PHYSICIAN REQUIREMENTS= 1990 Se} Cc f For aos Preventive Medidine OFFICE OF GRADUATE MEDICAL EDUCATION < 4 fo DOCUIE NTo 3 sr 6 ‘ 7 i ; Thi JUN 9 1981 UNIVERS) UIE ie OF. HEALTH AND HUMAN SERVICES Public Health Service Health Resources Administration '' '' ((PEIYSICIAN - REQUIREMENTS: 1990 j) For Preventive Medicine U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES Public Health Service Health Resources Administration Office of Graduate Medical Education , © ) DHHS Publication-No: (HRA) 81-637 / '' ''RA ¥/0 af “U55S5 | 198! FOREWORD Pp Ly 2 J One section of Healthy People: The Surgeon General's Report on Health Promotion and Disease Prevention is entitled "Prevention--An Idea Whose Time Has Come." This idea may indeed be timely, but the adequacy of human resources for preventive medicine has until now been paid scant attention. The Graduate Medical Education National Advisory Committee (GMENAC) discovered the consequent scarcity of knowledge regarding these resources when it began its consideration of the supply, utilization, and future requirements for physician manpower trained in preventive medicine. This paper began as an effort to improve this knowledge base for the benefit of the Committee's deliberations and was further expanded to reflect the Office of Graduate Medical Education's ongoing interest in this area, "Preventive Medicine: Physicians for the Present and the Future" was prepared by Janet M. Cuca, Program Analyst in the Office of Graduate Medical Education and Coordinator of the GMENAC Delphi Panel on Preventive Medicine. The report reviews the state of the art regarding the supply and utilization of specialists in preventive medicine. In addition, it analyzes the public health area of preventive medicine: examining the judgments and assumptions which need to be made and the data which need to be made available in order to estimate with some precision future requirements for these specialists. To be able to carry out its commitment to health promotion and disease prevention, the Nation must have a sufficient cadre of trained professionals in preventive medicine. This report is a first step toward development of a method for determining the appropriate numbers of these professionals. We welcome comments on this monograph as well as suggestions for further research. Office of Graduate Medical Education Health Resources Administration 3700 East-West Highway Hyattsville, Maryland 20782 218059 '' ''Table of Contents é Foreword e eo e@ e ° e ° e ee e ee ° e e e e EROE OE TOR Oe 2! a eas ek ee a Eat. TR SCGUE EI ok ig clk oes we we The Specialty of Preventive Medicine Graduate Training in the Specialty . II. Present Supply of Preventive Medicine Physicians Board-Certified Specialists ..... Uncertified Specialists ....... Projected Supply in 1990 ....... III. Present Patterns of Physician Utilization . Deployment of Public Health Physicians Deployment of Occupational Medicine Physicians IV. Estimating Physician Requirements . . Physicians Needed for Public Health . References: 6. oka ee oe be a se ee GE iii Page a 16 18 23 34 38 43 58 '' ''Table 10 11 12 13 14 15 16 List of Tables Institutions with Graduate Medical Programs in Preventive Medicine in 1978-79 by Special Area and PERRI TIO i a ee ee ee ek ee Number of Persons Ever Board-Certified in Preventive Medicine etd. dts Special Arede oo. 9 00. 6 ere Age Distribution of Physicians in Preventive UCR ROS LNT ee 5 ae ee ee we ee ee Number of Physicians Self-Designated as in Preventive Medicine, 1963-78 eT ee Va es Fels bo Site te Sie ele. Percentage Distributions of the Professional Activities of Self-Identified Preventive Medicine Physicians, BOOe WE TOTO ee so ea og ARE 4 Ee) eke aby te Redefined Professional Activities Profiles of Preventive Medicine Physicians, 1978 ......+eee-s Percentage ‘Distributions of the Work Settings of Physicians Whose Specialties Were Public Health, 1974. . Average Population, Average Percentage of Public Health Unit Heads with M.D. and with M.D. Plus Other Degrees, Dy OnQGRTeAtscnet Type” oo ie ate ee hs ee eee aS Percentage Distributions of Physicians on State Health Agency (SHA) Staffs by Program Area, 1977 ....... Professional Activities of Federally Employed Preventive Medicine Physicians by Specialty and Service Branch, 1978 Number of Plants and Employees with Physician and Other UN i ee) ge ee eh ee Se 0 og Se a. Ae GMENAC Recommendations for 1990 Manpower Needs in Pre- WROETWR TCU ic kg eR eee oe el a be Number of Local Governments in the U.S. by Type, 1977... Percentage Distributions of SHA Expenditures for All Program Areas and Categories, 1978 .....4+4+24+ee60e-6 Percentage of States Specifically Authorizing Various Public Health Services and Designating the Responsible Agency in Public:Health Statutes (1976) ..... 6 « « Common Job Titles in Public and Community Health .... iv Page 10 13 15 19 22 24 28 30 35 40 46 52 54 56 '' ''I. INTRODUCTION Two trends in U.S. health planning are now converging which have implications for the medical specialty of preventive medicine. One is a realization of the need for rational planning of the health care delivery system, especially with respect to the professionals working in that system; the other is a heightened awareness of the potential contribu- tions of preventive strategies to both individual health status and to the conservation of economic resources in the health care delivery system e and in the larger economic system. Planning activities concerning the deployment of health professionals have increased and, in the medical profession, have developed from concern solely with the aggregate number of physicians to a more discerning concern with their distribution both geographically and by specialty. That concern became such that, in 1976, then Secretary Matthews of the U.S. Department of Health, Education, and Welfare (DHEW) appointed a committee "to analyze the distribution among specialties of physicians and residents and to evaluate alternative approaches to ensure an appropriate balance between supply of and requirements for physicians" (1). That committee, the Graduate Medical Education National Advisory Committee (GMENAC), submitted its report to the Secretary of the Department of Health and Human Services (DHHS) in September 1980. ''The reawakening to the importance of prevention was marked by the publication in 1979 of the first Surgeon General's Report on Health Promotion and Disease Prevention (2). Secretary Califano in releasing the report pointed out that "Its purpose is to encourage a second public health revolution in the history of the United States.... It represents an emerging consensus among scientists and the health community that the Nation's health strategy must be dramatically recast to emphasize the prevention of disease" (2). To sustain the impetus given to prevention from the publication of the Surgeon General's Report, DHEW's Office of Disease Prevention and Health Promotion immediately convened a conference of experts to propose "measurable national objectives to be attained by 1990" (3). If ever there was a time for preventive medicine, it is now. Yet, GMENAC discovered that little is known about human resources in the specialty. This paper is an attempt to bring together available information on preventive medicine specialists, ascertain the present situation with regards to their training, availability, and utilization, and forecast their future availability and the demand/need for their services. The Specialty of Preventive Medicine Let us begin with a description of the specialty. A recent white paper on the definition of preventive medicine acknowledges that "multiple perceptions and definitions of preventive medicine exist". There are "many reasons for having a widely accepted definition" of the ''specialty including "to assist individuals and organizations outside of the field to better assess preventive medicine manpower requirements..." (4). Before proceeding to that definition, however, a common confusion should be pointed out in the hope of avoiding further confusion. It concerns the term "preventive medicine". The term is sometimes used to refer to the preventive health services rendered by any physician or nonphysician health care provider regardless of his/her specialty or profession. At other times it is used to refer to those specialty-specific services performed only by a physician trained in the specialty of preventive medicine. This paper is concerned primarily with the latter though it touches upon the relationship of specialist manpower to preventive services. It is generally agreed among its practitioners that preventive medicine is that medical specialty which is concerned primarily with health promotion and disease prevention for defined groups, communities, or populations, rather than for individual persons. In the United States it is currently subdivided into four areas of special concentration: aerospace medicine, general preventive medicine, occupational medicine, and public health. Certification can be obtained in one or more of the special areas but not in the overall field. Thus, physicians seeking board certification sit for two days of examination. On the first day, applicants for certification in all four special areas take the same examination. On the second day, applicants sit for the examination in the special area in which they seek certification. If certification in a ''second special area is sought, only the second-day examination in the second special area is required in addition to the two days of testing for certification in the first special area. The common core of knowledge which is shared by the four special areas and which characterizes the specialty includes: "1. Biostatistical principles and methodology. 2. Epidemiological principles and methodology. 3. Planning, administration and evaluation of health and medical programs. 4, Enviromental hazards to health and principles of their control. 5. Social, cultural and behavorial factors in medicine. 