Career
Plans of New Pediatricians:
Results
from a Survey
of Residency
Program
Directors
Sarah
E. Brotherton,
PhD
From the Division of Research in Child and Adolescent Health, American Academy of Pediatrics, Elk Grove Village, IL
ABSTRACT. Directors of pediatric residency programs in
the United States, Puerto Rico, and Canada were sur-veyed regarding plans of graduating residents to deter-mine whether new pediatricians experienced problems
finding employment in light of a decreasing growth rate
in the child population. Nearly 90% of directors re-sponded, providing information on 1915 residents. Of the
1782 nonmilitary residents in the United States, 815 were
entering general pediatric practice and one third (596)
were entering subspecialty training. Nearly one half (379)
of residents entering general pediatric practice were
join-ing a small group practice, almost one fourth (184) were joining a larger group, 6% (48) were becoming solo prac-titioners, 7% (57) were joining a health maintenance organization, and nearly 8% (62) were joining a hospital or academic staff. Most residents in the United States
experienced no difficulty finding a position and received
multiple offers for jobs. Canadian residents were similar to residents in the United States, whereas the
postresi-dency situations of graduates of military and Puerto Rican programs were very different. Despite manpower
predictions to the contrary, comments by program direc-tors indicated a demand for general pediatricians. This
paper presents only the viewpoint of program directors; whether this perceived need illustrates an avid market for young general pediatricians merits further study.
Pe-diatrics 1991;88:861-866; residents, gene rat pediatric prac-tice.
ABBREVIATIONS. GMENAC, General Medical Education Na-tional Advisory Committee; GPP, general pediatric practice;
HMO, health maintenance organization.
Interest in physician supply and the possibility of a surplus increased as we neared 1990, the first
Received for publication Jan 9, 1991; accepted Feb 25, 1991. Reprint requests to (S. E. B.) Research Associate, Division of
Research in Child and Adolescent Health, American Academy
of Pediatrics, P0 Box 927, Elk Grove Village, IL 60009-0927.
PEDIATRICS (ISSN 0031 4005). Copyright © 1991 by the
American Academy of Pediatrics.
prediction year used by the Graduate Medical Ed-ucation National Advisory Committee (GMENAC). GMENAC predicted a surplus of 60 000
physi-cians.’ A surplus (or shortage) of physicians can be
calculated only if a standard is established that
measures how many physicians the public “needs,”
a daunting task. GMENAC developed an “adjusted needs-based” model for prediction that has been the subject of much scrutiny and criticism.2’3 The American Medical Association elected not to fore-cast physician “need” in its extensive model, but instead used current physician utilization rates as
estimates of demand and then adjusted them for
foreseeable population characteristics.4 The Amer-ican Medical Association model forecasts overall utilization rates for physicians as well as for several individual specialties. The model analyzes the pro-jected increase in physician utilization relative to the projected increase in supply for the year 2000, leading to the conclusion that supply will outdist-ance utilization by 9.4%. The rapid growth of the supply of pediatricians (increasing by 24.2%
be-tween 1980 and 1986k) coupled with the relatively slow predicted growth of the child population (which decreased by 2.5% during the same time period5) creates a difference in growth rate between pediatric utilization and pediatric supply of
-31.8%, suggesting a surplus of pediatricians given
current estimates of demand. (See Singer6 and Weiner7 for discussions of the American Medical Association’s model as well as the models produced
by GMENAC and the Bureau of Health
Profes-sions.)
Some have argued against a current or future
surplus of physicians, most notably Schwartz and his colleagnes.’#{176} Others have suggested, based on
method to estimate supply and demand for physi-cians, eg, projecting future specialization rates from current rates, basing future estimates on current physician to patient ratios from prepaid group prac-tices and incorporating anticipated changes in such factors as technology and population distribution,
and analyzing changes in physician real income and
the number of patient visits.
In this study another proxy for demand is used:
the relative ease of entry into practice for new pediatricians. Although the number of pediatricians is growing more rapidly than the patient popula-tion, much anecdotal information has circulated
regarding a heightened demand for general
pedia-tricians. To develop better information, the
Com-mittee on Careers and Opportunities of the Amer-ican Academy of Pediatrics surveyed pediatric
res-idency program directors regarding the graduating class of 1990. Program directors were asked how many residents would graduate, the types of
prac-tice they would enter, and the problems they en-countered during their job search.
