Conversion
Experiences: Primary Care to Specialty Workforce
Robert C. Bowman, M.D.
The data sources involving primary care or specialty care percentages are a great challenge to compile and compare. Best estimates can be important in understanding sources of primary care.
Specialty Distribution Comparisons
|
Practicing Specialty, Not
Always Specialty of Training |
Recent Allopathic US |
Recent Osteopathic US |
Recent Inter-national |
Physician Assistants in 2007 |
Nurse Pract-itioners 2004 |
Advanced Nursing HRSA 2004 |
|
Numbers and Estimates |
219304 |
24760 |
72728 |
75,000 |
145000 |
240,460 |
|
Data Indicator |
Recent data |
Recent data |
Recent data |
26,000 responses |
39,000 responses |
1.2% sample |
|
Family Practice General
Practice |
13.4% |
33.5% |
10.3% |
24.9% |
|
25.0% |
|
General Internal Medicine |
12.2% |
11.3% |
27.7% |
6.9% |
|
|
|
Medicine Pediatrics |
1.0% |
0.4% |
0.4% |
|
|
|
|
General Pediatrics |
7.9% |
3.9% |
7.0% |
2.6% |
|
8.1% |
|
Adult Health Medical
Surgical |
|
|
|
|
|
14.3% |
|
Physician Primary Care
Measurement Comparison |
34.5% |
49.1% |
45.4% |
34.4% |
39.0% |
|
|
|
|
|
|
|
|
|
|
Extended Primary Care |
|
|
|
|
|
|
|
Obstetrics-Gyn/Women’s Health |
6.6% |
4.2% |
2.0% |
2.4% |
11.3% |
12.0% |
|
Geriatrics |
0.4% |
0.4% |
1.3% |
0.7% |
4.1% |
4.7% |
|
|
|
|
|
|
|
|
|
Nurse Practitioner Defined Primary
Care (expanded) |
41.5% |
53.7% |
48.7% |
37.5% |
54.4% |
|
|
|
|
|
|
|
|
|
|
Specialties Not Involving Primary Care |
|
|
|
|
|
|
|
Specialty Distribution Total |
58.5% |
46.2% |
51.3% |
62.5% |
45.8% |
|
|
Neonatal Perinatal |
0.4% |
0.3% |
0.8% |
0.4% |
2.5% |
1.4% |
|
Other Pediatric
Subspecialty |
1.5% |
0.4% |
2.2% |
1.0% |
4.0% |
|
|
Internal Medicine
Subspecialty |
11.4% |
6.4% |
19.7% |
14.7% |
14.6% |
8.2% |
|
Anesthesia, Palliative,
Pain |
5.6% |
4.7% |
5.0% |
1.5% |
2.0% |
13.1% |
|
Neurology |
1.3% |
1.1% |
2.1% |
0.6% |
|
|
|
General Surgery |
4.1% |
1.8% |
2.7% |
2.7% |
|
|
|
Orthopedic Surgery |
4.0% |
2.1% |
0.6% |
10.3% |
|
|
|
Surgical Subspecialty |
9.1% |
2.2% |
2.3% |
12.0% |
|
|
|
All Psychiatry, Mental
Health |
4.7% |
3.2% |
6.2% |
1.3% |
2.8% |
8.2% |
|
Preventive, Public, School
Health, Maternal Child |
0.5% |
0.4% |
0.2% |
0.2% |
3.6% |
5.6% |
|
Radiology, Nuclear Medicine |
6.0% |
2.2% |
2.4% |
1.2% |
|
|
|
Pathology |
2.0% |
0.8% |
3.2% |
|
|
|
|
Emergency Medicine |
5.3% |
6.5% |
0.8% |
10.3% |
4.0% |
|
|
Physical or Occupational
Med |
1.4% |
2.4% |
1.1% |
3.1% |
2.3% |
0.7% |
|
Other Specialties |
1.2% |
11.6% |
5.4% |
3.2% |
10.0% |
|
|
|
1987 – 2000 Class Years As Listed in the 2005 Masterfile
(most recent 40% of total physicians) |
AAPA 2007 Survey1 |
AANP 2004 Survey2 |
2004 RN National Sample3 |
||
Abstract and Documentation and References Below
Introduction: Progressive changes in admissions, training, and health policy have not been fully considered with respect to future primary care capacity.
Methods: The author compiled comparisons of specialty choices across allopathic and osteopathic United States graduates, international graduates, physician assistants, nurse practitioners, and advanced nurses.
Results: Primary care levels were less than 40% for allopathic physicians, nurse practitioners, and physician assistants and were approximately 50% for osteopathic physicians and most major international graduate sources. Nurse practitioner and physician assistant specialties resemble overall physician specialty distributions. NPs favor internal medicine subspecialties, geriatrics, and women’s health. Physician assistants have moved to emergency medicine, orthopedics, and surgical subspecialties. Osteopathic graduates have been a rich source of family physicians, a more permanent form of primary care. International graduates favor internal medicine residency, the least likely choice for primary care capacity. Allopathic private graduates supply surgical subspecialties at the highest levels with medical subspecialties.
