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Ophthalmology (Eye Physician and Surgeon) Manpower Studies for the United States
Viewpoint
Ophthalmology (Eye Physician and Surgeon) Manpower
Studies for the United States
Part III: A Survey of Ophthalmologists' Viewpoints and Practice Characteristics D. M. WORTHEN, MD, M. N. LUXEMBERG, MD, F. H. GUTMAN, MD, A. COLENBRANDER, MD, R. O. SCHULTZ, MD, H. D. CAVANAGH, MD, H. E. KAUFMAN, MD In response to a request from the U.S. General Accounting Office, major organizations in ophthalmology prepared an estimate of the theoretic need for ophthalmological manpower to treat all eye disease and to provide approximately one-half of all periodic eye examinations for the U.S. population.! The manpower requirements presented in that report were based upon population estimates of the prevalence and incidence of eye disease and other vision care needs, and the average time involved in diagnosis and treatment of eye disease and in providing refractions and preventive eye care. The estimated hours (in millions) needed to provide all of these services for the 1977 population for the various conditions or categories would have been: glaucoma-2.17; cataracts-2.07; retinal disorders-2.04; periodic eye examinations11. 79; cornea, sclera, external disease, and uveitis3.41; neuro-ophthalmology and optic nerve-0.04; systemic ophthalmology-6.0; injuries-0.67; strabismus and amblyopia-3.65; orbit, lids, lacrimal apparatus-0.46, for a total of over 32.3 million hours. This theoretic need exceeded the capacity of the 1977 supply of ophthalmologists to provide these services by almost 50% even if they had averaged a 48-hour workweek for 50 weeks during that year, with over 80% of that time devoted to patient care activities. Additional manpower studies have been undertaken to provide supplemental information that will be used to adjust the theoretical need-based estimates. Part II of the manpower studies involved a public opinion survey concerning the adequacy of present numbers, availability and utilization of ophthalmologists, and perception of need of ophthalmologists in the United States. 2 Reprint requests to American Academy of Ophthalmology, PO Box 7424, San Francisco. CA 94120.
It is the purpose of this paper to report the results of Part III of the manpower studies, which involved a survey of ophthalmologists concerning practice profile characteristics, reasons for practice locations, and their opinions about ophthalmological and optometric manpower. The funds supporting this study were provided by the Sloan Fund administered by the Association of University Professors of Ophthalmology. Other organizations continuing to participate in these manpower studies include the American Association of Ophthalmology, the American Academy of Ophthalmology, and the Contact Lens Association of Ophthalmologists.
METHODOLOGY Mendenhall surveyed the practice activity of 342 ophthalmologists by disproportionate, stratified sampling of five types of practice arrangements. The responses were then weighed on the basis of AMA data on ophthalmologists to extrapolate the results to all ophthalmologists. 3 For the present study, it was felt that, in comparison to the AMA listing, a more accurate and up-to-date list of ophthalmologists would be that maintained by one of the drug companies because their sales force in the field should be able to obtain current information about retirements, physicians who have moved, and new physicians entering practice. The data base used by the Allergan Pharmaceutical Company was obtained in the form of mailing labels arranged by zip code. The mailing list was manually searched to exclude labels destined for departments of ophthalmology, hospitals, or otherwise nonidentifiable individuals, such as multi-group clinics. That left a total of 11,736 potential mailing labels. In a systematic way, every fourth mailing label was pulled and a copy of the survey questionnaire was sent to the person indicated
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on that label. On a duplicate mailing list, the labels used from the other list were numbered in sequential order; that number was placed on the outside of the return envelope sent with the questionnaire. When the questionnaires were returned, the numbers on the envelopes were checked off the list and the envelopes were sent to the computer center where they were opened and the data processed. In that way the anonymous nature of the questionnaire was maintained, yet those who responded were known. A cutoff date of April 15, 1980 allowed five months from the date the questionnaires were originally mailed for ophthalmologists to respond. By that date 1,258 (43%) of the 2,934 surveys mailed had been returned, although not all respondents answered all questions. The questionnaire was divided into a series of questions designed to gather information about practice profile, the reasons for practice location and manpower opinions. The first question asked the respondents to indicate the zip code of their office. A chisquare correlation between zip codes of the resulting sample and the zip codes of the total population indicated a significant degree of association (P < 0.01). Therefore, this sample is distributionally representative of the total population, and the opinions expressed should be representative of ophthalmologists across the country. The age distribution and practice type are similar to those noted in previous studies. 3 ,4 The questionnaire and instructions are shown in Fig 1.
RESULTS The average age of the responding opthalmologists was 48 years, with a median age of 53 years and a range between 26 and 80. The mean age when entering practice was 32.5, with a median age of 38 years and a range between 24 and 53. The mean of projected retirement ages was 67 years.
The most common type of practice was solo practice, indicated by a little over one-half (56%) of the respondents. One-quarter (25.3%) indicated they were in an ophthalmology group, while only 4.6% were in a multi specialty group; 6.1% were at universities; 1.9% in state or federal government positions; and only 0.2% were in full-time research. Retirees accounted for 1.4%; 2.4% were residents or fellows; and 0.5% were in parttime practice. An additional 1.6% indicated their situation was a combination of these. Table 1 includes results from all the responding ophthalmologists. Other tables exclude groups not appropriate to the specific question. Table 2 lists the various practice types by age. The total number listed in this table is less than the total number of respondents as some did not indicate their age; also, those in research or retired are excluded as they had no active practice. Among those in solo practice, in multispecialty practice, and in state or federal positions, the largest age category is the 51 or older group. The largest age categories among those in ophthalmology group practice is the 36-40 group, while the 41-45 age group is the largest category among those in university practice. About one-sixth (17.4%) of the respondents indicated that they considered themselves to be subspecialists. The most commonly indicated subspecialty was retina, which accounted for 26.3% of that group. The other subspecialties indicated were cornea and external disease (17.5%), glaucoma (10.1%), strabismus and pediatrics (16.1%), plastic surgery (8.4%), neuro-ophthalmology (4.1%), and pathology (1.4%). Among the 16.1% who indicated "other" subspecialties, the overwhelming majority listed "cataract and intraocular lens surgery." In follow-up to previous studies, the respondents were asked to indicate the number of hours they spend each week in a variety of activities. The active practice group indicated that office practice occupied 32 hours,
Fig 1. Ophthalmology Manpower Opinion Survey. Dear Colleague: You have been selected to give your opinion regarding manpower in ophthalmology. This survey is being conducted by the Association of University Professors in Ophthalmology (AUPO) as part of a four part manpower report. The reports are a cooperative venture of the American Academy of Ophthalmology, the American Association of Ophthalmology, the Contact Lens Association of Ophthalmologists and the AUPO. Part One was published in the October 1978 issue of Ophthalmology. The reports were requested of the American Board of Ophthalmology and the American Academy of Ophthalmology by the General Accounting Office to assist the Congress in future legislation regarding health manpower training and other aspects of eye care delivery. Your name was selected by a random process. Not all ophthalmologists will be contacted. It is vital that you complete this questionnaire and return it in the self-addressed stamped envelope. Your office personnel may help you in gathering some of the estimates asked for. Please be as accurate as possible. Your help is greatly appreciated by all of ophthalmology. The results of the survey will be sent to you. Sincerely, MANPOWER COMMITIEE