METHODS
In the spring of 1990 a one-page questionnaire
was sent to all pediatric residency program directors
in the United States, Puerto Rico, and Canada (n = 243). Included with the questionnaire was a letter from the chairman of the Committee on Careers
and Opportunities urging cooperation from the
di-rectors, and a business reply return envelope. After
a second mailing, 215 questionnaires were returned (two of which were incomplete), a response rate of 88%. Average age, the proportion female, and the
proportion US medical school graduates of third
and fourth year resident classes were compared for
responding and nonresponding programs using data
of the American Academy of Pediatrics on US
pediatric residency programs. There were no statis-tical differences. Because of differences in
utiliza-tion of specialists and generalists, Canadian pro-grams were analyzed separately. Military programs
were also analyzed as a group, as pediatrician
place-ment is automatic. Because of unique placement problems in Puerto Rico, those programs also were
examined separately.
RESULTS
Table 1 presents the number of programs that
were surveyed within each type (US nonmilitary, military, National Institutes of Health, Puerto
Ri-can, Canadian), the number of programs that re-sponded, and the number of graduating pediatric
residents from the responding programs. Most of
this report will focus on the 183 programs that
responded that are located in the United States and are not affiliated with the military or National
Institutes of Health (88% of such programs). The
total number of residents graduating from these programs was 1782 (see Table 2). The median num-ber of graduates per program was 8 with a range of
1 to 46. Program directors were asked to indicate
how many graduates were entering the following areas: general pediatric practice (GPP), a subspe-cialty fellowship, a chief residency, and “other” or unknown. Six programs had either no residents entering GPP or did not specify how many.
Alto-gether, 815 residents (45.7%) were entering GPP.
Thirty-four percent of the directors noted that the number of GPP residents was more in 1990 than in 1989, 29% reported the number to be less, 33% reported no difference compared with 1989, and 4% were unable to make a comparison. Thirty-six
di-rectors did not respond to this question. Small
programs (fewer than five graduates) were more likely to report a decrease in GPP residents com-pared with 1989 or to have the same number (30.6% and 36.7%, respectively), whereas large programs
(1 1 or more graduates) were most likely to have
experienced an increase in GPP residents (44.4%)
(x2
21.4,P< .05).A total of 596 residents (33.4%) were entering
subspecialty fellowships. Thirty-one percent of the 133 directors who responded to this question mdi-cated that the number of graduates entering sub-specialty fellowships this year was more than in
1989, 38% reported it was less, and 27% reported
no difference. An additional 4% did not know if there was a change between years. Nine percent of graduating residents (164) were remaining as chief
residents. The future whereabouts of 160 residents
from 71 programs were either unknown or of an-other category.
The directors were asked to indicate how many
of their GPP graduates were entering the following
types of practice: solo; small group (two to three physicians); large group (four or more physicians); an HMO; hospital or academic; government, public health or military; or an other type of practice. Table 3 presents the distribution of GPP residents
into these settings. Seventy-eight percent of GPP
graduates (one third of all residents) were entering some form of group practice (small, large, or an
HMO); however, solo practice remained an
alter-native, attracting 48 residents.
Because program size might affect the career choices of residents, the proportion of GPP resi-dents choosing each practice option was determined for small, medium, and large size programs. Trends were evident, and for two practice options
resi-TABLE 1. Distribution of Total and Responding Nonmilitar Canadian, and National Institutes of Health Programs, and G Responding Programs
y, Military, Puerto Rican, raduating Residents from
Type of Program Total No. No. of Re- No. of Residents from of Programs sponding Responding Programs
Programs
Nonmilitary US 207 183 1782
Military 13 12 59
Puerto Rican 6 4 21
Canadian 16 13 53
National Institutes of Health 1 1 0
Total 243 213 1915
bii- program only trains subspecialty fellows.
