Erin P. Fraher

Recent Trends in the Urology Workforce in the United States

The present study examines the current status of urology physician manpower in the United States, in the context of trends in the demographics, geographic distribution, and practice make-up of urologists. Physicians were identified as surgeons and classified into surgical groups using a combination of American Medical Association primary and secondary self-reported specialties and American Board of Medical Specialties certifications. From these groups, urologic surgeons were isolated for analysis. The supply of urologists per capita has declined since 1981 - most dramatically since 1991. With an average age of 52.5 years, urology is one of the oldest surgical specialties. Over 7% of urologists are older than 70 years and 44% are older than 55 years, suggesting an aging urology workforce. The number of female urologists has grown almost a 1000-fold and represents a growing and younger cohort of the workforce. The number of rural urologists and the number of international medical graduates have continued to decline since 1981. Over the past 10 years, an increasing number of urologists are now in group practices (over 60%), and these tended to be younger and in urban settings. In contrast to most other surgical specialties, there has been a decrease in the supply of urologists relative to population growth, which is expected to be exacerbated by an aging and relatively older urology physician workforce, particularly in rural areas, a slight increase in female urologists, and the gravitation of younger urologists toward group practice in urban areas.

Projecting surgeon supply using a dynamic model.

Objective:To develop a projection model to forecast the head count and full-time equivalent supply of surgeons by age, sex, and specialty in the United States from 2009 to 2028. Summary Background Data:The search for the optimal number and specialty mix of surgeons to care for the United States population has taken on increased urgency under health care reform. Expanded insurance coverage and an aging population will increase demand for surgical and other medical services. Accurate forecasts of surgical service capacity are crucial to inform the federal government, training institutions, professional associations, and others charged with improving access to health care. Methods:The study uses a dynamic stock and flow model that simulates future changes in numbers and specialty type by factoring in changes in surgeon demographics and policy factors. Results:Forecasts show that overall surgeon supply will decrease 18% during the period form 2009 to 2028 with declines in all specialties except colorectal, pediatric, neurological surgery, and vascular surgery. Model simulations suggest that none of the proposed changes to increase graduate medical education currently under consideration will be sufficient to offset declines. Conclusions:The length of time it takes to train surgeons, the anticipated decrease in hours worked by surgeons in younger generations, and the potential decreases in graduate medical education funding suggest that there may be an insufficient surgeon workforce to meet population needs. Existing maldistribution patterns are likely to be exacerbated, leading to delayed or lost access to time-sensitive surgical procedures, particularly in rural areas.

Reconfiguring Health Workforce Policy So That Education, Training, And Actual Delivery Of Care Are Closely Connected

There is growing consensus that the health care workforce in the United States needs to be reconfigured to meet the needs of a health care system that is being rapidly and permanently redesigned. Accountable care organizations and patient-centered medical homes, for instance, will greatly alter the mix of caregivers needed and create new roles for existing health care workers. The focus of health system innovation, however, has largely been on reorganizing care delivery processes, reengineering workflows, and adopting electronic technology to improve outcomes. Little attention has been paid to training workers to adapt to these systems and deliver patient care in ever more coordinated systems, such as integrated health care networks that harmonize primary care with acute inpatient and postacute long-term care. This article highlights how neither regulatory policies nor market forces are keeping up with a rapidly changing delivery system and argues that training and education should be connected more closely to the actual delivery of care.

The Employed Surgeon: A Changing Professional Paradigm

OBJECTIVE To identify trends and characteristics of surgeon employment in the United States. Surgeons are increasingly choosing hospital or large group employment as their practice environment. DESIGN American Medical Association Physician Masterfile data were analyzed for the years 2001 to 2009. SETTING Surgeons identified within the American Medical Association Masterfile. PARTICIPANTS Surgeons were defined using definitions from the American Medical Association specialty data and the American Board of Medical Specialties certification data and included active, nonfederal, and nonresident physicians younger than 80 years of age. MAIN OUTCOME MEASURES Employment status and trends. RESULTS The number of surgeons who reported having their own self-employed practice decreased from 48% to 33% between 2001 and 2009, and this decrease corresponded with an increase in the number of employed surgeons. Sixty-eight percent of surgeons in the United States now self-identify their practice environment as employed. Between 2006 and 2011, there was a 32% increase in the number of surgeon in a full-time hospital employment arrangement. Younger surgeons and female surgeons increasingly favor employment in large group practices. Employment trends were similar for both urban and rural practices. CONCLUSIONS General surgeons and surgical subspecialists are choosing hospital employment instead of independent practice. The trend is especially notable among younger surgeons and among female surgeons. The trend denotes a professional paradigm shift of major importance.

