Health Care Practitioners
Health Care Practitioners
The art of medicine consists of amusing the patient while nature cures the disease.
One of the first duties of the physician is to educate the masses not to take medicine.
—William Osler, Sir William Osler: Aphorisms, from His Bedside Teachings and Writings (1950)
Physicians routinely perform medical examinations, provide preventive medicine services, diagnose illness, treat patients suffering from injury or disease, and offer counsel about how to achieve and maintain good health. There are two types of physicians trained in traditional Western medicine: the Doctor of Medicine (MD) is schooled in allopathic medicine and the Doctor of Osteopathy (DO) learns osteopathy. Allopathy is the philosophy and system of curing disease by producing conditions that are incompatible with disease, such as prescribing antibiotics to combat bacterial infection. The philosophy of osteopathy is different; it is based on recognition of the body's capacity for self-healing, and it emphasizes structural and manipulative therapies such as postural education, manual treatment of the musculoskeletal system (osteopathic physicians are trained in hands-on diagnosis and treatment), and preventive medicine. Osteopathy is also considered a holistic practice because it considers the whole person, rather than simply the diseased organ or system.
In modern medical practice, the philosophical differences may not be obvious to most health care consumers because MDs and DOs use many comparable methods of treatment, including prescribing medication and performing surgery. In fact, the American Osteopathic Association (2008, http://www.osteopathic.org/index.cfm?PageID=aoa_main), the national medical professional society that represents more than sixty-one thousand DOs, admits that many people who seek care from osteopathic physicians may be entirely unaware of their physician's training, which emphasizes holistic interventions or special skills such as manipulative techniques. Like MDs, DOs complete four years of medical school and postgraduate residency training; may specialize in areas such as surgery, psychiatry, or obstetrics; and must pass state licensing examinations to practice.
Medical School, Postgraduate Training, and Qualifications
Modern medicine requires considerable skill and extensive training. The road to gaining admission to medical school and becoming a physician is long, difficult, and intensely competitive. Medical school applicants must earn excellent college grades, achieve high scores on entrance exams, and demonstrate emotional maturity and motivation to be admitted to medical school. Once admitted, medical students spend the first two years primarily in laboratories and classrooms learning basic medical sciences such as anatomy (detailed understanding of body structure), physiology (biological processes and vital functions), and biochemistry. They also learn how to take medical histories, perform complete physical examinations, and recognize symptoms of diseases. During their third and fourth years, the medical students work under supervision at teaching hospitals and clinics. By completing clerkships—spending time in different specialties such as internal medicine, obstetrics and gynecology, pediatrics, psychiatry, and surgery— they acquire the necessary skills and gain experience to diagnose and treat a wide variety of illnesses.
Following medical school, new physicians must complete a year of internship, also referred to as postgraduate year one, that emphasizes either general medical practice or one specific specialty and provides clinical experience in various hospital services (e.g., inpatient care, outpatient clinics, emergency rooms, and operating rooms). In the past, many physicians entered practice after this first year of postgraduate training. In the present era of specialization, most physicians choose to continue in residency training, which lasts an additional three to six years, depending on the specialty. Those who choose a subspecialty such as cardiology, infectious diseases, oncology, or plastic surgery must spend additional years in residency and may then choose to complete fellowship training. Immediately after residency, they are eligible to take an examination to earn board certification in their chosen specialty. Fellowship training involves a year or two of laboratory and clinical research work as well as opportunities to gain additional clinical and patient care expertise.
Medical School Applicants
According to the Association of American Medical Colleges (AAMC; September 25, 2007, http://www.aamc.org/newsroom/pressrel/2007/071016.htm), the number of students entering medical school for the 2006–07 academic year was the largest ever—a 2.3% increase from the previous year—with 17,759 first-year students matriculated. The students were selected from a pool of 42,315 applicants. Applications from African-Americans and Hispanics rose by 9.2%.
Conventional and Newer Medical Specialties
Rapid advances in science and medicine and changing needs have resulted in a variety of new medical and surgical specialties, subspecialties, and concentrations. For example, geriatrics, the medical subspecialty concerned with the prevention and treatment of diseases in older adults, has developed in response to growth in this population. In 1909 Ignatz L. Nascher (1863–1944) coined the term geriatrics from the Greek geras (old age) and iatrikos (physician). Geriatricians are physicians trained in internal medicine or family practice who obtain additional training and certification in the diagnosis and treatment of older adults. According to the American Geriatrics Society (AGS; 2008, http://www.americangeriatrics.org/news/geria_faqs.shtml), the United States needs more geriatricians to care for its growing population of older adults. In 2008 there were only 7,590 board-certified geriatricians (one for every 2,500 Americans seventy-five and older) and 1,657 geropsychiatrists (one for every 11,451 Americans seventy-five and older). The AGS forecasts that this ratio will decrease by 2030 to one geriatrician for every 4,254 Americans seventy-five and older and one geropsychiatrist for every 20,195 Americans seventy-five or older.