6. Application o€. orien. secondary and tertiary preventive principles and measures in clinical practice, including genetic factors in disease and disability." (5) Graduate Training in the Specialty The structure of graduate medical education in the four special areas is similar in that it consists generally of a clinical year, an academic year, and a field year. Certain programs in general preventive medicine include a second academic year and/or a second field year and in occupational medicine, a second field year. There are also "combined" programs which do not separate or compartmentalize into specific years the clinical, academic and field aspects of training, and "integrated" programs which offer training in both a clinical specialty and preventive medicine. In the usual program, the clinical year involves direct patient care training in a residency program sponsored either by one of ''the clinical specialties or by preventive medicine. The settings in which the field year are usually taken are characteristic of the particular special area. Thus, in public health, the field year is likely to be in an health agency; in occupational medicine, in a medical school, school of public health, or a corporate setting; in aerospace medicine, in a military setting; and in general preventive medicine, in schools of medicine or public health, or in the military. Table 1 lists the institutions which had graduate medical education programs in one or more of the special areas of preventive medicine in 1978-79. The American Board of Preventive Medicine was founded when, in 1948, the American Public Health Association and the AMA Section on Preventive and Industrial Medicine combined into the American Board of Preventive Medicine and Public Health; the new Board was officially recognized the following year, in 1949 (6). In 1952, "and Public Health" was dropped from its name. The following year (1953) aerospace medicine branched off from the main trunk of public health and began to be certified as a separate area. Occupational medicine was first corti tied separately in 1955 and general preventive medicine in 1960. The wheel of special area development is about to come full circle since, sometime in 1981, it is expected that the examinations for general preventive medicine and for public health will be combined into a single examination. While the Board's combining of the two examinations is an issue separate from its petitioning the American Board of Medical Specialties to combine certification for the two areas of specialization, it would seem quite likely that the latter event, i.e. the combining certification of the two areas, will soon come to pass. ''Special Area Aerospace medicine General preventive medicine Table 1 Institutions with Graduate Medical Programs in Preventive Medicine in 1978-79 by Special Area and Training Type Training Type Institution Clinical Academic Naval Aerospace Medical Institute (Pensacola, Florida) x xe USAF School of Aerospace Medicine (Brooks AFB, Texas) x* Wright State University x Schools/Colleges of Medicine at: Alabama, University of - Birmingham xX xX - Tuscaloosa xX xX Arizona, University of xX x Charles R. Drew Postgraduate x Cornell University Combined Dartmouth College Combined Kentucky, University of x Maryland, University of X xX Massachusetts, University of x xX Mayo Graduate xX xX* Meharry Medical College xX xX Missouri, University of X X Mount Sinai Combined North Carolina, University of Ohio State University Rochester, University of Texas Tech University Utah, University of xX Wisconsin, Medical College of x Yale University Schools of Public Health at: California, University of - Berkeley x - Los Angeles oO PS Pd Pd Pd Od Od OS Harvard University Hawaii, University of Johns Hopkins University Michigan, University of Tulane University Washington, University of Pd Pd Pd Pt OPS Pd Pd DS (Table continued on next page) Pd PS PS Pd PS PS PS PS OS mS Pd Pa PS PS Pd PS PS PS PS Pd PS Pd PS PS OPS OS ''Table 1 (Continued) Training Type Special Area Institution Clinical Academic Field USAF School of Aerospace Medicine (Brooks AFB, Texas) x* x US Army Environmental Hygiene Agency (Aberdeen, Maryland) x* x US Center for Disease Control (Atlanta, Georgia) x Walter Reed Army Institute of Research xX xX* xX Occupational medicine Schools/Colleges of Medicine at: Arizona, University of xX California, University of - Irvine Cinncinati, University of Mayo Graduate School xX Mount Sinai North Carolina, University of School of Public Health at: Harvard Johns Hopkins X Texas, University of - Houston Cook County Hospital xX Rocky Mountain Center for Occupational and Environmental Combined and Integrated Health : US Environmental Hygiene Agency (Aberdeen, Maryland) x In-Plant Programs at: American Telephone and Telegraph Company Boeing Company Dow Chemical Company Eastman Kodak Company E.I. Dupont de Nemours and Company General Motors Corporation Hanford Environmental Health Foundation Harvard University Health Services Navy Industrial Environmental Health Center Tennessee Valley Authority x Pa Pd Og bd Pd Pd ~ mS OP Pt X x Pd Pd PS Pd Pd Pd Pd OO Od OM (Table continued on next page) ''Table 1 (Continued) Special Area Institution Public Health Departments of Health of: California Maryland Minnesota Mississippi New Jersey New York City New York State North Carolina Oregon Texas Utah Virginia Wisconsin Silas B. Hays Army Hospital (Fort Ord, California) University of Kentucky College of Medicine University of Washington School of Public Health and Community Medicine This table derived from material published in Directory of Preventive Medicine Residency Programs in the United States. Washington, D.C.: American College of Preventive Medicine, 1979. *Academic training not available on site. mM Pt PS Training Type Academic ms FE EE EES Integrated os Field Pd Pd Pd Pd BS Dd Od Pd PS Pd PS OS Pd ~ Note: "Combined" programs do not separate the clinical, academic, and field phases of training, while "integrated" programs provide training in a special area of preventive medicine along with training in a clinical specialty, e.g. family practice, internal medicine. ''II. PRESENT SUPPLY OF PREVENTIVE MEDICINE PHYSICIANS Let us turn now to an examination of the numbers of physicians in the specialty who have participated in the graduate training programs and certification activities described in the previous section as well as of a goodly number who have done neither. Board-Certified Specialists Table 2 presents data on the number of persons ever certified in each of the four special areas and the total ever certified in the specialty of preventive medicine. The oldest special area, public health, accounts for 47 percent of all certifications in preventive medicine while the relatively new area of general preventive medicine accounts for 12 percent. There is an important point to make in connection with the data of Table 2. It is that those data include persons who were certified but who are not currently active due to death, disability, retirement, etc. The AMA has reported that at the end of calendar year 1977 there were 2,486 persons certified by the American Board of Preventive Medicine (7). Those data probably exclude inactive persons given that the number "ever certified" regardless of present activity status is 3,894 (as reported in Table 2). With the information that approximately 70 to 80 persons have been certified annually in recent years (8), a good estimate of the number of active, certified physicians in the specialty at the end of 1978 would be approximately 2,550. That figure is arrived at as ''Table 2 Number of Persons Ever Board-Certified in Preventive Medicine and Its Special Areas (as of Spring 1980) Percentage of All Number of Persons Ever Certified in Special Area Ever Certified Preventive Medicine Aerospace medicine 783 20 General preventive medicine 475 12 Occupational medicine 794 20 Public health 1,842 47 All preventive medicine 3,894 1002 Source: Personal communication from Stanley Mohler, M.D., Secretary- Treasurer, American Board of Preventive Medicine, August 8, 1980. 10 ''follows: the 2,486 who were certified by 1977 plus an estimated 75 per- sons newly certified in 1978 yields a total of 2,561, minus an estimated few persons (about 11) who became inactive in 1978. In addition to those persons who are board-certified, there are a substantial number of physicians who are not certified in the specialty but who have indicated that their specialty is preventive medicine. In 1978, a total of 6,031 physicians responded to an AMA survey by indicating that their specialty was preventive medicine (9). Thus, if 2,550 persons are certified and active (as derived from the preceding calculations), 3,481 or 58 percent of the physicians currently active in preventive medicine are not certified. Unfortunately, there is no easy way to determine how many of these uncertified persons meet the requirements and are Board-eligible but have not petitioned for certification. Uncertified Specialists This situation, i.e. the specialty self-identification of three distinct groups: (1) Board-certified specialists, (2) Board-eligible (but uncertified) specialists, and (3) Board-ineligible (and uncertified) specialists, exists in all of the medical specialties to a greater or lesser degree. Among those specialties in which certification is a relatively new phenomenon or, as preventive medicine, in which certification is not sought to obtain the hospital admitting and operating privileges which are essential for the practice of the 11 ''specialty (such as surgery, internal medicine, family practice, etc.), most likely there is a greater proportion of Board-ineligible persons presently active in the specialty. The greatest proportion of Board-ineligible specialists is probably clustered in the older age groups of each specialty. As older, ineligible physicians become inactive and are replaced by new entrants almost all of whom plan to obtain certification (10), the level of training and the quality of skills available from each specialty pool rises. However, there are certain specialties which are physically less demanding and which therefore have attracted physicians from practice in other specialties in the middle or latter part of their career. These specialties also represent a natural progression in career for some physicians, e.g. the obstetrician-gynecologist in a maternal and child health clinic or the pulmonary specialist in a tuberculosis clinic. Both begin working as clinicians but then cross over into administration of their clinics and, thus, into the practice of preventive medicine. Preventive medicine seems to be one such specialty. Available data which bear directly on this phenomenon of mid-career switches to preventive medicine seem to be non-existent but the feeling of many in the specialty is that the phenomenon does exist. Table 3 presents data on the age distribution of preventive medicine specialists in 1973. By comparing the percentages of preventive medicine physicians to those of all physicians in each of the age categories, one sees that 12 ''Table 3 Age Distribution of Physicians In Preventive Medicine, 1973 (in percentages and means) e (in years) Mean Age 26-. 