Discussion: Current health policy is destroying primary care workforce. Policy design could protect, preserve, and retain primary care. United States policy drives existing primary care away with only the more resistant permanent forms remaining but the same policy results in fewest choosing permanent forms such as family medicine. Internal medicine is moving rapidly to specialty, hospital, hospitalist, urgent, and emergent careers. Primary care nurse practitioners and physician assistants are more valued as specialty workforce, have more support, generate more revenues as specialty workforce, and save substantial costs for employers compared to costly physician specialists.
Policy is the major factor impacting primary care delivery, but it is not the only factor. As more exclusive students gain admission, as training moves more exclusive, and as career choices move away from family practice, specialty workforce is a more and more likely result for medical schools, primary care training programs, nurse practitioner programs, and physician assistant programs. Policy, origins, career choice, and training combine for continued declines in primary care capacity.
Introduction
Current policy has moved from supportive of primary care in the 1990s, to less supportive, to destructive in more recent years. There is no other term that describes the current situation where primary care graduates depart primary care during primary care training, depart primary care at primary care program graduation, and depart primary care practices each year after graduation.
Moaning about primary care or focus distracted to a so-called continuity home is ridiculous distraction from the real problems.
To understand the United States health care design, or lack thereof, one must understand concentrations.
The compromise of primary care and basic health access would be obvious, except for the design flaws that obscure the changes and except for the slow steady changes class year to class year.
To understand primary care delivery in the United States, one must go back many decades when primary care graduates actually remained in primary care and delivered primary care throughout a career.
While it is possible to believe that progress has been made in primary care capacity since 1960, actually the United States has moved steadily backward. In the class of 1960 longitudinal study, 57% of primary care graduates remained in primary care throughout their careers.4 With survival curve analysis, this translates to 71% of full time capacity for 30 or more years of workforce. Best estimates at the current time are less than 10% of internal medicine graduates, 50% of pediatric graduates, and about 85 – 90% of family medicine graduates remaining in primary care. The actual output is 800 primary care internal medicine physicians, 1600 pediatric primary care physicians, and 2500 primary care family physicians. This is 4900 out of 14,000 graduates or about 35% for primary care contributions. With new physician assistants beginning at 28% primary care and nurse practitioners down below 40% primary care, the United States has actually cut primary care contributions in half compared to 1960. Despite substantially more graduates and despite three new forms of primary care, the actual increase in primary care has been minimal. If family medicine primary contributions were removed with fewest graduates (10%) and the most primary care delivered (35 – 45%), the actual primary care delivery would be abysmal. Only family practice residency graduates represent an improvement since 1960 with primary care capacity at levels beyond 83%.
Another way of expressing this is estimated primary care workforce years or the future capacity of primary care delivered. Family medicine residency graduates can be expected to deliver 25 primary care workforce years over an expected 35 year practice career. The estimates for pediatric residency graduates have decreased to 15 years while internal medicine, nurse practitioner, and physician assistant primary care contributions have declined to the 2 – 4 Standard Primary Care year per graduate level.
The most important factor in decline in primary care is policy. Poorly supportive policy moves primary care graduates away from primary care steadily during training, at graduation, and each year after graduation.
Policy is not the only limiting factor in primary care delivery. Common sense is required. Nurse practitioners and foreign origin international medical graduates begin primary care careers at age 38 leaving only 27 years. This is a 23% loss of primary care delivery before beginning a potential primary care career. Nurse practitioners have lowest volume of primary care delivered and also average 60% active. Fewest years, most part time and inactive, most in administrative careers, and lowest volume results in substantial limitations. Nurse practitioners can only contribute 9 Standard Primary Care years with 90% remaining and with only about one-third remaining in primary care, the result is not better than 3 – 4 Standard Primary Care years or 6 to 8 times lower than a family physician.
Movements away from primary care, part time and inactivity work, and lower volume care limit primary care capacity.5
Why Nurse Practitioners Are Not Good Solutions
http://www.ruralmedicaleducation.org/basichealthaccess/Why_NP_Primary_Care_Solution.htm
The Impact of Data Delay on Primary Care Workforce
Estimates
Steady declines in all forms of primary care mean that even recent studies and reports are now dated. Attempting to use the most recent secondary data sources can also be problematic. Sources such as the Masterfile take years to compile. Physicians must first complete residency training, complete one or more additional fellowships or other training, transition family needs, find a suitable practice and practice location, and then the practice location and career choice must be captured and updated.
International graduates illustrate the numerous errors commonly made in workforce calculations. International graduate internal medicine graduates of foreign origins contribute the least primary care of all. Studies that only include active FIMG IM graduates that remain in the United States fail to capture the true picture.
Thousands of foreign origin international medical graduates begin the process required to enter the United States, adapt, find a residency position, and begin. Unknown thousands fail to complete this journey.
An unknown number of FIMG graduates fail to complete residency training, have delays in training, or transition to other specialties.
