Pediatric Subspecialty Training, Certification, and Practice: Who's Doing What

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Pediatric

Subspecialty

Training,

Certification,

and

Practice:

Who’s

Doing

What

Sarah E. Brotherton, PhD

ABSTRACT. Objective. To examine the extent of

pe-diatric subspecialty training, certification, and practice

among general and subspecialty pediatricians and to

de-termine how the diversity of pediatric careers may affect physician workforce supply estimates.

Method.

A

sample of 4 000 sell-designated pediatri-cians and pediatric subspecialists from the American Medical Association’s Physician Masterfile were sur-veyed in 1991 by the American Academy of Pediatrics. Seventy-six percent of the sample responded to the 6-page questionnaire on practice characteristics, training,

and demographic information.

Results. Two-thirds of pediatricians are not subspe-dalty trained (66.3%), 15.1% are certified subspecialists, 11.3% are trained but not subboard certified, and 7.3% are subspecialty trained in an area with no certification

exam. Subspecialty training did not always predict sub-specialty practice; 19% of pediatricians without subspe-daily training spend some time in a subspecialty, and 13% of those who are subspecialty trained practice

gen-eral pediatrics exclusively. Certified subspecialists and those who cannot as yet become certified are most likely to practice their subspecialty. One-fourth of those trained in a certifiable subspecialty but who remain uncertified

practice general pediatrics exclusively. The proportion of direct patient care time spent overall, and the proportion of direct patient care time spent in the subspecialty are also related to subspedalty certification and training/ practice consistency.

Conclusion. Pediatric workforce supply projections should incorporate more than certification and training information in calculating estimates, as the practice of general and subspecialty pediatrics is very diverse and

accommodating of integrative styles. Pediatrics 199494: 83-89; general pediatrics, subspecialtij pediatrics,

pediat-nc manpower.

ABBREVIATIONS. AMA, American Medical Association; DPC,

direct patient care.

Recognizing that the United States is singular

among other countries in its high proportion of

med-ical specialists and, relatedly, its high medical care

costs,1 several bodies have instituted programs or

policies to promote primary care training, such as

From the Division of Research on Health Policy, the American Academy of

Pediatrics, Elk Grove Village, IL 60()09-0927.

Received for publication Jun 21, 1993; accepted Nov 19, 1993.

Reprint requests to (S.E.B.) Division of Research on Health Policy, the

American Academy of Pediatrics, 141 Northwest Point Blvd, P0 Box 927, Elk Grove Village, IL 60009-0927.

Acad-emy of Pediatrics.

The Robert Wood Johnson Foundation, Pew

Chari-table Trusts, The Kellogg Foundation, and the

Amer-ican Medical Association’s Primary Care Task Force.

Most importantly, the Council on Graduate Medical

Education has recommended that at least 50% of

new physicians be trained in family practice,

gen-eral internal medicine, or general pediatrics.2

With-out a national medical workforce policy, however,

it is unclear how this recommendation will be

implemented.3

Crucial to the development of a medical workforce

policy is information on the current trends of new

physicians’ specialty choices because these trends affect future physician supply estimates. The number

of general and subspecialty pediatricians can vary,

depending on how and of whom the question is

asked.412 addition, training in some subspecialty areas is acquired to enhance the practice of primary care.2’P Given the range of subspecialty areas pedia-tricians can pursue and still be considered general

pediatricians, a literature-based estimate of 70 to

80% of pediatricians practicing general pediatrics

is tenable.412

To determine more accurately not only the number

of general pediatricians and subspecialists, but also the proportion of time spent delivering subspecialty

care and time spent in other activities, the Committee

on Careers and Opportunities of the American

Acad-emy of Pediatrics surveyed a representative sample of pediatricians. This study’s major objective was to

enhance that committee’s ability to plan for and

serve the diversity of pediatric careers. Providing reliable estimates of the pediatric workforce supply is an important offshoot of this study.