30-" 35= -40=: 45=".50=— 55= 60- 65- 70- 75 or Special Area (in years)* 29 34 39 44 49 54 59 64. 69 74 More Total Aerospace medicine 40.8 20.-° 16-°: To 9 8 6 6 2 1 1 100% General preventive medicine 48.6 G12 TG 8s 188 12s 10. £0 7 4 2. 100% Occupational medicine 54.4 0 2 7 9 Na. LB a9) le 9 4 3 100% Public health 51.8 3 8 9 11 LL 14 13 15 10 4 Z 100% Total preventive medicine 5150 4 7 9.0 A 12.) 1A A a 8 4 2 100% Total all physicians 45.6 120" (AS 1a I alo 8 9 7 5 3 4 100% *Means were calculated on the midpoint of the age interval; 80 was used as the midpoint of the "75 or more" interval. Source: The data in this table were derived from American Medical Association, Medical School Alumni, 1973, Rockville, Maryland: Aspen, 1975, p.122 on the assumption that the average age of graduation from medical school was 26 years. 13 ''there is a smaller percentage of the former (preventive medicine physicians) in each category up to and including the 40-44 year category and a greater percentage of the former in the categories 45 years and older. This may be a reflection of the fact that the specialty is attracting fewer and fewer people in total, that is, both young physicians fresh from graduate medical education and older physicians making mid-career switches (as will be seen in Table 4); however, it may also be a reflection of mid-career switches beginning at about age 45. Some of the physicians who switch to preventive medicine in mid- to late-career do return to the medical education system for graduate training in their new specialty; however, again, the undocumented feeling is that the greater number do not and that they receive, instead, informal, "on-the-job" training. While a recent study does provide some data on this topic, because of the very small numbers upon which the data for preventive medicine are based, the results are questionable C13}; The study reports the results of a survey of the certification status in 1976 of 10 percent samples of the 1960, 1964, and 1968 medical school graduates. Of the 21 persons from all 3 classes self-identified as in preventive medicine in 1976, 13 were certified and 1 was not certified but had begun the certification process. 14 ''Table 4 Number of Physicians Self-Designated as in Preventive Medicine, 1963-1978 Special Area 1963 1968+ 1970 1972 1974 1976 1978 Aerospace medicine 1,554 1,456 1,188 921 708 660 584 General preventive medicine - 839 804 840 758 808 756 Occupational medicine 2,911 2 202 2o113., 2,906 2,300.5 aZipze ag ODL Public Health 3,884* 3,032 3,029 25906 .2,695°--2,600 2,340 Total 8, 349 8,029 15734) 7517376263739 26,390 6,031 (As percentage of all active, specialty classified M.D.'s) (30:2) (287) C255) (228) BSED. 0) 22 SOIS) ss C16) Sources: American Medical Association, Physician Distribution and Medical Licensure in the U.S., 1978, 1976, and 1974; Distribution of Physicians in the U.S., 1972 and 1970; Distribution of Physicians, Hospitals and Hospital Beds in the U.S., 1968; and Selected Characteristics of the Physician Population, 1963 and 1967. Chicago: AMA, various years. + Data adjusted for AMA reclassification (see reference 1, pp 31-32). * includes general preventive medicine 13 ''The trend data in Table 4 show that there has been a declining interest or participation in preventive medicine. Both the absolute numbers and the percentages of all physicians who have identified their primary activity as preventive medicine have declined steadily over the 15 years from 1963 to 1978. In 1978 there were less than three-fourths the number which there had been in 1963 (6,031 versus 8,349). The decline is particularly notable in aerospace medicine where it amounts to 62 percent (584 versus 1,554) and is generally felt to reflect cutbacks in the national space program. Occupational and general preventive medicine are the two areas in which interest has been most stable. Moreover, there was a slight upturn in 1978 for occupational medicine, with 29 more persons in the area than were in the area two years earlier in 1976 (2,351 versus 2,322). What do these trends mean for the future and what will be the available supply of trained persons in the specialty? Projected Supply in 1990 Other than a few casual estimates, which were derived by summing up over a given number of years the expected output of preventive medicine graduate medical education programs, the on ty attempt at a more precise forecast of future supply in the specialty is that of the Graduate Medical Education National Advisory Committee (GMENAC) (13). In its forecast three sets of variables concerning (1) medical student characteristics, (2) specialty branching and switching during graduate medical education, and (3) characteristics of physicians ta practice were factored into an Integrated Physician Supply Model. Unfortunately, the 16 ''projection which it produced was a single one for all preventive medicine specialists rather than four separate ones, one for each of the special areas of the specialty. That projection was for approximately 5,550 preventive medicine specialists to be available in 1990. Will that number be sufficient to meet the 1990 requirements for specialists in preventive medicine? In order to address that question it is necessary to consider the activities and settings for which these specialists will be needed. Since it is unlikely that the structure of the U.S. health care system 10 years from now will be drastically different from that of today, examination of present patterns of human resource utilization in the specialty is essential for predicting their likely utilization in 1990. Let us do so in the following section of this paper. 17 ''III. PRESENT PATTERNS OF PHYSICIAN UTILIZATION Table 5 presents data regarding trends in the professional activities of preventive medicine physicians over the decade from 1968 to 1978. The activity profile of each of the areas has remained essentially unchanged in its general outline though there have been some minor shifts among the different activities. The major activities of aerospace medicine continue to be office-based practice, hospital staff work, and administration though there was a slight increase in administration and a slight decrease in hospital staff work. In general preventive medicine, the major activities are and have been office-based practice and administration but there was a notable increase (7 percent) in office practice and concomitant decreases in teaching and research (3 percent and 4 percent, respectively). The activity profile of occupational medicine shows virtually no changes over the past decade with its predominant activity being office-based practice. Almost 70 percent of its profile is in office practice with about 20 to 23 percent in administration. The public health activity profile has also changed little over the years with almost 60 percent of its effort devoted to administration and about 20 percent to office-based practice. Some people question whether the activity represented by office-based practice should really be subsumed under preventive medicine rather than another specialty. It is likely that this activity refers to clinical services given to individual patients and, if so, in accordance with the 18 ''Table 5 Percentage Distributions of the Professional Activities of Self-Identified Preventive Medicine Physicians, 1968 and 1978 Special Area Major Professional Activity 1968 1978 Aerospace medicine 100% 100% Office-based practice 33 33 Hospital resident 6 8 Hospital full-time MD staff 28 22 Teaching 1 1 Administration 24 28 Research 5 3 Other * 3 3 General preventive medicine 100% 100% Office-based practice 24 ot Hospital resident 7 8 Hospital full-time MD staff 7 9 Teaching 7 4 Administration 36 34 Research 13 9 Other * 6 4 Occupational medicine 100% 100% Office-based practice 69 68 Hospital resident Li 1 Hospital full-time MD staff 3 4 Teaching 7 = Administration 20 23 Research 3 i Other * 4 3 Public health 100% 100% Office-based practice 19 2h Hospital resident 3 i Hospital full-time MD staff 8 7 Teaching 2 3 Administration 58 57 Research 6 6 Other * 4 5 All preventive medicine 100% 100% Office-based practice 39 42 Hospital residents 3 3 Hospital full-time MD staff 10 7 Teaching 2 2 Administration a 38 Research 5 4 Other* 4 4 Source: American Medical Association. Physician Distribution and Medical Licensure in the U.S., 1978 and Distribution of Physicians, Hospitals and Hospital Beds in the U.S. 1968. Chicago: AMA, 1979 and 1970 respectively. * Refers to other than the 6 activities listed above and includes "all types of insurance carriers, pharmacentical companies, corporations, voluntary organizations, medical societies, associations, grants, foreign countries, etc." 19 ''definition of the specialty as one which is population-oriented, the majority of such clinical services would not be considered within the boundaries of the field. That so many persons who are providing clinical care to individuals identify themselves as being in the specialty of preventive medicine probably results from their self-identification on the basis of work setting rather than of formal training or work activity. For example, the physician who is employed in a public health clinic where his/her primary activity is attending patients may identify his/her specialty as public health, rather than as general or family ‘practice or general internal medicine. Moreover, the majority of those employed in public or corporate clinics seems not to be certified or trained in preventive medicine. In an examination of the staffing patterns of seven corporate health clinics, for example, out of 29 physicians employed on both a full-time and a part-time basis, only 1 was identified as in preventive medicine (specifically public health) (14). One wonders, however, which specialties the 28 listed as their primary specialties in response to the AMA's Survey of Physicians' Professional Activities, which is the primary source of available data on physician specialization and professional activities. It may even be that most of those who are providing individual patient care in public health, occupational, aerospace, and other environments are the persons in preventive medicine who do not possess certification in preventive medicine, though they may possess certification in another specialty. The study of corporate health clinics would seem to indicate so. Nevertheless, there is a sore lack of comprehensive data on this question. 