Changes in the Workforce Characteristics of Providers Who Care for Adult Patients With Rheumatologic and Musculoskeletal Disease in the United States

OBJECTIVE

The aim of this study was to describe the adult rheumatology workforce in the United States, assess change in rheumatology providers over time, and identify variation in rheumatology practice characteristics.

METHODS

Using national Medicare claims data from 2006 to 2020, clinically active rheumatology physicians and advanced practice providers (APPs) were identified. Each calendar year was used for inclusion, exclusion, and analysis, and providers were determined to be entering, exiting, or stable based upon presence or absence in the prior or subsequent years of data. Characteristics (age, gender, practice type, rural, and region) of rheumatologists were determined for 2019 and in mutually exclusive study periods from 2009 to 2011, 2012 to 2015, and 2016 to 2019. The location of rheumatology practice was determined by billing tax identification and mapped. Demographics of physicians exiting or entering the rheumatology workforce were compared separately to those stable by logistic regression.

RESULTS

The clinically active adult rheumatology workforce identified in US Medicare in 2019 was 5,667 rheumatologists and 379 APPs. From 2009 to 2020, the number of rheumatologists increased 23% and the number of APPs increased 141%. There was an increase in female rheumatologists over time, rising to 43% in 2019. Women and those employed by a health care system were more likely to exit, and those in a small practice or in the South were less likely to exit.

CONCLUSION

The overall number of clinically active rheumatology providers grew more than 20% over the last decade to a high of 6,036 in 2020, although this rate of growth appears to be flattening off in later years.

Exploring Teamwork Challenges Perceived by International Medical Graduates in Emergency Medicine Residency

INTRODUCTION

Non-US international medical graduates (IMG) represent a gradually increasing portion of emergency medicine (EM) residents in the United States. Yet there are no previous studies that explore the needs of this learner population. We conducted a qualitative study to examine non-US IMGs' perceptions of challenges they face specifically regarding team dynamics during their first year of an EM residency.

METHOD

Nine non-US IMGs in EM from all over the US participated in anonymous, semi-structured phone interviews lasting 45-60 minutes. We then coded and analyzed the interviews to identify axes and themes using an inductive approach informed by grounded theory. Focused coding and member checking were employed.

RESULTS

Non-US IMGs' perceptions of challenges regarding team dynamics during their first year of an EM residency coalesced into two themes: system-based challenges, such as a new power dynamic and understanding the local hospital system, and interpersonal challenges, such as establishing rapport and articulation of critical thinking.

CONCLUSION

Non-US IMGs perceived several unique challenges regarding team dynamics during their first year of an EM residency, whether system-based or interpersonal-based. We propose solutions such as a transitional curriculum (as suggested by the participants as well) and cultural-competence training for academic leadership.

Responses of physicians to an objective safety and quality knowledge test: a cross-sectional study

OBJECTIVE

For physicians to practice safe high quality medicine they must have sufficient safety and quality knowledge. Although a great deal is known about the safety and quality perceptions, attitudes and beliefs of physicians, little is known about their safety and quality knowledge. This study tested the objective safety and quality knowledge of practicing US primary care physicians.

DESIGN

Cross-sectional objective test of safety and quality knowledge.

SETTING

Primary care physicians practicing in the USA.

PARTICIPANTS

Study consisted of 518 US practicing primary care physicians who answered an email invitation. Fifty-four percent were family medicine and 46% were internal medicine physicians.The response rate was 66%.

INTERVENTION

The physicians took a 24-question multiple-choice test over the internet.

OUTCOME

The outcome was the percent correct.

RESULTS

The average number of correct answers was 11.4 (SD, 2.69), 48% correct. Three common clinical vignettes questions were answered correctly by 45% of the physicians. Five common radiation exposures questions were answered correctly by 40% of the physicians. Seven common healthcare quality and safety questions were answered correctly by 43% of the physicians. Seven Donabedian's model of structure, process and outcome measure questions were answered correctly by 67% of the physicians. Two Institute of Medicine's definitions of quality and safety questions were answered correctly by 19.5% of the physicians.

CONCLUSION

Forty-eight per cent of the physicians' answers to the objective safety and quality questions were correct. To our knowledge, this is the first assessment of the objective safety and quality knowledge of practicing US primary care physicians.

Changes in dermatology practice characteristics in the United States from 2012 to 2017

Background

Dermatology practice has recently seen multiple changes. A better understanding of trends pertaining to dermatology practice setups is necessary.

Objective

To analyze the recent changes in dermatology practice in terms of geography, practice size, and gender distribution as well as to analyze the availability of dermatologists based on zip codes’ income levels.

Methods

This was a cross-sectional study. We extracted data on the sex and billing addresses of dermatologists from Medicare provider utilization and payment data for 2012 and 2017. We used 2017 tax returns data to calculate the poverty level for each zip code.

Results

Between 2012 and 2017, the number of solo practitioners decreased, while that of dermatologists working in large groups increased. The southern region experienced the largest changes. The male-to-female ratio decreased. Dermatology practices mainly comprised mixed genders, with a higher proportion of all-male groups versus that of all-female groups, but this difference decreased over time. In the northeastern and western regions, more than one third of dermatologists were located in the wealthiest zip codes.

Limitations

The Medicare data may not be exhaustively representative of the dermatology workforce, and the zip codes of 489 dermatologists’ billing addresses were missing in the tax return dataset.

Conclusions

These findings provide an understanding of the recent changes pertaining to dermatology practice setups and of the substantial health care disparities based on geographic distribution.

Physician death by suicide in the United States: 2012-2016

Reports of incidence of physician suicide in the United States (US) are outdated. The aims of this research were to assess incidence, methods, and associated risk factors of physicians compared to non-physicians in the general US population. Retrospective suicide data (victim age 25 and over) from the 2012-2016 National Violent Death Reporting System were analyzed to test for differences in rates, methods, and risk factors of male and female physicians to non-physicians. The dataset included 498 physician suicides (403 males and 95 females) and 74,420 non-physicians (57,188 males and 17,232 females). No significant difference was found in suicide incidence between gender and age-adjusted physicians vs. non-physicians, though the female physician rate of suicide appeared higher than female non-physicians. The male to female physician ratio of suicide was about 2:1, whereas the ratio in non-physicians was closer to 4:1. Female physicians used poisoning and hanging most often as a method of suicide, where males used firearms. Depressed mood (as perceived by self or others), mental health problems (defined by a diagnosis of depression, a prescribed antidepressants or toxicology report of antidepressants), poor general medical health, and work-related stressors were more frequently associated with physician than with non-physician suicides. In conclusion, results suggest a possible heightened risk to female physicians, which warrants further investigation. Several physician-specific modifiable suicide risk factors present opportunities for prevention.

Lactation challenges of resident physicians- results of a national survey

Background

There are unique challenges to parenting in residency and there is limited data to guide policy regarding lactation facilities and support for female physicians-in-training. We aimed to assess issues surrounding breast-feeding during graduate medical training for current residents or recent graduates from United States (US) residency programs.

Methods

A national cross-sectional survey was sent to current and recently graduated (2017 and later) female residents in June 2020. This questionnaire was administered using the Qualtrics Survey tool and was open to each participating woman’s organization for 4 weeks. Summary statistics were used to describe characteristics of all respondents and free-text responses were reviewed to identify common themes regarding avenues for improvement.

Results

Three hundred twelve women responded to the survey, representing a 15.6% response rate. The median duration of providing breastmilk was 9 months (IQR 6–12). 21% of residents reported access to usable lactation rooms within their training hospital, in which 12% reported a computer was present. 60% of lactating residents reported not having a place to store breast milk. 73% reported residency limited their ability to lactate, and 37% stopped prior to their desired goal. 40% reported their faculty and/or co-residents made them feel guilty for their decision to breastfeed, and 56% reported their difficulties with breastfeeding during residency impacted their mental health.

Conclusion

Residents who become mothers during training face significant obstacles to meeting their breastfeeding/pumping needs and goals. With these barriers defined, informed policy change can be instituted to improve the lactation experience for physicians-in-training.

Comparison of Physician Data in Two Data Files Available for Cancer Health Services Research

INTRODUCTION

Physicians are vital to health-care delivery, but assessing their impact on care can be challenging given limited data. Historically, health services researchers have obtained physician characteristics data from the American Medical Association (AMA) Physician Masterfile. The Center for Medicare and Medicaid Services' Medicare Data on Provider Practice and Specialty (MD-PPAS) file was assessed, as an alternative source of physician data, particularly in the context of cancer health services research.