METHODS

During the summer and fall of 1991, the Committee on Careers and Opportunities surveyed 4 000 pediatricians about various

aspects of their careers. The sample was drawn from the American

Medical Association’s (AMA) Physician Masterfile, which pro-vides a complete listing of all physicians in the United States, including AMA members and nonmembers. The sample was

drawn according to the major professional activity, as classified in the AMA Masterifie, of the pediatridans. Because a major focus of

this survey was to examine the careers of pediatridans not in

direct patient care, all pediatricians whose major professional activity was dassified in the Masterfile as administration or

“oth-er” were included in the sample. The remainder of the sample was composed of 8.5% of pediatricians, randomly selected, whose

major professional activities were full time hospital staff, medical teaching, office-based practice, or research. This percentage was chosen to have a total sample size of 4 000. The sample induded

self-designated general pediatridans, as well as pediatricians

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whose subspecialty, according to the AMA, was one of the fol-lowing: adolescent medicine, neonatal-perinatal medicine, pediat-tic allergy-immunology, pediatric cardiology, pediatric endocri-nology, pediatric pulmonology, pediatric hematology-oncology,

and pediatric nephrology. Other pediatric subspecialties were not

separately categorized by the AMA at that time; therefore, these subspecialties would have been included as general pediatrics in the sample. Pediatricians known to be retired, living outside the United States, or in training were exduded.

A 6-page questionnaire was mailed to the sample of 4 000. Three additional mailings were sent to nonrespondents. After exduding the 202 respondents who were retired, receiving

addi-tional training, or not actually pediatricians, 2 880 questionnaires were returned and used in these analyses, a return rate of 76%.

Respondents were significantly younger than nonrespondents (average age was 48 vs 50), more likely to be board-certified in

pediatrics (84.1 vs 65.9%), and more likely to have graduated from a United States or Canadian medical school (78.3 vs 64.9%)

(P < .01).

There was no statistically significant difference, however,

be-tween respondents and nonrespondents with respect to the

sam-pling variable of major professional activity. Because of the

dif-ferential sampling by major professional activity, the responses for the whole data set were weighted to represent the population of 33165 pediatricians from which the sample was taken. This was done by assigning weights based on major professional activity, eg, pediatric administrators received weights of approximately 1,

office-based pediatricians received weights of approximately 15. The analyses reported here exdude respondents who did not supply information regarding their dinical area or whose area of additional training was nondinical (eg, quality assurance).

Ex-cluding these individuals reduces the weighted sample to 28002 pediatricians. The number of cases in the analyses are reported in the Tables 1 through 6; however, statistics are based on the weighted sample. Statistical significance tests have been adjusted

to reflect the differential sampling.

Respondents to the questionnaire were asked to list the special-ties and subspedalties in which they were trained and their

cer-tification status. Pediatricians were then asked if they were known

in their community for specializing or providing care in a

subspe-dalty area and, if so, to indicate the one in which they were most involved. Alternatively, they could indicate that their practice was exdusively in general pediatrics. The term subspecialty was de-fined to indude organ-, age- and disease-based specialties as well as those areas of interest that broaden the scope of practice, rather than narrow it (eg, sports medicine, public health).

RESULTS

The results focus on four groups: pediatricians

without subspecialty training; pediatricians trained

and certified in a subspecialty; pediatricians who

received training in a board-certifiable or

subboard-certifiable subspecialty but are not certified; and

pediatricians trained in an area without a

certifica-tion exam.

Subspecialty Training and Practice Consistency

Two-thirds of pediatricians have not received

sub-specialty training (66.3%). Pediatricians trained and

certified in a board-certifiable subspecialty represent

15.1% of the population, although those trained but

as of yet not certified make up 11.3%. A little more

than 7% of pediatricians (7.3%) are trained in areas

without a subspecialty exam. The four groups

dif-fered significantly on several demographic

charac-teristics (Table 1). Three-fourths of board-certified

subspecialty pediatricians are male, compared with 64.3% of pediatricians overall. This group, and those

trained in an area without a certification exam, are

more likely to be white, nonHispanic. In comparison,

the group of pediatricians yet to become certified in

a subspecialty is the most racially and ethnically

diverse, and perhaps related to that observation, has

proportionately more international medical school

graduates. The average age of pediatricians in each

group is 46, and approximately 86% are married.

Table 2 presents the subspecialty areas of

train-ing described by respondents and presents the

distribution of subspecialty areas for which

pedi-atricians were known in their community.