20 ''By excluding persons in office-based practice and hospital residents-in-training from the 1978 data of Table 5, there would result the professional activities profiles that appear in Table 6. They are based on a total of 3,361 persons (342 in aerospace medicine, 456 in general preventive medicine, 747 in occupational medicine, and 1,816 in public health). In each of the special areas, the greatest proportion of activity is in administration. For the specialty of preventive medicine, administration would involve, for the most part, the operation, planning, and evaluation of various types of programs to deliver medical care to individuals. . Such programs are usually offered within the context of an organization rather than by an individual physician or even a small group of practicing physicians; thus, preventive medicine physicians in admini- stration tend to be employees, rather than self-employed, whether they work full-time for a single organization or part-time for one or more organizations. Actually, in addition to administrators, physicians who are either full-time hospital staff, teachers, researchers, or otherwise employed (as defined in Table 5) would also be employees, rather than self-employed private practitioners. Most preventive medicine physi- cians, then, are salaried rather than self-employed. The Federal Government itself employed 25 percent of them in 1978 (52 percent of those self-identified in aerospace medicine, 18 percent of those in general preventive medicine, 7 percent of those in occupational medicine, and 15 percent of those in public health) (9). 21 ''Table 6 Redefined Professional Activities Profiles of Preventive Medicine Physicians, 1978 (Percentage Distribution) Aerospace medicine Hospital full-time M.D. staff Teaching Administration Research Other * General preventive medicine Hospital full-time M.D. staff Teaching Administration Research Other * Occupational medicine Hospital full-time M.D. staff Teaching Administration Research Other * Public health Hospital full-time M.D. staff Teaching Administration Research Other * All preventive medicine ' Hospital full-time M.D. staff Teaching Administration Research Other * * See Table 5 for explanation. 22 (1002) 37 ee 48 8 5 (100%) 15 1 56 16 7 (100%) 12 1 ZZ 4 10 (100%) 9 4 a3 7 6 (100%) 13 4 68 8 7 ''Since one of the aims of this paper is to bring together all of the known data pertaining to human resources in the specialty in order to establish a knowledge base for the development of databases and of requirements-estimation methods, a brief review will be made here of studies that, though they cannot be fitted together readily to form a coherent whole, do provide pieces of the manpower picture. It is hoped that this compilation will facilitate the work of future researchers in the area. Almost all of these stasins pertain to public health -- a fact which probably reflects the longer tradition of this area compared to aerospace, general preventive medicine, and occupational medicine. Deployment of Public Health Physicians The first of the studies we will consider is the first of what is to be a biennial series of legislatively mandated reports on public and community health personnel (15). Among various data on the personnel, training institutions, and funding in public and community health, it reports the work settings of physicians who in 1974 reported their primary, secondary, or tertiary specialty as public health. Presented in Table 7 are the percentage distributions of the work settings of (a) those with a known work setting and (b) those whose primary, or whose primary, secondary, or tertiary setting was public health. It is immediately obvious that the majority of public health physicians are in government settings and, within government, more often in nonhospital than hospital settings. Of those employed by government, most are at the city/county level. They are followed in numbers by those at the state level, then those at the federal level. As is true for physicians working in government settings, the majority of those in nongovernmental 23 ''Table 7 . Percentage Distribution of the Work Settings of Physicians Whose Specialties Were Public Health, 1974 Primary Primary, Secondary, Specialty or Tertiary Work Settin Only Specialty (Number )*. (l,7oo7 *(5,018) Nongovernment [6.3 36.7 Other than hospital 1329 32.55 Medical school O55 10.1 Solo practice a5 16.0 Partnership 0.1 1.6 Arrangement (nongroup) 0.5 1.4 Group practice 0.7 3.7 Hospital 2.4 4.3 Government 77.4 57S Other than hospital 65.1 43.6 City/county 3147 20.5 State 24.9 16.0 Federal $65 Pia Military 152 1.4 Public Health Service 4.7 Jo Other federal agency 2.6 2.4 Hospital 12538 13.9 City/county 18 2:6 State 1.9 226 Federal 8.6 8.7 Military 0.7 1.6 Public Health Service Fae 539 Veterans Administration 055 1.0 Other 6.4 539 Total 100.0 100.0 Source: Computed from AMA data reported in A Report on Public and Community Health Personnel. DHEW Publication No. (HRA) 80-43, April 1980. *These numbers and percentage distributions are based on physicians in public health with known work settings. Excluded are 718 unclassified as to work setting for whom public health was their primary specialty and 154 for whom it was their secondary or tertiary specialty. ''settings are in nonhospital settings. Comparison of the two percentage distributions shows that a substantially greater percentage of those whose primary specialty was public health were in government settings than were those for whom public health was the secondary or tertiary specialty. Some recent studies (16, 17, 18, 19) shed light on physicians in local public health departments, which as Table 7 showed is the work setting of the largest percentage of physicians with a public health specialty. Consideration of these studies in the present context, however, warrants a strong caution. It is that while the physicians upon whom they report have been identified as working in public heath units, one cannot assume that they are either board certified or board eligible in public health/preventive medicine nor that they would identify their specialty as public health. Moreover, it is debatable whether those who are engaged primarily in rendering individual patient care, even though in a public health unit, should be qualified in preventive medicine rather than in a clinical specialty. A 1974 national survey of local heelth departments showed that 25 percent were involved in delivering direct personal services and "for many services the health department is the sole provider of essential services in the area of jurisdiction" (16). Thus, it is important to keep in mind that not every physician in a public health agency should be or is qualified in public health/preventive medicine. ''With respect to the actual number of physicians in local health agenices, that 1974 survey reported the following: There is an average of one physician for every 30 employees in health departments. "Nearly two-thirds of all health officers in the United States have an M.D. degree; ... about 23 percent have both an M.D. and M.P.H. (or similar) degree." Only 17 percent of city departments do not employ a full-time physician. A later survey of local public health units which focused on their organizational milieus reported in 1978 that: 63.3 percent (or 472 in number) of the 748 agency heads were M.D.'s3 29.9 percent (or 223) of the agency heads held another degree in addition to the M.D. -- 6.7 percent (or 5) the Dr. P.H., 26.5 percent (or 198) the M.P.H., and 2.7 percent (or 20) another degree; 35.8 percent of all agency heads listed as their principal previous professional work experience "clinical physician" -- 19.9 percent listed "public health officer", 3.2 percent listed "M.D. in hospital administration"; whether or not a physician was the agency head was related both to the agency's organizational type (separate health department, umbrella agency, integrated health services 26 ''“eS department, integrated human resources department, or other) and to the size of the population served by the agency (Table 8 presents these data); 75.6 percent (or 547) of both separate health departments and umbrella agencies employ their agency head (whether M.D. or not) full-time; of the 177 agencies which employ their heads part-time, 22 percent (or 38) share their heads (17). Reversing the issue of agency heads' professions, a 1978 survey (the results of which were published in 1980) ascertained levels of utilization of nonphysicians as directors of local health departments Two major findings were: 20 states increased, 1 state decreased, and 27 states remained the same in their utilization of nonphysicians as county and local health officers; " by late 1978 such persons (nonphysicians) filled almost one-third of the total local health director positions in the United States" or, reversing the wording, in late 1978 over two-thirds of director positions were occupied by M.D "ss. A study that examined the results of a law passed in Connecticut in 1971 which permits districts to utilize nonphysicians with public health training as directors of local health agencies found that: 19 of 31 district and municipal health directors were nonphysicians; and that ZT ''Table 8 Average Population, Average Percentage of Public Health Unit Heads with M.D. and with M.D. Plus Other Degrees, by Organizational Type Average Percent Population Per- Heads Total of Jurisdic- cent with Units tion Within Heads M.D. and Responding This Organi- with Other to This Organization Type zational Type M.D. Degree Question Other type agency 96,118 66.7 66.7 3 Separate health department 132,106 60.5 26.4 613 Umbrella agency 1575520 15367 95.9 103 Integrated agency: Human resource ~ 303,039 66.7 33.3 6 Health services - 806,614 84.2 47.4 19 Source: Shonick, W. and W. Price. Organizational milieus of local public health units: Analysis of response to questionnaire. Public Health Rep. 93(6): 648-665, 1978. 