TABLE 2. Activities Following Graduation of Nonmilitary Pediatric Residents in the
United States as Reported by Program Directors
Activity No. Total,*
%
Median No. per Program
Range among Programs
General pediatric practice 815 45.7 4 0-14
Subspecialty fellowship 596 33.4 3 0-18
Chief residency 164 9.2 1 0-4
Other/unknown 160 8.9 0 0-19
Total 1782 8 1-46
* Percentage was calculated from the total number of residents. Activity was missing for
47 residents.
TABLE 3. Practice Distribution of Nonmilitary General Pediatric Practice (GPP)
Grad-uates in the United States as Reported by Program Directors
Practice
Solo Small Large Health Hospital! Government! Other Don’t Group Group Maintenance Academic Public Health! Know
Organization Military
No. of residents 48 379 184 57 62 38 12 12
GPP residents 6.1 47.8 23.2 7.2 7.8 4.8 1.5 1.5
(n = 792),* %
All residents (n 2.7 21.3 10.3 3.2 3.5 2.1 0.7 0.7
= 1782), %
No. of programs 41 136 75 35 36 30 10 8
* Not all program directors reported GPP residents’ practice decisions.
dents of smaller programs appeared more attracted
to solo practice than residents of larger programs.
In turn, a greater proportion of GPP residents from
large programs entered large group practices,
HMOs, and hospital or academic settings. The
pro-portion of residents per program choosing subspe-cialty fellowship or GPP was not associated with program size. There was one observed regional ef-fect; residents in western US programs were more likely to be entering an HMO than residents from the southern, northeastern, or north central United States. Approximately 25% of all HMO plans and 40% of HMO enrollees are located in the western United States, which may explain the added attrac-tiveness of HMOs to residents in this area.13
Program directors were asked how many of the
GPP graduating residents were taking part-time
positions (less than 35 hours per week), and how many of all graduating residents received multiple offers for positions, or had difficulty finding a po-sition. Only 106 GPP residents were entering part-time positions. Sixty percent of the program direc-tors reported that none of their residents would be
working part-time. Only four program directors indicated that none of their residents had received multiple offers (although 22 did not respond to this question). The average number of residents receiv-ing multiple offers per program was 6.5, for a total of 1050 residents (see the Figure for a comparison of residents in the various types ofprograms). Along the same vein, 76% of the program directors re-ported that none of the residents had difficulty
finding positions. Altogether, to the directors’
prob-TABLE 4. Percent of Nonmilitary General Pediatric Practice Residents in the United States Entering
Differ-ent Practice Options by Size of Program as Reported
by Program Directors*
Practice S ize of Programs Total
Small Medium Large
Solo 15 7 4 8
Small group 55 52 43 49
Large group 13 20 28 21
Health Maintenance 4 4 8 6
Organization
Hospital/academic 5 8 8 7
Government/public 5 6 4 5
health/military
Other 2 2 2 2
Unknown 2 2 2 2
* Number of programs reporting: 57 small, 55 medium, 62 large, 173 total. Values stated are percentages.
:1:Small programs had fewer than 5 graduating residents,
medium programs had 6 to 10, and large programs had 1 1 or more. Percentages may not add up to 100% due to rounding.
§P< .05.
lems. Twenty-six residents received few offers, 30 residents had relocation problems, and 14
encoun-tered financially inadequate pay.
Eight-four directors provided comments
regard-ing the placement of residents. Forty directors
men-tioned that there were plenty of job opportunities for general pediatricians, and that they received several calls and letters a week from practices
seek-ing new partners. That their residents had no
prob-lem finding positions was mentioned by 11 direc-tors. Seven directors called attention to the problem of the inability of rural and inner city communities to attract new pediatricians. Another seven
direc-tors said that the majority of graduating residents
from their programs typically choose subspecialty fellowships. Six directors discussed some problems residents had faced: three said their residents seemed unsure ofwhat type ofpractice they wanted, and another three observed that group practices did not offer as much salary as expected by residents.
The Military
Twelve of the 13 military program directors
re-sponded to the survey, with a total of 59 graduating
residents. The average number of graduates per
program was five. Forty-six of these graduates were
entering GPP and nine were entering subspecialty fellowships. The remaining four graduates were entering an other type of practice, or the directors
did not know what their plans were. All of the 46 GPP residents were working for the government, a
public health clinic, or for the military. Graduating residents from military programs continue with the military as part of their obligation, thus eliminating
placement insecurity and extensive job searches; therefore directors did not report any placement problems.