The first marker known is the number that graduate from residency training in a particular specialty. For example about 8000 internal medicine residents graduate and about 45% are FIMG.
The next step is a departure back to home nations for about 20%. Studies also note an additional percentage departing for other nations.
Another complication is about 8 percentage points of FIMG that remain chronically unemployed,6
All told the 23% delay and more than this in departure results in loss of half of the workforce before beginning. A US origin graduate delivers twice the workforce compared to a foreign origin graduates due to delays in entry and departures after graduation.
The next consideration is primary care retention. Arrangements for staying in the United States can include J-1 Visa obligations that shape primary as well as underserved practice locations, but bypass routes are also available. Large systems and medical schools also can help FIMG graduates to bypass the J-1 Visa or can qualify for J-1 Visa positions that address medical school workforce.
There is also a concern about productivity and mismatches between the populations served and the origins of physicians.
Also sites that are desperate and dependent face difficulties recruiting lasting workforce as more and more physicians are temporary.
Physician assistant and nurse practitioner contributions to primary care, rural, and underserved locations were at top levels in the early years. Over 56% of physician assistants were working with family physicians in 1984 and primary care levels were even higher. The primary care, rural, and underserved levels of physician assistants are half of 1984 levels, shaped in many ways by the same declines in those working with family physicians. Declines in working with family physicians have been 1 – 2 percentage points a year for over a decade down to 25%. While family practice physician assistants have 30% rural location and the few physician assistants involved in mental health have 20% rural levels, all other types of physician assistants make less than average rural contributions.1, 5
Since the beginning of nurse practitioners and physician assistants, the annual average rate of primary care retention decline has been 2 – 3 percentage points.
Beyond Intermittent Declines to Predictable Declines
In the past decade, the declines in family medicine choice, declines in retention in generalist internal medicine and generalist pediatrics, and declines in physician assistant primary care, rural, and family practice levels have become quite predictable. Declines in primary care retention are steady for nurse practitioners. Policy continues to drive these changes and policy is unchanged. The policy involved is more than just insufficient primary care reimbursement, rather the entire design favors movement to specialty careers.
Comparisons of the specialization rates can be helpful in understanding the differences and changes.
Methods
Physician data from the American Medical Association Masterfile, nurse practitioner surveys, and annual physician assistant reports were used to compare specialty distributions. The physician assistant reports are current as of September 2007.1 The nurse practitioner reports date back to 2004.2, 3, 7-9 The physician data involves the 2005 Masterfile but considers the 1987 – 2000 graduates who have had time to complete training and distribute. The more recent 1987 – 2000 graduates have graduation years similar to the physician assistants. This is due to the fact that rapid increases in nurse practitioners and physician assistants insure that a greater proportion are recent graduates.
An advantage of secondary databases is that workforce can be captured in equilibrium conditions regarding career choice and practice location. Such studies include a cross section of graduates. Secondary databases can also represent career and location decisions fixed in time. Physicians that have not completed training or those with missing or uncertain data can be excluded for a more accurate version.
Physician assistant data is collected consistently each year with reasonable response rates (33%). The 2007 physician assistant report had detailed information regarding specialty employment and the data matches up to physician specialty categories.1
The nurse practitioner data remains the most challenging. Up to 30% of nurse practitioners do not list themselves as NPs even though they have completed training. In media releases the figure of 125,000 is used but actual graduates are over 160.000. There is some consideration that missing graduates and those not listing themselves as nurse practitioners are inactive or involved in hospital careers. This could result in greater activity with fewer inactive or part time than actual. This would result in an overestimate of primary care. Also if the hospital based nurse practitioners do not respond, this would also artificially increase the percentage listing primary care for the active graduates that did respond. This makes numbers of nurse practitioner graduates difficult to determine. Also by the time surveys are collected and analyzed and reported over 18 – 24 months, nurse practitioner and physician assistant primary care retention has typically decreased 2 or 3 percentage points. There are valid reasons to believe that primary care and activity levels are overestimated.
To gain perspective regarding the advanced nursing distributions of all types, the advanced nursing table from the 2004 registered nurse estimate was added. This combines the various advanced nursing forms such as nurse practitioners, certified nurse midwives and nurse anesthetists. Nurse anesthetists are different in many ways including balanced distributions in gender and much higher salaries. Across nursing the specialty and hospital nurses have greater income compared to ambulatory forms with community and public nursing forms at the lowest salaries.3 Levels of nursing support, assistants, and autonomy increase steadily with increasing hospital and specialty focus, as with physicians and potentially influenced by the same market forces set by the same health policies.
There are differences in the primary care definitions used by physicians and nurse practitioners. The physician primary care definition includes family medicine, general practice, general pediatrics, general internal medicine, medicine pediatrics. Geriatric and women’s health physicians were combined with primary care physicians to provide comparable measures as used by nurse practitioners. Nurse practitioner defined primary care was reduced by geriatric and women’s health components to meet the physician and physician assistant definition.
Inclusion of women’s health and geriatric care specialties can be an issue when the care has hospital and facility focus as compared to office based ambulatory primary care.