28 ''- "the proportion of Connecticut towns covered by full-time directors had risen from 14 percent to 38 percent and the proportion of the population covered had risen from 46 percent to 63 percent" (19). In contrast to the four sources of data cited above on physicians in public health agencies at the local level, there seems to be only one source on the staffing of health agencies at the state (and territorial) level. That source is the Association of State and Territorial Health Officials' (ASTHO) National Public Health Program Reporting System (NPHPRS). Of the 57 state and territorial health officials listed in the ASTHO directory, 47 are physicians (20). Of 50 officials who responded to an ASTHO survey, 29 indicated that the M.D. was a requirement for the position (21). ‘The NPHPRS report of staffing as of December 31, 1977 indicated that of 124,976 total state health agency employees (including both salaried and contract drakeeun) 3,937 were physicians (22). Also indicated were the number of physicians employed in each of seven dif- ferent program areas. In interpreting these data, it is important to note that the NPHPRS staffing figures "are based on full-time equivalents (FTE): 40 hours per week or 2,080 hours per year equals one full-time equivalent". The percentage distribution by program area (see Table 9) shows that over 80 percent of physician deployment by public health agencies at the state level is for personal health services programs with over half being delivered through state institutions and over one-fourth noninstitutionally. 29 ''Table 9 Percentage Distributions of Physicians on State Health Agency (SHA) Staffs by Program Area, 1977 Percentage of Physicians as Percentage of Professional, Administrative, Physicians as Percentage of MD Staff in and Technical All Staff in Program Area Area Staff in Area Area Personal health: Noninstitutional oF 5 5 5 SHA-operated institutions 55.6 10 5 Environmental health 023 - N/A Health resources Teo 3 2 Laboratory 1.3 1 N/A General administration and services 6.0 5 5 Other and not allocable 4.0 ot N/A Total 100.0 5 3 Source: Derived from data reported by Association of State and Territorial Health Officials in Comprehensive NPHPRS Report: Services, Expenditures and Programs of State and Territorial Health Agencies Fiscal Year 1978. Pub. No. 47, January 1980. 30 Silver Spring, MD: ASTHO-NPHPRS | ''With respect to physicians in public health at the Cakisie’ level, the data (see Table 10) indicate that most of them (83.3 percent) are involved either in administration or patient care (41.5 percent and 41.8 percent respectively) and that the latter is delivered primarily through hospital settings (33.8 percent). The U.S. Public Health Service employs the majority of federally employed physicians in public health (70 percent). Let us now attempt to summarize and fit together the various items of data which have been cited to see if we can obtain a comprehensive picture of how public health physicians are currently deployed. Only 16 percent are not employed in government and that 16 percent includes the 10 percent employed in medical schools, presumably as teachers, researchers and administrators. Of the other 84 percent, 65 percent work in nonhospital settings with 32 percent at the local level, 25 percent at the state level and 9 percent at the federal level. While the percentages of physicians employed in hospital settings at the state and local level are negligible (2 percent each), the percentage at the federal level is considerably higher (9 percent) and equal to that of federal physicians in nonhospital settings. In local government nonhospital settings physicians constitute about two-thirds of all health officers, the other third being nonphysicians. Moreover, “ trend seems to be towards greater utilization of nonphysicians since they provide full-time coverage where none was previously available (19). Nonphysician utilization is related to both 31 ''Special Area Branch Public health Army Navy Air Force Public Health Service Veterans' Administration Other Total - No. - Percent ce Aerospace medicine Army Navy Air Force Public Health Service Veterans' Administration Other Total - No. - Percent Table 10 Professional Activities of Federally Employed Preventive Medicine Physicians by Special Area and Service Branch, 1978 Patient Care Professional Activity Office Hospital Teaching Administration L 10 1 9 0 3 0 4 1 2 0 3 14 96 3 91 1 6 0 5 dt 1 0 33 ‘28 118 4 145 8.0 $3.8 qe 41.5 3 18 - 13 1 63 20 9 60 2 55 1 2 i fa ae! 2 m E 13 - - sz 25 145 2 LS $42 47.4 0.7 36.9 (Table continued on next page) Research oor 28 ai oe Cw . No} wt e Blan Other oow 13 Behe. be 1 RPNN N ee NIN I Nn . oO Total No. 245 13 51 349 34 90 130 456 306 Percent ''GE Source: Special Area Patient Care Table 10 ‘continued ) Professional Activity Association, 1979. Branch Office Hospital Teaching Administration General preventive medicine Army 3 10 1 9 Navy 2 8 1 8 Air Force 1 4 - 3 Public Health Service - 39 - 7 Veterans' Administration - 3 - > Other io) = riage 10 Total - No. i} 64 2 37 - Percent 8. 47.8 1.5 27.6 Occupational medicine Army ll 4 = 11 Navy 15 12 1 20 Air Force 6 2 - 3 Public Health Service 9 5 = Veterans' Administration 7 9 - - Other 34 4 vale AT. Total - No. 76 . 34 2 54 - Percent As 2 19.3 Uy 29.0 All preventive medicine Army 16 42 2 42 Navy 18 86 2 52 Air Force 17 68 2 64 Public Health Service 24 142 3 98 Veterans' Administration 2 20 - 5 Other _63 tid od _85 Total - No. 140 361°, 10 346 - Percent T4..5 SL 140 35.9 Research 35 a aticc 6 Wunderman, L. E. Physician Distribution and Medical Licensure in the U.S., 1978. Other No. - 29 3 22 - 8 1 53 2 6 ee 16 6 134 te - 28 1 5. 1 LZ 5 18 2 12 ad 55 8 176 4.5 7 118 6 170 z 156 17 319 5 34 see 168 44 965 4.6 Chicago: American Total Percent 1. 16. 6. oFfFO 39.6 100.0 L262 17.6 1652 33.1 100.0 Medical ''the population of the jurisdiction and to the organizational type of the local health agency (17). At the state level physicians constitute 82 percent of agency heads. Of all the physicians on state health agency staffs (both agency heads and others) over 80 percent are involved in personal health service programs; however, it is unknown whether their activities in connection with these programs are primarily administrative or clinical. Physicians in public haeish ae the federal level are employed mostly by the Public Health Service and are equally involved in administration and hospital provision of patient care. Deployment of Occupational Medicine Physicians In addition to the data on all preventive medicine specialists cited previously (in Tables 3-6 and in reference 14), the only other data on physicians in occupational medicine appear to be those collected in a nationwide survey of business and industrial facilities conducted by NIOSH in 1972-1974 (23). Again, the caveat holds that though these physicians may be employed in occupational settings they are not necessarily preventive medicine board-certified or eligible or consider their specialty to be occupational medicine. Table 11 summarizes relevant data from that survey. It shows that large plants are where health services are available to workers, and that though 70 percent of large plants have a health unit only 26 percent have a health unit headed by a physician. While 14 percent employ a physician full-time, 32 percent of large plants employ both a physician and a nurse. The average number of hours per week which a physician spent in the health unit was 12 versus 51 by a nurse. 34 we ''Ge aa Table 11 Number of Plants and Employees with Physician and Other Services Plants Employees in Plants Percent of Plants and Employees Small Medium Large Small Medium Large in Plants Which: (8-249) (250-500) (Cover 500) Total (8-249) (250-500) (over 500) Total Employ a Physician Full-Time O25 0.4 14.4 0.7 0.7 0.7 34.8 11.4 Employ a Physician and a Nurse* 0:2 Let 3253 0.7 0.5 Dal DD:,.7 16.9 Have a Formally Established Health 233 13.6 70.0 4.0 3.3 18.4 79.6 31.5. Unit Have a Formally Established Health 0.8 re3 26:5 bed Eel Lt 45.0 £5.68 Unit with a Physician in Charge Employ a Physician Full-Time and: Receive Industrial Hygiene Services 0.0 OLT 3.1 0.1 0.0 0.3 2951 952 Regularly Record Health Information 0.2 0.4 14.4 0.4 0.4 ON 7 34.8 It .2 Require Pre-Placement Physical Examinations OieL 0.4 13.6 0.3 6.3 0.7 3465 WA A Provide Periodic Medical Examinations 0.1 0.4 13.6 0.3 0.3 0.7, Ses. 10.4 Total Number of Plants and Employees in the National Universe 671 60 9 739 15,394 10,883 11,985 38, 263 (in thousands) Source! USDHEW, NIOSH. National Occupational Hazard Survey, Volume III. DHEW Pub No. (NIOSH) 78-114, December 1977. *Average number of physician hours devoted to the facility per week is 12 hours for large plants, n. a. for other; average number of nursing hours is 2 hours for medium-size plants, 51 hours for large plants, 1 hour for total, and n.a. for small plants. ''In a paper presented at a 1977 symposium on "clinic-based occupational safety and health programs for small businesses", Kerr mentioned the following data (though without reference): Estimates show that, currently, services for industry or employer groups are being