Grassroots activism and the pursuit of an expanded physician supply

Ophthalmic Education and Ophthalmologists Growth Trends in Iran (1979-2016)

Purpose

To analyze the growth trends in ophthalmic education in Iran since 1979, and to discuss their implications on the profession.

Methods

This comprehensive national study was performed by the Academy of Medical Sciences of I.R. Iran. The data were gathered from the Specialty Training Council of the Ministry of Health and from the Medical Council of Iran.

Results

Our analysis revealed ten important current growth trends and seven future trends and implications. Between 1979-80 and 2015-16, the number of residents annually admitted to ophthalmology increased from 21 to 84 and related fellowships and from 0 to 34. The number of ophthalmologists graduating in the country increased from 21 (45%) in 1979 to 69 (98%) in 2015. The ratio of ophthalmologists per 100,000 people averaged 1.91 in 1979 and 3.00 in 2016. Considering migrant and retired ophthalmologists, there are approximately 2400 active ophthalmologists in Iran. In 1979, there was one active ophthalmologist per 52,112 people; in 2014, there was one per 33,333 people. This represents a per capita increase of 57%. Since 1979, the number of active ophthalmologists has increased by 234%. The number of active women ophthalmologists has increased by more than 600%, from 65 (9%) in 1979 to 470 (20%) in 2016.

Conclusion

Equitable geographic distribution and balanced combination of ophthalmologists (women/men and specialists/fellowships) are necessary to optimize community eye health. We propose further studies on the effects of fellowship training growth and work patterns of female and male ophthalmologists.

Evaluating the Impact of a Clinician Improvement Program for Treating Patients with Intellectual and Developmental Disabilities: The Challenging Case of Mississippi

In recent years, people with intellectual and developmental disabilities (IDD) have moved from institutionalized settings to local community residences. While deinstitutionalization has yielded quality of life improvements for people with IDD, this transition presents significant health-related challenges. Community clinicians have typically not been trained to provide sound medical care to people with IDD, a subpopulation that exhibits unique medical needs and significant health disparities. This study reports the results of a comprehensive evaluation of an IDD-focused clinician improvement program implemented throughout Mississippi. DETECT (Developmental Evaluation, Training and Consultative Team) was formed to equip Mississippi’s physicians and nurses to offer competent medical care to people with IDD living in community residences. Given the state’s pronounced health disparities and its clinician shortage, Mississippi offers a stringent test of program effectiveness. Results of objective survey indicators and subjective rating barometers administered before and after clinician educational seminars reveal robust statistically significant differences in clinician knowledge and self-assessed competence related to treating people with IDD. These results withstand controls for various confounding factors. Positive post-only results were also evident in a related program designed specifically for medical students. The study concludes by specifying a number of implications, including potential avenues for the wider dissemination of this program and promising directions for future research.

The Drivers of Discretionary Utilization: Clinical History Versus Physician Supply

PURPOSE

Because the effect of physician supply on utilization remains controversial, literature based on non-Medicare populations is sparse, and a physician supply expansion is under way, the potential for physician-induced demand across diverse populations is important to understand. A substantial proportion of gastrointestinal endoscopies may be inappropriate. The authors analyzed the impact of physician supply, practice patterns, and clinical history on esophagogastroduodenoscopy (EGD, defined as discretionary) among patients hospitalized with lower gastrointestinal bleeding (LGIB).

METHOD

Among 34,344 patients hospitalized for LGIB from 2004 to 2009, 43.1% and 21.3% had a colonoscopy or EGD, respectively, during the index hospitalization or within 6 months after. Linking to the Dartmouth Atlas via patients' hospital referral region, gastroenterologist density and hospital care intensity (HCI) index were ascertained. Adjusting for age, gender, comorbidities, and race/education indicators, the association of gastroenterologist density, HCI index, and history of upper gastrointestinal disease with EGD was estimated using logistic regression.

RESULTS

EGD was not associated with gastroenterologist density or HCI index, but was associated with a history of upper gastrointestinal disease (OR 2.30; 95% CI 2.17-2.43), peptic ulcer disease (OR 4.82; 95% CI 4.26-5.45), and liver disease (OR 1.34; 95% CI 1.18-1.54).

