Different Measures and Ways to Categorize Pediatrician Burnout and the Association with Satisfaction.

OBJECTIVE: Compare pediatrician burnout when measured and categorized in different ways to better understand burnout and the association with satisfaction. STUDY DESIGN: We analyzed national survey data from a cohort study of early to midcareer pediatricians. In 2017, participants randomly received 1 of 3 question sets measuring burnout components (emotional exhaustion, depersonalization, and personal accomplishment): group A received the Maslach Burnout Inventory, group B received a previously used measure, and group C received a new severe measure. Repeated measures ANOVA tested differences across burnout categorizations: high emotional exhaustion and high depersonalization and low personal accomplishment; high emotional exhaustion and high depersonalization; and high emotional exhaustion or high depersonalization. Logistic regression tested relationships between burnout profiles (engaged, intermediate, and burnout) and satisfaction. Seventy-one percent of participants completed the survey (1279/1800). RESULTS: Burnout varied depending on measurement (groups A, B, and C) and categorization. For example, for group A, when categorized as high emotional exhaustion, high depersonalization, and low personal accomplishment, burnout was lower (4.8%) than categorized as high emotional exhaustion and depersonalization (15.2%) (P < .001) or categorized as high emotional exhaustion or depersonalization (44.6%) (P < .001). Most participants were satisfied with their career (83.6%). Using burnout profiles, 38.4%-85.1% fell in the engaged profile. For each group, burnout profiles were associated with satisfaction. For example, group A participants in the burnout or intermediate profile were less likely than those engaged to be satisfied with their careers (aOR, 0.08 [95% CI, 0.03-0.24]; and aOR, 0.23 [95% CI, 0.10-0.56], respectively). CONCLUSIONS: The way burnout is measured and categorized affects burnout prevalence and its association with satisfaction. Transparency in methodology used is critical to interpreting results.

Incidence of Thyroid Disease in Adolescent Females Presenting with Heavy Menstrual Bleeding.

The incidence of thyroid disease in adolescents with heavy menstrual bleeding is unknown. A retrospective cross-sectional study of 427 adolescents presenting with heavy menstrual bleeding found 0.23% (95% CI 0%-0.7%) had thyroid disease, lower than that expected in the general population. Thyroid testing should only be considered when other symptomatology is present.

Timing and Stability of Fellowship Choices during Pediatric Residency: A Longitudinal Survey.

OBJECTIVES: To determine, among pediatric residents, the timing and stability of decisions to pursue fellowship training and select a specific subspecialty, which can be used to inform strategies to better match the distribution of pediatric subspecialist with the needs of children. STUDY DESIGN: A longitudinal survey administered with the General Pediatrics In-training Exam to pediatric residents in the US and Canada, 2010-2014. The study included residents who responded in each of their first 3 years of residency and indicated plans to enter fellowship or matriculated, 2013-2016, into 1 of the 14 medical subspecialty fellowships for which the American Board of Pediatrics grants a certificate. Descriptive and χ2 statistics were calculated. RESULTS: Of the 7580 residents who completed 3 annual surveys (response rate 99%) 4963 (65.5%) indicated plans to pursue fellowship training and 2843 (37.5%) matriculated into fellowship. Residents who did not enter fellowship were in smaller residency programs and programs with less interest in fellowship among interns. Most residents who matriculated into fellowship (68.4%) planned to do so as interns and maintained that plan throughout residency. In contrast, 22.7% had selected a specific subspecialty as interns. Fellowship decisions were made later in residency by female residents, American Medical Graduates, and residents in programs where <50% of interns planned to pursue fellowship training. Timing and stability of decisions varied across subspecialty fields. CONCLUSIONS: Understanding the timing of pediatric medical subspecialty fellowship decisions could be used to shape medical education and, ultimately, the pediatric workforce.

Variation in Part-Time Work among Pediatric Subspecialties.

