Health Care Practitioners

Health Care Practitioners

The art of medicine consists of amusing the patient while nature cures the disease.

Voltaire

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

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 clerkshipsspending 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 200607 academic year was the largest evera 2.3% increase from the previous yearwith 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 (18631944) 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:

  • Anesthesiologistadministers anesthesia (partial or complete loss of sensation) and monitors patients in surgery
  • Cardiologistdiagnoses and treats diseases of the heart and blood vessels
  • Dermatologisttrained to diagnose and treat diseases of the skin, hair, and nails
  • Family practitionerdelivers primary care to people of all ages and, when necessary, refers patients to other physician specialists
  • Gastroenterologistspecializes in digestive system disorders
  • Internistprovides diagnosis and nonsurgical treatment of a broad array of illnesses affecting adults
  • Neurologistspecializes in the nervous system and provides diagnosis and treatment of brain, spinal cord, and nerve disorders
  • Obstetrician-gynecologistprovides health care for women and their reproductive systems, as well as care for mothers and babies before, during, and immediately following delivery
  • Oncologistdedicated to the diagnosis and treatment of cancer
  • Otolaryngologistskilled in the medical and surgical treatment of ear, nose, and throat disorders and related structures of the face, head, and neck
  • Pathologistuses skills in microscopic chemical analysis and diagnostics to detect disease in body tissues and fluids
  • Psychiatristspecializes in the prevention, diagnosis, and treatment of mental health and emotional disorders
  • Pulmonologistspecializes in diseases of the lungs and respiratory system
  • Urologistprovides 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 200708 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 mortgagean 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 LimitsFour 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 systemthe 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.

Working Conditions

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.

Specialty 1949a 1960a 1970 1980 1990 1995 2000 2002 2004 2005
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.
Number
      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
      Internal medicine 12,453 26,209 39,924 58,462 76,295 88,240 101,353 106,499 111,800 112,934
      Obstetrics/gynecology 18,532 24,612 30,220 33,519 35,922 36,810 37,779 38,285
      Pediatrics 4,789 11,127 17,950 27,582 36,519 43,594 51,066 53,628 55,752 56,945
Primary care subspecialists 3,161 16,642 30,911 39,659 52,294 57,929 62,322 65,420
      Family medicine 236 483 627 768 835
      Internal medicine 1,948 13,069 22,054 26,928 34,831 38,821 41,471 43,552
      Obstetrics/gynecology 344 1,693 3,477 4,133 4,319 4,228 4,280 4,315
      Pediatrics 869 1,880 5,380 8,362 12,661 14,253 15,803 16,718
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
      Internal medicine 6.5 10.6 12.8 13.4 13.6 13.7 13.7 13.9 14.1 14.1
      Obstetrics/gynecology 6.0 5.7 5.4 5.2 4.9 4.8 4.8 4.8
      Pediatrics 2.5 4.5 5.8 6.3 6.5 6.7 6.9 7.0 7.0 7.1
Primary care subspecialists 1.0 3.8 5.5 6.1 7.1 7.5 7.9 8.2
      Family medicine 0.0 0.1 0.1 0.1 0.1
      Internal medicine 0.6 3.0 3.9 4.2 4.7 5.1 5.2 5.4
      Obstetrics/gynecology 0.1 0.4 0.6 0.6 0.6 0.6 0.5 0.5
      Pediatrics 0.3 0.4 1.0 1.3 1.7 1.9 2.0 2.1
0.0 Percent greater than zero but less than 0.05.
Notes: Data are as of December 31 except for 19901994 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.

Physician Visits

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.