Another relatively new medical specialty has resulted in physician intensivists. Intensivists, as the name indicates, are trained to staff hospital intensive care units (ICUs, which are sometimes known as critical care units), where the most critically ill patients are cared for using a comprehensive array of state-of-the-art technology and equipment. This specialty arose in response to both the increasing complexity of care provided in ICUs and the demonstrated benefits of immediate availability of highly trained physicians to care for critically ill patients. The Health Resources and Service Administration (HRSA) notes in The Critical Care Workforce: A Study of the Supply and Demand for Critical Care Physicians (May 6, 2006, ftp://ftp.hrsa.gov/bhpr/nationalcenter/criticalcare.pdf) that the demand for intensivists will likely fail to meet the demands of the aging population in the United States by 2020. The HRSA predicts a shortfall of forty-three hundred intensivists in 2020. According to the article “U.S. Predicts Shortage of Intensivists” (California Healthline, May 23, 2006), the Critical Care Workforce Partnership (an alliance of medical societies) advocates increasing medical school capacity to train intensivists and asserts that increasing the supply of intensivists could help save as many as fifty-four thousand lives per year.
The fastest-growing new specialty is hospitalists, physicians who are hospital based as opposed to office based and who provide a variety of services from caring for hospitalized patients who do not have personal physicians to explaining complex medical procedures to patients and families and coordinating many aspects of inpatient care. Robert M. Wachter reports in “The State of Hospital Medicine in 2008” (Medical Clinics of North America, vol. 92, no. 2, March 2008) that there were twenty thousand hospitalists in the United States in 2006 and their ranks are expected to grow in coming years. Wachter opines “that hospitalists have quickly become indispensable to their patients, their hospitals, and to the health care system as a whole. There are no indications that the situation is likely to change in the future.”
More traditional medical specialties include:
- Anesthesiologist—administers anesthesia (partial or complete loss of sensation) and monitors patients in surgery
- Cardiologist—diagnoses and treats diseases of the heart and blood vessels
- Dermatologist—trained to diagnose and treat diseases of the skin, hair, and nails
- Family practitioner—delivers primary care to people of all ages and, when necessary, refers patients to other physician specialists
- Gastroenterologist—specializes in digestive system disorders
- Internist—provides diagnosis and nonsurgical treatment of a broad array of illnesses affecting adults
- Neurologist—specializes in the nervous system and provides diagnosis and treatment of brain, spinal cord, and nerve disorders
- Obstetrician-gynecologist—provides health care for women and their reproductive systems, as well as care for mothers and babies before, during, and immediately following delivery
- Oncologist—dedicated to the diagnosis and treatment of cancer
- Otolaryngologist—skilled in the medical and surgical treatment of ear, nose, and throat disorders and related structures of the face, head, and neck
- Pathologist—uses skills in microscopic chemical analysis and diagnostics to detect disease in body tissues and fluids
- Psychiatrist—specializes in the prevention, diagnosis, and treatment of mental health and emotional disorders
- Pulmonologist—specializes in diseases of the lungs and respiratory system
- Urologist—provides diagnosis as well as medical and surgical treatment of the urinary tract in both men and women as well as male reproductive health services
HIGH COSTS, LONG HOURS, AND LOW WAGES. According to the AAMC (2008, http://services.aamc.org/tsfreports/report_median.cfm?year_of_study=2008), the medical school tuition and fees during the 2007–08 academic year were $22,199 for in-state residents at public schools and $39,964 for students at private schools. The AAMC indicates in “With Debt on the Rise, Students and Schools Face an Uphill Battle” (AAMC Reporter, January 2008) that medical school students graduating in 2006 had incurred a median debt comparable to a home mortgage—an average of $130,000. Even though a physician's earning power is considerable, and many students are able to repay their debts during their first years of practice, some observers believe the extent of medical students' indebtedness may unduly influence their career choices. They may train for higher-paying specialties and subspecialties rather than follow their natural interests or opt to practice in underrepresented specialties or underserved geographic areas. The high cost of medical education is also believed to limit the number of minority applicants to medical school.
Historically, medical training has been difficult and involved long hours. Fiona McDonald notes in “Working to Death: The Regulation of Working Hours in Health Care” (Law and Policy, vol. 1, no. 1, January 2008) that residents typically work twenty-four- to thirty-six-hour shifts and more than eighty hours per week. Lack of sleep and low wages are a way of life for most medical students and residents, although the thirty-six-hour shift has come under criticism as an unnecessary, and possibly dangerous, practice. In 1995 New York State limited most residents to twenty-four-hour shifts and eighty-hour weeks. The regulations were the first of their kind in the country.
In 2003 the Accreditation Council for Graduate Medical Education, which oversees thousands of residency programs every year, adopted guidelines that limited duty hours to eighty hours per week (surgical programs were permitted to have residents work eighty-eight hours per week) for the nation's one hundred thousand physicians-in-training. In “Adapting to Duty-Hour Limits—Four Years On” (New England Journal of Medicine, vol. 356, no. 26, June 28, 2007), Harry H. Yoon reports that many medical residency programs have had to refashion or overhaul their programs to comply with the new standards.
The Number of Physicians in Practice Is Increasing
In 2005, of the 902,053 physicians in the United States, 300,022 were primary care physicians. (See Table 2.1.) Primary care physicians are the front line of the health care system—the first health professionals most people see for medical problems or routine care. Family practitioners, internists, pediatricians, obstetrician/gynecologists, and general practitioners are considered to be primary care physicians. Primary care physicians tend to see the same patients regularly and develop relationships with patients over time as they offer preventive services, scheduled visits, follow-up, and urgent medical care. When necessary, they refer patients for consultation with, and care from, physician specialists.
