PEBLIO £501 LIBRARY ang STATE HEALTH LPN ade) Th 53 REFERENCES The | Supply Of Health Manpower : 1970 PROFILES AND gt PROJECTIONS TO 1990 HEALTH MANPOWER REFERENCES The Supply Of Health Manpower 1970 PROFILES AND PROJECTIONS TO 1990 DHEW PUBLICATION NO. (HRA) 75-38 U. S. DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE Public Health Service + Health Resources Administration (4.5. Bureau of Health Resources Development December 1974 For sale by the Superintendent of Documents, U.S. Government Printing Office Washington, D.C. 20402 - Price $3.00 Stock Number 1741-00081 FOREWORD This report provides descriptive profiles of the current and past supply of health manpower and projections of manpower supply to 1990. It presents detailed descriptions of the methodology and techniques used to derive the profiles and projections, and provides interpretations and evaluations of the adequacy and comparability of existing statistics, with descriptions of the more conspicuous gaps in the current health manpower information system. The health manpower occupations covered are the major health professional categories, including a number of specialties within these categories, and selected groups of allied health professions and occupations. j The report was developed to provide a wide range of users of health manpower statistics with a comprehensive reference compendium of basic information on major health occupations. It was prepared in 1972 and 1973 as part of a major manpower study within the Bureau of Health Resources Development (then the Bureau of Health Manpower Education). This broader effort, termed “Project SOAR” (Supply, Output, and Requirements), was primarily designed to provide baseline supply and requirements information useful to the Federal Government in the development of optional strategies and policies concerning the Nation’s health manpower production and health care delivery systems. The product of the initial phase of this broader effort is presented in the report that follows. This report is a first step and is not considered or offered as the final word in manpower supply analysis and projection methodology. It has many limitations, stemming partly from the lack of an adequate data base, partly from the lack of a fully developed methodology. Despite these limitations, which are made as explicit as possible in the report, the consensus of reviewers both inside and outside the Government was that it represents an advance in the state-of-the-art and the best available single source of manpower supply data, primarily because of the use of iii TAY 10 ws 19274 stated and verifiable methods. 2 S y was deemed of value both to the Nation’s ali Yah community and to all those who are involvéd in ‘making decisions that affect the future supply of health manpower. The work reported herein was initiated in the Division of Manpower Intelligence, which was a component of the Bureau of Health Resources Development until March 1, 1974, when it was dissolved in conjunction with reorganiza- tion of the Bureau. The report was prepared under the direction of Howard V. Stambler, Assistant Director of DMI for Manpower and Program Analysis. Paul Schwab, head of the Occupational Analysis Section of DMI, coordi- nated and supervised the preparation of the report. Other professional staff of the fection io SORTHise) were: Mary C. McGuire, Stuart Bernstein, Pamela C. Roddy, Robert M. Politzer, Alan H. Simmons, Robert C. Hambleton, James S. Morrow, James M. Cultice, Barbara Deroba, Alice W. Walton, Stephen Cohen, Michael Addis, and Joanne Panza. Sections of the report were also prepared by James N. Ake and Jerald B. McClendon of the Bureau's Division of Dental Health, Dr. Merrill Packer, Acting Director; and Helen H. Hudson of the Division of Nursing, Jessie M. Scott, Director. Special thanks go to Grace T. Snyder, Robin A. Imber, Ruth E. Kent, and Tilman W. Steen, who typed and retyped the report in its various draft stages; to Anna E. Gatling, who assembled the report for final copy; and to Harold J. King, who undertook data processing activities related to development of the report. INTRODUCTION In 1972, the then Bureau of Health Manpower Educa- tion (BHME) asked its Division of Manpower Intelligence (DMI) to assume primary responsibility for providing information and analyses that could be used in developing alternative strategies for the education of health manpower. This overall effort, termed Project SOAR (Supply, Output, and Requirements), was designed as a multiphased system- atic analysis of the Nation’s health manpower situation today and as it might be in the years ahead, under clearly specified assumptions. The effort was timed so that its results could be used as an analytic input for deliberations likely to be engendered by the expiration in June 1974 of several major health manpower legislative authorizations. Thus SOAR was viewed as an integrating and synthesizing analysis, with primary reliance placed on ‘best use’ of available data and knowledge, supplemented with short- term new analyses that could be accomplished within the time-frame established. The design of the overall SOAR effort reflects a sequential logic in which outputs of early phases are to be utilized in later stages, but study activities for all phases can be undertaken concurrently. This structure, in addition, allows the development of “free-standing” reports of studies completed during the overall process, so that data and analytic outputs can be used for a variety of purposes apart from the SOAR effort itself. Consequently, the report that follows, although representing the output of the first phase of Project SOAR, has been developed as an indepen- dent document for wider distribution. During the prelimi- nary stages in developing this supply report, a number of reviewers in both the public and private sectors encouraged publication of the material to a wide audience of potential users. Their interest focused largely on providing to health manpower planners and analysts the following analysis of the past and current manpower scene, the projections of manpower supply, the assumptions underlying the projec- tions, and detailed description of methodology used, including the inherent limitations of the techniques and their corresponding implications. The Bureau of Health Resources Development (BHRD) has incorporated the SOAR activities into its ongoing work program. The manpower information and supply projec- tions presented in this report are to be revised and updated periodically as new data and research results become available and as new developments emerge on the national health scene. Furthermore, the analytical efforts that served as the basis for this report highlighted significant informa- tion gaps in available data and existing knowledge, thereby providing valuable insights concerning longer-range data collection, analysis, and research efforts that might be needed to better understand the dynamics of health manpower and to improve future estimates of manpower supply. Major efforts are now under way within the Health Resources Administration (HRA) and other parts of the Department of Health, Education, and Welfare (DHEW) to. improve the data base and to utilize new and more sophisticated analytical and other techniques for projection purposes. It is expected that these efforts, coupled with the continuing flow of research results from a number of current studies, will provide the means of filling some of the glaring gaps in the existing information system that are highlighted in this document. In order that the reader may understand and utilize more effectively the findings of this report, a discussion of the various phases of the SOAR effort seems in order. The first two phases of the project involved the development of a series of baseline supply projections of health manpower to 1990, which are presented in this report, and baseline requirements forecasts, which are being planned for sepa- rate publication. These efforts were aimed at providing estimates of future supply and requirements conditions given present experience, the continuation of experiences of recent years, and any future changes already known. Thus, they represent relatively straightforward “if-then” statements, resulting in a heuristic profile of the future rather than an actual prediction of a most likely situation. The first two phases, therefore, represent initial efforts to provide decisionmakers and planners with rationally derived data for formulating policy decisions, legislative proposals, and program options, and to improve the state-of-the-art and methodology of manpower analysis and data. The third phase, called the contingency phase, consists of forecasts of health manpower requirements based on the assumed effects of a number of major new health care developments on future manpower utilization and produc- tivity—those developments that represent significant depar- tures from historical trends. In this phase—also now nearing completion—several analytic studies have been undertaken as part of BHRD’s extramural program to examine the potential derivative impact on manpower requirements of a variety of possible developments in the health service sector, such as changes in health care financing (e.g. national health insurance) and in patterns of health care delivery organization (e.g., spread of health maintenance organizations), as well as the expanded use of task delegation and the possible future impact of technological advances. The end product of this phase will be a broad “fan” of alternative requirements forecasts, built upon adjustments of the earlier baseline requirements projections and clearly reflecting defined assumptions about the poten- tial interactive impact of various combinations of the major developments under study. In logical progression, the fourth phase of SOAR consists of an analysis of the comparability of supply and