The Supply and Distribution of the Preventive Medicine Physician Workforce.

CONTEXT: Preventive medicine physicians work at the intersection of clinical medicine and public health. A previous report on the state of the preventive medicine workforce in 2000 revealed an ongoing decline in preventive medicine physicians and residents, but there have been few updates since. OBJECTIVE: The purpose of this study was to describe trends in both the number of board-certified preventive medicine physicians and those physicians who self-designate preventive medicine as a primary or secondary specialty and examine the age, gender distribution, and geographic distribution of this workforce. DESIGN: Analysis of the supply of preventive medicine physicians using data derived from board certification files of the American Board of Preventive Medicine and self-designation data from the American Medical Association Masterfile. SETTING: The 50 US states and District of Columbia. PARTICIPANTS: Board-certified and self-designated preventive medicine physicians in the United States. MAIN OUTCOME MEASURES: Number, demographics, and location of preventive medicine physicians in United States. RESULTS: From 1999 to 2018, the total number of physicians board certified in preventive medicine increased from 6091 to 9270; the number of self-identified preventive medicine physicians has generally decreased since 2000, with a leveling off in the past 4 years matching the trend of preventive medicine physicians per 100 000 population; there is a recent increase in women in the specialty; the practice locations of preventive medicine physicians do not match the US population in rural or micropolitan areas; and the average age of preventive medicine physicians is increasing. CONCLUSIONS: The number of preventive medicine physicians is not likely to match population needs in the United States in the near term and beyond. Assessing the preventive medicine physician workforce in the United States is complicated by difficulties in defining the specialty and because less than half of self-designated preventive medicine physicians hold a board certification in the specialty.

Using State Licensure Data to Assess North Carolina's Health Workforce COVID-19 Response Capacity.

BACKGROUND In the early months of the COVID-19 pandemic, health care decision-makers in North Carolina needed information about the available health workforce in order to conduct workforce surge planning and to anticipate concerns about professional or geographic workforce shortages.METHOD Descriptive and cartographic analyses were conducted using licensure data held by the North Carolina Health Professions Data System to assess the supply of respiratory therapists, nurses, and critical care physicians in North Carolina. Licensure data were merged with population data and numbers of intensive care unit (ICU) beds drawn from the Centers for Medicare and Medicaid Services (CMS) Healthcare Cost Report Information System (HCRIS).RESULTS The pandemic highlighted how critical data infrastructure is to public health infrastructure. Respiratory therapists and acute care, emergency, and critical care nurses were diffused broadly throughout the state, with higher concentrations in urban areas. Critical care physicians were primarily based in areas with academic health centers.LIMITATIONS Data were unavailable to capture the rapid changes in supply due to clinicians reentering or exiting the workforce. County-level analyses did not reflect individual, facility-level supply, which was needed to plan organizational responses.CONCLUSIONS Health care decision-makers in North Carolina were able to access information about the supply of clinicians critical to caring for COVID-19 patients due to the state's long-standing investments in health workforce data infrastructure. Ability to respond was made easier due to strong working relationships between the University of North Carolina at Chapel Hill Cecil G. Sheps Center for Health Services Research, the North Carolina Area Health Education Centers Program, the health professional licensure boards, and state government health care agencies.

Future Supply of Pediatric Surgeons: Analytical Study of the Current and Projected Supply of Pediatric Surgeons in the Context of a Rapidly Changing Process for Specialty and Subspecialty Training.

