Using the American Medical Association physician masterfile to measure physician supply in small towns

A cross-sectional study of the practice types of US adult primary care physician specialists

BACKGROUND

Many physicians listed as primary care in databases such as the American Medical Association (AMA) Masterfile do not provide traditional ambulatory primary care.

OBJECTIVE

To compare physicians listed in the AMA Masterfile as primary care physician (PCPs) specialists for adult patients with their actual practice type.

METHODS

We conducted a cross-sectional study of the AMA Masterfile report for PCPs who care for adults (listed as family medicine, internal medicine, medicine-paediatrics, and geriatrics) in the summer and fall of 2018 (spring of 2019 for Hartford, CT) in the primary counties of 8 metropolitan areas across the United States. We searched multiple websites to determine the actual practice type of each physician in the study counties. We correlated the 2 datasets: the AMA Masterfile list vs the results of our searches.

RESULTS

Family physicians were more likely to function as traditional ambulatory PCPs than internists [1,738/2,101 (82.7%) vs 1,241/2,025 (60.9%), P < 0.001], and less likely to be hospitalists [83/2,101 (4.0%) vs 631/2,025 (31.0%), P < 0.001]. Other practice types included urgent care [105 (5.0%) family physicians, 16 (0.8%) internists] and emergency medicine [49 (2.3%) family physicians, 20 (1.0%) internists]. The AMA Masterfile identified 4,892 practicing PCPs for adult patients in the study counties, of which 3,084 (63.0%) matched by location and ambulatory PCP practice type [3,695 (75.5%) for ambulatory PCP practice type only].

CONCLUSIONS

We provide an updated estimate using a unique methodology to estimate how to correct the AMA Masterfile for PCPs who actually provide traditional ambulatory primary care to adult patients.

Using State All-Payer Claims Data to Identify the Active Primary Care Workforce: A Novel Study in Virginia

PURPOSE

Primary care is the foundation of the health care workforce and the only part that extends life and improves health equity. Previous research on the geographic and specialty distribution of physicians has relied on the American Medical Association's Masterfile, but these data have limitations that overestimate the workforce.

METHODS

We present a pragmatic, systematic, and more accurate method for identifying primary care physicians using the National Plan and Provider Enumeration System (NPPES) and the Virginia All-Payer Claims Database (VA-APCD). Between 2015 and 2019, we identified all Virginia physicians and their specialty through the NPPES. Active physicians were defined by at least 1 claim in the VA-APCD. Specialty was determined hierarchically by the NPPES. Wellness visits were used to identify non-family medicine physicians who were providing primary care.

RESULTS

In 2019, there were 20,976 active physicians in Virginia, of whom 5,899 (28.1%) were classified as providing primary care. Of this primary care physician workforce, 52.4% were family medicine physicians; the remaining were internal medicine physicians (18.5%), pediatricians (16.8%), obstetricians and gynecologists (11.8%), and other specialists (0.5%). Over 5 years, the counts and relative percentages of the workforce made up by primary care physicians remained relatively stable.

CONCLUSIONS

Our novel method of identifying active physicians with a primary care scope provides a realistic size of the primary care workforce in Virginia, smaller than some previous estimates. Although the method should be expanded to include advanced practice clinicians and to further delineate the scope of practice, this simple approach can be used by policy makers, payers, and planners to ensure adequate primary care capacity.

The Supply and Distribution of the Preventive Medicine Physician Workforce

CONTEXT

Preventive medicine physicians work at the intersection of clinical medicine and public health. A previous report on the state of the preventive medicine workforce in 2000 revealed an ongoing decline in preventive medicine physicians and residents, but there have been few updates since.

OBJECTIVE

The purpose of this study was to describe trends in both the number of board-certified preventive medicine physicians and those physicians who self-designate preventive medicine as a primary or secondary specialty and examine the age, gender distribution, and geographic distribution of this workforce.

DESIGN

Analysis of the supply of preventive medicine physicians using data derived from board certification files of the American Board of Preventive Medicine and self-designation data from the American Medical Association Masterfile.

SETTING

The 50 US states and District of Columbia.

PARTICIPANTS

Board-certified and self-designated preventive medicine physicians in the United States.