requirements profiles developed earlier. The end product will be a “fan” of supply projections built upon adjustments in the Phase | baseline projections, which reflects potential supply responses under clearly defined sets of assumptions about the demand for health manpower (Phase 111 output) and other major supply influences; e.g., size and character- istics of foreign medical graduate additions to physician supply. Specific emphasis will be given to apparent disjunc- tions in supply and requirements, particularly those that might indicate a manpower oversupply, in order to facilitate the formulation of goals with respect to the manpower production system. It should be emphasized here that the supply and requirements estimates developed and examined will not comprise a single set of figures but rather will include a broad range of alternatives. Disjunc- tions among all combinations of projections are being studied. The last two phases of Project SOAR are concerned first with defining the specific kinds of manpower production goals that might be suggested by the profile matching of adjusted baseline supply projections with the requirements forecasts and, second, with delineating a number of issues, such as the financial viability of medical schools and physician specialty and geographic maldistribution, which do not stem directly from goal definition but rather emanate from other viewpoints and analyses of the health care production system. Education and training system goals (in terms of manpower output, type, and quantity) will then be formulated by examining and evaluating disjunctions in the supply and requirements profiles. Goals will be defined so as to minimize risks of overproduction (particularly in long-lead time and costly production categories) and of shortages in critical service delivery functions. This discussion of the overall Project SOAR effort should serve to illustrate two key points to the reader: 1. This report represents the output of the first baseline phase of a complex, interactive set of analytic activities, and 2. The nature of the report reflects the particular emphasis and direction utilized to meet the information needs of that phase. It is also important to note here that the projections presented in the following chapters are in no manner to be viewed by the reader as “official” DHEW, HRA, or BHRD estimates. The projections developed for health manpower supply, as explained later in more detail, are based largely on one critical assumption regarding the future productive vi capacity of educational institutions to attract and subse- quently graduate students. Simply stated, this assumption is that the health manpower production system will receive such future support, whether from Federal or other sources, as is needed to maintain and operate the produc- tion system at its 1974-75 output capacity level as a minimum. Consequently, the “reality” of these supply projections for the coming years must be viewed in the context of the actual political and financial setting existing at that time. Such a caveat, obviously, holds true in general terms for any assumptions advanced for these or any other set of projections. As approaches, objectives, and assump- tions change to meet different purposes, so do the resulting projections. It is also true that for different policy purposes, different projections would be required. Thus, it is inappropriate to use or to view the projections in this report as “official” estimates of any kind. The text of the report treats in detail the conceptual framework and the assumptions and projection methodol- ogies utilized, in terms of both their strengths and their limitations. It is important, however, to identify and summarize here a few of the more salient parameters of the report which are indicated or implied above. 1. The 1970 data base utilized is neither comprehensive nor uniform. While the report does contain some new data and analyses not previously presented, it largely represents reassessment and analysis of available data, using as consistent a set of data standards as possible. Where available, more current data are presented in the report. 2. Beyond attempting to use comparable and consistent methodologies, the projections presented are based on the key assumption mentioned earlier: that no additional Federal financial support beyond that authorized by legislation in force through fiscal year 1974 would be available for increasing the output capacity of the health manpower system. That is, the projections assume no further direct Federal support for construction or other financial inducements to increase the enrollment capacity of the Nation's health education and training institutions beyond those efforts already programmed. A corollary im- plicit assumption is that the health manpower production system will receive future support from the Federal Government or other sources, that will be required to maintain and operate the system at its output capacity. 3. Even within the basic assumption specified in 2. above, several alternative assumptions are possible with respect to production system operations and output capacity. Where appropriate, these assump- tions are made as explicit as possible and alternative projections are made when feasible. 4. As a part of the baseline concept, the report is not concerned with changes in projected supply that might be forecast as a result of possible major future changes in manpower demand. Nor does it consider changes in the nature and magnitude of health manpower production system outputs that might be brought about by future Federal involvements ad- dressed to specific problems and issues; e.g., specialty distribution output. In effect, then, the projections— not predictions—are intended to indicate what the likely future supply would be if the health manpower system, particularly the production system, continues to operate in the general direction in which it now appears to be headed. Subsequent efforts (not pre- sented in this report) will be focused on changes in the supply projections which might be forecast as the result of changed demand factors and possible changes in the Federal involvement in the manpower production system. The following chapters are divided into two main parts. The first part provides an overview of the concepts, methodology, and assumptions underlying the estimates and projections. It also presents summary highlights of the vii study in both tabular and narrative form. The second part presents detailed statistical material on the current man- power profile and projected supply in specific health fields. These two parts are followed by appendixes which include detailed projection tables presenting information on an individual year basis, as well as other relevant information not shown separately in individual chapters. It should be noted that the detail of narratives presented in various sections of this report represents an explicit effort to outline fully the assumptions and methodologies used in developing the projections. In addition, an attempt has been made to provide readers with meaningful background information in order to enhance their understanding of the projections. As noted in the Foreword, the various chapters of the report were prepared by different groups of specialists. Moreover, since it is believed that individual chapters will be consulted by different groups of readers, it is necessary to repeat explanations of basic assumptions and methodol- ogy as applied in projections for each field. Both of these facts serve to explain apparent duplications of material within the chapters that follow. CONTENTS Page FOREWORD « + + 4% « « so 9 # + + + vn #5 5,8 6 5 + 5 = xa 2 8 6 0 2+ + 4 & 3 8 % % 0 4 3 iii INTRODUCTION oo ot oe ee ee ee ee ee ee eee ee ee eee ee eee v PART | — AN OVERVIEW Chapter 1 — CONCEPTS, DEFINITIONS, ASSUMPTIONS, AND METHODOLOGY . . . . . . . . . . . .. 3 Occupational COVErage . . . . . + + + vv «oo ve eee ee ee eee eee 3 Problems of Comparability . . . . . . «o.oo. eee ee 4 Projection Assumptions and Methodology . . . . . . . «o.oo eee eee 5 Chapter 2 — PROJECTIONS OF HEALTH MANPOWER — ASUMMARY . . . . «vv he ee eee 13 Supply of Health Professions. . . . . . . . «oo. 13 Supply of Allied Health Personnel. . . . . . . . . «coo 20 PART Il — DETAILED OCCUPATIONAL PROFILES Chapter 3 — PHYSICIANS . . . LL. Li hth tt er se es esse 25 Current Characteristicsand Trends . . . . . . . «+ ov + tv vb ee ee ee ee eee 25 Projections of the Supply of Physicians to 1990 . . . . . . . . «oo cee ee 38 Chapter 4 — MEDICAL SPECIALISTS (MDS) vv eee ee ee ee ee ee ee eee eee 57 Current Characteristicsand Trends . . . . . . « « «vv tv tt ee eee eee eee ee 57 Projections of the Supply of M.D.’s by Specialty to 1990. . . . . . . . . . . . . . . .. .. 63 Chapter 5 — DENTISTS . . © « « « «cv vss vt ts ess vss tats ss stv ox vss ww 77 Current Characteristicsand Trends . . . . « + + vv «tt vv vt ee ee ee ee ee ee 78 Projections of the Supply of Dentists to 1990 . . . . . . . . «ooo 79 Chapter 6 — OPTOMETRISTS . . . . . . . «oc ih bite t eee eee es 85 Current Characteristicsand Trends . . . . + « + «+ tv tv tt ee eee eee ee eee 85 Projections of the Supply of Optometrists to 1990 . . . . . . . . . . . . «cc ov vee 88 Chapter 7 — PHARMACISTS . . . . . . «tt ttt tee esse eee eee anne es 93 Current Characteristics and Trends . . . . . . « «© «ot vb eee eee ee ee eee 93 Projections of the Supply of Pharmacists to 1990 . . . . . . . . . . o.oo oo. 94 Chapter 8 — PODIATRISTS . . . . . «tt ht tt ttt betes sts ss ese ses een 103 Current Characteristics and Trends . . . . . « « « «+ «ov vb 0 ee eee eee ee ee 103 Projections of the Supply of Podiatrists to 1990 . . . . . . . . . «ooo eee 107 Chapter 9 — VETERINARIANS . . . . . .. Hea eam maa tia es a Ete 111 Current Characteristicsand Trends . . . . . . . « «© «tv ve he eee ee ee eee 111 Projections of the Supply of Veterians to 1990 . . . . . . . . . «o.oo ee 116 Chapter 10 — REGISTEREDNURSES . . . . . . . . oo vv vv vive eee ee 121 Current Characteristics and Trends . . . . . « «+ © ov vt te ee eee ee eee eee 121 Projections of the Supply of Registered Nurses to 1990 . . . . . . . . . . . . . 