Subspecialty Workforce Research Articles

Noncompletion in Pediatric Rheumatology Fellowships

One challenge facing the health care workforce is a paucity of pediatrics subspecialists. No prior studies have investigated fellowship noncompletion as an influence of the subspecialty workforce. We sought to determine the noncompletion rate for pediatric rheumatology fellowships and to identify demographic characteristics associated with noncompletion. A retrospective cohort study of all trainees entering US pediatric rheumatology fellowship programs between 1997 and 2007 was performed. American Board of Pediatrics tracking data were used to determine completion status (completer or noncompleter) for each trainee. Completers were compared with noncompleters, using the independent variables sex, medical school location, and age. The noncompletion rate was calculated overall and individually. Program size was examined as a predictor of nonompletion rate. Data analysis used χ(2) tests, Kruskal-Wallis tests, and Spearman correlation. The cohort included 182 trainees from 28 pediatric rheumatology fellowship programs. Program size ranged from 1 to 18 trainees. The overall noncompletion rate was 16%. Male fellows, especially male international medical graduates, were more likely to be noncompleters. Noncompletion rates varied among programs: 15 programs had noncompletion rates of 0% and 4 programs had noncompletion rates of 50% or higher. Program size was not associated with noncompletion rate. During the study period, 1 of 6 pediatric rheumatology fellows did not complete training. Noncompletion was concentrated in a small number of programs. Further research should investigate noncompletion across specialties, identifying the causes of noncompletion at the individual, program, and specialty levels to inform future interventions to improve fellowship completion.

Variability of the Pediatric Subspecialty Workforce in Canada

To assess the regional variability of the pediatric subspecialty workforce in the academic health science centers in Canada, because effective and efficient delivery of specialized pediatric health care depends on the pediatrician workforce. This was an analysis of the pediatric subspecialty workforce database of the Pediatric Chairs of Canada for the surveys obtained between 2003/04 and 2005/06. In 2003/2004, 960 pediatrician specialists who spent a majority of their time supporting clinical, educational, research, and administrative activities within the 16 Canadian medical schools were reported. In 2004/05, this figure was 1044, and in 2005/06, it was 1140. The growth was due predominantly to increases in physician workforce in the fields of emergency medicine, respiratory medicine, and neonatology. The average academic pediatric workforce, excluding general pediatricians, increased from 12.86/100 000 child population in 2003/04 to 13.99 in 2004/05 and 15.27 in 2005/06. Substantial regional variability exists, with 4-fold differences in academic pediatrician workforce among the low-supply provinces (Saskatchewan, British Columbia, and Ontario) and high-supply provinces for both total workforce and subspecialists. The substantial variability in the supply of pediatric subspecialists across Canada requires additional analysis to determine any relationship to child health outcomes.

Primary Care Pediatricians' Satisfaction with Subspecialty Care, Perceived Supply, and Barriers to Care

To compare satisfaction with specialty care by primary care pediatricians (PCPs), perceived barriers to care, and adequacy of specialist supply. A survey of U.S. pediatricians was conducted in 2007. PCPs were asked about satisfaction with specialty care for their patients, as well as supply of specific pediatric subspecialists. Responses of rural and nonrural PCPs were compared regarding 10 potential barriers to care. Most PCPs are satisfied with the quality of subspecialty care. However, they were not satisfied with wait times for appointments, and the availability of many pediatric medical subspecialties and several pediatric surgical specialties. Rural PCPs were significantly more likely to report these shortages compared with nonrural pediatricians; these included 9 of the 18 medical and 5 of the 7 surgical specialties. In addition to wait times for appointments, PCPs reported that subspecialists' nonparticipation in health insurance plans and lack of acceptance of uninsured patients were also barriers to obtaining subspecialty care for their patients. PCPs provide valuable insight into access to the pediatric subspecialty workforce. This survey of PCPs raises significant concerns about the adequacy of children's access to pediatric subspecialists, especially in rural communities.