In 2005, 563,225 physicians maintained office-based practices; 155,248 were in hospital-based practices; and 95,391 physicians were residents and interns. (See Table 2.2.) Besides the growing number of graduates of U.S. medical schools, the ranks of international medical graduates grew by 46,334, from 144,306 in 1995 to 190,640 in 2005.
The number of active physicians devoted to patient care, as opposed to research, administration, or other roles, varies by geographic region and by state, from a high of 38.4 physicians per 10,000 civilian population in Massachusetts in 2005 to a low of 15.7 physicians per 10,000 people in Oklahoma. (See Table 2.3.) New England has the most physicians devoted to patient care per 10,000 population (33.4), whereas the West South Central and Mountain divisions have the fewest, 19.5 and 20, respectively.
Many physicians work long, irregular hours. The Bureau of Labor Statistics (BLS; December 18, 2007, http://www.bls.gov/oco/ocos074.htm) reports that in 2006 more than one-third of full-time physicians worked sixty hours or more per week performing patient care and administrative duties such as office management. Physicians and surgeons held about 633,000 jobs in 2006, and 15% were self-employed. About 50% of physicians held salaried positions, and 18% were employed by private hospitals. Physicians in salaried positions, such as those employed by health maintenance organizations, usually have shorter and more regular hours and enjoy more flexible work schedules than those in private practice. Instead of working as solo practitioners, growing numbers of physicians work in clinics or are partners in group practices or other integrated health care systems. Medical group practices allow physicians to have more flexible schedules, to realize purchasing economies of scale, to pool their money to finance expensive medical equipment, and to be better able to adapt to changes in health care delivery, financing, and reimbursement.
|— Data not available.|
|aEstimated by the Bureau of Health Professions, Health Resources Administration. Active doctors of medicine (M.D.s) include those with address unknown and primary specialty not classified.|
|bIncludes M.D.s engaged in federal and nonfederal patient care (office-based or hospital-based) and other professional activities.|
|cStarting with 1970 data, M.D.s who are inactive, have unknown address, or primary specialty not classified are excluded.|
|Total doctors of medicineb||201,277||260,484||334,028||467,679||615,421||720,325||813,770||853,187||884,974||902,053|
|Active doctors of medicinec||191,577||247,257||310,929||435,545||559,988||646,022||737,504||768,498||792,154||801,742|
|General primary care specialists||113,222||125,359||134,354||170,705||213,514||241,329||274,653||286,294||296,495||300,022|
|General practice/family medicine||95,980||88,023||57,948||60,049||70,480||75,976||86,312||89,357||91,164||91,858|
|Primary care subspecialists||—||—||3,161||16,642||30,911||39,659||52,294||57,929||62,322||65,420|
|Percent of active doctors of medicine|
|General primary care specialist||59.1||50.7||43.2||39.2||38.1||37.4||37.2||37.3||37.4||37.4|
|General practice/family medicine||50.1||35.6||18.6||13.8||12.6||11.8||11.7||11.6||11.5||11.5|
|Primary care subspecialists||—||—||1.0||3.8||5.5||6.1||7.1||7.5||7.9||8.2|
|0.0 Percent greater than zero but less than 0.05.|
|Notes: Data are as of December 31 except for 1990–1994 data, which are as of January 1, and 1949 data, which are as of midyear. Outlying areas include Puerto Rico, the U.S. Virgin Islands, and the Pacific islands of Canton, Caroline, Guam, Mariana, Marshall, American Samoa, and Wake. Data are based on reporting by physicians.|
Physicians' Earnings and Opportunities
Physicians' earnings are among the highest of any profession. According to the Medical Group Management Association (MGMA), in Physician Compensation and Production Survey: 2007 Report Based on 2006 Data (2007, http://www.mgma.com/WorkArea/showcontent.aspx?id=14288), the median annual total compensation for primary care physicians in 2006 was $171,519, and for specialists it was $322,259. The range of salaries varies widely and is often based on a physician's specialty, the number of years in practice, the hours worked, and the geographic location. The MGMA reports that in 2006 orthopedic surgeons and invasive cardiologists were among the top earners, with median annual earnings of $446,517 and $457,563, respectively, whereas pediatricians and family practitioners earned the least: $174,209 and $164,021 per year, respectively.
In 2005 Americans made 963.6 million office visits to physicians. (See Table 2.4.) Women aged eighteen to forty-four visited physicians nearly twice as often as men, and, as expected, people over seventy-five years of age of both genders saw doctors more than twice as often as most younger people.
