PEDIATRICS Vol. 106 No. 6 December 2000, pp. 1325-1333

Providing Pediatric Subspecialty Care: A Workforce Analysis

Jeffrey J. Stoddard, MD^*, William L. Cull, PhD, Ethan A. B. Jewett, MA, Sarah E. Brotherton, PhD, Holly J. Mulvey, MA, Errol R. Alden, MD, and for the AAP Committee on Pediatric Workforce Subcommittee on Subspecialty Workforce

From the American Academy of Pediatrics, Elk Grove Village, Illinois.

	ABSTRACT

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Objective.  To provide a snapshot of pediatric subspecialty practice, examine issues pertaining to the subspecialty workforce, and analyze subspecialists' perspective on the health care market.

Background.  Before the effort of the Future of Pediatric Education II (FOPE II) Project, very little information existed regarding the characteristics of the pediatric subspecialty workforce. This need was addressed through a comprehensive initiative involving cooperation between subspecialty sections of the American Academy of Pediatrics and other specialty societies.

Methods.  Questionnaires were sent to all individuals, identified through exhaustive searches, who practiced in 17 pediatric medical and surgical subspecialty areas in 1997 and 1998. The survey elicited information about education and practice issues, including main practice setting, major professional activity, referrals, perceived competition, and local workforce requirements. The number of respondents used in the analyses ranged from 120 (plastic surgery) to 2034 (neonatology). In total, responses from 10 010 pediatric subspecialists were analyzed.

Results.  For 13 of the subspecialties, a medical school setting was specified by the largest number of respondents within each subspecialty as their main employment site. Direct patient care was the major professional activity of the majority of respondents in all the subspecialties, with the exception of infectious diseases. Large numbers of subspecialists reported increases in the complexity of referral cases, ranging between 20% (cardiology) and 44% (critical care), with an average of 33% across the entire sample. In all subspecialties, a majority of respondents indicated that they faced competition for services in their area (range: 55%-90%; 71% across the entire sample); yet in none of the subspecialties did a majority report that they had modified their practice as a result of competition. In 15 of the 17 subspecialties, a majority stated that there would be no need in their community over the next 3 to 5 years for additional pediatric subspecialists in their discipline. Across the entire sample, 42% of respondents indicated that they or their employer would not be hiring additional, nonreplacement pediatric subspecialists in their field in the next 3 to 5 years (range: 20%-63%).

Conclusion.  This survey provides the first comprehensive analysis to date on how market forces are perceived to be affecting physicians in the pediatric subspecialty workforce. The data indicate that pediatric subspecialists in most areas are facing strong competitive pressures in the market, and that the market's ability to support additional subspecialists in many areas may be diminishing.  Key words:  pediatric subspecialty care, workforce analysis.

Before the effort of the Future of Pediatric Education II (FOPE II) Project, very little information existed regarding the characteristics of the pediatric subspecialty workforce. In work that is now dated, various authors explored definitional issues pertaining to pediatric subspecialty practice and characterized various aspects of the training, certification, and practice characteristics of subspecialty pediatrics.^1,2

As has been the case with all physicians, the numbers of pediatricians have increased sharply over the past 3 decades.^3,4 Although the growth curves for both pediatric generalists and pediatric subspecialists have been steep, interest in subspecialty training is leveling off or dropping, while simultaneously growing for general pediatrics.^3,4

Prior research has demonstrated broad evidence of aggregate oversupply (surplus) of specialists; however, this work typically combined all pediatric and adult subspecialists together, distinguishing them only from aggregated primary care physicians.^5,6 In this context, this limitation in the available literature (and the existence of only piecemeal pediatric-specific evidence) stymied meaningful debate. At another level, a few individual pediatric subspecialty workforce analyses were conducted in various ways by individual subspecialties.^7-15 Many of these studies suggested the likelihood of either current or impending surplus.^7,8,10,13 Other authors decried the decline in the numbers of trainees in their specific pediatric subspecialty, pointed out the high degrees to which pediatric subspecialists engage in nonclinical activities, and predicted future shortages in their subspecialties.^11,12 In this vein, the relatively greater involvement in research, teaching, and other academic and administrative pursuits by pediatric subspecialists, compared with adult subspecialists, has been cited as a chief factor contributing to the difficulty in assessing the adequacy of the pediatric subspecialty workforce.³

