Pediatric Urological Manpower Report

0022-534 7/93/1502-0675$03.00/0 THE JOURNAL OF UROLOGY Copyright © 1993 by AMERICAN UROLOGICAL ASSOCIATI O N , INC.

Vol. 150, 675-679, August 1993 Printed in U. S. A .

PEDIATRIC UROLOGICAL MANPOWER REPORT ELLEN SHAPIRO AND DAVID A. HATCH ON BEHALF OF THE PEDIATRIC UROLOGICAL MANPOWER COMMITTEE OF THE AMERICAN ASSOCIATION OF PEDIATRIC UROLOGY* ABSTRACT

The American Association of Pediatric Urology initiated a Pediatric Urological Manpower Study in 199 1 . A 24-question survey was distributed to the members of the Society of Pediatric Urology and the American Academy of Pediatrics Section on Urology. The objective of the questionnaire was to obtain information related to fellowship training, regional distribution of pediatric urologists, and practice patterns and attitudes. As of December 3 1 , 199 1 , 345 questionnaires were distributed, and 244 ( 71 % ) were completed and entered into a computer program. The number of pediatric urologists was evenly distributed among 3 consecutive 10-year age groups ranging between age 3 1 and 60 years. The majority (78% ) of urologists practicing 100% pediatric urology were between 3 1 and 50 years old. Approximately 6 0 % of the responders practiced full-time (100 % ) pediatric urology and 59% of this group were university based. Pediatric urologists were practicing in 42 states and the District of Columbia. Based upon the United States Department of Commerce 1990 census, the number of pediatric urologists practicing in each state in relation to the total pediatric (less than 18 years old) populations was determined. The number of pediatric urology fellowships has steadily increased since the mid 1950s. Currently, more than 10 fellows are trained annually. Of the 1 72 responders practicing at least 75% pediatric urology 24% indicated that practice was "too busy" and 53% indicated that practice was "just right." Approximately 44 % of the responders were considering adding a partner: 21 indicated that they planned to add a partner in 1 year, 65 in 5 years and 10 in 10 years. Hopefully, the Pediatric Urological Manpower Study will serve as a useful instrument for assessing the pediatric practice patterns and training needs in the United States, thereby enhancing the quality of urological care for children. During the last 2 decades the American Urological Associa­ tion (AUA) has evaluated the urological manpower in the United States. 1 The first Manpower Committee was commis­ sioned in 1976 to determine the number, location and practice patterns of urologists in America. The report revealed that there were 5,587 urologists in active practice servicing a popu­ lation of 2 14,544,900 Americans. This translated to a ratio of 1 urologist for every 38,401 persons. The report of the Manpower Committee predicted a decrease in this ratio to 1 urologist for every 30,000 persons by 1985. The second Manpower Study was performed in 1980. A 30% increase in the number of practicing urologists was observed and the ratio decreased to 1 urologist for every 3 1 ,446 persons. This ratio was achieved 5 years earlier than anticipated. This study suggested that the unexpected increase in urologists was due to heavy immigration of fully trained urologists from other countries. The most recent Manpower Survey was performed by the AUA in 1985. This comprehensive report determined that there were 8,702 urologists in active practice serving a population of 240,833,500 with a ratio of 1 urologist for every 27,676 persons. This study predicted an excess of 10,000 urologists in active practice by 1995. Despite the relative increase in the number of urologists per population from 1975 to 1985, the practice patterns have been stable and the number of major urological procedures performed per 1 million population has increased by 42 % . It was not discernible from the questionnaire whether urological procedures increased because more operations were performed by a urologist, more urological diseases were being diagnosed or certain urological diseases were now being man­ aged surgically. In January 1991 the future of pediatric urological fellowships was discussed at the annual business meeting of the American * Members of the Committee include Drs. H. Gil Rushton, Michael L. Ritchey, Jack S. Elder, William C. Hulbert, Jr. and J. David Moorhead. 675

Association of Pediatric Urology. It became evident that na­ tional decisions related to the optimal number of pediatric urological fellowships must be based upon pediatric urological manpower to predict future needs accurately in this country. It was recommended that a 7-member committee of the American Association of Pediatric Urology conduct a pediatric urological manpower study. A 24-question survey was outlined. METH O D S