CONCLUSIONS

Among patients hospitalized with LGIB, large variation in gastroenterologist density did not predict EGD, but relevant clinical history did, with association strengths commensurate with risk for upper gastrointestinal bleeding. In the scenario studied, no evidence was found that specialty physician supply increases will result in more discretionary care within commercially insured populations.

Specialist availability in emergencies: contributions of response times and the use of ad hoc coverage in New York State

OBJECTIVES

Nationwide, hospitals struggle to maintain specialist on-call coverage for emergencies. We seek to further understand the issue by examining reliability of scheduled coverage and the role of ad hoc coverage when none is scheduled.

METHODS

An anonymous electronic survey of all emergency department (ED) directors of a large state. Overall and for 10 specialties, respondents were asked to estimate on-call coverage extent and "reliability" (frequency of emergency response in a clinically useful time frame: 2 hours), and use and effect of ad hoc emergency coverage to fill gaps. Descriptive statistics were performed using Fisher exact and Wilcoxon sign rank tests for significance.

RESULTS

Contact information was obtained for 125 of 167 ED directors. Sixty responded (48%), representing 36% of EDs. Forty-six percent reported full on-call coverage scheduled for all specialties. Forty-six percent reported consistent reliability. Coverage and reliability were strongly related (P<.01; 33% reported both), and larger ED volume correlated with both (P<.01). Ninety percent of hospitals that had gaps in either employed ad hoc coverage, significantly improving coverage for 8 of 10 specialties. For all but 1 specialty, more than 20% of hospitals reported that specialists are "Never", "Rarely" or "Sometimes" reliable (more than 50% for cardiovascular surgery, hand surgery and ophthalmology).

CONCLUSIONS

Significant holes in scheduled on-call specialist coverage are compounded by frequent unreliability of on-call specialists, but partially ameliorated by ad hoc specialist coverage. Regionalization may help because a 2-tiered system may exist: larger hospitals have more complete, reliable coverage. Better understanding of specialists' willingness to treat emergencies ad hoc without taking formal call will suggest additional remedies.

A Census of Actively Licensed Physicians in the United States, 2014

Marked changes have occurred in health care delivery in the United States with the implementation of the Affordable Care Act (ACA), including the advancement of integrated health systems, the introduction of patient centered medical homes and the creation of accountable care organizations. With millions of Americans newly insured, never has there been a more pressing need for accurate physician workforce information and planning. Opinions vary about the nature and degree of anticipated physician shortages, and health care workforce determinations are fraught with variables and uncertainties that are challenging to address definitively. Identifying accurate information about the nation's currently licensed physician workforce, however, is an important starting point.

This article reviews data received in 2014 by the Federation of State Medical Boards from the nation's state medical and osteopathic boards about the current supply of actively licensed physicians in the United States and the District of Columbia. Our census data demonstrates the total population of licensed physicians (916,264) has increased by 4% since 2012, and the nation, on average, added 12,168 more licensed physicians annually than it lost. The average physician is now older (by a year), predominantly male (but increasingly female at entry level) and increasingly a graduate of a medical school in the Caribbean. Meanwhile, the percentage of physicians with a single state medical license has remained constant at 79%.

Factors associated with increased specialty care access in an urban area: the roles of local workforce capacity and practice location

This article explores how a specialty type's local workforce capacity and a specialty practice's location relate to the likelihood of denying care to children covered by Medicaid and the Children's Health Insurance Program (CHIP) while accepting private insurance. Data on discriminatory denials of care to children with public insurance came from an audit study involving 273 practices across seven medical specialties serving children in Cook County, Illinois. These data were linked to physician workforce data and neighborhood poverty data to test for associations with discriminatory denials of public insurance, after adjusting for control variables. In a large metropolitan county, discriminatory denials of specialty care access for publicly insured children were attenuated for specialty types with greater local workforce capacity (odds ratio [OR]: 0.74, 95 percent; confidence interval [CI]: 0.57-0.98) and for practices located in higher-poverty neighborhoods (OR: 0.95, 95 percent; CI: 0.93-0.98). Although limited as a single-site study, our findings support the widespread consensus that payment rates are the strongest driver of decisions to serve patients enrolled in public insurance programs. At a time when state and federal budgets are under strain, ensuring access equity for children covered by Medicaid and CHIP may require policies focused on economic levers tailored based on practice location.

