) could deliver up to 33% of child health
services.14 According to a letter from Cathie Burns,
PhD, RN, CPNP, in October 1997, unpublished data from the most recent
membership survey (1997) of the National Association of Pediatric Nurse
Associates and Practitioners (NAPNAP) reveal that approximately 10 000
PNPs are now actively practicing in the United States. An estimated 600 new PNPs applied to enter the workforce in 1996. The 1992 NAPNAP
membership survey demonstrated that one third of PNPs practice in
hospital clinics, while 23% are in private practice settings. Community and public health settings accounted for another 13% of PNP
practice patterns. The remaining 30% of PNPs were in a wide variety of
settings including schools and health maintenance settings.34 Unpublished data from the previously identified 1997 NAPNAP membership survey also indicates that during the past 5 years, PNPs in hospitals and hospital-based clinics decreased to
approximately 25%, while PNPs in office practice (employee) increased
to just over 38%. PNPs in community and public health settings
increased modestly to slightly over 16%. Although PNPs undergo shorter
training than pediatricians, their collaborative relationships with
pediatricians seem to compensate for possible deficiencies in their
background with regard to caring for children with subtle or complex
medical problems.
Other allied health professionals include physician assistants (PAs)
whose numbers have also increased dramatically over the last few years.
As of November 1996, there were 71 accredited PA programs and 14 programs with provisional accreditatation expected to graduate 2528 PAs
per year. The American Academy of Physician Assistants (AAPA) estimates
that by the beginning of 1997, there were approximately 28 828 PAs in
clinical practice. Approximately 4% of AAPA members work in general
pediatrics or a pediatric subspecialty.35 According to a
1996 survey of AAPA members and nonmembers, approximately half of the
respondents practice in a primary care specialty, while 40% of PAs
practice with physicians in family medicine, where they are, therefore,
likely to see pediatric patients. Slightly over 8% practice in
internal medicine, and almost 3% practice in general pediatrics. In
addition, the remaining 56% not now practicing in pediatrics or family
medicine may, however, work in pediatrics or family medicine at some
future time, because many PAs change specialties over the course of
their careers.36
Studies comparing either nurse practitioners (NPs) or PAs to physicians
have evaluated only their respective care of adult patients. The PAs
worked more efficiently, seeing more patients and generating higher
gross revenue than NPs.37 Both PAs and NPs directly
reflect, in their productivity, the levels of physician task
delegation.
The cost of care by PNPs or PAs compared with pediatricians is
difficult to analyze, as no studies examine independent practice. There
is, hence, a pressing need for data on this subject. One may expect
that, based on the reduced training time and lower salaries, PNPs and
PAs are likely to become increasingly employed in the provision of
child health services. Although PNPs are frequently suggested as lower
cost replacements or substitutes for pediatricians, they may represent
a comparable rather than a lower cost option, because of increasing PNP
salaries, limited working hours, fewer patients seen per hour on
average than physicians, and the need for physician supervision to
assure an appropriate standard of quality.
Concerns have been raised regarding the impact of provider type on the
health status of all children, and particularly children from
underserved groups, such as the poor. In general, PNPs function with
assigned protocols, and are neither trained nor expected to develop
differential diagnoses and treatment plans. These differences in
training may have clinical relevance and result in divergent tiers of
care, as some children may disproportionately depend on PNPs and other
nonphysician providers (such as PAs, nurses, etc).
The need for collaboration between the pediatric medical community and
the allied health professional community is well-recognized. For this
reason, and because of the aforementioned concerns, the Academy
acknowledges the importance of developing qualitative, outcomes- and
process-based comparisons between pediatric care delivered by both
pediatricians and nonpediatricians. Most importantly, the Academy
believes that all children should receive care that is equal in
quality, and that differential tiers of care should not be tolerated.