The 24-question survey was initially distributed at the 1991 annual meeting of the Society of Pediatric Urologists (SPU) in Toronto. Additional surveys were mailed to the members of the SPU and the American Academy of Pediatrics (AAP) Section on Urology, who had not submitted a completed questionnaire within 4 weeks of the SPU meeting. Questionnaires were also mailed to nonresponders who were known to practice 75 to 100% pediatric urology and nonresponders who had completed their fellowships and were practicing 100% pediatric urology but were not yet Board certified and eligible for membership in the SPU or AAP Section on Urology and, therefore, were not on the membership rosters. The purpose of the questionnaire was to obtain information related to fellowship training, re­ gional distribution, and practice patterns and attitudes. Popu­ lation figures for 1990 were obtained from the United States Department of Commerce Census Bureau. 2 A computer drawn population map of the United States was also used to identify the practicing pediatric urologists and indicate the location of practice. Regional service areas were determined based upon the total state populations and the state populations of those individuals less than 18 years old. All of the responses were entered into a computer program of the Department of Urology, Medical College of Wisconsin, Milwaukee, Wisconsin. The data were formatted by a computer programmer. RESULTS

As of December 31, 199 1 , 345 questionnaires were distributed, and 244 (71 % ) were completed and entered into a computer

676

PEDIATRIC UROLOGICAL MANPOWER REPORT

program. The age distribution of pediatric urologists is shown in table 1. The number of pediatric urologists is evenly distrib­ uted among 3 consecutive 10-year age groups, ranging between age 31 and 60 years. The majority (78%) of urologists practicing 100% pediatric urology are between 31 and 50 years old. Of the urologists between 31 and 50 years old practicing pediatric urology 88% practice more than 50% pediatric urology. Of the urologists between 51 and 70 years old practicing pediatric urology 43% practice more than 50% pediatric urology. Approximately 60% of responders practiced full-time (100%) pediatric urology and 59% of this group were university based (table 2). Only 21% of the full-time pediatric urologists are in private practice, whereas 65% of the individuals practicing 25% or less pediatric urology are in private practice. Of the 144 urologists who practice 100% pediatric urology 74 are in a solo practice and 70 have at least 1 associate. Pediatric urologists practice in 42 states and the District of Columbia. Figure 1 shows the distribution of the total number of pediatric urologists throughout the United States. Figure 2 illustrates the distribution of pediatric urologists by AUA geo­ graphical section and the level of activity. Table 3 lists the states in population rank order according to the United States Department of Commerce 1990 Census, the number of pediatric urologists practicing in each state and the inhabitants of each state per pediatric urologist. The number of pediatric urologists is expressed as the total number of individuals who practice pediatric urology and as the number of pediatric urology full­ time equivalents, which considers those individuals who do not practice 100% pediatric urology. For example, 2 pediatric urolTABLE

Age (yrs.)

No.

31-40 41-50 51-60 61-70 >70

75 72

1. Age distribution of pediatric urologists

77

19 1

% Pediatric Urology 100

75

50

24.0 22.0 l l .4 1.6

4.5 2.5 4.0 0.4

1.6 2.5 3.6 2.0

25 or less 0.4 2.9 12.0 3.7 0.4

Total 31 29 32 8 0.4

TABLE 2. Pediatric urology practice trends

% Activity

Total No. (%)*

Type of Practice

University

Private

Corporate

86 100 31 144 (59) 7 28 (ll) 9 12 2 75 50 6 24 (10) 13 1 9 25 or less 5 48 (20) 31 Totals llO 244 87 15 Not shown are other practice combinations and no response. * Includes Section members outside of the United States.