The Changing Composition of the Pediatric Medical Subspecialty Work-force

The Changing Composition of the Pediatric Medical Subspecialty Work-force

The Pediatric Subspecialty Workforce: Time to Test Our Assumptions

Over 20 years ago, my experiences as a rural National Health Service Corps physician challenged my assumptions that nearby pediatric care was of primary importance to parents. About halfway through my first year of practice, I was surprised to realize that many families continued to drive as long as 90 minutes to be seen by a family practitioner or an exceedingly busy pediatrician—this despite my Johns Hopkins training and wide-open practice. At the time, I ignored the contradiction that my family and I would routinely bypass our small town's grocery store and travel the extra hour to a slightly larger emporium that sold Pepperidge Farm cookies and Thomas' English Muffins, which were considered luxury foods in the northern tip of New Hampshire. Geography may be important in rural areas, but it is not destiny. In this issue of Pediatrics , Mayer1 provides a vivid and detailed description of the geographic availability of pediatric subspecialists. The limited supply of these physicians can vex families, primary care physicians, children's hospitals, and medical schools. This is a long-standing problem,2 with a recent heightened level of concern.3 Despite efforts over 4 decades to address the overall shortage and geographic disparities, the goal of reducing supply barriers to children's subspecialty care remains a mirage on the horizon; we keep on walking but never seem to get closer. Perhaps this is because of the assumptions that we hold close to our professional hearts. For example, my experience as a rural pediatrician revealed that the “cost” and perception of travel and quality vary by parents. Assuming that closer medical care is always better can bind us to policy goals that are difficult, perhaps impossible, to achieve. What other assumptions do we make about the pediatric subspecialty workforce? I will review some of the assumptions … Address correspondence to David C. Goodman, MD, MS, Dartmouth Medical School, Department of Pediatrics, Center for Evaluative Clinical Sciences, 7251 Strasenburgh Hall, Hanover, NH 03755. E-mail: david.goodman{at}dartmouth.edu

The Pediatric Subspecialty Workforce: Public Policy and Forces for Change

Policy has not adequately addressed the unique circumstances of pediatric subspecialties, many of which are facing workforce shortages. Pediatric subspecialties, which we define to include all medical and surgical subspecialties, are discrete disciplines that differ significantly from each other and from adult medicine subspecialties. Concerns about a current shortage of pediatric subspecialists overall are driven by indicators ranging from recruitment difficulties to long wait times for appointments. The future supply of pediatric subspecialists and patient access to pediatric subspecialty care will be affected by a number of key factors or forces for change. We discuss 5 of these factors: changing physician and patient demographics; debt load and lifestyle considerations; competition among providers of subspecialty care; equitable reimbursement for subspecialty services; and policy to regulate physician supply. We also identify issues and strategies that medical and specialty societies, pediatric subspecialists, researchers, child advocates, policy makers, and others should consider in the development of subspecialty-specific workforce-policy agendas.

The Changing Composition of the Pediatric Medical Subspecialty Workforce

To characterize the composition of the pediatric subspecialty workforce in terms of the distribution of women and international medical graduates (IMGs) across pediatric medical subspecialties and to determine whether the proportions of board-certified pediatric subspecialists who are women or IMGs differ between graduation cohorts. We used board certification data from the American Board of Pediatrics. Within each pediatric subspecialty, we classified physicians into 2 groups, ie, recent graduates, defined as those who completed medical school after January 1, 1987, and nonrecent graduates, who completed medical school before that date. We calculated the percentage of female physicians for each subspecialty and computed 95% confidence intervals around those estimates to identify male-dominated subspecialties. Using Pearson chi2 tests, we compared the percentages of women between the 2 graduation cohorts for each subspecialty. Similar calculations were performed for the percentage of IMGs in each subspecialty. Sensitivity analyses were performed with data from the 2002 American Medical Association Physician Masterfile. For 9 of 16 pediatric medical subspecialties studied, the percentages of board-certified women were significantly greater in the recent cohort than in the nonrecent cohort. Subspecialties that remain predominantly male in the recent graduation cohort include cardiology, critical care medicine, gastroenterology, pulmonology, and sports medicine. In contrast, the percentages of board-certified IMGs were significantly lower for 6 of the 16 specialties studied; endocrinology and gastroenterology remain relatively reliant on IMGs. For the majority of pediatric medical subspecialties, concerns that the predominance of women in pediatric training may negatively affect the supply of subspecialists are likely unfounded; however, a small number of procedure-based specialties, as well as sports medicine, continue to rely disproportionately on men. There do not seem to be consistent differences in the role of IMGs across the pediatric medical subspecialties between recent and nonrecent graduates, which may reflect differing tendencies to become certified.