122 AddEnOUTT . + + + « 4 ov a oo 5» % » + + a Ip EE Ww x x a ae aw ows we aE we 130 Chapter 11 — APPENDICES A. C. D. CONTENTS (continued) ALLIED HEALTH OCCUPATIONS © . . . ©. ee ee eee, Conceptual and Statistical Concerns. . . . . . . . . Lo... Current Characteristicsand Trends . . . . . . . . . . . . . ee Projections of the Supply of Allied Health Personnel to 1990 . . . . . . . . . . . . . . .... Derivation of Separation Estimates in Supply Projection Methodology . . . . . . . . . . . . .. Overview . . LL LL ee ee ee Adjustment Io Death Ra1BS , . . + 4 ov oa oo % 2 + * © & dh 5 2 9 + 5 5 +59 » « vu Adjustment of Retirement Rates . . . . . . . . . . . . . Development of Adjusted Separation Rates . . . . . . . . . . . . . Limitations of the Approach . . . . . . . . . Detaled Tables + ov = vs st 0+ + 5 4 5.6» 8 5 5 SEH BH b+ 2 tw menos Updated Tables . . . . . . . . . . Bibliography . . . . LL GOMEIAl uw 5 wv ms a 24 HH EEE Rm ee vr EA Ett REY ow He re. Medicine . . & + « «+ + oo «wv v5 Mae ow om EN tm Md EE EE WY Eos EE Dentistry . . . LL. ee ee Optometry . . . LL LL ee ee ee PHARINACY & « 4 o 5 + 5 6 5 6.5 ¥ 5 1 5 0 2 0 9 4 # 2. 5 2 9 9 2 4s mw now we Podiatry . . . . LLL ee ee Veterinary Medicine . . . . . . LL. LL ee ee ee ee Nursing © LL LL ee ANCA HEIN + . 4 5s wens be EEE Eee ne re see EE ae Page 133 133 135 139 155 155 155 156 158 158 159 TEXT TABLES Table number — — CONCEPTS — - 1: Alternative projections of U.S. population: July 1,1975-90 . . . . . . . . . . «o.oo oo 2 Projections of the resident population of geographic regions, divisions, and States: July 1, 197590 . . . + + « — — SUMMARY — -— 3. Supply of active health professions: December 31,1970 . . . . . . . . . «o.oo Supply of total allied health manpower, by occupation: December 31,1970 . . . . . . . . . . . . . . .. 5. Supply of all active health professionals, using basic methodology: actual 1960 and 1970; projected 1980 and TOD 4 © « & & & ® 5 8 8 £ * % ® 2 ow ow wow ove sha hE EE WE ME EAE EEK Wyo Supply of active physicians (M.D.), by major specialty group: actual 1963 and 1970; projected 1975-90 Alternative projections of the supply of active physicians (M.D. and D.O.) in the United States: 1990 . . . . . 8. Supply of active formally trained selected allied health personnel: 1970 and projected 1975-90 . . . . . . . . > > — — PHYSICIANS — — . Number ofactive physicians (M.D. and D.O.), by age group and sex: December 31,1970 . . . . . . . . .. 10. Number of active physicians (M.D. and D.O.) and physician/population ratios, by geographic region, division, and State: December 31,1970 . . . . . «LL he eee ee eee eee ee ee ee ee 11. Number of active physicians (M.D. and D.0.), by major professional activity: December 31,1970 ~~. . . . . . 12. Trend in number of active physicians (M.D. and D.O.) and physician/population ratios: selected years, December BI1950:72 © 2 i a 5 5 + + «8 % © % % % 6 4 + +x ew rw www me haw EE WA 13. Trend in number of schools, enrollments, and graduates for medical and osteopathic schools: academic years 1960-61 through 1971-72 . . . © ©. «© © i i eh eh eee eee eee eee ee ee ee 14. Trend in supply of total physicians (M.D. and D.O.) in the United States, by country of graduation: selected years, December 31, 1959-72. . . . LL... aoe eee eee eee 15. Number of foreign-trained physicians (M.D.) in the United States, by geographic region of graduation: December FLAGI0 «+ + si soa own EE moa wr 4% ww wm ww oe we hoa wk wwe EEN WE a0 d 16. Percent distribution of foreign-trained physicians M. D.) in the United States for selected countries of graduation: 1967 ANA T9097 . . vt x 4 uo x vb home EEE aE wm ee Fs kere wae eee 17. Number of physicians (M.D.) in the United States, by age group and country of graduation: December 31, 1970 18. Number of active physicians (M.D.), by major professional wiiy and country of graduation: December 31, 3 Ir Zo EE OO 19. Number of physicians (M.D.), by location and country of eration: December 31,1970 . . . . . . . . . . 20. Projected annual number of graduates of medical schools in the United States under proposed accelerated programs compared with number of graduates in conventional programs: academic years 1970-71 through | TOBOOO © vw vw sn 4 5 ts 2 ts tw om ow wm EEE EA Ea ERNE BEETS EAE wy 21. First-year enrollments and graduates in medical schools in the United States under basic and alternative assumptions: actual 1970-71 and projected 1971-72 through 1989-90 . . . . . . . . . . . . . . . . .. 22. First-year enrollments and graduates in osteopathic schools under basic and alternative assumptions: actual 1970-71 and projected 1971-72 through 1989-90 . . . . . . . . . . . . «oo oe 23. First-year medical students, bachelor’s degrees, and 22-year olds: selected years, actual 1960-61 through 1972-73; projected 1974-75 through 1980-81 . . . . . . . . . « «LLL ee 24. Supply of active physicians (U.S. trained M.D. and D.0.) and physician/population ratios, ‘using basic methodology and alternative assumptions: actual 1960 and 1970; projected 1975-90 . = + + + + w % = = ‘ee fi X 25. Supply of active physicians (U.S. trained M.D. and D. 0.), using basic methodology and alternative assumptions: actual 1960 and 1970; projected 1975-90 . . . . . . . Lo eee eee ee ee Page 15 17 20 21 26 28 30 31) 32 33 33 34 35 36 37 41 42 45 26. 27. 28. 29. 30. 31. 32, 33, 34, 3s. 36. 37. 38. 39. 40. 40a. 40b. 41. 42. 43. 45. 46. 47. 48. 49. TEXT TABLES (Continued) — — PHYSICIANS — — (Continued) Physicians admitted to the United States, by immigration classification: fiscal years 1968-72 . . . . . . . . . Supply of active foreign trained physicians, using basic methodology and alternative assumptions: actual 1970; projected 1975-90 . . . LL LL LLL ] Supply of active physicians (M.D. and D.0O.) and physician/population ratios, using basic methodology and alternative assumptions: actual 1960 and 1970; projected 1975-90 . . . . . . . . . . . — — MEDICAL SPECIALISTS — — Percent distribution of active physicians (M.D.) and of first-year residents, by specialty and country of graduation from medical school: 1970 . . . . . . LL. LLL Trend data on number of active physicians (M.D.) by specialty: December 31 1963-72 . . . . Changes in the supply of active physicians (M.D.), by specialty: selected years 1963-90 . . . . . . . . . . Trend in first-year residents, by specialty: selected years September 1, 1960-71 . . . . . . . . . . . . .. Trend in total residents and of FMG residents, by specialty: Septenber 1, 1960, 1965, and 1971 Number of active physicians (M.D.) engaged in primary care: actual 1963 and 1970; projected 1980 and 1990 Supply of active physicians (M.D.), by specialty: actual 1970; projected 1980 and 1990 . . . . . . . Supply of active foreign trained physicians (M.D.), by specialty: actual 1970; projected 1980 and 1990 Supply of active United States and Canadian trained physicians (M.D.), by specialty: actual 1970; projected 1980 and 1990. LLL LL Ratios of active physicians (M.D.) to population, by specialty and country of graduation: actual 1970; projected 1980 and 1990 . . LL LLL Comparison of two alternative specialty projections of physicians (M.D. ) with the basic methodology projections: 19803Nd 1990" vx x + 4 2 1B BEB EE ER eh Ee EY EE EES rR. Ee Percent distribution of two alternative specialty projections of physicians (M.D.) with the basic methodology projections: 1980and 1990 . . . . . . . LL... Ce Supply of active physicians (M.D.), by specialty: actual 1970; projected 1980 and 1990 . . . . . . . . . . . Comparison of two alternative specialty projections of physicians (M.D.) with the basic methodology projections: 1980and 1990 ©. . LL LLL — — DENI — — Number of active dentists, by sex and by age group: December 31,1970 . . . . . . . . . . . . . . . .. Number of active civilian dentists, by major professional activity: December 2 IL 4 TS Trend in number of active dentists and dentist/population ratios: selected years, December 31, 1950-71 Number of active civilian dentists and dentist/population ratios, by geographic region, division, and State: December3l, 1920) & « «0 2 # 56 5 4 + 45 5 2 5 uv 9s rrr rw EE. rr... Eo Number of active dentists, by type of practice: December 31,1970 . . . . . . . . . «oo... Trend in number of active dental specialists, by specialty: 1952-71 . . . . . . . . . . . . . . . . . ... Trend in number of schools, enrollments, and graduates for dental schools: academic years 1960-61 through a Se First-year enrollments and graduates in dental schools using basic methodology: actual 1970-71 and projected 1971-72 through 1989- D0 vbr sh Ch mss EE EE REN aa sa mee wre sek ww xii Page 58 60 62 65 67 68 69 70 71 73 74 75 76 78 78 79 80 82 82 83 xR 50. 51, 52. 53. 54. 55. 56. 57. 58. 39. 60. 61. 62. 63. 65. 66. 67. 68. 69. 70. 7: 72. 73. 