Ethan Alexander Jewett

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.

Pediatric Residency Duty Hours Before and After Limitations

OBJECTIVES. The goals were to examine pediatric resident and program director experiences implementing the Accreditation Council for Graduate Medical Education work hour limits and to compare duty hours, moonlighting, and fatigue before and after the limits became effective. METHODS. National random samples of 500 pediatric residents who graduated in 2002 and in 2004 were surveyed to compare resident duty hours and fatigue before and after the Accreditation Council for Graduate Medical Education limits were implemented. In addition, all US pediatric residency program directors were surveyed at the end of the 2003/2004 academic year, to provide a complementary retrospective examination of limit implementation. RESULTS. Totals of 65%, 61%, and 83% of 2002 residents, 2004 residents, and program directors, respectively, responded. The proportion of residents who reported working >80 hours per week declined from 49% for NICU/PICU rotations before the limits to 18% after limit implementation. Resident well-being was the factor identified most often by both residents and program directors as being improved since the limitations. Multivariate modeling also showed reductions in the proportions of residents who reported falling asleep while driving from work or making errors in patient care because of fatigue. Overall, 89% of pediatric residents and program directors reported that the current system is effective in ensuring appropriate working hours. CONCLUSIONS. Since the Accreditation Council for Graduate Medical Education duty hour limits went into effect, pediatric residents report working fewer hours and making fewer patient care errors because of fatigue. Although room for additional improvement remains, the experiences of residents and program directors suggest that implementation of the Accreditation Council for Graduate Medical Education limits in pediatric residency programs is improving resident well-being.

The practice of clinical genetics: a survey of practitioners.

Purpose: A survey of clinical geneticists was undertaken to learn more about current practice.Methods: An attempt was made to survey all geneticists practicing in the United States to elicit information on a variety of issues.Results: A total of 69% of geneticists responded. Most practice at a medical school, most receive a portion of their income from salary, and many receive personal financial support from research grants.Conclusion: The specialty of medical genetics is primarily housed in tertiary care settings. Although a substantial amount of time is required to see patients, reimbursement for these services does not cover the costs to maintain such practices.

A comparison of pediatric emergency medicine and general emergency medicine physicians' practice patterns: results from the Future of Pediatric Education II Survey of Sections Project.

Background This survey was conducted to obtain information about career and practice issues facing pediatric emergency medicine (PEM) physicians and general emergency medicine (GEM) physicians. We hypothesized that PEM physicians work fewer clinical hours and perform more teaching and research in their positions than GEM physicians. Methods Two surveys sponsored by the Future of Pediatric Education II Project were sent to 1545 emergency physicians identified by the American Board of Pediatrics, the American Academy of Pediatrics, and the American College of Emergency Physicians between October 1997 and February 1998. Data on demographics, job description, recent job changes, and career expectations were obtained and analyzed using Student t test or Welch analysis of variance for continuous variables and χ2 for categorical data. P values less than 0.05 were considered significant. Comparisons between PEM and GEM physicians were adjusted using analysis of covariance to control for the effect of medical school affiliation. Results Effective response rate was 934 (64%) of 1451. A total of 705 (75%) respondents identified themselves as a PEM physician, and 229 (25%) identified as a GEM physician. PEM physicians were younger (41.0 y vs 45.1 y) and more likely to be women (44% vs 15%, P < 0.0001 for both). Children younger than 18 years made up 80.9% and 28.6% of patients seen by PEM and GEM physicians, respectively (P < 0.001). Seventy-nine percent of PEM physicians and 42% of GEM physicians held an academic appointment (P < 0.0001). No differences were found for full-time equivalents per physician group (9.7 vs 9.1) or clinical hours spent in the emergency department (ED) (31.5 vs 32.7) when means were adjusted for academic appointment. During ED clinical activities, PEM physicians reported more time spent supervising trainees (34% vs 16%, P < 0.0001), and GEM physicians reported more time spent in direct patient care (77% vs 57%, P < 0.0001). Total clinical hours worked per week were greater for GEM physicians (37.9 vs 35.3, P < 0.05). PEM physicians spent more time than GEM physicians teaching (12% vs 8%, P < 0.005) and conducting clinical research (5% vs 2%, P < 0.0003). Of PEM and GEM physicians combined, 26% reported a job change in the past 3 years. Extended reduction of ED clinical duties occurred most commonly because of child care issues and was reported more commonly by women than men (53% vs 6%, P < 0.0001) irrespective of PEM or GEM practice. The likelihood of leaving emergency medicine practice within 5 years increased with age for both groups: 10% of PEM and GEM physicians under 40 years old anticipated leaving practice versus 30% of those older than 50 years (P < 0.0001). PEM physicians were more likely than GEM physicians to predict an increased need for additional pediatric subspecialists in general (60% vs 26%, P < 0.001) and for pediatric subspecialists in their discipline (54% vs 17%, P < 0.001). PEM subspecialists were twice as likely as GEM specialists to perceive competition in their subspecialty (60% vs 31%, P < 0.001). Conclusions According to our sample, GEM and PEM physicians worked the same number of clinical hours in the ED but reported significant differences in how those hours are spent. Job changes and extended leaves were common in both groups. These results suggest that PEM and GEM physicians face similar vocational challenges, especially in the areas of balancing of family time, clinical hours, and academic productivity. These data also have important implications for workforce projection for the PEM physician supply, given the current estimated attrition rate, frequency of leave from clinical duties, and projection for increased need for PEM physicians in the future.