Family Practitioners
In the past, physician workforce studies have estimated that about
15% to 25% of services to children are delivered by family practitioners; but in rural areas this percentage may be
higher.14,38 However, pediatricians continue to treat
the largest percentage of children in the infant and preschool age
groups.31 Whereas a significant number of older children
and adolescents received care from family practitioners in the past,
pediatricians are increasingly being consulted and recognized as the
primary health care experts for these age groups as well.33
Internal Medicine/Pediatrics
Of the new residency programs, one of the fastest growing is the
combined residency in internal medicine/pediatrics (Med/Peds). This
4-year program, which prepares residents for Board eligibility in both
specialties, offered 456 PGY-1 positions in 106 programs in 1998, 82%
of which were filled by US graduates.25 Since 1988, there has been a >135% increase in residents entering these positions through the "match." The practice patterns of these programs' graduates are not well-studied; however, the ABP has just completed a
survey to determine their practice characteristics.39
Med/Peds residencies require 4 full years of training as a prerequisite to double board certification; yet, attempts to secure full GME funding
for all 4 years of Med/Peds training have been contentious.
Pediatric Subspecialization
Pediatrics has shared in the increase in knowledge and technology
available for diagnosis and patient management, much of which requires
subspecialty training. There are currently 12 areas of pediatric
subspecialization for which there are ABP certification examinations:
adolescent medicine, cardiology, critical care medicine, emergency medicine, endocrinology, gastroenterology,
hematology/oncology, infectious disease, neonatology/perinatology,
nephrology, pulmonology, and rheumatology. Certification of added
qualifications is also provided in sports medicine and
medicine/toxicology.26 Allergy/immunology, however, is
an independently boarded specialty. Some pediatric subspecialty
training (such as general ambulatory, adolescent, and developmental
pediatrics) is often undertaken to enhance the pediatrician's ability
to provide optimal primary care services. In the past, many
pediatricians took 1 or 2 years of subspecialty training before
entering primary care practice. Current trends indicate that many
pediatricians subspecialize in highly technical areas and care for
children with specific complex diseases. The expected life span for
children with many chronic conditions is lengthening, thereby
increasing the need for pediatric subspecialty care. The Academy
believes that all children with complex diseases should have a
well-trained primary care pediatrician, as well as available and
appropriate consultations with pediatric subspecialists.40
A 1991 survey by the Academy found that 34% of all practicing
pediatricians in the United States have had some subspecialty training.
Of these, 28% were neonatologists, 12% were in hematology/oncology, and 11% were in cardiology.41 In addition, IMGs currently
make up 49% of subspecialty fellows.26
Not surprisingly, for the pediatric subspecialists who are certified in
their field, only 59% of their time was spent in direct patient care.
The remainder of their time was spent in administration, research, and
teaching, as 60% of all pediatric subspecialists practice in AHCs,
compared with <33% of internal medicine subspecialists.42 Because the relative and absolute amounts of time pediatric
subspecialists devote to clinical responsibilities vary greatly, the
definition of a pediatric subspecialist (clinical) full-time equivalent
is elusive, thus making workforce projections difficult for this group.
To some extent, the prevalence of practice opportunities in academic
medicine has been beneficial to pediatric subspecialists. Fewer
pediatric subspecialists have had difficulties finding employment compared with internal medicine subspecialists. As many as 10% of
internal medicine subspecialists are currently having difficulty finding positions.42
AHCs are facing an uncertain future. In a recent study involving
members of the Association of Academic Health Centers, all of the
centers were placing less emphasis on their teaching and research
functions, while plans were being made for expansion in primary care
services and vigorous cost-cutting.43 It is well-known that
health maintenance organizations are moving in the direction of
increasing the scope of practice of generalist physicians and
decreasing referrals to specialists, and particularly, to
subspecialists.
In response to these market forces, both the number of fellowship
positions and the number of applicants may decline in the coming years.
