A report card on the physician work force in the United States

The impact of an early_exposure program on medical students' interest in and knowledge of rural medical practices: a questionnaire survey

BACKGROUND

Many medical students in Japan were brought up in urban areas, thus rural medical practice is often unfamiliar to them. The University of Tsukuba created a one-day early_exposure program to provide freshman students with experience in rural practices. This study was designed to clarify how this one-day early_exposure program affected medical students' attitudes toward and knowledge of rural practices.

FINDINGS

First-year medical students (n = 103) were assigned to one of seven rural clinics in which they experienced rural practice for one day. A pre- and post-program questionnaire, rated on a 5-point Likert scale, was administered to assess students' interest in and knowledge of rural medical practice, with higher scores indicating greater interest and knowledge. Respondents who gave answers of 4 or 5 were defined as having high interest and knowledge. One hundred and one (98.1%) responses were received from students. After the program, the percentage of students interested in rural medical practices was increased (pre- and post-program: 39.0% and 61.0%, respectively; P < .001), as was the number of students who wanted to become physicians in a rural medical practice (pre- and post-program: 53.0% and 73.0%, respectively; P < .01).

CONCLUSIONS

Our one-day early_exposure program demonstrated a positive impact on medical students' interest in and knowledge of rural medical practice. Further follow-up surveys are needed to clarify whether these effects are sustained long-term.

Role of Osteopathic Structural Diagnosis and Osteopathic Manipulative Treatment for Diabetes Mellitus and Its Complications

Osteopathic physicians have a unique opportunity to affect the US epidemic of type 2 diabetes mellitus (T2DM). Osteopathic physicians make up a disproportionately high number of primary care physicians who are on the front lines of managing T2DM. In addition, the unique training of osteopathic physicians allows them to direct additional diagnostic and treatment modalities toward the musculoskeletal complications of diabetes. The present review surveys the literature that explores the effects of osteopathic structural diagnosis of and osteopathic manipulative treatment for T2DM, as well as the management and prevention of complications. The authors reviewed the databases for PubMed, Google Scholar, and The Journal of the American Osteopathic Association. Although the available literature is limited, the authors identify areas in which osteopathic-focused research has shown benefits and in which future research should be directed.

Does salary affect the choice of residency in non-university teaching hospitals? A panel analysis of Japan Residency Matching Programme data

BACKGROUND

Previous studies have investigated factors that are influential on the choice of training hospitals among residency physicians, but the effect of salary was not conclusive. In this study, we aimed to examine whether a higher salary attracted more residents to non-university hospitals participating in the Japanese Residency Matching Programme.

METHODS

Data on 475 hospitals/programmes between 2006 and 2009 were available for analysis. We first conducted an ordinary least squares regression analysis on the ratio of the number of applicants to the residency programme quota as an index of resident's choice, for comparison with previous studies. We further performed panel data analysis to better control for unobserved heterogeneity across hospitals, which could be confounded by the amount of salary. We also performed stratified analysis by the population size of the hospital location.

RESULTS

In ordinary least squares regression, salary showed a positive, but not significant association, with the ratio of the number of applicants to the programme quota, while the results of a fixed effect model exhibited a positive and significant effect of salary (ε= 0.4995, P = 0.015) on the ratio. Analysis stratified by city size showed that the elasticity of salary was comparable (ε= 1.9089, P = 0.016 in large cities versus ε= 1.9185, P = 0.008 in small cities), while that of the number of teaching physicians was larger in large cities (ε= 1.9857, P = 0.009) compared with that in small cities (ε= 1.6253, P = 0.033). The number of teaching physicians had a significant and negative effect modification on salary, implying an antagonistic effect between these two attributes (ε= -1.5223, P = 0.038).

CONCLUSIONS

Our results indicate that the amount of salary influences the choice of training hospitals among medical graduates who choose non-university settings. Use of a monetary reward in a residency programme could be a feasible tactic for hospitals to attract residents.

Geographical distributions of physicians in Japan and US: Impact of healthcare system on physician dispersal pattern

OBJECTIVES

This study examined the effect of increased physician numbers overall on the geographic distribution of the physicians in Japan and the US.

METHODS

Equity of physician distribution with reference to community population and community income was evaluated in all municipalities in Japan, and all counties in the US.

