- Email: [email protected]
Pediatric workforce: A look at pediatric rheumatology data from the American Board of Pediatrics
PEDIATRIC WORKFORCE: A LOOK AT PEDIATRIC RHEUMATOLOGY DATA FROM THE AMERICAN BOARD OF PEDIATRICS LINDA A. ALTHOUSE, PHD,
AND JAMES
A. STOCKMAN III, MD
his report, which is part of a series discussing workforce trends for general pediatrics and related subspecialty areas, highlights the American Board of Pediatrics’ (ABP) workforce data for pediatric rheumatology. Readers are encouraged to read the initial report1 in the series, as it provides information regarding general pediatrics and summary information about other ABP subspecialties. In 1990, pediatric rheumatology became the 10th ABP subboard to offer a certification examination, with the first examination yielding 87 board-certified pediatric rheumatologists. Today, more than 200 pediatricians have been certified by the ABP as pediatric rheumatologists. The focus of this report is to provide a snapshot of the current ABP workforce data for this subspecialty. The full ABP workforce data are available on the ABP Web site at www.abp.org.
T
METHODS As described in the initial report, the ABP uses three primary methods to collect and maintain data about workforce numbers: tracking of residents and fellows, examination application surveys, and continual maintenance of the ABP master database as persons become certified. Tracking for first-year fellows began in 1995. By 1997–1998, all subspecialty fellows in all training levels were tracked. In 2005, the ABP contacted all accredited pediatric rheumatology training programs in the US (n ⫽ 25) and Canada (n ⫽ 3) to obtain tracking information. All but two programs returned their tracking information.
RESULTS Pediatric Rheumatology Fellow Tracking Table I provides the total number of fellows in training since the 1997–1998 academic year, with a breakdown by sex and medical school. The number of fellows enrolled in pediatric rheumatology has been steadily increasing, more than doubling since 1997. The total percentage of women in pediatric rheumatology training is currently at 64.6%. The percent of women has fluctuated from a high of 74.2% in 2000 to a low of 54.2% in 1997 and 1998. However, these fluctuations are expected given the small sample size. The number of American Medical School Graduates (AMG) fellows has increased since 1997, from 58.3% to a current peak of 72.3% in 2005. The Figure illustrates the number of fellows in training at each level. Since 1997–1998, the average drop rate from training year 1 to training year 3 is 21%. The decline may be attributed to many factors such as personal leave, visa restrictions, and ABP-approved abbreviated training pathways. In addition, those who have completed fellowship training in Canada only need 2 years of training to be certified by the Royal College of Physicians and Surgeons of Canada. These various factors make it difficult to ascertain whether the drop rate is a true reflection of those actually leaving the subspecialty. Pediatric Rheumatology Career Data The ABP has two primary opportunities to gather information regarding career interest in pediatric rheumatology: a survey given to all first-time applicants for the general pediatrics certification examination and a survey given to all first-time applicants for the pediatric rheumatology certification examination. The following section highlights results from both the 2005 general pediatrics and 2004 pediatric rheumatology applications (no pediatric rheumatology examination was administered in 2005). From the American Board of Pediatrics, Chapel Hill, North Carolina. Of the 2994 first-time candidates applying for the general pediatrics certification Submitted for publication Aug 31, 2006; examination in 2005, 866 (29%) indicated an interest in one of the subspecialty areas in accepted Sep 23, 2006. which the ABP awards or jointly awards certificates. Pediatric rheumatology was selected Correspondence: Linda A. Althouse, PhD, American Board of Pediatrics, 111 Silver by 2.7% of these 866 applicants, making it the 12th most selected pediatric subspecialty. Cedar Court, Chapel Hill, NC 27514. EThe pediatric rheumatology certifying examination is given every 2 years. In 2004, there mail: [email protected]. were 21 first-time applicants for the pediatric rheumatology certification examination. Of J Pediatr 2006;149:869-70 ABP AMG
American Board of Pediatrics American Medical School Graduates
FOPE II
Future of Pediatric Education II
0022-3476/$ - see front matter Copyright © 2006 Mosby Inc. All rights reserved. 10.1016/j.jpeds.2006.09.038
869
Table I. Total number of pediatric rheumatology fellows in training since 1997 Year
Total
Female
Male
AMG
IMG
1997–1998 1998–1999 1999–2000 2000–2001 2001–2002 2002–2003 2003–2004 2004–2005 2005–2006