MAIN OUTCOME MEASURES

Number, demographics, and location of preventive medicine physicians in United States.

RESULTS

From 1999 to 2018, the total number of physicians board certified in preventive medicine increased from 6091 to 9270; the number of self-identified preventive medicine physicians has generally decreased since 2000, with a leveling off in the past 4 years matching the trend of preventive medicine physicians per 100 000 population; there is a recent increase in women in the specialty; the practice locations of preventive medicine physicians do not match the US population in rural or micropolitan areas; and the average age of preventive medicine physicians is increasing.

CONCLUSIONS

The number of preventive medicine physicians is not likely to match population needs in the United States in the near term and beyond. Assessing the preventive medicine physician workforce in the United States is complicated by difficulties in defining the specialty and because less than half of self-designated preventive medicine physicians hold a board certification in the specialty.

Growth and Distribution of Child Psychiatrists in the United States: 2007-2016

BACKGROUND

Historically, there has been a shortage of child psychiatrists in the United States, undermining access to care. This study updated trends in the growth and distribution of child psychiatrists over the past decade.

METHODS

Data from the Area Health Resource Files were used to compare the number of child psychiatrists per 100 000 children ages 0 to 19 between 2007 and 2016 by state and county. We also examined sociodemographic characteristics associated with the density of child psychiatrists at the county level over this period using negative binomial multivariable models.

RESULTS

From 2007 to 2016, the number of child psychiatrists in the United States increased from 6590 to 7991, a 21.3% gain. The number of child psychiatrists per 100 000 children also grew from 8.01 to 9.75, connoting a 21.7% increase. County- and state-level growth varied widely, with 6 states observing a decline in the ratio of child psychiatrists (ID, IN, KS, ND, SC, and SD) and 6 states increasing by >50% (AK, AR, NH, NV, OK, and RI). Seventy percent of counties had no child psychiatrists in both 2007 and 2016. Child psychiatrists were significantly more likely to practice in high-income counties (P < .001), counties with higher levels of postsecondary education (P < .001), and metropolitan counties compared with those adjacent to metropolitan regions (P < .05).

CONCLUSIONS

Despite the increased ratio of child psychiatrists per 100 000 children in the United States over the past decade, there remains a dearth of child psychiatrists, particularly in parts of the United States with lower levels of income and education.

Toward graduate medical education (GME) accountability: measuring the outcomes of GME institutions

PURPOSE

Graduate medical education (GME) plays a key role in the U.S. health care workforce, defining its overall size and specialty distribution and influencing physician practice locations. Medicare provides nearly $10 billion annually to support GME and faces growing policy maker interest in creating accountability measures. The purpose of this study was to develop and test candidate GME outcome measures related to physician workforce.

METHOD

The authors performed a secondary analysis of data from the American Medical Association Physician Masterfile, National Provider Identifier file, Medicare claims, and National Health Service Corps, measuring the number and percentage of graduates from 2006 to 2008 practicing in high-need specialties and underserved areas aggregated by their U.S. GME program.

RESULTS

Average overall primary care production rate was 25.2% for the study period, although this is an overestimate because hospitalists could not be excluded. Of 759 sponsoring institutions, 158 produced no primary care graduates, and 184 produced more than 80%. An average of 37.9% of internal medicine residents were retained in primary care, including hospitalists. Mean general surgery retention was 38.4%. Overall, 4.8% of graduates practiced in rural areas; 198 institutions produced no rural physicians, and 283 institutions produced no Federally Qualified Health Center or Rural Health Clinic physicians.

CONCLUSIONS

GME outcomes are measurable for most institutions and training sites. Specialty and geographic locations vary significantly. These findings can inform educators and policy makers during a period of increased calls to align the GME system with national health needs.

Projecting surgeon supply using a dynamic model

OBJECTIVE

To develop a projection model to forecast the head count and full-time equivalent supply of surgeons by age, sex, and specialty in the United States from 2009 to 2028.

SUMMARY BACKGROUND DATA

The search for the optimal number and specialty mix of surgeons to care for the United States population has taken on increased urgency under health care reform. Expanded insurance coverage and an aging population will increase demand for surgical and other medical services. Accurate forecasts of surgical service capacity are crucial to inform the federal government, training institutions, professional associations, and others charged with improving access to health care.

