The Pediatric Subspecialty Workforce: A Policy PrimerPresentation Transcript
The Pediatric Subspecialty Workforce: A Policy Primer Ethan Alexander Jewett, MA Senior Health Policy Analyst July 2005
What are pediatric subspecialists?
“Pediatric subspecialists” is a global term that refers to the wide range of medical subspecialists, surgical specialists, and other specialist physicians that care for children.
These physicians care primarily for children with complex and chronic illnesses, as well as children with special health care needs.
How many kinds of pediatric subspecialists are there?
This is not an easy question to answer. Increasing subspecialization within medicine has led to an explosion of subspecialties within the last couple of decades.
However, subspecialists can be grouped into those that are certified by the American Board of Pediatrics and those that are certified by other specialty boards.
Subspecialty Certification by the American Board of Pediatrics
Subspecialty Certification by Other Specialty Boards
Child and adolescent psychiatry
Pediatric emergency medicine
Pediatric rehabilitation medicine
Some pediatric subspecialists, particularly pediatric surgical specialists, are certified by other specialty boards. In a couple of cases, these boards offer certification in pediatric subspecialties also covered by the American Board of Pediatrics.
Other Pediatric Specialists
Some physicians who provide specialty care to children are not certified as “pediatric specialists” by their primary specialty board. Instead, they are certified in both primary disciplines (eg, pediatrics and medical genetics), or have extensive training or experience in the pediatric aspects of the specialty (eg, urology).
Pediatric orthopedic surgery
Pediatric plastic surgery
How many pediatric subspecialists are there?
Because people differ on who qualifies as a pediatric subspecialist, and on which data set to use, doing a “head count” can be difficult.
However, the most expansive definition of “pediatric subspecialist,” which would include surgical specialists and other specialist physicians, would place the number at around 22,000 (AMA, 2003). 1
A “Head Count” of Some of the Major Pediatric Subspecialties Source: Amer Med Assoc, 2003 1 157 Urology 290 Infectious Diseases 789 Surgery 1553 Hematology-Oncology 84 Rheumatology 473 Gastroenterology 635 Radiology 749 Endocrinology 555 Pulmonology 501 Emergency Medicine 78 Pathology 997 Critical Care Medicine 114 Otolaryngology 6726 Child & Adolescent Psychiatry 165 Ophthalmology 1741 Cardiology 453 Nephrology 199 Anesthesiology 3812 Neonatal-Perinatal Medicine 223 Allergy & Immunology 14 Medical Genetics 473 Adolescent Medicine
How reliable are these counts?
Potential limitations to workforce data:
Physician specialty counts are based on data reported by survey respondents: individual physician’s specialties cannot be verified.
Numbers can count
all physicians in a particular subspecialty
only those that are active (not retired)
only those that are involved in direct patient care
only those who are board-certified
any of the above, minus residents.
How meaningful are these counts?
“ Head counts” are not necessarily the best way to predict the need for physicians.
Poor access to care can be caused by many other factors besides physician supply (eg, lack of insurance, poverty, poor reimbursement for services).
Not all physicians are a “full-time equivalent.” Some work part-time, and some work in areas other than patient care.
Many physicians work in research, teaching, administration, and other professional roles.
Then, why count at all?
Physician supply is one factor that determines access to care. It is important to know whether the number of people entering the subpsecialty workforce is sufficient to replace those that are leaving it.
It is also important to know where these physicians are practicing, so that geographic maldistributions of physicians can be addressed through policy and recruitment activities.
The Pediatric Subspecialty Debate
Since 2000, a great deal of new information has emerged about pediatric subspecialties.
Documentation of workforce shortages has appeared in peer-reviewed journals.
Concern about these shortages has fueled debate.
How do we know there’s a shortage?
Not all subspecialties have the same workforce issues. The neonatology supply, for example, is very robust. However, a number of indicators point to a workforce shortage in many pediatric subspecialties. These indicators have become increasingly visible since 2000.
Documented increases in patient/referral volume.
Long wait times to obtain an appointment.
Difficulty recruiting physicians for vacant job positions.
In 2004, the National Association of Children’s Hospitals and Related Institutions (NACHRI) reported on the number of weeks a patient had to wait to obtain an appointment to see a particular subspecialist. For many subspecialties, a patient had to wait between 5 weeks and 3 months.
