The Pediatric Subspecialty Workforce: A Policy Primer

1
The Pediatric Subspecialty WorkforceA Policy
Primer

• Ethan Alexander Jewett, MA
• Senior Health Policy Analyst
• July 2005

2
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.

3
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.

4
Subspecialty Certification by the American Board
of Pediatrics

• Adolescent medicine
• Cardiology
• Developmental-behavioral pediatrics
• Emergency medicine
• Endocrinology
• Gastroenterology
• Hematology/oncology
• Infectious diseases

• Medical toxicology
• Neonatal-perinatal medicine
• Neurodevelopmental disabilities
• Nephrology
• Pulmonlogy
• Rheumatology
• Sports medicine

5
Subspecialty Certification by Other Specialty
Boards
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.

• Adolescent medicine
• Child and adolescent psychiatry
• Pediatric emergency medicine
• Pediatric otolaryngology

• Pediatric pathology
• Pediatric rehabilitation medicine
• Pediatric radiology
• Pediatric surgery

6
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 allergy
• Pediatric anesthesiology
• Pediatric dermatology
• Pediatric genetics
• Pediatric neurology
• Pediatric ophthalmology
• Pediatric orthopedic surgery
• Pediatric plastic surgery
• Pediatric urology

7
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

8
A Head Count of Some of the Major Pediatric
Subspecialties
9
How reliable are these counts?

• Potential limitations to workforce data
• Physician specialty counts are based on data
  reported by survey respondents individual
  physicians 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.

10
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.

11
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.

12
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.

13
How do we know theres 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.
• Articles in journals and the medical press.

14
Increase in Referral Volume
Percent of Survey Respondents Who Indicated
Change in Referral Volume
15
Wait Times for Appointments

• In 2004, the National Association of Childrens
  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, 20043
16
Recruitment Problems

• Recruitment problems have been documented for a
  number of pediatric subspecialties3-8
• Anesthesiology
• Dermatology
• Gastroenterology
• Neurology
• Radiology
• Rheumatology
• Some candidate searches last well over a year.

17
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.

18
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.

19
Demographic Profile of thePediatric
Subspecialist Pipeline
Source American Board of Pediatrics, First-time
Applicants for Subspecialty Certification
Examinations, 2003-4.9
20
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
21
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

22
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

23
Recruiting Residents into Pediatric
Subspecialties

• Pan et al. (2002) analyzed career choice by
  gender16
• 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

24
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.

25
What can be done about the pediatric
subspecialist shortage?

• 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

• Many subspecialties are increasingly using
  telemedicine to address the workforce shortage,
  particularly in rural areas.

26
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 future20
• 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.

27
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.

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References

• Pasko T, Smart DR. Physician Characteristics and
  Distribution in the US, 2005 Edition. Chicago,
  Ill American Medical Association 2005.
• Stoddard JJ, Cull WL, Jewett EAB, Brotherton SE,
  Mulvey HJ, Alden ER. Providing pediatric
  subspecialty care a workforce analysis. 2000
  Dec106(6)1325-33.
• 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 Mar50(3)431-4.
• Forman HP, Traubici J, Covey AM, Kamin DS,
  Leonidas JC, Sunshine JH. Pediatric radiology at
  the Millennium. Radiol. 2001 Jul220(1)109-114.
• Werner RM, Polsky D. Strategies to attract
  medical students to the specialty of child
  neurology. Pediatr Neurol. 200430(1)35-8.
• Laureta E, Moshe SL. State of training in child
  neurology 1997-2002. Neurol. 2004 Mar62864-9.

• 8. Mayer ML, Mellins ED, Sandborg CI. Access to
  pediatric rheumatology care in the United States.
  Arthritis Rheumatol. 2003 Dec49(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-Aug19(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 Aug108(2)354-8.

29
References (cont.)

• 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
  Oct36(10)1510-3
• 14. Hampers LC, Faries SG, Practice variation in
  the emergency management of croup. Pediatrics.
  2002 Mar109(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 Jun107(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 Feb109(2)182-8.
• 17. Cull WL, Mulvey HJ, OConnor KG, Sowell DR,
  Berkowitz CD, Britton CV. Pediatricians working
  part-time past, present, and future. Pediatrics.
  2002 Jun109(6)1015-20.

• 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 Oct112 (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
  Mar159212-6.
• 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
• http//www.aap.org/workforce