RESULTS

Between 1980 and 2005, Japan and the US experienced a 55% and 47% increase in the number of physicians per unit population, respectively. The Gini coefficients against population were at similar values between Japan and the US, and have been almost unchanged in the past 25 years in both countries. The Gini coefficient against income in the US was lower than the coefficient in Japan, and the US value has decreased since 1980. Correlation between physician-to-population ratio and per capita income among the communities was stronger in the US than in Japan and has increasingly been strengthened during the period examined.

CONCLUSIONS

In spite of constant growth of physician numbers, physicians do not diffuse according to population distribution in both countries. Rather, US physicians seem to diffuse according to income distribution. In order to reverse the continuing maldistribution of physicians, political intervention is required in both countries.

Self-employment, specialty choice, and geographical distribution of physicians in Japan: A comparison with the United States

OBJECTIVES

Geographic and specialty maldistributions of physicians are political concerns in Japan. This study examined the associations of physician employment status with the number and geographic distribution of the physicians in each specialty in Japan, in comparison with the US.

METHODS

The number of physicians per unit population, proportion of clinic (Japan) or office (US) based physicians, and Gini coefficient of physicians against population were calculated in each of 20 specialties in Japan, and 21 specialties in the US. The geographic unit of Gini coefficient was municipality in Japan, and county in the US. Correlations among these three variables were also examined.

RESULTS

The lower the proportion of clinic-based physicians was, the lower the number of physicians and the higher the Gini coefficient were in Japanese specialties, while there was no association between office-based rate and Gini coefficient in the US specialties. In radiology, anaesthesiology, emergency medicine, and pathology, Japanese clinic-based rates were less than one-tenth, and the numbers of physicians per unit population were less than half of the US values, and the Gini coefficients were substantially higher than the US values.

CONCLUSIONS

Difficulty in being self-employed created low numbers in some specialties, and highly urban-biased distributions of these specialists in Japan.

Community characteristics that attract physicians in Japan: a cross-sectional analysis of community demographic and economic factors

BACKGROUND

In many countries, there is a surplus of physicians in some communities and a shortage in others. Population size is known to be correlated with the number of physicians in a community, and is conventionally considered to represent the power of communities to attract physicians. However, associations between other demographic/economic variables and the number of physicians in a community have not been fully evaluated. This study seeks other parameters that correlate with the physician population and show which characteristics of a community determine its "attractiveness" to physicians.

METHODS

Associations between the number of physicians and selected demographic/economic/life-related variables of all of Japan's 3132 municipalities were examined. In order to exclude the confounding effect of community size, correlations between the physician-to-population ratio and other variable-to-population ratios or variable-to-area ratios were evaluated with simple correlation and multiple regression analyses. The equity of physician distribution against each variable was evaluated by the orenz curve and Gini index.

RESULTS

Among the 21 variables selected, the service industry workers-to-population ratio (0.543), commercial land price (0.527), sales of goods per person (0.472), and daytime population density (0.451) were better correlated with the physician-to-population ratio than was population density (0.409). Multiple regression analysis showed that the service industry worker-to-population ratio, the daytime population density, and the elderly rate were each independently correlated with the physician-to-population ratio (standardized regression coefficient 0.393, 0.355, 0.089 respectively; each p<0.001). Equity of physician distribution was higher against service industry population (Gini index=0.26) and daytime population (0.28) than against population (0.33).

CONCLUSION

Daytime population and service industry population in a municipality are better parameters of community attractiveness to physicians than population. Because attractiveness is supposed to consist of medical demand and the amenities of urban life, the two parameters may represent the amount of medical demand and/or the extent of urban amenities of the community more precisely than population does. The conventional demand-supply analysis based solely on population as the demand parameter may overestimate the inequity of the physician distribution among communities.

Medical education program with obligatory rural service: analysis of factors associated with obligation compliance

OBJECTIVES

National or local governmental scholarship programs for medical students with a period of contractual obligation to serve in rural areas are a possible solution to the shortage of rural physicians in many countries. This study reports the outcomes of Jichi Medical University (JMU), one such program, and assesses which personal and familial factors of its graduates have positive impacts on their fulfillment of rural obligation.

METHODS

JMU has a unique contract system under which all the graduates have the obligation to work in rural areas in exchange for having their undergraduate tuition waived. In this retrospective cohort study, personal, familial, and academic information of 2988 JMU students who graduated between 1978 and 2006 was collected on admission and graduation, and follow-up information on contract fulfillment status was collected every year after graduation.