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Fig 1. (continued). Ophthalmology Manpower Opinion Survey. Practice Profile 1. Zip Code of your office: UUUUU 2. Year of your birth: UU 3. Year you began ophthalmology practice (after residency):
UU
4. Age you think you will retire (make your best guess but put 99 if UU totally undecided): 5. Type of practice (list only one) U a) Solo f) Full-time research b) Ophthalmology group g) Retired c) Multispecialty group h) Resident or Fellow d) University i) Part-time e) State or Federal j) Other (specify under government comments 6. Indicate only if you consider your practice to be as a subspecialist: U a) Retina e) Plastic Surgery f) Pathology b) Cornea and external disease g) Neuro-ophthalmology c) Glaucoma h) Other (specify under d) Strabismus and pediatrics comments) How many hours a week do you spend in: 7. Active office practice UU 8. Surgery and hospital care UU UU 9. Administration 10. Teaching UU 11. Continuing education UU UU 12. Other (specify under comments) How many weeks a year do you spend in activities away from practice: UU 13. Attending medical meetings 14. On vacation UU UU 15. Other (specify under comments) How many patients do you see in an average week: UUU 16. New UUU 17. Return How many surgical procedures do you personally perform as primary surgeon per year in the following categories: 18. Hospital-based (major) UUUU 19. Office-based (minor) UUUU 20. How many office patients do you see a week? UUU How many of the following examinations do you perform during an average week: 21. Refraction UUU 22. Routine eye exam UUU Evaluations exclusively for: 23. Glaucoma UUU 24. External disease UUU 25. Retina disease UUU UUU 26. Neuro-ophthalmology 27. Medical ophthalmology UUU 28. Strabismus UUU 29. Cataract UUU 30. Orbit and Plastic Surgery UUU 31. Injuries UUU 32. Other (specify under comments UUU 33. What is the average time in weeks between when a new patient calls for a routine eye exam and the time they seek you. If you UU don't see new patients, put 99. How many people do you employ in your office (put zero if none) 34. Receptionist UU 35. Secretary UU
36. 37. 38. 39. 40. 41.
Nurse Photographer Ophthalmic technician or assistant Orthoptist Optometrist Other (specify under comments)
UU UU UU UU UU UU
Practice Location What was the major reason for selecting your current practice location: (rank 1 through 4) a) Where I was born or grew up h) Opportunity to do b) Where my spouse was born research i) Opportunity for teaching or grew up j) Cultural opportunities c) To be near my family d) To be near my spouse's family k) Climate e) To be near my medical school I) Educational opportunif) To be near my residency ties for my family g) Community need for m) Recreation facilities ophthalmology care n) Hospital facilities 0) Other (specify under comments 42. Number one reason U 43. Number two reason U U 44. Number three reason U 45. Number four reason Manpower Opinion 46. In your opinion, do you believe the number of ophthalmologists trained in your area should: U a) be increased b) be decreased c) remain the same 47. In your opinion, do you believe the number of ophthalmologists U trained nationally should: a) be increased b) be decreased c) remain the same 48. In your opinion, do you believe the number of optometrists (0.0.) trained in your area should: U a) be increased b) be decreased c) remain the same 49. In your opinion, do you believe the number of optometrists (00.) trained nationally should: U a) be increased b) be decreased c) remain the same COMMENTS: Please I ist the question number before each comment.
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OPHTHALMOLOGY. OCTOBER 1981 • VOLUME 88 • NUMBER 10
Table 1. Ophthalmology Manpower Opinion Survey 1. Mean age: 47.7 years; median age: 53 years; range: 26-80 years . 2. Age when entering practice: Mean 32.5 years; median 38 years; range 24-53 years. 3. Average age of projected retirement: 67 years. 4. Type of practice: Solo-56.0% FUll-time research-0 .2% Ophthalmology group-25.3% Retired-1.4% Multispecialty group-4.6% Resident or fellow-2 .4% University-6.1% Part-time-O.5% State or Federal government-l .9% Other-l.6% 5. Declared subspecialty-17.4% Retina-26.3% Plastic surgery-8.4% Cornea & external disease-17.5% Pathology-l .4 % Neuro-ophthalmologyGlaucoma-l0.l% 4.1% Strabismus & pediatrics-16.1 % Other-16.1% 6. Work week (mean in hours) Office practice-32 Surgery and hospital care-7 .4 Administration-3 .3 Teaching-2 .9 Continuing education-3 . 7 Other-l .0 Average total-50.3 7. Weeks away from practice (mean in weeks) Medical meetings-2.6 Vacation-3.0 Other-0.2 Average total-5.8 8. Patients seen per week: 32 new, 72 return (104 total) 9. Surgical procedures as primary surgeon per year: 103 major, 73 minor. 10. Total office visits per week (mean) : 104 11 . Examinations per week (mean): Refraction--44 Medical ophthalmology-9 Routine exam-38 Strabismus-5 Glaucoma-14 Cataract-13 External disease-15 Orbit and plastic surgery-2 Retina-9 Injuries-6 Neuro-ophthalmology-3 Other-l 12. Average time for new, routine exam (mean): 3.6 weeks 13. People employed in office (mean number): Receptionist-l.3 Ophthalmic technician or Secretary-l.0 assistant-l.0 Nurse-O.6 Orthoptist-O.l Photog rapher-O.l Optometrist-O.2 Other-O.4 Average total-4 .7 employees (Over 99% employed at least one person)
while surgery and hospital care accounted for 7.4 hours. Administration consumed 3.3 hours; teaching, 2.9 hours; continuing education, 3.7 hours; and other activities, 1 hour. Thus, an average total of 50.3 hours per week were spent in practice and related activities, of which 38.4 hours were spent in direct care. When asked how many weeks per year were spent in activities away from practice, the respondents reported an average total of 5.8 weeks, which comprised of 2.6 weeks for medical meetings, 3 weeks for vacations, and 0.2 weeks for other activities. During the remaining 46.2 weeks, the respondents saw an average of 104 office patients per week, of which 32 were new patients and 72 were return patients. The estimate of 104 office visits per week is somewhat lower than a 1977 survey of ophthalmologists, 5 which reported that the "typical" patient load for ophthalmologists was 126 patient visits per week. However, this latter estimate may have included hospital inpatient visits in addition to office visits. Our estimate is also similar to an earlier survey of ophthalmology clinical practice characteristics, which reported a median of 102 visits per week. 6 As primary surgeon, the average ophthalmologist in our sample performed 103 hospital-based or major surgeries and 73 office surgeries for a total of 176 surgeries per year. Table 3 lists the hours worked, weeks away from active practice, volume of office visits, and surgery by age. Once established in practice (after age 30), the number of hours worked and yearly weeks worked were fairly even. In contrast, office and surgery volume increase until age 50 and then decline slightly . These differences in practice volume are also reflected by the average number of weeks a patient waits for an appointment. Among the average number of 104 patients seen during the week, 38 visits were for periodic eye examinations; 42% of all visits included a refractive examination. The average number of examinations performed during the week for specific diseases were: external disease-IS; glaucoma-14; cataract-13; medical ophthalmology-9; retinal disease-9; injuries-6; strabismus-5 ; neuro-ophthalmology-3; orbit
Table 2. Age and Type of Practice Age (Yrs)
Practice type Solo Ophth group Univ Multi group Res/fellow State/fed Other Part-time
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31-35
<31
41 - 45
36-40
46-50
> 50
N
%
N
%
N
%
N
%
N
%
N
%
N
%
658 303 72 56 28 22 18 6 1163
(56 .6) (26 .1) ( 6 2. ) ( 4 .8) ( 2.4) ( 1 .9) ( 1.5) ( 0.5)
6
(1.0)
16
(57.1)
131 87 17 11 2 5 2
(20 .0) (28.7) (23.6) (19.6) ( 7 .2) (22.7) (11.1 )
(17 .0) (18 .8) (27.8) (16 .1)
101 44 13 9
(15.3) (14 .5) (18 .0) (16 .1)
251 79 16 19
(38.0) (26 .0) (22 .2) (33 .9).