74. TEXT TABLES (Continued) — — OPTOMETRISTS — — Number of active optometrists, by sex and by age group: December 31,1970 . . . . . . . . . . . Number of active optometrists and optometrist/population ratios, by geographic division and State: Oecemiser 31, £71 EE EE EE EE EE EE EE EE Er ET EEE EE EE IE Number of active optometrists, by major professional activity: December 31,1970 . . . . . . . . . . . .. Number of active optometrists by type of practice: December 31,1970 . . . . . . . . . . . . . . . .. Trend in number of active optometrists and optometrist/population ratios: selected years 1930-70 . . . . . . Trend in number of schools, enrollments, and graduates for optometry schools: academic years 1960-61 through 1971-72 0 oo ee ee ee ee ee ee ee ee ee ee ee ee ee ee eee First-year enrollments and graduates in optometry schools under basic and alternative assumptions: actual 1970-71 and 1971-72; projected 1972-73 through 1989-90 . . . . . . . . . . . . « «oo «oo Supply of active optometrists and optometrist/population ratios, using basic methodology and alternative assumptions: actual 1960 and 1970; projected 1975-90 vt kk ww hw lm ok EWR TT EE — — PHARMACISTS — -— Number of active pharmacists, by age group and sex: December 31,1970 . . . . . . . . . . . . . . . .. Number of active pharmacists and pharmacist/population ratios, by geographic division and State: December 31, i i; + J EE EEE EE EE EE EE EE EEE EET EY Number of active pharmacists, by type of employer: December 31,1970 . . . . . . . . . . . . . . . .. Trend in number of active pharmacists and pharmacist/population ratios: selected years 1900-71 : Trend in number of schools, enrollments, and graduates for pharmacy schools: academic years 196041 dioudh 1.2 brs Mp 1 1 I ER EVE TEER ol RE EE ER Third-to-last year enrollments and graduates in pharmacy schools under basic and alternative assumptions: actual 1970-71 and 1971-72; projected 1972-73 through 1989-90 . . . . . . . . . . «oo «0 Supply of active pharmacists and pharmacist/population ratios, using basic methodology and alternative assumptions: actual 1960 and 1970; projected 197590 . . . . . . . . . . «oe Supply of active pharmacists and full-time equivalents, by sex, using basic methodology: actual 1970 and projected 1975-90 . . . LL. LL Lh ee ee ee eee ee ee ee ee eee eee Supply of active pharmacists, by sex, using basic methodology and alternative assumptions: actual 1960 and 1970; projected 1975-90 . . . . LL LL Loo eee eee eee ee ee eee Number of active podiatrists, by sex and by age group: December 31,1970 . . . . . . . . . . . . . . .. Number of active podiatrists and podiatrist/population ratios, by geographic division and State: December 31, 1970 . . . . . . . .. ee ee eee ee eee eee eee eee Number of active podiatrists, by major professional activity: December 31,1970 . . . . . . . . . . . . . . Number of active podiatrists, by type of practice: December 31,1970 . . . . . . . . . . . . . . . . .. Trend in number of active podiatrists and podiatrist/population ratios: selected years 1950-70 . . . . . . . . Trend in number of schools, enrollments, and graduates for podiatry schools: academic years 1960-61 through 1971-72 oe eh ee eee eee ee ee ee ee ee eee eee eee ee ee eee es First-year enrollments and graduates in podiatry schools under basic and alternative assumptions: actual 1970-71 and 1971-72; projected 1972-73 through 1989-90 . . . . . . . . . . . «0 oo oe Supply of active podiatrists and podiatrist/population ratios, using basic methodology and alternative assumptions: actual 1960 and 1970; projected 1975-90 . . . . . . . «o.oo xiii 86 87 89 89 89 90 91 92 94 95 97 98 99 100 101 102 102 103 104 106 106 106 107 108 75. 76. 27. 78. 29, 80. 81. 82. 83. 84. 85. 86. 87. 88. 89. 90. 91. 92, 93. 94. 95. 96. 97. 98. 99. 100. TEXT TABLES (Continued) — — VETERINARIANS — — Page Number of active veterinarians, by sex and by age group: December 31,1970 . . . . . . . . . . .. . .. 112 Number of active veterinarians and veterinarian/population ratios, by geographic division and State: December 31, 1970 . . . .. EES EEE SEE Aw he wom mts tes 113 Number of active veterinarians, by major professional activity: December 31,1970 . . . . . . . . . . . .. 114 Trend in number of active veterinarians and veterinarian/population ratios: selected years 1930-70 . . . . . . 115 Trend in number of schools, enrollments, and graduates for veterinary schools: academic years 1960-61 through Lt 116 First-year enrollments and graduates in veterinary schools under basic and alternative assumptions: actual 1970-71 and 1971-72; projected 1972-73 through 1989-90 . . . . . . . . . . . . . . . 118 Supply of active veterinarians and veterinarian/popualtion ratios, using basic methodology an alternative assumptions: actual 1960 and 1970; projected 197590 . . . . . . . . . . . 119 — — REGISTERED NURSES — — Percent distribution of active registered nurses by sex and by age group: 1966 . . . . . . .. . .. .... 122 Number of employed registered nurses and nurse/population ratios, by geographic division and State: 1966 : » 323 Number of active registered nurses, by field of employment: December B,T970° 4 vo st 5 5. 26 56 2 0 6 2 = a 124 Trend in number of active registered nurses and nurse/popualtion ratios: selected years December 31, 1953-72 . 125 Trend in number of programs, enrollments, admissions, and graduates for registered nursing schools: academic years 1960-61 through 1972-73... . LLL 126 Admissions and graduates in schools of nursing under basic and alternative assumptions: actual 1970-71 and 1971-72; projected 1972-73 through 1989-90 . . . . . . . . . . . . 128 Trend in number of active full- and part-time registered nurses: selected years December 31, 1955-72 . . . . . 129 Supply of active registered nurses and nurse/population ratios, using basic methodology and alternative assumptions: actual 1960 and 1970; projected 1975-90 . . . . . . . . . . . . . 129 Supply of active full- and part-time registered nurses, using basic methodology: actual 1970-72 and projected PFZBO0 «vo vs vs he ht EEE Ee re rE EEE Ss EE... 130 — — ALLIEDHEALTH OCCUPATIONS — — Number of States requiring licensing for allied health occupations: 1971-72. . . . . . . . . . .. .... 134 Estimated supply of active allied health manpower: 1970 . . . . . . . . . . . . . . . .. 136 Supply of active formally trained selected allied health personnel and percent change: 1970; projected 1980 and J 143 Additions and losses to the supply of active formally-trained dietitians: 1970 and projected 197590 . . . . . 144 Additions and losses to the supply of active formally-trained medical record administrators: 1970 and projected 197590 . .. . .. “ae woe ew ow WE HH SBR EE hae ome wees ee woe a 144 Additions and losses to the supply of active formally-trained medical technologists: 1970 and projected 1975-90 145 Additions and losses to the supply of active formally-trained occupational therapists: 1970 and projected 197590 145 Additions and losses to the supply of active formally-trained physical therapists: 1970 and projected 1975-90 . 146 Additions and losses to the supply of active formally-trained speech pathologists and audiologists: 1970 and projected 1975-90. . . LL. LLL . 146 Additions and losses to the supply of active formally-trained certified laboratory assistants: 1970 and projected 197590 . . . LL. xiv 101. 102. 103. 104. 105. 106. 107. 108. 109. TEXT TABLES (Continued) — — ALLIED HEALTH OCCUPATIONS — — (Continued) Additions and losses to the supply of active formally-trained cytotechnologists: 1970 and projected 1975-90 Additions and losses to the supply of active formally-trained dental assistants: 1970 and projected 1975-90 Additions and losses to the supply of active formally-trained dental hygienists: 1970 and projected 1975-90 Additions and losses to the supply of active formally-trained dental laboratory technicians: 1970 and projected VOTZ-B0 4 «ho ww wow ow WEES RES FN EEE EE NM 4 TE EE MEE EYES EY Additions and losses to the supply of active formally-trained licensed practical nurses: 1970 and projected 1975:00 uo 2 + 5 5 9 % © w 5 % #5» 0 5 2 wows 2 sss ww dd ES BEER REE FEW Additions and losses to the supply of active formally-trained respiratory therapists: 1970 and projected 1975-90 Additions and losses to the supply of active formally-trained medical record technicians: 1970 and projected i 1 70 o JE VEE a EE EE EE EE EE EE Additions and losses to the supply of active formally-trained occupational therapy assistants: 1970 and projected 1975-90 LL ee ee ee ee eee ee ee ee ee ee eee vow Additions and losses to the supply of active formally-trained radiologic technologists: 1970 and projected (172% a EE EE EE EE EE EE EE EE ET EY Ce ee Page 147 148 148 149 149 149 150 150 . 151 .“ Ed PART I AN OVERVIEW a. Chapter 1 « CONCEPTS, DEFINITIONS, ASSUMPTIONS, AND METHODOLOGY Over the years, statistics on health manpower have been collected by a number of different organizations for a variety of purposes. Yet no comprehensive and comparable data system on all types of health manpower has been developed. As a consequence, differences in definitions, coverage, timing, and data collection methods have given rise to numerous problems of noncomparability among the statistics. The discussion of the estimates of manpower supply presented in this report—current, historical, and projected—describe not only some of the comparability problems but also the essential weakness of much of the data. In recognition of these problems, an effort has been undertaken here to minimize the more glaring inconsist- encies among the estimates of current supply, such as the absence of common reference periods, and to provide a more consistent and manageable framework for analysis. This chapter describes in general terms the conceptual framework of the statistics presented in this report and explains the guidelines developed to obtain improved consistency in the estimates, including the rationale under- lying the definitions, concepts, and techniques used. Also discussed are a number of comparability problems which still remain and their significance in any evaluation of the data. The remainder of the chapter is concerned with a general description of the assumptions underlying the projections and the methodologies used to develop the projections. More detailed descriptions of these considera- tions are provided in subsequent chapters of the report that deal with specific health manpower fields. OCCUPATIONAL COVERAGE The information on health manpower presented in this report is for the most part limited to those health professions and occupations for which the Bureau of Health Resources Development (BHRD) has legislative responsibil- ities. The report is not designed to provide manpower supply estimates and projections for all personnel