University/ Private 13 3 3

19

ogists practicing 50% pediatric urology equals 1 full-time equiv­ alent. The present survey identified 179 prediatric urology equivalents in the United States. The total 1990 population of the United States was 248,709,873 with 1 pediatric urologist for every 1,390,000 Americans. Figure 3 shows the distribution of full-time equivalents per 1,000,000 population. The 1990 United States population less than age 18 years was 63,604,432 (25.5% of total population) with 1 pediatric urologist caring for an average of 355,332 children. Figure 4 illustrates the distri­ bution of full-time equivalents per 100,000,000 population less than 18 years old. Since the mid 1950s urologists have been seeking pediatric fellowship training to enhance their knowledge and surgical skills following residency. The number of pediatric urology fellowships has steadily increased between 1965 and 1975. By the late 1970s as many as 10 fellows were trained each year. Currently, more than 10 fellows are trained annually. The number of pediatric fellows trained at each institution between 1956 and 1991 is shown in table 4. Between 1956 and 1980, 40% of the fellows completing training studied in London (David Innes Williams) or Liverpool (Herbert Johnston), Eng­ land. Since 1980, the programs in the United States, including Children's Hospital of Philadelphia, Children's Memorial Hos­ pital (Chicago), Children's Hospital of Michigan, Boston Chil­ dren's Hospital and Texas Children's Hospital, have provided more than half of the fellowship training in the United States. The Hospital for Sick Children in Toronto has also been an important institution for fellowship education. During the years the length of fellowship training has varied but it has been primarily 1 year in duration at most institutions. Of the 172 responders practicing at least 75% pediatric urology 24% have practices that are currently "too busy" and 63% indicated that the practice load was "just right," whereas the remaining 11% thought that the practice was not busy enough. Half of the individuals in the latter group completed pediatric fellowship training within the last 4 years. The ques­ tionnaire solicited whether the responders would encourage or discourage another pediatric urologist to settle in their area. Although these questions had a significant "no response" rate, only 20% indicated that they would encourage a pediatric urologist to practice in their area. Approximately 44% of the responders (108) were considering adding a partner, 54% (132) were not and 2% (4) had no response. Of the group who considered adding a pediatric urologist to the practice 21 indi­ cated that they would add a partner in 1 year, 65 in 5 years and 10 in 10 years. Table 5 shows the distribution of pediatric urologists by activity level and the number of operations performed each week. Although the questionnaire also asked about the number of patients seen weekly or annually, many of the responders did not discriminate between adult visits and pediatric visits in their response. Also, in group practices the response often reflected the group and not the individual practitioner. There­ fore, data related to patient visits could not be accurately interpreted. DISCUSSION

FIG. 1. Distribution of total number of pediatric urologists through­ out United States.

In 1975 Hodgson and Walsh estimated that the number of major pediatric urology surgical discharges per year was 60 per 100,000 of the United States population, or a total of 127,000 discharges. 3 They calculated that if 8,000 general urologists treated these cases, each would operate on 16 children per year, or 1 child every 3 weeks. If a subspecialist treated a major pediatric urological case each day, 526 subspecialists would be required. It was further noted that since 90% of the pediatric urological operations could be performed by a general urologist, only 53 pediatric urologists would be required to treat the more complex cases. 4 According to the present Manpower Study, an estimated 64,000 pediatric urological cases are treated by the 179 pediatric

PEDIATRIC UROLOGICAL MANPO WER REP O RT

677

N o rt heastern Sect i o n

M i d - At l a n t i c Sect i o n

S o u t h Cent r a l Sect i o n

New E n g l a n d Sect i o n

S o u t heastern Sect i o n N e w Y o r k Sect i o n

• Panama C i t '!' . Panam& • Mayaguez !>R

Western S e ct i o n N o rt h C e n t r a l Sect i o n

.

a

11'

FIG. 2. Distribution of pediatric urologists by AUA geographical section. Level of pediatric urology activity: e, 100% A, 75% •. 50% 0, 25% or less.