OBJECTIVE: To describe the future supply and demand for pediatric surgeons using a physician supply model to determine what the future supply of pediatric surgeons will be over the next decade and a half and to compare that projected supply with potential indicators of demand and the growth of other subspecialties. BACKGROUND: Anticipating the supply of physicians and surgeons in the future has met with varying levels of success. However, there remains a need to anticipate supply given the rapid growth of specialty and subspecialty fellowships. This analysis is intended to support decision making on the size of future fellowships in pediatric surgery. METHODS: The model used in the study is an adaptation of the FutureDocs physician supply and need tool developed to anticipate future supply and need for all physician specialties. Data from national inventories of physicians by specialty, age, sex, activity, and location are combined with data from residency and fellowship programs and accrediting bodies in an agent-based or microsimulation projection model that considers movement into and among specialties. Exits from practice and the geographic distribution of physician and the patient population are also included in the model. Three scenarios for the annual entry into pediatric surgery fellowships (28, 34, and 56) are modeled and their effects on supply through 2030 are presented. RESULTS: The FutureDocs model predicts a very rapid growth of the supply of surgeons who treat pediatric patients-including general pediatric surgeon and focused subspecialties. The supply of all pediatric surgeons will grow relatively rapidly through 2030 under current conditions. That growth is much faster than the rate of growth of the pediatric population. The volume of complex surgical cases will likely match this population growth rate meaning there will be many more surgeons trained for those procedures. The current entry rate into pediatric surgery fellowships (34 per year) will result in a slowing of growth after 2025, a rate of 56 will generate a continued growth through 2030 with a likely plateau after 2035. CONCLUSIONS: The rate of entry into pediatric surgery will continue to exceed population growth through 2030 under two likely scenarios. The very rapid anticipated growth in focused pediatric subspecialties will likely prove challenging to surgeons wishing to maintain their skills with complex cases as a larger and more diverse group of surgeons will also seek to care for many of the conditions and patients which the general pediatric surgeons and general surgeons now see. This means controlling the numbers of pediatric surgery fellowships in a way that recognizes problems with distribution, the volume of cases available to maintain proficiency, and the dynamics of retirement and shifts into other specialty practice.

Building a Value-Based Workforce in North Carolina.

Health care in the United States is likely to change more in the next 10 years than in any previous decade. However, changes in the workforce needed to support new care delivery and payment models will likely be slower and less dramatic. In this issue of the NCMJ, experts from education, practice, and policy reflect on the "state of the state" and what the future holds for multiple health professional groups. They write from a broad range of perspectives and disciplines, but all point toward the need for change-change in the way we educate, deploy, and recruit health professionals. The rapid pace of health system change in North Carolina means that the road map is being redrawn as we drive, but some general routes are evident. In this issue brief we suggest that, to make the workforce more effective, we need to broaden our definition of who is in the health workforce; focus on retooling and retraining the existing workforce; shift from training workers in acute settings to training them in community-based settings; and increase accountability in the system so that public funds spent on the health professions produce the workforce needed to meet the state's health care needs. North Carolina has arguably the best health workforce data system in the country; it has historically provided the data needed to inform policy change, but adequate and ongoing financial support for that system needs to be assured.

Projecting surgeon supply using a dynamic model.

OBJECTIVE: To develop a projection model to forecast the head count and full-time equivalent supply of surgeons by age, sex, and specialty in the United States from 2009 to 2028. SUMMARY BACKGROUND DATA: The search for the optimal number and specialty mix of surgeons to care for the United States population has taken on increased urgency under health care reform. Expanded insurance coverage and an aging population will increase demand for surgical and other medical services. Accurate forecasts of surgical service capacity are crucial to inform the federal government, training institutions, professional associations, and others charged with improving access to health care. METHODS: The study uses a dynamic stock and flow model that simulates future changes in numbers and specialty type by factoring in changes in surgeon demographics and policy factors. RESULTS: : Forecasts show that overall surgeon supply will decrease 18% during the period form 2009 to 2028 with declines in all specialties except colorectal, pediatric, neurological surgery, and vascular surgery. Model simulations suggest that none of the proposed changes to increase graduate medical education currently under consideration will be sufficient to offset declines. CONCLUSIONS: The length of time it takes to train surgeons, the anticipated decrease in hours worked by surgeons in younger generations, and the potential decreases in graduate medical education funding suggest that there may be an insufficient surgeon workforce to meet population needs. Existing maldistribution patterns are likely to be exacerbated, leading to delayed or lost access to time-sensitive surgical procedures, particularly in rural areas.