Physician Satisfaction

Changes in the health care delivery systemparticularly 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 relationshipshave 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
Professionally activea 340,280 497,140 625,443 692,368 719,431 736,211 744,143 762,438
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
Activity:
        Nonfederalc 312,089 475,573 604,364 672,987 699,249
              Patient cared 287,837 431,527 564,074 631,431 658,123 691,873 700,287 718,473
                      Office-based practice 213,334 329,041 427,275 490,398 516,246 529,836 538,538 563,225
                              General and family practice 46,347 53,862 59,932 67,534 71,696 73,508 73,234 74,999
                              Cardiovascular diseases 5,046 9,054 13,739 16,300 16,989 17,301 17,252 17,519
                              Dermatology 3,442 5,325 6,959 7,969 8,282 8,477 8,651 8,795
                              Gastroenterology 1,696 4,135 7,300 8,515 9,044 9,326 9,430 9,742
                              Internal medicine 28,188 52,712 72,612 88,699 96,496 99,670 101,776 107,028
                              Pediatrics 12,687 22,392 33,890 42,215 46,097 47,996 49,356 51,854
                              Pulmonary diseases 1,166 3,035 4,964 6,095 6,672 6,919 7,072 7,321
                              General surgery 19,710 24,708 24,086 24,475 24,902 25,284 25,229 26,079
                              Obstetrics and gynecology 15,613 23,525 29,111 31,726 32,738 33,636 33,811 34,659
                              Ophthalmology 8,795 12,212 14,596 15,598 16,052 16,240 16,304 16,580
                              Orthopedic surgery 8,148 13,033 17,136 17,367 18,118 18,423 18,632 19,115
                              Otolaryngology 4,297 5,751 7,139 7,581 8,001 8,103 8,160 8,206
                              Plastic surgery 1,706 3,299 4,612 5,308 5,593 5,725 5,845 6,011
                              Urological surgery 5,025 7,081 7,991 8,460 8,615 8,804 8,793 8,955
                              Anesthesiology 8,970 15,285 23,770 27,624 28,661 29,254 29,984 31,887
                              Diagnostic radiology 1,978 7,735 12,751 14,622 15,896 16,403 16,828 17,618
                              Emergency medicine 11,700 14,541 16,907 17,727 18,961 20,173
                              Neurology 1,862 4,691 7,623 8,559 9,034 9,304 9,632 10,400
                              Pathology, anatomical/clinical 4,195 6,877 9,031 10,267 10,103 10,209 10,653 11,747
                              Psychiatry 12,173 18,521 23,334 24,955 25,350 25,656 25,998 27,638
                              Radiology 6,970 7,355 5,994 6,674 6,916 7,010 6,900 7,049
                              Other specialty 15,320 28,453 29,005 35,314 34,084 34,861 36,037 39,850
                      Hospital-based practice 74,503 102,486 136,799 141,033 141,877 162,037 161,749 155,248
                              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
        Federalc 28,191 21,567 21,079 19,381 20,182
              Patient care 24,100 17,293 18,057 15,999 16,701
                      Office-based practice 2,095 1,156 . . . . . . . . .
                      Hospital-based practice 22,005 16,137 18,057 15,999 16,701
                              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