678

PEDIATRIC UROLOGICAL MANPOWER REPORT 1990 Population

TABLE 3

Pediatric Urologists

Population Full-Time Full-Time Less Than Full-Time Equivalents/ No. Equivalents/ 18 Yrs. Equivalents* Million Less Million Old Than 18 23 1 CA 29,760,021 7,750,725 18 0.60 2.32 31 2 NY 17,990,455 4,259,549 24.75 1.38 5.81 3 TX 16,986,510 4,835,839 18 12.5 0.74 2.58 4 FL 12,937,926 2,866,237 14 10 0.77 3.49 5 PA 11,881,643 2,794,810 9 9 0.76 3.22 6 IL 11,430,602 2,946,366 9 7 0.61 2.38 7 OH 10,847,115 2,799,744 10 8 0.74 2.86 8 MI 9,295,297 2,458,765 5.5 6 0.59 2.24 9 NJ 1,799,462 7,730,188 3.5 4 0.45 1.95 10 NC 6,628,637 1,606,149 3.5 5 0.53 2.18 11 GA 6,478,216 3.75 1,727,303 5 0.58 2.17 12 VA 6,187,358 1,504,738 4.5 8 0.73 2.99 13 MA 6,016,425 1,353,075 7 7 1.16 5.17 14 IN 5,544,159 1,455,964 3.5 5 0.63 2.40 15 MO 5,117,073 1,314,826 3 4 0.59 2.28 16 WI 4,891,769 1,288,982 4 2.75 0.56 2.13 17 TN 4,877,185 1,216,604 5 6 1.03 4.11 18 WA 4,866,692 1,261,387 2.5 3 0.51 1.98 19 MD 4,781,468 1,162,241 3 4 0.63 2.58 20 MN 4,375,099 1,166,783 5 4.25 0.97 3.64 21 LA 4,219,973 1,227,269 5.75 6 1.36 4.69 22 AL 4,040,587 1,058,788 4 2 0.49 1.89 23 KY 3,685,296 954,094 2.5 4 0.68 2.62 24 AZ 3,665,228 981,119 1 1 0.27 1.02 25 SC 3,486,703 920,207 2 3 0.58 2.17 26 co 3,294,394 861,266 3 3 0.91 3.48 27 CT 2 3,287,116 749,581 1.75 0.53 2.33 28 OK 3,145,585 2 837,007 1 0.32 1.19 29 OR 2,842,321 724,130 1 1 0.35 1.38 30 IA 2,776,755 718,880 0.75 1 0.27 1.04 31 MS 2,573,216 746,761 1 1 0.39 1.34 32 KS 2,477,574 661,614 0 0 0.00 0.00 33 AR 2,350,725 2 621,131 1.25 0.53 2.01 34 WV 1,793,477 3 443,577 1 0.56 2.25 1,722,850 35 UT 3 527,444 2.25 1.31 4.27 36 NE 1,578,385 429,012 3 2 1.27 4.66 37 NM 1,515,069 0 446,741 0 0.00 0.00 38 ME 1,227,928 309,002 1 0.25 0.20 0.81 39 NV 1,201,833 0 296,948 0 0.00 0.00 40 NH 2 1,109,252 278,755 1.25 1.13 4.48 41 HI 1,108,229 1 280,126 0.5 0.45 1.78 42 ID 1,006,749 308,405 0 0 0.00 0.00 43 RI 1,003,464 1 1 225,690 1.00 4.43 44 MT 799,065 0.25 222,104 1 0.31 1.13 45 SD 696,004 0 198,462 0 0.00 0.00 46 DE 666,168 1 163,341 1 1.50 6.12 47 ND 638,800 0 175,385 0 0.00 0.00 48 DC 606,900 4 4 117,092 6.59t 34.16t 49 VT 2 562,758 143,083 1 1.78 6.99 50 AK 172,344 550,043 0 0 0.00 0.00 51 WY 453,588 0 135,525 0 0.00 0.00 * Full-time equivalent is pediatric urologist times proportion of practice spent in pediatrics. t This ratio is based only on the population of the District of Columbia. These figures would be more accurate if based upon the population of the greater metropolitan Washington area (approximately 2.5 million). The ratios would then be 1.6 and 6.67. Rank Order of State

Total Population

urological equivalents who responded to the questionnaire. Therefore, 355 cases are treated by each pediatric urology equivalent per year. In order for a comparison to be made to the 1975 calculations, the pediatric urological case rate based on the total United States population is 25:100,000, a rate substantially lower than the previous estimation of 60:100,000. This rate would be 100:1,000,000 if it were based only on the population less than age 18 years. If 90% of the present cases were treated by a general urologist, only 20 pediatric urologists would be required to manage the remaining complex cases. The present Manpower Study suggests that the majority of all pediatric urological cases are treated by full-time pediatric urologists, indicating that pediatric urology has truly estab­ lished itself as an important surgical specialty among pediatri­ cians and family practice physicians. This recognition has taken decades to evolve, since pediatric urology was first estab­ lished as a specialty in 1951 with the founding of what was to become the SPU.