(5.4) (16.7) (2.1)
( 8 7. ) (12 .0) .( 8.4) (14 .3) (35 .7) (18 .2) (16.7)
112 57 20 9
1 1 24
57 36 6 8 10 4 3
4 3
(18 .2) (16.7)
124
(10 .7)
255
(21.9)
205
(17.6)
1 3 2 173
( 4.5) (16.7) (33.3) (14.9)
8 6 3 382
(36.4) (33.4) (50.0) (32.8)
Table 3. Age and Practice Profile (Excluding Residents, Fellows, Retired, Research) Age (Yrs)
1. Activity (hrs) Office Su rgery/hosp Admin Teaching Cont ed Other Total 2. Time away from practice (wks) Medical meetings Vacation Other Total 3. Number of visits Patients new Patients retu rn Total 4. Number of surgical procedures Major surgery Minor surgery Total 5. Time to new appointment (wks)
<31
31-35
36-40
41-45
46-50
>50
22.2 10.1 2.1 1.6 4.6 4.7 45.3
32.2 7.3 3.2 3.5 4.0 0.7 50.9
33.8 7.6 3.1 3.0 4.0 0.8 52.3
32.6 7.9 3.8 3.2 3.7 0.9 52.1
32.1 7.9 4.6 3.0 3.5 1.6 52.7
32.9 7.1 2.8 2.5 3.7 0.8 49.8
2.9 2.7 5.6
2.0 2.4 0.1 4.5
2.3 2.6 0.2 5.1
2.4 2.7 0.1 5.2
3.1 3.1 0.2 6.4
3.0 3.6 0.2 6.8
15.8 27.7 43.5
34.1 49.8 83.9
37.1 69.5 106.6
33.1 78.0 111.1
36.3 85.5 121.8
27.8 75.3 103.1
41.5 20.9 62.4 2.0
83.2 42.6 125.8 2.0
96.5 64.0 160.5 3.1
110.0 65.8 175.8 3.5
118.4 72.7 191.1 5.1
98.3 77.7 176.0 4.1
Statel
Resl Fellow (28)
Table 4. Practice Type (N) and Practice Profile
1. Activity (hrs) Office Surgery/hosp Admin Teaching Cont ed Other Total (hrs) 2. Time away from practice (wks) Medical meetings Vacation Other Total (wks) 3. Number of visits New Return Total 4. Number of surgical procedures Major Minor Total 5. Time to new appointment (wks)
Solo (658)
Ophthal Group (303)
MultiGroup (50)
Univ (72)
34.8 7.0 2.6 1.9 3.9 0.5 50.7
33.7 8.1 2.8 2.4 3.5 0.5 51.0
35.8 6.7 2.7 2.2 3.0 0.3 50.7
17.7 8.9 9.8 10.7 4.2 6.3 57.6
25.1 8.7 7.9 7.0 3.7 2.4 54.8
24.2 11.9 3.3 3.4 7.4 4.2 54.4
2.6 2.9 0.1 5.6
2.5 3.3 0.1 5.9
2.2 3.4 0.4 6.0
3.8 2.7 0.7 7.2
1.8 3.2 1.6 6.6
1.4 2.7 4.1
34.0 74.3 108.3
36.0 84.3 120.3
41.1 79.7 120.8
16.6 41.5 58.1
23.7 40.4 64.1
19.2 29.1 48.3
102.1 85.4 187.5 3.7
124.3 74.6 198.9 3.8
94.1 79.8 173.9 3.5
101.1 28.6 129.6 2.9
86.1 47.2 133.3 4.6
50.4 18.0 68.4 2.0
and plastic surgery-2; and other-l. Some patients were examined for more than one disease on a given visit. The respondents indicated that the average length of
Fed (22)
time between a new patient's request for a periodic eye examination and the scheduled appointment was 3.6 weeks. Table 4 lists the hours worked, weeks away from
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Table 5. First and Second Practice Location Reason by Age (%) Age (Yrs)
<31 Reason Where I grew up Near family Near residency Community need Teaching Climate Recreation Other
--
13.1 15.8 13.1
15.8
31-35 36-40 41-45 46-50
>50
13.6 8.9
11.6 9.2
9.0 8.3
11.1
18.0 9.3
20.6
20.6
20.7
20.0
11.2
13.9
19.9 9.4 11.6
9.8
9.7
Table 6. First and Second Practice Location Reason by Practice Type (%)
Where I grew up Near family Community need Research Teaching Climate Recreation
Solo
Ophth Group
MultiGroup
14.510.4 22.5
12.6 7.5 20.0
10.6
11.1
13.3
22.1 16.8 11.5
Univ
Statel Fed
10.2 10.2
19.3 30.4 20.7
18.0
6.7
28.2
- Percent of respondents listing this as first or second reason among all reasons listed (see sample questionnaire).
active practice, and practice volume by practice type. The total work week was longer for university, state, and federal ophthalmologists and those in training. Time away from practice was highest for those associated with university and least for those in training. Ophthalmologists in group practice saw more patients and did more surgery than other practice types. The averages of the numbers of people that ophthalmologists reported they employed in their office are: receptionist-I.3; secretary-I.O; ophthalmic technician-I.O; nurse-0.6; optometrist-0.2; orthoptist-O.l; photographer-O.l; and others-O.4. This is an average total of 4.7 individuals assisting the ophthalmologist in the office. In response to the question asking ophthalmologists to rank the reasons for selecting their current practice location on a scale of one through four, the following were listed as primary reasons: (a) community need for ophthalmological care (31 %) ; (b) proximity to hometown (22%); (c) climate (12%); and (d) proximity to family (7%). The four most common secondary reasons for location included: (a) community need for ophthalmological care (12%); (b) proximity to family (12%); (c) climate (11%); and (d) hospital facilities (10%). It is noteworthy that 42% selected their practice location with community need as either their primary or secondary factor. The four most common reasons ranked as either third or fourth in importance included the following: (a) hospital facilities (32%); (b) cultural opportunities (18%); (c) educational opportunities for my family (21%); and (d) climate (20%). Responses are related to age and practice type in Tables 5 and 6.