Too Many, Too Few, Too Concentrated?

To summarize recent pediatric subspecialty workforce analyses and to highlight similarities and differences across studies. By using MEDLINE, we conducted a systematic search of the literature published from January 1, 1992, through December 31, 2002. We included research articles and task force reports, and abstracted author, year of publication, specialty, sample size, analytic perspective (eg, physician or academic department), inclusion of data on nonclinical activities, inclusion of an objective measure of demand, and workforce-related conclusions. We identified 41 relevant articles. Physician surveys provided data for most (n = 24) of these studies. Only 8 studies attempted to make future workforce projections; of these 8 studies, 1 explicitly accounted for nonclinical activities in its projections. An additional 16 studies presented data on involvement in nonclinical activities. While some studies suggest that additional pediatric subspecialists are not needed, these studies did not include objective assessments of demand in geographic areas where pediatric subspecialty physicians are not available. Of those studies that took a market perspective and attempted to account for demand, workforce recommendations varied considerably across specialties. We know little about the distribution of the pediatric subspecialty workforce relative to the demand for their services. Given concerns about the adequacy of the pediatric subspecialty workforce, future research should assess the availability of these physicians relative to need for their services and account for nonclinical activities in workforce projections.

The FOPE II Commentary

To the Editor—In a recent issue of Pediatrics, a subspecialty task force of the AAP offered a commentary about the Future of Pediatric Education II (FOPE II) document with regard to pediatric subspecialists. We concur with this committee that organized pediatrics should be concerned with the appropriate training of subspecialty educators, clinicians, and researchers. As recommended in the FOPE II report, there should be an ongoing process for assessing the manner in which subspecialty fellows are trained. We also strongly believe that innovative approaches are necessary for the appropriate methods to train these fellows so that they can achieve clinical skills, teaching techniques, and research training leading to subboard certification. It is noteworthy that 2 members of the FOPE II Task Force have given major addresses at annual Pediatric Academic Society meetings concerning the need for innovation in this process. Both Dr James Stockman, in his 1999 St Geme Award Address, and Dr Thomas Boat, in his 2001 American Pediatric Society Presidential Address, vigorously emphasized the need for flexibility in the education of subspecialists with differing pathways dependent on the ultimate goal of training.It should be recognized that a process is being developed to follow up the FOPE II recommendations. At least 3 specific efforts have already been accomplished. First, a new committee, the Pediatric Education Steering Committee (PESC), has been charged with carrying on the work of FOPE II and its recommendations. This committee, comprised of a representative from each of the 7 organizations that form the Federation of Pediatric Organizations, is choosing a chair. Second, the implementation of the Task Force’s recommendations regarding pediatric subspecialists was undertaken with a meeting of major subspecialty groups in March 2001 in San Diego sponsored by the Federation of Pediatric Organizations and the Association of Medical School Pediatric Department Chairs. This was an exciting meeting, and leaders of many of the pediatric subspecialty groups found areas of common interest. Third, the American Board of Pediatrics has formed a group that is reexamining the training pathways leading to eligibility for subspecialty certification to determine if changes are needed. It is unlikely, however, that certification in general pediatrics and a subspecialty can be accomplished within a 4-year period, as the Pediatrics commentary proposes. The competencies required are too extensive.Many of the issues raised by the AAP subspecialty committee were thoroughly discussed by the FOPE II Task Force and the Future of Pediatric Subspecialists Workgroup and are included in the Final Subspecialty Workgroup Report published in the November 2000 issue of Pediatrics.1 It is noteworthy that the Task Force did not detect the bias against pediatric subspecialists mentioned in the commentary. Moreover, the Task Force agreed that children with complex subspecialty problems should be taken care of by pediatric subspecialists, but until there is an adequate supply, other alternatives had to be considered.Regarding the adequacy of the pediatric subspecialty workforce, the Pediatrics commentary indicates that there are declining numbers of subspecialty trainees. It should be noted, however, that while the percentage of those who have exited residency training who went on to subspecialty fellowship training declined in the mid- to late-1990s, a reversal of this trend has recently been seen. The actual numbers of starting fellows never significantly declined throughout this period and is, in fact, higher now than 10 years ago. Nonetheless, there does appear to be a true shortage of pediatric subspecialists in the workforce, a shortage largely driven by an increase in the demand for clinical care provided by the subspecialist.The Task Force also fully realizes that the needs of other pediatric subspecialty groups, including pediatric subspecialties in other disciplines such as surgery, radiology and psychiatry, must be fully supported to provide appropriate care to chronically and severely ill children and adolescents. Encouraging greater teamwork between subspecialties and generalists does not diminish the support of the subspecialist but, by developing improved systems of care, makes best use of available pediatric subspecialists. It is important to recognize, however, that the need for more pediatric subspecialists to advance medical science and teach should not be put in a zero sum game relationship with the role of generalists and other health care providers. Collaboration among all the stakeholders in the pediatric community is the best way to understand and advocate for the needs of the subspecialty community and the patients they serve. That is the concept behind the formation of the Pediatric Subspecialty Education Committee, which answers to the Federation of Pediatric Organizations. Through this mechanism, all invested parties, such as the Pediatric Subspecialty Committee of the AAP, will have an effective voice.