Developing a research agenda for cardiovascular disease prevention in high-risk rural communities.

The National Institutes of Health convened a workshop to engage researchers and practitioners in dialogue on research issues viewed as either unique or of particular relevance to rural areas, key content areas needed to inform policy and practice in rural settings, and ways rural contexts may influence study design, implementation, assessment of outcomes, and dissemination. Our purpose was to develop a research agenda to address the disproportionate burden of cardiovascular disease (CVD) and related risk factors among populations living in rural areas. Complementary presentations used theoretical and methodological principles to describe research and practice examples from rural settings. Participants created a comprehensive CVD research agenda that identified themes and challenges, and provided 21 recommendations to guide research, practice, and programs in rural areas.

How the Affordable Care Act will affect access to health care in North Carolina.

Reforming health care in the United States often focuses on improving access to care by removing financial barriers and bringing practitioners closer to patients. This article reviews the provisions of the Patient Protection and Affordable Care Act of 2010 (ACA) that are intended to improve access and discusses how the ACA will change access to care for Americans.

The impact of Assertive Community Treatment on utilization of primary care and other outpatient health services: the North Carolina experience.

BACKGROUND: A number of states have implemented Assertive Community Treatment (ACT) teams statewide. The extent to which team-based care in ACT programs substitutes or complements primary care and other types of health services is relatively unknown outside of clinical trials. OBJECTIVE: To analyze whether investments in ACT yield savings in primary care and other outpatient health services. DESIGN: Patterns of medical and mental health service use and costs were examined using Medicaid claims files from 2000 to 2002 in North Carolina. Two-part models and negative binomial models compared individuals on ACT (n = 1,065 distinct individuals) with two control groups of Medicaid enrollees with severe mental illness not receiving ACT services (n = 1,426 and n = 41,717 distinct individuals). RESULTS: We found no evidence that ACT affected utilization of other outpatient health services or primary care; however, ACT was associated with a decrease in other outpatient health expenditures (excluding ACT) through a reduction in the intensity with which these services were used. Consistent with prior literature, ACT also decreased the likelihood of emergency room visits and inpatient psychiatric stays. CONCLUSIONS: Given the increasing emphasis and efforts toward integrating physical health and behavioral health care, it is likely that ACT will continue to be challenged to meet the physical health needs of its consumers. To improve primary care receipt, this may mean a departure from traditional staffing patterns (e.g., the addition of a primary care doctor and nurse) and expansion of the direct services ACT provides to incorporate physical health treatments.

Cholecystectomies performed in children by pediatric surgeons compared to general surgeons in North Carolina are associated with higher institutional charges.

INTRODUCTION: The delivery of pediatric surgical care for gallbladder (GB) and biliary disease involves both General Surgeons (GS) and Pediatric Surgeons (PS). There is a lack of data describing how surgeon specialty impacts practice patterns and healthcare charges. METHODS: We performed a retrospective review of the North Carolina Inpatient Hospital Discharge Database (2013-2017) on pediatric patients (≤18 years) undergoing surgery for biliary pathology. We performed multivariate linear regression comparing surgeons with surgical charge. RESULTS: 12,531 patients had GB or biliary pathology and 4023 (32.1%) had cholecystectomies. The most common procedure for PS and GS was cholecystectomy for cholecystitis (n = 509, 54.0% and n = 2275, 76.4%, p < 0.001), respectively. The hospital ($26,605, IQR $18,955-37,249, vs. $17,451, IQR $13,246-23,478, p < 0.001) and surgical charges ($15,465, IQR $12,233-22,203, vs. $10,338, IQR $6837-14,952, p < 0.001) were higher for PS than GS. Controlling for pertinent variables, surgical charges for PS were $4192 higher than for GS (95% CI: $2162-6122). CONCLUSION: The cholecystectomy charge differential between PS and GS is significant and persisted after controlling for pertinent covariates.