Cutbacks are beginning to be made by GME programs, especially in
fellowships that lack board certification status. The ABP reports that
fewer residents taking the General Pediatrics Examination in 1996, only
22%, plan to subspecialize, marking a decline from 27% in 1995, and
32% in 1985.26,44
Although there does not seem to be a large oversupply of pediatric
subspecialists at present, some definite trends are evident. Both the
size and number of subspecialty programs can reasonably be expected to
decrease. Those who enter these programs will need to be educated in
the needs and priorities of managed care organizations. Research may
well be proprietary research, performed for pharmaceutical companies as
a source of income; and teaching may well include, not only education
of residents in AHCs, but also contractual outreach education for
pediatric practitioners who work in a wide variety of community
practice settings.43
Ethnic Composition
Except for physicians of Asian-American background, minorities are
underrepresented in all specialties including pediatrics. According to
unpublished data from a 1994 a survey of young pediatricians (conducted by the AAP Department of Research), 5% are black; 0.1% are
American Indian or Alaskan Native; 12.7% are Asian or Pacific Islander; and 80.6% are white. More specifically, nearly 12% of young
pediatricians are Hispanic, while the number of black pediatric residents has fluctuated over the past 15 years. Overall, there has
been an increase between 1981 and 1996 (from 390 to
432),20,45 but the growth remains slow and the total
numbers low.
The widening disparity in the health status between nonminority
children and minority children has received considerable attention during the past few years. Many of the US Public Health Service's Healthy People 2000 Objectives are intended to address the
high concentration of disease and disability among racial and ethnic minority populations.46 In 1994, the Academy published the
Report of the AAP Task Force on Minority Children's Access to
Pediatric Care, which speaks to need for expanding access to
pediatric care for minority children, and greater diversity within the
pediatrician population. The report also calls for training in the
delivery of culturally effective health care for nonminority medical
students, resident physicians, and pediatricians in
practice.47
The proportion of the population represented by minority children is
increasing. These children are known to have poorer health status and
diminished access to health care, independent of other factors.48 Evidence supports the conclusion that increasing the numbers of minority pediatricians will address this problem. Minority pediatricians disproportionately serve minority children and
children in underserved areas. In addition, minority physicians are
more likely to be sensitive to the culture of their minority patients,
thereby having the potential to deliver health care services more
effectively.49-51 Furthermore, minority pediatricians have
a unique opportunity to serve as role models by influencing children
and adolescents to pursue careers in medicine.
To increase the number of minority pediatricians, the Academy therefore
supports the following efforts:
CONTEXT: THE TOTAL PHYSICIAN WORKFORCE
PEDIATRIC WORKFORCE
KEY FACTORS INFLUENCING PEDIATRIC WORKFORCE
The Academy believes, moreover, that barriers, such as medical student indebtedness, which is significantly higher for minority medical students,52 must receive immediate attention. Affirmative action programs in medical school admissions policies have increased the number of minorities enrolled, and should continue.47 The AAP supports the position that more minority pediatricians will not provide the sole solution to solve the problem of lack of access to care for minority children; however, more caring, concerned pediatricians, who are involved in primary care, and who are actively engaged in providing health care for minority infants and children, can enhance the health status of minorities.51
Indebtedness
Several studies examining the impact of indebtedness on medical students' choice of specialty have produced conflicting results.53,54 However, studies have identified indebtedness and income potential as important issues to medical students in specialty selection.52,55 According to recent surveys of residents conducted by the Association of American Medical Colleges, >80% of the respondents were in debt, which, on average, amounted to >$69 000.56 Of particular note is the large and increasing percentage of medical school graduates with high levels of indebtedness. For example, in 1996 the Association of American Medical Colleges reported that an accumulated debt of >$75 000 was reported by 33.2% of all medical school graduates and by 47.1% of graduates of private US medical schools.56
The Academy is concerned with the disproportionate impact that indebtedness may have on efforts to increase the number of minorities in medicine, and on these doctors' choice of specialty and practice.47 Addressing the complex issue of medical student indebtedness through loan repayment/forgiveness programs is one avenue endorsed by the Academy in the effort to maintain and enhance pediatrics' diversity and ability to attract medical students of the highest caliber into the specialty.