The fundamental step in physician workforce assessment, namely counting those in clinical practice, has been uniquely challenging for these physicians because defining a clinical full-time equivalent is complicated by a variety of issues, including those associated with time-allocation.³ In one of the few analyses comparing available medical school faculty position openings with the numbers of fellowship-level trainees, one leading scholar concluded that "these data clearly suggest that we are training, in many areas, more subspecialists than can be absorbed by the academic community."¹⁶ Attempts to determine the adequacy of the supply of pediatric subspecialists must also account for pediatric health care delivered by nonpediatricians and nonphysicians. Indeed, competition for pediatric services may arise from the overlapping scopes of practice of physicians in adult specialties and nonphysician clinicians.

In the absence of definitive data, opinions varied greatly within the pediatric community at the close of the 20th century as to the nature of pediatric subspecialty practice, the adequacy of the subspecialty workforce, and the precise impacts of rapidly changing market forces. It was perceived by the FOPE II Project members that up-to-date and detailed data on these topics were sorely needed. This need was addressed through a comprehensive initiative led by FOPE II and involved cooperation between subspecialty sections of the American Academy of Pediatrics (AAP) and other specialty societies. Data from this initiative constitute the foundation of this report.

The objective of this study was to provide a current snapshot of pediatric subspecialty practice and to examine issues pertaining to the subspecialty workforce, as well as subspecialists' perspectives on the current and future state of the health care market. It is hoped that these data will be useful to all practicing pediatricians, fellows, residents, and students contemplating careers in a pediatric subspecialty, leaders of the academic medicine community (including program directors), leaders of specialty societies, and the broader audience of individuals and organizations interested in children's health.

	METHODS

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The FOPE II Project was a 3-year, grant-funded initiative of the entire pediatric community. As part of this Project, key leaders in the pediatric community addressed the future supply and training of pediatricians and the provision of pediatric care in the new millennium. The results of their deliberations are presented in the final report of the FOPE II Task Force.⁴ An important component of the FOPE II Project was the gathering of insights, information, and data, which served as the underpinning of the Task Force recommendations. As part of this endeavor, 17 medical and surgical subspecialty sections of the AAP and appropriate subspecialty societies participated in the Survey of Sections Project. Included within the scope of this work were 9 pediatric medical subspecialties, 4 separate specialty areas certifiable through distinct boards, and 4 surgical specialty areas. Outside the scope of this study were the following: gastroenterology, nephrology, hematology/oncology, rheumatology, rehabilitation medicine, toxicology, sports medicine, child psychiatry, general pediatric surgery, neurosurgery, urology, radiology, anesthesiology, and pathology. Reasons varied as to why these subspecialties were not included.

The target list of participants for each of the subspecialties was created from membership rosters of the various participating professional societies and board certification organizations. A complete list of the organizations that provided information is listed in the "Appendix."

Between March 1997 and October 1998, multiple mailings of surveys were completed for all of the 17 subspecialties included in the Project. For nearly all of the subspecialties, surveys were sent to participants 5 times within 5 months. Repeat mailings were only administered for those subspecialists who failed to return the surveys. The mailing pattern was slightly different for 2 subspecialties. For plastic surgery, 4 mailings were completed instead of 5, and for endocrinology, the duration of mailings spanned 11 months because of a delay in receiving updated society membership information. Each mailing contained a standard questionnaire, a subspecialty-specific questionnaire, a cover letter emphasizing the importance of the survey, and a return envelope.

The current paper focuses on the results of the standard questionnaire that was administered to all subspecialties and was named the Workforce Survey for Child Health Care. This questionnaire was designed to be applicable to all of the subspecialties and collected information on several topic areas, including demographics, training and certification, practice setting, major professional activity, referrals, and perceived competition. This questionnaire, as well as each subspecialty-specific questionnaire, was pilot-tested with small groups of physicians and revised based on comments received.