Com-parisons were made for each pediatrician between

the subspecialty of training and of practice. Not all

pediatricians spend time in the subspecialty for

which they were trained; this is shown in the third

column of Table 2, in which the degree of

consis-tency between training and practice is presented.

Nineteen percent of pediatricians are inconsistent,

in that they have either trained in one subspecialty area and practice general pediatrics exclusively, or

practice in a subspecialty area in which they have

no training. For example, of the pediatricians

re-porting no training in a subspecialty, 19.1%

mdi-cated that they are known in their community for

specializing or providing care in a subspecialty. To

put it another way, 35% of those practicing in a

subspecialty have not received training in it.

TABLE 1. Distribution of Subspecialty Certification Status by Ge nder, Race/Et hnicity, and Medical Sch ool Origin

Total Not Subspecialty Certified Not Certified/ Not Certified/No

Trained Exam Available Exam Available

Gender

Male 64.3 63.2 76.4 58.9 57.0

Female 35.7 36.8 23.6 41.1 43.0

n 2549 1524 455 303 267

Race/Ethnicity

White, nonHispanic 76.7 76.6 83.6 63.2 84.0

Asian 15.2 15.0 132 24.9 5.3

Hispanic 5.2 5.3 2.7 7.7 6.1

Black 2.4 2.9 .1 2.7 3.0

Other .5 .2 .4 1.5 1.6

n 2521 1507 453 299 262

School Origin*

US/Canada 76.6 78.1 78.5 59.0 86.9

International 23.4 21.9 21.5 41.0 13.1

n 2596 1551 459 310 276

*P .001.

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TABLE 2. Percentage of Pediatricians in Areas of Training, Areas Known for Providing Care in, and Training/Practice Consistency (n = 2596)

Area Pediatricians Trained

in Subspecialty* (%)

Pediatricians Known

for a Subspecialty (%)

Trained Pediatricians Practicing in Subspecialty Areat (%)

None-general pediatrics Neonatology/perinatology Hematology/oncology Cardiology 66.3 9.5 4.0 3.6 58.1 8.7 3.1 3.3 80.9 85.0 64.1 86.6

Allergy/immunology 3.0 2.9 71.2

Adolescent medicine 2.7 4.6 73.5

Developmental/behavioral 2.6 5.0 80.5

Endocrinology 2.3 2.1 82.8

Infectious diseases 1.6 1.2 65.0

Pulmonology 1.3 1.7 74.0

Genetics 1.0 .8 67.2

Critical care medicine .7 .4 66.8

General preventive medicine/public health .7 .3 19.3

Gastroenterology Nephrology .6 .5 .5 .4 88.3 69.3

Neurology .5 .5 69.5

Emergency medicine .5 2.2 97.1

Ambulatory pediatrics Child abuse/neglect .3 .3 0 .8 0 98.8 Sports medicine Psychiatry .3 2 .5

HI

39.7

HI

Administration/management

Quality assurance/utilization review

.1 .1 .4 0 47.5 0

Other .8 2.4 -‘I

* Percentages sum to >100% as some pediatricians have trained in more than one area. t 18.9% of pediatricians are inconsistent between training and practice area.

:1:Induding child psychiatry.

§

95% confidence interval is >10 percentage points.

II

Included in developmental/behavioral. 11Not calculated.

Nearly 8% (7.6%) of those practicing general

pedi-atrics exclusively have been trained in a

sub-specialty.

Consistency between training and practice ranged

from 20% for those trained in general preventive

medicine/public health to 98.8% for child abuse!

neglect. Table 3 presents the relationship between

practicing in the subspecialty of training and certifi-cation status, ie, certified, not certified in an area with a certification exam, and not certified in an area without a certification exam. Almost all pediatricians

certified in a subspecialty area practice in that

sub-specialty (93.8%). Those trained in an area without a

certification exam are the next most likely to be

prac-ticing in the same area (83.2%). Those pediatricians

who are trained in an area that has an exam but who

are not certified are significantly less likely to be

practicing consistently with subspecialty training

(64.1%) and the most likely to state they practice

general pediatrics exclusively (27.5%).