Geographic Distribution of Pediatricians
The variability in the geographic distribution of general pediatricians needs to be factored into any analysis of pediatric workforce. Although the total number of pediatricians has been steadily increasing, a shortage of pediatricians remains in rural areas, remote rural or "frontier" areas, and impoverished urban areas. There remain a small number of difficult-to-fill positions within the Indian Health Service, although recent years have witnessed better "fill rates" overall for these positions. Better data regarding the current distribution of pediatricians (especially in underserved areas) and the factors that influence geographic distribution of pediatricians are needed.
There appear to be several barriers that must be overcome to encourage the location of pediatric practices in underserved areas. The most obvious is financial viability with respect to the often limited child population in rural areas, and to the large uninsured or Medicaid-insured populations in both rural and urban underserved areas. Other factors serve as disincentives, such as lifestyle considerations (including social, cultural, and educational opportunities), the availability of medical resources (eg, location of hospital facilities, access to continuing medical education, coverage respite, proximity of medical colleagues), and career opportunities for spouses.
The Academy supports financial incentives at both the state and national levels to attract and retain pediatricians in underserved areas. This should be a multifaceted approach that considers issues, such as expansion of the National Health Service Corps, greater awareness and utilization of the programs available through the Indian Health Service, other loan forgiveness programs, financial incentives and reimbursement differentials in Medicaid, and other publicly financed care.
Teaching sites should encourage career choices in primary care so that trainees witness the pediatric role modeling, care for the more common problems of pediatric patients, and better understand the relationship between the training program, the pediatrician, and the community. Training of residents and students in outpatient sites and private offices will continue to expand as residency and medical school curricula increasingly emphasize ambulatory medicine. Although not a significant factor at this time, these changes may influence pediatrician requirements in terms of the numbers and types of practitioners, as practicing pediatricians add more teaching responsibilities to their daily activities. Also, funding for training programs will need to factor in appropriate reimbursement for the practicing pediatricians' time spent in teaching.
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The Academy maintains that pediatricians are the optimal health professionals to provide care for infants, children, adolescents and young adults.40 Insurance reform and market forces (including the influence of managed care organizations and the provision of care delivered by nonpediatricians, such as family physicians and NPs) make it difficult to state with precision the workforce requirements for pediatricians. Although the absolute number of physicians caring for children is increasing; and although the numbers of pediatricians per 100 000 US children is increasing and projected to increase further, significant unmet health needs in the pediatric population continue to exist. Thus, defining with precision the appropriate number of pediatricians is a virtually impossible task.
In the aggregate, the current pediatric workforce appears adequate to meet the health needs of US children, yet its rate of growth substantially outpaces the current and projected growth in the US child population, as market forces shape health care delivery in an ongoing way. To meet the health needs of children into the next century more completely, improved geographic distribution of pediatricians and an increase in representation of underrepresented minority groups in pediatrics will need to occur. Most importantly, with respect to children's access to pediatric care, expanded health insurance is imperative. This has far greater potential to solve access problems for underserved children than does increasing physician supply. Thus, the Academy supports three recommendations for action and suggests that they be implemented in the following ways:
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PEDIATRIC WORKFORCE RECOMMENDATIONS |
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Recommendation One
Support the continued education and training of appropriate numbers of well-trained pediatricians in accordance with the needs of America's children.
Implementation Strategies 1. Encourage medical school admissions committees to select students with an interest in primary care and the health and welfare of children.