Defining the key roles and competencies of the clinician-educator of the 21st century: a national mixed-methods study

PURPOSE

To determine a consensus definition of a clinician-educator and the related domains of competence.

METHOD

During September 2010 to March 2011, the authors conducted a two-phase mixed-methods national study in Canada using (1) focus groups of deans of medicine and directors of medical education centers to define the attributes, domains of competence, and core competencies of clinician-educators using a grounded theory analysis, and (2) a survey of 1,130 deans, academic chairs, and residency program directors to validate the focus group results.

RESULTS

The 22 focus group participants described being active in clinical practice, applying theory to practice, and engaging in education scholarship-but not holding a particular administrative position-as essential attributes of clinician-educators. Program directors accounted for 68% of the 350 survey respondents, academic chairs for 19%, and deans for 13% (response rate: 31%). Among respondents, 85% endorsed the need for physicians with advanced training in medical education to serve as educational consultants. Domains of clinician-educator competence endorsed by >85% of respondents as important or very important were assessment, communication, curriculum development, education theory, leadership, scholarship, and teaching. With regard to training requirements, 55% endorsed a master's degree in education as effective preparation, whereas 39% considered faculty development programs effective.

CONCLUSIONS

On the basis of this study's findings, the authors defined a clinician-educator as a clinician active in health professional practice who applies theory to education practice, engages in education scholarship, and serves as a consultant to other health professionals on education issues.

The Impact of Disasters on Populations With Health and Health Care Disparities

Context:A disaster is indiscriminate in whom it affects. Limited research has shown that the poor and medically underserved, especially in rural areas, bear an inequitable amount of the burden.

Objective:To review the literature on the combined effects of a disaster and living in an area with existing health or health care disparities on a community's health, access to health resources, and quality of life.

Methods:We performed a systematic literature review using the following search terms: disaster, health disparities, health care disparities, medically underserved, and rural. Our inclusion criteria were peer-reviewed, US studies that discussed the delayed or persistent health effects of disasters in medically underserved areas.

Results:There has been extensive research published on disasters, health disparities, health care disparities, and medically underserved populations individually, but not collectively.

Conclusions:The current literature does not capture the strain of health and health care disparities before and after a disaster in medically underserved communities. Future disaster studies and policies should account for differences in health profiles and access to care before and after a disaster.

(Disaster Med Public Health Preparedness. 2010;4:30-38)

Evaluating the quality of care provided by graduates of international medical schools

One-quarter of practicing physicians in the United States are graduates of international medical schools. The quality of care provided by doctors educated abroad has been the subject of ongoing concern. Our analysis of 244,153 hospitalizations in Pennsylvania found that patients of doctors who graduated from international medical schools and were not U.S. citizens at the time they entered medical school had significantly lower mortality rates than patients cared for by doctors who graduated from U.S. medical schools or who were U.S. citizens and received their degrees abroad. The patient population consisted of those with congestive heart failure or acute myocardial infarction. We found no significant mortality difference when comparing all international medical graduates with all U.S. medical school graduates.

Attracting and retaining GPs: a stakeholder survey of priorities

BACKGROUND

Despite being a key player in the healthcare system, training and practising general practice has become less attractive in many countries and is in need of reform.

AIM

To identify political priorities for improving GPs' attraction to the profession and their retention within it.

DESIGN AND SETTING

Stakeholder face-to-face survey in Belgium, 2008.

METHOD

A total of 102 key stakeholders were recruited from policymakers, professional groups, academia, GP leaders, and the media. All interviewees were asked to score 23 policies on four criteria: effectiveness in attracting and retaining GPs, cost to society, acceptance by other health professionals, and accessibility of care. An overall performance score was computed (from -3 to +3) for each type of policy - training, financing, work-life balance, practice organisation, and governance - and for innovative versus conservative policies.

RESULTS

Practice organisation policies and training policies received the highest scores (mean score ≥ 1.11). Financing policies, governance, and work-life balance policies scored poorly (mean score ≤ 0.65) because they had negative effects, particularly in relation to cost, acceptance, and accessibility of care. Stakeholders were keen on moving GPs towards team work, improving their role as care coordinator, and helping them to offload administrative tasks (score ≥ 1.4). They also favoured moves to increase the early and integrated exposure of all medical students to general practice. Overall, conservative policies were better scored than innovative ones (beta = -0.16, 95% confidence interval = -0.28 to -0.03).