Inactive 21,449 38,646 72,326 75,168 84,166 84,360 92,323 99,823
Not classified 26,145 13,950 20,579 45,136 49,067 50,447 48,011 39,304
Unknown address 5,868 2,980 1,977 1,098 523 517 497 488
Notes: Data for doctors of medicine are as of December 31, except for 19901994 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
United States 15.3 20.7 24.2 26.9 13.5 18.0 21.3 23.8
New England 19.1 26.7 32.5 37.5 16.9 22.9 28.8 33.4
      Connecticut 19.8 27.6 32.8 35.4 17.7 24.3 29.5 31.8
      Maine 12.8 18.7 22.3 30.1 10.7 15.6 18.2 24.3
      Massachusetts 20.8 30.2 37.5 42.8 18.3 25.4 33.2 38.4
      New Hampshire 14.3 18.1 21.5 26.7 13.1 16.7 19.8 24.1
      Rhode Island 17.8 23.3 30.4 35.8 16.1 20.2 26.7 32.0
      Vermont 18.2 23.8 26.9 35.4 15.5 20.3 24.2 32.1
Middle Atlantic 19.5 26.1 32.4 35.0 17.0 22.2 28.0 30.0
      New Jersey 16.2 23.4 29.3 32.6 14.0 19.8 24.9 27.6
      New York 22.7 29.0 35.3 38.0 20.2 25.2 31.6 33.9
      Pennsylvania 16.6 23.6 30.1 32.0 13.9 19.2 24.6 25.8
East North Central 13.9 19.3 23.3 26.6 12.0 16.4 19.8 22.8
      Illinois 14.5 20.5 24.8 27.5 13.1 18.2 22.1 24.4
      Indiana 10.6 14.7 18.4 21.9 9.6 13.2 16.6 19.8
      Michigan 15.4 20.8 24.8 27.4 12.0 16.0 19.0 21.5
      Ohio 14.1 19.9 23.8 27.7 12.2 16.8 20.0 23.4
      Wisconsin 12.5 17.7 21.5 25.7 11.4 15.9 19.6 23.4
West North Central 13.3 18.3 21.8 25.0 11.4 15.6 18.9 21.7
      Iowa 11.4 15.6 19.2 21.1 9.4 12.4 15.1 16.6
      Kansas 12.8 17.3 20.8 23.6 11.2 15.1 18.0 20.4
      Minnesota 14.9 20.5 23.4 27.9 13.7 18.5 21.5 25.7
      Missouri 15.0 20.5 23.9 25.9 11.6 16.3 19.7 21.5
      Nebraska 12.1 15.7 19.8 23.8 10.9 14.4 18.3 21.8
      North Dakota 9.7 15.8 20.5 24.2 9.2 14.9 18.9 22.3
      South Dakota 8.2 13.4 16.7 22.3 7.7 12.3 15.7 20.6
South Atlantic 14.0 19.7 23.4 26.7 12.6 17.6 21.0 23.8
      Delaware 14.3 19.7 23.4 26.1 12.7 17.1 19.7 22.4
      District of Columbia 39.6 55.3 63.6 75.6 34.6 45.6 53.6 65.8
      Florida 15.2 20.2 22.9 25.3 13.4 17.8 20.3 22.4
      Georgia 11.5 16.2 19.7 22.0 10.6 14.7 18.0 20.1
      Maryland 18.6 30.4 34.1 39.9 16.5 24.9 29.9 34.4
      North Carolina 11.7 16.9 21.1 24.8 10.6 15.0 19.4 22.8
      South Carolina 10.0 14.7 18.9 23.0 9.3 13.6 17.6 21.3
      Virginia 12.9 19.5 22.5 26.8 11.9 17.8 20.8 24.4
      West Virginia 11.0 16.3 21.0 25.2 10.0 14.6 17.9 20.9
East South Central 10.5 15.0 19.2 22.8 9.7 14.0 17.8 21.0
      Alabama 9.2 14.2 18.4 21.4 8.6 13.1 17.0 19.8
      Kentucky 10.9 15.1 19.2 22.9 10.1 13.9 18.0 21.1
      Mississippi 8.4 11.8 13.9 18.1 8.0 11.1 13.0 16.5
      Tennessee 12.4 17.7 22.5 26.1 11.3 16.2 20.8 24.1
West South Central 11.9 16.4 19.5 21.8 10.5 14.5 17.3 19.5
      Arkansas 9.1 13.8 17.3 20.4 8.5 12.8 16.0 18.9
      Louisiana 11.4 17.3 21.7 24.5 10.5 16.1 20.3 23.2
      Oklahoma 11.6 16.1 18.8 20.5 9.4 12.9 14.7 15.7
      Texas 12.5 16.8 19.4 21.7 11.0 14.7 17.3 19.4
Mountain 14.3 17.8 20.2 22.8 12.6 15.7 17.8 20.0
      Arizona 16.7 20.2 21.4 22.5 14.1 17.1 18.2 19.2
      Colorado 17.3 20.7 23.7 26.8 15.0 17.7 20.6 23.6
      Idaho 9.5 12.1 13.9 17.9 8.9 11.4 13.1 16.2
      Montana 10.6 14.0 18.4 23.0 10.1 13.2 17.1 21.2
      Nevada 11.9 16.0 16.7 19.6 10.9 14.5 14.6 17.5
      New Mexico 12.2 17.0 20.2 23.9 10.1 14.7 18.0 21.5
      Utah 14.1 17.2 19.2 21.2 13.0 15.5 17.6 19.1
      Wyoming 9.5 12.9 15.3 19.4 8.9 12.0 13.9 17.7