24 24 33 31 38 44 47 58 65
54.2% 54.2% 63.6% 74.2% 68.4% 59.1% 68.1% 55.2% 64.6%
45.8% 45.8% 36.4% 25.8% 31.6% 40.9% 31.9% 44.8% 35.4%
58.3% 58.3% 54.5% 67.7% 68.4% 59.1% 57.4% 63.8% 72.3%
41.7% 41.7% 45.5% 32.3% 31.6% 40.9% 42.6% 36.2% 27.7%
District of Columbia. Pediatric rheumatologists older than the average retirement age of 65 years were excluded. Based on these adjustments, the total number of certified pediatric rheumatologists categorized in Table II is 186. Only two states have a pediatric rheumatologist-tochild ratio of at least 1 per 100,000 children, with the District of Columbia having the largest ratio (3.7), followed by Delaware (1.0). The remaining states have a ratio of ⬍1; in 14 states no certified pediatric rheumatologists practice. The 25 US pediatric rheumatology training programs are distributed across 25 states and the District of Columbia, as noted by the asterisk in Table II. The number in parentheses denotes the number of training programs in the state that were tracked during the 2005–2006 tracking period.
DISCUSSION
Figure. Number of pediatric rheumatology fellows in training at each training level.
these applicants, 76% were women and 71% were AMGs. Approximately 67% plan to practice exclusively in pediatric rheumatology in an academic setting. An additional 10% plan to practice exclusively in pediatric rheumatology but in a private practice or combined private practice and academic setting.
Certified Diplomates As a pediatric subspecialty, pediatric rheumatology is one of the smallest disciplines, with approximately 215 certified practitioners (as of 12/31/2005), having only more pediatric specialists than Sports Medicine and Medical Toxicology, whose examinations are administered jointly with other boards. The mean age of certified pediatric rheumatologists is 50.1 years, with approximately 95% ranging from 31 to 65 years of age. The ratio of current ABP-certified pediatric rheumatologists to children younger than 18 years of age in each of the 50 states and the District of Columbia is shown in Table II (available at www.jpeds.com). The population of children listed in the table is based on the US Census Bureau Population Estimates and includes all children under the age of 18.2 These numbers are based on a list of pediatric rheumatologists with known addresses in each of the 50 states or the
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Althouse and Stockman
Although many studies have projected physician workforce needs, it was not until the Future of Pediatric Education II (FOPE II) task force report that a recent and detailed study focused exclusively on pediatrics, both at the generalist and subspecialty level.3,4 In 2005, the total number of pediatric rheumatologists in training (training years 1 through 3) increased 12.1% from the previous year. The average rate of increase in the number of entering fellows since 1997 is 14.5%. However, as noted earlier, given the small number of trainees percentage values can easily fluctuate. Although the data in Table II provide the pediatric rheumatologist-to-child ratio, the data do not indicate who is working full-time or part-time. General pediatrics research has shown an increasing trend toward part-time work, particularly with the increase in the number of women entering pediatrics.5,6 However, there are no current data to indicate that this is the case in pediatric rheumatology, but further research is needed. In fact, studies have reported that women are equally likely to work full-time and treat an equal number of patients as their male colleagues.6,7 In addition, although it is important to have an adequate number of physicians, where these physicians practice is just as critical in determining if appropriate care is available to all children. With the lack of pediatric rheumatologists in many geographic locations, there has been necessary reliance on adulttrained rheumatologists in providing care to children.8,9 As Stoddard et al note, the FOPE II study provides the supply-side perspective.4 The ABP data in this report provide the same perspective. These data are useful not only to those studying workforce trends, but also to medical students and pediatric residents making career decisions. However, these data do not address or gauge the need for medical services. Although workforce studies are not new, attention to workforce issues for pediatric subspecialties is relatively new, with two recent studies conducted for pediatric rheumatology.8,10 It is important that workforce research continues from both the supply and demand perspective. Only then can we be sure that the goal of providing all children with access to high-quality care will be met. References available at www.jpeds.com.