engaged in the health care delivery system. Manpower groups covered include health professions—physicians (M.D.’s and D.O.’s), dentists, optometrists, pharmacists, podiatrists, veterinarians, and registered nurses—and a selected number of allied health professions and occupations. Estimates of the supply of occupational categories in public or community health manpower are not provided in this report. The field of public health is relatively unstructured, consisting of varying groups of professionals and other workers organized around specific problems. Thus separate estimates are not generally available of the number of persons in a specific discipline who work in community health. The reader, however, will find in Appendix C recent supply estimates for selected categories of public and community health personnel. As this docu- ment was being prepared, a report of the Task Force on Professional Health Manpower for Community Health Programs’ was in process. The Task Force estimated the total number of professionals with master’s level or higher training in 11 occupational categories of community health at about 19,700 in 1970. The supply estimates presented in this document cover only “active workers”; i.e., those persons who are actively working in the health fields. In this respect, some of the data may differ from other published figures. It should be recognized too that these estimates have been obtained from a variety of sources and consequently the definition of “active” may vary by source. For an illustration of this situation, the reader is referred to the discussion in Chapter 3 of recent statistics available on “active” physicians. In fact, many of the sources do not even define what is meant by “active,” often leaving it up to individual survey respondents to designate whether they are active or not. In addition, the estimates include a number of persons who are working in a health occupation but may not be providing health services on a full-time basis. No attempt has been made to provide figures on the “potential” pool of workers, either current or projected, since inactive health manpower are not providing services related to the delivery of health care. It is important to note, however, that in some fields (such as nursing) there is a large pool of inactive trained workers who might be attracted back into active status under certain conditions. The supply estimates of active workers cover both Federal and non-Federal personnel. The former category includes the Armed Forces, where data are available. For the health professions, current supply information is generally shown separately for the number active in each of these components. The projections of total supply, however, do not provide such separate estimates. ! Task Force on Professional Health Manpower for Community Health Programs. (Thomas H. Hall, Coordinator.) Professional Health Manpower for Community Health Programs, 1973. Chapel Hill, N.C.: University of North Carolina, School of Public Health, Department of Health Administration, 1973. Analysis of health manpower resources in individual occupations is often limited by the absence of common- time reference periods in the data. However, to provide a more consistent framework for analysis and in line with a general and growing interest among statistical agencies in comparability and uniformity of reporting, all current (and projected) manpower supply figures presented in this report utilize a December 31, 1970 base. Supply estimates provided here thus may differ in some instances from published data found in other sources. For example, 1970 estimates (December 31) shown here for active registered nurses are presented as 1971 estimates (January 1) in a number of other publications. Furthermore, published 1970 estimates for certain occupations, such as dentists, have often been reported as of July 1; new estimates for these occupations have been developed on a December 31 basis. The fact that December 31, 1970 was utilized as the base year for the development of this volume does not mean that more recent manpower statistics are unavailable for some occupations. To the contrary, as in the case of M.D.’s, later manpower supply figures have been published. An effort has been made within individual chapters of this report to update selected trend tables where appropriate, and Appendix C presents additional updated figures. PROBLEMS OF COMPARABILITY The guidelines noted above provide the basic approach used to facilitate interoccupational comparisons. Other comparability problems also exist with respect to current and historical data. A number of these problems are described below. SOURCES OF SUPPLY DATA As indicated earlier, information on health manpower supply has been collected or estimated by a wide variety of groups, such as professional associations, other private organizations and institutions, and public agencies. This report utilizes the best available information on health manpower, from whatever source. The resulting data thus represent a rather heterogeneous assortment of survey findings, actual counts, and estimates based on professional judgment. In view of this heterogeneity, efforts are made in this report to indicate clearly the sources and derivation of the figures presented. Nonetheless, the presentation of current and projected manpower profiles based largely on secondary data sources in part reflects those limitations generally characteristic of such data. GEOGRAPHIC COVERAGE The geographic coverage of various series of health manpower data is by no means consistent. The lack of uniformity reflects, in part, limitations in the availability of data as well as program and historical considerations underlying the preparation of the estimates. In general, manpower supply information shown here for M.D.’s (including medical specialists), pharmacists, and veterinar- ians covers the 50 States, the District of Columbia, Puerto Rico, and the outlying territories. Data presented for other health professions cover only the 50 States and the District of Columbia.? This lack of uniform geographic coverage poses some problems in developing common reference points for comparative purposes. But, given the magnitudes of the supply estimates, the slight variations in geographic cover- age are believed to represent more of a conceptual than a practical limitation for analysis. Nevertheless, the existence of these variations should be noted in any interpretation of the statistics. POPULATION COVERAGE Manpower /population ratios are frequently found in the literature on health manpower and are an important tool in the analysis of resources and requirements. However, there is considerable variation in the population employed in the denominator of such ratios. In part, this lack of uniformity can legitimately be explained by conceptual considerations— the fact, for example, that the population served by one group of health personnel may indeed differ from popula- tion served by others. Other conceptual problems tend to create additional discrepancies—for example, in the popula- tion groups served by Federal health professionals, both here and abroad. Apart from these considerations, there appears to be little agreement among the many data sources as to which population ratios are most relevant for a particular group of health workers. Population estimates used may vary in accordance with a particular reference period or with a particular area. The development of a uniform and conceptually valid population denominator to be used for all health occupations is desirable but virtually unattainable, given all these considerations. In this report, the population denominators used generally conform to those reported in Health Resources Statistics® and Health 2 Supply estimates for physicians and dentists include the Armed Forces both in the United States and abroad. 3 National Center for Health Statistics. Health Resources Sta- tistics. Health Manpower and Health Facilities, 1971. DHEW Pub. No. (HSM) 72-1509. U.S. Government Printing Office, 1972. Manpower Source Book, Section 20.* However, as discussed later in this chapter, a consistent population framework was developed for use with the supply projections. MANPOWER CHARACTERISTICS COVERAGE At the present time, current information is severely limited on the characteristics of the work force actively engaged in allied health professions and occupations; i.e. their age, sex, education, race, and mobility patterns. Although professional judgment has often been the key element in developing estimates of characteristics, the lack of reliable current data on this subject represents one of the more conspicuous deficiencies in the health manpower information system. Even in those health professions where data bases have been developed, the coverage is far from comprehensive and often not current. This report provides information on selected major characteristics of health professions: age, sex, race, geo- graphic distribution, professional activity, and type of practice or employer. Given the above data constraints, however, current information on even these characteristics is often not available for all occupations. The recent availability of data from the 1970 Census of Population has assisted in filling this void to some extent. For all tables presenting data on characteristics, the most recent informa- tion (generally in the form of percent distributions) was applied to the number of active health workers as of December 31, 1970 to provide “current” estimates. Where such procedures were adopted, they have been clearly noted in the text or on the tables. Other limitations that should be considered in interpreting these statistics have been detailed in subsequent chapters where they specifi- cally apply. HISTORICAL COVERAGE The lack of uniformity in statistics on health manpower becomes much more apparent when historical data are considered. In addition to the points discussed above, two factors compound the comparability problems of historical data: 1. For any given occupation, no one source provides a complete and consistent series of historical estimates. In no field has a consistent and uniform set of statistics been developed and maintained over a period of time. In some instances, revisions in survey design or in other aspects of data collection have made earlier estimates not comparable. 