Because nurse practitioner levels in geriatrics and women’s health are significantly greater, there are major differences in the two forms using the nurse practitioner comparisons. There are fewer differences when using the physician primary care comparison.
Nurse practitioner studies often list the specialty of training (family nurse practitioner, adult, women’s health), but the actual employment activity can be quite different. This is because flexible primary care forms can and do switch to different specialties and may even provide care in two or three different specialties with some in primary care and some activities not primary care.
Not surprisingly it is particularly difficult to gain an understanding of actual percentages involved in primary care. The 2004 AANP survey did include a determination of primary care. Goolsby appeared to make a maximal effort to capture all possible primary care with 22,000 FTE of primary care collected from up to 3 different locations per response for the 39,000 nurse practitioners who responded.2 The raw FTE from this calculation was 56.4% for the responding NPs.
There are still difficulties with this measurement.
The NP studies vary in the consideration of full time, using either 32, 35, or 36 hours for a full time FTE. Actual FTE would be 10 – 20% lower if the 36 hour measurement was adjusted to 40 hours. This would decrease NP primary care FTE from 56.4% to 50.8%.
The NP extended primary care measure includes women’s health (11.3%) and geriatrics (4.1%). Subtracting this 15.4% from the 56.4% leaves 41.0% in the more typical physician primary care in 2004, over 5 years ago.
Another 6 percentage points was deducted due to primary care changes over time for an estimate of 35%. The rate of primary care decline has been consistent in nurse practitioners over decades.
The best measures of annual decline have involved physician assistants who do comprehensive annual surveys and have recorded a consistent 1 – 2 percentage points a year for the past decade dating back to the early 1990s when managed care and primary care peak levels turned around to consistent declines in all other forms of primary care: FM medical student choice, IM and PD generalist percentage retention, and PA primary care retention. It is not likely that NPs are any different than all the other forms of primary care in the current policy driven declines.
The 39% is likely to be conservative. Nurse practitioners have less full time work, there is no adjustment in the AANP data for inactivity or non-responders, nurse practitioners see fewer patients, and there is a time lag since the 2004 data was collected. Nurses are noted to have 69 – 70% active FTE compared to the total nursing graduates. Nurses and nurse practitioners also have a consistent 58% listed as full time. It is likely that activity levels are determined by similar factors for both. It is important to remember that registered nurses are over 55% hospital based with 12% ambulatory and 11% community or public health. Nursing shares the broad horizontal perspective of primary care, but the employment forces shape hospital focus and 8 – 11 years on average of hospital practice experiences over the prior to becoming a nurse practitioner. Hospital based nurse practitioners averaged $75,000 or $5,000 more than ambulatory NPs and $10,000 more than community or public health nurse practitioners.2, 3
Actual nurse practitioner primary care FTE is likely to be below 35% for the physician measure of primary care and below 50% for the nurse practitioner measure of primary care when compared to all who graduated from nurse practitioner programs.
More important than who is doing better or worse is the fact that all primary care forms are declining together, and in the most needed health care locations and populations.
Results
Specialty Distribution Comparisons – see first table
When the basic 3 physician specialties are used for primary care measurements, the comparative differences in primary care contributions were small. Of course in the last 6 years, declines in primary care have been substantial in internal medicine, nurse practitioner, and physician assistant active graduates. About 30,000 internal medicine primary care physicians have converted to hospitalist care with more departing for hospital, urgent, emergent, and specialty careers. Internal medicine journals, articles, and experts have noted these changes as well as dysfunctional primary care deflecting graduates away from primary care.10-15 Best estimates of future primary are involve less than 10% of the residents graduating from internal medicine programs. Also the foreign origin international medical graduates are about 45% of total IM graduates and contribute only half of the workforce of US origin graduates. The medical school contributions of primary care have primarily declined as internal medicine training has converted to 90% specialist in outcomes.
Allopathic graduates choose subspecialty, women’s health, public health, pediatrics, and hospital support specialties. Allopathic private medical school family medicine contributions are the lowest as are their rural and underserved contributions (except Loma Linda, Creighton, Meharry, Morehouse)
Osteopathic graduates maintain the same internal medicine primary care contributions as other physician forms, but add much higher levels of family practice compared to other physician forms. Osteopathic graduates follow primary care and hands-on focus to family medicine, primary care, and various musculoskeletal specialties. Unfortunately the rate of family practice has declined from 60% to 40% for the 1990s to 20% by 2004 and should be less than 15% for the next decade. This means that a doubling of osteopathic graduates from 2004 – 2017 will result in no more family medicine graduates and no more primary care (fewer IM and PD remaining in primary care at graduation also).
Physician assistants already contribute 35% of graduates to surgical subspecialties, emergency medicine, and orthopedics and their doubling from 3100 to 6500 from 1998 to 2008 was also accompanied by no more primary care delivery as they declined from 54% to 28% in primary care for the 2008 class year. With only 20% beginning in family practice, the rural and underserved contributions are also decreasing.