At this time the majority of children's hospitals in the United States have at least 1 full-time pediatric urologist. These "cen­ ters of excellence" are primarily affiliated with universities and have continued to not only provide the pediatric urological training experience for urology residents but also to stimulate clinical and laboratory research due to the large volume of patients and commitment to basic science. During the last decade pediatric urologists have been striving to define the domain of their speciality and set the standard for pediatric urological practice in the United States. An im­ portant area that distinguishes the pediatric urologist from other urologists is pediatric urological fellowship training. Since there has never been a comprehensive pediatric urological manpower survey of this type, it has been difficult to predict accurately the optimal number of pediatric urology fellowships required to meet the needs of our communities now and in the future. Many pediatric urological fellowship training programs are

679

PEDIATRIC UROLOGICAL l\i!:ANPOWER REPORT

!Ill > 2

f!li C] [] D

1 - 1 .99 0.5 - 0.99 0.1 - 0.49 o

FIG. 3. Distribution of full-time equivalents per 1,000,000 popula­ tion.

TABLE 4. Pediatric urology fellowships Institution 1955-1975 1976-1980 1981-1985 1986-1991 Great Ormond Street, London 15 4 3 4 Alder Hey, Liverpool 10 5 Children's Hospital of Phila1 5 7 8 delphia Children's Memorial Hospital, 4 4 5 9 Chicago Hospital for Sick Children, To2 10 7 16 ronto Children's Hospital of Michi2 4 6 gan Boston Children's Hospital 1 4 6 Massachusetts General Hospi2 3 1 ta! Texas Children's Hospital 5 6 The Johns Hopkins Hospital 4 2 The Mayo Clinic 1 2 3 The Children's Hospital, San 1 4 1 Diego Eggleston Hospital/Emory 1 2 University Duke University Medical Cen2 2 ter 6 Other 2 3 3 TABLE 5. Operations performed weekly by pediatric urologists

No. Operations ill li\ll f!li C] 121 D

> 10 5.0 - 9.99 3.0 - 4.99 2.0 - 2.99 .01 - 1 .99 o

FIG. 4. Distribution of full-time equivalents per 1,000,000 popula­ tion less than age 18 years. 14

0

12

0 u

·c

�

-0

0 0 -----------

(l_

0 1 950

� tt\J'

}j

10

1 960

o J

(\\J

o

boi

1 9 70

'

1}

1 980

1 990

Ye a r FIG. 5 . Pediatric urology fellows trained between 1955 and 1991

available in the United States. The clinical and laboratory requirements for certification are currently being standardized, and specialty training in this area has represented the founda­ tion for the continued growth and acceptance of pediatric urology. Therefore, it is important for pediatric urologists to examine periodically the pediatric practice patterns of all urol­ ogists in the United States, which will ensure that there are an appropriate number of well trained pediatric urologists to pro­ vide quality urological care for children.

0-1 2 3 4 5 6 7 8 or more

No. Pediatric Urologists 25 13 15 23 35 21 18 79

% Practice Activity

100 3 1 1 8 20 15 13 74

75 2 1 3 7 4 5 5

50 6 10 6 2

25 22 10 7 2 2

In addition, if current fellowship practices continue to train 10 to 12 pediatric urologists per year, the availability of posi­ tions for these individuals should be determined before they are trained. The survey indicates that during the next 10 years, 95 positions will be available for fellowship-trained pediatric urologists. Therefore, training 8 to 10 individuals each year would meet the anticipated manpower need during the next 10 to 15 years. After that time, the needs may change depending upon the population growth, health care policies and referral patterns, and the retirement plans of the older pediatric urol­ ogists. Therefore, as positions are filled, it will be important to update periodically our manpower database so that we can increase or reduce the number of new individuals being trained. If manpower is correctly predicted, pediatric urologists should continue to care for sufficient numbers of patients to remain on the forefront in this challenging and changing speciality of urology. REFERENCES 1. Urological Manpower Report for the year ending December 31, 1985. 2. 1990 Bureau of the Census Report. The United States Department of Commerce News, Washington, D. C., 1991. 3. Hodgson, N. B. and Walsh, J. P.: Demography and pediatric urology (editorial). J. Urol., 1 14: 2, 1975. 4. Hinman, F., Jr.: American Pediatric Urology. San Francisco: Nor­ man Publishing, 1991.