Changes in the health care delivery system—particularly the shift from traditional fee-for-service practice to managed care, with its efforts to standardize medical practice, which reduces physicians' ability to manage their time, schedules, and professional relationships—have been named as factors contributing to physicians' dissatisfaction with their choice of career. Other changes, including decreasing reimbursement andanever-increasingemphasisondocumentationtosatisfy government and private payers, as well as administrative requirements that infringe on time physicians would rather spend caring for patients, have also increased physician dissatisfaction.
|Activity and place of medical education||1975||1985||1995||2000||2002||2003||2004||2005|
|— Data not available.|
|. . . Category not applicable.|
|aExcludes inactive, not classified, and address unknown.|
|bInternational medical graduates received their medical education in schools outside the United States and Canada.|
|cStarting with 2003 data, separate estimates for federal and nonfederal doctors of medicine are not available.|
|dSpecialty information based on the physician's self-designated primary area of practice. Categories include generalists and specialists.|
|eStarting with 1990 data, clinical fellows are included in this category. In prior years, clinical fellows were included in the other professional activity category.|
|fIncludes medical teaching, administration, research, and other. Prior to 1990, this category also included clinical fellows.|
|Number of doctors of medicine|
|Doctors of medicine||393,742||552,716||720,325||813,770||853,187||871,535||884,974||902,053|
|Place of medical education:|
|U.S. medical graduates||—||392,007||481,137||525,691||544,779||558,167||563,118||571,798|
|International medical graduatesb||—||105,133||144,306||164,437||172,770||178,044||181,025||190,640|
|General and family practice||46,347||53,862||59,932||67,534||71,696||73,508||73,234||74,999|
|Obstetrics and gynecology||15,613||23,525||29,111||31,726||32,738||33,636||33,811||34,659|
|Residents and internse||53,527||72,159||93,650||95,125||96,547||100,033||102,563||95,391|
|Full-time hospital staff||20,976||30,327||43,149||45,908||45,330||62,004||59,186||59,857|
|Other professional activityf||24,252||44,046||40,290||41,556||41,126||44,338||43,856||43,965|
|Office-based practice||2,095||1,156||. . .||. . .||. . .||—||—||—|
|Residents and interns||4,275||3,252||2,702||600||390||—||—||—|
|Full-time hospital staff||17,730||12,885||15,355||15,399||16,311||—||—||—|
|Other professional activityf||4,091||4,274||3,022||3,382||3,481||—||—||—|
|Notes: Data for doctors of medicine are as of December 31, except for 1990–1994 data, which are as of January 1. Outlying areas include Puerto Rico, the U.S. Virgin Islands, and the Pacific islands of Canton, Caroline, Guam, Mariana, Marshall, American Samoa, and Wake. Data are based on reporting by physicians.|
Bruce E. Landon, James Reschovsky, and David Blumenthal report in “Changes in Career Satisfaction among Primary Care and Specialist Physicians, 1997– 2001” (Journal of the American Medical Association, vol. 289, no. 4, January 22, 2003) that even though most physicians were satisfied with their careers, there was significant geographic variation in physician satisfaction.
|Total physiciansa||Doctors of medicine in patient careb|
|Geographic division and state||1975||1985||1995c||2005d, e||1975||1985||1995||2005e|
|Number per 10,000 civilian population|
|East North Central||13.9||19.3||23.3||26.6||12.0||16.4||19.8||22.8|
|West North Central||13.3||18.3||21.8||25.0||11.4||15.6||18.9||21.7|
|District of Columbia||39.6||55.3||63.6||75.6||34.6||45.6||53.6||65.8|
|East South Central||10.5||15.0||19.2||22.8||9.7||14.0||17.8||21.0|
|West South Central||11.9||16.4||19.5||21.8||10.5||14.5||17.3||19.5|
In three separate rounds (1997–97, 1998–99, and 2000–01), Landon, Reschovsky, and Blumenthal surveyed more than twelve thousand primary care and specialist physicians who spent at least twenty hours per week in patient care. Each round found that approximately 80% of primary care and specialist physicians were somewhat or very satisfied with their careers, and about 18% were somewhat or very dissatisfied with their careers. The study also examined physician career satisfaction in twelve market regions in an effort to identify some of the underlying reasons for satisfaction and dissatisfaction.
Even though state regulations and health plan mergers, as well as changes in hospital competition and practice ownership, may have contributed to the geographic variation in physician dissatisfaction, Landon, Reschovsky, and Blumenthal find that physician independence—the freedom to make clinical decisions in the best interest of patients, being able to spend adequate time with patients, and maintaining ongoing relationships with patients—was more important than income in predicting changes in physician satisfaction. Physicians who felt they had the greatest degree of autonomy appeared to be the most satisfied with their career choices.
|Total physiciansa||Doctors of medicine in patient careb|
|Geographic division and state||1975||1985||1995c||2005d, e||1975||1985||1995||2005e|
|aIncludes active doctors of medicine and active doctors of osteopathy.|
|bExcludes doctors of osteopathy (DOs); states with more than 3,000 active DOs are California, Florida, Michigan, New York, Ohio, Pennsylvania, and Texas. States with fewer than 100 active DOs are North Dakota, South Dakota, Vermont, Wyoming, and the District of Columbia. Excludes doctors of medicine in medical teaching, administration, research, and other non-patient care activities.|
|cData for doctors of osteopathy are as of July 1996.|
|dData for doctors of osteopathy are as of June 2005.|
|eStarting with 2003 data, federal and nonfederal physicians are included. Data prior to 2004 include nonfederal physicians only.|
|Number per 10,000 civilian population|
|Notes: Data for doctors of medicine are as of December 31. Data for additional years are available. Data are based on reporting by physicians.|
Registerednurses(RNs)arelicensedbythestatetocare for the sick and to promote health. RNs supervise hospital care, administer medication and treatment as prescribed by physicians, monitor the progress of patients, and provide health education. Nurses work in a variety of settings, including hospitals, nursing homes, physicians' offices, clinics, and schools.