METHODS

The study uses a dynamic stock and flow model that simulates future changes in numbers and specialty type by factoring in changes in surgeon demographics and policy factors.

RESULTS

: Forecasts show that overall surgeon supply will decrease 18% during the period form 2009 to 2028 with declines in all specialties except colorectal, pediatric, neurological surgery, and vascular surgery. Model simulations suggest that none of the proposed changes to increase graduate medical education currently under consideration will be sufficient to offset declines.

CONCLUSIONS

The length of time it takes to train surgeons, the anticipated decrease in hours worked by surgeons in younger generations, and the potential decreases in graduate medical education funding suggest that there may be an insufficient surgeon workforce to meet population needs. Existing maldistribution patterns are likely to be exacerbated, leading to delayed or lost access to time-sensitive surgical procedures, particularly in rural areas.

Spatial error in geocoding physician location data from the AMA Physician Masterfile: implications for spatial accessibility analysis

The accuracy of geocoding hinges on the quality of address information that serves as input to the geocoding process; however errors associated with poor address quality are rarely studied. This paper examines spatial errors that arise due to incorrect address information with respect to physician location data in the United States. Studies of spatial accessibility to physicians in the U.S. typically rely on data from the American Medical Association's Physician Masterfile. These data are problematic because a substantial proportion of physicians only report a mailing address, which is often the physician's home (residential) location, rather than the address for the location where health care is provided. The incorrect geocoding of physicians' practice locations based on inappropriate address information results in a form of geocoding error that has not been widely analyzed. Using data for the Chicago metropolitan region, we analyze the extent and implications of geocoding error for measurement of spatial accessibility to primary care physicians. We geocode the locations of primary care physicians based on mailing addresses and office addresses. The spatial mismatch between the two is computed at the county, zip code and point location scales. Although mailing and office address locations are quite close for many physicians, they are far apart (>20 km) for a substantial minority. Kernel density estimation is used to characterize the spatial distribution of physicians based on office and mailing addresses and to identify areas of high spatial mismatch between the two. Errors are socially and geographically uneven, resulting in overestimation of physician supply in some high-income suburban communities, and underestimation in certain central city locations where health facilities are concentrated. The resulting errors affect local measures of spatial accessibility to primary care, biasing statistical analyses of the associations between spatial access to care and health outcomes.

Specialty choice and practice location of physician alumni of University of California premedical postbaccalaureate programs

PURPOSE

To investigate the longer-term career outcomes, such as specialty choice and practice location, of underrepresented minority and disadvantaged students who finished a University of California postbaccalaureate (UCPB) premedical program.

METHOD

The authors compared 303 UCPB alumni from the 1986-1987 to 2001-2002 cohorts who matriculated into medical school and could be matched to the 2008 American Medical Association Physician Masterfile with 586 randomly selected control physicians who graduated from the same medical schools in the same years as the UCPB alumni. Outcome variables included specialty, practice in a Health Professional Shortage Area (HPSA) or Medically Underserved Area (MUA), and practice in a California community with high concentrations of African American, Latino, or low-income residents.

RESULTS

A greater percentage of UCPB alumni (161/303 [53.1%]) than control physicians (235/586 [40.1%]) were in primary care (P < .001). Although there were no differences between the two groups in the percentages of physicians working in HPSAs or MUAs, a greater percentage of UCPB alumni than control physicians working in California practiced in high-poverty communities (31/191 [16.2%] versus 22/252 [8.7%], P < .016), high-Latino communities (35/191 [18.3%] versus 22/252 [8.7%], P <. 01), and high-African American communities (57/191 [29.8%] versus 50/252 [19.8%], P <. 02).

CONCLUSIONS

UCPB programs have enhanced the number of physicians entering primary care and working in disadvantaged California communities. However, many UCPB alumni practice in disadvantaged communities in California that are not federally designated as HPSAs or MUAs.