OBJECTIVE: To assess the part-time workforce and average hours worked per week among pediatric subspecialists in the 15 medical subspecialties certified by the American Board of Pediatrics. STUDY DESIGN: We examined data from pediatric subspecialists who enrolled in Maintenance of Certification with the American Board of Pediatrics from 2009 to 2015. Data were collected via an online survey. Providers indicated whether they worked full time or part time and estimated the average number of hours worked per week in clinical, research, education, and administrative tasks, excluding time on call. We calculated and compared the range of hours worked by those in full- and part-time positions overall, by demographic characteristics, and by subspecialty. RESULTS: Overall, 9.6% of subspecialists worked part time. There was significant variation in part-time employment rates between subspecialties, ranging from 3.8% among critical care pediatricians to 22.9% among developmental-behavioral pediatricians. Women, American medical graduates, and physicians older than 70 years of age reported higher rates of part-time employment than men, international medical graduates, and younger physicians. There was marked variation in the number of hours worked across subspecialties. Most, but not all, full-time subspecialists reported working at least 40 hours per week. More than one-half of physicians working part time in hematology and oncology, pulmonology, and transplant hepatology reported working at least 40 hours per week. CONCLUSIONS: There are unique patterns of part-time employment and hours worked per week among pediatric medical subspecialists that make simple head counts inadequate to determine the effective workforce. Our findings are limited to the 15 American Board of Pediatrics-certified medical subspecialties.

Pediatric nurse practitioners in the United States: current distribution and recent trends in training.

OBJECTIVE: To assess the current distribution and training patterns of pediatric nurse practitioners (PNPs). STUDY DESIGN: Secondary data analysis from the National Association of Pediatric Nurse Practitioners and the 2008 US Census Bureau were used to estimate the distribution of PNPs per 100,000 children. Data on nurse practitioner (NP) graduation and specialty education programs were obtained from the American Association of Colleges of Nursing. RESULTS: PNPs have the greatest concentration in the New England and mid-Atlantic regions and a narrow band of Midwestern states. States that allow PNPs to practice or prescribe independently do not consistently have a higher density of PNPs per child population. There has been a slight decrease in the proportion of programs that offer PNP training. In the last decade, the proportion of NP graduates pursuing family nurse practitioner education has increased, and the proportion pursuing PNP education has decreased. CONCLUSION: Workforce planning for the health care of children will require improved methods of assessment of the role of PNPs and the volume of care they provide. Increased use of PNPs in pediatrics will likely require greater effort at recruitment of NPs into the PNP specialty.

Which pediatricians are providing care to America's children? An update on the trends and changes during the past 26 years.

OBJECTIVE: To determine the current proportion of pediatric primary care and specialty visits being conducted by pediatricians versus other providers. STUDY DESIGN: We used data from 1980-2006 National Ambulatory Medical Care Surveys (NAMCS) to examine trends in office visits by patients 0 to 17 years of age. During our years of interest, the total number of visits in NAMCS by children ranged from 2597 to 9220 per year. RESULTS: Overall, the percentage of all nonsurgical physician office visits for children 0 to 17 years of age made to general pediatricians increased from 61% in 1996 to 71% in 2006 and those to nonpediatric generalists fell from 28% to 22%. The greatest changes between 2000 and 2006 occurred in the adolescent age group where the proportion of visits to general pediatricians increased from 38% to 53%. CONCLUSIONS: Pediatricians continue to provide most primary care visits for children in the United States. For the first time, pediatricians now provide most visits for adolescents.

Perspectives and preferences among the general public regarding physician selection and board certification.