Education for Nurses
There are three types of education for RNs. These include associate degrees (two-year community college programs), baccalaureate programs (four years of college), and postgraduate (master's degree and doctorate) programs. The baccalaureate degree provides more knowledge of community health services, as well as the psychological and social aspects of caring for patients, than does the associate degree. Those who complete the four-year baccalaureate degree and the other advanced degrees are generally better prepared to eventually attain administrative or management positions and may have greater opportunities for upward mobility in related disciplines such as research, teaching, and public health.
Between 1999 and 2005 the number of RNs grew from 2.2 million to 2.4 million. (See Table 2.5.) In The Registered Nurse Population: Findings from the March 2004 National Sample Survey of Registered Nurses (June 2006, ftp://ftp.hrsa.gov/bhpr/workforce/0306rnss.pdf), the HRSA reports that as of 2004 there were more than 2.9 million RNs working in the United States; however, just 83.2%, or 2.4 million, were working in the field of nursing. The largest percentage increases occurred among those holding baccalaureate, master's, and doctorate degrees. Figure 2.1 shows the trend from 2000 to 2004 of increasing numbers of RNs receiving master's and doctorate degrees.
NEED FOR NURSES EXCEEDS SUPPLY. Even though the number of RNs holding baccalaureate degrees increased sharply during the 1990s, there is still a shortage of nurses that is predicted to persist until 2020. Some health care experts believe the shortage is intensifying because more lucrative fields are now open to women, the traditional nursing population. In health occupations alone, the percentage of female students entering traditionally male professions continues to increase. For example, in 1980–81 women accounted for just 17% of first-year dentistry students, compared to 43.8% of the class entering in 2004–05. (See Table 2.6.) Similarly, increasing percentages of women are attending medical school and training to become optometrists, pharmacists, podiatrists, and public health care workers. Meanwhile, nursing school enrollment has declined. In “Iowa Faces Severe Nursing Shortage” (Associated Press, February 22, 2008), James Beltran reports that about 41% of registered nurses in the United States are at least fifty years old and nearing retirement. Along with relatively low wages, industry observers also attribute the shortfall to a lack of faculty in nursing programs, which has acted to limit enrollment. According to the American Association of Colleges of Nursing, in the press release “Enrollment Growth Slows at U.S. Nursing Colleges and Universities in 2007” (December 3, 2007, http://www.aacn.nche.edu/media/NewsReleases/2007/enrl.htm), about thirty thousand applicants were denied admission to nursing schools in 2007 because of faculty shortages.
|All placesa||Physician offices|
|Age, sex, and race||1995||2000||2003||2005||1995||2000||2003||2005|
|aAll places includes visits to physician offices and hospital outpatient and emergency departments.|
|bEstimates are age-adjusted to the year 2000 standard population using six age groups: under 18 years, 18–44 years, 45–54 years, 55–64 years, 65–74 years, and 75 years and over.|
|cStarting with 1999 data, the instruction for the race item on the patient record form was changed so that more than one race could be recorded. In previous years only one race could be checked. Estimates for race in this table are for visits where only one race was recorded. Because of the small number of responses with more than one racial group checked, estimates for visits with multiple races checked are unreliable and are not presented.|
|Number of visits in thousands|
|Under 18 years||194,644||212,165||223,724||238,389||150,351||163,459||169,392||185,186|
|65 years and over||192,712||231,014||258,206||278,272||168,135||200,289||227,520||247,683|
|75 years and over||90,106||114,510||137,552||144,938||77,591||97,842||121,096||128,623|
|Number of visits per 100 persons|
|Under 18 years||275||293||307||325||213||226||232||253|
|65 years and over||612||706||753||792||534||612||664||705|
|75 years and over||683||766||850||865||588||654||748||768|
|Sex and age|
|Under 18 years||273||302||317||338||209||231||241||265|
|75 years and over||711||771||881||833||616||670||777||741|
|Under 18 years||277||285||297||311||217||221||223||240|
|75 years and over||666||763||830||886||571||645||730||785|
|Race and agec|
|Under 18 years||295||306||330||348||237||243||260||280|
|75 years and over||689||764||844||854||598||658||747||763|
|Black or African American, age-adjusted||309||353||393||398||204||239||261||270|
|Black or African American, crude||281||324||365||369||178||214||236||243|
|Under 18 years||193||264||248||278||100||167||131||162|
|75 years and over||534||745||774||982||395||568||608||806|
|Notes: Rates for 1995–2000 were computed using 1990-based postcensal estimates of the civilian noninstitutionalized population as of July 1 adjusted for net underenumeration using the 1990 National Population Adjustment Matrix from the U.S. Census Bureau. Starting with 2001 data, rates were computed using 2000-based postcensal estimates of the civilian noninstitutionalized population as of July 1. The difference between rates for 2000 computed using 1990-based postcensal estimates and 2000 census counts is minimal. Rates will be overestimated to the extent that visits by institutionalized persons are counted in the numerator (for example, hospital emergency department visits by nursing home residents) and institutionalized persons are omitted from the denominator (the civilian noninstitutionalized population). Starting with Health, United States, 2005, data for physician offices for 2001 and beyond use a revised weighting scheme.