Puerto Rico
Four of the six pediatric residency programs in Puerto Rico responded to the survey, with 21 grad-uating residents. Eighteen of these graduates were entering GPP, one was entering a subspecialty fel-lowship, and two were remaining on as chief
resi-dents. Ten of the 18 GPPs were going into solo
practices, three were joining small group practices, two were joining hospital or academic settings, and three were working for the government in some
capacity. One of the graduating residents was tak-ing a part-time position, 5 of the 15 received mul-tiple offers, and 11 had difficulties finding positions. The primary difficulty experienced by the residents
was few offers for jobs (6). Two Puerto Rican resi-dents had relocation problems, and one also was
concerned with financially inadequate pay. One
director provided the comment that there were too
many pediatricians (more than 900) for the child
population of Puerto Rico.
Canada
Thirteen of the 16 program directors in Canada
returned the survey. Fifty-three residents were graduating from these programs, a median of four graduates per program. Twenty-three residents
were entering GPP (43%), graduating from 11 of
the programs. Thirty-four residents were entering
a subspecialty fellowship (64%), and the future plans of six residents were unknown to the program directors. Two GPP residents were entering solo
practice, eight and six were entering small and large group practices, respectively, and five were joining
hospital or academic settings. Two residents were entering an other practice type. Altogether, five residents were entering part-time positions, 17
re-ceived multiple offers (although five program direc-tors did not answer this question), and three had
difficulty finding positions. Six of the 13 directors made comments, mostly centered around general
pediatric residents not having problems finding p0-sitions.
DISCUSSION
The findings ofthis survey indicate that one third
of pediatric residents enter subspecialty training.
In 1989 there were approximately 1300
pediatri-cians training in more than 20 different
subspe-cialty areas in the United States,’4 including the
many fellowships in areas that at present do not
pediatri-(1,050)
65 -
U
Non-military
U.S.60- Military
n
Puerto Rican
50-45 .
a
Cann40.
-35.
30 .5
25
20 15
10 (69) (3)
g
-__
_
Received Multiple Offers Experienced Difficulties
Figure. Percentage and number (in parentheses) of nonmilitary residents in the United
States, military residents, Puerto Rican residents, and Canadian residents who received
multiple offers for jobs and experienced difficulties finding a position.
70-cians may pursue training in a subspecialty that is
without a certification examination with the antic-ipation of practicing general pediatrics eventually. Some of the pediatricians whose future plans were unknown to the program directors (9% of the
grad-uates) are likely to choose general pediatrics as
well. Therefore, when including this latter group and pediatricians entering GPP after subspecialty training, it is quite likely that the number of new entrants to general pediatric practice in the United States for 1990 is higher than the figure of 815 found here.
The responses to this survey of pediatric resi-dency program directors suggest that practice op-portunities for these new general pediatricians are
numerous, with some positions remaining unfilled.
Unfortunately, this survey presents only one view of the pediatric career entry picture, that of the program director. To admit that one’s residents have problems finding positions upon graduation may be difficult for some directors. In some cases lack of accurate information may lead to an exag-geration of success rate. However, the consistent and frequent comments regarding “starving prac-tices” searching for young general pediatricians and the “inaccuracy” ofthe GMENAC findings suggests that there is indeed a prevalent need for additional pediatricians. Nonetheless, the possibility is very real that pediatric practices are contacting multiple residency programs in their search and thus inflat-ing the perceived need for general pediatricians.
Unfortunately, this cannot be determined from this study. Also beyond the scope of this study is an
examination of whether subgroups of residents (eg,
female, foreign medical graduates) face different
experiences postresidency, because only aggregate
resident data were collected.
