Specialty Maldistribution Research Articles

WORK–LIFE BALANCE OF YOUNG PHYSICIANS IN JAPAN

Background: Geographical and specialty maldistribution of physicians are key
 issues in the Japanese healthcare system. These are strongly related to work–life
 balance issues that physicians face, including long working hours, burnout, and
 discontinuation of female physicians’ careers.
 Objective: To obtain the opinions of young physicians in Japan on policies
 regarding work–life balance and career building.
 Method: A cross-national study was conducted using a questionnaire that was sent
 to physician across Japanese Red Cross Hospitals.
 Results: Young physicians view work–life balance as important in choosing
 specialties and work location. In addition to the motivation to gain training
 experience, they seek adequate rest through shift work, and work efficiency by
 sharing tasks with other medical professionals, using IT, and improving operation
 management.
 Discussion: As an example of work-style reform in progress, we would like to
 introduce the shift-work system at our institution’s Obstetrics and Gynecology
 Department. By clarifying the line between work and life, physicians can balance
 career building and time for self-improvement.
 Conclusion: For young physicians to continue their careers without burning out
 and excel in various fields, we must create a system that allows for efficient
 learning and work–life balance for both mental and physical well-being.

Where to next for rural general practice policy and research in Australia?

[Extract] Australia is in a critical period of rural workforce policy reform. The Australian government is responding to a surge of domestic and international doctors, while addressing the pervasive problem of geographic and specialty maldistribution. There is renewed commitment to strengthen rural health policy and further develop a well skilled, adaptable rural general practitioner workforce. GPs underpin resilient, healthy rural and remote communities and are essential for a coordinated and efficient health system. This article seeks to inform future directions and research priorities by reflecting on 20 years of policy activity and outcomes.

Addressing Physician Specialty Maldistribution

Addressing Physician Specialty Maldistribution

Addressing Physician Specialty Maldistribution—Reply

Addressing Physician Specialty Maldistribution—Reply

The Impact of Title VII on General and Pediatric Dental Education and Training

The authors describe the impact of the Title VII, Section 747 Training in Primary Care Medicine and Dentistry (Title VII) grant program on the development, growth, and expansion of general and pediatric dentistry residency programs in the United States. They first briefly review the legislative history of the Title VII program as it pertains to dental education, followed by a historical overview of dental education in the United States, including a description of the differences between dental and medical education and the routes to professional practice. The authors then present an extensive assessment of the role of the Title VII grant program in building general and pediatric dental training capacity, diversifying the dental workforce, providing outreach and service to underserved and vulnerable populations, stimulating innovations in dental education, and engaging collaborative and interdisciplinary training with medicine. Finally, the authors call for broadening the scope of the Title VII program to allow for predoctoral training (dental student education) and faculty development in general and pediatric dentistry. In doing so, the Title VII program can more effectively address current and future challenges in dental education, dentist workforce, and disparities in oral health and access to care.This article is part of a theme issue of Academic Medicine on the Title VII health professions training programs.

Laboratories and the health care marketplace: the limits of state workforce policy.

Nearly every state has enacted its own effort to change both the composition and the practice patterns of America's medical workforce. At the same time, the health care marketplace is altering the nation's medical workforce, encouraging more medical students to enter primary care and fewer to become specialists. In this article, I consider various issues raised by these trends. Do the various state programs constitute an effective policy laboratory? Is the market solving problems government could not? Are the government initiatives now irrelevant? I conclude that the market is solving the problem of specialty maldistribution (too many specialists) but not the problem of geographic maldistribution (too many medically underserved communities). I also conclude that state workforce efforts have not constituted good policy laboratories and that only federal action can seriously address the geographic maldistribution problem.

Geographic benefit from decentralized medical education: student and preceptor practice patterns.