In three separate rounds (199797, 199899, and 200001), 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 independencethe freedom to make clinical decisions in the best interest of patients, being able to spend adequate time with patients, and maintaining ongoing relationships with patientswas 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
Pacific 17.9 22.5 23.3 26.0 16.3 20.5 21.2 23.6
      Alaska 8.4 13.0 15.7 24.1 7.8 12.1 14.2 21.3
      California 18.8 23.7 23.7 25.7 17.3 21.5 21.7 23.3
      Hawaii 16.2 21.5 24.8 31.2 14.7 19.8 22.8 28.2
      Oregon 15.6 19.7 21.6 26.9 13.8 17.6 19.5 24.2
      Washington 15.3 20.2 22.5 26.6 13.6 17.9 20.2 23.9
Notes: Data for doctors of medicine are as of December 31. Data for additional years are available. Data are based on reporting by physicians.

REGISTERED NURSES

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 198081 women accounted for just 17% of first-year dentistry students, compared to 43.8% of the class entering in 200405. (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, 1844 years, 4554 years, 5564 years, 6574 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
      Total 860,859 1,014,848 1,114,504 1,169,333 697,082 823,542 906,023 963,617
Under 18 years 194,644 212,165 223,724 238,389 150,351 163,459 169,392 185,186
1844 years 285,184 315,774 331,015 324,108 219,065 243,011 251,853 247,568
4564 years 188,320 255,894 301,558 328,564 159,531 216,783 257,258 283,180
      4554 years 104,891 142,233 164,431 170,674 88,266 119,474 138,634 145,034
      5564 years 83,429 113,661 137,126 157,890 71,264 97,309 118,624 138,146
65 years and over 192,712 231,014 258,206 278,272 168,135 200,289 227,520 247,683
      6574 years 102,605 116,505 120,655 133,334 90,544 102,447 106,424 119,061
      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
Total, age-adjustedb 334 374 391 400 271 304 317 329
Total, crude 329 370 390 402 266 300 317 331
Under 18 years 275 293 307 325 213 226 232 253
1844 years 264 291 301 294 203 224 229 224
4564 years 364 422 442 454 309 358 377 391
      4554 years 339 385 406 405 286 323 343 344
      5564 years 401 481 494 523 343 412 428 458
65 years and over 612 706 753 792 534 612 664 705
      6574 years 560 656 667 725 494 577 588 647
      75 years and over 683 766 850 865 588 654 748 768
Sex and age
Male, age-adjustedb 290 325 338 352 232 261 273 289
Male, crude 277 314 329 345 220 251 264 283
      Under 18 years 273 302 317 338 209 231 241 265
      1844 years 190 203 203 212 139 148 147 158
      4554 years 275 316 335 331 229 260 280 278
      5564 years 351 428 422 468 300 367 365 411
      6574 years 508 614 632 691 445 539 558 619
      75 years and over 711 771 881 833 616 670 777 741
Female, age-adjustedb 377 420 442 445 309 345 360 367
Female, crude 378 424 449 456 310 348 368 377
      Under 18 years 277 285 297 311 217 221 223 240
      1844 years 336 377 397 375 265 298 309 290
      4554 years 400 451 475 476 339 384 403 408
      5564 years 446 529 561 574 382 453 486 501
      6574 years 603 692 696 754 534 609 613 671
      75 years and over 666 763 830 886 571 645 730 785
Race and agec
White, age-adjustedb 339 380 399 413 282 315 332 347
White, crude 338 381 404 420 281 316 337 355
      Under 18 years 295 306 330 348 237 243 260 280
      1844 years 267 301 308 306 211 239 242 242
      4554 years 334 386 409 416 286 330 352 362
      5564 years 397 480 500 534 345 416 439 476
      6574 years 557 641 653 727 496 568 582 656
      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
      1844 years 260 257 329 295 158 149 199 172
      4554 years 387 383 445 422 281 269 315 297
      5564 years 414 495 487 515 294 373 349 374
      6574 years 553 656 761 745 429 512 602 589
      75 years and over 534 745 774 982 395 568 608 806
Notes: Rates for 19952000 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 practitionershealth 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 nurses141,209 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 Assistantsthe 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.