Characteristics of Practice Among Rural and Urban General Surgeons in North Carolina

Objective:To examine variation in the practice patterns of individual general surgeons and how they differ between rural and urban areas of North Carolina. Summary of Background Data:Traditional physician supply analyses often rely on “head counts” and do not take into account how physicians’ practice patterns differ. Practice characteristics including the volume and the breadth of services that a physician provides may be especially important in understanding the supply and distribution of specialists, such as general surgeons. Methods:Cross-sectional study using physician licensure data linked with administrative records on all inpatient hospital discharges and all surgeries performed at freestanding ambulatory surgery centers in North Carolina in 2004. Results:Total procedure volumes varied widely (interquartile range: 356–700). The average general surgeon in a rural county performed 54 different procedures at least once during the year, compared to 59 in counties with small urban areas and 62 in metropolitan counties. The 10 procedures that a general surgeon performed most frequently accounted for 72% of that surgeons total annual procedures in rural counties, 67% in counties with small urban areas, and 66% in metropolitan counties. These rural metropolitan differences were smaller after controlling for secondary specialty and other surgeon characteristics. Conclusions:There was significant variation in the volume and scope of procedures that North Carolina general surgeons performed in the year. Many general surgeons in metropolitan areas performed an array of procedures that was broader than those in rural areas.

Physical Therapy Health Human Resource Ratios: A Comparative Analysis of the United States and Canada

Background and Purpose: Health human resource (HHR) ratios are a measure of workforce supply and are expressed as a ratio of the number of health care practitioners to a subset of the population. Health human resource ratios for physical therapists have been described for Canada but have not been fully described for the United States. In this study, HHR ratios for physical therapists across the United States were estimated in order to conduct a comparative analysis of the United States and Canada. Methods: National US Census Bureau data were linked to jurisdictional estimates of registered physical therapists to create HHR ratios at 3 time points: 1995, 1999, and 2005. These results then were compared with the results of a similar study conducted by the same authors in Canada. Results: The national HHR ratio across the United States in 1995 was 3.8 per 10,000 people; the ratio increased to 4.3 in 1999 and then to 6.2 in 2005. The aggregated results indicated that HHR ratios across the United States increased by 61.3% between 1995 and 2005. In contrast, the rate of evolution of HHR ratios in Canada was lower, with an estimated growth of 11.6% between 1991 and 2005. Although there were wide variations across jurisdictions, the data indicated that HHR ratios across the United States increased more rapidly than overall population growth in 49 of 51 jurisdictions (96.1%). In contrast, in Canada, the increase in HHR ratios surpassed population growth in only 7 of 10 jurisdictions (70.0%). Discussion and Conclusion: Despite their close proximity, there are differences between the United States and Canada in overall population and HHR ratio growth rates. Possible reasons for these differences and the policy implications of the findings of this study are explored in the context of forecasted growth in demand for health care and rehabilitation services.

How Many Nurse Practitioners Provide Primary Care? It Depends On How You Count Them

This study compares different approaches to measuring the number of nurse practitioners (NPs) providing primary care services using data from the 2012 U.S. National Sample Survey of Nurse Practitioners, North Carolina licensing data from 2011, and a 2010 California survey of nurse practitioners and nurse midwives. Estimates of the number and share of NPs providing primary care depend on how one defines primary care. If the definition is based on the field of NP education, the estimated shares in primary care specialties are 83.5% in North Carolina and 90.7% in California; if the definition is based on current or past fields of certification, the estimated shares are 79.9% in North Carolina and 74.5% nationally. The estimated number is even smaller if one considers employment setting (58.4% in North Carolina, 66.8% in California, and 67.8% nationally), and shrinks to about half of NPs if focusing on current field of clinical specialization.