CONCLUSION

The reforming of general practice is made difficult by the small-step approach, as well as the importance of decision criteria related to cost, acceptance, and access.

Assessment of an innovative instructional program to return non-practicing physicians to the workforce

INTRODUCTION

Few formal educational programs are available in the United States to assist physicians wishing to return to medical practice after clinical inactivity. Little published data on physicians who complete these programs exist. We describe the Drexel Medicine Physician Reentry/Refresher course and present our findings on participant demographics, performance, and goal attainment following course completion.

METHODS

Physician self-assessment, future career goals, recommendations of referring organizations, and a quantitative assessment of knowledge and skills were used to create individualized learning objectives and physician's curriculum. Initial assessment included demonstration of clinical skills using standardized patients and medical knowledge using the National Board of Medical Examiners Comprehensive Clinical Medicine Self-Assessment Examination. Progress in knowledge and clinical skills was measured by repeat assessment at course completion. We questioned physicians 3 months after course completion to determine if initial goals were attained.

RESULTS

Thirty-six physicians completed the program from November 2006 through November 2010. Most physicians demonstrated significant improvement in core clinical skills and knowledge at the end of the course. All physicians who sought employment, hospital privileges, and refreshing skills as initial goals were successful.

CONCLUSION

The Drexel Medicine Physician Reentry/Refresher course provides a unique model for successfully returning inactive physicians to clinical practice.

Returning physicians to the workforce: history, progress, and challenges

There is growing recognition of the need to reeducate clinically inactive physicians seeking to return to practice and in the facilitation of this return. Physicians seeking to return to practice face many challenges: maneuvering the various requirements of licensing, medical, and credentialing boards; finding an appropriate educational program to become up to date in current practice; paying for the program; and overcoming personal obstacles. Educational programs also face challenges: cost of development and maintenance; allocation of staff and faculty time to reeducate returning physicians alongside other learners; provision of emotional counseling and career guidance; interpretation of varied licensing and board guidelines; and the need to tailor one's program to individual trainees. Despite these challenges, some programs are returning physicians to the workforce. To provide perspective, we review why physicians leave medicine and return. We then discuss challenges for returning physicians and program developers and highlight current educational resources and organizational efforts to facilitate return. We close by offering next steps for programs to facilitate return.

Commentary: Meeting future medical care needs: a perfect storm on the horizon

Recent studies indicate that the number of first-year residency positions must increase to meet the United States' projected need for physicians, but these studies rarely consider whether it will be possible to increase the country's graduate medical education system to meet the need. State-level studies suggest that most existing programs have already reached their approved capacity, and nonteaching hospitals are unlikely to create new programs because of the financial impact and their lack of faculty and staff who would meet accreditation standards as program directors and institutional officials. A perfect storm is therefore brewing: The effects of the Patient Protection and Affordable Care Act of 2010, the obesity epidemic, the rise in chronic disease, and the aging and continuing growth of the population will combine to create a much greater demand for medical services at the same time as the relative size of the physician workforce will begin to decline. Given the urgency of the situation, the author calls for medical professionals (with significant representation from the academic medicine community) to enter into meaningful partnerships with state and federal officials to develop strategies for addressing this challenge. They must work together to increase the number of entry-level positions to the level needed to produce the doctors required to meet the growing demand for medical care. Otherwise, the perfect storm will soon disrupt the U.S. health care system.

Seniors' perceptions of health care not closely associated with physician supply

We conducted a national random survey of Medicare beneficiaries to better understand the association between the supply of physicians and patients' perceptions of their health care. We found that patients living in areas with more physicians per capita had perceptions of their health care that were similar to those of patients in regions with fewer physicians. In addition, there were no significant differences between the groups of patients in terms of numbers of visits to their personal physician in the previous year; amount of time spent with a physician; or access to tests or specialists. Our results suggest that simply training more physicians is unlikely to lead to improved access to care. Instead, focusing health policy on improving the quality and organization of care may be more beneficial.