Data are based on reporting by a sample of office-based physicians, hospital outpatient departments, and hospital emergency departments.
Industry observers feel this shortage results from a combination of factors including an aging population, a sicker population of hospitalized patients requiring more labor-intensive care, and public perception that nursing is a thankless, unglamorous job involving grueling physical labor, long hours, and low pay. In “Good Careers for 2006” (U.S. News and World Report, January 5, 2006), Marty Nemko deems nursing a “good career,” with salaries ranging from $57,000 to well over $100,000 per year and with excellent job security. Observers also note that the public, particularly high school students considering careers in health care, are unaware of the many new opportunities in nursing, such as advanced practice nursing, which offers additional independence and increased earning potential, and the technology-driven field of applied informatics (computer management of information).
ADVANCED PRACTICE NURSES AND PHYSICIAN ASSISTANTS
Much of the preventive medical care and treatment usually delivered by physicians may also be provided by midlevel practitioners—health professionals with less formal education and training than physicians. Advanced practice nurses make up a group that includes certified nurse midwives, nurse practitioners (NPs; RNs with advanced academic and clinical experience), and clinical nurse specialists (RNs with advanced nursing degrees who specialize in areas such as mental health, gerontology, cardiac or cancer care, and community or neonatal health). Physician assistants (PAs) are midlevel practitioners who work under the auspices, supervision, or direction of physicians. They conduct physical examinations, order and interpret laboratory and radiological studies, and prescribe medication. They even perform procedures (e.g., flexible sigmoidoscopy, biopsy, suturing, casting, and administering anesthesia) that were once performed exclusively by physicians.
The origins of each profession are key to understanding the differences between them. Nursing has the longer history, and nurses are recognized members of the health care team. For this reason, NPs were easily integrated into many practice settings.
PA is the newer of the two disciplines. PAs have been practicing in the United States since the early 1970s. The career originated as civilian employment for returning Vietnam War veterans who had worked as medics. The veterans needed immediate employment and few had the educational prerequisites, time, or resources to pursue the training necessary to become physicians. At the same time, the United States was projecting a dire shortage of primary care physicians, especially in rural and inner-city practices. The use of PAs and NPs was seen as an ideal rapid response to the demand for additional medical services. They could be deployed quickly to serve remote communities or under-served populations for a fraction of the costs associated with physicians.
The numbers of PAs and NPs have increased dramatically since the beginning of the 1990s. The HRSA reports in Registered Nurse Population that in 2004 there were 240,460 advanced practice nurses—141,209 NPs (59%), 72,521 clinical nurse specialists (30%), 32,523 certified RN anesthetists (14%), and 13,684 certified nurse midwives (6%). Advanced practice nurses accounted for 8.3% of the total RN population. According to the American Academy of Physician Assistants (http://www.aapa.org/research/07census-intro.html), there were 75,260 PAs eligible to practice in 2007. When combined, midlevel practitioners outnumber primary care physicians.
Training, Certification, and Practice
Advanced practice nurses usually have considerable clinical nursing experience before completing certificate or master's degree NP programs. Key components of NP programs are instruction in nursing theory and practice as well as a period of direct supervision by a physician or NP. The American College of Nurse Practitioners (April 20, 2007, http://www.ejfhc.org/American%20College%20of%20Nurse%20Practitioners.htm) states that NPs are prepared to practice “either independently or as part of a health care team,” but the NP scope of practice varies by state.
The Commission on Accreditation of Allied Health Education Programs accredits PA training programs. According to the American Academy of Physician Assistants (AAPA), in “Physician Assistants and Anesthesiologist Assistants—the Distinctions” (February 2005, http://www.aapa.org/gandp/issuebrief/aas.pdf), most students have an undergraduate degree and about forty-five months of health care experience before they enter a two-year PA training program. Graduates sit for a national certifying examination and, once certified, must earn one hundred hours of continuing medical education every two years and pass a recertification exam every six years.