2. Support recruitment efforts to encourage medical students of the highest caliber to select pediatrics as a career. 3. Explore reimbursement differentials in Medicaid and other publicly financed care to pay higher rates for services delivered in identified underserved areas. 4. Explore the creative use of tax credits and other means as financial incentives to physicians for providing care in identified underserved areas. 5. Support efforts to increase the enrollment of minority students in medical school. 6. Encourage specific recruitment of underrepresented minority students into pediatrics according to current estimates of the population of children and pediatricians in the United States:
encouraging more minorities at
appropriate educational levels to pursue the study of the sciences in
preparation for careers in
medicine increasing the number of
minorities enrolled in and graduating from mainland US and Puerto Rican
medical schools increasing the number of
minority medical students choosing pediatrics as a
career increasing the racial and ethnic diversity of medical school faculty.
7. Support the continuation and expansion of primary care
training, such as the Title VII programs.
8. Insist on the inclusion of pediatrics and pediatric
training programs in all primary care incentive programs at the local, state, and federal level. Ensure that policymakers recognize pediatrics as a primary care specialty and include pediatricians in all legal definitions of primary care providers.
9. Support the restructuring of student loan repayment
schedules so they are based on a percentage of earnings, rather than on
fixed payments.
10. Support changes in GME financing that favor the training
of primary care physicians, including pediatricians, at levels adequate
to meet agreed upon target requirements.
11. Support GME reforms that entail an all-payer system to
support GME costs, and that will provide payments directly to GME
programs, thereby enhancing ambulatory training.
12. Support the provision of appropriate funding and teaching
resources for community pediatricians who agree to train medical students, pediatric interns, and residents in their office practices.
13. Endorse the stance that first-year GME positions be
reduced in number to more closely correspond to the number of US medical school graduates.
14. Support reform efforts to assure that reduced, but
adequate, numbers of well-trained pediatricians enter the labor market in accordance with the needs and numbers of American children.
Recommendation Two
Seek the remediation of geographic maldistribution that has resulted in an undersupply of pediatricians in rural and inner-city areas.
Implementation Strategies 15. Support further research on geographic distribution of pediatricians (eg, trends in employment patterns, efficacy of incentive programs, regional and community level geographic distribution analysis, etc).
16. Support creative student loan forgiveness programs for physicians practicing in designated underserved areas. 17. Explore alternative methods to: a) provide child health services by pediatricians in the event GME reform leads to cutbacks in residency positions in urban hospitals and children's hospitals; and b) ensure the stability of these institutions. 18. Support the expansion of the National Health Service Corps to increase opportunities for pediatricians where market forces do not facilitate private pediatric practice. 19. To improve access to care for infants, children, adolescents and young adults, some form of health insurance for the uninsured must be established.Recommendation Three
Support national workforce planning efforts.
Implementation Strategies 20. Continue to provide accurate, timely information to COGME, congressional subcommittees, and other governmental and nongovernmental entities.
21. Support the development of realistic, scientifically sound workforce models for both primary and subspecialty pediatric care. 22. Support the consideration of developing a sound, independent, national physician workforce planning body that has the authority to allocate GME positions based upon the best available information. 23. Continue monitoring pediatric workforce issues by following the significant changes occurring in the delivery and financing of health care. COMMITTEE ON PEDIATRIC WORKFORCE, 1997 TO 1998| |
FOOTNOTES |
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The recommendations in this statement do not indicate an exclusive course of treatment or serve as a standard of medical care. Variations, taking into account individual circumstances, may be appropriate.
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ABBREVIATIONS |
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GMENAC, Graduate Medical Education National Advisory Committee. COGME, Council on Graduate Medical Education. AAP, American Academy of Pediatrics. IMG, international medical graduate. NRMP, National Resident Matching Program. PGY-1, postgraduate year 1. ABP, American Board of Pediatrics. GME, graduate medical education. AHC, academic health center. PNP, pediatric nurse practitioner. NAPNAP, National Association of Pediatric Nurse Associates and Practitioners. NP, nurse practitioner. PA, physician assistant. AAPA, American Academy of Physician Assistants. Meds/Peds, combined residency in internal medicine/pediatrics.
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REFERENCES |
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The following policy statement is a revision:
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