Source: NACHRI, 2004 3
Recruitment problems have been documented for a number of pediatric subspecialties 3-8 :
Some candidate searches last well over a year.
Articles in the Medical Press
Journal articles, news stories, and editorials serve as another indicator of a potential workforce shortage.
In the last several years, articles reporting a workforce shortage for many pediatric subspecialties have increased in number and frequency.
In the aggregate, this evidence, though in many cases only anecdotal, becomes difficult to ignore. Even in the absence of hard data, physicians practicing in the trenches learn from their day-to-day experiences (often supported by other indicators) when a supply problem might be around the corner.
Recent Information about Pediatric Subspecialties
There is a lot of timely information on the pediatric subspecialist workforce, ranging from costs of care to practice characteristics. Of particular significant, was the Future of Pediatric Education II (FOPE II) Project which conducted surveys of 17 subspecialties.
The trick to accessing this information is to search by individual subspecialty or clinical topic. Articles on the subspecialty workforce at large are rare, as it is difficult to do meaningful analysis at such a global level.
Demographic Profile of the Pediatric Subspecialist Pipeline Source: American Board of Pediatrics, First-time Applicants for Subspecialty Certification Examinations, 2003-4. 9
How much do pediatric subspecialists earn? Compensation for pediatric subspecialists varies by region, practice type, and a number of other factors. This variability is reflected in the different numbers generated by salary surveys, one of which is presented here. Source: AMGA, 2003, Medical Group Compensation and Productivity Survey. 10 $270,000 Pediatric surgery $169,662 Pediatric pulmonary disease $339,650 Pediatric orthopedic surgery $159,044 Pediatric neurology $173,453 Pediatric nephrology $174,088 Pediatric intensive care $146,382 Pediatric infectious diseases $162,002 Pediatric hematology/oncology $167,391 Pediatric gastroenterology $130,245 Pediatric endocrinology $213,933 Pediatric cardiology $136,429 Pediatric allergy $165, 437 Child psychiatry Salary (2003) Pediatric subspecialty/specialty
What does subspecialty care cost?
JT Smith et al. (1999) found that for closed femoral shaft fractures, length of stay was shorter and hospital charges were less when the child was treated by a pediatric, rather than an adult, orthopedic surgeon. 11
Isaacman et al (2001) demonstrated that young children treated for fever spent 2.26 hours in the pediatric emergency department, compared to 3.0 hours in the adult emergency department. 12
Alexander (2001) showed that children with significantly perforated appendicitis have lower complication rates and shorter lengths of stay when treated by pediatric surgeons as compared with HMO adult surgeons. 13
What does subspecialty care cost?
Hampers and Faries (2002) calculated that pediatric emergency medicine physicians treating croup reduced length of stay by 40 minutes and direct costs by $90 when compared to the same treatment delivered by adult emergency medicine physicians. 14
Kokoska et al. (2004) found that younger children treated by pediatric surgeons with appendicitis had significantly shorter hospital stay and/or decreased hospital charges than younger children treated by general surgeons for the same condition. 15
Recruiting Residents into Pediatric Subspecialties
Pan et al. (2002) analyzed career choice by gender 16 :
female residents, US medical graduates, underrepresented minorities, and residents married to non-physicians were more likely to report an interest in primary care careers.
international medical graduates and male residents are more likely to pursue subspecialty training, regardless of educational debt.
Cull et al. (2002) learned that 42% of graduating female residents in 2000 were interested in part-time practice, compared with only 14% of graduating male residents. 17
Recruiting Residents into Pediatric Subspecialties (cont.)
Cull et al. (2003) found a strong association between pediatrics’ residents towards research and the pursuit of subspecialty fellowship training. 18
Harris et al. (2005) determined that career decisions for pediatric residents are complex. 19
Those interested in generalist careers are driven more by lifestyle and personal/financial considerations.
Career decisions for subspecialists, in contrast, are attracted by the teaching, research, and technical skills associated with subspecialty practice.
What can be done about the pediatric subspecialist shortage?
Many subspecialties are increasingly using telemedicine to address the workforce shortage, particularly in rural areas.
Changes to fellowship training and subspecialty practice that address the lifestyle concerns of residents are likely to foster subspecialization.
Opportunities for shared or part-time fellowships make encourage more women to subspecialize.