provided by 10,000 physicians, of whom about 2,600 are employed full- time. Of the latter group, more than a fourth never see a patient. Nearly all of these physicians are located in the 11,500 establishments with more than 500 workers (24). In sum, the only two sources of data on physicians in occupational settings additional to those already cited indicate that a rather small number of physicians are employed in such settings full-time and rie they are most often employed in plants with high worker populations. There seem to be no supplemental data on the current supply and deployment of aerospace and general preventive medicine specialists. The absence of data on the latter group is especially critical for validating their claim that they provide unique clinical services such as risk assessment and wellness care which are not provided by any other specialty. In this overview of human resources in preventive medicine, we have examined: the supply of Board-certified and uncertified persons in the specialty, trends in supply over the past 15 years, estimated 1990 supply, the age distribution of the specialty and profiles of 36 ''af professional activity. With this baseline, let us now look at the other side of the coin, namely, requirements for human resources in the specialty. ST ''Iv. ESTIMATING PHYSICIAN REQUIREMENTS The state-of-the-art in estimating human resource requirements in medicine is such that there are two basic approaches, one based on the biological need for medical treatment and the other based on patient demand for medical services (25). The first approach utilizes data on the incidence and prevalence of morbidity and on appropriate levels of care. It estimates requirements without regard to the availability and price of services or to patient knowledge and inclination to seek services. The other major approach, the demand-based approach, utilizes data based on the actual past purchase or utilization of services. Demand-based modeling is based on specified assumptions about future general economic conditions or other possible constraints on and inducements to the probable future consumption of medical services. Thus, demand-based models because of their sensitivity to constraints on utilization imply that a certain proportion of future morbidity will not be treated. If social planning is the act of determining societal goals, demand-based modeling, in contrast to needs-based modeling, does not yield targets toward which present decisions and actions can be aimed but rather tends to perpetuate what presently exists. In its work involving the modeling of 1990 requirements in 22 specialties, GMENAC used the needs-based approach for most specialties. However, for a few specialties including that of preventive medicine it became apparent that a medical needs-based model was not serviceable (13). Instead, 38 ''requirements were estimated based on (a) a recommended distribution of preventive medicine manpower effort across 5 different professional activities in each of 3 areas of the specialty and (b) the ceiling on 1990 supply resulting from the size of the preventive medicine graduate training enterprise even assuming that during the 1980's it will operate at full capacity, i.e. that all exisiting residency positions will be funded/filled. Table 12 summarizes the results of that effort. If one goes back to the definition of preventive medicine as the specialty concerned with the health of defined populations, it is also logical to base the estimation of manpower requirements in preventive medicine on the provision of health programs for defined populations. It becomes necessary, then, to specify: (1) the populations for which services will be provided, (2) the type and scope of the programs which will be provided for them, and (3) the contribution or role of preventive medicine specialists vis a vis the programs to be provided. Specification of each of the three items listed above requires making certain assumptions and judgements -- as do requirements-estimation methods based on the biological need for medical services. However, the latter methods because they utilize the more objective data of disease incidence and prevalence are somewhat less open to debate. Nevertheless, let me consider whether it is possible to estimate future requirements for physicians in preventive medicine using the three-component model outlined above. 39 ''Table 12 Graduate Medical Education National Advisory Committee (GMENAC) Recommendations for 1990 Manpower Needs in Preventive Medicine Public Health Preventive Professional Aerospace Occupational and General Medicine Activity Medicine Medicine Preventive Medicine Total Program acti- vities 250 1,400 2,100 3,750 Research 150 200 400 750 Teaching 60 300 450 810 Clinical services 500 400 400 1,300 Other ¢ ) 200 200 Total 960 2,300 3,550 6,810 Source: USDHHS, HRA. Report of the Graduate Medical Education National Advisory Committee -- Vol. 2: Modeling, Research and Data Technical Panel. DHHS Pub. No. (HRA) 81-652, November 1980. 40 ''Though there have been a few instances in the literature where expected requirements and shortages in the specialty have been predicted, except for the work of GMENAC, those predictions have not been based on a detailed breakdown of the utilization of human resources in the spe- cialty. For example, in the milestone publication Preventive Medicine USA (26), it is observed that "It is exceedingly difficult to translate what are obviously significant needs into concrete figures, and there is often a great difference between need and effective demand" (p. 473). The section then proceeds to discuss requirements in each of the four special areas. For aerospace medicine, it mentions a 1968 conference which estimated a need of the civilian sector for 18 to 20 additions to the pool of aerospace physician specialists annually, however, the method of estimation is not mentioned. For occupational medicine, a 1972 article is cited in which the author projected a need for 3,000 occupational medicine specialists. Inspection of that article, however, reveals only a blanket statement that such a shortage exists with no discussion of the estimation method or citation of source (27). Neither does the section on occupational medicine mention an earlier study which cites NIOSH estimates of the supply of board-qualified or certified occupational physicians in 1973 to be 500 and the deficit to be 1,200 (28). Again, no method is described or reference source cited in the latter study. Also excluded from the occupational medicine section is any reference to the New York Academy of Medicine's "Statement on the Health Manpower Situation in Occupational Medicine" which includes the following statement: 4l ''According to the A.M.A. Profile of Medical Practice for 1973, 2,374 physicians listed their principal profes- sional activity as occupational medicine, a total far below the 5,400 physicians with appropriate training which the National Institute of Occupational Safety and Health (N.1.0.S.H.) estimated would be required in 1973 (29). The section on general preventive medicine notes that the largest numbers of physicians in that special area are either epidemiologists or teachers in departments of preventive or community medicine or schools of public health though growing numbers are involved with health care programs. It then proceeds to note that "Studies of requirements and needs have been made for two categories, teachers of preventive medicine and epidemiologists" and excerpts at length from a paper which synthesized those studies. Again, however, all of the estimates 4 contained therein seem to be best guesses. The section on public health: (a) states that "Estimates of the number of public health physicians (required) are not available", (b) points out the substantial number of vacant physician public health positions, and (c) declares that the annual input of physicians to public health "will have to be significantly increased." From this quick review of the few crude estimates which have been made of future requirements in the specialty, the need to develop methods for requirements-estimation becomes obvious. In an effort to advance the 42 ''methodology, what follows is an attempt to quantify requirements for the public health area of the specialty using the model outlined earlier. Public health was selected since it is the area for which the most information is available, though it seems at this writing that the same general approach or method, i.e., that of identifying the populations to be served, the settings and programs which serve them, and the contribution of the physician specialists in question to those programs, can also be used with the other areas of preventive medicine. Physicians Needed for Public Health With regard to specifying populations for health services, universal health care is the common goal; for there are few, if any, persons who would contend that any groups should be intentionally restricted from receiving needed health care. The most inclusive method of accounting for the various populations to be served by public health programs would appear to be through the geopolitical system and its divisions since every geographic location in the nation is included in one of the political jurisdictions or divisions. That highly mobile groups are susceptible ta Raeetumies in this approach is an objection that might be raised, but it is countered by the fact that because public health includes passive (as well as active) treatment, e.g. the recipient receives care without actively seeking it (water fluoridation programs, for example), lengthy residence in the political jurisdication is not required to be included. 