Sample

All pediatric subspecialists within the 17 subspecialties were targeted; thus, the sampling frame comprised a census rather than a representative sample. A total of 18 274 subspecialists were initially surveyed. The target samples in Table 1 represent counts that were revised based on returned information from the surveys that indicated that some physicians did not belong in the target samples, ie, the physicians were deceased, were retired, were practicing out of the country, did not treat children, or did not practice in the target subspecialty. Overall, 11 938 (65%) of the targeted physicians responded to the survey. The lowest response rate was 42% for plastic surgery and the highest response rate was 77% for developmental and behavioral pediatrics.

To ensure that the physicians who were included in our statistical analyses were subspecialists concentrating on pediatric care, an additional screening was performed. This step was necessary because some subspecialists with an adult patient focus were included in the survey for other study purposes. Accordingly, physicians were eliminated from the final analyses if they reported that <26.5% of their patients were <18 years old. This threshold value was chosen based on the 1997 Census Bureau estimate that 26.5% of the population is <18 years old.¹⁷ Physicians were also excluded from the final analysis if they identified themselves as not being a pediatric subspecialist or if they failed to estimate the proportion of their patients who are <18 years old. Because other definitions could be used to define a pediatric focus, a covariate reporting the percentage of each physician's patients who are <18 years old was included in all regression analyses. The total numbers of physicians included in the final analyses are reported in the last column of Table 1.

Statistical Approach

Multivariate logistic regression was used to develop 2 predictive models. One dependent variable was whether physicians face competition, and the other was whether physicians believe their community will not need additional pediatric subspecialists in the next 3 to 5 years. Regression modeling was completed using several steps. First, all candidate predictor variables were screened based on their individual association with the dependent variable. All predictor variables that showed no association with the dependent variable, as indicated by a P value >.10 from individual logistic regressions, were excluded from the list of candidate variables. All variables surviving this univariate screening were then entered simultaneously in a logistic regression model. All variables that were not significant at P  .05 in this full multivariate model were then identified and eliminated. The model was then rerun with only the significant predictors to provide a final model. For the categorical predictor variables, all dummy coded variables, significant and nonsignificant, were included in the final model if any single coded dummy category was significant.

	RESULTS

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In all, 10 010 usable responses fitting our screening criteria were received and tabulated, constituting a response rate of 55% across the 17 subspecialties (Table 1). These responses represent the sample from which all subsequent analyses were performed. The number of respondents ranged from 120 (plastic surgery) to 2034 (neonatology), and the response rates ranged from 15% (plastic surgery) to 75% (developmental-behavioral pediatrics).

On average, respondents were in their mid-40s to early 50s, and anticipated retirement at about age 65 (Table 2). Approximately 80% of the sample was white (range: 70%-92%), and about two-thirds of respondents were male (range: 49%-92%). The respondents were overwhelmingly board-certified (Table 2).

As shown in Table 3, most subspecialists reported spending about two-thirds of their time in direct patient care (range: 42% for infectious diseases to 82% for allergy/immunology). Across subspecialties, surprisingly little time was dedicated to research, with larger commitments to administrative responsibilities and teaching overshadowing research time. An especially dominant emphasis on direct patient care was observed among the surgical subspecialists.

As expected, our data reflect that academic medicine represents the predominant practice setting for these physicians (Table 4). For 13 of the 17 disciplines, a medical school setting was specified by the largest number of respondents within that subspecialty as their main employment site. This tendency was especially strong for pediatric medical subspecialists, where majorities reported medical school employment in 7 of 9 subspecialty areas (the exceptions being neonatology and adolescent medicine). Across the entire sample, 44% of pediatric subspecialists reported mainly working within an academic medical center (range: 13% for allergy/immunology to 70% for infectious diseases). At the other end of the spectrum, one-third of pediatric allergists reported being in solo practice, as did 10% to 25% of pediatric surgical subspecialists. Equally noteworthy were the scant numbers of subspecialists working for health maintenance organizations (<3% of the total sample; range 0.5%-6%), and practicing in rural areas (4% across the full sample; range: 3%-7%).