4 us. Department of Health, Education, and Welfare; Public Health Service; Bureau of Health Professions Education and Manpower Training. Health Manpower Source Book 20. Manpower Supply and Educational Statistics for Selected Health Occupations: 7968. Public Health Service Pub. No. 263, Section 20. U.S. Government Printing Office, 1969. 2. For individual occupations, furthermore, different sources often provide conflicting estimates for given years. , Since relatively complete historical series are lacking, estimates for some years may be available from one source, while estimates for other years are available only from a different source. For an illustration of a dilemma incurred with “competing” historical data, see the discussion of historical data on optometrists in Chapter 6. Despite these limitations, available trend data for indi- vidual health occupations are presented in this report. Given the variety of sources from which these estimates were obtained, however, comparability between (and some- times even within) occupational groups may not be fully realized. Thus, any analysis of the trend data shown should be undertaken with caution and with cognizance of the sources and definitions noted. Small differences should not be overemphasized. The inadequacy of some of the historical data also poses problems in developing projections of supply. Although historical supply has been examined and related to the projected estimates for comparative purposes, the historical estimates themselves have been used only sparingly in the projection methodologies employed in this report. As would be expected, the supply projections draw much more heavily on the fairly adequate data on enrollments, gradu- ates, and educational institutions, so that the projections are believed to represent reasonable approximations of future resources. PROJECTION ASSUMPTIONS AND METHODOLOGY The supply projections presented in this report were largely developed by the Division of Manpower Intelligence. The projections provided for dental and nursing supply, however, were developed by the Divisions of Dental Health and Nursing, respectively. Given the limitations in the data available and the fact that different organizational units contributed to the report, the projection assumptions and methodologies tend to vary somewhat from one occupation to another. The general discussion which follows attempts to provide an overall framework for an understanding of the basic assumptions and methodologies used; detailed descriptions by occupation can be found in later chapters. ASSUMPTIONS UNDERLYING THE PROJECTIONS As stated in the Introduction the supply projections presented here were developed initially as the first phase of Project SOAR, a comprehensive analytical effort designed to provide useful inputs and insights for developing health manpower strategies and options at the national level. Consequently, it is essential that the reader be alerted at this point to the major considerations related to the assumptions that underlie the projections. The supply projections developed for this report are, in essence, based on one critical set of assumptions relating to the future level and direction of financial support for schools and students, and the overall role of the public and private sectors in the health manpower production system. As a baseline concept, consequently, the projections assume that: 1. The number of first-year places mandated by Federal legislative provisions® existing at the end of 1972 would be maintained through academic year 1974-75; and 2. Upon the expiration of current legislation in fiscal year 1974, a combination of both public and private support would be available to at least maintain (but not necessarily increase) the productive capacity of schools needed to ensure the level of professional school enrollment resulting from these Acts. Hence, the assumption is that the health manpower production system will receive the future support from Federal or other sources that is needed for the maintenance and operation of the system at its assumed 1974-75 capacity level. Implicit in the assumption is that the effect on the health manpower production system of late-1972 levels of Federal biological research and medical support programs will not change significantly in the years ahead, and that the effects of military and Public Health Service recruitments and needs will remain roughly as they are today. The rationale for such a set of assumptions largely reflects the original purpose for developing the supply projections; namely, as a useful input for planning and decision making. In effect, the projections were designed to provide “baseline” estimates of the future supply of health manpower, so that alternative health manpower education strategies could be examined for possible use in program and policy planning and evaluation. Given these considera- tions, it was believed that the most meaningful projections of supply would be those that would most reasonably reflect a setting removed from the sharp increases in enrollment of the late 1960's and early 1970’s that were aided largely by Federal funding, but would still permit a long-run Federal role that seemed realistic. Thus, the projections assume that after fiscal year 1974, no further direct Federal support for construction or otk2+ induce- 5 The Comprehensive Health Manpower Training Act of 1971 replaced previous institutional (formula) grant authority with new authority for capitation grants, with incentives to encourage shortened curricula, promote assistants’ training, and increase enrollment. ments will be available to increase the enrollment of the Nation’s health education and training institutions beyond those efforts already programmed in late 1972. However, they also imply a Federal presence if needed to maintain given levels of enrollment in health professional schools over the projection period. Put in another way, the rationale underlying the set of assumptions was to provide estimates of what the likely future supply of health manpower would be if the manpower production system were to continue to operate in the general direction in which it appeared to be headed as of late 1972. The set of assumptions does not represent any official policy objective of DHEW, On the basis of the assumption that some type of funding would be available to support and maintain capacity levels in institutions, a number of alternative projections were subsequently developed which attempted to capture different responses of the educational system to different assumed conditions. Specifically, high and low projections were undertaken for all the “health profes- sions” but not for the “allied health occupations.” It must be recognized that a significant departure from the public and private health manpower role that existed in 1972 would tend to alter the realism of the assumptions. Because of the many factors to be considered, however, such as the interrelationships among the different Federal programs—in education and health as well as research—and the interface between Federal, State, and private interests, it becomes quite difficult to estimate quantitatively the possible impact upon the output of health occupation training programs and therefore upon the supply of health manpower. A major variable affecting the possible impact of any major funding changes in support, for example, would be the decisions made on the allocation of funds within the educational institutions themselves, which can- not be forecast at this time. Furthermore, any analysis would have to consider that major developments in programs not specifically identified with health manpower (e.g., changes in support for higher education programs) could also have an effect on the health manpower produc- tion system. Policies concerning all types of training programs will influence the production of health manpower to some immeasurable extent, especially in the area of biomedical research training. Overall, from the beginning of the HPEA program in FY 1965 through FY 1973, a total of $826 million in Federal matching funds for construction has been awarded to 151 schools in the seven health professions. When construction is completed, these grants will result in 5,700 additional first-year student places and almost 5,900 more beds in teaching hospitals. The capitation grant program (and earlier formula grants) has resulted in total awards of $517 million since the first year of the program in FY 1966. Special project grants (including financial distress grants in FY 1972 and 1973) have amounted to $284 million since 1968. Student assistance in the form of loans (beginning in FY 1965) and scholarships (beginning in FY 1967) totalled $295 million through FY 1973. In addition, smaller amounts were awarded in FY 1972 and 1973 under the CHMT Act of 1971 for conversion of 2-year medical schools to degree-granting institutions, start-up assistance for new schools, teacher training, family medicine, etc. Despite the difficulty of measuring its exact dimensions, the historical evidence on the output growth of health professions schools suggests that this Federal support has had a marked impact on the supply of health professionals. Evidence for a prima facie case on the impact of Federal support was recently presented in a Rand study on medical education.