This survey produces a “snapshot” of graduating residents, as taken by program directors; therefore,
broad statements concerning trends cannot be made. Other recent findings, however, suggest that a current heightened demand for general
pediatri-cians may not be an anomaly. Martinez and Ryan15
have described an increase in the pediatric “market
share,” ie, that during the period of 1977 through 1987 the proportion of children seen by
pediatri-cians had increased compared with other physi-cians. Other changes in practice patterns may in-troduce a need for additional generalists, such as decreased hours worked per week per physician,16
extension of practice hours to include more evening
and weekend hours, increased need for part-time pediatricians to “share” one positio&7 and more pediatricians requesting time off for parenting and other personal needs. These changes have been reported to be on the rise; whether they fully ex-plain an increased need for general pediatricians in
the face of a declining patient base has yet to be
determined.
ACKNOWLEDGMENTS
The author gratefully acknowledges the contributions of the Committee on Careers and Opportunities and the
American Academy of Pediatrics. In addition, the
Baker, and two anonymous reviewers were most appre-ciated.
REFERENCES
1. Summary Report of the Graduate Medical Education Na-tional Advisor- Committee to the Secretary, Department of Health and Human Services. Washington, DC: Department
of Health and Human Services; 1981. DHHS publication
(HRA) 81-561
2. Budetti PP. The impending pediatric ‘surplus’: causes, im-plications, and alternatives. Pediatrics. 1981;67:597-606.
3. Reinhardt UE. The GMENAC forecast: an alternative view.
Am J Public Health. 1981;71:1149-1157
4. Marder WD, Kletke PR, Silberger AB, Willke RI. Physician Supply and Utilization by Specialty: Trends and Projections.
Chicago, IL: American Medical Association; 1988
5. Statistical Abstract of the United States: 1989. 109th ed. Washington, DC: US Bureau of the Census; 1989
6. Singer AM. Projections of physician supply and demand: a summary of HRSA and AMA studies. Acad Med.
1989;64:235-240
7. Weiner JP. Forecasting physician supply: recent develop-ments. Health Aff (Millu’ood). 1989;8:173-179
8. Schwartz WB, Newhouse JP, Bennett BW, Williams, AP. The changing geographic distribution ofboard-certified phy-sicians. N Engi J Med. 1980;303:1032-1038
9. Schwartz WB, Sloan FA, Mendelson DN. Why there will be
little or no physician surplus between now and the year
2000.N Engi J Med. 1988;318:892-897
10. Schwartz WB, Mendelson DN. No evidence of an emerging
physician surplus. JAMA. 1990;264:557-560
11. Crozier DA, Iglehart JK. Datawatch: trends in health man-power. Health Aff (Millwood). 1984;3:122-131
12. Kindig D, Dunham NC. Physician specialist growth into the 21st Century. J Med Educ. 1985;263:557-560
13. HMO Industry Profile. Vol. I. Washington, DC: Group Health Association of America, Inc; 1989
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1989;143:924-928
16. Willke RI, Cotter PC. Young physicians and changes in medical practice characteristics between 1975-1987. In-quiry. 1989;26:84-99
17. Wheeler R, Candib L, Martin M. Part-time doctors: reduced working hours for primary care physicians. J Am Med Wom Assoc. 1990;45:47-54
STATES
OF HEALTH
VARY
FROM
STATE
TO STATE
Minnesota and Utah are the healthiest states, Alaska the least healthy. So says a complex rating system developed by Northwestern National Life
Insur-ance Co. ...
Utah won a tie for first place for overall healthiness by coming in first in the
life-style category and ranking well on mortality, disease and disability, though
it was only 20th on access to health care. Minnesota tied with Utah by getting
high grades on disease, mortality, access to health care, and life style, though it
didn’t do so well on the disability scale.
New Hampshire and Hawaii were close behind the top two, followed by
Nebraska, Connecticut, Massachusetts, Wisconsin and Iowa. Connecticut
ranked first on access to health care, North Dakota had the lowest death rates,
Wyoming had the best record on major diseases, and Hawaii had the least
disability.
Other than Alaska, the states ranked the worst were West Virginia,
Missis-sippi, Nevada, Louisiana and New Mexico.
States of health vary from state to state. The Wall Street Journal. September 26, 1990. People
1991;88;861
Pediatrics
Sarah E. Brotherton
Directors
Career Plans of New Pediatricians: Results from a Survey of Residency Program
Services
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1991;88;861
Pediatrics
Sarah E. Brotherton
Directors
Career Plans of New Pediatricians: Results from a Survey of Residency Program
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