developmental and Behavioral Pediatric Practice Patterns and Implications for the Workforce: Results of the Future of Pediatric Education Ii Survey of Sections Project

&NA; A survey of developmental‐behavioral pediatricians was conducted to obtain data and insights on their current practice. As part of the Future of Pediatric Education (FOPE) II Survey of Sections Project, questionnaires were sent to individuals who were most likely to represent those pediatricians engaged in the subspecialty of developmental‐behavioral pediatrics. Four groups of physicians were compared within the survey: developmental‐behavioral fellowship group (n = 272), developmental disabilities fellowship group (n = 139), general academic pediatrics or other fellowship group (n = 57), and a nonfellowship group (n = 224). A majority of respondents indicated a need for an increased number of subspecialists in developmental‐behavioral pediatrics in their community during the next 3 to 5 years. There were significant differences in the survey results of a variety of practice issues between those who had and had not received formal fellowship training. The survey data illustrate a developmental‐behavioral pediatrician workforce that is becoming increasingly fellowship trained, receiving more referrals, and encountering constraints to seeing more patients in an era of declining reimbursement for services. To overcome these obstacles, stakeholders in child health, including health care payers, will need to be educated about the unique skills and clinical expertise of physicians in developmental‐behavioral pediatrics and neurodevelopmental disabilities. J Dev Behav Pediatr 24:180‐188, 2003. Index terms: workforce, developmental‐behavioral pediatrics, neurodevelopmental disabilities, practice.

A national survey of 'inactive' physicians in the United States of America: enticements to reentry

BackgroundPhysicians leaving and reentering clinical practice can have significant medical workforce implications. We surveyed inactive physicians younger than typical retirement age to determine their reasons for clinical inactivity and what barriers, real or perceived, there were to reentry into the medical workforce.MethodsA random sample of 4975 inactive physicians aged under 65 years was drawn from the Physician Masterfile of the American Medical Association in 2008. Physicians were mailed a survey about activity in medicine and perceived barriers to reentry. Chi-square statistics were used for significance tests of the association between categorical variables and t-tests were used to test differences between means.ResultsOur adjusted response rate was 36.1%. Respondents were fully retired (37.5%), not currently active in medicine (43.0%) or now active (reentered, 19.4%). Nearly half (49.5%) were in or had practiced primary care. Personal health was the top reason for leaving for fully retired physicians (37.8%) or those not currently active in medicine (37.8%) and the second highest reason for physicians who had reentered (28.8%). For reentered (47.8%) and inactive (51.5%) physicians, the primary reason for returning or considering returning to practice was the availability of part-time work or flexible scheduling. Retired and currently inactive physicians used similar strategies to explore reentry, and 83% of both groups thought it would be difficult; among those who had reentered practice, 35.9% reported it was difficult to reenter. Retraining was uncommon for this group (37.5%).ConclusionAvailability of part-time work and flexible scheduling have a strong influence on decisions to leave or reenter clinical practice. Lack of retraining before reentry raises questions about patient safety and the clinical competence of reentered physicians.