A preponderance of pediatric subspecialists receive referrals (Table 5). Although the majority of respondents indicated no change in the volume of referrals, it must be noted that one third (range: 24%-47%) reported an increase in volume of referrals. For the entire sample, only 14% (range 9%-28%) reported a decline in referrals. For most of the subspecialties, the percentage of respondents reporting increased referral volume was double the percentage reporting a decline within the given subspecialty. In only one subspecialty, allergy/immunology, did more respondents report a decrease in referral volume than the number reporting an increase. Of great importance, large numbers of subspecialists reported increases in the complexity of referral cases. These observed increases ranged between 20% (cardiology) and 44% (critical care), with an average of 33% across the entire sample (Table 5). Less than 3% of the entire sample reported a decrease in referral complexity.

In all subspecialties, a majority of respondents indicated that they faced competition for services in their geographic area (Table 6); across the entire sample, 71% reported facing competition (range: 56% for infectious diseases to 90% for ophthalmology). The most frequently identified source of competition was from other pediatric subspecialists. For the medical subspecialties combined, 68% of respondents experienced competition with 49% of respondents reporting competition specifically from other pediatric subspecialists. For the separate specialty boards, 74% faced competition overall, with 55% facing competition from pediatric subspecialists. Surgical subspecialists reported encountering the most competition (84%), with 66% facing competition from other pediatric subspecialists. Other sources of competition reported less frequently included general pediatricians, family physicians, adult subspecialists, and nonphysicians.

Despite the high levels of reported competition, relatively few subspecialists reported modifying their practice as a result of competition. In general, only one-quarter to one-third of all respondents (across subspecialties) modified their practice as a result of competition. The outliers were cardiology and infectious diseases, where 45% and 17%, respectively of the totals modified their practice. The most common modifications included expanding hours (12.5%), increasing the number of physicians (9.2%), increasing support staff or staff responsibilities (8.4%), and decreasing the amount of research/administrative activities (6.8%).

Subspecialists were also asked for their impressions concerning the future need for pediatric subspecialists. In 15 of the 17 subspecialties, a majority stated that no need would exist over the next 3 to 5 years within their community for additional pediatric subspecialists in their discipline (Table 6). Across the entire sample, 42% of respondents indicated that they or their employer would not be hiring additional, non-replacement pediatric subspecialists in their field in the next 3 to 5 years (range: 20%-63%).

Results of Regression Analysis

To better understand the high levels of perceived competition by subspecialty, two logistic regression analyses were conducted to identify those variables that independently predict that a subspecialist will report facing competition and that the "community will need no additional pediatric subspecialists in the next 3 to 5 years." In each case, the affirmative response is indicative of a perception of a competitive market. A positive sign indicates a variable is associated with a perception of competition, while a negative sign indicates the variable is associated with a perception of no competition after controlling for the other covariates.

As shown in the top portion of Table 7, there were several significant predictors of "facing competition." Based on the magnitude of the Wald ² statistic, the strongest predictors were physicians' type of employment site (practice setting) and type of subspecialty. Specifically, subspecialists who work in solo practices, group practices, or a medical school were more likely to experience competition than doctors who work in staff/group model health maintenance organizations, community hospitals, or other sites. Consistent with the unadjusted results, the regression results demonstrated that the physicians in the pediatric surgical specialties and the separate specialty boards were more likely to report facing competition than the pediatric medical subspecialists, after controlling for other factors. Additionally, competition was more likely to be reported by subspecialists who were from the the Midwest and Southern regions compared with physicians in the Northeast. US or Canadian medical school graduates, when compared with international medical graduates, were more likely to face competition, as were physicians in practice relatively fewer years. Rural subspecialists were unlikely to report facing competition. Male subspecialists were more likely to report facing competition. Percentage of time in direct patient care is positively associated with a perception of competition.

In the multivariate analysis of "Community will need no additional pediatric subspecialists," subspecialty type was the strongest independent predictor. The pediatric surgical subspecialties were far more likely to report no need for additional subspecialists (87%) than the separate specialty boards (63%) or the pediatric medical subspecialties (59%). Other predictors that showed consistent relationships in both regression models included gender and type of location. Male physicians were more likely to report no need for additional subspecialists, and physicians practicing in suburban and urban inner city locations were more likely than physicians in rural or urban noninner-city locations to report no additional need. Relative to the Northeast, subspecialists in other parts of the country were less likely to report no need for additional subspecialists in their community.