Determinants of intrauterine contraception provision among US family physicians: a national survey of knowledge, attitudes and practice

BACKGROUND

Poor contraception adherence contributes to unintended pregnancy. Intrauterine contraception (IUC) is user-independent thus adherence is not an issue, yet few US women use IUC. We compared family physicians (FPs) who do and do not insert IUC in order to ascertain determinants of inserting IUC.

STUDY DESIGN

We surveyed 3500 US FPs. The primary outcome variable was whether a physician inserts IUC in their current clinical practice. We also sought to describe their clinical practice with IUC insertions.

RESULTS

FPs who insert IUC had better knowledge about IUC (adjusted OR 1.85, 95% CI 1.32-2.60), more comfort discussing IUC (adjusted OR 2.35, 95% CI 1.30-4.27), and were more likely to believe their patients are receptive to discussing IUC (adjusted OR 2.96, 95% CI 2.03-4.32). The more IUC inserted during residency, the more likely to insert currently (adjusted OR 1.44, 95% CI 1.12-1.84). Only 24% of respondents inserted IUC in the prior 12 months.

CONCLUSIONS

US FPs have training and knowledge gaps, as well as attitudes, that result in missed opportunities to discuss and provide IUC for all eligible patients.

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.

Practice location choice by new physicians: the importance of malpractice premiums, damage caps, and health professional shortage area designation

OBJECTIVE

To understand the factors affecting the choice of initial practice location by new physicians.

DATA SOURCES/STUDY SETTING

A unique survey of exiting medical residents in New York State from 1998 to 2003.

STUDY DESIGN

We estimate conditional logit models to examine the factors affecting the choice of initial practice location by new physicians.

DATA COLLECTION/EXTRACTION METHODS

We identify all physicians completing their training in obstetrics/gynecology or surgery and primary care physicians (PCPs) (general internal medicine, pediatrics, and family medicine) who had accepted a job in patient care and who provided the location (zip code) of their job. This resulted in 3,758 physicians in our sample.

PRINCIPAL FINDINGS

Our results indicate that malpractice insurance premiums are a significant deterrent for surgeons, but they do not appear to deter OB/GYNs or PCPs from locating in particular areas. In addition, caps on malpractice damage awards attract surgeons to areas. Shortage area designations attract PCPs without education debt yet deter PCPs with debt, suggesting that subsidies do not outweigh the perceived costs of locating in underserved areas.

CONCLUSIONS

In general our results highlight that new physicians are sensitive to the characteristics of the locations in which they could potentially locate when beginning their careers in patient care.

The accuracy of the Jamaican national physician register: a study of the status of physicians registered and their countries of training

BACKGROUND

The number of physicians per 10,000 population is a basic health indicator used to determine access to health care. Studies from the United States of America and Europe indicate that their physician registration databases may be flawed. Clinical research activities have suggested that the current records of physicians registered to practice in Jamaica may not be accurate. Our objective was to determine whether the Medical Council of Jamaica (MCJ) accurately records and reports the identities, number and specialty designation of physicians in Jamaica. An additional aim was to determine the countries in which these physicians were trained.

METHODS

Data regarding physicians practicing in Jamaica in 2005 were obtained from multiple sources including the MCJ and the telephone directory. Intense efforts at tracing were undertaken in a sub-sample of physicians, internists and paediatricians to further improve the accuracy of the data. Data were analysed using SPSS, version 11.5.

RESULTS

The MCJ listed 2667 registered physicians of which 118 (4.4%) were no longer practicing in Jamaica. Of the subset of 150 physicians who were more actively traced, an additional 11 were found to be no longer in practice. Thus at least 129 (4.8%) of the physicians on the MCJ list were not actively practising in Jamaica. Twenty-nine qualified physicians who were in practice, but not currently on the Jamaican register, were identified from other data sources. This yielded an estimate of 2567 physicians or 9.68 physicians per 10,000 persons. Seven hundred and twenty six specialists were identified, 118 from the MCJ list only, 452 from other sources, in particular medical associations, and 156 from both the MCJ list and other sources. Sixty-six percent of registered doctors completed medical school at the University of the West Indies (UWI).