METHODS

We used physician National Provider Identifiers in the MD-PPAS data (2008-2014) to identify physicians in the AMA data current as of July 18, 2016. Within each source, we grouped physicians into six broad specialty groups. Percent agreement and Cohen's kappa coefficient (k) were calculated for age, sex, specialty, and practice state.

RESULTS

Among the 698 202 included physicians, there was excellent agreement for age (percent agreement = 97.7%, k = 0.97) and sex (99.4%, k = 0.99) and good agreement for specialty (86.1%, k = 0.80). Within specialty, using AMA as the reference, agreement was lowest for oncologists (77%). Approximately 85.9% of physicians reported the same practice state in both data sets.

CONCLUSION

Although AMA data have been commonly used to account for physician-level factors in health services research, MD-PPAS data provide researchers with an alternative option depending on study needs. MD-PPAS data may be optimal if nonphysicians, provider utilization, practice characteristics, and/or temporal changes are of interest. In contrast, the AMA data may be optimal if more granular specialty, physician training, and/or a broader inclusion of physicians is of interest.

U.S. Physician Recommendations to Their Patients About the Use of Complementary Health Approaches

Objective: There are no nationally representative studies using a probability sample that have been published examining whether physicians recommend complementary health approaches (CHAs) to their patients, as previous research has focused only on selected medical specialties or a particular U.S. region. This article fills a void in the current literature for robust data on recommendations for CHAs by office-based physicians in the United States. Design: Descriptive statistics and multivariable regression analyses of physician-level data were from the 2012 Physician Induction Interview of the National Ambulatory Medical Care Survey (NAMCS PII), a nationally representative survey of office-based physicians. Weighted response rate among eligible physicians sampled for the 2012 NAMCS PII was 59.7%. Setting/Location: United States. Outcome measures: Recommendations by physicians to their patients for any CHA, and individual CHAs: massage therapy, herbs/nonvitamin supplements, chiropractic/osteopathic manipulation, yoga, acupuncture, and mind-body therapies. Differences in recommendations by physician demographic characteristics were identified. Results: Massage therapy was the most commonly recommended CHA (30.4%), followed by chiropractic/osteopathic manipulation (27.1%), herbs/nonvitamin supplements (26.5%), yoga (25.6%), and acupuncture (22.4%). The most commonly recommended CHAs by general/family practice physicians were chiropractic/osteopathic manipulation (54.0%) and massage therapy (52.6%). Of all U.S. physicians, 53.1% recommended at least one CHA to patients during the previous 12 months. Multivariable analyses found physician's sex, race, specialty, and U.S. region to be significant predictors of CHA recommendations. Female physicians were more likely than male physicians to recommend massage therapy (adjusted odds ratio [aOR] = 1.76, 95% confidence interval [CI] = 1.40-2.20), herbs/nonvitamin supplements (aOR = 1.85, 95% CI = 1.46-2.35), yoga (aOR = 2.16, 95% CI = 1.70-2.75), acupuncture (aOR = 1.65, 95% CI = 1.27-2.13), and mind-body therapies (aOR = 2.63, 95% CI = 2.02-3.41) to patients. Psychiatrists (aOR = 0.13, 95% CI = 0.07-0.23), OB/GYNs (aOR = 0.38, 95% CI = 0.24-0.60), and pediatricians (aOR = 0.26, 95% CI = 0.18-0.38) were all less likely to recommend chiropractic/osteopathic manipulation than general and family practitioners. Conclusions: Overall, more than half of office-based physicians recommended at least one CHA to their patients. Female physicians recommended every individual CHA at a higher rate than male physicians except for chiropractic and osteopathic manipulation. These findings may enable consumers, physicians, and medical schools to better understand potential differences in use of CHAs with patients.