Years in practice and geographic region showed reversed relationships between the two regression models. Physicians with more years in practice, although less likely to report facing competition, were more likely to report that there was no need in the community for additional subspecialists. Also, physicians from the Northeast were least likely to experience competition but were the most likely to think there was no need for additional subspecialists. The region reversal may be partially explained by significantly higher rates of reported competition from sources other than pediatric subspecialists in the Midwest and South relative to the Northeast (P = .05), or might reflect regional variation in perceptions of supply vis-a-vis demand and need. Finally, physicians who treat relatively fewer pediatric patients were significantly more likely to think that there was no need for additional pediatric subspecialists. The only candidate variable that was not significant in either model was subspecialty/primary board certification.

	DISCUSSION

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These data provide important new information on a variety of dimensions of subspecialty pediatrics. At a basic level, this snapshot yields comprehensive information on practice arrangements, practice location and characteristics, and demographics of pediatric subspecialists. More importantly, the allocation of time and the dynamics of referrals are elucidated. Finally, the perspective of pediatric subspecialists on the degrees to which they are experiencing market-induced shifts and on their short-term projections of local needs for their services are revealed.

No previous survey has ever been conducted that directly addresses the question of competition for pediatric subspecialty services. Given the turbulence in today's health care marketplace, the data from the FOPE II Survey of Sections are both novel and timely. Data such as these are especially valuable for workforce analyses that will inform policymakers, academic health centers, physicians, and families about the pediatric subspecialty workforce and access to pediatric subspecialty services. These data may also provide useful information to medical students and pediatric residents as they make their career decisions. Based on a survey of the totality of practicing pediatric subspecialists (within the 17 fields), these data are especially powerful. As is true with any methodological approach, however, it must be recognized that the approach taken in this study has important limitations. The data presented here provide the supply-side perspective of the subspecialists themselves regarding the degree to which they and their colleagues are meeting current marketplace demand for clinical services. Their perceptions reflect a snapshot of the current market for pediatric subspecialty services and may not accurately gauge the level of need for these services. An important related issue concerns the unique role that pediatric subspecialists play in generating and disseminating new knowledge. These research and teaching functions are crucial ones, but are exceedingly difficult to measure in the context of market forces. Thus, the degree to which these functions are being fulfilled is not addressed by this study. Despite these limitations, this study presents the first comprehensive set of data examining directly the question of perceived competition across the pediatric subspecialties.

Given its consistency and its foundation of a large census sample, the magnitude of the perceived levels of competition across the broad array of subspecialties is noteworthy. It appears from these data that pediatric subspecialists perceive themselves to be facing an even greater oversupply situation than the broader community of all medical specialists.⁵ For example, Donelan et al,⁵ using 1995 data, reported that 36% of medical specialists reported that the supply of practicing medical specialists in their community was greater than demand. However, caution must be exercised in making comparative interpretations insofar as differential wording of the questions in the respective surveys makes direct comparisons impossible.

We conclude from the FOPE II data that the burgeoning supply of pediatric subspecialists in practice is a major contributing cause for the competitive pressures over and above pressures imposed by managed care. It must be acknowledged, however, that respondents were not directly asked about the impact of managed care within this particular survey, nor have we conducted a market-level analysis. The high level of perceived competition documented in this study is especially troublesome in light of the high degree to which the respondents reported increases in the volume of referrals. It would seem from this facet of our data that the underlying explanation for the competition experienced by subspecialists is not a result of limitations on referrals imposed by managed care. Other recent work has demonstrated that referrals to pediatric subspecialists, while relatively uncommon in the course of general pediatric practice, appear not to be decreased by gatekeeping arrangements, common mechanisms employed by managed care to limit access to specialty services.^18,19

The discrepancy between the generally high degree of perceived competition and the generally low rates of specific modifications made in response raises questions about the feasibility for pediatric subspecialists to respond effectively to competitive pressure. Such difficulties could be attributable to a host of reasons, including insufficient experience in these matters or a lack of viable actions one could take. The data do not reveal, moreover, whether the failure to respond to increased competition reflects an inability to respond, resulting from limited financial or other resources, or an unwillingness to do so. Many physicians who are employees, rather than owners, of their practices, may lack the administrative authority to enact practice modifications in response to competition.