43 ''The most reasonable alternative to the geopolitical populations approach ‘would be one in which groups or populations were defined in terms of their spheres of activity or the institutions with which they are associated, however, the probability of overlooking certain groups is higher than the geopolitical populations approach. For example, if one identified the populations associated with schools, the military, the workplace, residential institutions for the chronically ill, etc., several groups of persons who are associated with none of those institutions, i.e. preschool children, retired persons, the unemployed, etc., would be overlooked. On the other hand, even highly mobile, ‘institutionally-unaffiliated groups have some probability of coming into contact with the public health programs sponsored by one or another of the different government agencies. For example, the Federal Government through the Department of Health and Human Services' Health Services Administration has a program specifically designed to provide health services to migrants. Actually, identifying populations to be served by public health physi- cians through geopolitical jurisdictions can result in overcounting. Residents of a city or municipality are also residents of a county, regional district, Health Service Area (HSA), State, and the Nation. oweyeir ; much duplication is eliminated because (1) certain services are most appropriately provided by a certain jurisdictional level, e.g. water treatment at the county or regional or even special water district level, and (2) lower-level governments actually are the sole providers of 44 ''certain services though money for the service is channeled through a higher-level authority. The 1978 report on State Health Agencies (SHA's) reported the following: Of the 46 SHA's (reporting that they had local health departments), 42 provided SHA resources to LHD's (local health departments).... The 42 SHA's reported providing $693 million to 2,280 LHD's with four- fifths of the amount spent for local personal health services. One-half of the $693 million came from state sources, one-third from Federal grants and contracts, and the remainder from local sources, fees, reimbursements and other sources (22, p. 35). Proceeding with the geopolitical populations approach, a quick review of the statistics on governmental jurisdictions shows that there are: 57 States, territories and the District of Columbia; 204 health service areas (189 "are entirely within one State and 15 are interstate. Twelve States have a single statewide health service area" (30)); and approximately 80,000 local governments of 5 types (see Table 13) (31). Should all 80,249 of these State, HSA, and local level units provide programs? Let us examine the issue. There is little dispute about the State's necessity for doing so. As Ingraham points out, the State is technically sovereign in this matter since the Constitution, assigns to the States all powers not specifically assigned to the Federal Government, and health is not designated as a federal responsibility (32). Moreover, the State may be the only unit 45 ''Table 13 Number of Local Goverments in the U.S. by Type, 1977 Type Number Counties 3,042 Municipalities 18,862 Townships 16,822 Special districts 25,962 School districts 15,174 Total 79 ,862 Source: U.S. Department of Commerce, Bureau of the Census. Statistical Abstract of the United States, 100th Edition. Washington, D.C.: Government Printing Office, 1979. 46 ''appropriate for assuming responsibility for public health programs where it is either small in size or sparsely populated. In both of these cases, public health activity at a level below that of the State is not practicable. In addition, almost all States have under their jurisdictions, counties or other local entities whose populations are so small that, again, public health activity at that level would not be practicable. Finally, there are certain public health activities, such as the statewide health planning called for in The National Health Planning and Resources Development Act of 1974 (PL 93-641) which only state-level agencies can conduct. Thus, there is little argument that each of the States (and the territories and the District of Columbia) should be engaged in public health programs. Regarding the involvement in public health of HSA's, the level next below that of the State, a survey designed to discover their involvement in health promotion (33) revealed that the average percentage of FTE staff time in four categories of activity was as follows: Remedial health care services 40% and facilities Preventive medicine 13 Health promotion/wellness ll All other agency activities 34 (The professional staffs of the 146 HSA's which responded to the survey ranged in number from 3 to 69 with a median of 10.) "Health promotion activities (for this study) were those intended to enhance the existing state of health, and prevention activities were those intended to obviate 47 ''or avoid disease.... The largest resource allocations were in the areas of remedial health care services and facilities and all other activities. This is understandable, since PL 93-641 mandates heavy planning and review responsibilities, which are categorized as health care services and facilities, and since the ‘all other' category would include agency management as well as other functions." The survey demonstrates not only considerable health promotion involvement but a total involvement in all of the different aspects. of public health. Moving on to consideration of local level contributions to the provision of public health programs, the following is pertinent: The small health department is not feasible from an economic standpoint. The establishment of a health unit in a jurisdiction of less than 50,000 people is discour- aged as being inefficient. A population base of 100,000 is more desirable. Practically speaking, this leaves counties and cities as the basic units around which to organize a local health department. Some sparsely populated counties combine resources to form health districts that serve two or more counties jointly (32, p. 746).. The next question which springs to mind is "How many governmental units of such size are there?" In 1977, 342 of the 3,042 counties and 163 of the 18,862 municipalities had populations of 100,000 or more making a total of 505 local governments of sufficient size to warrant a 48 ''local health department (31). What the number of such local governments warranting a health department will be in the future is unknown; moreover, there are no Census Bureau projections of the number of local governments in the U.S. by population. However, use of the number existing in 1977. would most likely not yield highly distorted projections. To sum up, then, public health programs should be provided by 57 State and territorial agencies, 204 HSA's and 505 local governments in addition to the federal government. The issue now becomes one of the specific public health services to be delivered. From Ingraham we learn that: The APHA (American Public Health Association) lists six major program areas that a state health agency ought to offer if it is to fulfill its basic responsibilities: personal health services, control of the environment, research, professional education, public health education, and administrative services. These six areas should not be considered as the last word, however, since new problems emerge that require new organizational units (32, p. 143). He goes on to point out new problems and organizational trends which are relevant to state-level provision of public health programs, namely: - increasing responsibility for the cost, quality, and availability of medical care; - greater involvement in the regulation and subsidization of the private health care industry; 49 ''- the birth of new, autonomous agencies to deal with environmental issues, with health agencies moving toward programs which require special expertise about specific health hazards and their reduction; - ‘an attempt to restrict direct health services as much as possible; - a move to decentralize activity; and - an attempt to keep the number of major organizational subdivisions down to six to ensure a more effective span of control. In contrast to the APHA's standards for what a state health agency ought to provide in the way of services and Ingraham's analysis of recent developments affecting state-level provision of public health programs, the NPHPRS national database on state-level health departments documents the actuality of public health at the State level. It annually reports in detail the types of programs and the resources, both monetary and human, expended by each State/territorial government on each of various programs (34). (Unfortunately, no such database exists at the HSA and local levels.) Earlier in this report on page 30, NPHPRS data on the numbers of physician employees of state health agencies (SHA's) were reported. However, it is the distribution of SHA expenditures which better reflects the relative importance of the various program areas. The NPHPRS data in Table 14 indicate that personal health programs constitute the largest component of state-level activities and, in the personal health area, 50 ''maternal and child health and operation of institutions are the largest components. The health services listed in Table 14 are those currently being provided, but are they the services which should be provided in the future and in the same relative proportions? With regard to HSA's, their stated purposes are to: "Improve health, increase accessibility, acceptability, continuity, and quality of care, restrain cost increases and prevent unnecessary duplication of health resources" (35). However, with respect to specific activities, other than the planning activities which they are required by law to engage in, i.e. the development of Health Systems Plans and Annual Implementation Plans, there exist no prescriptions for the other public health activities, if any, in which they should engage. On the functions of a local health department, we can again turn to Ingraham, who provides the following general guidance: Whenever a locality is unable to provide services, it is the responsiblity of the state health department to do so. However, certain basic functions should be carried out by local health departments. What follows serves only as an overview of areas that require the health agency's involvement if needs are to be met. - Regulate health facilities - Maintain a healthful environment - Health education - Operation of direct service facilities 51 ''Table 14 Percentage Distributions of SHA Expenditures for All Program Areas and Categories, 1978 Percentage of Program Area Expenditures Percentage of All Program Category in Program Area SHA Expenditures Personal health Tas General and supporting personal health Ltee Maternal and child health 330 Crippled children 7.8 Communicable disease 4.8 Dental health 1.2 Chronic disease 3.9 Mental health and related programs den \ Other personal health 3.0 SHA-operated institutions 28.5 100.02 Environmental health LoS Consumer protection and sanitation 35.0 Water quality 23.5 Air quality 10.0 Waste management 5.5 Occupational health, safety and related areas 4.5 Radiation control 4.8 2 General environmental health 16.2 100.0% Health resources 9.2 Planning 6.6 Development 6.0 Regulation 52.8 Statistics Ties Emergency medical services 15.1 Other 3.8 100.02 Laboratory 4.0 General laboratory 66.1 Clinical 17.8 Environmental 8.8 Laboratory improvement 4.3 Medical examiner 3.0 100.0% General administration and services 6.0 Nonprogram funds to local health departments 1.9 100.0% Source: Association of State and Territorial Health Officials. Comprehensive NPHPRS Report: Services, Expenditures and Programs of State and Territorial Health Agencies Fiscal Year 1978. Silver Spring, MD: ASTHO-NPHPRS Pub. No. 47, January 1980. 