The Journal of Pediatrics • December 2006
REFERENCES 1. Althouse LA, Stockman JA. Pediatric Workforce: A look at general pediatrics data from the American Board of Pediatrics. J Pediatr 2006:148:166-9. 2. US Bureau of the Census. Population Estimates by State. Revised July 1, 2004. Available online at: http://www.census.gov/popest/states/asrh/SCest2004-02.html. Accessed April 18, 2005. 3. The Future of Pediatric Education II: organizing pediatric education to meet the needs of infants, children, adolescents, and young adults in the 21st century. Pediatrics 2000;105:163-212. 4. Stoddard JJ, Cull WL, Jewett EA, Brotherton SE, Mulvey HJ, Alden ER. Providing pediatric subspecialty care: a workforce analysis. Pediatrics 2000;106:1325-33. 5. Freed GL, Nahra TA, Wheeler JR. Predicting the pediatric workforce: use of trend analysis. J Pediatr 2003;143:570-5.
6. Brotheron SE, Mulvey HJ, O’Conner KG. Women in pediatric practice: trends and implications. Pediatr Ann 1999; 28:177-83. 7. Mayer ML, Preisser JS. The changing composition of the pediatric medical subspecialty workforce. Pediatrics 2005;116:833-40. 8. Mayer ML, Mellins ED, Sandborg CI. Access to pediatric rheumatology care in the United States. Arthritis Rheum 2003;49:759-65. 9. Mayer ML, Sandborg CI, Mellins ED. Role of pediatric and internist rheumatologists in treating children with rheumatic diseases. Pediatrics 2004; 113(3 Pt 1):e173-e181. 10. American College of Rheumatology Blue Ribbon Committee for Academic Pediatric Rheumatology. The future status of pediatric rheumatology in the United States: strategic planning for the year 2000. Arthritis Rheum 2003;43:239-42.
Pediatric Workforce: A Look At Pediatric Rheumatology Data From The American Board Of Pediatrics
870.e1
Table II. Number of ABP-certified pediatric rheumatology diplomates by state (as of 12/31/05)
State Alabama Alaska Arizona Arkansas California* (4) Colorado Connecticut Delaware* (1) District of Columbia Florida Georgia Hawaii Idaho Illinois* (2) Indiana* (1) Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts* (2) Michigan* (1) Minnesota Mississippi Missouri* (2) Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York* (3) North Carolina* (1) North Dakota Ohio* (1) Oklahoma Oregon Pennsylvania* (2) Rhode Island South Carolina South Dakota Tennessee* (1) Texas* (2) Utah Vermont Virginia Washington* (1) West Virginia Wisconsin* (1) Wyoming
Number of ABP diplomates in pediatric rheumatology
Child population
Physician-to-child ratio (per 100,000 children)
0 0 0 0 22 1 4 2 4 10 2 2 0 7 2 1 1 2 1 0 6 12 6 5 1 7 0 1 0 0 6 1 18 3 0 10 3 2 14 1 0 0 1 6 2 1 6 8 0 5 0 186
1,094,533 188,229 1,547,260 676,550 9,596,463 1,178,889 838,788 193,506 109,547 4,003,290 2,332,567 298,693 372,411 3,238,150 1,600,295 680,437 683,491 980,187 1,164,961 282,129 1,394,808 1,464,189 2,533,439 1,240,280 749,569 1,384,542 208,093 434,566 603,596 304,994 2,156,059 492,287 4,572,363 2,118,492 138,955 2,779,212 859,870 852,357 2,837,009 243,813 1,024,700 190,874 1,391,289 6,266,779 740,114 134,894 1,804,900 1,486,020 384,641 1,307,986 116,932 73,277,998
0 0 0 0 0.2 0.1 0.5 1 3.7 0.2 0.1 0.7 0 0.2 0.1 0.1 0.1 0.2 0.1 0 0.4 0.8 0.2 0.4 0.1 0.5 0 0.2 0 0 0.3 0.2 0.4 0.1 0 0.4 0.3 0.2 0.5 0.4 0 0 0.1 0.1 0.3 0.7 0.3 0.5 0 0.4 0 0.3
*Note: States with an asterisk denote those with a pediatric rheumatology training program. The number in parentheses indicates the number of programs tracked in the 2005–2006 academic year.
