Pediatrician supply could outstrip demand

Nancy Tofil, MD, a pediatric critical care resident at the University of Alabama, Birmingham, says the pediatricians graduating from UAB favor the city's thriving suburbs, but finding a job there can be tough.

Alison Volpe Holmes, MD, a third-year pediatric resident in North Carolina, said the residents willing to move to Greensboro are the first to find jobs, while those wanting to stay in or near Chapel Hill or Raleigh face a longer search.

"Most of my class went straight into practice," she said. "Everybody found what they wanted, but it took longer. It seems if you are willing to go a little outside of the Chapel Hill area, it's easier to find a job."

What these young pediatricians are experiencing may be signals that the pediatric work force is outpacing its patient base, according to Scott Shipman, MD, MPH, assistant professor of pediatrics at Oregon Health & Science University School of Medicine. Dr. Shipman predicts a massive expansion of the pediatric work force, with the number of full-time equivalent pediatricians soaring 58% higher in 2020 than in 2000, while the population of children will go up only 9.3%.

In the March 3 Pediatrics, Dr. Shipman and co-authors of "The General Pediatrician: Projecting Future Workforce Supply and Requirements," write that there will be 1,438 children for every FTE pediatrician in 2020, a number they cite as barely enough to maintain a full-time practice. In 2000, he estimates there was one pediatrician for every 2,040 kids.

A changing environment

Richard Pan, MD, associate pediatric resident director at University of California, Davis, said signs of a pediatrician oversupply have been evident for several years. Citing an earlier study he contributed to that surveyed third-year residents from 1997 to 2002, Dr. Pan said general pediatricians' salaries were trending lower during this time, and fewer graduating residents were landing their first choice in jobs.

To cope with this changing environment, Dr. Shipman speculates pediatricians may expand the kinds of services they provide to patients in order to maintain their workload, seek to add more young adults as patients or compete for a greater share of the children being treated by family physicians. Or, he said, they may take the decrease in patients in stride and use more of their time on child advocacy issues.

"While some may take away the message this is a bad thing and there needs to be fewer pediatricians as a result, that's not the way I see this," Dr. Shipman said. "I see this as an opportunity and want to make the most of it. The field of pediatrics has already evolved significantly since immunizations changed the face of illness for children. This is just another shift."

Michael Fleming, MD, president of the American Academy of Family Physicians, said family physicians will continue to see plenty of patients, though there may be fewer children in the mix if a boom in pediatricians materializes. "I don't do obstetrics care in my practice anymore," Dr. Fleming said, because the number of obstetricians in the area has grown. "So, I don't do as much pediatric care as 10 years ago. This reflects a bit of the evolution of where we're going in our country. There's more specialist care. On the other side, I haven't met an [AAFP] member yet who needs to see more patients, they're working as hard as they can."

Geographic distribution at issue

While many expect the aging baby boomer population will create heavy demand for primary care physicians, Dr. Shipman said pediatricians will be facing an entirely different situation.

"Family practice is dealing with an aging population by necessity, as are internists," Dr. Shipman said. "The primary care work force has been lumped together in past work force studies, but because of the aging population, in work force matters, pediatrics is very different from internal medicine and family medicine."

Carmelita Britton, MD, chair of the American Academy of Pediatrics' work force committee, said an overabundance of pediatricians may bring about a better geographic distribution.

"The question of whether the population is saturated as far as pediatricians are concerned is a real issue," Dr. Britton said. "One of the major issues for the academy is how to address the maldistribution. What are the barriers to getting pediatricians into areas that are underserved, and how should we address those barriers?"

Meanwhile, demand is strong for pediatric subspecialists.

"Entire communities are going wanting for pediatric surgeons, pediatric nephrologists -- the list goes on and on," Dr. Britton said.

Residents are hearing this message and are responding.

Dr. Tofil said she's seeing more residents choose the subspecialty path.

"Six years ago at UAB, one out of 20 pediatric residents did a fellowship," Dr. Tofil said. "Now more than 50% are doing fellowships. There's definitely a sense that the need is in the pediatric subspecialties."

While more subspecialists may reduce the pediatric generalist population, it would take a 50% reduction in general pediatric residents to keep the ratio of pediatricians to children at 2000 levels, according to Dr. Shipman.

Such forecasts have the pediatric profession on the alert.

"This is a warning to those of us in pediatric education to be cautious, to closely monitor what is happening so we don't make a tremendous investment in these people and not have them be able to make it," said Dr. Pan. "There's definitely a softening of the market, but there's plenty of work to do. We're not seeing hoards of pediatricians driving taxis."