Providing pediatric subspecialty care: A workforce analysis. AAP Committee on Pediatric Workforce Subcommittee on Subspecialty Workforce.

To provide a snapshot of pediatric subspecialty practice, examine issues pertaining to the subspecialty workforce, and analyze subspecialists' perspective on the health care market. Before the effort of the Future of Pediatric Education II (FOPE II) Project, very little information existed regarding the characteristics of the pediatric subspecialty workforce. This need was addressed through a comprehensive initiative involving cooperation between subspecialty sections of the American Academy of Pediatrics and other specialty societies. Questionnaires were sent to all individuals, identified through exhaustive searches, who practiced in 17 pediatric medical and surgical subspecialty areas in 1997 and 1998. The survey elicited information about education and practice issues, including main practice setting, major professional activity, referrals, perceived competition, and local workforce requirements. The number of respondents used in the analyses ranged from 120 (plastic surgery) to 2034 (neonatology). In total, responses from 10 010 pediatric subspecialists were analyzed. For 13 of the subspecialties, a medical school setting was specified by the largest number of respondents within each subspecialty as their main employment site. Direct patient care was the major professional activity of the majority of respondents in all the subspecialties, with the exception of infectious diseases. Large numbers of subspecialists reported increases in the complexity of referral cases, ranging between 20% (cardiology) and 44% (critical care), with an average of 33% across the entire sample. In all subspecialties, a majority of respondents indicated that they faced competition for services in their area (range: 55%-90%; 71% across the entire sample); yet in none of the subspecialties did a majority report that they had modified their practice as a result of competition. In 15 of the 17 subspecialties, a majority stated that there would be no need in their community over the next 3 to 5 years for additional pediatric subspecialists in their discipline. Across the entire sample, 42% of respondents indicated that they or their employer would not be hiring additional, nonreplacement pediatric subspecialists in their field in the next 3 to 5 years (range: 20%-63%). This survey provides the first comprehensive analysis to date on how market forces are perceived to be affecting physicians in the pediatric subspecialty workforce. The data indicate that pediatric subspecialists in most areas are facing strong competitive pressures in the market, and that the market's ability to support additional subspecialists in many areas may be diminishing.

Subspecialty Work Force Issues

Letters15 May 1995Subspecialty Work Force IssuesLewis G. Sandy and Steven A. SchroederLewis G. SandyFor the Association of Subspecialty Professors, Philadelphia, PA 19104. The Robert Wood Johnson Foundation, Princeton, NJ 08543-2316.Search for more papers by this author and Steven A. SchroederFor the Association of Subspecialty Professors, Philadelphia, PA 19104. The Robert Wood Johnson Foundation, Princeton, NJ 08543-2316.Search for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/0003-4819-122-10-199505150-00026 SectionsAboutFull TextPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail IN RESPONSE:We applaud the Association of Subspecialty Professors' continued commitment to addressing subspecialty work force issues. The Association continues to voice skepticism over existing work force projections and prefers need-based modeling. However, decades of research have been devoted to the study of physician-induced demand [1, 2], highlighting the instability of population “need.” Moreover, the number of physicians required for any population's “need” is sensitive to population and organizational factors, such as service regionalization.Although we agree with the Association that the United States is headed towards an excess of physicians in aggregate, existing projections estimate that the bulk of ...