52 ''- Control of communicable disease - Detection and control of chronic diseases - Research and evaluation. A much more specific identification of the public health activities in which local departments should engage is found in "a study of public health statutes of the 50 states (which) identified 44 specific services or functions that are assigned to local health departments by all or some of the states" (36). Table 15, reproduced from that study, lists the functions and the entities responsible for each. It should be pointed out that, by examining functions assigned by statute directly to local health departments, the study automatically excluded those functions which are delegated from state health agencies and other state and local agencies as well as those either assigned or delegated to local agencies other than the health department. Thus, impressive as the list may seem, it is a far cry from a complete inventory of public health activities at the local level. D3 ''Table 15 Percentage of “States Specifically Authorizing Various Public Health Services and Designating the Responsible Agency in Public Health Statutes (1976)** Per Cent Per Cent of States of States Fixing Responsibility To: Specifically Service or Function Authorizing Local State State and/or Some Service Health Health Local Other in Public Department Department Health Agency* Health Statutes Exclusively Exclusively Department State/Local Communicable Disease Control 100 10 14 76 -/4 Vital Statistics 100 -/- Promulgate Rules and Regulations 100 2 30 68 -/2 Veneral Disease Control 92 16 8 68 2/2 Quarantines 92 8 10 74 -/- Tuberculosis Control 90 14 30 46 4/2 Water/Stream Pollution Control 88 4 30 36 26/2 Facilities Inspection 84 4 62 18 6/- Facilities Licensure 84 4 70 10 8/2 Laboratory Services 82 - 50 32 =/2 Refuse Disposal 82 14 24 26 16/4 Air Pollution Control 78 2 34 14 28/2 Abate Nuisances/Filth 76 30 4 42 -/2 Health Education 72 10 40 22 -/- Radiological Health 72. 2 64 2 12/- Food Inspection 70 10 32 20 12/2 Mental Health 66 10 14 26 12/6 ‘Prevention of Blindness 66 14 8 42 -/2 Maternal/Child Health 64 12 16 36 =/= Immunizations 64 18 10 36 -/- Occupational Health 60 4 34 22 4/- Care of Indigent 60 20 10 28 2/- Establish Local Hospitals 60 16 14 20 6/14 Qualifications of Local Health Officer 58 16 36 4 2/- Chronic Disease Control 58 6 28 24 10/- Crippled Children 58 2 22 24 6/2 Milk Inspection 58 10 20 18 12/4 _ Health Planning 54 2 40 8 4/- : Housing Inspection 54 10 12 12 8/20 PKU/Metabolic Screening 54 4 26 22 2/2 Alcohol and Addiction Control 52 2 16 24 => Dental Health 50 10 20 18 =f 2 Rabies Control 48 14 12 16 2/- Ambulance Service 42 6 24 8 4/2 School Health 40 24 6 10 =/= Health Personnel Registration 36 2 12 6 6/12 Home Health : 32 10 6 14 =72 Needs and Resource Assessment 32 4 22 4 2/- Nursing Care 28 14 8 4 -/2 Family Planning 26. - 6 18 2/- Extermination Services 26 8 12 4 6/2 Compulsory Hospitalization 24 4 6 14 -/2 Nutrition Program 22 6 6 10 =/= Emergency Medical Service 14 - 4 10 ~/= Insofar as possible the phraseology as it commonly occurs in the statutes is used without attempt to avoid duplication--e.g., communicable disease control, immunizations, and quarantine are all listed if they are separately provided for by law; so, too, are health planning and needs/resource assessment; and ambulance service and emergency medical service. * In many instances the responsibility to other agencies is shared with state/local health departments, indicated when the sum of columns 2-5 exceeds the figure in column l. *k Public Health Statutes for this purpose means those statutes that are indexed or codified under public health in statute books. Source: Miller, C.A. et al. Amer. J. Public Health 67(10): 940-945, 1977. 54 Statutory authorizations for the work of local health departments. ''In fact, it is just such an inventory, namely an inventory of the specifically mandated and designated public health functions of each government level, but regardless of agency, which will provide the data which can establish what the minimum level of program provision must be. ‘To establish that level is the second necessary step in estimating requirements, after determining the population to be served and before determining the role of the public health physician in providing those. programs. With regard to the latter, that is, what the role of the physician who is professionally trained in the public health discipline should be in public health activities, there is a complete lack of either data or guidelines. Atwater observes that: there is a growing need for a careful assessment of the specific functions in the planning and delivery of. community health services which require the special skills of a public health trained physician as opposed to skills requiring medical competence, or those obtainable through other than medical training (37). When one examines the partial listing of the various types of personnel involved in public. and community health in Table 16, areas of overlapping activity and responsibility become apparent. How to resolve the issue?) Atwater seems to have indicated the direction which must be taken in order to be able to resolve the third component in estimating 55 ''Table 16 Common Job Titles in Public & Community Health Administrator Director (of a specific service or program) Health administrator Health care Administrator Health officer Health services administrator Hospital administrator Nursing home administrator Analyst Computer specialist Demographer Epidemiologist Systems analyst Dentist Public health dentist Engineer Air pollution engineer Environmental engineer Product safety engineer Sanitary engineer Waterworks engineer Health Educator Community health educator Public health educator School health educator Hygienist Dental hygienist Industrial hygienist Inspector Food and drug inspector Hospital inspector Milk and food inspector Nursing home inspector Nurse Industrical health nurse Mental health nurse Occupational health nurse Public health nurse School nurse Nutritionist Community nutritionist Public health nutritionist School nutritionist Physician Industrial health physician Occupational health physician Public health physician School health physician Planner Facilities planner Health planner Manpower planner Services planner Program evaluator Laboratory Technician/Technologist Biochemical technologist Food technologist Laboratory technician Microbiology technologist Radiologic technologist Sanitarian Environmental technician Sanitarian Scientist Bacteriologist Biologist Chemist Dairy scientist Ecologist Entomologist Microbiologist Parasitologist Soil scientist Zoologist Social Worker Medical social worker Mental health counselor Public health social worker Psychiatric social worker Statistician Analyst Biometrician Biostatistician Survey statistician Vital statistician Therapist Occupational therapist Physical rehabilitation therapist Physical therapist Speech therapist Vocational rehabilitation therapist Veterinarian Public health veterinarian Source: USDHEW, HRA. A Report on Public and Community Health Personnel. DHEW Pub. No. (HRA) 80-43, April 1980. 56 ''the need for physicians in public health, namely, assessment of the specific functions which only a physician with special training in public health can carry out. Thus, it must be concluded that planning for human resources in public health cannot proceed without this assessment nor without the previously mentioned inventory of the specifically assigned public health functions of each government agency at each level of government. Further research on each of these issues is sorely needed -- not only for public health but for each of the areas of preventive medicine. 57 ''10. Pl, 125 References U.S. Department of Health, Education, and Welfare, Health Resources Administration. Interim Report of the Graduate Medical Education National Advisory Committee. DHEW Publication No. (HRA) 79-633. Washington, D.C., Government Printing Office, April 1979. 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Silver Spring, Maryland: ASTHO-NPHPRS Publication No. 46, January 1980. 60 ''35. 93rd Congress, 2nd Session. National Health Planning and Resources Development Act of 1974. House of Representatives Report, p. 2, No. 93-164. 36. Miller, C.A., B. Gilbert, D.G. Warren, E.F. Brooks, G.H. De Friese, S.C. Jain, and F. Kavaler. Statutory authorizations for the work of local health departments. Amer. J. Public Health 67(10):940-945, 1977. 37. Atwater, J.B. Must local health officers be physicians? Amer. J. Public Health 70(1): 11, 1980. *U S GOVERNMENT PRINTING OFFICE: 1981 727-285/1581 61 '' '' '' '' ''HAS U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES Public Health Service Health Resources Administration DHHS Publication No. (HRA) 81-637 April 1981 ''€0088687784_ ''