870.e2
Althouse and Stockman
The Journal of Pediatrics • December 2006
AND JAMES
A. STOCKMAN III, MD
his report, which is part of a series discussing workforce trends for general pediatrics and related subspecialty areas, highlights the American Board of Pediatrics’ (ABP) workforce data for pediatric rheumatology. Readers are encouraged to read the initial report1 in the series, as it provides information regarding general pediatrics and summary information about other ABP subspecialties. In 1990, pediatric rheumatology became the 10th ABP subboard to offer a certification examination, with the first examination yielding 87 board-certified pediatric rheumatologists. Today, more than 200 pediatricians have been certified by the ABP as pediatric rheumatologists. The focus of this report is to provide a snapshot of the current ABP workforce data for this subspecialty. The full ABP workforce data are available on the ABP Web site at www.abp.org.
T
METHODS As described in the initial report, the ABP uses three primary methods to collect and maintain data about workforce numbers: tracking of residents and fellows, examination application surveys, and continual maintenance of the ABP master database as persons become certified. Tracking for first-year fellows began in 1995. By 1997–1998, all subspecialty fellows in all training levels were tracked. In 2005, the ABP contacted all accredited pediatric rheumatology training programs in the US (n ⫽ 25) and Canada (n ⫽ 3) to obtain tracking information. All but two programs returned their tracking information.
RESULTS Pediatric Rheumatology Fellow Tracking Table I provides the total number of fellows in training since the 1997–1998 academic year, with a breakdown by sex and medical school. The number of fellows enrolled in pediatric rheumatology has been steadily increasing, more than doubling since 1997. The total percentage of women in pediatric rheumatology training is currently at 64.6%. The percent of women has fluctuated from a high of 74.2% in 2000 to a low of 54.2% in 1997 and 1998. However, these fluctuations are expected given the small sample size. The number of American Medical School Graduates (AMG) fellows has increased since 1997, from 58.3% to a current peak of 72.3% in 2005. The Figure illustrates the number of fellows in training at each level. Since 1997–1998, the average drop rate from training year 1 to training year 3 is 21%. The decline may be attributed to many factors such as personal leave, visa restrictions, and ABP-approved abbreviated training pathways. In addition, those who have completed fellowship training in Canada only need 2 years of training to be certified by the Royal College of Physicians and Surgeons of Canada. These various factors make it difficult to ascertain whether the drop rate is a true reflection of those actually leaving the subspecialty. Pediatric Rheumatology Career Data The ABP has two primary opportunities to gather information regarding career interest in pediatric rheumatology: a survey given to all first-time applicants for the general pediatrics certification examination and a survey given to all first-time applicants for the pediatric rheumatology certification examination. The following section highlights results from both the 2005 general pediatrics and 2004 pediatric rheumatology applications (no pediatric rheumatology examination was administered in 2005). From the American Board of Pediatrics, Chapel Hill, North Carolina. Of the 2994 first-time candidates applying for the general pediatrics certification Submitted for publication Aug 31, 2006; examination in 2005, 866 (29%) indicated an interest in one of the subspecialty areas in accepted Sep 23, 2006. which the ABP awards or jointly awards certificates. Pediatric rheumatology was selected Correspondence: Linda A. Althouse, PhD, American Board of Pediatrics, 111 Silver by 2.7% of these 866 applicants, making it the 12th most selected pediatric subspecialty. Cedar Court, Chapel Hill, NC 27514. EThe pediatric rheumatology certifying examination is given every 2 years. In 2004, there mail: [email protected]. were 21 first-time applicants for the pediatric rheumatology certification examination. Of J Pediatr 2006;149:869-70 ABP AMG
American Board of Pediatrics American Medical School Graduates
FOPE II
Future of Pediatric Education II
0022-3476/$ - see front matter Copyright © 2006 Mosby Inc. All rights reserved. 10.1016/j.jpeds.2006.09.038
869
Table I. Total number of pediatric rheumatology fellows in training since 1997 Year
Total
Female
Male
AMG
IMG
1997–1998 1998–1999 1999–2000 2000–2001 2001–2002 2002–2003 2003–2004 2004–2005 2005–2006
24 24 33 31 38 44 47 58 65
54.2% 54.2% 63.6% 74.2% 68.4% 59.1% 68.1% 55.2% 64.6%
45.8% 45.8% 36.4% 25.8% 31.6% 40.9% 31.9% 44.8% 35.4%
58.3% 58.3% 54.5% 67.7% 68.4% 59.1% 57.4% 63.8% 72.3%
41.7% 41.7% 45.5% 32.3% 31.6% 40.9% 42.6% 36.2% 27.7%
District of Columbia. Pediatric rheumatologists older than the average retirement age of 65 years were excluded. Based on these adjustments, the total number of certified pediatric rheumatologists categorized in Table II is 186. Only two states have a pediatric rheumatologist-tochild ratio of at least 1 per 100,000 children, with the District of Columbia having the largest ratio (3.7), followed by Delaware (1.0). The remaining states have a ratio of ⬍1; in 14 states no certified pediatric rheumatologists practice. The 25 US pediatric rheumatology training programs are distributed across 25 states and the District of Columbia, as noted by the asterisk in Table II. The number in parentheses denotes the number of training programs in the state that were tracked during the 2005–2006 tracking period.