Excellent hospital care for all: open and operating 24/7

Nights and weekends are the times when most people are admitted to the hospital. They are also synonymous with reduced staffing levels and fewer specialized diagnostic, procedural, and treatment options. Indeed, there is increasing evidence suggesting that patient care is compromised during these times. Equally important is the inefficient use of capital investments during nights and weekends, and inappropriate utilization of hospital beds caused by poor weekend discharge flexibility. We believe that these findings should be of concern not just to hospital care providers, but across care settings and to the general public. In this perspective article, we highlight how our current office-hours system of running hospitals threatens the lives of our sickest, most vulnerable patients, describe solutions currently implemented in hospitals that may alleviate this disparity, and discuss challenges to wider scale implementation.

The pediatric orthopaedics workforce demands, needs, and resources

The Pediatric Orthopaedic Society of North America Practice Management Committee evaluated current and future pediatric orthopaedic workforce needs. The resulting informational article summarizes its findings and makes recommendations for improvement of our workforce. Whereas policy decisions are often in the hands of the government with its emphasis on access and cost containment, the area that we can control, the quality of our workforce should be our primary effort. Specific recommendations include the prospective collection of accurate workforce data, increasing the interest of residents and students to enter our specialty, assisting members to improve practice efficiencies and assuming leadership in the musculoskeletal education of our primary care colleagues. We expect that by improving our workforce and professional work environment, we can make a difference for our young patients and for the society.

Anatomy of a new U.S. medical school: The Commonwealth Medical College

In response to the Association of American Medical Colleges' call for increases in medical school enrollment, several new MD-granting schools have opened in recent years. This article chronicles the development of one of these new schools, The Commonwealth Medical College (TCMC), a private, not-for-profit, independent medical college with a distributive model of education and regional campuses in Scranton, Wilkes-Barre, and Williamsport, Pennsylvania. TCMC is unique among new medical schools because it is not affiliated with a parent university. The authors outline the process of identifying a need for a new regional medical school in northeastern Pennsylvania, the financial planning process, the recruitment of faculty and staff, the educational and research missions of TCMC, and details of the infrastructure of the new school. TCMC's purpose is to increase the number of physicians in northeastern Pennsylvania, and in the next 20 years it is expected to add 425 practicing physicians to this part of the state. TCMC is characterized by autonomy, private and public support, assured resources in good supply, a relatively secure clinical base, strong cultural ties to the northeast, recruiting practices that reflect the dean's convictions, and strong support from its board of directors. TCMC has invested heavily in social and community medicine in its educational programs while still developing a strong research emphasis. Major challenges have centered on TCMC's lack of a parent university in areas of accreditation, infrastructure development, faculty recruitment, and graduate medical education programs. These challenges, as well as solutions and benefits, are discussed.

Trends in the work hours of physicians in the United States

CONTEXT

Recent trends in hours worked by physicians may affect workforce needs but have not been thoroughly analyzed.

OBJECTIVES

To estimate trends in hours worked by US physicians and assess for association with physician fees.

DESIGN, SETTING, AND PARTICIPANTS

A retrospective analysis of trends in hours worked among US physicians using nationally representative workforce information from the US Census Bureau Current Population Survey between 1976 and 2008 (N = 116,733). Trends were estimated among all US physicians and by residency status, sex, age, and work setting. Trends in hours were compared with national trends in physician fees, and estimated separately for physicians located in metropolitan areas with high and low fees in 2001.

MAIN OUTCOME MEASURE

Self-reported hours worked in the week before the survey.

RESULTS

After remaining stable through the early 1990s, mean hours worked per week decreased by 7.2% between 1996 and 2008 among all physicians (from 54.9 hours per week in 1996-1998 to 51.0 hours per week in 2006-2008; 95% confidence interval [CI], 5.3%-9.0%; P < .001). Excluding resident physicians, whose hours decreased by 9.8% (95% CI, 5.8%-13.7%; P < .001) in the last decade due to duty hour limits imposed in 2003, nonresident physician hours decreased by 5.7% (95% CI, 3.8%-7.7%; P < .001). The decrease in hours was largest for nonresident physicians younger than 45 years (7.4%; 95% CI, 4.7%-10.2%; P < .001) and working outside of the hospital (6.4%; 95% CI, 4.1%-8.7%; P < .001), and the decrease was smallest for those aged 45 years or older (3.7%; 95% CI, 1.0%-6.5%; P = .008) and working in the hospital (4.0%; 95% CI, 0.4%-7.6%; P = .03). After adjusting for inflation, mean physician fees decreased nationwide by 25% between 1995 and 2006, coincident with the decrease in physician hours. In 2001, mean physician hours were less than 49 hours per week in metropolitan areas with the lowest physician fees, whereas physician hours remained more than 52 hours per week elsewhere (P < .001 for difference).