Continuity of Physicians' Dedication to Inpatient Hospice and Palliative Care: A 14-year Nationwide Survey in Taiwan

Background: The work continuity of physicians in hospice and palliative medicine (HPM) has a great impact on the quality of care and practice experiences. However, nationwide studies providing a general overview of the work continuity of HPM physicians are scarce. Methods: Data relating to inpatient HPM care provided from July 2000 to December 2013 were obtained from the National Health Insurance Research Database of Taiwan. Specifically, the numbers of hospitals, patients, patient hospitalization days, and physicians involving HPM in each year were calculated. The years of HPM work experience and total HPM workdays of each physician were also computed. Results: Of the 40,965,153 inpatient records during the study, 121,258 (0.3%) records were related to inpatient HPM care, with 60 participating hospitals and 604 attending physicians. The annual number of HPM physicians increased with time from 77 in 2000 to 217 in 2013. The largest percentage (38.4%) of physicians practiced HPM for only one year, while only 23 (3.8%) physicians practiced HPM in each year without interruption. Of the 217 HPM physicians in 2013, 45 (20.7%) were newcomers, 78 (36.0%) had 1–4 years of prior HPM work experience, 54 (24.9%) had 5–9 years, and 40 (18.4%) had at least 10 years. Conclusions: Among HPM physicians in Taiwan, only a small percentage exhibited long-term dedication to the field, whereas most HPM physicians had short practice periods. More strategies are needed to improve work continuity among HPM physicians.

Sexual Violation of Patients by Physicians: A Mixed-Methods, Exploratory Analysis of 101 Cases

A mixed-method, exploratory design was used to examine 101 cases of sexual violations in medicine. The study involved content analysis of cases to characterize the physicians, patient-victims, the practice setting, kinds of sexual violations, and consequences to the perpetrator. In each case, a criminal law framework was used to examine how motives, means, and opportunity combined to generate sexual misconduct. Finally, cross-case analysis was performed to identify clusters of causal factors that explain specific kinds of sexual misconduct. Most cases involved a combination of five factors: male physicians (100%), older than the age of 39 (92%), who were not board certified (70%), practicing in nonacademic settings (94%) where they always examined patients alone (85%). Only three factors (suspected antisocial personality, physician board certification, and vulnerable patients) differed significantly across the different kinds of sexual abuse: personality disorders were suspected most frequently in cases of rape, physicians were more frequently board certified in cases of consensual sex with patients, and patients were more commonly vulnerable in cases of child molestation. Drawing on study findings and past research, we offer a series of recommendations to medical schools, medical boards, chaperones, patients, and the national practitioners database.

FSMB Census of Licensed Physicians in the United States, 2018

There are 985,026 physicians with Doctor of Medicine (MD) and Doctor of Osteopathic Medicine (DO) degrees licensed to practice medicine in the United States and the District of Columbia, according to physician census data compiled by the Federation of State Medical Boards (FSMB). These qualified physicians graduated from 2,089 medical schools in 167 countries and are available to serve a U.S. national population of 327,167,434. While the percentage of physicians who are international medical graduates have remained relatively stable over the last eight years, the percentage of physicians who are women, possess a DO degree, have three or more licenses, or are graduates of a medical school in the Caribbean have increased by varying degrees during that same period.

This report marks the fifth biennial physician census that the FSMB has published, highlighting key characteristics of the nation's available physician workforce, including numbers of licensees by geographic region and state, type of medical degree, location of medical school, age, gender, specialty certification and number of active licenses per physician. The number of licensed physicians in the United States has been growing steadily, due in part to an expansion in the number of medical schools and students during the past two decades, even as concerns of a physician shortage to meet health care demands persist. The average age of licensed physicians continues to increase, and more licensed physicians appear to be specialty certified, though the latter finding may reflect more comprehensive reporting. This census was compiled using the FSMB's Physician Data Center (PDC), which collects, collates and analyzes physician data directly from the nation's state medical and osteopathic boards and is uniquely positioned to provide a comprehensive snapshot of information about licensed physicians. A periodic national census of this type offers useful demographic and licensure information about the available physician workforce that may be useful to policy makers, researchers and related health care organizations to better understand and address the nation's health care needs.

A Qualitative, Interview-Based Study of the Health Policy Fellowship's Osteopathic Identity

CONTEXT

Since 1993, the Health Policy Fellowship (HPF) has trained osteopathic professionals in health policy and leadership. Although almost 250 fellows have graduated from the program, many of whom have assumed leadership roles within the osteopathic medical profession, the HPF has, to the authors' knowledge, never been subjected to scholarly analysis.

OBJECTIVE

To understand the HPF's professional significance as a health policy and leadership training program that has enrolled mostly osteopathic physicians.