RESULTS

Overall 97% of JMU graduates have completed or are completing their contracts. Graduates who complied with the rural obligation were more likely to have attended public high schools, specialize in primary care, and have had shorter careers than those who broke the contract. The graduates who broke their contracts had mothers with higher academic background than compliers did.

CONCLUSIONS

JMU attained a high rate of obligation compliance. Familial background of entrants and primary care specialty of graduates may be key factors to the contract compliance.

The Canadian Plastic Surgery Workforce Survey: Interpretation and Implications

BACKGROUND

Few studies have monitored physician supply in Canada, and no studies have specifically examined the Canadian plastic surgery workforce.

METHODS

In this study, data were gathered by three methods. A survey was distributed to all members of the Canadian Society of Plastic Surgeons in October of 2004. Opinions on the availability of plastic surgery services were solicited. A second survey that focused on demographics and workload was distributed in December of 2004. Finally, the locations of all Canadian trainees graduating between 1995 and 2005 were reviewed.

RESULTS

The response rate to the first survey was 42 percent. Seventy-eight percent of respondents felt that there was a shortage of plastic surgeons in their community. The response rate to the second survey was 40 percent. Twenty-eight percent of respondents were within 5 years of retirement and 3.2 percent stated that they planned to emigrate by 2010. The mean waiting time for an elective consultation was 32 +/- 33 weeks. Review of all 179 plastic surgery graduates over the past 10 years revealed that 23 percent now practice outside of Canada.

CONCLUSIONS

When these results are projected to the total workforce, they indicate that there will be a future shortage of plastic surgeons in Canada. To prevent a further deficit, there is a need to increase the number of plastic surgery trainees in Canada, to offer incentives for graduates to stay in Canada, and to possibly recruit more foreign-trained plastic surgeons to practice within Canada.

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.

A recurring theme: the need for minority physicians

There is compelling evidence for the need to increase diversity within the physician workforce to ensure high-quality medical education, access to health care for the underserved, advances in research, and improved business performance. To have enough physicians to meet the future needs of the general public, as well as of minority citizens, we must recruit from diverse populations. The need for physicians, particularly under-represented minorities, will continue to grow. Addressing shortages requires inventive efforts to counter obstacles created by the anti-affirmative action movement, as well as strategies to encourage institutions to become more engaged in diversity efforts.

Dynamics of change in local physician supply: an ecological perspective

The purpose of this study is to employ an ecological framework to identify factors that have an impact on change in local physician supply within the USA. A particular specialty type of patient care physicians in a local market is defined as a physician population. Four physician populations are identified: generalists, medical specialists, surgical specialists, and hospital-based specialists. Based on population ecology theory, the proposed framework explains the growth of a particular physician population by four mechanisms: the intrinsic properties of this physician population; the local market's carrying capacity, which is determined by three environmental dimensions (munificence, concentration, diversity); competition within the same physician population; and interdependence between different physician populations. Data at the level of Metropolitan Statistical Areas (MSAs) were compiled from the US Area Resources File, the American Hospital Association Annual Surveys of Hospitals, the American Medical Association Census of Medical Groups, the InterStudy National HMO Census, and the US County Business Patterns. Changes in the number and percentage of physicians in a particular specialty population from 1985 to 1994 were regressed, respectively, on 1985-94 changes in the explanatory variables as well as their levels in 1985. The results indicate that the population ecology framework is useful in explaining dynamics of change in the local physician workforce. Variables measuring the three environmental dimensions were found to have significant, and in some cases, differential effects on change in the size of different specialty populations. For example, both hospital consolidation and managed care penetration showed significant positive eflects on growth of the generalist population but suppressing effects on growth of the specialist population. The percentage of physicians in a particular specialty population in 1985 was negatively related to change in the size of that specialty population between 1985 and 1994, suggesting the existence of competition. Overall, the findings of this study facilitate a better understanding of the complexity of physician workforce supply.