Nurse practitioner contributions are hospital in focus. Even women’s health, geriatric, neonatal, and adult careers are hospital in focus. The selection and training of nursing school focuses on low volume, one on one, hospital orientation and the career movements are in the same direction. Current contributions are significant in internal medicine subspecialties such as cardiology with 6% levels. Nurse practitioners have grown rapidly in this area and have already reached double the physician percentages found in cardiology, oncology, endocrine, and mental health careers.
Family practice components are greater in osteopathic, physician assistant, and nurse practitioner graduates. Lower ranking (MCAT scores) medical schools also are important sources of family physicians. This is important to understand regarding greater levels of distribution. Losses of the active family practice component in physicians, physician assistants, and nurse practitioners may increase the probability of workforce concentration in practice zip codes with 75 or more physicians that are 4% of the land area and 3400 zip codes.
Internal medicine and pediatric primary care forms concentrate 70% in this 4% of the land area in top concentrations without origins outside to help move graduates away from concentrations or unless shaped by temporary obligations as in international graduates.
Because estimates were used for the nurse practitioner primary care contribution, it was necessary to provide an additional calculation involving nurse practitioner non-primary care specialty percentages. To do this it was best to match up physician, physician assistant, and nurse practitioner forms whenever possible. The major specialty choices do confirm reasonable agreement between the primary care FTE contributions and the primary care contribution estimated from the remaining non-primary care component. The internal medicine subspecialization rates for nurse practitioners are a major reason for the changes. Primary care NPs and PAs have ideal preparation to convert to any of these new careers. Initial areas of emphasis such as surgery in physician assistants and women’s health and geriatrics in nurse practitioners do shape specialty distributions.
Nurse practitioner and physician assistants are less likely to be found in careers where technicians or other personnel are involved such as pathology, ophthalmology/optometry, and radiology.
Discussion
Movements to similar lower or lowest concentrations of primary care suggest that all forms of primary care are impacted in similar ways by United States policies. Physicians, physician assistants, and nurse practitioners are all moving steadily toward hospital and specialty concentrations of physicians, non-physicians, and health resources.
The only specialty choice associated with distribution outside of top concentrations is family practice. With fewer family physician graduates, with nurse practitioners and physician assistants departing the family practice broad generalist mode, with concentrations of health funding found inside of concentrations, difficulties recruiting and retaining workforce in zip codes with 65% of the American people will be present for some time.
Arbitrary decisions are made regarding workforce literature. These decisions are usually made by “experts” that have the favor of their specialty or association and every reason not to be as critical of specialty or association policies.
Limitations of this Study
Weak areas involve the missing or unknown category such as 10% of physicians and nurse practitioners that have “other specialty.”
Changes in primary care demand more regular and comprehensive updating of actual primary care delivery for all forms of primary care. With rapid declines in primary care retention, delays in reporting only lead to overpredictions of current and future primary care capacity.
The current table also overestimates physician primary care contributions. Pediatric and internal medicine contributions are relatively stable across medical school types and locations across the nation in the data above, but office primary care levels have continued to decline in the past ten years. With family medicine levels in US MD Grads at record lows, total primary care contributions will be lower. The table is a reflection of current specialty distributions, but may not reflect future careers.
Comprehensive reviews are only as good as the databases. The
limitations in nurse practitioner data can be significant. An attempt was made
to bring some understanding with a more uniform comparison using both the
primary care and extended primary care measurements. Both measurements claim
The initial training of physicians, physician assistants, and nurse practitioners does not reflect final careers. Physician workforce studies often confuse actual careers as in internal medicine where many are hospital based or involved in other activities that lessen or prevent primary care delivery. Physician assistant data does a better job with this clarification. Nurse practitioner data needs to reflect actual careers with less emphasis on past training specialty. Estimates also may need to involve combined careers with primary care and specialty contributions.
Toward Permanent
Primary Care
Family practice remains the more permanent form of primary care in physicians, physician assistants, and nurse practitioners. Family practice components have the broadest scope of distribution, especially for rural locations. Physician assistants working with family physicians still have 30% rural location.1 Family practice distributions are not limited to rural. Family physicians are 53% outside of major medical center locations with 75 or more physicians at a zip code while all other physician types are 70% or more inside of major medical centers. Family practice residency graduates remain 98% in family medicine and 90% in primary care. Family physicians and family practice forms of physician assistants have 2 – 4 times greater probability of rural and underserved distribution with the greatest levels of distribution in the most rural and lowest income locations that have the fewest other physicians or practitioners. Family physician percentages remain relatively stable with declining numbers. Physician assistant distributions decline along with declines in physician assistants associated with family physicians.