CONCLUSION

A steady decrease in hours worked per week during the last decade was observed for all physicians, which was temporally and geographically associated with lower physician fees.

Comparison of physician workforce estimates and supply projections

CONTEXT

Estimates of physician supply in the United States have been based on data that may overestimate the number of older physicians in the workforce.

OBJECTIVE

To compare physician workforce estimates and supply projections using the American Medical Association Physician Masterfile (Masterfile) data with estimates and projections using data from the US Census Bureau Current Population Survey (CPS).

DESIGN, SETTING, AND PARTICIPANTS

Parallel retrospective cohort analyses of employment trends of the number of active physicians by age and sex using annual data from the Masterfile and the CPS between 1979 and 2008. Recent workforce trends were used to project future physician supply by age.

MAIN OUTCOME MEASURE

Annual number of physicians working at least 20 hours per week in 10-year age categories.

RESULTS

In an average year in the sample period, the CPS estimated 67,000 (10%) fewer active physicians than did the Masterfile (95% confidence interval [CI], 57,000-78,000; P < .001), almost entirely due to fewer active physicians aged 55 years or older. The CPS estimated more young physicians (ages 25-34 years) than did the Masterfile, with the difference increasing to an average of 17,000 (12%) during the final 15 years (95% CI, 13,000-22,000; P < .001). The CPS estimates of more young physicians were consistent with historical growth observed in the number of first-year residents, and the CPS estimates of fewer older physicians were consistent with lower Medicare billing by older physicians. Projections based on both the CPS and the Masterfile data indicate that the number of active physicians will increase by approximately 20% between 2005 and 2020. However, projections for 2020 using CPS data estimate nearly 100,000 (9%) fewer active physicians than projections using the Masterfile data (957,000 vs 1,050,000), and estimate that a smaller proportion of active physicians will be 65 years or older (9% vs 18%). The increasing proportion of female physicians had little effect on physician supply projections because, unlike male physicians, female physicians were found to maintain their work activity after age 55 years.

CONCLUSION

Compared with the Masterfile data, estimates using the CPS data found more young physicians entering the workforce and fewer older physicians remaining active, resulting in estimates of a smaller and younger physician workforce now and in the future.

Estimation of physician supply by specialty and the distribution impact of increasing female physicians in Japan

Background

Japan has experienced two large changes which affect the supply and distribution of physicians. They are increases in medical school enrollment capacity and in the proportion of female physicians. The purpose of this study is to estimate the future supply of physicians by specialty and to predict the associated impact of increased female physicians, as well as to discuss the possible policy implications.

Methods

Based on data from the 2004 and 2006 National Survey of Physicians, Dentists and Pharmacists, we estimated the future supply of physicians by specialty, using multistate life tables. Based on possible scenarios of the future increase in female physicians, we also estimated the supply of physicians by specialty.

Results

Even if Japan's current medical school enrollment capacity is maintained in subsequent years, the number of physicians per 1000 population is expected to increase from 2.2 in 2006 to 3.2 in 2036, which is a 46% increase from the current level. The numbers of obstetrician/gynecologists (OB/GYNs) and surgeons are expected to temporarily decline from their current level, whereas the number of OB/GYNs per 1000 births will still increase because of the declining number of births. The number of surgeons per 1000 population, even with the decreasing population, will decline temporarily over the next few years. If the percentage of female physicians continues to increase, the overall number of physicians will not be significantly affected, but in specialties with current very low female physician participation rates, such as surgery, the total number of physicians is expected to decline significantly.

Conclusion

At the current medical school enrollment capacity, the number of physicians per population is expected to continue to increase because of the skewed age distribution of physicians and the declining population in Japan. However, with changes in young physicians' choices of medical specialties and as the percentage of female physicians increases, patterns of physician supply will vary between specialties. Specialties less often chosen by young physicians and where males have dominated will face a decline in physician supply. These results highlight the necessity for developing a work environment that attracts female physicians to these types of specialties. This will also lead to improved gender equality in the workforce and more effective use of human resources.