DISCUSSION
Figure. Number of pediatric rheumatology fellows in training at each training level.
these applicants, 76% were women and 71% were AMGs. Approximately 67% plan to practice exclusively in pediatric rheumatology in an academic setting. An additional 10% plan to practice exclusively in pediatric rheumatology but in a private practice or combined private practice and academic setting.
Certified Diplomates As a pediatric subspecialty, pediatric rheumatology is one of the smallest disciplines, with approximately 215 certified practitioners (as of 12/31/2005), having only more pediatric specialists than Sports Medicine and Medical Toxicology, whose examinations are administered jointly with other boards. The mean age of certified pediatric rheumatologists is 50.1 years, with approximately 95% ranging from 31 to 65 years of age. The ratio of current ABP-certified pediatric rheumatologists to children younger than 18 years of age in each of the 50 states and the District of Columbia is shown in Table II (available at www.jpeds.com). The population of children listed in the table is based on the US Census Bureau Population Estimates and includes all children under the age of 18.2 These numbers are based on a list of pediatric rheumatologists with known addresses in each of the 50 states or the
870
Althouse and Stockman
Although many studies have projected physician workforce needs, it was not until the Future of Pediatric Education II (FOPE II) task force report that a recent and detailed study focused exclusively on pediatrics, both at the generalist and subspecialty level.3,4 In 2005, the total number of pediatric rheumatologists in training (training years 1 through 3) increased 12.1% from the previous year. The average rate of increase in the number of entering fellows since 1997 is 14.5%. However, as noted earlier, given the small number of trainees percentage values can easily fluctuate. Although the data in Table II provide the pediatric rheumatologist-to-child ratio, the data do not indicate who is working full-time or part-time. General pediatrics research has shown an increasing trend toward part-time work, particularly with the increase in the number of women entering pediatrics.5,6 However, there are no current data to indicate that this is the case in pediatric rheumatology, but further research is needed. In fact, studies have reported that women are equally likely to work full-time and treat an equal number of patients as their male colleagues.6,7 In addition, although it is important to have an adequate number of physicians, where these physicians practice is just as critical in determining if appropriate care is available to all children. With the lack of pediatric rheumatologists in many geographic locations, there has been necessary reliance on adulttrained rheumatologists in providing care to children.8,9 As Stoddard et al note, the FOPE II study provides the supply-side perspective.4 The ABP data in this report provide the same perspective. These data are useful not only to those studying workforce trends, but also to medical students and pediatric residents making career decisions. However, these data do not address or gauge the need for medical services. Although workforce studies are not new, attention to workforce issues for pediatric subspecialties is relatively new, with two recent studies conducted for pediatric rheumatology.8,10 It is important that workforce research continues from both the supply and demand perspective. Only then can we be sure that the goal of providing all children with access to high-quality care will be met. References available at www.jpeds.com.