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Finally, the section on manpower opinion asked four questions regarding the individual's perception of the local and national need and supply of ophthalmologists and optometrists. In their local area, 51% felt the number of ophthalmologists trained should remain the same, while 41% thought it should be decreased and only 8% indicated the number should be increased. Concerning the number of ophthalmologists trained nationally, 45% felt it should remain the same; 40% indicated it should be decreased, while 15% thought it should be increased. Hence, over 90% of the respondents felt the number of ophthalmologists trained should remain the same or be decreased in their local area, and 85% felt there should either be no change or a decrease in the numbers nationally. Table 7 relates ophthalmologists' opinions regarding the number of ophthalmology residents trained in their local area and nationally to age of respondent. In general, the younger ophthalmologists, especially those in their 30s, were more inclined to feel that the number should remain stable or be decreased. Table 8 relates the opinions on ophthalmology manpower to practice type. A striking but perhaps expected finding is that over half of ophthalmologists-in-training felt their numbers should be decreased both locally and nationally. In response to the question about the number of optometrists being trained in their local area, 65% expressed that this number should be decreased, while 34% felt it should remain the same, and only 1% thought it should be increased. Regarding the national scene, 70% of respondents felt the number of optometrists in training should be decreased, 29% indicated that it should remain the same, and only 1% thought it Table 7. Opinion About Ophthalmology Manpower By Age Age (Yrs) <31 (27) Local area (N) Increase (%) 7 Decrease (%) 33 Same (%) 60 National (N) (27) Increase (%) 11 Decrease (%) 41 Same (%) 48
31-35 36-40 41-45 46-50 >50 (120) 3 55 42 (119) 5 58 37
(257) 4 49 47 (256) 8 53 39
(207) 7 42 51 (207) 12 45 43
(178) 10 45 45 (175) 17 40 43
(401) 10 30 60 (396) 23 25 52
Table 8. Opinion About Ophthalmology Manpower By Practice Type Solo Local area (N) Increase (0/0) Decrease (0/0) Same (0/0) National (N) Increase (0/0) Decrease (0/0) Same (0/0)
(647) 8 42 50 (642) 17
37 46
Ophth Group
MultiGroup
Univ
(294) 4 44 52 (291) 12 47 42
(56) 9 43 48 (55) 16 53 31
(71) 7 35 58 (71) 6 45 49
Statel Fed
Res! Fellow
(21) 24 29 47 (21) 14 38 48
(25) 0 52 48 (25) 8 60 32
should be increased. Hence, 99% of ophthalmologists felt that the number of optometry students being trained locally and nationally should either be decreased or remain the same.
Part IV of the ophthalmology manpower studies will be based on a synthesis of the preceding three parts and will present an overview and recommendations concerning the future supply and requirements for ophthalmologists and other allied health personnel.
DISCUSSION Among our sample, approximately 6% of those who responded indicated that they were not in full-time active clinical practice. Assuming this is representative of the population sampled, this would reduce the supply of clinically active ophthalmologists to about 11,000. Nationally, the productivity or the supply of ophthalmological services based on the average of39.4 hours per week (the total of office and hospital care) for 46.2 weeks per year for 11,000 ophthalmologists would equal slightly more than 20 million hours. This figure falls short of the 32.2 million hours of estimated requirements for 1977 in the Part I report. 1 In addition, the latest "Report to the President and Congress on the Status of Health Professions Personnel in the United States"7 indicated that for physician requirements projections the "largest 1975-1990 increases are foreseen for ophthalmologists .... The large increase in ophthalmologists requirements reflects increases in the age 65 and over population and the population growth in the higher income groups which have relatively high rates of vision care utilization." The requirement in this report for ophthalmologists for 1990 is 20,000. This number is in sharp contrast to the recently released report of the Graduate Medical Education National Advisory Committee (GMENAC).8 The GMENAC report projected that the 1990 requirement for ophthalmologists would be only 11,600. The GMENAC report also estimated that the supply of ophthalmological specialists would total 16,300 in 1990. Hence, GMENAC predicted an oversupply, yet the requirements projection contained in the "Report to the President and Congress ... " would clearly indicate an undersupply. These two reports present widely divergent estimates of the number of ophthalmologists required to meet assumed 1990 population needs. This major discrepancy should add further emphasis to concerns expressed about the GMENAC report; namely, that the data presently available are simply inadequate to yield precise estimates. In addition, the nature of the assumption on which projections are based can substantially influence the results. Hence, at present, there does not appear to be a reliable estimate of the need for ophthalmological services in the future. Estimates of the requirement for ophthalmologists should be continually evaluated as better data become available, and the assumptions on which projections are based should be continually reviewed to determine if they are still accurate and appropriate.
SUMMARY The figures in this survey regarding the number of hours worked, the practice profile, and use of office personnel are similar to previous surveys. 3,4 The reasons for practice location are noteworthy in that they indicate a strong desire to practice in a community needing ophthalmological care. Only when the third and fourth reasons are considered, did elements such as educational opportunities, climate, recreational facilities, and other reasons enter into the decision. Interestingly, being near one's family or practicing in an area where one was born or grew up remain important factors even in our mobile society. Finally, the majority of ophthalmologists responding to this survey indicated that the number of ophthalmologists presently being trained, whether locally or nationally, was either appropriate or excessive and that the number of optometrists being trained is already excessive.
REFERENCES t Reinecke RD, ed. Ophthalmology (eye physician and surgeon) 2.
3.
4. 5. 6.
7.
8.
manpower studies for the United States, part I. Ophthalmology 1978; 85: 1057 -138. Reinecke RD, Steinberg T, eds. Ophthalmology manpower studies for the United States (Part II): demand for eye care. A public opinion poll based upon a Gallup poll survey. Ophthalmology 1981; 88:34A -47 A. Mendenhall RC, et a!. Ophthalmology practice study report, contract no. USPHS (HRA) 232-78-0160. University of Southern California School of Medicine, April 1979. Worthen, DM. Future use and development of eye-care manpower. Surv Ophthalmol 1974; 18:442-8. Goldberg, JH. Ophthalmologists: still spending more to earn more. Med Econ January 22, 1979; 172-6. US Dept of Health, Education, and Welfare, Public Health Service: Ophthalmology Manpower: Characteristics of Clinical Practice. DHEW Pub No (HSM) 73-1802, March 1973. A Report to the President and Congress on the Status of Health Professions Personnel in the United States. US Dept of Health, Education, and Welfare, Health Resources Administration, Bureau of Health Manpower, Division of Manpower Analysis. DHEW Publication No (HRA) 80-53, August 10, 1980, pp IV-13. Graduate Medical Education National Advisory Committee: GMENAC Summary Report, Vol 1, September 1980, p 19 (Dept of Health and Human Services, Health Resources Administration).