Shared decision-making and the orthopaedic workforce

Studies of physician workforce need a standard of an appropriately sized workforce to compare projections. Although many studies use average rates of healthcare use as a standard, regional benchmarks provide a pragmatic alternative approach to estimating a reasonably sized physician workforce and avoid many of the problems of needs- and demand-based planning. Wide geographic variations in the rates of many procedures, unexplained by differences in population characteristics, suggest that supply-induced demand or physician practice style or both may be the major determinates of the rates for these procedures. In the current study, the authors explore some of these differences in orthopaedic procedure rates and their implications for workforce planning. For example, the rates of hip fracture are fairly uniform across geographic regions, whereas the rates of spine surgery vary sixfold and the rates of spinal fusion vary 10-fold. Shared decision-making is the process of giving patients informed choices about their treatment options based on current best evidence. Careful studies of treatment effectiveness and shared decision-making hold the promise of allowing patients' preferences and values to determine the right rate of healthcare use. These rates could allow workforce projections to be compared with optimal benchmarks for future planning.

Approaches to quality of control in diabetes care

Management methods for quality of diabetes care need new approaches because of the poor metabolic control of most of these patients. Poor quality of care generally results from poor instruction and training rather than from misbehaviour of both patients and their families. Structure quality of care (who and where?), process quality (how?, which are the goals, what resolution is taken and what advice for every-day life is given) and outcome quality (which measurements must be done for the evaluation of the progression of the disease and its control) must all be ameliorated and improved. Regional governments and communities should raise funds for the establishment of diabetes centers, giving recognition and economic support to diabetic children and their families and providing for educational programs on diabetic management and care. The educational aspect seems to be crucial for a good metabolic control not only for the practice of treatment (insulin dosage, home blood glucose monitoring, diet, insulin algorithms), but especially for the active involvement of patients and their families in the management of diabetes. It is also important to consider social and cultural differences among patients in order to arrange therapy according to the individual's characteristics and needs. Improvement of quality of care in diabetic children and adolescents must be pursued; better glycemic control is, in fact, one of the major factors which can contribute to possibly reduce the frequency of macro- and microvascular diabetic complications in the coming years.

The workforce in otolaryngology-head and neck surgery: moving into the next millennium

OBJECTIVE

The goal was to examine the current scope of otolaryngologists' practices, their geographic distribution, and the roles otolaryngologists and other specialists play in caring for patients with otolaryngic and related conditions of the head and neck.

STUDY DESIGN

A large national survey and administrative claims databases were examined to develop practice profiles and compile a physician supply for otolaryngology. A focus group of otolaryngologists provided information to model future scenarios.

RESULTS

The current and predicted workforce supply and demographics are at a satisfactory level and are decreasing as a proportion of the increasing population. Empiric data analysis supports the diverse nature of an otolaryngologist's practice and the unique role for otolaryngologists that is not shared by many other providers. Together with the focus group results, the study points to areas for which more background and training are warranted.

CONCLUSIONS

This study represents a first step in a process to form coherent workforce recommendations for the field of otolaryngology.

Three strategies used by academic health centers to expand primary care capacity

The growth of managed care in the late 1980s and early 1990s severely disadvantaged academic health centers (AHCs). The reliance on primary care gatekeeping and selective contracting by managed care plans were two contributing factors. Because most AHCs had only a modest primary care capacity, they were understandably concerned about their strategic positions. Thus, many felt it was essential to expand their primary care capacities to ensure downstream referrals, to improve contract negotiations with third parties, and to permit assumption of risk for defined populations. Among the different approaches used, three principal strategies emerged for the expansion of the primary care capacity of AHCs: (1) the "assembly strategy," in which many AHCs recruited new generalist faculty into existing clinical departments; (2) the "acquisition strategy," in which AHCs purchased established primary care practices in the community; and (3) the "affiliation strategy," in which some AHCs affiliated with primary care physicians in the community and formed networks of academic and community physicians. For each of these approaches, the author reviews the relative merits and disadvantages, and analyzes why some AHCs' original assumptions about the imperative for increasing primary care capacity may have been spurious. He concludes that recent marketplace and regulatory changes may make it less necessary for AHCs to secure substantial primary care bases in the future.

The cost and efficiency of hospital care provided by primary care physicians and medical subspecialists

There is a perceived excess of subspecialists compared with primary care doctors, but there are few severity-adjusted data that characterize the care provided by these physician groups. In a nationwide hospital network, we studied outcomes of 17,185 patients who were hospitalized for 1 of 9 common internal medicine illnesses. For 4 of 9 conditions, the subspecialists treated more severely ill (P < .001) patients. The raw total charges for their care were higher (P < .002) for 4 of 9 conditions and longer stays were required for 2 conditions. After adjusting for severity of illness, differences between the physician groups became minimal. In nine-severity adjusted medical illnesses, subspecialists and primary care physicians provide care that produces similar results for length of stay, charge, and mortality. Health care manpower projections should be re-evaluated in light of this information.