CONCLUSION

These data suggest that the MCJ list includes some physicians no longer practicing in Jamaica while underestimating the number of specialists. Difficulty in accurately estimating the number of practicing physicians has been reported in studies done in other countries but the under-reporting of the number of specialists is uncommon. Additional consideration should be given to strategies to ensure compliance with the annual registration that is mandated by law and to changing the law to include registration of specialist qualifications.

International medical graduate physicians in the United States: changes since 1981

Nearly a quarter of all active U.S. physicians are international medical graduates (IMGs)--physicians trained outside the United States and Canada. We describe changes in characteristics of IMGs from 1981 to 2001 and compare them with their U.S. medical graduate (USMG) counterparts. Since 1981, the leading source countries for IMGs have included India, the Philippines, and Mexico. IMGs were more likely to be generalists and to practice in designated underserved areas than USMGs but slightly less likely to practice in isolated small rural areas and persistent-poverty counties. IMGs are an important source of primary care physicians in rural and underserved areas.

Counting physicians: inconsistencies in a commonly used source for workforce analysis

PURPOSE

To assess the accuracy of the AMA Masterfile.

METHOD

In 2002, the authors compared the listing in the Masterfile for pediatric cardiologists with a roster of all such physicians documented by the American Board of Pediatrics (ABP) to have completed pediatric cardiology training. Physicians listed on the Masterfile but without ABP records of training completion received a mail survey. For main outcome measures, the differences in state-level distribution of pediatric cardiologists were used, depending on whether data were from the ABP or the AMA Masterfile. Survey items included nature and duration of medical training, the amount of time caring for pediatric or adult cardiology patients, and whether the respondent conducted echocardiograms and/or cardiac catheterizations on children and/or adults.

RESULTS

Of the 2,675 unique, individual physicians obtained from the queries of both lists, 58% (1,558) were listed by both the Masterfile and the ABP. Another 28% (738) were listed by the AMA Masterfile only, and 4% (108) were listed by the ABP only.Of those listed by the Masterfile only, 40% reported they provide no pediatric cardiology care. The amount of pediatric cardiology training was highly variable among the remainder of the respondents.

CONCLUSIONS

There are large differences in the number and distribution of physicians identified as pediatric cardiologists between these two datasets. Also, many are potentially providing care for which they have little or no training. Use of such data has the potential to lead to policy options at odds with the actual needs of our nation as a whole or of specific geographic areas.

How adults' access to outpatient physician services relates to the local supply of primary care physicians in the rural southeast

OBJECTIVE

To examine how access to outpatient medical care varies with local primary care physician densities across primary care service areas (PCSAs) in the rural Southeast, for adults as a whole and separately for the elderly and poor.

DATA SOURCES

Access data from a 2002 to 2003 telephone survey of 4,311 adults living in 298 PCSAs within 150 rural counties in eight Southeastern states were linked geographically with physician practice location data from the American Medical and American Osteopathic Associations and population data from the U.S. Census.

STUDY DESIGN

In a cross-sectional study design, we used a series of logistic regression models to assess how 26 measures of various aspects of access to outpatient physician services varied for subjects arranged into five groups based on the population-per-physician ratios of the PCSAs where they lived.

PRINCIPAL FINDINGS

Among adults as a whole, more individuals reported traveling over 30 minutes for outpatient care in PCSAs with more than 3,500 people per physician than in PCSAs with fewer than 1,500 people per physician (39.1 versus 18.5 percent, p<.001) and more reported travel difficulties. Otherwise, PCSA density of primary care physicians was unrelated to reported barriers to care, unrelated to people's satisfaction with care, and unrelated to indicators of people's use of services. Use rates of six recommended preventive health services varied in no consistent direction with physician densities. Among the elderly, only the proportion traveling over 30 minutes for care was greater in areas with lowest physician densities. Among subjects covered under Medicaid or uninsured, lower local physician densities were associated with longer travel time, difficulties with travel and reaching one's physician by phone, and two areas of dissatisfaction with care.

CONCLUSIONS

For adults as a whole in the rural South and for the elderly there, low local primary care physician densities are associated with travel inconvenience but not convincingly with other aspects of access to outpatient care. Access for those insured under Medicaid and the uninsured, however, is in more ways sensitive to local physician densities.