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Ophthalmology (Eye Physician and Surgeon) Manpower
Studies for the United States
Part III: A Survey of Ophthalmologists' Viewpoints and Practice Characteristics D. M. WORTHEN, MD, M. N. LUXEMBERG, MD, F. H. GUTMAN, MD, A. COLENBRANDER, MD, R. O. SCHULTZ, MD, H. D. CAVANAGH, MD, H. E. KAUFMAN, MD In response to a request from the U.S. General Accounting Office, major organizations in ophthalmology prepared an estimate of the theoretic need for ophthalmological manpower to treat all eye disease and to provide approximately one-half of all periodic eye examinations for the U.S. population.! The manpower requirements presented in that report were based upon population estimates of the prevalence and incidence of eye disease and other vision care needs, and the average time involved in diagnosis and treatment of eye disease and in providing refractions and preventive eye care. The estimated hours (in millions) needed to provide all of these services for the 1977 population for the various conditions or categories would have been: glaucoma-2.17; cataracts-2.07; retinal disorders-2.04; periodic eye examinations11. 79; cornea, sclera, external disease, and uveitis3.41; neuro-ophthalmology and optic nerve-0.04; systemic ophthalmology-6.0; injuries-0.67; strabismus and amblyopia-3.65; orbit, lids, lacrimal apparatus-0.46, for a total of over 32.3 million hours. This theoretic need exceeded the capacity of the 1977 supply of ophthalmologists to provide these services by almost 50% even if they had averaged a 48-hour workweek for 50 weeks during that year, with over 80% of that time devoted to patient care activities. Additional manpower studies have been undertaken to provide supplemental information that will be used to adjust the theoretical need-based estimates. Part II of the manpower studies involved a public opinion survey concerning the adequacy of present numbers, availability and utilization of ophthalmologists, and perception of need of ophthalmologists in the United States. 2 Reprint requests to American Academy of Ophthalmology, PO Box 7424, San Francisco. CA 94120.
It is the purpose of this paper to report the results of Part III of the manpower studies, which involved a survey of ophthalmologists concerning practice profile characteristics, reasons for practice locations, and their opinions about ophthalmological and optometric manpower. The funds supporting this study were provided by the Sloan Fund administered by the Association of University Professors of Ophthalmology. Other organizations continuing to participate in these manpower studies include the American Association of Ophthalmology, the American Academy of Ophthalmology, and the Contact Lens Association of Ophthalmologists.
METHODOLOGY Mendenhall surveyed the practice activity of 342 ophthalmologists by disproportionate, stratified sampling of five types of practice arrangements. The responses were then weighed on the basis of AMA data on ophthalmologists to extrapolate the results to all ophthalmologists. 3 For the present study, it was felt that, in comparison to the AMA listing, a more accurate and up-to-date list of ophthalmologists would be that maintained by one of the drug companies because their sales force in the field should be able to obtain current information about retirements, physicians who have moved, and new physicians entering practice. The data base used by the Allergan Pharmaceutical Company was obtained in the form of mailing labels arranged by zip code. The mailing list was manually searched to exclude labels destined for departments of ophthalmology, hospitals, or otherwise nonidentifiable individuals, such as multi-group clinics. That left a total of 11,736 potential mailing labels. In a systematic way, every fourth mailing label was pulled and a copy of the survey questionnaire was sent to the person indicated
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on that label. On a duplicate mailing list, the labels used from the other list were numbered in sequential order; that number was placed on the outside of the return envelope sent with the questionnaire. When the questionnaires were returned, the numbers on the envelopes were checked off the list and the envelopes were sent to the computer center where they were opened and the data processed. In that way the anonymous nature of the questionnaire was maintained, yet those who responded were known. A cutoff date of April 15, 1980 allowed five months from the date the questionnaires were originally mailed for ophthalmologists to respond. By that date 1,258 (43%) of the 2,934 surveys mailed had been returned, although not all respondents answered all questions. The questionnaire was divided into a series of questions designed to gather information about practice profile, the reasons for practice location and manpower opinions. The first question asked the respondents to indicate the zip code of their office. A chisquare correlation between zip codes of the resulting sample and the zip codes of the total population indicated a significant degree of association (P < 0.01). Therefore, this sample is distributionally representative of the total population, and the opinions expressed should be representative of ophthalmologists across the country. The age distribution and practice type are similar to those noted in previous studies. 3 ,4 The questionnaire and instructions are shown in Fig 1.
RESULTS The average age of the responding opthalmologists was 48 years, with a median age of 53 years and a range between 26 and 80. The mean age when entering practice was 32.5, with a median age of 38 years and a range between 24 and 53. The mean of projected retirement ages was 67 years.
The most common type of practice was solo practice, indicated by a little over one-half (56%) of the respondents. One-quarter (25.3%) indicated they were in an ophthalmology group, while only 4.6% were in a multi specialty group; 6.1% were at universities; 1.9% in state or federal government positions; and only 0.2% were in full-time research. Retirees accounted for 1.4%; 2.4% were residents or fellows; and 0.5% were in parttime practice. An additional 1.6% indicated their situation was a combination of these. Table 1 includes results from all the responding ophthalmologists. Other tables exclude groups not appropriate to the specific question. Table 2 lists the various practice types by age. The total number listed in this table is less than the total number of respondents as some did not indicate their age; also, those in research or retired are excluded as they had no active practice. Among those in solo practice, in multispecialty practice, and in state or federal positions, the largest age category is the 51 or older group. The largest age categories among those in ophthalmology group practice is the 36-40 group, while the 41-45 age group is the largest category among those in university practice. About one-sixth (17.4%) of the respondents indicated that they considered themselves to be subspecialists. The most commonly indicated subspecialty was retina, which accounted for 26.3% of that group. The other subspecialties indicated were cornea and external disease (17.5%), glaucoma (10.1%), strabismus and pediatrics (16.1%), plastic surgery (8.4%), neuro-ophthalmology (4.1%), and pathology (1.4%). Among the 16.1% who indicated "other" subspecialties, the overwhelming majority listed "cataract and intraocular lens surgery." In follow-up to previous studies, the respondents were asked to indicate the number of hours they spend each week in a variety of activities. The active practice group indicated that office practice occupied 32 hours,
Fig 1. Ophthalmology Manpower Opinion Survey. Dear Colleague: You have been selected to give your opinion regarding manpower in ophthalmology. This survey is being conducted by the Association of University Professors in Ophthalmology (AUPO) as part of a four part manpower report. The reports are a cooperative venture of the American Academy of Ophthalmology, the American Association of Ophthalmology, the Contact Lens Association of Ophthalmologists and the AUPO. Part One was published in the October 1978 issue of Ophthalmology. The reports were requested of the American Board of Ophthalmology and the American Academy of Ophthalmology by the General Accounting Office to assist the Congress in future legislation regarding health manpower training and other aspects of eye care delivery. Your name was selected by a random process. Not all ophthalmologists will be contacted. It is vital that you complete this questionnaire and return it in the self-addressed stamped envelope. Your office personnel may help you in gathering some of the estimates asked for. Please be as accurate as possible. Your help is greatly appreciated by all of ophthalmology. The results of the survey will be sent to you. Sincerely, MANPOWER COMMITIEE