US health care: a look ahead to 2025

The chapter begins with a reminder that forecasting changes in the health care sector a quarter to a third of a century in the future is likely to be a losing effort, based on past experience. It next considers changing organization and financing and questions that managed care and market competition will be the key forces introducing change. The author looks forward to the passage of universal health insurance coverage for essential care by early in the new century, with patients having to pay for more choice and more quality. The analysis next focuses on the physician supply and points to three challenges: how to moderate the numbers being trained; whether to reconsider the conventional wisdom of training more generalists; and how to support more resources for the National Health Service Corps to improve coverage in underserved areas. The author predicts the restructuring of acute care hospitals, with a marked reduction of in-patient beds, and that leading-edge research-oriented academic health centers should be able to remain out in front. There are also potential gains in health status from prevention and molecular medicine in a nation where chronic disease will dominate.

The employment status of 1995 graduates from radiation oncology training programs in the United States

PURPOSE

To quantify the employment status of 1995 graduates of radiation oncology training programs in the United States.

METHODS AND MATERIALS

All senior residents (149) and fellows (36) who completed training in 1995 were mailed an employment survey questionnaire by the Association of Residents in Radiation Oncology (ARRO). Telephone follow-up of nonrespondents achieved a 100% response rate. Twenty graduates who chose to continue training and five who returned to their home countries were removed from the study. Of the 160 who attempted to enter the U.S. workforce, 106 were men and 54 were women. Initial job status and job status at 6-8 months following graduation were determined.

RESULTS

Unemployment was 6.9% at graduation and 4.4% at 6-8 months. Underemployment (part-time employment) was 10.6% at graduation and 11.9% at 6-8 months postgraduation. Of those working part-time 6-8 months after graduation, 63% (12 of 19) did so involuntarily after unsuccessfully seeking full-time employment. For the 20 graduates who chose to continue training with fellowships, seven (35%) did so solely to avoid unemployment, four (20%) were partially influenced by the job market, and nine (45%) were not influenced by the job market. Adverse employment search outcome was defined as being either unemployed as a radiation oncologist or involuntarily working part-time. Excluding those who chose to work part-time, a total of 19 (11.9%) graduates at 6-8 months following graduation, compared to 22 (13.8%) at graduation, were either unemployed or involuntarily working part-time. In terms of gender, this represented 18.5% (10 of 54) of females and 8.6% (9 of 105) of males. In terms of geographic restrictions in the job search, 56% of males and 70% of females with an adverse employment outcome limited their job search to certain parts of the country. This compares to 62% of all graduates in this study with geographic restrictions in their job search. In terms of perceptions of the workforce and employment opportunities, 95% of all graduates believed there was an oversupply of radiation oncologists and 95.5% believed the job market was worse than what they had anticipated on entering training. Only 42.8% of all graduates were satisfied with the job opportunities available to them. A significant number of private practice positions (41%) did not offer a partnership track, and those that did so had an increased median employment period before partnership (3.25 years) compared to previous years.

CONCLUSION

This is the only employment survey for any specialty in which a 100% response rate was achieved. Upon graduation, a significant number of residents and fellows were either unemployed or involuntarily underemployed. The job market absorbed only a fraction of them at 6-8 months. Most graduates, including those employed full-time, were not satisfied with the practice opportunities available to them during their job search. Many private-sector jobs did not offer a partnership track, and those that did required an increased employment period. A higher rate of involuntary part-time employment was seen for female graduates. Geographic restrictions in job search alone could not account for graduates being unemployed or underemployed, and could not account for gender differences. An overwhelming majority of 1995 radiation oncology graduates believed that the job market had deteriorated and that there was an oversupply of radiation oncologists. As one of two major studies tracking the employment status of radiation oncology graduates, we believe this study to be superior in methodology. We also believe this study presents data in a manner useful to medical students, training program directors, and healthcare policymakers.

Availability of primary care providers and pharmacists in the United States

OBJECTIVE

To determine the rural distribution of primary care providers (primary care physicians, physician assistants, nurse practitioners, and nurse midwives) and pharmacists.

DESIGN

Five-digit ZIP code mapping to study the availability of primary care providers and pharmacists, alone and in combinations, in rural areas and ZIP code-based health professional shortage areas (HPSAs). National averages for annual physician visits for hypertension, asthma, and diabetes were used to estimate the sufficiency of the rural physician supply.

