"The results of this study give us a roadmap for the future of children's health care and the role the pediatrician will play in that care," said Scott A. Shipman, M.D., M.P.H., principal investigator, assistant professor of pediatrics in the Oregon Health & Science University School of Medicine. "We need to act now so this increase in pediatricians can be leveraged to benefit our children, not harm our health care system."
In the 1980s some experts predicted there would be a surplus of physicians by the year 2000. In the 1990s many professional health care organizations concluded there would be an oversupply of subspecialists, but perhaps too few primary care physicians, including pediatricians. More recently, waning interest in primary care specialties by U.S. medical students has heightened fears of an impending shortage of these physicians. This study questions this belief, at least for physicians who specialize in caring for the nation's children. The study uses a novel approach to projecting the work force, allowing researchers to model the impact of various influences on the physician supply.
Shipman and colleagues used the current number of working pediatricians and the child population in 2000 as the baseline for comparison. They then created a statistical model that looked at several factors that may contribute to the change in the pediatric work force:
- Current supply of pediatricians
- Age and gender of new pediatricians entering the work force
- New pediatricians from foreign countries who trained in the United States
- Population of the United States
- Changing work styles (full-time versus part-time)
- Deaths of and retirement ages for pediatricians
- Market share (number of children that may choose to see primary care providers other than pediatricians)
The American Academy of Pediatrics concluded in 1998 that the total supply of pediatricians in the nation was adequate to meet the needs of the population. Today, there is approximately one pediatrician for every 2,040 children in the U.S. population. By 2020 this model predicts there will be one pediatrician for every 1,400 children. Shipman's study found that the experience in pediatrics differs greatly from other primary care specialties, including family medicine and internal medicine, which are projected to begin a decline during the next 20 years relative to the growth in the populations they serve. According to researchers, the expanding elderly population is the driving force behind this disparity.
One of the demographic impacts researchers considered was the changing age and gender of pediatricians. The average age of pediatricians is increasing as is the number of female pediatricians (more than 65 percent of pediatric residents are women). Older physicians and female physicians tend to work fewer hours to accommodate changing lifestyle priorities. But this trend did not significantly impact the study's conclusions.
Even education appears not to have much of impact. The study found that even if there were a 50 percent decrease in students entering pediatrics training or pediatric residents selecting careers in general pediatrics; the pediatrician work force could nearly maintain its current size relative to the child population for the next 20 years.
A change in care providers or market share didn't make much of a difference either. Based on the model used, if all children ages 0 to 19 years were to switch their care from family physicians to pediatricians so that pediatricians treated all children in the United States, there would still be more of these specialists in practice than necessary to maintain today's pediatrician-to-child ratio.
What this study's model doesn't consider is the significant variation in access to pediatricians across different regions of the United States, or the impact of racial and ethnic variations in the pediatrician work force. Currently, there are three times as many pediatricians in some parts of the United States than in others.
"We need to find incentives that will motivate pediatricians to provide care in parts of our country that continue to lack access despite the growing work force. The past 30 years have shown that producing more physicians as an end in itself will not achieve this goal," said Shipman, who is also a pediatrician at OHSU Doernbecher Children's Hospital. "Inequities in health care won't be solved simply by having more doctors, but will require an alignment of training and incentives that target needed improvements in access and quality of care."
Another way the researchers suggest that this work force could benefit the community is by shifting the roles of some pediatricians toward advocacy in education, politics and/or public health. "The potential for redefining the traditional role of the general pediatrician to better serve the needs of children is exciting. The projected growth in the work force may open up new opportunities for pediatricians to extend their reach," said Shipman.
To maintain their workload and income, however, the researchers said pediatricians may be forced to change the way they practice medicine by providing more medical services to fewer children in their care; expanding their patient population to include more young adults or attracting a greater number of children who are currently seeing non-pediatricians. Such changes could invite competition and induce demand for unnecessary services that could drive up health care costs without improving the health of children. Additionally, medical training will need to evolve to prepare future pediatricians for the many changes they may encounter in their practices.
Shipman collaborated on this study with colleagues Jon D. Lurie, M.D, M.S., assistant professor of internal medicine and David C. Goodman, M.D., M.S., associate professor of pediatrics, both at the Center for the Evaluative Clinical Sciences at Dartmouth Medical School, Hanover, N.H..
OHSU is Oregon's only health and research university. OHSU includes four schools, two hospitals, numerous primary and specialty care clinics, multiple research centers and institutes and dozens of outreach programs. The OHSU School of Medicine is ranked second in the nation among American medical schools for its primary care education program for the eighth consecutive year as reported in U.S. News & World Report . OHSU's fundamental purpose is to improve the well-being of people in Oregon and beyond.
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