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Fig 1. (continued). Ophthalmology Manpower Opinion Survey. Practice Profile 1. Zip Code of your office: UUUUU 2. Year of your birth: UU 3. Year you began ophthalmology practice (after residency):
UU
4. Age you think you will retire (make your best guess but put 99 if UU totally undecided): 5. Type of practice (list only one) U a) Solo f) Full-time research b) Ophthalmology group g) Retired c) Multispecialty group h) Resident or Fellow d) University i) Part-time e) State or Federal j) Other (specify under government comments 6. Indicate only if you consider your practice to be as a subspecialist: U a) Retina e) Plastic Surgery f) Pathology b) Cornea and external disease g) Neuro-ophthalmology c) Glaucoma h) Other (specify under d) Strabismus and pediatrics comments) How many hours a week do you spend in: 7. Active office practice UU 8. Surgery and hospital care UU UU 9. Administration 10. Teaching UU 11. Continuing education UU UU 12. Other (specify under comments) How many weeks a year do you spend in activities away from practice: UU 13. Attending medical meetings 14. On vacation UU UU 15. Other (specify under comments) How many patients do you see in an average week: UUU 16. New UUU 17. Return How many surgical procedures do you personally perform as primary surgeon per year in the following categories: 18. Hospital-based (major) UUUU 19. Office-based (minor) UUUU 20. How many office patients do you see a week? UUU How many of the following examinations do you perform during an average week: 21. Refraction UUU 22. Routine eye exam UUU Evaluations exclusively for: 23. Glaucoma UUU 24. External disease UUU 25. Retina disease UUU UUU 26. Neuro-ophthalmology 27. Medical ophthalmology UUU 28. Strabismus UUU 29. Cataract UUU 30. Orbit and Plastic Surgery UUU 31. Injuries UUU 32. Other (specify under comments UUU 33. What is the average time in weeks between when a new patient calls for a routine eye exam and the time they seek you. If you UU don't see new patients, put 99. How many people do you employ in your office (put zero if none) 34. Receptionist UU 35. Secretary UU
36. 37. 38. 39. 40. 41.
Nurse Photographer Ophthalmic technician or assistant Orthoptist Optometrist Other (specify under comments)
UU UU UU UU UU UU
Practice Location What was the major reason for selecting your current practice location: (rank 1 through 4) a) Where I was born or grew up h) Opportunity to do b) Where my spouse was born research i) Opportunity for teaching or grew up j) Cultural opportunities c) To be near my family d) To be near my spouse's family k) Climate e) To be near my medical school I) Educational opportunif) To be near my residency ties for my family g) Community need for m) Recreation facilities ophthalmology care n) Hospital facilities 0) Other (specify under comments 42. Number one reason U 43. Number two reason U U 44. Number three reason U 45. Number four reason Manpower Opinion 46. In your opinion, do you believe the number of ophthalmologists trained in your area should: U a) be increased b) be decreased c) remain the same 47. In your opinion, do you believe the number of ophthalmologists U trained nationally should: a) be increased b) be decreased c) remain the same 48. In your opinion, do you believe the number of optometrists (0.0.) trained in your area should: U a) be increased b) be decreased c) remain the same 49. In your opinion, do you believe the number of optometrists (00.) trained nationally should: U a) be increased b) be decreased c) remain the same COMMENTS: Please I ist the question number before each comment.
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Table 1. Ophthalmology Manpower Opinion Survey 1. Mean age: 47.7 years; median age: 53 years; range: 26-80 years . 2. Age when entering practice: Mean 32.5 years; median 38 years; range 24-53 years. 3. Average age of projected retirement: 67 years. 4. Type of practice: Solo-56.0% FUll-time research-0 .2% Ophthalmology group-25.3% Retired-1.4% Multispecialty group-4.6% Resident or fellow-2 .4% University-6.1% Part-time-O.5% State or Federal government-l .9% Other-l.6% 5. Declared subspecialty-17.4% Retina-26.3% Plastic surgery-8.4% Cornea & external disease-17.5% Pathology-l .4 % Neuro-ophthalmologyGlaucoma-l0.l% 4.1% Strabismus & pediatrics-16.1 % Other-16.1% 6. Work week (mean in hours) Office practice-32 Surgery and hospital care-7 .4 Administration-3 .3 Teaching-2 .9 Continuing education-3 . 7 Other-l .0 Average total-50.3 7. Weeks away from practice (mean in weeks) Medical meetings-2.6 Vacation-3.0 Other-0.2 Average total-5.8 8. Patients seen per week: 32 new, 72 return (104 total) 9. Surgical procedures as primary surgeon per year: 103 major, 73 minor. 10. Total office visits per week (mean) : 104 11 . Examinations per week (mean): Refraction--44 Medical ophthalmology-9 Routine exam-38 Strabismus-5 Glaucoma-14 Cataract-13 External disease-15 Orbit and plastic surgery-2 Retina-9 Injuries-6 Neuro-ophthalmology-3 Other-l 12. Average time for new, routine exam (mean): 3.6 weeks 13. People employed in office (mean number): Receptionist-l.3 Ophthalmic technician or Secretary-l.0 assistant-l.0 Nurse-O.6 Orthoptist-O.l Photog rapher-O.l Optometrist-O.2 Other-O.4 Average total-4 .7 employees (Over 99% employed at least one person)
while surgery and hospital care accounted for 7.4 hours. Administration consumed 3.3 hours; teaching, 2.9 hours; continuing education, 3.7 hours; and other activities, 1 hour. Thus, an average total of 50.3 hours per week were spent in practice and related activities, of which 38.4 hours were spent in direct care. When asked how many weeks per year were spent in activities away from practice, the respondents reported an average total of 5.8 weeks, which comprised of 2.6 weeks for medical meetings, 3 weeks for vacations, and 0.2 weeks for other activities. During the remaining 46.2 weeks, the respondents saw an average of 104 office patients per week, of which 32 were new patients and 72 were return patients. The estimate of 104 office visits per week is somewhat lower than a 1977 survey of ophthalmologists, 5 which reported that the "typical" patient load for ophthalmologists was 126 patient visits per week. However, this latter estimate may have included hospital inpatient visits in addition to office visits. Our estimate is also similar to an earlier survey of ophthalmology clinical practice characteristics, which reported a median of 102 visits per week. 6 As primary surgeon, the average ophthalmologist in our sample performed 103 hospital-based or major surgeries and 73 office surgeries for a total of 176 surgeries per year. Table 3 lists the hours worked, weeks away from active practice, volume of office visits, and surgery by age. Once established in practice (after age 30), the number of hours worked and yearly weeks worked were fairly even. In contrast, office and surgery volume increase until age 50 and then decline slightly . These differences in practice volume are also reflected by the average number of weeks a patient waits for an appointment. Among the average number of 104 patients seen during the week, 38 visits were for periodic eye examinations; 42% of all visits included a refractive examination. The average number of examinations performed during the week for specific diseases were: external disease-IS; glaucoma-14; cataract-13; medical ophthalmology-9; retinal disease-9; injuries-6; strabismus-5 ; neuro-ophthalmology-3; orbit
Table 2. Age and Type of Practice Age (Yrs)
Practice type Solo Ophth group Univ Multi group Res/fellow State/fed Other Part-time
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31-35
<31
41 - 45
36-40
46-50
> 50
N
%
N
%
N
%
N
%
N
%
N
%
N
%
658 303 72 56 28 22 18 6 1163
(56 .6) (26 .1) ( 6 2. ) ( 4 .8) ( 2.4) ( 1 .9) ( 1.5) ( 0.5)
6
(1.0)
16
(57.1)
131 87 17 11 2 5 2
(20 .0) (28.7) (23.6) (19.6) ( 7 .2) (22.7) (11.1 )
(17 .0) (18 .8) (27.8) (16 .1)
101 44 13 9
(15.3) (14 .5) (18 .0) (16 .1)
251 79 16 19
(38.0) (26 .0) (22 .2) (33 .9).