Subspecialty Time in Direct Patient Care

Pediatricians who indicated they were known in

their community for specializing or providing care in

a subspecialty area were asked to estimate the

pro-portion of time in direct patient care (DPC) spent in

that subspecialty. The proportion of time was

di-vided as follows: 0%, 1 to 25%, 26 to 50%, 51 to 75%,

and 76 to 100%. Table 4 presents the responses of

pediatricians who practice in a subspecialty area con-sistent with their training.

The proportion of time in DPC spent in

subspe-cialty areas varies significantly by subspecialty.

Close to 50% or more of practitioners in 7

subspe-cialty areas spend 76 to 100% of DPC time in their areas of training, while one-third or more of pedia-tricians in 10 areas spend <25% of their DPC time in their area of training. Some subspecialties, as in the case of allergy,/immunology, have many

pediatri-cians spending one-fourth or less of their time in

DPC in the area, and another substantial proportion

TABLE 3. Certification Status dalty Training (n = 1045)

and Training/ Practice Consistency for Pediatricians With

Subspe-Subspecialty Area Known for/Practice In*

Subspecialty Certification Status

Certified Not Certified/ Not Certified/ Exam Available No Exam Available

General pediatrics only Area consistent with training Different subspecialty area

2.4% 93.8% 3.9% 27.5% 132% 64.1% 832% 8.4% 3.6% *P .001.

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TABLE 4. Proportion of Time in L)irect Patient Care Spent in Subspecialty Area Consistent with Training (n = 816)

Subspecialty Area* % of Time in Direct Patient Care in Subspecialty Area

0 1 to 25 26 to 50 51 to 75 76 to 100

Neonatology/perinatology .4 13.8 152 19.1 51.4

Hematology/oncology .3 44.3 16.7 11.6 27.0

Cardiology .1 192 11.2 23.6 45.9

Allergy/immunology 0 34.0 15.5 5.0 45.5

Adolescent medicine 3.0 36.1 19.6 17.2 242

Developmental/behavioral 3.0 39.9 11.3 20.5 25.3

Endocrinology .4 34.9 19.1 20.9 24.6

Infectious diseases 2.0 37.5 22.6 21.4 16.6

Pulmonology 0 14.4 11.8 27.9 45.9t

Genetics 8.3 35.8t 3.6 17.9 34.5f

Critical care medicine 0 1.8 0 24.Ot 74.Ot

General preventive medicine/public health 6.4t 452t 42.Ot 0 6.4f

Gastroenterology 0 12.4 322t .8 54.5t

Nephrology 0 37.8t 16.8t 15.5t 29.9t

Neurology 0 28.6+ 28.6t 0 42.9+

Emergency medicine .9 .9 4.6 34.8+ 58.9+

Child abuse/neglect 0 21.5+ 19.3+ 20.7+ 38.6t

Sports medicine 0 100.0 0 0 0

*P .001.

t 95% confidence interval is >10 percentage points.

spending three-fourths or more of their DPC time in pediatricians’ time with respect to subspecialty

train-the area. ing and certification status, and training!practice

Analyzing the proportion of DPC time spent in consistency. Pediatricians not trained in a

subspe-the subspecialty area by training and certification cialty and providing care in general pediatrics

exclu-status again demonstrates the relationship be- sively spend a significantly larger proportion of

tween certification and practicing consistently time in DPC than those who spend part of their

with training. As shown in Table 5, pediatricians time in a subspecialty area (86.7 vs 77.3%, t = 5.99,

known for providing care in an area consistent P < .001). General pediatricians practicing in

with their training, certified or not, spend signifi- a subspecialty area, on the other hand, spend

cantly more DPC time in that area than pediatri- proportionately more time in teaching (t = 3.38,

cians known for an area in which they did not P < .001), research (t = 5.23, P < .001), and

admin-receive training. There are no significant differ- istration (t = 3.91, P < .001).

ences among those who are not certified because Those certified in a subspecialty, those trained but

no exam is available, practicing consistently or not, not certified in an area with an exam, and those

in the proportion of time spent in their area. Fur- trained in an area without an exam are also included

thermore, those with certification spend more time in Table 6. Pediatricians not certified in an area with

in the area than those not certified. an available exam spend more time in DPC, on

av-erage, than the other two groups, although any

prac-The Distribution of Time titioner practicing general pediatrics spends more

Respondents were asked to estimate how many time in DPC than those who spend some of their time hours a week they typically worked and the propor- in a subspecialty area. Certified subspecialists spend

tion of a typical week spent in the following activi- proportionately more time in research than the other

ties: DPC, teaching, research, administration, and two groups. Pediatricians practicing in a

subspe-other activities. Table 6 presents the distribution of cialty area different than the one in which they were

TABLE 5. Subspecialty Certification Status, Training/Practice Consistency, and Proportion of Direct Patient Care Time Spent in

Subspedalty Area

Time Spent in Certification Status and Training

DPCin . . .