|aEstimates do not include self-employed workers and were rounded to the nearest 10.|
|bAverage annual percent change. AACP is the American Association of Colleges of Pharmacy.|
|cThe mean hourly wage rate for an occupation is the total wages that all workers in the occupation earn in an hour divided by the total employment of the occupation.|
|Healthcare practitioner and technical occupations||Number of employeesa||AAPCb||Mean hourly wagec||AACPb|
|Cardiovascular technologists and technicians||41,490||40,080||43,540||43,560||0.8||$16.00||$16.81||$19.09||$19.99||3.8|
|Diagnostic medical sonographers||29,280||31,760||41,280||43,590||6.9||$21.04||$22.03||$25.78||$26.65||4.0|
|Dietitians and nutritionists||41,320||43,030||46,530||48,850||2.8||$17.96||$18.76||$21.46||$22.09||3.5|
|Emergency medical technicians and paramedics||172,360||165,530||187,900||196,880||2.2||$11.19||$11.89||$13.30||$13.68||3.4|
|Licensed practical and licensed vocational nurse||688,510||679,470||702,740||710,020||0.5||$13.95||$14.65||$16.75||$17.41||3.8|
|Nuclear medicine technologists||17,880||18,030||17,520||18,280||0.4||$20.40||$21.56||$29.43||$29.10||6.1|
|Pharmacy technicians||196,430||190,940||255,290||266,790||5.2||$ 9.64||$10.38||$11.87||$12.19||4.0|
|Radiologic technologists and technicians||177,850||172,080||177,220||184,580||0.6||$17.07||$17.93||$21.41||$22.60||4.8|
|Respiratory therapy technicians||33,990||28,230||24,190||22,060||−7.0||$16.07||$16.46||$18.00||$18.57||2.4|
|Healthcare support occupations|
|Home health aides||577,530||561,120||596,330||663,280||2.3||$ 9.04||$ 8.71||$ 9.13||$ 9.34||0.5|
|Medical equipment preparers||29,070||32,760||40,380||41,790||6.2||$10.20||$10.68||$12.14||$12.42||3.3|
|Nursing aides, orderlies, and attendants||1,308,740||1,273,460||1,384,120||1,391,430||1.0||$ 8.59||$ 9.18||$10.39||$10.67||3.7|
|Occupational therapist aides||9,250||8,890||5,240||6,220||−6.4||$10.92||$11.21||$12.51||$13.20||3.2|
|Occupational therapist assistants||17,290||15,910||20,880||22,160||4.2||$15.97||$16.76||$18.49||$19.13||3.1|
|Pharmacy aides||48,270||59,890||47,720||46,610||−0.6||$ 9.14||$ 9.10||$ 9.52||$ 9.76||1.1|
|Physical therapist aides||44,340||34,620||41,910||41,930||−0.9||$ 9.69||$10.06||$11.14||$11.01||2.2|
|Physical therapist assistants||48,600||44,120||57,420||58,670||3.2||$16.20||$16.52||$18.14||$18.98||2.7|
|Notes: This table excludes occupations such as dentists, physicians, and chiropractors, with a large percentage of workers who are self-employed and/or not employed by establishments. Data are based on a semi-annual mail survey of nonfarm establishments.|
PA practice is always delegated by the physician and conducted with physician supervision. The extent and nature of physician supervision varies from state to state. For example, Connecticut permits a physician to supervise up to six PAs, whereas California limits a supervising physician to two. Even though PAs work interdependently with physicians, supervision is not necessarily direct and onsite; some PAs working in remote communities are supervised primarily by telephone.
In 2007 AAPA Physician Assistant Census Report (October 12, 2007, http://www.aapa.org/research/07census-intro.html), the AAPA states that in 2007 the mean (average) annual income of physician assistants who were not self-employed was $86,214. New graduates (in 2006) could anticipate a mean annual income of $73,013.
Distinctions between Midlevel Practitioners Blurring
Pohla Smith reports in “Doing Doctors' Work” (Pittsburgh Post-Gazette, March 12, 2008) that even though their training may be different, in terms of their day-to-day job responsibilities, NPs and PAs are becoming essentially interchangeable. Both types of practitioners diagnose and treat illness, take medical histories, and perform physical examinations. They can order diagnostic tests, prescribe medication, and assist in operating rooms and emergency departments.
Dentists diagnose and treat problems of the teeth, gums, and mouth, take x-rays, apply protective plastic sealant to children's teeth, fill cavities, straighten teeth, and treat gum disease. The BLS (December 18, 2007, http://www.bls.gov/oco/ocos072.htm) reports that in 2006 there were 161,000 professionally active (as opposed to retired or employed in other fields) dentists in the United States.
Fluoridation of community water supplies and improved dental hygiene have dramatically improved the dental health of Americans. Dental caries (cavities) among all age groups have declined significantly. As a result, many dental services are shifting focus from young people to adults. In the twenty-first century, many adults are choosing to have orthodontic services, such as straightening their teeth. In addition, the growing older adult population generally requires more complex dental procedures, such as endodontic (root canal) services, bridges, and dentures.
The overwhelming majority of dentists own solo dental practices, where only one dentist operates in each office. The BLS reports that in 2006 about one-third of dentists were self-employed, nearly all were in private practice, and that one out of seven dentists belonged to a partnership. On average, dentists work between thirty-five and forty hours per week and supervise staffers, such as dental assistants and hygienists. In May 2007 National Occupational Employment and Wage Estimates (May 12, 2008, http://www.bls.gov/oes/current/oes_nat.htm), the BLS notes that self-employed dentists in general practice had mean annual wages of $147,010 in 2007, whereas dental specialists' mean annual wages ranged from $120,360 to $185,340.