The Journal of Pediatrics • December 2006
REFERENCES 1. Althouse LA, Stockman JA. Pediatric Workforce: A look at general pediatrics data from the American Board of Pediatrics. J Pediatr 2006:148:166-9. 2. US Bureau of the Census. Population Estimates by State. Revised July 1, 2004. Available online at: http://www.census.gov/popest/states/asrh/SCest2004-02.html. Accessed April 18, 2005. 3. The Future of Pediatric Education II: organizing pediatric education to meet the needs of infants, children, adolescents, and young adults in the 21st century. Pediatrics 2000;105:163-212. 4. Stoddard JJ, Cull WL, Jewett EA, Brotherton SE, Mulvey HJ, Alden ER. Providing pediatric subspecialty care: a workforce analysis. Pediatrics 2000;106:1325-33. 5. Freed GL, Nahra TA, Wheeler JR. Predicting the pediatric workforce: use of trend analysis. J Pediatr 2003;143:570-5.
6. Brotheron SE, Mulvey HJ, O’Conner KG. Women in pediatric practice: trends and implications. Pediatr Ann 1999; 28:177-83. 7. Mayer ML, Preisser JS. The changing composition of the pediatric medical subspecialty workforce. Pediatrics 2005;116:833-40. 8. Mayer ML, Mellins ED, Sandborg CI. Access to pediatric rheumatology care in the United States. Arthritis Rheum 2003;49:759-65. 9. Mayer ML, Sandborg CI, Mellins ED. Role of pediatric and internist rheumatologists in treating children with rheumatic diseases. Pediatrics 2004; 113(3 Pt 1):e173-e181. 10. American College of Rheumatology Blue Ribbon Committee for Academic Pediatric Rheumatology. The future status of pediatric rheumatology in the United States: strategic planning for the year 2000. Arthritis Rheum 2003;43:239-42.
Pediatric Workforce: A Look At Pediatric Rheumatology Data From The American Board Of Pediatrics
870.e1
Table II. Number of ABP-certified pediatric rheumatology diplomates by state (as of 12/31/05)
State Alabama Alaska Arizona Arkansas California* (4) Colorado Connecticut Delaware* (1) District of Columbia Florida Georgia Hawaii Idaho Illinois* (2) Indiana* (1) Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts* (2) Michigan* (1) Minnesota Mississippi Missouri* (2) Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York* (3) North Carolina* (1) North Dakota Ohio* (1) Oklahoma Oregon Pennsylvania* (2) Rhode Island South Carolina South Dakota Tennessee* (1) Texas* (2) Utah Vermont Virginia Washington* (1) West Virginia Wisconsin* (1) Wyoming
Number of ABP diplomates in pediatric rheumatology
Child population
Physician-to-child ratio (per 100,000 children)
0 0 0 0 22 1 4 2 4 10 2 2 0 7 2 1 1 2 1 0 6 12 6 5 1 7 0 1 0 0 6 1 18 3 0 10 3 2 14 1 0 0 1 6 2 1 6 8 0 5 0 186
1,094,533 188,229 1,547,260 676,550 9,596,463 1,178,889 838,788 193,506 109,547 4,003,290 2,332,567 298,693 372,411 3,238,150 1,600,295 680,437 683,491 980,187 1,164,961 282,129 1,394,808 1,464,189 2,533,439 1,240,280 749,569 1,384,542 208,093 434,566 603,596 304,994 2,156,059 492,287 4,572,363 2,118,492 138,955 2,779,212 859,870 852,357 2,837,009 243,813 1,024,700 190,874 1,391,289 6,266,779 740,114 134,894 1,804,900 1,486,020 384,641 1,307,986 116,932 73,277,998
0 0 0 0 0.2 0.1 0.5 1 3.7 0.2 0.1 0.7 0 0.2 0.1 0.1 0.1 0.2 0.1 0 0.4 0.8 0.2 0.4 0.1 0.5 0 0.2 0 0 0.3 0.2 0.4 0.1 0 0.4 0.3 0.2 0.5 0.4 0 0 0.1 0.1 0.3 0.7 0.3 0.5 0 0.4 0 0.3
*Note: States with an asterisk denote those with a pediatric rheumatology training program. The number in parentheses indicates the number of programs tracked in the 2005–2006 academic year.
870.e2
Althouse and Stockman
The Journal of Pediatrics • December 2006