Practice of pediatric critical care medicine: results of the Future of Pediatric Education II survey of sections project.

Objective To summarize the demographics and practice patterns of the current pediatric critical care workforce and to identify the key workforce issues that may affect the delivery of pediatric critical care services in the future. Design A questionnaire designed to analyze current pediatric critical care workforce demographics and future workforce trends. Subjects Pediatric critical care physicians from the United States were identified from the American Academy of Pediatrics Critical Care Section, from a list of physicians certified in pediatric critical care medicine (PCCM) by the American Board of Pediatrics, and from a list of pediatrician members of the Society for Critical Care Medicine. Interventions None. Measurements PCCM physicians were polled regarding board certification, practice characteristics, professional activities, referral patterns, patient profiles, competition, job satisfaction, and projected retirement age. Main Results A total of 805 PCCM physicians completed the survey. When grouped by age, 40% of the responding PCCM physicians were younger than 40 yrs, 49% were 40 to 49 yrs old, and only 11% were 50 yrs of age or older. The younger group had a higher percentage of female pediatricians than the older groups. For all age groups, the largest proportion of time was devoted to direct patient care time in pediatric critical care. This was especially true for the youngest age group that had the largest amount of patient care time devoted to critical care (43%). Time devoted to research was also significantly higher for the younger age group, although very few respondents reported that they have >50% of their time protected for research. For all age groups, those reporting increases in referral volume and referral complexity over the previous 12 months far outnumbered those reporting decreases. The majority of respondents reported being satisfied with their career choice. In general, respondents were more likely to report that too many rather than too few PCCM physicians were currently being trained. Approximately one third of respondents (34%) planned on leaving the field of critical care medicine before retiring from medicine completely. Conclusions PCCM physicians were increasingly women and working for >65 hrs/wk, with a good level of job satisfaction. Competition from a variety of sources seems to affect the work of PCCM physicians. The relatively small percentage of time devoted to research, however, is a finding of great concern.

New workforce, practice, and payment reforms essential for improving access to pediatric subspecialty care within the medical home