The performance of area health education center (AHEC)-stimulated programs and decentralized education for medicine is not well understood. The Statewide Education Activities for Rural Colorado's Health (SEARCH)/AHEC project at the University of Colorado School of Medicine was examined to determine if the program had an effect on the practice location of its graduates. Practice location and specialty of graduates of the University of Colorado School of Medicine (UCSOM) classes 1980-1985 were compared for students who had participated in decentralized SEARCH/AHEC experiences versus students who had not. The majority of the graduates were practicing out of state in 1990. Non-Colorado doctors were more often practicing in rural (non-metropolitan statistical area [MSA]) counties and in towns of fewer than 2,500, 5,000 and 10,000 residents, respectively. In addition, of the 251 active patient care physicians practicing in Colorado communities of fewer than 10,000 in non-MSA counties in 1986, those who precepted UCSOM students on SEARCH rotations were more likely to have remained in their same practice location in 1992 (77.8% versus 62.1% for those who had not precepted students). This analysis of both student and preceptor practice patterns documents the value of decentralized medical education in addressing the geographic and specialty maldistribution of physicians. These results have important policy implications for funding medical education programs.

Specialty maldistribution. The next nursing crisis?

Clinical specialty maldistribution is a problem in the United States due, in part, to ongoing supply and demand problems created by the nursing shortage. Although the extent of difficulty is unclear, predictions of future shortages in some specialties are startling. If unresolved, maldistribution may affect quality of care or result in rationing of care in some specialties areas.

Recruitment, retention, and follow-up of graduates of a program to increase the number of family physicians in rural and underserved areas.

To help address the geographic and specialty maldistribution of physicians, Jefferson Medical College initiated the Physician Shortage Area Program (PSAP) in 1974. This unique program, which combines a selective medical school admissions policy with a special educational program, has been shown to be successful in increasing the number of family physicians in rural and underserved areas, but it is not known whether they remain in this type of practice. Graduates of the PSAP were tracked longitudinally and compared with their non-PSAP classmates. Information was obtained about the retention of family physicians in rural areas and areas with a physician shortage over the previous five years, the geographic and specialty choices of more recent graduates, and the recruitment of applicants into the program. Of the 47 PSAP graduates from the classes of 1978 through 1981, reported on earlier, the number who combined a career in family medicine with practice in a rural area or one with a physician shortage remained unchanged, although there was substantial attrition among non-PSAP graduates practicing family medicine in rural (32 percent) and underserved (40 percent) areas. Among the 101 PSAP graduates of the classes of 1982 through 1986, the results were similar to those for the first four classes. Overall, PSAP graduates from the classes of 1978 through 1986 were approximately four times as likely as non-PSAP graduates to practice family medicine (55 percent vs. 13 percent), to practice in a rural area (39 percent vs. 11 percent), and to practice in underserved areas (33 percent vs. 8 percent). They were approximately 10 times more likely to combine a career in family medicine with practice in a rural (26 percent vs. 3 percent) or underserved (23 percent vs. 2 percent) area. Overall, 85 percent of PSAP graduates were either practicing a care specialty or practicing in a rural or small metropolitan area or one with a shortage of physicians. In parallel with national trends, the number of applicants and matriculants to the program decreased during the past decade, so that the percentage of available places filled decreased from 97 percent to 33 percent. However, there has been a recent increase in the number of applicants and matriculants. The results of this study indicate that the PSAP was successful in increasing the number of family physicians in rural and underserved areas as well as in retaining them. This suggests that medical schools can have a substantial influence on the distribution of physicians according to specialty choice and the geographic location of their practices, principally through admission criteria.

Specialists or Generalists? The Medical Outcomes Study-Reply

In Reply. —Although the recent intensity of attention to primary care medicine cited by Dr Balestra may be unusual, the problem of specialty maldistribution in the United States is not new. National health personnel policy has revolved around this issue for much of the last 20 years. 1 What is new is the realization that the growing disarray of our medical care system is in some measure a consequence of the decline of the role of the generalist in American medicine. Balestra certainly is correct in his observation that the solution to the problem is neither simple nor likely to be solved by any single intervention. Physician specialty choice is influenced by preferences of admission committees, the shape and emphasis of medical school curricula, the availability and attractiveness of residency slots, and the differential rewards that society confers on those who follow disparate paths. Only by addressing the problem at