OBJECTIVES: To characterize parental attitudes regarding board certification and other factors that influence selection of physicians to care for children. STUDY DESIGN: A web-based survey administered in 2008 to a random sample of 3621 adults >or=18 years of age stratified by parents and non-parents. Proportion of respondents who view board certification and other measures of quality as important factors in selecting a physician to care for children. RESULTS: Survey completion rate was 62%. Almost all (95%) believe it is important or very important for doctors who care for children to be assessed on their quality of care, receive high ratings from patients (91%), and pass a written test at regular intervals (88%). Most reported that recommendations from friends or family (84%) and board certification (82%) were important or very important factors in choosing a physician for their child. Seventy-seven percent of parents stated that they would be likely to change their child's physician if he/she did not maintain board certification. CONCLUSION: Parents report a preference for board-certified physicians and expect them to participate in Maintenance of Certification. Greater understanding of quality measures and the board certification process would empower consumers to make more informed decisions in selecting a physician for their children.

Permanent pediatric diplomate awareness of and perspectives on maintenance of certification.

OBJECTIVE: Since diplomates of the American Board of Pediatrics with permanent certificates will not be required to participate in the Maintenance of Certification (MOC) program, we determined the perceptions of permanent certificate holders about MOC and their degree of interest in participation. STUDY DESIGN: We conducted a 12-item mail survey of 1693 diplomates with permanent certificates. Frequency distributions were calculated for all survey items. chi(2) statistics were used to explore associations between the variables. RESULTS: The response rate was 77.7%. Less than one-third of generalist respondents (28%, n = 122) and 13% of subspecialists (n = 63) agreed that they would be willing to participate in general pediatrics MOC (P < .0001). However, approximately half the subspecialists (48%, n = 221) agreed that they would be willing to participate in subspecialty MOC. Approximately three-fourths of generalists (79%, n = 354) and subspecialists (74%, n = 338) disagreed that MOC is necessary for keeping up-to-date in clinical pediatrics. Few respondents believed that parents understand the MOC program. CONCLUSION: A wide range of attitudes and perceptions about MOC exists among holders of permanent certificates. Concerns about the importance of MOC to parents and the usefulness of MOC participation in improving quality of care will need to be addressed.

Geographic distribution of childhood diabetes and obesity relative to the supply of pediatric endocrinologists in the United States.

OBJECTIVE: To determine the geographic distribution of childhood diabetes and obesity relative to the supply of US pediatric endocrinologists. STUDY DESIGN: Estimation of observed and "index" ratios of children with diabetes (by region and division) and obesity (body mass index >/=95th % for age and sex) (by region and state) to board-certified pediatric endocrinologists. RESULTS: At the national level, the ratio of children with diabetes to pediatric endocrinologists is 290:1, and the ratio of obese children to pediatric endocrinologists is 17,741:1. Ratios of children with diabetes to pediatric endocrinologists in the Midwest (370:1), South (335:1), and West (367:1) are twice as high as in the Northeast (144:1). Across states, there is up to a 19-fold difference in the observed ratios of obese children to pediatric endocrinologists. Under conditions of equitably distributed endocrinologist supply, variation across states would be mitigated considerably. CONCLUSIONS: The distribution of children with diabetes and obesity does not parallel the distribution of pediatric endocrinologists in the United States, due largely to geographic disparities in endocrinologist supply. Given the large burden of obese children to endocrinologists, multidisciplinary models of care delivery are essential for the US health care system to address the needs of children with diabetes and obesity.

Who claims to be a pediatrician?

OBJECTIVE: The purpose of this study was to determine the proportion of physicians who self or otherwise declare themselves to be pediatricians but who have never achieved board certification. STUDY DESIGN: We compared a roster from the state licensure file of eight geographically diverse states containing those designated as pediatricians with a listing from the American Board of Pediatrics (ABP) of those who had ever achieved board certification. We then sent a mail survey to a sample of 500 physicians who appeared as pediatricians on the state licensure files but for whom there was no record of certification with the ABP. RESULTS: The proportion of unmatched pediatricians ranges from 6.9% in Massachusetts to 16.8% in Maryland, and averages 11% across all of the states in our study. The survey response rate was 64%. The majority (61%) of respondents described having undertaken residency training in categorical pediatrics or medicine-pediatrics. The remainder reported surgical residencies (31%) or were combined into an "other" category (8%). Eighty-five percent reported having completed 3 or more years of postgraduate training. Almost all (94%) completed training in the United States or Canada. CONCLUSIONS: There is increasing attention to board certification and patient safety among the media and public. A clearer delineation of the proportion of physicians in a given state reporting to be pediatricians who have not completed board certification can help inform parents of the odds they will encounter noncertified physicians in the hospitals and among the health plans in which they seek care for their children.