® As outlined in that study, for example, the strong Federal program thrust appeared to be responsible for a sizable number of medical schools (23) reversing their earlier record of only slight increases in enrollment to substantial increases in 1970-71. Since the beginning of the program in FY 1965, 78 medical and three osteopathic schools have received con- struction assistance under the HPEA program through FY 1973. Nineteen of the 22 new medical schools built during this period were constructed with the help of Federal matching grants. Overall, when all construction funded through FY 1973 is completed, the Federal construction program will have resulted in the creation of over 3,200 new first-year places in medical and osteopathic schools. While it is virtually impossible to assign increases in first-year places to such parts of the HPEA program as formula grants and special project grants, the mandatory increases required for the FY 1972 capitation grants resulted in 935 additional first-year places in medical schools and 54 more in osteopathic schools. As an illustration of the problems confronting estima- tion of the precise impact of Federal funding upon health manpower education, Federal programs specifically tar- geted on improving the supply of health manpower may have either a direct or indirect relationship, or both, to institutional output. Some programs, such as capitation support, are directly tied to enrollment increases, and the support is thus directly related to the institutions and their output capacity. Other programs such as special project grants, while targeted on specific manpower issues and educational goals, may not necessarily directly impact on output but may indirectly affect the institutional capacity - Carter, Grace M.; Chu, David S. C.; Koehler, John E.; Slighton, Robert L.; and Williams, Albert P., Jr. Federal Manpower Legisla- tion and the Academic Health Centers: An Interim Report. Santa Monica, Cal., The Rand Corporation, December 1973 draft. through the support provided for faculty and other operating expenses. Given the need to consider individual decisions on allocations at the institutional level, it remains somewhat uncertain what the possible impact of shifting public and private funding policies might be in quantitative terms. For example, it is unknown at this point whether, or to what extent, support from State govern- ments (even with revenue sharing) would be available to replace possible reduction in Federal funding support. And, given such a situation, it would be equally unknown at this juncture which schools would be affected or in what specific time frame. The reader, therefore, must interpret the usefulness of the set of assumptions posed earlier and the resulting projections in the time frame of both their original development and the funding environment in late 1972. In this regard, the reader must also be reminded of the fact that projections have been developed here for a 20-year period, in which time the pattern of non-Federal support, as well as the Federal role, may change significantly, as it changed several times in the last decade. The above discussion has focused entirely on critical’ assumptions and related issues pertaining to the domestic production of health personnel. With respect to the U.S. supply of physicians, however, unlike other health workers covered in this report, a significant segment of the working population in the Nation consists of graduates of foreign schools. Given the important role played by foreign medical graduates (FMG’s) in the current health manpower pool, therefore, the reader should also be alerted at this point to the assumptions presented underlying the projections of the future flow of FMG'’s. As indicated earlier, the rationale underlying the set of “domestic production’ assumptions was to provide a future manpower profile likely to exist, given the general direction of the production system as of late 1972. To a large extent, the basic assumptions utilized to project the likely future size of the FMG population were developed along similar lines. In effect, these assumptions did not include the likelihood or the possibility of any major intervention in the FMG flow over the projection period, such as a significant modification in immigration and naturalization laws. To have included such a possible legislative change would have violated the purpose of this report—to provide baseline data that would be useful for planning—and would have produced estimates of limited value to planners. Consequently, a fine line was maintained between supply projections (as shown here) and forecasts. The potential size of the annual inflow of FMG’s into the health care system is believed by many to be almost limitless and perhaps even capable of equaling the output of U.S. medical schools. Barring any significant interventions, the factors currently operating to draw foreign-trained physicians into the United States are likely to continue in the future. For example, the economic incentive is likely to remain strong, since the average residency salary in this country is higher than the fully licensed physician’s annual income in many countries of the world, particularly the countries that have provided the bulk of recent FMG’s. In addition, the opportunities for graduate medical education and for satisfying and rewarding practice in the countries “from which the largest proportion of FMG’s are emigrating are not likely to be enhanced appreciably for many years to come. In fact, however, although virtually all manpower experts anticipate continued growth in the size of the FMG population over time, no consensus has emerged regarding the future size of the annual additions. This lack of agreement reflects, in part, numerous questions about the reliability of both current and historical information on this segment of the physician supply. Different views have been articulated as to the impact of changes in immigration and licensing laws; for example, it is believed by some that the recent sharp increases in FMG entry reflect little more than a diminution of the backlog of FMG’s in this country resulting from the recent changes in U.S. immigration laws. In view of these considerations and given a number of limitations inherent in the data base (to be discussed later), several projections were developed, each of which viewed the recent (1970-71) FMG experience in a somewhat different light. The basic assumption utilized in this report viewed the 1970-71 increase in the FMG population (as measured by the American Medical Association) as the initiation of a continuing, but not accelerating, trend throughout the next two decades. Two other projections were also developed: (a) a ‘high’ approach that assumed the recent experience to be the beginning of a new incremental trend in the supply of FMG’s; and (b) a “low” approach that considered the 1970-71 increase as being atypically high for the coming years, with future trends in FMG supply assumed to revert to the growth nattern evidenced over the 1963-70 period. In developing these projections, assumptions of virtually unlimited continuous growth in the supply of FMG’s and, on the-other hand, extremely sharp increases in the supply were both rejected as unrealistic. (Such a projection is shown in this report, but it is simply illustrative of the way in which large, possibly atypical, numbers can be extrapo- lated.) In this connection, one factor taken into considera- tion is the proposed abolition of the “free-standing” internship. Entry of foreign graduates into the United States presumably will be curtailed as greater numbers of U.S. graduates become available to fill training positions now vacant. In addition, with an elimination of the free-standing internship and a tightening of requirements for approval of residency training programs, which may develop as the Liaison Committee on Graduate Medical Education begins to function, one could anticipate a substantial reduction in the number of approved training programs and still further limitation in the slots available to FMG'’s. Nonetheless, it is evident from the projections developed in this report that, regardless of the alternative adopted, the foreign-trained physician will continue to play an increas- ingly important role in the U.S. medical care system. To assess the desirability of this development, however, is beyond the scope of this report. In sum, then, the projections of the supply of physicians presented here are as heavily dependent on assumptions relating to the future influx of FMG’s as on assumptions about domestic production. For this reason, projections of the supply of physicians and medical specialists have been undertaken separately for U.S. and foreign graduates. It is hoped that such presentation will enhance understanding of the salient issues regarding each group as well as interrela- tionships between the two groups. OVERVIEW OF PROJECTION METHODOLOGY It is important for the reader to recognize at the outset that the projections developed for this report relate to the future profiles of supply, independent of any considera- tions of demand. The report must be viewed in the context of its development; namely, as the initial phase of a number of sequential analytic efforts. For planning purposes, it was considered analytically feasible and desirable to project supply and requirements independently, leaving synthesis and further modification in line with traditional economic supply-demand analysis to be undertaken later. (The project of which this report is a part is outlined in the Introduction.) Although a number of arguments can be raised to support the position that the supply of many health groups is relatively inelastic in the short run (however defined), the fact remains that the presentation here pays only minor attention to some of the major demand dynamics of the health care system and their ultimate impact on supply. Such factors as productivity shifts, organizational changes (e.g, Health Maintenance Organizations), new develop- ments in health insurance, licensure review, and task delegation, to name a few, may very well affect directly or indirectly the future education and supply of health manpower. The methodology as shown does not consider the impact of any one manpower projection on other related health personnel projections, such as the possible effect of a sharp increase in allied health manpower on the training and supply of other professional services or the impact of projected U.S.