More physicians or practitioners will not fix the problems
in primary care or physician distribution. With major leaks in primary care
capacity, it may make little sense to fill up the tank unless graduates are
resistant to leakage. Only one choice has this resistance. Unfortunately this
permanent choice is a most difficult choice for medical students at the current
time. This requires changes in medicine and in areas such as health policy to
increase the concentrations of primary care, family practice, rural, and
underserved capacity of the nation. In some ways there are ethical
considerations that have yet to surface regarding the nurse or nurse
practitioner situation and also regarding the nurses that become 20 – 30% of
physician assistants. In underdeveloped nations, the debates can be significant
regarding nursing workforce as nurses are the dominant health profession.16 Debates should also involve
the current overall health professional workforce in the
Health policy involving primary care reimbursement and support is insufficient to support the medical student decision for a permanent form of primary care, the internal medicine resident in a decision to remain in generalist practice, or a primary care nurse practitioner or physician assistant in primary care.
Different factors are involved in pediatrics. Pediatric primary care markets are saturated. Fewer children, more pediatric residency graduates, declining rural location, and increasing competition in major medical center primary care areas mean increasing rates of subspecialization as seen in the most recent decade.19-21 Only a different pediatric specialty (training, training location, funding, accreditation), fewer pediatric residency positions, or decreased competition for major medical center and most urban pediatric care (declines in primary care NP, PA, FM, medicine pediatrics) will restore pediatric resident generalist choices back to 70% levels.
The changes in nursing and in nurse practitioners are more than just primary care. The average 8 – 11 years experience as a registered nurse makes an excellent nurse practitioner (or physician or PA). Movements of nurses to nurse practitioner or advanced nursing forms involve departures from nursing capacity. The impacts are felt in critical areas of nursing, including nursing faculty, management, and critical care. Few interventions appear to be able to stop the conversion from nursing to nurse practitioners or from primary care nurse practitioners to specialty care outside of major changes in health policy. Only shortages of nursing faculty seem to have intervened. Until the nation pays more for nurses and nursing faculty (or less for nurse practitioners and specialists), it will remain vulnerable to even minor winter flu epidemics, must less pandemics. The same is true of shortages of physician faculty.
Most of all the nation health workforce leadership seems to have failed in the ability to critique current decisions, methods, and potential outcomes. Where are the voices of public health nurses, public health physicians, or advocacy primary care groups? Who will advocate for primary care when the primary care associations no longer have majority primary care membership? How will the nation move primary care training to more relevant locations and a more relevant focus with nearly all trained in the least suitable environments for ambulatory training?
1. American Academy of Physician Assistants. Data and Statistics. http://www.aapa.org/research/index.html. Accessed October 26, 2006.
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3. Health Resources and Services Administration. The Registered Nurse Population: Findings from the 2004 National Sample Survey of Registered Nurses. Washington, DC; 2004.
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14. Hauer KE, Fagan MJ, Kernan W, Mintz M, Durning SJ. Internal medicine clerkship directors' perceptions about student interest in internal medicine careers. J Gen Intern Med. Jul 2008;23(7):1101-1104.
15. Keirns CC, Bosk CL. Perspective: the unintended consequences of training residents in dysfunctional outpatient settings. Acad Med. May 2008;83(5):498-502.
16. Stark R, Nair NV, Omi S. Nurse practitioners in developing countries: some ethical considerations. Nurs Ethics. Jul 1999;6(4):273-277.
17. Rosenblatt RA, Andrilla CH, Curtin T, Hart LG. Shortages of medical personnel at community health centers: implications for planned expansion. Jama. Mar 1 2006;295(9):1042-1049.
18. UNICEF. Child Poverty in Perspective: An overview of child well-being in rich countries. Innocenti Report Card 7 ed:
UNICEF Innocenti Research Centre, Florence.; 2007.
19. Committee on Pediatric Workforce. Pediatrician workforce statement. Pediatrics. Jul 2005;116(1):263-269.
20. Randolph GD, Pathman DE. Trends in the rural-urban distribution of general pediatricians. Pediatrics. Feb 2001;107(2):E18.
21. Shipman SA, Lurie JD, Goodman DC. The general pediatrician: projecting future workforce supply and requirements. Pediatrics. Mar 2004;113(3 Pt 1):435-442.
22. Vermont AHEC. AHEC's Vermont Primary Care Summary Report 2006: University of Vermont AHEC Program; 2006.
Specialty Comparison Tables
N.B. Moody, P.L. Smith, and L.L. Glenn, "Client Characteristics and Practice Patterns of Nurse Practitioners and Physicians," Nurse Practitioner 24, no. 3 (1999): 94–96, 99–100, 102–103; and
P.D. Jacobson, L.E. Parker, and I.D. Coulter, "Nurse Practitioners and Physician Assistants as Primary Care Providers in Institutional Settings," Inquiry (Winter 1998/99): 432–446
A. Running et al., “A Survey of Nurse Practitioners across
the
NPs make 9.4% more by moving from community/public health to ambulatory and make 7.4% more by moving from ambulatory to hospital http://www.bhpr.hrsa.gov/healthworkforce/rnsurvey04/appendixa.htm#40
Full time for NPs is 58% as listed in by Running (Nurse Practitioner 2000) also in Hooker and Berlin, full time for RNs is also 58.3% as listed in HRSA 2004 83% are full or part time
The Vermont AHEC studies captured 60% activity for NP and also did not consider women’s health to be primary care.22
It is important to understand the forces impacting nurse career change.