Occupation title 1999 2000 2004 2005 19992005 1999 2000 2004 2005 19992005
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
Audiologists 12,950 11,530 9,810 10,030 4.2 $21.96 $22.92 $26.47 $27.72 4.0
Cardiovascular technologists and technicians 41,490 40,080 43,540 43,560 0.8 $16.00 $16.81 $19.09 $19.99 3.8
Dental hygienists 90,050 148,460 155,810 161,140 10.2 $23.15 $24.99 $28.58 $29.15 3.9
Diagnostic medical sonographers 29,280 31,760 41,280 43,590 6.9 $21.04 $22.03 $25.78 $26.65 4.0
Dietetic technicians 29,190 28,010 24,630 23,780 3.4 $10.09 $10.98 $11.89 $12.20 3.2
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
Occupational therapists 78,950 75,150 83,560 87,430 1.7 $24.96 $24.10 $27.19 $28.41 2.2
Opticians, dispensing 58,860 66,580 62,350 70,090 3.0 $12.11 $12.67 $14.37 $14.80 3.4
Pharmacists 226,300 212,660 222,960 229,740 0.3 $30.31 $33.39 $40.56 $42.62 5.8
Pharmacy technicians 196,430 190,940 255,290 266,790 5.2 $ 9.64 $10.38 $11.87 $12.19 4.0
Physical therapists 131,050 120,410 142,940 151,280 2.4 $28.05 $27.62 $30.00 $31.42 1.9
Physician assistants 56,750 55,490 59,470 63,350 1.9 $24.35 $29.17 $33.07 $34.17 5.8
Psychiatric technicians 54,560 53,350 59,010 62,040 2.2 $11.30 $12.53 $13.43 $14.04 3.7
Radiation therapists 12,340 13,100 14,470 14,120 2.3 $20.84 $25.59 $29.05 $30.59 6.6
Radiologic technologists and technicians 177,850 172,080 177,220 184,580 0.6 $17.07 $17.93 $21.41 $22.60 4.8
Recreational therapists 30,190 26,940 23,050 23,260 4.3 $14.08 $14.23 $16.48 $16.90 3.1
Registered nurses 2,205,430 2,189,670 2,311,970 2,368,070 1.2 $21.38 $22.31 $26.06 $27.35 4.2
Respiratory therapists 80,230 82,670 91,350 95,320 2.9 $17.72 $18.37 $21.24 $22.24 3.9
Respiratory therapy technicians 33,990 28,230 24,190 22,060 7.0 $16.07 $16.46 $18.00 $18.57 2.4
Speech-language pathologists 85,920 82,850 89,260 94,660 1.6 $22.99 $23.31 $26.71 $27.89 3.3
Healthcare support occupations
Dental assistants 175,160 250,870 264,820 270,720 7.5 $11.60 $12.86 $13.97 $14.41 3.7
Home health aides 577,530 561,120 596,330 663,280 2.3 $ 9.04 $ 8.71 $ 9.13 $ 9.34 0.5
Massage therapists 21,910 24,620 32,200 37,670 9.5 $13.82 $15.51 $17.63 $19.33 5.8
Medical assistants 281,480 330,830 380,340 382,720 5.3 $10.89 $11.46 $12.21 $12.58 2.4
Medical equipment preparers 29,070 32,760 40,380 41,790 6.2 $10.20 $10.68 $12.14 $12.42 3.3
Medical transcriptionists 97,260 97,330 92,740 90,380 1.2 $11.86 $12.37 $14.01 $14.36 3.2
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
Psychiatric aides 51,100 57,680 54,520 56,150 1.6 $10.76 $10.79 $11.70 $11.47 1.1
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

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.

Both sexes Women
Enrollment and occupation 19801981 19901991 20042005a 19801981 19901991b 20042005a
Data not available.
aStarting with 20032004 data, osteopathic medicine data include the students of the Edward Via Virginia College of Osteopathic Medicine.
bPercentage of women podiatry students is for 19911992.
cInclude data from schools in Puerto Rico.
d20042005 optometry data are for 20052006.
eFirst-year enrollment data for pharmacy schools are for students in the first year of the final three years of pharmacy education. Prior to 19921993, pharmacy total enrollment data were for students in the final three years of pharmacy education. Starting in 19921993, pharmacy total enrollment data are for all students.
fFor 20032004 data, first-year enrollment data for public health schools include Spring, Summer, and Fall enrollment. All other years of data including 20042005 are for Fall enrollment only and are not directly comparable to 20032004 data.
First-year enrollment Number of students Percent of students
Dentistry 6,030 4,001 4,612 19.8 38.0
Medicine (allopathic)c 17,186 16,876 17,059 28.9 38.8 49.4
Medicine (osteopathic) 1,496 1,950 3,646 22.0 34.2 50.1
Nurses, registered 110,201 113,526 92.7 89.3
Optometryc, d 1,258 1,239 1,429 25.3 50.6 64.9
Pharmacyc, e 7,377 8,267 10,437 48.4 65.4
Podiatry 695 561 519 28.0 49.0
Public healthc, f 3,348 4,289 7,206 62.1 70.9
Total enrollment
Dentistry 22,842 15,951 18,315 17.0 34.4 43.8
Medicine (allopathic)c 65,189 65,163 67,466 26.5 37.3 48.7
Medicine (osteopathic) 4,940 6,792 12,525 19.7 32.7 48.8
Nurses, registered 230,966 221,170 94.3
Optometryc, d 4,641 4,760 5,377 47.3 63.1
Pharmacyc, e 26,617 29,797 43,908 47.4 62.4 66.5
Podiatry 2,577 2,154 1,584 11.9 28.9 46.9
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.

Dental Specialists

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 educationmost 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 graduatesabout 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