One possible outcome of increasing levels of competition is the expansion of one's scope of practice. An example of this push has been observed in the case of neonatology, for which our data indicate that the level of competition appears to be average relative to other subspecialties. Within this field, there are proponents who advocate for expansion of the role of the neonatologist into primary care.²⁰ On a broad level, evidence exists that many pediatric subspecialists view themselves as making major contributions to pediatric primary care.²¹ On this note, some thoughtful reexaminations of the appropriate interface between pediatric generalists and subspecialists have recently appeared in the literature.²² Our data demonstrate that many pediatric subspecialists perceive substantially increased complexity in the cases referred. This trend, if sustained, would seemingly make expansion of the scope of practice a difficult if not unobtainable goal. Perceptions of increased competition may also be attributable to overlapping scopes of practice between pediatric providers, including nonphysicians. In recent years the number of discrete, certifiable pediatric subspecialties has increased, further blurring the lines that separate the scope of practice of one subspecialty from another. The combined effect of overlapping scopes of practice and the proliferation of pediatric subspecialties might be that it becomes more difficult for physicians to know to whom they should refer a child for care, especially in a competitive environment.

To address the issues of competition and the adequacy of the subspecialist workforce more fully, additional studies should be undertaken from other vantage points. For example, household surveys or surveys of health plan members could be conducted to elicit information from a consumer-demand perspective on the availability and accessibility of pediatric subspecialty services. Equally valuable perspectives on the question of the adequacy of the pediatric subspecialist workforce, in all domains, could come from surveys of health plan administrators, teaching hospital leaders, pediatric department chairs, fellowship training program directors, primary care physicians, and public health officials. The opinions and perspectives from other vantage points may or may not diverge from those of the practicing pediatric subspecialists themselves. Nevertheless, the views expressed by subspecialists through the FOPE II Survey of Sections data provide new insight into perceptions of the level of competition in this unique sector of child health services. These data, therefore, constitute a valid and important source of information on the current subspecialty workforce market, and lay the groundwork for much needed studies on the composition and supply of the pediatric subspecialty workforce.

	APPENDIX

Below is the list of professional societies that made this project possible by providing the membership information used to assemble the target lists of subspecialists.

American Academy of Pediatrics

American Board of Pediatrics

Society for Adolescent Medicine

American College of Allergy, Asthma, and Immunology

Society for Critical Care Medicine

Society for Developmental and Behavioral Pediatrics

Society for Developmental Pediatrics

Society of Pediatric Dermatology

American College of Emergency Physicians

American Board of Medical Genetics

Lawson Wilkins Pediatric Endocrine Society (LWPES)

Child Neurology Society

American Association for Pediatric Ophthalmology and
  Strabismus

American Academy of Ophthalmology

Pediatric Orthopaedic Society of North America

American Academy of Orthopaedic Surgeons

American Academy of OtolaryngologyHead and Neck
  Surgery

American Cleft PalateCraniofacial Association

US Shriners Hospitals for Children

American Society of Maxillofacial Surgeons

American Thoracic Society

	ACKNOWLEDGMENTS

We thank the project members and staff of the Future of Pediatric Education II Project, Thomas M. Gorey, JD, Jadranka Karacic, the leaders of the AAP Sections, the members of the AAP Committee on Pediatric Workforce, and the many physicians who responded to the surveys for their essential contributions to this project.

	FOOTNOTES

^* Chair, AAP Committee on Pediatric Workforce; Chair of the AAP Subcommittee on Subspecialty Workforce; and Senior Physician Researcher, Center for Studying Health System Change, Washington, DC.

Sarah E. Brotherton, PhD, was with the American Academy of Pediatrics at the time of her participation in this study.

Received for publication Apr 28, 2000; accepted Apr 28, 2000.

Reprint requests to (J.J.S.) Center for Studying Health System Change, 600 Maryland Ave, SW, Washington, DC 20024-2512. E-mail: jstoddard{at}hschange.com

	ABBREVIATIONS

FOPE II, Future of Pediatric Education II; AAP, American Academy of Pediatrics.

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