Career and lifestyle satisfaction among surgeons: what really matters? The National Lifestyles in Surgery Today Survey

BACKGROUND

Optimizing recruitment of the next surgical generation is paramount. Unfortunately, many nonsurgeons perceive surgeons' lifestyle as undesirable. It is unknown, however, whether the surgeons-important opinion makers about their profession-are indeed dissatisfied.

STUDY DESIGN

We analyzed responses to a survey mailed to all surgeons who were certified by the American Board of Surgery in 1988, 1992, 1996, 2000, and 2004. We performed multivariate analyses to study career dissatisfaction and inability to achieve work-life balance, while adjusting for practice characteristics, demographics, and satisfaction with reimbursement.

RESULTS

A total of 895 (25.5%) surgeons responded: mean age was 46 years; 80% were men; 88% were married; 86% had children; 45% were general surgeons; 72% were in urban practice; and 83% were in nonuniversity practice. Surgeons worked 64 hours per week; ideally, they would prefer to work 50 hours per week (median). Fifteen percent were dissatisfied with their careers. On multivariate analysis, significant (p < 0.05) risk factors were nonuniversity practice (odds ratio [OR] 3.3) and dissatisfaction with reimbursement (OR 5.9). Forty percent would not recommend a surgical career to their own children. On multivariate analysis, significant risk factors were nonuniversity practice (OR 2.5) and dissatisfaction with reimbursement (OR 3.4). In all, 33.5% did not achieve work-life balance. On multivariate analysis, dissatisfaction with reimbursement (OR 3.0) was a significant risk factor. Respondents' lives could be improved by "limiting emergency call" (77%), "diminishing litigation" (92%), and "improving reimbursement" (94%).

CONCLUSIONS

Most surgeons are satisfied with their careers. Areas in need of improvement, particularly for nonuniversity surgeons, include reimbursement, work hours, and litigation. Strong local and national advocacy may not only improve career satisfaction, but could also render the profession more attractive for those contemplating a surgical career.

Access and affordability: an update on health reform in Massachusetts, fall 2008

Massachusetts continues to move forward on comprehensive health reform. Uninsurance is at historically low levels, despite the recent economic downturn. Building on that coverage expansion, access to and affordability of care in the commonwealth have improved. Notwithstanding these successes, some of the early gains in reducing barriers to care and improving the affordability of care had eroded by fall 2008, reflecting trends that predate health reform in Massachusetts: constraints on provider capacity and increasing health care costs. Because these are national concerns as well, Massachusetts continues to offer lessons for national reform efforts.

Clinical inactivity among pediatricians: prevalence and perspectives

INTRODUCTION

During their careers, physicians may have periods of clinical inactivity for a variety of reasons. Concerns have been raised about the impact of clinical inactivity on the growing physician workforce shortage. It is unknown how these periods of clinical inactivity impact physician competence and patient safety. With this study we sought to determine the rates of clinical inactivity, the duration of periods of inactivity, professional activities during those periods, and the perspective of pediatricians regarding future requirements of competency for return to clinical practice.

PATIENTS AND METHODS

A random sample of 6757 American Board of Pediatrics diplomates aged < or =65 years received a structured questionnaire by mail. The survey explored the prevalence of and reasons for clinical inactivity and perspectives on the return to clinical practice. Clinical inactivity was defined as a period of absence of > or =12 months from any direct or consultative clinical care.

RESULTS

The response rate was 74%. Of respondents, 88% (n = 4176) were currently engaged in pediatric clinical care. Twelve percent (n = 554) indicated that they had experienced a period of clinical inactivity lasting > or =12 months. Women were more likely than men (16% vs 7%) to have had periods of clinical inactivity. Controlling for gender, generalists were no more likely than subspecialists to report a past period of clinical inactivity. More than one third of the respondents (n = 1672 [36%]) agreed that pediatricians who return from clinical inactivity after >1 year should undergo a competency evaluation.

CONCLUSIONS

Almost 1 in 8 pediatricians has suspended clinical care for > or =1 year, and a similar proportion of respondents were inactive at the time of our survey. Currently, all of these physicians may maintain both their licensure and board certification during these periods. The impact of clinical inactivity on patient care and patient safety is unknown.