Primary Care Applicants — They Get No Respect

In the late 1960s it was conventional wisdom that physicians were in short supply and unevenly distributed according to geography and specialty.1 The shortage, if it ever really existed, was rapidly corrected, but geographic maldistribution — the relative dearth of doctors in rural areas and inner cities —persisted, and as Colwill articulates in this issue of the Journal , 2 specialty maldistribution, exemplified by an excessive number of specialists and a corresponding paucity of generalists, is getting worse. I agree with Colwill that the shortage of general physicians is not in the best interest of the American health care system and must . . .

Factors Affecting the Distribution of Physician Assistants in New York State: Policy Implications

HE belief that all Americans should have access to high quality medical care, coupled with heightened concerns T t n 2 regarding the geographical and specialty maldistribution of physicians, were the driving forces behind the ' Federal government's decision in the 70s to provide *\Ae funds to expand the number of training sites for physician assistants. Earlier policies designed to correct the maldistribution problem concentrated on increasing the training capacity for physicians. While such policies have effectively increased physician supply they have done little to change distribution (i). In fact, there appears to be a continuing decrease in the concentration of physicians in rural and low income urban and suburban areas. Coleman (2) has noted that "physicians who established or relocated their practices between 1970 and 1975 appeared to be adding to, rather than reducing distributional inequality." A DHEW 1978 report (3) states: "In spite of the unprecedented increases in the total numbers of health professionals, indications are that shortages remaini in many geographic areas and specialties, and uneven and inappropriate geographic and specialty distributions remain the most serious manpower problems." The failure of physicians to meet the health needs of all Americans clearly highlights the need for alternative measures. The training of physician assistants is one approach that has been undertaken to address the problem of the uneven distribution of medical manpower and to relieve the shortage of primary care providers. Cawley and Golden (4) have noted that as of 1982 there were 16,ooo PAs practicing in the United States. They are deployed mainly in primary care settings and have helped improve access and expand the range of physician services. Several studies have shown that physician assistants are more willing than physicians to practice in underserved areas. The Comptroller Gen

Sex differences in the professional orientation of first-year medical students

This article, presenting the findings from a 1975 survey of first-year medical students in the state of North Carolina, explores the relationship between students' sex and professional orientations considered relevant to current health care problems. The professional orientations concern four problem areas: (1) physicians' relationships with patients, (2) political and economic change in the medical profession, (3) the treatment of women physicians and women patients, and (4) geographic and specialty mal-distribution of physicians. Substantial sex differences are found for some professional orientations. As hypothesized, women orient more highly than men to humanizing physician-patient relationships, political and economic change in medicine, the problems facing women physicians and patients, and expecting an inner-city practice. Implications of the findings for health care and medical education are discussed.

Changes in the professional orientation of medical students: a follow-up study.

This paper is a report of the findings of a 1978 follow-up survey on senior medical students in North Carolina tracing changes in their professional orientations since their freshman year. The professional orientations concern four health care problem areas: physicians' relationship with patients, political and economic change in the medical profession, the treatment of women physicians and patients, and geographic and specialty maldistribution of physicians. Medical students generally become more conservative on political and economic issues in the profession and less committed to choosing a practice based on patient need. Although most seniors have maintained their desire to help people, they are more realistic about physicians' limitations than they were during their freshman year. Seniors have more definite opinions on issues concerning women physicians and patients, some becoming more sympathetic with women and some representing a conservative backlash.