(5.4) (16.7) (2.1)
( 8 7. ) (12 .0) .( 8.4) (14 .3) (35 .7) (18 .2) (16.7)
112 57 20 9
1 1 24
57 36 6 8 10 4 3
4 3
(18 .2) (16.7)
124
(10 .7)
255
(21.9)
205
(17.6)
1 3 2 173
( 4.5) (16.7) (33.3) (14.9)
8 6 3 382
(36.4) (33.4) (50.0) (32.8)
Table 3. Age and Practice Profile (Excluding Residents, Fellows, Retired, Research) Age (Yrs)
1. Activity (hrs) Office Su rgery/hosp Admin Teaching Cont ed Other Total 2. Time away from practice (wks) Medical meetings Vacation Other Total 3. Number of visits Patients new Patients retu rn Total 4. Number of surgical procedures Major surgery Minor surgery Total 5. Time to new appointment (wks)
<31
31-35
36-40
41-45
46-50
>50
22.2 10.1 2.1 1.6 4.6 4.7 45.3
32.2 7.3 3.2 3.5 4.0 0.7 50.9
33.8 7.6 3.1 3.0 4.0 0.8 52.3
32.6 7.9 3.8 3.2 3.7 0.9 52.1
32.1 7.9 4.6 3.0 3.5 1.6 52.7
32.9 7.1 2.8 2.5 3.7 0.8 49.8
2.9 2.7 5.6
2.0 2.4 0.1 4.5
2.3 2.6 0.2 5.1
2.4 2.7 0.1 5.2
3.1 3.1 0.2 6.4
3.0 3.6 0.2 6.8
15.8 27.7 43.5
34.1 49.8 83.9
37.1 69.5 106.6
33.1 78.0 111.1
36.3 85.5 121.8
27.8 75.3 103.1
41.5 20.9 62.4 2.0
83.2 42.6 125.8 2.0
96.5 64.0 160.5 3.1
110.0 65.8 175.8 3.5
118.4 72.7 191.1 5.1
98.3 77.7 176.0 4.1
Statel
Resl Fellow (28)
Table 4. Practice Type (N) and Practice Profile
1. Activity (hrs) Office Surgery/hosp Admin Teaching Cont ed Other Total (hrs) 2. Time away from practice (wks) Medical meetings Vacation Other Total (wks) 3. Number of visits New Return Total 4. Number of surgical procedures Major Minor Total 5. Time to new appointment (wks)
Solo (658)
Ophthal Group (303)
MultiGroup (50)
Univ (72)
34.8 7.0 2.6 1.9 3.9 0.5 50.7
33.7 8.1 2.8 2.4 3.5 0.5 51.0
35.8 6.7 2.7 2.2 3.0 0.3 50.7
17.7 8.9 9.8 10.7 4.2 6.3 57.6
25.1 8.7 7.9 7.0 3.7 2.4 54.8
24.2 11.9 3.3 3.4 7.4 4.2 54.4
2.6 2.9 0.1 5.6
2.5 3.3 0.1 5.9
2.2 3.4 0.4 6.0
3.8 2.7 0.7 7.2
1.8 3.2 1.6 6.6
1.4 2.7 4.1
34.0 74.3 108.3
36.0 84.3 120.3
41.1 79.7 120.8
16.6 41.5 58.1
23.7 40.4 64.1
19.2 29.1 48.3
102.1 85.4 187.5 3.7
124.3 74.6 198.9 3.8
94.1 79.8 173.9 3.5
101.1 28.6 129.6 2.9
86.1 47.2 133.3 4.6
50.4 18.0 68.4 2.0
and plastic surgery-2; and other-l. Some patients were examined for more than one disease on a given visit. The respondents indicated that the average length of
Fed (22)
time between a new patient's request for a periodic eye examination and the scheduled appointment was 3.6 weeks. Table 4 lists the hours worked, weeks away from
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Table 5. First and Second Practice Location Reason by Age (%) Age (Yrs)
<31 Reason Where I grew up Near family Near residency Community need Teaching Climate Recreation Other
--
13.1 15.8 13.1
15.8
31-35 36-40 41-45 46-50
>50
13.6 8.9
11.6 9.2
9.0 8.3
11.1
18.0 9.3
20.6
20.6
20.7
20.0
11.2
13.9
19.9 9.4 11.6
9.8
9.7
Table 6. First and Second Practice Location Reason by Practice Type (%)
Where I grew up Near family Community need Research Teaching Climate Recreation
Solo
Ophth Group
MultiGroup
14.510.4 22.5
12.6 7.5 20.0
10.6
11.1
13.3
22.1 16.8 11.5
Univ
Statel Fed
10.2 10.2
19.3 30.4 20.7
18.0
6.7
28.2
- Percent of respondents listing this as first or second reason among all reasons listed (see sample questionnaire).
active practice, and practice volume by practice type. The total work week was longer for university, state, and federal ophthalmologists and those in training. Time away from practice was highest for those associated with university and least for those in training. Ophthalmologists in group practice saw more patients and did more surgery than other practice types. The averages of the numbers of people that ophthalmologists reported they employed in their office are: receptionist-I.3; secretary-I.O; ophthalmic technician-I.O; nurse-0.6; optometrist-0.2; orthoptist-O.l; photographer-O.l; and others-O.4. This is an average total of 4.7 individuals assisting the ophthalmologist in the office. In response to the question asking ophthalmologists to rank the reasons for selecting their current practice location on a scale of one through four, the following were listed as primary reasons: (a) community need for ophthalmological care (31 %) ; (b) proximity to hometown (22%); (c) climate (12%); and (d) proximity to family (7%). The four most common secondary reasons for location included: (a) community need for ophthalmological care (12%); (b) proximity to family (12%); (c) climate (11%); and (d) hospital facilities (10%). It is noteworthy that 42% selected their practice location with community need as either their primary or secondary factor. The four most common reasons ranked as either third or fourth in importance included the following: (a) hospital facilities (32%); (b) cultural opportunities (18%); (c) educational opportunities for my family (21%); and (d) climate (20%). Responses are related to age and practice type in Tables 5 and 6.
