Why estimates of physician supply and requirements disagree

Physician supply forecast: better than peering in a crystal ball?

BACKGROUND

Anticipating physician supply to tackle future health challenges is a crucial but complex task for policy planners. A number of forecasting tools are available, but the methods, advantages and shortcomings of such tools are not straightforward and not always well appraised. Therefore this paper had two objectives: to present a typology of existing forecasting approaches and to analyse the methodology-related issues.

METHODS

A literature review was carried out in electronic databases Medline-Ovid, Embase and ERIC. Concrete examples of planning experiences in various countries were analysed.

RESULTS

Four main forecasting approaches were identified. The supply projection approach defines the necessary inflow to maintain or to reach in the future an arbitrary predefined level of service offer. The demand-based approach estimates the quantity of health care services used by the population in the future to project physician requirements. The needs-based approach involves defining and predicting health care deficits so that they can be addressed by an adequate workforce. Benchmarking health systems with similar populations and health profiles is the last approach. These different methods can be combined to perform a gap analysis. The methodological challenges of such projections are numerous: most often static models are used and their uncertainty is not assessed; valid and comprehensive data to feed into the models are often lacking; and a rapidly evolving environment affects the likelihood of projection scenarios. As a result, the internal and external validity of the projections included in our review appeared limited.

CONCLUSION

There is no single accepted approach to forecasting physician requirements. The value of projections lies in their utility in identifying the current and emerging trends to which policy-makers need to respond. A genuine gap analysis, an effective monitoring of key parameters and comprehensive workforce planning are key elements to improving the usefulness of physician supply projections.

Differences in characteristics among new pediatric neurology patients: the effect of a newly established private pediatric neurology practice

OBJECTIVE

To investigate changes in volume and characteristics of new patients referred when a private pediatric neurology practice (PP) opened in 2004 in an area served primarily by an academic medical center's (AMC) pediatric neurology practice.

METHODS

Retrospective analysis of medical and billing records to examine changes in volume, diagnosis, and sociodemographic factors of new patients at the AMC from July 2004 to June 2005; the PP during the same period; and the AMC during the year before.

RESULTS

One year after the PP opened, 40% more new pediatric neurology patients were seen in this area than the year before. Compared with the AMC, PP saw a greater proportion of seizures (34% vs 26%, P < .05) and headaches (32% vs 17%, P < .001), and a lesser proportion of developmental delay/musculoskeletal disorders (12% vs 19%, P < .001) and congenital/metabolic disorders (<1% vs 2%, P < .001). Fewer PP patients lived >20 miles from the practice (32% vs 64%, P < .001), and fewer had public insurance (4% vs 33%, P < .001).

CONCLUSIONS

The establishment of the PP dramatically increased the volume of new pediatric neurology patients in this area. After the PP opened, the AMC continued to care for most patients with rare diseases and fewer financial resources. Future research should examine whether the increase in volume reflects relief of pent-up demand or increased referral rates due to eased access, and should elucidate how differences in patient populations at academic and private subspecialty practices relate to access to subspecialty care and financial well-being of academic practices.

The mental health professions: workforce supply and demand, issues, and challenges

The U.S. mental health (MH) workforce is comprised of core disciplines: psychology, psychiatry, social work, psychiatric nursing, and marriage and family therapy. A broader group of practitioners also deserves recognition. Diverse professions provide significant services in a variety of settings, extending the de facto mental health workforce. A tally of key disciplines estimates there are 537,857 MH professionals, or 182 per 100,000 U.S. population. This article provides an overview of the need and demand for mental health services and summarizes the MH professions (e.g., training, educational credentials, workforce estimates). It also discusses a range of challenges confronting MH professionals and the need for greater understanding of the workforce and integration of services. Methodological factors that confound estimates of the magnitude of the MH workforce are reviewed.

The subspecialization rate of third year internal medicine residents from 1992 through 1998

BACKGROUND

The appropriateness of U.S. physician workforce size and the proportion of generalists versus specialists have long been debated. Difficulty collecting reliable data and varying methodologies complicate clear analysis of workforce questions.