T HE AVAILABILITY OF pediatric subspecialty care is critically important to the heal th and wel l being of infants, children, and adolescents. Moreover, timely collaboration with pediatric subspecialists is an essential element of the standard of care for children: the community-based medical home. The medical home model of care, with a generalist physician as the leader, has been shown to produce considerable economic and patient-level benefits. In this model, primary care practice teams coordinate all care for a patient, including subspecialty care. Unfortunately, lack of access to pediatric subspecialty care within the medical home has reached crisis proportions in the United States owing to several interrelated factors: an insufficient number of pediatric subspecialists, dramatically increasing demand for pediatric subspecialty care, a fragmented system of pediatric primary and specialty care, and inadequate f inancing of medical education and collaborative primary and specialty pediatric care through the medical home. In the United States, approximately 28 000 medical and surgical pediatric subspecialists serve 80 million children and youth. The ratio of board-certified pediatric subspecialists to children in each of the 31 specialties is hazardously low. Although the number of pediatric subspecialists has increased in the last decade, far too few physicians are being trained in nearly every pediatric subspecialty. For example, the American Board of Pediatrics reports that in 2007 there were only 19 first-year fellows in developmental behavioral pediatrics, 24 in adolescent medicine, and 26 in pediatric rheumatology. Compounding the pipeline problems are increasing retention difficulties, a growing retirement rate, the tendency of younger physicians to limit their hours of practice, and the overall shortage of physicians. Furthermore, as the elderly population grows, the availability of adult specialists, many of whom care for children in areas where pediatric subspecialists are unavailable, is eroding. In addition to the problem of a shrinking workforce, demand for pediatric subspecialty care has reached unprecedented levels. During the last few decades, the incidence and prevalence of certain chronic conditions, such as attention-deficit/ hyperactivity disorder, asthma, depression, and obesity, have dramatically increased. Furthermore, the survival of infants and children with complex, formerly fatal conditions has become commonplace. Advances in medical and surgical care, technology, and drugs have clearly created new benefits and stresses on our pediatric care delivery systems. Changes in families’ knowledge and preferences for referral to specialty care are resulting in higher rates of referrals to pediatric subspecialists. Also affecting higher rates of specialty referral is the lack of adequate primary care capacity, resulting in a reduced amount of time that physicians can devote to identifying and managing chronic conditions. Underlying these obvious supplyand-demand problems is the worsening fragmentation between primary and specialty pediatric care. Despite the supporting evidence, resources to enable primary care practices to provide this level of care are not generally available. Lack of recognition of the importance of the medical home as the base of care coordination from the standpoint of reimbursement along with the absence of organized and efficient systems for referral, consultation, and collaborative care at the community and regional levels result in worsening fragmentation. Fragmentation is also aggravated by the uneven geographic distribution of pediatric subspecialists, the everchanging insurance and health plan enrollment of families, and the shifting composition of plans’ provider networks. Inadequate financing of graduate medical education and the lack of financing for continuing medical education for primary care providers further compromises access to pediatric subspecialty care within the medical home. Because payment for graduate medical education is a function, in part, of the percent of inpatient days attributable to caring for Medicare patients, hospitals serving children are at a distinct disadvantage. While a separate graduate medical education program operates for children’s hospitals, it is subject to low annual appropriations. In addition, the graduate medical education program is structured to discourage subspecialty training in favor of primary care training by counting fellows in subspecialty training at lower levels than resident physicians in their initial specialty training. Moreover, no funding sources are available to support primary care providers who are interested in pursuing additional specialized training. Equally significant is inadequate third-party payment. Between one-third to one-half of all children (depending on their age) are insured by Medicaid or the State Children’s Health Insurance Program, and children with special

Financing graduate medical education to meet the needs of children and the future pediatrician workforce

This policy statement articulates the positions of the American Academy of Pediatrics on graduate medical education and the associated costs and funding mechanisms. It reaffirms the policy of the American Academy of Pediatrics that graduate medical education is a public good and is an essential part of maintaining a high-quality physician workforce. The American Academy of Pediatrics advocates for lifelong learning across the continuum of medical education. This policy statement focuses on the financing of one component of this continuum, namely residency education. The statement calls on federal and state governments to continue their support of residency education and advocates for stable means of funding such as the establishment of an all-payer graduate medical education trust fund. It further proposes a portable authorization system that would allocate graduate medical education funds for direct medical education costs to accredited residency programs on the basis of the selection of the program by qualified student or residents. This system allows the funding to follow the residents to their program. Recognizing the critical workforce needs of many pediatric medical subspecialties, pediatric surgical specialties, and other pediatric specialty disciplines, this statement maintains that subspecialty fellowship training and general pediatrics research fellowship training should receive adequate support from the graduate medical education financing system, including funding from the National Institutes of Health and other federal agencies, as appropriate. Furthermore, residency education that is provided in freestanding childrens hospitals should receive a level of support equivalent to that of other teaching hospitals. The financing of graduate medical education is an important and effective tool to ensure that the future pediatrician workforce can provide optimal heath care for infants, children, adolescents, and young adults.