The geographic distribution of physicians revisited

CONTEXT

While there is debate over whether the U.S. is training too many physicians, many seem to agree that physicians are geographically maldistributed, with too few in rural areas.

OBJECTIVE

Official definitions of shortage areas assume the market for physician services is based on county boundaries. We wished to ascertain how the picture of a possible shortage changes using alternative measures of geographic access. We measure geographic access by the number of full-time equivalent physicians serving a community divided by the expected number of patients (possibly both from within the community and outside) receiving care from those physicians. Moreover, we wished to determine how the geographic distribution of physicians had changed since previous studies, in light of the large increase in physician numbers.

DESIGN

Cross-sectional data analyses of alternative measures of geographic access to physicians in 23 states with low physician-population ratios.

RESULTS

Between 1979 and 1999, the number of physicians doubled in the sample states. Although most specialties experienced greater diffusion everywhere, smaller specialties had not yet diffused to the smallest towns. Multiple measures of geographic access, including physician-to-population ratios, average distance traveled to the nearest physician, and projected average caseload per physician, confirm that residents of metropolitan areas have better geographic access to physicians. Physician-to-population ratios exhibit the largest degree of geographic disparity, but ratios in rural counties adjacent to metropolitan areas are smaller than in those not adjacent to metropolitan areas. Distance-traveled and caseload models that allow patients to cross county lines show less disparity and indicate that residents of isolated rural counties have less access than those living in counties adjacent to metropolitan areas.

CONCLUSION

Geographic access to physicians has continued to improve over the past two decades, although some smaller specialties have not diffused to the most rural areas. While substantial variation in the supply of physicians across communities remains, current measures of geographic access to physicians overstate the extent of maldistribution and yield an incorrect ranking of areas according to geographic accessibility of physicians.

Attitudes of family physicians in Washington state toward physician-assisted suicide

CONTEXT

The topic of physician-assisted suicide is difficult and controversial. With recent laws allowing physicians to assist in a terminally ill patient's suicide under certain circumstances, the debate concerning the appropriate and ethical role for physicians has intensified.

PURPOSE

This paper utilizes data from a 1997 survey of family physicians (FPs) in Washington State to test two hypotheses: (1) older respondents will indicate greater opposition to physician-assisted suicide than their younger colleagues, and (2) male and rural physicians will have more negative attitudes toward physician-assisted suicide than their female and urban counterparts.

METHODS

A questionnaire administered to all active FPs obtained a 68% response rate, with 1074 respondents found to be eligible in this study. A ZIP code system based on generalist Health Service Areas was used to designate those practicing in rural versus urban areas.

FINDINGS

One-fourth of the respondents overall indicated support for physician-assisted suicide. When asked whether this practice should be legalized, 39% said yes, 44% said no, and 18% indicated that they did not know. Fifty-eight percent of the study sample reported that they would not include physician-assisted suicide in their practices even if it were legal. Responses disaggregated by age-groups closely paralleled the group overall. There was a significant pattern of opposition on the part of rural male respondents compared to urban female respondents. Even among those reporting support for physician-assisted suicide, many expressed reluctance about including it in their practices.

CONCLUSIONS

These findings highlight the systematic differences in FP attitudes toward one aspect of health care by gender, rural-urban practice location, and other factors.

The future supply of family physicians: implications for rural America

Throughout the past century rural health care has been dependent upon general practitioners (GPs) and their successors, family physicians (FPs). Only FPs and GPs have practiced in rural areas in proportion to the population, then and now. As specialization occurred, numbers of GPs declined and physician shortages developed in rural areas. The creation of family practice residencies in the 1970s halted this decline, but rural shortages persist today. During the 1990s the number of allopathic and osteopathic FP residency graduates rose 54 percent. At the same time, the percentage of women enrolled in these residencies increased to 46 percent, and women have been less likely than men to select rural practice. We project that if current numbers of graduates continue, the nonmetropolitan FP/GP-to-population ratio will increase 17 percent by the year 2020. However, today, medical students' interest in primary care residencies (including family practice) is declining precipitously. If numbers of FP graduates return to 1993 levels, the density of FPs in rural America and in the nation as a whole will decline after 2010.