Medicare costs and surgeon supply in hospital service areas.

OBJECTIVE: To quantify the correlates of variations of Medicare per beneficiary costs at the hospital service area level and determine whether physician supply and the specialty of physicians has a significant relationship with cost variation. BACKGROUND: The American Medical Association Masterfile data on physician and surgeon location, characteristics and specialty; Census derived sociodemographic data from 2006 ZIP code level Claritas PopFacts database; and Medicare per beneficiary costs from the Dartmouth Atlas of Health Care project. METHODS: A correlational analysis using bivariate plots and fixed effects linear regression models controlling for hospital service area sociodemographics and the number and characteristics of the physician supply. Data were aggregated to the Dartmouth hospital service area level from ZIP code level files. RESULTS: We found that costs are strongly related to the sociodemographic character of the hospital service areas and the overall supply of physicians but a mixed correlation to the specialist supply depending on the interaction of the proportion of the physician supply who are international medical graduates. The ratio of general surgeons and surgical subspecialists to population are associated with lower costs in the models, again with difference depending on the influence of international medical graduates. There is a strong association between higher costs and the local proportion of physician supply made up of graduates of non-US or Canadian medical schools and female graduates. CONCLUSIONS: These results suggest that strategies to reduce overall costs by changing physician supply must consider more than just overall numbers.

The health care workforce: will it be ready as the boomers age? A review of how we can know (or not know) the answer.

The baby-boom generation will reach the age of eligibility for Medicare starting in 2011. This large group of Americans will require more health care, and more health care workers will be needed to meet those needs. Understanding the needs as well as the size of the workforce needed requires substantial analysis and extensive data. Two major approaches can be used to make these estimates, and the choice of both methods and assumptions can affect the outcomes of any analysis. For the United States to make workforce policy decisions with the best information, we must invest in systems and resources to generate those data and support policy-making bodies that can interpret and make recommendations consistent with the analyses.

The association of changes in local health department resources with changes in state-level health outcomes.

We explored the association between changes in local health department (LHD) resource levels with changes in health outcomes via a retrospective cohort study. We measured changes in expenditures and staffing reported by LHDs on the 1997 and 2005 National Association of County and City Health Officials surveys and assessed changes in state-level health outcomes with the America's Health Rankings reports for those years. We used pairwise correlation and multivariate regression to analyze the association of changes in LHD resources with changes in health outcomes. Increases in LHD expenditures were significantly associated with decreases in infectious disease morbidity at the state level (P = .037), and increases in staffing were significantly associated with decreases in cardiovascular disease mortality (P = .014), controlling for other factors.

The migration of surgeons.

This study attempted to determine if there were identifiable trends in where surgeons moved from and to over time. Physicians, including surgeons, change the location of their practices over their careers. If this movement follows economic theory that surgeons, like most professionals, seek better economic opportunities, then their movements should be toward better markets for their services. Using US national data (American Medical Association Masterfile) that describes the practice locations of surgeons, this study tracked county-level changes of practice location and summarized the characteristics of the places surgeons left and those they moved to. The analysis was primarily descriptive with linear multivariate regression models constructed to determine the characteristics of the surgeons who moved and of the places from and to which they moved. Approximately 30,262 (32.1%) of 94,630 actively practicing, post-training, nonfederal surgeons moved in the 10-year period 1996-2006. The overall tendency of movers was to go to places that had more physicians and a better overall economic environment. These trends, if they continue, may create pressure on access in rural and urban underserved areas.

Geographic and temporal trends in peritoneal dialysis services in the United States between 1995 and 2003.