PURPOSE

This work examines the rate at which internists subspecialized during the 1990s. It also compares two approaches for estimating subspecialization rates: (a) following resident classes longitudinally ("cohort" approach), and (b) comparing 1st year fellowship (F-1) class size to the previous year's 3rd-year resident (R-3) class size (F-1/R-3).

METHODS

Data were collected through the American Board of Internal Medicine's tracking program. Physicians completing their R-3 year in 1992 through 1998 were the participants. The proportion of each R-3 group that eventually entered subspecialty training was examined. Demographic data for those entering subspecialty training and those who did not were compared. Subspecialization rate estimates for the cohort and F-1/R-3 approaches were also compared.

RESULTS

The number of internists increased, whereas the number entering subspecialty training declined. Men were more likely to enter a subspecialty than women. International medical school graduates were more likely to enter a subspecialty than U.S. medical school graduates. University-based residency program trainees were more likely to enter a subspecialty than community hospital program trainees. Those entering subspecialty training tended to be younger and score higher on the internal medicine certification examination than those who did not. Almost identical estimates where produced by the cohort and F-1/R-3 approaches.

CONCLUSIONS

There was a downward trend in the rate at which internists entered subspecialty training during the 1990s. The two methodologies examined produced similar results.

Thoracic surgery workforce: snapshot at the end of the twentieth century and implications for the new millennium

BACKGROUND

An appropriately sized physician workforce is an essential component for healthcare planning. Contemporary economic forces and the impact of managed care have stimulated renewed interest in understanding and monitoring workforce issues.

METHODS

Between August and December of 1999, the Workforce Committee of the American Association for Thoracic Surgery and The Society of Thoracic Surgeons conducted a survey detailing demographic, geographic, and socioeconomic practice characteristics of the membership.

RESULTS

The 2,515 returned surveys represented a 62.6% return rate (+/- 1.6% margin of error), providing a highly statistically valid sample. Active thoracic surgeons are a mean of 50 years old, 98% men, with a high level of career satisfaction. Length of training and educational debt has been escalating. Adult cardiac surgical case volumes have increased (mean, 225 cases) and 52% of adult cardiac surgeons perform general thoracic procedures. Surgeons work 67 hours/week and 47 weeks/year. Most are organized in single specialty groups (50%) in urban areas (59%) as for-profit corporations (77%). Half of the respondents will be retired a mean of 13 years from now corresponding to a median calendar year of 2011.

CONCLUSIONS

This survey highlights significant workforce retirement during the next 10 to 15 years. Currently, the workforce in thoracic surgery appears "right sized." These valuable data provide a profile of the specialty. The information enhances our ability to strategically plan.

Integrating Health Services Research Into Nursing Doctoral Programs: The Evolution of Nursing Research

Traditionally, nursing research has focused on the effect of an intervention on selected patients without considering the influence of the system of care and its myriad characteristics. Health services research (HSR) focuses on organization and financing of health services; access to health care; quality of care; clinical evaluation and outcomes research; informatics and clinical decision making; practitioner, patient, and consumer behavior; health professions workforce; health policy formulation and analyses; and health care model and service use. Doctoral students can benefit from HSR's broad perspective if it is included in existing nursing curricula. Ultimately, HSR could help the nursing profession achieve the capacity to develop health policy and new systems of health care for the 21st century.

The longitudinal study of surgical residents, 1994 to 1996

BACKGROUND

The American College of Surgeons (ACS) has conducted a detailed annual survey of residents enrolled in surgical graduate medical education (GME) programs since 1982 and has regularly published the resulting data as the Longitudinal Study of Surgical Residents. This report documents surgical resident enrollment and graduation for the academic years 1994-95 and 1995-96.

STUDY DESIGN

The Medical Education Research and Information Database of the American Medical Association was supplemented by the existing ACS Resident Masterfile and by personal contact with program directors and their staffs to verify accuracy and completeness of reporting. Each resident was tracked individually through surgical GME.