METHODS

Semistructured interviews were conducted with graduates supplemented by interviews with other professionals involved with the HPF. Using an inductive grounded theory approach, we coded interviews for major themes.

RESULTS

Forty-three interviews were conducted, 38 of which were with graduates of the program and 5 of which were with HPF staff. The data suggest that although the content of the HPF is applicable to all medical professionals, the program's language and structure are designed to accommodate specific needs of osteopathic professionals. Specifically, the language of the fellowship emphasizes the "high ground" (considering multiple perspectives on an issue), and the structure of the fellowship allows fellows to continue in their jobs but travel to several COMs and to Washington, DC, throughout the year.

CONCLUSION

Closer examination of the HPF helped convey the relevance of this program, and perhaps programs like it, for a minority medical profession still finding its voice within the policy climate of US health care.

Patient centred medical home (PCMH) and patient-practitioner orientation: Is there a relationship?

BACKGROUND

The patient-centred medical home (PCMH) and utilisation of a patient-centred care approach have been promoted as opportunities to improve healthcare quality while controlling expenditures.

OBJECTIVES

To determine the penetration of PCMH within physician practices, and to evaluate physician attitudes towards patient-practitioner orientation. The ultimate objective was to explore relationships between the patient-practitioner orientation of respondents and the presence of PCMH elements within their practice.

METHODS

A survey instrument was developed following a comprehensive literature review. Lead physicians practicing in four states were surveyed.

RESULTS

The adjusted response rate was 26.7%. Responses indicated increased utilisation of PCMH elements (electronic medical records, e-mail and telephone consultations, and physician performance monitoring and feedback) compared with previous research. Within a logistic regression model, medical school graduation year (1990 or later >prior to 1990), practice size (group >solo), and percentage of time allocated to patient care (less >more) were significant predictors of working in a high PCMH alignment setting. Physician and practice characteristics did not predict the level of patient-practitioner orientation, though rural physicians were more patient-centred than urban physicians. A non-linear correlation between patient-practitioner orientation and the likelihood of practicing in a low or high PCMH-aligned practice was observed.

CONCLUSIONS

There is a non-linear correlation between patient-practitioner orientation and the likelihood of a physician practicing in a low or high PCMH-aligned practice. The ability of a physician to work in a PCMH setting or practicing patient-centred care can go beyond a physician's aspirations to work and practice in that manner.

Assessment of fitness for duty of underperforming physicians: The importance of using appropriate norms

Objective

To determine whether population-specific normative data should be employed when screening neurocognitive functioning as part of physician fitness for duty evaluations. If so, to provide such norms based on the evidence currently available.

Methods

A comparison of published data from four sources was analyzed. Data from the two physician samples were then entered into a meta-analysis to obtain full information estimates and generate provisional norms for physicians.

Results

Two-way analysis of variance (Study x Index) revealed a significant main effect and an interaction. Results indicate differences in mean levels of performance and standard deviation for physicians.

Conclusions

Reliance on general population normative data results in under-identification of potential neuropsychological difficulties. Population specific normative data are needed to effectively evaluate practicing physicians.

A Census of Actively Licensed Physicians in the United States, 2016

An accurate understanding of the demographic and state medical licensure characteristics of physicians in the United States is critical for health care workforce planning. Overall changes in the nation's population demographics, state and federal medical regulatory policies and dynamics surrounding the ongoing health care reform debate further highlight the need to have an up-to-date census of actively licensed physicians across all medical specialties.

This article uses data received by the Federation of State Medical Boards (FSMB) from the nation's state medical and osteopathic licensing boards to report and summarize key features of actively licensed physicians in the United States and the District of Columbia. Our biennial census, current through the end of 2016, identifies a total of 953,695 actively licensed allopathic and osteopathic physicians serving a national population of 323 million people. This represents a net physician-increase of 12% from the 2010 census. From 2010 to 2016, the actively licensed U.S. physician-to-population ratio increased from 277 physicians per 100,000-population to 295 physicians per 100,000-population. Females now make up one-third of all licensed physicians, with osteopathic physicians and Caribbean medical graduates continuing to demonstrate substantial increases in both their absolute numbers and as a percentage of all actively licensed physicians from the 2010 to 2016 time period.