BACKGROUND: Peritoneal dialysis (PD) is the preferred dialysis modality for many patients with end-stage renal disease (ESRD) in the United States. However, in sharp contrast to the high rates of PD use in other industrialized countries, PD use in the United States is low and decreasing. PD availability is a necessary condition for PD use; however, little is known about the availability and geographic distribution of PD services. This study describes trends in the regional supply of PD services in dialysis facilities between 1995 and 2003. STUDY DESIGN: Longitudinal cohort study. SETTING & PARTICIPANTS: Nonfederal outpatient dialysis facilities treating patients with ESRD in the United States using data from the US Renal Data System. PREDICTORS: Annual ESRD patient and dialysis facility composition in hospital referral regions. OUTCOME: Annual proportion of dialysis facilities offering PD treatment services in hospital referral regions. RESULTS: The average proportion of facilities offering PD services in hospital referral regions was 56% in 1996, which decreased to 47% in 2003. There was geographic variation in PD services, with greater PD availability in metropolitan cities (compared with rural regions) and the Northeast (relative to the South and Midwest). Variation in PD availability was not explained by disease trends or patient characteristics believed to be important for PD use. An increasing regional presence of chain-affiliated facilities was associated with less PD supply. LIMITATIONS: Accuracy of patient registry data, inability to account for consolidation of PD services among chain providers, sensitivity of results to definition of regional markets. CONCLUSIONS: The small and decreasing availability of PD therapy seems counterintuitive given its demonstrated appeal to patients and payers. Further research is needed to investigate dialysis facilities' role in the underuse of a potentially useful therapy.

Measuring the migration of surgical specialists.

BACKGROUND: The lack of access to essential surgical care in low-income countries is aggravated by emigration of locally-trained surgical specialists to more affluent regions. Yet, the global diaspora of surgeons, obstetricians, and anesthesiologists from low-income and middle-income countries has never been fully described and compared with those who have remained in their country of origin. It is also unclear whether the surgical workforce is more affected by international migration than other medical specialists. In this study, we aimed to quantify the proportion of surgical specialists originating from low-income and middle-income countries that currently work in high-income countries. METHODS: We retrieved surgical workforce data from 48 high-income countries and 102 low-income and middle-income countries using the database of the World Health Organization Global Surgical Workforce. We then compared this domestic workforce with more granular data on the country of initial medical qualification of all surgeons, anesthesiologists, and obstetricians made available for 14 selected high-income countries to calculate the proportion of surgical specialists working abroad. RESULTS: We identified 1,118,804 specialist surgeons, anesthesiologists, or obstetricians from 102 low-income and middle-income countries, of whom 33,021 (3.0%) worked in the 14 included high-income countries. The proportion of surgical specialists abroad was greatest for the African and South East Asian regions (12.8% and 12.1%). The proportion of specialists abroad was not greater for surgeons, anesthesiologists, or obstetricians than for physicians and other medical specialists (P = .465). Overall, the countries with the lowest remaining density of surgical specialists were also the countries from which the largest proportion of graduates were now working in high-income countries (P = .011). CONCLUSION: A substantial proportion of all surgeons, anesthesiologists, and obstetricians from low-income and middle-income countries currently work in high-income countries. In addition to decreasing migration from areas of surgical need, innovative strategies to retain and strengthen the surgical workforce could involve engaging this large international pool of surgical specialists and instructors.

Characteristics of practice among rural and urban general surgeons in North Carolina.

