NEW ORLEANS – The proportion of American College of Obstetricians and Gynecologists fellows practicing in private settings has declined steadily over the past 2 decades, survey data show.
Between 1992 and 2012, the percentage of fellows in solo practice decreased from 32% to 19%, while the percentage employed by hospitals increased steadily from 5% to 15%, and those employed as academic faculty increased from 9% to 12%, Jeffrey C. Klagholz reported in a poster at the annual meeting of the American College of Obstetricians and Gynecologists (ACOG). Three percent were employed by HMOs, and 2% by the government; these remained basically static over time.
The percentage of fellows in private practice groups ranged from 44% to 52% (median of 48%) across the seven ACOG surveys on professional liability administered during the study period, according to Mr. Klagholz of ACOG in Washington, who noted that the findings were confirmed, and expanded upon, by data from a recent Socioeconomic Survey of ACOG Fellows.
During a session on workforce issues affecting ACOG fellows at the annual meeting, poster coauthor William Rayburn expanded on this report, and outlined a number of other recent and predicted changes in workforce trends and demand for obstetric and gynecologic care.
Of note, the proportion of resident graduates has not kept pace with increases in the population, and the proportion moving on to an accredited fellowship program – such as female pelvic medicine and reconstructive surgery, gynecologic oncology, maternal-fetal medicine, or reproductive endocrinology – more than doubled, increasing from 7% to 17% between 2000 and 2009. The percentage increases to 27% when minimally invasive surgery, pediatric and adolescent gynecology, and family planning and reproductive health fellowship programs are included, said Dr. Rayburn, chair of obstetrics and gynecology at the University of New Mexico, Albuquerque.
"We’re getting the message here that ... our graduates are moving more in the direction of subspecializing, and that concerns me with regard to the number of general obstetricians and gynecologists for our growing population, with there not being an increase in the number of residents," he said.
Adding to the shortage problem is the fact that a greater number of ACOG fellows are physicians aged 60 years or older, who are reaching "very senior status," compared with those who are aged 39 years or younger (about 5,500 vs. about 4,000 in 2012), he said.
Traditionally, the drop off in the number of ob.gyns. actually practicing obstetrics begins at about age 55 years. In fact, only one in three ACOG fellows and junior fellows in practice is aged 55 years or older.
"I daresay, anyone who is that age or older, at some time, is thinking of what they will do down the road and when they will eventually retire," he said, adding, "I think this is an important concept, because we have what’s called a static pipeline. That is, the number of resident graduates, which is not increasing, is actually lower than the number who are entering retirement age," Dr. Rayburn said.
If those residents are subspecializing more, the value that general ob.gyns. bring to the health care of women is tremendous, he added.
As for where women’s health care is most needed, it appears that while there is a shortage of ob.gyns., the bigger problem is "maldistribution," Dr. Rayburn said, explaining that the vast majority of ob.gyns. practice in metropolitan areas.
Generally speaking, one full-time ob.gyn. equivalent is needed per 10,000 population, but 49% of the more than 3,300 counties in the United States have no ob.gyn.
This affects about 10 million women who will be eligible for health care coverage under the Affordable Care Act, if they aren’t covered already, Dr. Rayburn said.
Reaching these patients will require "getting creative" about finding ways to deliver care. Outreach clinics, greater use of physician extenders, and collaborative efforts with primary care physicians are among the approaches he mentioned.
A related concept – demand for care – is an important one, especially considering the aging of the population, but it can be difficult to predict. Although 80% of ob.gyn. care is provided to reproductive-age women, and little is provided to those over age 65 years, ob.gyns. are "still a significant player in taking care of women who are aged 40-64 years," he said.
Given shortages in the primary care fields, it is likely that ob.gyns. will play an increasing role in taking care of these women.
Data from a recent study, which Dr. Rayburn hopes to publish soon, suggest that demand for women’s health care services will grow by about 6% by 2020.