Subsn’eialty Certified* Not Certified/ Not Certified/

Ar (%) Exam Available* No Exam Available

Not Practice with Practice Practice with Practice Practice with Practice

Trained Training Different Training Different Training Different

Consistent Area Consistent Area Consistent Area

0 3.7 .3 8.1 1.8 37.3+ 2.5 16.7+

I to 25 56.4 18.4 48.4+ 33.0 32.1 35.7+ 33.8+

26 to 50 13.3 17.0 11.7 11.4 13.5 15.8 23.1+

51 to 75 9.9 20.5 21.0+ 11.0 .7 19.6 0

76 to 100 16.7 43.9 10.8 42.8 16.3 26.5 26.4+

n 336 443 229 237

*P .001.

t 95% confidence interval is >10 percentage points.

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by Subspecialty TABLE 6. Average Percent Time Spent in Different Work Activities and Average Hours Worked Per Week

Certification Status and Training/Practice Consistency

Not Trained*

Percentage of Time in Activities

Certified Not Certified! Not Certified/ Total

Exam Available No Exam Average

Time in Direct Patient Care

Practice consistent with training 58.9 69.1 64.2 62.7t

Practice general pediatrics

Practice different area

86.7

77.3

71.6 41.0

842 78.3

52.3 39.9

81.9 46.8

Total average 84.9 58.5 71.8 65.2

Time in Teaching

Practice consistent with training 13.1 9.3 12.0 11.9+

Practice general pediatrics 3.5 3.2 2.0 8.8 3.61

Practice different area 6.0 19.5 5.8 9.0 10.71

Total average 4.0 132 7.0 11.5

Time in Research

Practice consistent with training 11.9 9.6 5.9 10.0+

Practice general pediatrics .5 .6 1.8 .3 1.31

Practice different area 2.5 18.5 13.7 19.8 16.24

Total average .9 11.9 7.8 5.7

Time in Administration

Practice consistent with training 11.9 7.1 12.3 8.7+

Practice general pediatrics

Practice different area Total average

5.1 9.9 5.8

17.1 17.8 12.311

7.3 7.7

25.3 25.5

8.7 12.2

12.31

12.2

Average Hours Worked Per Week

48.8 57.7 52.8 49.4 50.61

* Statistical comparisons in Table 6 are for groups trained in a subspedalty. Percent time spent in other activities is not shown as there

were no differences between groups.

t Consistency main effect significant, P < .001.

I

Not induding those not trained in a subspecialty.

§

Certification main effect significant, P < .001.

II

Certification main effect significant, P < .01. #{182}P<.001.

trained spend more time in research than those prac-ticing general pediatrics exdusively, or who practice a subspecialty area consistent with training. Pedia-tricians not certified in an area with an exam spend less time in administrative activities than the other

groups, as do those practicing consistently with

training. Certified subspecialists work significantly

more hours per week (58) than any of the other

groups, although the three other groups work

ap-proximately 50 hours per week.

Multivariate analyses were used to examine what

demographic characteristics distinguish between

pe-diatricians who are subspecialty trained and those

who are not. Characteristics that appeared to be

as-sociated with subspecialty training were being male,

an international medical school graduate, single,

white, and having no educational debt upon

gradu-ation from medical school. Unfortunately, these

vari-ables as a group were unable to distinguish reliably between the two types of pediatricians.

DISCUSSION

The general goal of this study was to attempt to

capture the diversity of pediatric careers. That the

practice of pediatrics can be accomplished with a

variety of skills and training in a number of settings is readily apparent. There are several more specific condusions that can be made:

1. Spending time in a subspecialty is very common,

even for those without training in the

subspe-cialty; two-thirds of pediatricians have not trained in a subspecialty, yet 19% of this group are known in their community for specializing or providing care in a subspecialty.