OBJECTIVE: To examine variation in the practice patterns of individual general surgeons and how they differ between rural and urban areas of North Carolina. SUMMARY OF BACKGROUND DATA: Traditional physician supply analyses often rely on "head counts" and do not take into account how physicians' practice patterns differ. Practice characteristics including the volume and the breadth of services that a physician provides may be especially important in understanding the supply and distribution of specialists, such as general surgeons. METHODS: Cross-sectional study using physician licensure data linked with administrative records on all inpatient hospital discharges and all surgeries performed at freestanding ambulatory surgery centers in North Carolina in 2004. RESULTS: Total procedure volumes varied widely (interquartile range: 356-700). The average general surgeon in a rural county performed 54 different procedures at least once during the year, compared to 59 in counties with small urban areas and 62 in metropolitan counties. The 10 procedures that a general surgeon performed most frequently accounted for 72% of that surgeon's total annual procedures in rural counties, 67% in counties with small urban areas, and 66% in metropolitan counties. These rural metropolitan differences were smaller after controlling for secondary specialty and other surgeon characteristics. CONCLUSIONS: There was significant variation in the volume and scope of procedures that North Carolina general surgeons performed in the year. Many general surgeons in metropolitan areas performed an array of procedures that was broader than those in rural areas.

The global health workforce shortage: role of surgeons and other providers.

The debate over the status of the physician workforce seems to be concluded. It now is clear that a shortage of physicians exists and is likely to worsen. In retrospect it seems obvious that a static annual production of physicians, coupled with a population growth of 25 million persons each decade, would result in a progressively lower physician to population ratio. Moreover, Cooper has demonstrated convincingly that the robust economy of the past 50 years correlates with demand for physician services. The aging physician workforce is an additional problem: one third of physicians are over 55 years of age, and the population over the age of 65 years is expected to double by 2030. Signs of a physician and surgeon shortage are becoming apparent. The largest organization of physicians in the world (119,000 members), the American College of Physicians, published a white paper in 2006 titled, "The Impending Collapse of Primary Care Medicine and Its Implications for the State of the Nation's Health Care" [37]. The American College of Surgeons, the largest organization of surgeons, has published an article on access to emergency surgery [38], and the Institute of Medicine of the National Academies of Science has published a book on the future of emergency care (Fig. 10). The reports document diminished involvement and availability of emergency care by general surgeons, neurologic surgeons, orthopedists, hand surgeons, plastic surgeons, and others. The emergency room has become the primary care physician after 5 PM for much of the population. A survey done by the Commonwealth Fund revealed that less than half of primary care practices have an on-call arrangement for after-hours care. Other evidence of evolving shortage are reports of long wait times for appointments, the hospitalist movement, and others. The policies for the future should move beyond dispute over whether or not a shortage exists. The immediate need is for the United States, as a society, to commit to workforce self sufficiency in health care. The reliance on international graduates for more than 25% of the nation's physicians is a transnational problem. Reliance on IMGs, nurses and other health professions for the United States workforce is an issue of international distributive justice. Wealthy, developed countries, such as the United States, should be able to educate sufficient health professionals without relying on a less fortunate country's educated health workers. The 2000 Report of the Chair of the AAMC, the accrediting agency for United States and Canadian medical schools through the LCME, recommended expansion of medical school class sizes and expansion of medical schools [41]. For the past 25 years, the AAMC has supported a no-growth policy and the goal that 50% of USMGs be primary care physicians. In 2003, the AAMC developed a workforce center,-led by Edward Salsberg. The workforce center has provided valuable data and monitoring of the evolving workforce graduating from medical and and osteopathic schools in the United States. The NRMP, also managed by the AAMC, has begun useful studies analyzing the specialty choices of the more than 20,000 participants in the Match each year. The AAMC workforce policy was altered in 2006, and a 12-point policy statement was issued (see http://aamc.workforceposition.pdf). Three of the 12 points reflected significant change from past positions. They are a call for a 30% increase in physicians graduated by United States allopathic medical schools and an increase in residency positions now limited by the BBA of 1997. The recommendation that students make personal specialty choices reversed the prior recommendation that a majority of students enter primary care practice.

Mortality and physician supply: does region hold the key to the paradox?