|Enrollment and occupation||1980–1981||1990–1991||2004–2005a||1980–1981||1990–1991b||2004–2005a|
|—Data not available.|
|aStarting with 2003–2004 data, osteopathic medicine data include the students of the Edward Via Virginia College of Osteopathic Medicine.|
|bPercentage of women podiatry students is for 1991–1992.|
|cInclude data from schools in Puerto Rico.|
|d2004–2005 optometry data are for 2005–2006.|
|eFirst-year enrollment data for pharmacy schools are for students in the first year of the final three years of pharmacy education. Prior to 1992–1993, pharmacy total enrollment data were for students in the final three years of pharmacy education. Starting in 1992–1993, pharmacy total enrollment data are for all students.|
|fFor 2003–2004 data, first-year enrollment data for public health schools include Spring, Summer, and Fall enrollment. All other years of data including 2004–2005 are for Fall enrollment only and are not directly comparable to 2003–2004 data.|
|First-year enrollment||Number of students||Percent of students|
|Public healthc, f||3,348||4,289||7,206||—||62.1||70.9|
|Public healthc, f||8,486||11,386||19,434||55.2||62.5||69.6|
|Notes: Total enrollment data are collected at the beginning of the academic year while first-year enrollment data are collected during the academic year. Data for chiropractic students and occupational, physical, and speech therapy students were not available for this table. Some numbers in this table have been revised and differ from previous editions of Health, United States. Data are based on reporting by health professions associations.|
The ADA explains in What Can a Career in Dentistry Offer You? (2008, http://www.ada.org/public/careers/team/dentistry_fact.pdf) that 20% of all dentists practice in one of the nine specialty areas that the ADA recognizes. Orthodontists, who straighten teeth, make up the largest group of specialists. The next largest group, oral and maxillofacial surgeons, operates on the mouth and jaws. The balance of the specialists concentrates in pediatric dentistry (dentistry for children), periodontics (treating the gums), prosthodontics (making dentures and artificial teeth), endodontics (root canals), public health dentistry (community dental health), and oral pathology (diseases of the mouth).
According to the BLS (December 18, 2007, http://www.bls.gov/oco/ocos072.htm), as of 2006, seventeen states licensed or certified dentists who practice in specialty areas. Requirements vary by state and specialty and may include two to four years of postgraduate education and a passing score on a state-administered examination. Dentists who teach or conduct research generally spend an additional two to five years in advanced dental training in programs operated by dental schools or university-affiliated hospitals.
Training to Become a Dentist
Entry into dental schools requires two to four years of college-level predental education—most dental students have earned excellent grades and have at least a bachelor's degree when they enter dental school. Dentists should have good visual memory, excellent judgment about space and shape, a high degree of manual dexterity, and scientific ability. Development and maintenance of a successful private practice requires business acumen, the ability to manage and organize people and materials, and strong interpersonal skills.
Dental schools require applicants to take the Dental Admissions Test (DAT). During the admission process, schools consider scores earned on the DAT, applicants' grade-point averages, and information gleaned from recommendations and interviews. Dental school usually lasts four academic years. A student begins by studying the basic sciences, including anatomy, microbiology, biochemistry, and physiology. During the last two years, students receive practical experience by treating patients, usually in dental clinics supervised by licensed dentists.
Visiting the Dentist
In 2005 more than half (57.7%) of Americans over two years of age had visited their dentists at least once in the past year. (See Table 2.7.) Children aged two to seventeen (76.2%) were more likely to have visited the dentist than any other age group, and women aged sixty-five and older were somewhat more likely to see the dentist than men. Among adults aged eighteen to sixty-four, the proportion of non-Hispanic whites (67.9%) visiting dentists was considerably higher than the proportions of non-Hispanic African-Americans (57%) and Hispanics (48.5%). People who were poor or near poor were much less likely to visit the dentist annually than those who were not poor.
SEVERE SHORTAGES OF DENTISTS IN SOME AREAS. The United States boasts the highest concentration of dentists of any country in the world. Nonetheless, health care planners caution that dentists' ranks will begin to decline during the coming decade as the number of dental school graduates—about four thousand or so annually, according to Eric S. Solomon, in “The Future of Dentistry” (Dental Economics, November 2004)—falls below the number of dentists retiring from the workforce. Even before this decline, residents of many states do not have adequate access to dental care, especially people in rural communities and poor urban neighborhoods, where, arguably, the need is greatest.
Even though the American Dental Hygienists' Association (ADHA) believes access to quality, affordable dental care is a right, according to the fact sheet “ADHA Access to Care Facts and Stats” (2008, http://www.adha.org/media/facts/access.htm), 40% of Americans do not receive needed care. Access to care is limited by both a shortage of practicing dentists in many communities and many Americans' inability to pay for care. In “Access to Care Position Paper, 2001” (June 9, 2008, http://www.adha.org/profissues/access_to_care.htm), the ADHS asserts that the shortage of dentists will persist and that by 2020 the number of dentists per 100,000 U.S. population will fall to 52.7. In areas where there are few practicing dentists, uninsured and low-income families have even more difficulty gaining access to already overbooked dentists.
In February 2008 the death of a twelve-year-old boy from complications resulting from an untreated dental problem underscored how lack of access to dental care has created a situation the Oral Health in America: A Report of the Surgeon General (September 2000, http://silk.nih.gov/public/hck1ocv.@www.surgeon.fullrpt.pdf) calls a “silent epidemic.” The report asserts that dental disease afflicts the nation's most vulnerable populations: poor children, older adults, and many members of racial and ethnic minority groups.
ALLIED HEALTH CARE PROVIDERS
Many health care services are provided by an interdisciplinary team of health professionals. The complete health care team may include physicians, nurses, midlevel practitioners, and dentists; physical and occupational therapists; audiologists and speech-language pathologists; licensed practical nurses, nurse