The medical press provides suggestions to increase the supply of subspecialists and improve access to care:
Jewett, et al. ( Pediatrics, in press)
In 2005, Jewett et al. provided an overview of the current pediatric subspecialty workforce and identified 5 forces that were likely to shape the workforce in the near future 20 :
Changes in the demographics of physicians and patient populations.
Physician debt load and lifestyle considerations.
Competition among providers of pediatric subspecialty care.
Equitable reimbursement for subspecialty services.
Policies aimed at regulating specialist physician training and supply.
Jewett et al.: Recommendations
Restructure fellowships and practices to accommodate the lifestyle priorities of a workforce that is increasingly female.
Expand diversity/cultural competency training.
Expand federal loan repayment and other financial incentive programs (eg, NHSC).
Train nonphysicians, as appropriate, to provide some subspecialty care in underserved areas.
Reform reimbursement for subspecialty care.
Advocate for responsible workforce policy.
Pasko T, Smart DR. Physician Characteristics and Distribution in the US, 2005 Edition. Chicago, Ill: American Medical Association; 2005.
Donna Shelton. Written communication. September 28, 2004.
Hester EJ, McNealy KM, Kelloff JN, et al. Demand outstrips supply of US pediatric dermatologists: Results from a national survey. J Am Acad Dermatol . 2004 Mar;50(3):431-4.
Forman HP, Traubici J, Covey AM, Kamin DS, Leonidas JC, Sunshine JH. Pediatric radiology at the Millennium. Radiol. 2001 Jul;220(1):109-114.
Werner RM, Polsky D. Strategies to attract medical students to the specialty of child neurology. Pediatr Neurol . 2004;30(1):35-8.
Laureta E, Moshe SL. State of training in child neurology 1997-2002. Neurol . 2004 Mar;62:864-9.
8. Mayer ML, Mellins ED, Sandborg CI. Access to pediatric rheumatology care in the United States. Arthritis Rheumatol . 2003 Dec;49(6):759-765.
9. American Board of Pediatrics. Workforce Data, 2004-2005. Chapel Hill, NC: American Board of Pediatrics; March 2005.
10. American Medical Group Association. Physician Compensation: 2003 Medical Group Compensation and Productivity Survey, Median Compensation. Available at: http://www.cejkasearch.com/ content.asp Accessed January 16, 2004.
11. Smith JT, Price C, Stevens PM, Masters KS, Young M. Does pediatric orthopedic subspecialization affect hospital utilization and charges? J Pediatr Orthop. 1999 Jul-Aug;19(4):553-5.
12. Isaacman DJ, Kaminer K, Veligeti H, Jones M, Davis P, Mason JD. Comparative practice patterns of emergency medicine physicians and pediatric emergency medicine physicians managing fever in young children. Pediatrics . 2001 Aug;108(2):354-8.
13. Alexander F, Magnuson D, DiFiore J, Jirosek K, Secic M. Specialty versus generalist care of children with appendicitis: an outcome comparison. J Pediatr Surg. 2001 Oct;36(10):1510-3
14. Hampers LC, Faries SG, Practice variation in the emergency management of croup. Pediatrics. 2002 Mar;109(3):505-8.
15. Kokoska ER, Minkes RK, Silen ML, et al. Effect of pediatric surgical practice on the treatment of children with appendicitis. Pediatrics . 2001 Jun;107(6):1298-1301.
16. Pan RJ, Cull WL, Brotherton SE. Pediatric residents’ career intentions: data from the leading edge of the pediatrician workforce. Pediatrics. 2002 Feb;109(2):182-8.
18. Cull WL, Yudkowsky BK, Shipman SA, Pan RJ. Pediatric training and job market trends: results from the American Academy of Pediatrics Third-Year Resident Survey, 1997-2002. Pediatrics . 2003 Oct;112 (4):787-92.
19. Harris MC, Marx J, Gallagher PR, Ludwig S. General vs. subspecialty pediatrics: factors leading to residents’ career decisions over a 12-year period. Arch Pediatr Adolesc Med . 2005 Mar;159:212-6.
20. Jewett EA, Anderson MR, Gilchrist GS. The pediatric subspecialty workforce: public policy and forces for change. Pediatrics. [in press].
For more information on workforce issues, please visit the AAP Committee on Pediatric Workforce Web page: