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Nephrology Manpower: The Supply Side
EDITORIALS
Nephrology Manpower: The Supply Side Emil Paganini, MD, Nathan Levin, MD, and Louis Diamond, MD
A
N EVALUATION of the self-designated supply side of the supply/demand nephrology manpower equation has been undertaken to establish an initial picture of the current status of nephrology manpower, with projections based on certain assumptions. The initial evaluation has been undertaken using existing databases, thus avoiding the collection of new data during this initial phase. It is anticipated that many questions will be raised by the initial evaluation. The intent of this report is to present as much information as possible from existing databases on physician manpower. Given the constraints of existing data, the report succeeds in providing useful information about current trends in the size and composition of the nephrologist population. However, a number of weaknesses have been exposed. These weaknesses, as well as the issues that have been raised in regard to the use of the existing data and the implications for the future, include the following: • the classification of nephrologists in the American Medical Association (AMA) Masterfile is by self-designation (but without new data collection, no more accurate database exists); • the predictive model used has not been fully tested, ie, prior projections have not been confirmed by re-evaluation; • the predictive model is based on assumptions for all of medicine, rather than on actual data for From the Renal Physicians Association (RPA), Washington, DC.
Address reprint requests to Louis Diamond, MD, Medical Director, RPA, 1101 Vermont Ave, NW, Suite 500, Washington, DC 20005-3457. © 1991 by the National Kidney Foundation, Inc. 0272-6386/91/1803-0015$3.00/0
392
nephrology, with specific assumptions crafted for nephrology; • the projection assumptions are based on the most recent NASIMM data available, ie, 1988 to 1989 (no more recent data available); • all data are based on self-designation and projections are not based on certification status; • the number of self-designated nephrologists who have received training is not known; • the input of first-year nephrology fellows in 1988 and separately for 1989 are not available; • the projective model may not take into account the employment status (ie, part-time v fulltime) of the increasing female population; • the real impact of the large number offoreign medical graduates cannot be fully evaluated given the lack of knowledge of their visa and citizenship status, or the changes in immigration requirements for foreign medical graduates; Some of the highlights of the findings include: • 11.8% of renal physicians are women; • foreign medical graduates constitute 25.7% of nephrologists, which is higher than for all physicians (20.2% for all internal medicine subspecialists); • for adult nephrologists, 60% of time is spent in office-based practice and 20% in research; • participation in research at 20% of effort is higher than for all internal medicine subspecialists (17%) and for all physicians (5.5%); • there has been a change in the percent activity in direct patient care, which was 51 % of effort in 1970, to 73% of effort in 1987, with a concomitant erosion of percent effort attributable to nonpatient care, mostly in the research area, from 32% effort in 1970 to 19% effort in 1987; • the geographical distribution of renal physicians is concentrated in the large metropolitan areas in a pattern, similar to general internal
American Journal of Kidney Diseases, Vol XVIII, No 3 (September), 1991: pp 392-393
NEPHROLOGY MANPOWER: THE SUPPLY SIDE
medicine and internal medicine subspecialties, but a little different than for all physicians; • since 1976, there has been a decline in the nephrology fellowship pool (nephrology fellows as a percent of internal medicine fellows decreased from 11% for time frame 1976/1977 to 7.9% in 1987/1988). There appears to be some cause for concern and caution with regard to the distribution of
393
renal physicians, the declining number of physicians entering nephrology training, and the high percentage of foreign medical graduates, all of which render predictions for the future uncertain at best. The changing pattern of activities, with a decline of percent effort directed at research, is an added and additional concern. Further study and evaluation of these supply-side issues are called for.
Nephrology Manpower: The Supply Side Emil Paganini, MD, Nathan Levin, MD, and Louis Diamond, MD
A
N EVALUATION of the self-designated supply side of the supply/demand nephrology manpower equation has been undertaken to establish an initial picture of the current status of nephrology manpower, with projections based on certain assumptions. The initial evaluation has been undertaken using existing databases, thus avoiding the collection of new data during this initial phase. It is anticipated that many questions will be raised by the initial evaluation. The intent of this report is to present as much information as possible from existing databases on physician manpower. Given the constraints of existing data, the report succeeds in providing useful information about current trends in the size and composition of the nephrologist population. However, a number of weaknesses have been exposed. These weaknesses, as well as the issues that have been raised in regard to the use of the existing data and the implications for the future, include the following: • the classification of nephrologists in the American Medical Association (AMA) Masterfile is by self-designation (but without new data collection, no more accurate database exists); • the predictive model used has not been fully tested, ie, prior projections have not been confirmed by re-evaluation; • the predictive model is based on assumptions for all of medicine, rather than on actual data for From the Renal Physicians Association (RPA), Washington, DC.
Address reprint requests to Louis Diamond, MD, Medical Director, RPA, 1101 Vermont Ave, NW, Suite 500, Washington, DC 20005-3457. © 1991 by the National Kidney Foundation, Inc. 0272-6386/91/1803-0015$3.00/0
392
nephrology, with specific assumptions crafted for nephrology; • the projection assumptions are based on the most recent NASIMM data available, ie, 1988 to 1989 (no more recent data available); • all data are based on self-designation and projections are not based on certification status; • the number of self-designated nephrologists who have received training is not known; • the input of first-year nephrology fellows in 1988 and separately for 1989 are not available; • the projective model may not take into account the employment status (ie, part-time v fulltime) of the increasing female population; • the real impact of the large number offoreign medical graduates cannot be fully evaluated given the lack of knowledge of their visa and citizenship status, or the changes in immigration requirements for foreign medical graduates; Some of the highlights of the findings include: • 11.8% of renal physicians are women; • foreign medical graduates constitute 25.7% of nephrologists, which is higher than for all physicians (20.2% for all internal medicine subspecialists); • for adult nephrologists, 60% of time is spent in office-based practice and 20% in research; • participation in research at 20% of effort is higher than for all internal medicine subspecialists (17%) and for all physicians (5.5%); • there has been a change in the percent activity in direct patient care, which was 51 % of effort in 1970, to 73% of effort in 1987, with a concomitant erosion of percent effort attributable to nonpatient care, mostly in the research area, from 32% effort in 1970 to 19% effort in 1987; • the geographical distribution of renal physicians is concentrated in the large metropolitan areas in a pattern, similar to general internal
American Journal of Kidney Diseases, Vol XVIII, No 3 (September), 1991: pp 392-393
NEPHROLOGY MANPOWER: THE SUPPLY SIDE
medicine and internal medicine subspecialties, but a little different than for all physicians; • since 1976, there has been a decline in the nephrology fellowship pool (nephrology fellows as a percent of internal medicine fellows decreased from 11% for time frame 1976/1977 to 7.9% in 1987/1988). There appears to be some cause for concern and caution with regard to the distribution of
393
renal physicians, the declining number of physicians entering nephrology training, and the high percentage of foreign medical graduates, all of which render predictions for the future uncertain at best. The changing pattern of activities, with a decline of percent effort directed at research, is an added and additional concern. Further study and evaluation of these supply-side issues are called for.