RESULTS

The total number of surgical residents graduating from surgical GME in 1995 and 1996 has not changed since 1982. Most graduates of surgical residency programs are in obstetrics and gynecology, followed by general surgery; demographic analysis of the graduating cohort shows that most are Caucasian male graduates of US or Canadian medical schools, and that their age at graduation is 33 to 35 years. International medical graduates (IMG) make up 8.9% of entering surgical residents and 6% of graduates. Osteopathic medical school graduates account for 1.2% to 1.3% of entering and graduating surgical residents. Women represent 27% of entering and 23% to 24% of graduates of surgical GME. The largest number and proportion of women in surgical GME are enrolled in obstetrics and gynecology residency programs, where they make up the majority of entering and graduating classes. When all other surgical residency program enrollments are considered together, women make up 17% and 16% of entering residents in 1994 and 1995, respectively, and 13% and 14% of graduates in those years.

CONCLUSIONS

Surgical GME enrollment and graduation is stable. Few women and ethnic minorities are enrolled in surgical residency programs. IMG enrollment and graduation in surgical GME is low.

The rural health care workforce implications of practice guideline implementation

BACKGROUND

Rural health care workforce forecasting has not included adjustments for predictable changes in practice patterns, such as the introduction of practice guidelines.

PURPOSE

To estimate the impact of a practice guideline for a single health condition on the needs of a rural health professional workforce.

METHODS

The current care of a cohort of rural Medicare recipients with diabetes mellitus was compared with the care recommended by a diabetes practice guideline. The additional tests and visits that were needed to comply with the guideline were translated into additional hours of physician services and total physician full-time equivalents.

RESULTS

The implementation of a practice guideline for Medicare recipients with diabetes in rural Minnesota would require over 30,000 additional hours of primary care physician services and over 5,000 additional hours of eye care professionals' time per year. This additional need represents a 1.3% to 2.4% increase in the number of primary care physicians and a 1.0% to 6.6% increase in the number of eye-care clinicians in a state in which the rural medical provider to population ratios already meet some recommended workforce projections.

CONCLUSIONS

The implementation of practice guidelines could result in an increased need for rural health care physicians or other providers. That increase, caused by guideline implementation, should be accounted for in future rural health care workforce predictions.

Some thoughts about the past and future of pathology workforce

Comprehensive information on pathology workforce is currently not available. Prudent planning for pathology Graduate Medical Education (GME) requires more timely data than presently exist. In addition, we lack understanding of workforce kinetics in academic pathology which often serves as a buffer in times of surplus. Although the heads of community hospital and private laboratory groups control the majority of decisions regarding pathology workforce, a database of these decision-makers does not exist. However, information from the most recent published sources strongly suggests that a significant surplus already exists. Furthermore, this position is supported by earlier unpublished work from the 1994-1995 Conjoint Committee on Pathology Enhancement (CCOPE) surveys.

Retirement age and the work force in general surgery

OBJECTIVE

This study examines the age of retirement of general surgery Fellows of the American College of Surgeons from 1984 through 1995 and analyzes the potential effect on the work force in general surgery of age of retirement.

SUMMARY BACKGROUND DATA

Data from the Fellowship files of the American College of Surgeons, the American Board of Medical Specialties, and the American Medical Association disclosed that the number of practicing general surgeons in the United States in 1994 was between 17,289 and 23,502, or approximately 7 general surgeons per 100,000 population in the United States.

METHODS

The Fellowship files of the American College of Surgeons from 1984 through 1995 were searched for general surgeons who had written to ask for retirement status or who had died before retirement. Calculations were made of the effect of years in practice on the total general surgeon work force. All living retirees from 1984 to 1985 and 1994 to 1995 were questioned to learn the factors leading to a decision to retire.

RESULTS

The average age of retirement for general surgeon Fellows has risen from 60.45 in 1984 to 62.97 in 1995. Because of increasing diversion of general surgery graduates into surgical specialties, total practice years are declining despite increasing length of practice time. The principal factors for retirement decisions in 1984 and 1985 were disability (26%), leisure time (20%), and unfavorable changes in surgery (29%). In 1994 and 1995, disability was a major factor in 14% of decisions, leisure time in 20%, and unfavorable changes in surgery in 56%.

CONCLUSIONS

Fewer general surgeons enter the work force each year. Thus, despite working longer, the total number of years practiced by each cohort of new general surgeons has decreased.