OBJECTIVE: Historically, most pediatric subspecialists have conducted their clinical work in academic health centers. However, increases in the absolute numbers of pediatric subspecialists in past decades, combined with greater concentrations of children in urban and suburban settings, might result in more opportunities for pediatric subspecialists to enter private practice. Our goal was to assess the proportions of subspecialists in private practice.
METHODS: We surveyed a stratified, random, national sample of 1696 subspecialists from 5 subspecialties and assessed the ownership of their current clinical practice settings.
RESULTS: The response rate was 77%. Two-thirds of respondents (65% [n = 705]) reported that they work in academic hospitals or outpatient clinics. Compared with other subspecialists, greater proportions of neonatologists (38% [n = 92]) and critical care physicians (19% [n = 44]) reported that they work in community hospitals. Larger proportions of cardiologists (27% [n = 58]) and gastroenterologists (24% [n = 47]) reported that they work in private outpatient practices.
CONCLUSIONS: There were significant proportions of pediatric subspecialists in private practice in most of the 5 subspecialties studied. Ensuring children's access to pediatric subspecialists likely will require a robust workforce in both academic and private clinical settings. Ongoing studies of the career trajectories of pediatric subspecialists with respect to their venues of practice will be essential for future workforce planning.
WHAT'S KNOWN ON THIS SUBJECT:
Historically, most pediatric subspecialists practice in academic health centers.
WHAT THIS STUDY ADDS:
This study provides documentation that significant proportions of pediatric subspecialists are in private practice, and the proportions vary according to subspecialty.
Historically, most pediatric subspecialists have conducted their clinical work in academic health centers. This is in contrast to adult care subspecialists, for whom there is a significant private practice model in most fields.1 The prevalence of many pediatric conditions requiring subspecialty care is relatively low, compared with adult conditions. Therefore, a large population concentration is required to maintain an economically viable practice. Also, since the early 1980s, all pediatric subspecialist fellows are required to undergo research training and to conduct research as part of their fellowships.2 Internal medicine subspecialties do not emphasize research training to the extent seen in pediatrics.3 Such training results in longer subspecialty fellowships for most pediatrics fellowship training, compared with internal medicine.3,4 The goal of the research training requirement is to create a cadre of subspecialty investigators to advance knowledge and care in the pediatric subspecialties. These subspecialists, thus trained, would then be qualified to remain in academic settings to conduct research, to teach, and to provide clinical care.
As a result of the expansion of training programs and positions, there has been an increase in the absolute numbers of pediatric subspecialists in the past 2 decades. Because the population of children in the United States has remained relatively unchanged, this has resulted in an increase in the number of pediatric subspecialists per capita for children younger than 18 years of age in the United States. In addition, as survival rates for children with complex chronic illnesses have increased, so has the disease burden faced by pediatric subspecialists These 2 trends might result in more opportunities for pediatric subspecialists to enter private practice.
Recently, concern has been expressed regarding potential shortages of pediatric subspecialists in academic centers and children's hospitals.5 As part of a larger study examining aspects of subspecialty care, we sought to determine the proportion of subspecialists currently in private practice. We further investigated whether there were variations across 5 specific subspecialties and whether there were differences in private practice rates according to gender.
The American Board of Pediatrics maintains a database that includes all physicians who are certified as generalists or subspecialists within the field of pediatrics. As part of a larger study, we surveyed a stratified random national sample of 1696 subspecialists from 5 subspecialties. The total sample included 350 pediatric cardiologists, 323 pediatric critical care physicians, 300 pediatric gastroenterologists, 350 pediatric hematologists-oncologists, and 373 neonatologists.
In collaboration with the American Board of Pediatrics Research Advisory Committee, we developed a 15-item, fixed-choice, structured questionnaire to be administered by mail. The survey was designed to be completed in ≤10 minutes. One question specifically addressed the ownership of the current clinical practice setting.
The first mailing of questionnaires was sent via Priority Mail to the 1696 subspecialists in the sample in March 2010. The survey packet contained a personalized cover letter signed by Dr Freed, the survey instrument, a business reply mail envelope, and a $5 bill as an incentive to complete the questionnaire. Two additional mailings were sent to nonrespondents, in May and June 2010.
First, frequency distributions were calculated for all survey items. Proportions of different types of practice ownership were calculated for each of the 5 subspecialties. Then, bivariate analyses of responses were conducted according to gender and subspecialty. The study was approved by the University of Michigan Medical School institutional review board.
Of the 1696 survey packets mailed, 1193 surveys were returned and 138 were undeliverable. This yielded an overall response rate of 77%. One hundred twelve of those who returned the survey were ineligible because they had retired or were no longer working in the field of pediatrics, and 13 subspecialists refused to complete the survey. This left a total of 1067 surveys for analysis. The response rates ranged from 84% for pediatric cardiologists to 64% for pediatric hematologists-oncologists (Table 1).