SETTING

Rural areas of the United States.

RESULTS

In rural areas, all providers were present in lower densities than national averages, particularly in HPSAs. The primary care physician supply was insufficient to meet national averages for office visits for hypertension, asthma, and diabetes. Among available providers, the most prevalent co-presence was primary care physician with pharmacist. HPSAs showed very low physician density (1 per 22,122), and the most prevalent providers were pharmacists. States varied widely in provider density.

CONCLUSION

Despite longstanding efforts and the expansion of managed care, primary care providers remain in short supply in rural areas, especially ZIP code-based HPSAs. Making the best use of available providers should be encouraged. The continued shortfall of primary care providers in rural areas, particularly HPSAs, makes it logical to use other available providers and combinations to increase health care access. Pharmacists could increase care for patients with conditions treated with medications. Other available providers, based on skills and work site, could also offset shortages.

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.

Resolving the conflicts between general and subspecialty medicine: the internist as consulting physician-scientist

Internal medicine is confronting a conflict between its generalist and specialty roles, coupled with a conflict between the needs of academic internal medicine in contrast to those of private practice. The historical origins of these conflicts are explored. To resolve these conflicts, internal medicine must rediscover the common ground shared by the general internist and specialist, academician and practitioner. This common ground is best found in the role of internist as physician-scientist. In the future, specialists and general internists will need to emphasize their roles as consultants. In the process, internal medicine will become smaller and more "academic." The benefits of this role for internal medicine should be rapidly demonstrated through outcomes based research in order to win over skeptical payors, peers, and the public at large.

What predicts medical student career choice?

The literature on medical student career choice has identified several influences that can be categorized as student demographics, medical school characteristics, students' perceptions of specialty characteristics, and student-held values. A logistic regression model that included demographics, medical school, and student-rated influences as a proxy for perceptions and values was used to determine their relative contribution to student career choice for three consecutive cohorts of senior medical students attending two schools (n = 649). This model identified a positive relation between choice of primary care career and both student-rated influences and one student demographic characteristic, but not between career choice and school attended. Variables positively correlated with primary care career choice were related to working with people and marital status. Negatively correlated variables were related to income and prestige.

A position paper of the North American Society for Pediatric Gastroenterology and Nutrition. Pediatric gastroenterology Workforce Survey and future supply and demand

BACKGROUND

The North American Society for Pediatric Gastroenterology and Nutrition (NASPGN) performed a Workforce Survey to determine the current number and distribution of pediatric gastroenterologists in the United States and Canada and to estimate the supply and demand in the future in the United States.

METHODS

The response rate was more than 90%. There were 624 pediatric gastroenterologists in the United States, and 48 in Canada.

RESULTS

There were 2.4 pediatric gastroenterologists per million population in the United States, ranging from 3.1 per million in the Northeast to 1.9 per million in the West, and 1.6 per million in Canada. In the United States, fewer than 5 pediatric gastroenterologists retire each year, but more than 40 fellows per year complete training. In the United States, 30% of pediatric gastroenterologists believe there is already an excess supply; only 12% believe there is a shortage (p < 0.001).

CONCLUSIONS

If the number of fellows who complete training each year remains unchanged, in 10 years there will be more than 950 pediatric gastroenterologists in the United States (3.3 per million population). At the same time, if the demand for pediatric gastroenterologists remains 2.4 per million population, there will be a demand for only 675. If these assumptions are correct, it is necessary to reduce the number of fellows to be trained. Although it is difficult to predict future workforce needs reliably, we recommend that the number of fellowship positions in training programs in the United States be reduced by 50% to 75%. Changes in health care in the coming years will be challenging, and effective planning is necessary for pediatric gastroenterologists to achieve their clinical, research, and educational missions.

Reinventing public health

This chapter is a review of the current state of public health in light of the social, political, economic, scientific, and technological changes buffeting the United States. As an assessment of progress in current public health efforts, we address the five major issues in public health for the 1990s raised by Breslow (8): reconstruction of public health; setting objectives for public health; from disease control to health promotion; determinants of health and health policy; continuing social inequities and their impacts on health; and the health implications of accelerating developments in technology. Finally, we look to the twenty-first century and provide five clear paths necessary to strengthen the capacity of public health agencies to protect and improve the health status of the population.