Radically changing the research framework during a health geography study

This paper focuses on the issue of how a research project can shift from a positivist to a nonpositivist framework. Specific attention is given to changes in research methods and philosophical paradigm that emerged while conducting a study on the replacement of immigrant physicians in rural America. In its original conceptualization, the study was expected to yield a simple, right answer. Specifically, one or more types of health professionals (e.g., nurse practitioners, National Health Service Corps physicians) would be identified as expected replacements in the event of a cutback on immigrant physicians. However, as the research progressed, the quest for a simple, right answer became less realistic. The theoretical framework, methods, and research question changed, thereby allowing for greater complexity and ambiguity than anticipated at the outset of the study. What had been a positivist, statistical study was now a nonpositivist, qualitative study, and the research question shifted to include individual perspectives. An overview of such transitions leads to a discussion of the importance of context and ambiguity in research.

How many rural doctors do we have?

The number of physicians practicing in the nonmetropolitan areas of the United States in relation to population has increased over the past two decades, but more slowly than the number of physicians in metropolitan counties. During the same period, there was a growing acceptance of the perception that the physician work force in the United States exceeded the number necessary to meet the requirements of an efficient health care system. This has caused policy-makers to consider reforming the incentives for training physicians and restricting the entry of physicians from other countries into the United States. The supply figures on which these assessments of oversupply were made are based on "head counts" of the number of licensed, active physicians. By using more detailed data describing the licensed practicing physicians in the states of North Carolina and Washington, and by using estimates of professional activity collected as part of the Socioeconomic Monitoring System of the American Medical Association, estimates of the number of full-time equivalent physicians actually in practice in the two states and the comparative productivity of those physicians were made. Based on the state-level data, the estimates of actively practicing physicians are approximately 14 percent lower than the head-count number in North Carolina and, by using a more conservative estimation method, are approaching a 10 percent lower number than the head-count number in Washington. Using national productivity data, the effective supply of nonmetropolitan physicians appears to have not grown significantly over the past 10 years, and for family physicians the supply has declined by 9 percent. These estimates of the effective physician supply support long-held claims that rural communities continue to experience a severe undersupply of practitioners. These results suggest that the way in which physicians are counted needs to be re-examined, especially in rural places where the ratios of providers to population are more sensitive to small changes in supply.

Trends in the rural-urban distribution of general pediatricians

OBJECTIVE

A major objective of national and state health policy has been to increase primary care physician supply in rural areas. It is not known whether this objective has been met for general pediatricians. This study examines trends in the rural-urban distribution of general pediatricians in the United States from 1981 to 1996.

DESIGN

Descriptive serial cross-sectional study.

PARTICIPANTS

At selected 5-year intervals, all clinically active general pediatricians in the United States listed in the American Medical Association Physician Masterfile.

MAIN OUTCOME MEASURES

The proportion of pediatricians practicing in rural counties and the ratio of pediatricians to the child population (per 100 000 children <18 years old) for US counties.

RESULTS

Between 1981 and 1996, the total number of general pediatricians increased from 19 739 to 34 100. However, rural pediatrician-to-child population ratios (PCPRs) remained well below urban ratios. Although rural counties of all population sizes experienced some gains over time, only those over 25 000 populations had a meaningful increase in their PCPR. Overall, the urban PCPR increased by 14.0 (or an additional pediatrician for every 7150 children) whereas the rural ratio only increased by 4.1 (an additional pediatrician for every 24 400 children). The percentage of recent residency graduates opting for rural practice declined by half (14.6% to 7.4%) over the 15-year study period. Women and international graduates were consistently less likely to practice in rural counties than were men and US graduates, respectively.

CONCLUSIONS

The near doubling in general pediatrician numbers from 1981 to 1996 yielded only a modest increase in pediatrician availability for rural children. The discrepancy between urban and rural pediatrician supply increased during this period and should continue growing based on the increasingly urban location of recent residency graduates and the continued growth of women in pediatrics. New policy strategies are needed to improve rural pediatrician availability, including focusing on larger rural counties and addressing barriers to rural practice for women. pediatrics/manpower, pediatrics/trends, rural health, physicians/supply and distribution, medically underserved area.