The Registered Nurse Population: Findings from the 2004 National Sample Survey of Registered Nurses
Table 40
|
Career change |
65.8 |
|
Burnout/stressful work environment |
44.9 |
|
Scheduling/too many hours |
41.4 |
|
Salaries too low/better pay elsewhere |
34 |
|
Inadequate staffing |
33.3 |
|
Taking care of home and family |
29.6 |
|
Physical demands of job |
28.1 |
|
Skills are out-of-date |
20.6 |
|
Lack of collaboration/communication |
20.5 |
|
Liability concerns |
20.4 |
|
Lack of advancement opportunities |
16.5 |
|
Retired |
11.4 |
One can only imagine the 2009 contributions in these areas with fewer faculty, lower support for salaries and entry level positions, fewer nursing school graduates, more graduate degrees and training, and more losses from nursing will do other than more than one million short by 2020.
|
Summary of reasons for other
occupations |
|
|
Personal/family reasons |
41.9 |
|
Personal career reasons |
82.8 |
|
Workplace reasons |
68.3 |
|
Retirement reasons |
11.4 |
|
Other reasons |
0.4 |
|
|
Physicians Listed in Actual Practice Careers |
PAs Listed in Actual Practice Careers |
Nursing Generally Categorized by Training Career but
Not Career Actually Practiced |
||||
|
Practicing Specialty, Not
Always Specialty of Training |
All |
|
|
Inter-national |
Physician Assistants in 2007 |
Nurse Pract-itioners 2004 |
Advanced Nursing HRSA 2004 |
|
Numbers and Estimates |
316792 |
219304 |
24760 |
72728 |
65,000 |
145000 |
240,460 |
|
Family Practice General
Practice |
14.2% |
13.4% |
33.5% |
10.3% |
24.9% |
|
25.0% |
|
General Internal Medicine |
15.7% |
12.2% |
11.3% |
27.7% |
6.9% |
|
|
|
Medicine Pediatrics |
0.8% |
1.0% |
0.4% |
0.4% |
|
|
|
|
General Pediatrics |
7.4% |
7.9% |
3.9% |
7.0% |
2.6% |
|
8.1% |
|
Adult Health Medical
Surgical |
|
|
|
|
|
|
14.3% |
|
Physician Primary Care
Measurement Comparison Note Declines of 1 – 2 percentage
points in each for each passing year since 2004 or 2005 |
38.1% |
34.5% |
49.1% |
45.4% |
34.4% |
39.0% |
|
|
|
|
|
|
|
|
|
|
|
Estimated Primary Care for all Active Graduates with
Adjustment for Decline |
28 – 33% |
24 – 30% |
Higher but rapid change |
28 – 33% |
33% |
35% |
|
|
Extended Primary Care |
|
|
|
|
|
|
|
|
Obstetrics-Gyn/Women’s Health |
5.3% |
6.6% |
4.2% |
2.0% |
2.4% |
11.3% |
12.0% |
|
Geriatrics (considered PC
in federal definitions but may not be ambulatory office based) |
0.6% |
0.4% |
0.4% |
1.3% |
0.7% |
4.1% |
4.7% |
|
|
|
|
|
|
|
|
|
|
Nurse Practitioner Defined Primary
Care Measurement Comparison |
43.9% |
41.5% |
53.7% |
48.7% |
37.5% |
54.4% |
|
|
|
|
|
|
|
|
|
|
|
Specialties Not Involving Primary Care |
All |
|
|
Inter-national |
Physician Assistants in 2007 |
Nurse Pract-itioners 2004 |
Advanced Nursing HRSA 2004 |
|
Total from Data or Surveys |
56.1% |
58.5% |
46.2% |
51.3% |
62.5% |
45.8% |
|
|
Neonatal Perinatal |
0.5% |
0.4% |
0.3% |
0.8% |
0.4% |
2.5% |
1.4% |
|
Other Pediatric
Subspecialty |
1.6% |
1.5% |
0.4% |
2.2% |
1.0% |
4.0% |
|
|
Internal Medicine
Subspecialty |
12.3% |
11.4% |
6.4% |
16.5% |
14.7% |
14.6% |
8.2% |
|
Anesthesia, Palliative,
Pain |
5.4% |
5.6% |
4.7% |
5.0% |
1.5% |
2.0% |
13.1% |
|
Neurology |
1.7% |
1.3% |
1.1% |