Respondent Demographic Features and Practice Ownership
Seventy-three percent of respondents (n = 788) were US medical school graduates and 39% (n = 420) were female. Eighty-seven percent of respondents (n = 926) were younger than 60 years.
Two-thirds of respondents (65% [n = 705]) reported that they worked in an academic hospital or outpatient clinic. Compared with other subspecialists, greater proportions of neonatologists (38% [n = 92]) and critical care physicians (19% [n = 44]) reported that they worked in a community hospital. Larger proportions of cardiologists (27% [n = 58]) and gastroenterologists (24% [n = 47]) reported that they worked in a private outpatient practice (Table 2). No differences were seen in the proportions of men or women in academic or private practice for any subspecialty.
Among the most important findings of this study are the significant proportions of pediatric subspecialists in private practice in most of the 5 subspecialties studied. Also of importance are the differences among these specialties in the proportions of physicians in private practice. Neonatology is the most populated pediatric subspecialty and had the largest proportion of providers in nonacademic settings. Hematology-oncology is the subspecialty with the largest proportion of providers practicing in academic settings. This is likely attributable, at least in part, to the relative rarity of childhood cancers and the need for highly sophisticated treatment environments, which usually are available only in academic centers.
Respondents from procedurally based subspecialties had the largest proportions of providers in private outpatient practice. Such procedures provide significant opportunities for income generation in private practice. Previous studies sought to determine similar aspects of the distribution of subspecialty care in different contexts. However, none asked specifically about practice ownership. Stoddard et al6 examined employment site and location and found that 28% of cardiologists were in group practice, compared with 57% in a medical school hospital. It is unclear whether those practices were owned by or affiliated with an academic institution.
The ability to develop a private practice model of care has been thought to influence the distribution of pediatric subspecialists in some markets. Mayer and Skinner7 noted that the major factors impeding movement of pediatric subspecialists into areas currently lacking subspecialists include the financial viability of private practice and inadequate demand. Stockman and Freed8 posited that there likely is a market threshold influenced by population density, disease incidence, and economic opportunity.
In 1998, Pollack et al9 reported that 38% of neonatologists were practicing in university hospitals, compared with 49% in our study. This might reflect the marked expansion of NICUs in academic centers in the United States as greater advances in care have resulted in increased survival rates for very low birth weight premature infants. Another possibility involves increased recognition by children's hospitals and academic pediatric departments of the significant financial advantages of the provision of neonatal intensive care and subsequent expansion of service offerings.
Recent statements addressed subspecialty shortages in academic medical centers,5 and any increase in the proportions of subspecialists entering private practice would exacerbate those concerns. The needs of academic centers for subspecialists go beyond clinical care and include teaching of the next generation of pediatricians and discovery of new knowledge in each of the subspecialty areas. Conversely, it is likely that subspecialists in private practice spend greater proportions of their professional time in the clinical care of children, because they do not have the added responsibilities of education and research that frequently are found in academic settings.
It is not known whether other pediatric subspecialties have similar proportions of practitioners in private or academic practices. This study examined only 5 subspecialties, including both cognitive and procedure-oriented types. Future studies should examine other pediatric subspecialties to determine whether there might be trends occurring over time in the proportions of practitioners in private or academic practices. Understanding employment trends would allow academic centers to understand better the components of the available workforce in specific subspecialties.
Ensuring the ability of children to have access to pediatric subspecialists likely will require a robust workforce in both academic and private clinical settings. Ongoing studies of the career trajectories of pediatric subspecialists with respect to their venues of practice will be essential for future workforce planning.
The American Board of Pediatrics Research Advisory Committee included Linda Althouse, William Balistreri, Alan Cohen, Lewis First, Gary Freed, Marshall Land, George Lister, Gail McGuinness, Julia McMillan, Paul Miles, Joseph St Geme, and James Stockman.
- Accepted June 10, 2011.
- Address correspondence to Gary L. Freed, MD, MPH, University of Michigan, Child Health Evaluation and Research Unit, 300 N Ingalls Building, Room 6E08, Ann Arbor, MI 48109-0456. E-mail:
FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.
- Grosso L,
- Iobst W,
- Lipner R,
- Jacobs C
- Pearson H
American Board of Internal Medicine. Internal medicine and subspecialty policies, 2010. Available at: www.abim.org/certification/policies/imss.aspx. Accessed March 15, 2011
American Board of Pediatrics. General criteria for certification in the pediatric subspecialities, 2010. Available at: www.abp.org/ABPWebStatic/#murl%3D%2FABPWebStatic%2FresidentFellowEval.html%26surl%3Dhttps%3A%2F%2Fwww.abp.org%2Fabpwebsite%2Fcertinfo%2Fsubspec%2Feligibil%2Fgencrit.htm%3Fsection%3Dsubcert. Accessed June 6, 2011
- Landro L
- Stoddard JJ,
- Cull WL,
- Jewett EA,
- Brotherton SE,
- Mulvey HJ,
- Alden ER
- Pollack LD,
- Ratner IM,
- Lund GC
- Copyright © 2011 by the American Academy of Pediatrics