Changes in the proportion and volume of care provided to children by generalists and subspecialists.

OBJECTIVE: To assess whether primary care physicians, via referrals or other mechanisms, are now providing proportionally less care for children with specific common diagnoses, thus driving greater demand for specialist services. STUDY DESIGN: Secondary data analysis (1993-2001) from one of the largest commercial healthcare organizations in the United States. Evaluation and management (E/M) common procedural terminology (CPT) visit codes and International Classification of Diseases (ICD) codes pertaining to asthma, constipation, headache, and heart murmurs were selected. Visits were then assigned to the specialty of physician providing care. Significant differences between and among categories of physicians were tested using logistic regression. RESULTS: Overall, pediatrician generalists and specialists provided a greater proportion of E/M visits to children in 2001 than in 1993, compared with nonpediatrician providers. However, although the absolute increase in the proportion of all E/M visits by children <18 years of age to pediatrician generalists was greater than that of pediatrician subspecialists (4.77% vs 0.69%; P <.0001), the relative increase was much smaller for the generalists (8.9% vs 19.7%; P <.0001). Findings were consistent for most of the specific diagnoses examined. CONCLUSIONS: The increases in both the proportion and number of visits made to specialists has not been accompanied by a decrease in visits to generalists.

Relation of per capita income and gross domestic product to the supply and distribution of pediatricians in the United States.

OBJECTIVE: To describe the number and distribution of pediatricians per child nationally and on a state-by-state basis relative to the economic conditions within each state. STUDY DESIGN: Real inflation-adjusted gross domestic product (GDP) per capita (1996 dollars) was plotted against the number of all active physicians and pediatricians in the United States for all years data were available. GDP was then compared with the active number of pediatric medical physicians per child 0 to 14 years of age. RESULTS: The number of pediatricians per 100000 children has more than doubled, from 49.8 to 106.2. Since 1929, the growth in the total number of physicians per capita in the United States has followed a linear relation (r(2)=0.977) with per capita national GDP. This relation is consistent with that specifically for all pediatricians as well (r(2)=0.980) for the years in which data are available (1963 to 2000). There is an extremely uneven distribution of pediatricians. Income differences only partially explain this maldistribution. CONCLUSIONS: There has been a marked increase in the number of pediatricians relative to the number of children in the United States, correlating strongly with the rise in per capita GDP. However, there has been a furthering of their uneven distribution across the United States.

Predicting the pediatric workforce: use of trend analysis.

OBJECTIVE: To develop a predictive model for projecting the pediatric workforce and retrospectively test its accuracy at different points in time over the past several decades. METHODS: We applied a modified version of the physician workforce trend model developed by Cooper et al. We first analyzed and tested the relationship between economic activity and the number of active pediatric medical physicians for several periods from 1963 to 2000. To project economic activity and population changes in the United States, we conducted linear trend analyses by using the available historical data through the year before the forecast period of interest. RESULTS: There has been significant growth of the absolute numbers of the pediatrician workforce over the past several decades. There was a strong correlation (R2=.98) of gross domestic product per capita (using 1996 dollars) with the number of active pediatricians (generalists and specialists) per 100,000 children in the United States by year over a 37-year period from 1963 to 2000. Predictions of pediatrician supply using historical census and economic data to inform the trend analysis were also very highly correlated with actual supply. CONCLUSIONS: The methods used in this study to predict the pediatric workforce were very accurate and consistent over a 37-year period.