OBJECTIVE: . To determine if the supply of physicians has a consistent relationship with mortality across regions. DATA SOURCES: County-level data describing the supply of physicians, mortality, and socioeconomic conditions of the population as provided in the Area Resource File (BHPr, HRSA) and the Compressed Mortality File (NCHS, CDC). STUDY DESIGN: Ordinary least squares and geographically weighted regression models with age-adjusted all-cause and disease-specific mortality as the dependent variables were specified using pooled data from 1996 to 2000 to test for the relationship with primary care and specialist physician-population ratios. The residuals from the OLS models were mapped and examined for potential clustering. A series of geographically weighted regression models were run for all 3,070 counties and the z-scores and significance of the models mapped. PRINCIPAL FINDINGS: The association between primary care physician supply and mortality was not observed in contrast to other studies; mapping the residuals of those models suggested regional clustering. When weighted geographically, the relationship between primary care and specialist physician supply and mortality presents a mixed pattern. The results show strong regional patterns that may explain the lack of a consistent national association. Primary care physicians are associated with decreased mortality on the east coast and upper midwest, but that correlation disappears or is reversed in the west (with the exception of Washington State) and south central states. CONCLUSIONS: We find evidence that there are regionally focused association between physician supply and mortality, holding constant population characteristics that reflect the influence of social and economic characteristics. However, these relationships are not consistent across the United States; there are regions where there are stronger and weaker associations between type of practitioner and mortality and other regions where no association is apparent. This suggests that the direction for further analysis lies in the understanding of the regional differences and whether there are policy alternatives to address these different patterns.

The precarious supply of physical therapists across Canada: exploring national trends in health human resources (1991 to 2005).

BACKGROUND: Health Human Resource (HHR) ratios are one measure of workforce supply, and are often expressed as a ratio in the number of health professionals to a sub-set of the population. In this study, we explore national trends in HHR among physical therapists (PTs) across Canada. METHODS: National population data were combined with provincial databases of registered physical therapists in order to estimate the HHR ratio in 2005, and to establish trends between 1991 and 2005. RESULTS: The national HHR ratio was 4.3 PTs per 10,000 population in 1991, which increased to 5.0 by 2000. In 2005, the HHR ratios varied widely across jurisdictions; however, we estimate that the national average dropped to 4.8 PTs per 10,000. Although the trend in HHR between 1991 and 2005 suggests positive growth of 11.6%, we have found negative growth of 4.0% in the latter 5-years of this study period. CONCLUSION: Demand for rehabilitation services is projected to escalate in the next decade. Identifying benchmarks or targets regarding the optimal number of PTs, along with other health professionals working within inter professional teams, is necessary to establish a stable supply of health providers to meet the emerging rehabilitation and mobility needs of an aging and increasingly complex Canadian population.

Urban-rural flows of physicians.

CONTEXT: Physician supply is anticipated to fall short of national requirements over the next 20 years. Rural areas are likely to lose relatively more physicians. Policy makers must know how to anticipate what changes in distribution are likely to happen to better target policies. PURPOSE: To determine whether there was a significant flow of physicians from urban to rural areas in recent years when the overall supply of physicians has been considered in balance with needs. METHODS: Individual records from merged AMA Physician Masterfiles for 1981, 1986, 1991, 1996, 2001, and 2003 were used to track movements from urban to rural and rural to urban counties. Individual physician locations were tracked over 5-year intervals during the period 1981 to 2001, with an additional assessment for movements in 2001-2003. FINDINGS: Approximately 25% of physicians moved across county boundaries in any given 5-year period but the relative distribution of urban-rural supply remained relatively stable. One third of all physicians remained in the same urban or rural practice location for most of their professional careers. There was a small net movement of physicians from urban to rural areas from 1981 to 2003. CONCLUSIONS: The data show a net flow from urban to rural places, suggesting a geographic diffusion of physicians in response to economic forces. However, the small gain in rural areas may also be explained by programs that are intended to counter normal market pressures for urban concentrations of professionals. It is likely that in the face of an overall shortage, rural areas will lose physician supply relative to population.