2. Although one-third of pediatricians have received subspecialty training, training does not

automati-cally result in spending time in the area. Five

percent of subspecialty trained pediatricians

spend time in a subspecialty for which they have

not received training or, if trained, one in which

they are not certified. Another 13% spend their

time exclusively in general pediatrics. The degree

to which subspecialty training is applied to

prac-tice varies widely by subspecialty, even for areas

with certification exams. One-third of

hematolo-gists-oncologists do not practice their

subspe-cialty, representing a low participation rate, while

88% of gastroenterologists practice their

sub-specialty.

3. The best predictor of practicing in the subspecialty

of training is certification status; pediatricians

who are subboard certified and those who at

present cannot be subboard certified are the most

likely to practice consistently. Pediatricians who

are trained in a subspecialty but not certified in it

are less likely to practice in that subspecialty. Lack

of subboard certification in the face of its

avail-abffity can be seen as an indicator of interest in the

subspecialty not matched with a desire to be con-sidered a subspecialist, but it could also represent

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an inability to pass the subspecialty certification

exam or a failure to complete the necessary

re-quirements for the exam. In some respects,

pedi-atricians in subspecialties without a certification

exam are much like their certified counterparts.

Once these subspecialties become certifiable, as

many wifi soon, it will be interesting to see if these

pediatricians-many subspecialty trained several

years ago-will alter practice patterns in response

to certification. Overall, however, the DPC time

spent in the subspecialty, again, varies by

subspe-cialty; some areas lend themselves to intensive involvement, although others seem to be practiced

almost as avocations. This is true of

hospital-based subspecialties as well as subspecialties

con-sidered to augment the practice of primary care

pediatrics.

4. The greater the identification with general

pediat-rics, the more proportionate time spent in DPC

overall. General pediatricians who are without subspecialty training and not known in their com-munity for a subspecialty, on average, spend 87%

of their time in DPC. Those with additional

train-ing who are practicing general pediatrics

exclu-sively spend 82% of their time in DPC.

Subspecialty Care and General Pediatric Care

One potentially troublesome finding from this

study is how subspecialty patient care fits in with overall DPC, as delivered by subspecialists. Certified subspecialists practicing in an area consistent with

their training spend significantly less time in DPC

than most other groups, having more time allotted to

research and teaching. This is how many believe it

should be. What is puzzling is that one-third or more

of subspecialists in 10 areas spend <25% of their DPC

time in their subspecialty. One can only speculate on the types of clinical activities that make up the

re-mainder of DPC time. It seems highly probable that

such time is spent in general pediatrics, although the possibility of time spent in other subspecialty areas cannot be excluded based on a limitation of the data

set. If indeed large amounts of subspecialist DPC

time is spent in general pediatrics, as seems likely, is it because of economic factors, an interest on the part

of subspecialists to retain their generalist base, a

requirement of some employment arrangements, or

a combination of these possibffities?

The reverse situation is of the general pediatrician

without subspecialty training who spends DPC time

in a subspecialty. One quarter of these pediatricians

spend over half of their DPC time in a subspecialty

area. However, this uncommon situation involves

<4% of all pediatricians. In addition, a fellowship is not the only way to obtain training in a subspecialty.

Like many of the general pediatricians with a

sub-specialty interest in the study by McCrindle and

associates,’2 these pediatricians may have become educated in a subspecialty through means other than

a fellowship program, but they may have not

con-sidered themselves trained in response to a question that also asked about board certification.

Workforce Prediction Concerns

The failure of multivariate analyses to distinguish

with any precision the pediatricians who are subspe-cialty trained from those who are not subspecialty trained does not mean that there are no

characteris-tics that distinguish the two groups. However, it

does suggest that the variety of ways pediatricians pursue their livelihood reflects the diversity of the motivations behind such actions. Further research into the reasons why pediatricians choose to subspe-cialize is necessary before we can classify “types” of pediatric subspecialists and generalists accurately

enough to design programs and incentives to

influ-ence the decisions of future pediatricians. The

rela-tionship between general and subspecialty pediatric

training, subspecialty practice intensity, and patient

care needs also requires further research.