2.1% |
0.6% |
|
|
|
General Surgery |
3.6% |
4.1% |
1.8% |
2.7% |
2.7% |
|
|
|
Orthopedic Surgery |
2.4% |
4.0% |
2.1% |
0.6% |
10.3% |
|
|
|
Surgical Subspecialty |
7.5% |
9.1% |
2.2% |
2.3% |
12.0% |
|
|
|
All Psychiatry, Mental
Health |
5.0% |
4.7% |
3.2% |
6.2% |
1.3% |
2.8% |
8.2% |
|
Preventive, Public, School
Health, Maternal Child |
0.4% |
0.5% |
0.4% |
0.2% |
0.2% |
3.6% |
5.6% |
|
Radiology, Nuclear Medicine |
5.5% |
6.0% |
2.2% |
2.4% |
1.2% |
|
|
|
Pathology |
2.0% |
2.0% |
0.8% |
3.2% |
|
|
|
|
Emergency Medicine |
4.4% |
5.3% |
6.5% |
0.8% |
10.3% |
4.0% |
|
|
Physical or Occupational
Medicine |
1.4% |
1.4% |
2.4% |
1.1% |
3.1% |
2.3% |
0.7% |
|
Other Specialties |
3.0% |
1.2% |
11.6% |
5.4% |
3.2% |
10.0% |
|
|
|
Physician Graduates 1987 – 2000 for the Masterfile
2005 Version |
AAPA 2007 Annual Survey |
AANP 2004 Survey |
2004 RN National Sample |
|||
|
|
Recent Grad |
PA 2007 |
NP 2004 |
NP, Nurse Anesthesia, Nurse Midwives |
|
Physician Primary Care
Measurement Comparison |
38.1% |
34.4% |
39.0% |
29.5% |
|
Nurse Practitioner Primary
Care Measurement Comparison |
43.9% |
37.5% |
54.4% |
44.0% |
|
Total from Data or Surveys |
56.1% |
62.5% |
45.8% |
56.3% |
|
Primary and Non-Primary
Care Total |
100.0% |
100.0% |
100.2% |
100.3% |
|
|
|
|
|
|
|
Internal Medicine
Subspecialty |
|
|
|
|
|
Cardiology |
2.8% |
3.8% |
6.0% |
4.5% |
|
Dermatology |
1.4% |
3.5% |
|
|
|
Endocrinology |
0.6% |
0.6% |
2.2% |
1.7% |
|
Gastroenterology |
1.4% |
1.7% |
2.1% |
1.6% |
|
Hematology Oncology |
1.4% |
0.2% |
2.3% |
1.7% |
|
Infectious Disease |
0.9% |
0.5% |
|
|
|
Nephrology |
1.0% |
0.6% |
|
|
|
Rheumatology |
1.0% |
0.3% |
|
|
|
Allergy Immunology |
0.4% |
0.5% |
|
|
|
Pulmonary and Critical Care |
1.6% |
0.9% |
Likely |
Likely |
|
Other IM Subspecialty |
0.3% |
0.3% |
2.0% |
1.5% |
|
|
|
|
|
|
|
Neurology |
1.7% |
0.6% |
|
|
|
|
|
|
|
|
|
Anesthesia |
5.0% |
0.3% |
|
21.6% |
|
Pain Management |
0.4% |
1.2% |
|
0.0% |
|
Palliative |
|
|
2.0% |
1.5% |
|
|
|
|
|
|
|
Orthopedic Surgery |
2.4% |
10.3% |
|
|
|
|
|
|
|
|
|
General Surgery |
3.6% |
2.7% |
|
|
|
|
|
|
|
|
|
Surgical Subspecialty |
|
|
|
|
|
Neurosurgery |
0.6% |
2.4% |
|
|
|
Otorhinolaryngology |
1.1% |
1.0% |
|
|
|
Plastic Surgery |
0.3% |
0.8% |
|
|
|
Thoracic Surgery |
0.3% |
0.2% |
|
|
|
Urology |
1.1% |
1.2% |
|
|
|
Vascular Surgery |
0.3% |
3.7% |
|
|
|
Ophthalmology |
2.1% |
0.1% |
|
|
|
Other Surgical Subspecialties |
1.7% |
2.6% |
|
|
|
|
|
|
|
|
|
Diagnostic Radiology |
3.1% |
0.2% |
|
|
|
Neuroradiology |
0.4% |
|
|
|
|
Radiation Oncology |
0.6% |
0.2% |
|
|
|
Vascular Intervent Radiology |
1.4% |
0.8% |
|
|
|
|
|
|
|
|
|
Gen Prev
Med/Public Health |
0.4% |
0.2% |
3.0% |
2.3% |
|
School Health |
|
|
0.6% |
0.4% |
|
Physical Medicine |
1.3% |
0.7% |
|
|
|
Occupational Medicine |
0.1% |
2.4% |
2.3% |
1.7% |
|
|
|
|
|
|
|
Pediatric Subspecialty |
1.6% |
1.0% |
4.0% |
3.0% |
|
Neonatal Perinatal |
0.5% |
0.4% |
2.5% |
2.1% |
|
|
|
|
|
|
|
Emergency Medicine |
4.4% |
10.3% |
4.0% |
3.0% |
|
|
|
|
|
|
|
All Psychiatry |
5.0% |
1.3% |
2.8% |
2.1% |
|
|
|
|
|
|
|
Hospital |
|
1.0% |
|
|
|
Other Specialties |
3.0% |
2.2% |
10.0% |
7.6% |
www.physicianworkforcestudies.org