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Finally, the section on manpower opinion asked four questions regarding the individual's perception of the local and national need and supply of ophthalmologists and optometrists. In their local area, 51% felt the number of ophthalmologists trained should remain the same, while 41% thought it should be decreased and only 8% indicated the number should be increased. Concerning the number of ophthalmologists trained nationally, 45% felt it should remain the same; 40% indicated it should be decreased, while 15% thought it should be increased. Hence, over 90% of the respondents felt the number of ophthalmologists trained should remain the same or be decreased in their local area, and 85% felt there should either be no change or a decrease in the numbers nationally. Table 7 relates ophthalmologists' opinions regarding the number of ophthalmology residents trained in their local area and nationally to age of respondent. In general, the younger ophthalmologists, especially those in their 30s, were more inclined to feel that the number should remain stable or be decreased. Table 8 relates the opinions on ophthalmology manpower to practice type. A striking but perhaps expected finding is that over half of ophthalmologists-in-training felt their numbers should be decreased both locally and nationally. In response to the question about the number of optometrists being trained in their local area, 65% expressed that this number should be decreased, while 34% felt it should remain the same, and only 1% thought it should be increased. Regarding the national scene, 70% of respondents felt the number of optometrists in training should be decreased, 29% indicated that it should remain the same, and only 1% thought it Table 7. Opinion About Ophthalmology Manpower By Age Age (Yrs) <31 (27) Local area (N) Increase (%) 7 Decrease (%) 33 Same (%) 60 National (N) (27) Increase (%) 11 Decrease (%) 41 Same (%) 48
31-35 36-40 41-45 46-50 >50 (120) 3 55 42 (119) 5 58 37
(257) 4 49 47 (256) 8 53 39
(207) 7 42 51 (207) 12 45 43
(178) 10 45 45 (175) 17 40 43
(401) 10 30 60 (396) 23 25 52
Table 8. Opinion About Ophthalmology Manpower By Practice Type Solo Local area (N) Increase (0/0) Decrease (0/0) Same (0/0) National (N) Increase (0/0) Decrease (0/0) Same (0/0)
(647) 8 42 50 (642) 17
37 46
Ophth Group
MultiGroup
Univ
(294) 4 44 52 (291) 12 47 42
(56) 9 43 48 (55) 16 53 31
(71) 7 35 58 (71) 6 45 49
Statel Fed
Res! Fellow
(21) 24 29 47 (21) 14 38 48
(25) 0 52 48 (25) 8 60 32
should be increased. Hence, 99% of ophthalmologists felt that the number of optometry students being trained locally and nationally should either be decreased or remain the same.
Part IV of the ophthalmology manpower studies will be based on a synthesis of the preceding three parts and will present an overview and recommendations concerning the future supply and requirements for ophthalmologists and other allied health personnel.
DISCUSSION Among our sample, approximately 6% of those who responded indicated that they were not in full-time active clinical practice. Assuming this is representative of the population sampled, this would reduce the supply of clinically active ophthalmologists to about 11,000. Nationally, the productivity or the supply of ophthalmological services based on the average of39.4 hours per week (the total of office and hospital care) for 46.2 weeks per year for 11,000 ophthalmologists would equal slightly more than 20 million hours. This figure falls short of the 32.2 million hours of estimated requirements for 1977 in the Part I report. 1 In addition, the latest "Report to the President and Congress on the Status of Health Professions Personnel in the United States"7 indicated that for physician requirements projections the "largest 1975-1990 increases are foreseen for ophthalmologists .... The large increase in ophthalmologists requirements reflects increases in the age 65 and over population and the population growth in the higher income groups which have relatively high rates of vision care utilization." The requirement in this report for ophthalmologists for 1990 is 20,000. This number is in sharp contrast to the recently released report of the Graduate Medical Education National Advisory Committee (GMENAC).8 The GMENAC report projected that the 1990 requirement for ophthalmologists would be only 11,600. The GMENAC report also estimated that the supply of ophthalmological specialists would total 16,300 in 1990. Hence, GMENAC predicted an oversupply, yet the requirements projection contained in the "Report to the President and Congress ... " would clearly indicate an undersupply. These two reports present widely divergent estimates of the number of ophthalmologists required to meet assumed 1990 population needs. This major discrepancy should add further emphasis to concerns expressed about the GMENAC report; namely, that the data presently available are simply inadequate to yield precise estimates. In addition, the nature of the assumption on which projections are based can substantially influence the results. Hence, at present, there does not appear to be a reliable estimate of the need for ophthalmological services in the future. Estimates of the requirement for ophthalmologists should be continually evaluated as better data become available, and the assumptions on which projections are based should be continually reviewed to determine if they are still accurate and appropriate.
SUMMARY The figures in this survey regarding the number of hours worked, the practice profile, and use of office personnel are similar to previous surveys. 3,4 The reasons for practice location are noteworthy in that they indicate a strong desire to practice in a community needing ophthalmological care. Only when the third and fourth reasons are considered, did elements such as educational opportunities, climate, recreational facilities, and other reasons enter into the decision. Interestingly, being near one's family or practicing in an area where one was born or grew up remain important factors even in our mobile society. Finally, the majority of ophthalmologists responding to this survey indicated that the number of ophthalmologists presently being trained, whether locally or nationally, was either appropriate or excessive and that the number of optometrists being trained is already excessive.
REFERENCES t Reinecke RD, ed. Ophthalmology (eye physician and surgeon) 2.
3.
4. 5. 6.
7.
8.
manpower studies for the United States, part I. Ophthalmology 1978; 85: 1057 -138. Reinecke RD, Steinberg T, eds. Ophthalmology manpower studies for the United States (Part II): demand for eye care. A public opinion poll based upon a Gallup poll survey. Ophthalmology 1981; 88:34A -47 A. Mendenhall RC, et a!. Ophthalmology practice study report, contract no. USPHS (HRA) 232-78-0160. University of Southern California School of Medicine, April 1979. Worthen, DM. Future use and development of eye-care manpower. Surv Ophthalmol 1974; 18:442-8. Goldberg, JH. Ophthalmologists: still spending more to earn more. Med Econ January 22, 1979; 172-6. US Dept of Health, Education, and Welfare, Public Health Service: Ophthalmology Manpower: Characteristics of Clinical Practice. DHEW Pub No (HSM) 73-1802, March 1973. A Report to the President and Congress on the Status of Health Professions Personnel in the United States. US Dept of Health, Education, and Welfare, Health Resources Administration, Bureau of Health Manpower, Division of Manpower Analysis. DHEW Publication No (HRA) 80-53, August 10, 1980, pp IV-13. Graduate Medical Education National Advisory Committee: GMENAC Summary Report, Vol 1, September 1980, p 19 (Dept of Health and Human Services, Health Resources Administration).
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