Estimators of pediatric supply should be cognizant of the sensitivity of questions on training and prac-tice characteristics. In a society appearing to value

subspecialists more than primary care physicians, it

is no surprise many general pediatricians would

claim allegiance to a subspecialty that, in reality, is

practiced infrequently. Future supply projections

would do well to incorporate more than certification and training information in calculating estimates.12 Reliance on stated preferences for specialty and sub-specialty certification of senior United States medical students to forecast specialty and subspecialty distri-butions ignores the fact that many wifi change their career plans,13 and that certification and training do not necessarily produce a practicing subspecialist. The calculation of full time equivalent physicians,

although often encumbered with many necessary

assumptions, is likely to be more accurate for

de-scribing the supply of practicing specialists and sub-specialists than summing subspecialty certificates.

Such a methodology would allow assumptions

about DPC involvement by specialty and

subspe-cialty based on practice characteristics data of

those trained and,’or certified, thereby producing estimates based on practice preferences rather than practice categories.

The assumption of rigid categorizations to

esti-mate pediatric supply belies the complexity of pedi-atric practice. The practice style that pediatricians

choose diverges widely among subspecialists and

generalists, defying easy classification. One of the tenets of pediatrics is that pediatric subspecialists are pediatricians first and subspecialists second, and that all pediatricians (including subspecialists) embody

a generalist/primary care orientation to a much

greater degree than is the case among adult-focused

subspecialists.

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Century. Washington, DC: US Department of Health and Human

Services; 1992

3. Mullan F. Missing: a national medical manpower policy. Milbank Q.

1992;70:381-386

4. Brotherton SE. Career plans of new pediatricians: results from a survey

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EFFECTIVE? MAYBE. PROFITABLE? CLEARLY.

SANTA ANA, CALIF.-The Tokos Medical Corporation, which sells a service

that detects early labor in pregnant women, recently started a program to reward

obstetricians who ordered it for their patients.

In its ifies the company called the program “Dr. Deal.” The deal: earn up to

$20,000 annually on an investment of $1,000.

The program, in which 300 to 400 obstetricians nationwide are participating,

works like this: The doctors put up $1,000 each to become shareholders in a

company set up by Tokos that typically exists only on paper. In return, the doctors pocket 15 percent of the payment for any Tokos services prescribed by members of

the physician-owned company. Tokos says participating physicians currently

av-erage about $5,000 a year from the arrangement; literature from one Tokos sub-sidiary boasted that annual earnings could reach $22,500

But a debate is growing about the effectiveness of the home uterine monitor that

is the keystone of Tokos’s service. The Food and Drug Administration is also

investigating Tokos’s marketing claims. Separately, there is a scientific controversy

about the safety of the drugs Tokos sells to prolong pregnancy.

Some doctors are concerned about not only Tokos’s marketing practices but also the willingness of some physicians to take part in its investment plans. “It is a sad

day for medicine,” say Dr. Benjamin Sachs, chief of obstetrics and gynecology at

Beth Israel Hospital in Boston.

A look at Tokos’s marketing efforts highlights one of the most troubling issues

in health care: Medical companies often go to great lengths to encourage doctors to use their products, and to persuade insurers to pay for them. And they can succeed even when significant questions exist about a product’s efficacy and safety.

Health-care experts say that nothing will change-and medical costs will never

be satisfactorily controlled-without a systematic effort, whether by the

Govern-ment or the private sector, to study medical technologies and identify who will

benefit most from them.

“This is an extraordinarily pervasive problem,” said Dr. Robert H. Brook, direc-tor of the health sciences program at the Rand Corporation in Santa Monica, Calif.

“The Government has to step in to help resolve the risks and benefits of these

practices and then decide what is going to be used in basic medical care” Some experts think the problem so great that the Clinton Administration’s effort

to reform the health-care system by managing competition among insurers will fail

unless it identifies which competing treatments and technologies are most

effec-tive. “Managed competition does not have the ability to deal with this problem,”

said Dr. Mark Chassin, Commissioner of the New York State Department of

Health.

Meier B. Effective? Maybe. Profitable? Clearly. The New York Times. February 14, 1993.

Noted by J.F.L., MD

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1994;94;83

Pediatrics

Sarah E. Brotherton