The contribution of "plasticity" to modeling how a community's need for health care services can be met by different configurations of physicians.

This article introduces the concept of “plasticity” to health care workforce modeling and policy analysis. The authors define plasticity as the notion that individual physicians within the same specialty each provide a different scope of service, while the scope of service of physicians in different specialties may overlap. This notion represents a departure from the current, silo-based conception of physician supply as physician headcounts by specialty; the implication is that multiple configurations of physicians (and, by further application, other health care professionals) can meet a community’s utilization of health care services. Within-specialty plasticity and between-specialty plasticity are two facets of plasticity. Within-specialty plasticity is the idea that individual physicians within the same specialty may each provide a different mix and scope of services, and between-specialty plasticity is the idea that patterns of service provision overlap across specialties. Changes in physician specialty supply in a community affect both the between-specialty and within-specialty plasticity of that community’s physicians. Notably, some physician specialties are more “plastic” than others. The authors demonstrate how to implement a plasticity matrix by assessing the sufficiency of physician supply in a specific community (Wayne County, North Carolina). Additional literature and data can provide further insights into the influences on (and of) plasticity, improving this approach and expanding it to include task-shifting across health care professions.

Future Supply of Pediatric Surgeons: Analytical Study of the Current and Projected Supply of Pediatric Surgeons in the Context of a Rapidly Changing Process for Specialty and Subspecialty Training

Objective: To describe the future supply and demand for pediatric surgeons using a physician supply model to determine what the future supply of pediatric surgeons will be over the next decade and a half and to compare that projected supply with potential indicators of demand and the growth of other subspecialties. Background: Anticipating the supply of physicians and surgeons in the future has met with varying levels of success. However, there remains a need to anticipate supply given the rapid growth of specialty and subspecialty fellowships. This analysis is intended to support decision making on the size of future fellowships in pediatric surgery. Methods: The model used in the study is an adaptation of the FutureDocs physician supply and need tool developed to anticipate future supply and need for all physician specialties. Data from national inventories of physicians by specialty, age, sex, activity, and location are combined with data from residency and fellowship programs and accrediting bodies in an agent-based or microsimulation projection model that considers movement into and among specialties. Exits from practice and the geographic distribution of physician and the patient population are also included in the model. Three scenarios for the annual entry into pediatric surgery fellowships (28, 34, and 56) are modeled and their effects on supply through 2030 are presented. Results: The FutureDocs model predicts a very rapid growth of the supply of surgeons who treat pediatric patients—including general pediatric surgeon and focused subspecialties. The supply of all pediatric surgeons will grow relatively rapidly through 2030 under current conditions. That growth is much faster than the rate of growth of the pediatric population. The volume of complex surgical cases will likely match this population growth rate meaning there will be many more surgeons trained for those procedures. The current entry rate into pediatric surgery fellowships (34 per year) will result in a slowing of growth after 2025, a rate of 56 will generate a continued growth through 2030 with a likely plateau after 2035. Conclusions: The rate of entry into pediatric surgery will continue to exceed population growth through 2030 under two likely scenarios. The very rapid anticipated growth in focused pediatric subspecialties will likely prove challenging to surgeons wishing to maintain their skills with complex cases as a larger and more diverse group of surgeons will also seek to care for many of the conditions and patients which the general pediatric surgeons and general surgeons now see. This means controlling the numbers of pediatric surgery fellowships in a way that recognizes problems with distribution, the volume of cases available to maintain proficiency, and the dynamics of retirement and shifts into other specialty practice.

Area Health Education Centers: strengths, challenges, and implications for Academic Health Science Center leaders.

Drawing from the results of an empirical study, we discuss the strengths and challenges of Area Health Education Centers in three domains-mission, programs, and organization--and highlight their implications for Academic Health Science Center leaders.