The supply of dental manpower in the United States

This description of the supply of dental services in the United States addresses the number, kind, distribution, and training of dentists and dental auxiliaries, and the organizational factors that affect the production of dental services. Beginning with a brief historical review, the paper gives a general overview of the different types of dental personnel including the dentist, dental hygienist, dental assistant, and laboratory technician. The discussion of these categories of providers includes consideration of manpower planning as it has evolved over the past two decades, National manpower legislation is mentioned first as a reaction to the projected dentist shortage and then in response to the issues of geographic maldistribution and the effects of specialization. The second section of the paper discusses the dynamics of the dental care market. The distribution of the supply of services is identified and related to patterns of utilization and productivity. These factors are considered to be part of the set of dynamic relationships that help explain the current manpower problems of geographic and specialty maldistribution. A concluding section superficially discusses policy implications regarding the potential for increasing supply by: (1) increasing the number of dentists, (2) increasing the numbers and functions of auxiliaries, (3) increasing practice efficiency through group practice, and (4) reducing the restrictions that result from current state dental practice acts.

The professional values and expectations of medical students.

This paper, presenting the findings from a 1975 survey of first-year medical students in the state of North Carolina, describes medical students' professional orientations by focusing on specific values and expectations which may have relevance for health care problems. The professional orientations concern four problem areas: physicians' relationships with patients, political and economic change in the medical profession, the treatment of women physicians and patients, and geographic and specialty maldistribution of physicians. The data suggest that incoming medical students are concerned with helping people but not necessarily through political means, committed to some geographic and specialty areas of patient need, choosing medicine for reasons other than economic rewards but not opposed to physicians' large income and status, and somewhat unaware of discrimination toward women physicians and patients.

Practice habits in a group of eight internists.

A method was devised to offer a group of internists a system by which to analyze their practices, allowing them to identify areas where a change in practice habits might be beneficial. More than 3000 encounters between patients and internists in an eight-man group were analyzed for a number of variables. Significant differences existed between physicians as to the percentage of encounters that were physician-initiated rather than patient-initiated. Disposition of the encounters also varied significantly. The effect that the recycling of patients has on productivity, cost, and use of hospital facilities is discussed. In addition to geographic and specialty maldistribution, the maldistribution of physician time is a significant barrier to meeting the demands for medical care.

Quality, quantity and distribution of medical education and care: regulation by the private sector or mandate by government?

The public, the federal government and most state governments have become increasingly concerned with the lack of access to primary care as well as the specialty and geographic maldistribution problems. Currently, there is a race in progress between the private sector and the federal government to devise solutions to these problems. In the federal sector, varying pieces of legislation are under active consideration to mandate the correction of specialty and geographic maldistribution; proposals include: 1) setting up federal machinery to regulate the numbers and types of residencies; 2) make obligatory the creation of Departments of Family Practice in each medical school; 3) withdraw current education support from medical schools causing tuition levels to increase substantially--federal student loans would then provide the necessary leverage to obligate the borrower to two years of service in an under-served area in exchange for loan forgiveness. In the private sector, for the first time in the history of the United States, the five major organizations involved in medical care have organized to form the Coordinating Council on Medical Education (CCME) and the Liaison Committee on Graduate Medical Education (LCGME). One of the initial major endeavors of the CCME has been to address itself to the problem of specialty maldistribution. The LCGME has been tooling up to become the accrediting group for residency training thus providing an overview of the quality and quantity of specialty training. It will be the intent of this presentation to bring the membership of the Southern Surgical Association an up-to-date report on these parallel efforts. The author's personal hope is that the private sector can move sufficiently rapidly to set up its own regulatory mechanisms and avert another federally controlled bureaucracy that will forever change the character of the medical profession in the United States.

Health manpower: numbers, distribution, quality.

Although the "health care crisis" was thought solvable by simply increasing the number of physicians, this has turned out not to be the case. The major problems in physician manpower are geographic maldistribution with a sparsity of physicians in the rural areas and the inner city and an overproduction of specialists. Certain changes in undergraduate and postgraduate medical education have contributed to this maldistribution. There is good evidence that there is an overproduction of surgeons and of medical subspecialists such as cardiologists. Much of the excess subspecialization can be laid at the foot of graduate training programs. The role of the specialty boards in affecting career choices and with them health manpower is analyzed. Some solutions to solve the geographic and specialty maldistribution problems are suggested. It is clear that more primary care physicians including general internists, family physicians, and pediatricians are needed.