-trained M.D.’s on the future entry patterns of FMG’s. An examination of demand considera- tions such as these is beyond the purview of this report, in view of the fact that other efforts being undertaken within the Bureau of Health Resources Development (BHRD) will be concerned specifically with these points. As indicated earlier, there is a considerable amount of empirical data on health professions, and therefore it has been possible to develop supply projections for all the major health professional groups. However, data on most allied health fields are limited to gross estimates of currently active personnel, with very little information on training of these workers or on the detailed characteristics of the supply, a fact which severely limits the options for utilizing adequate projection techniques. As a result, estimates of the future supply of allied health workers have been undertaken for only a selected group of professions and occupations—using as projected inputs only “appropri- ately trained” personnel, that is, those persons who will be receiving formal training in programs geared to the specific field in which they will be employed. Consequently, most of the following generalized discussion relates to the projection methodologies applied for health professions. BASIC PROJECTION METHODOLOGY In general, the basic methodological approach used to estimate total active supply was to estimate the flow of graduates into the active supply over the 20-year period and to estimate the losses to the existing work force during this period due to deaths and retirements. Except for minor variations, as in projecting the future supply of registered nurses, estimates have not generally been undertaken of the possible number of reentrants to the active supply during the projection period, since their numbers are believed to be relatively small in most health professions. GRADUATE ADDITIONS. In developing the supply pro- jections, the basic assumption has been made that no major new Federal programs aimed at increasing enrollments will exist at the expiration of current legislation and that Federal support will be at least sufficient to maintain enrollment levels resulting from earlier legislation. These baseline projections thus permit an evaluation of the future supply of manpower in the absence of the massive support of recent years to increase enrollment. U.S. professional schools whose enrollments and gradu- ates are projected in the general methodology include those schools identified in capitation grant applications filed with BHRD, as well as any schools where expectations were firm as to opening in the next few years. Projections of graduates through the latter 1970’s were based largely on data and projections of first-year enrollment by schools on the applications.” Information submitted by schools on projected graduates was generally not used in this approach, since many schools excluded any consideration of attrition from their first-year enrollments in deriving their graduate estimates. These “pipeline” estimates of enrollment provided the basis for projecting the number of graduates until approxi- mately 1978. After that date, the number was more difficult to project. Given the assumption as to Federal support, a consensus seemed to prevail that enrollment would continue to increase for most health occupations but at a rate below that which characterized the late 1960’s and early 1970s, when the impact of the Federal dollar was apparently greatest. This report consequently presents alternative projections of the graduate inflow, based upon different assumptions as to the possible future educational impact of this altered Federal involvement. The “basic” projection methodology used for each health occupation has utilized the specific graduate projection that seems most reasonable for that occupation. “High” and “low” estimates were also developed for a number of fields. In addition to this consideration of enrollment changes over the 20-year period, it was also necessary to consider the matter of attrition. Estimates of student attrition vary: (1) between schools within the same field, (2) between occupations, and (3) over time. The basic projection methodology used in this report has generally been to adopt a recent attrition experience for schools within an occupation and maintain this rate for the length of the projection period. In some instances, information is pre- sented on the impact upon the supply projections of using alternative estimates of student attrition. The supply methodologies in this report also consider, where applicable, the existence of accelerated (abbreviated) programs in professional schools. Experts in the educational field have somewhat different views as to the likely course of such programs in the coming years. For example, there are some indications that such programs present problems and the current shift in this direction may slow down. A more detailed discussion of this topic, as it relates particu- larly to medical schools and projected graduates, can be found in Chapter 3. This discussion of graduate additions has thus far been concerned solely with the projected supply of U.S. gradu- ates. However, a significant input to the current and 7 It should be noted that schools often revise (update) their first-year enrollment figures after initial submission of capitation grant applications to BHRD. Because schools indicate these changes at varying points during the year, BHRD makes an effort to tally the responses periodically. Projections of supply developed in this report were based on fiscal year 1972 applications tallied as of Fall 1972. projected supply of physicians is represented by foreign- trained physicians. Although foreign graduates also provide an input into some other health occupations, their numbers are small, and the projection methodologies employed for these groups did not include projected estimates of their foreign-trained components. Because of the critical importance of physicians and the FMG component, however, alternative assumptions of FMG’s have been developed to provide several different projections of active physicians. The treatment of this group of physicians is covered in considerable detail in Chapters 3 and 4. SEPARATIONS FROM THE LABOR FORCE. In addition to the flow of graduates into the manpower pool over time, estimates of the future supply of active workers are also dependent on such factors as losses to the active work force through death, retirement, and occupation shifts, as well as reentry of workers into the active pool. The approach undertaken in this report has generally been to provide estimates only of the losses to active supply incurred through deaths and retirements. In general, information on separation and reentry patterns relating specifically to health occupations is rather limited. Although a number of cohort analyses have been undertaken, the scope of the studies has often been too limited to permit a direct transfer of the results to the active work force at large. In some instances, projections of supply reported in the literature have made no allowance for losses to the occupation. In others, arbitrary estimates of losses have been developed, with no consideration given to the age characteristics of the occupation analyzed. For most occupations for which projections are pre- sented in this report, estimates of deaths and retirements have been computed utilizing age-specific separation rates for the general working population as an initial input.® The use of age-specific data has been adapted to reflect differences in estimated losses among professions accounted for by variations in respective age distributions. Wherever possible, attempts have been undertaken to provide reason- able approximations of death and retirement patterns for each occupation, depending on the extent of supportive empirical evidence available. Age-specific death rates for the general work force (usually male workers) have been utilized to estimate the mortality losses for most occupational groups. One notable exception to this approach is the mortality estimates for physicians, where an adjusted death rate series was devel- oped utilizing the mortality patterns of male workers modified on the basis of empirical data on the longevity experience of physicians. 8 Fullerton, Howard N. A Table of Expected Working Life for Men, 1968. Monthly Labor Review, 94: 49-55, June 1971. 10 For a number of the health occupations covered in this report, there exists evidence that these professionals tend to have a somewhat longer working life than does the general working population. Where such evidence was available, a number of occupation-specific series of retirement rates were constructed, based initially on the generalized retire- ment patterns for male workers. This approach was applied to physicians, optometrists, podiatrists, and veterinarians. A variation of this approach was adopted for dentists. A brief description of the particular separation meth- odology utilized for each occupation is presented in respective occupational chapters in Part Il. A more detailed examination of the assumptions, underlying rationale, and methodology is presented in Appendix A. Some of the limitations of the general approach, however, should be noted at this time: 1. Separation rates were applied both to the supply of active health manpower in 1970 and to the estimated graduate input to 1990. With respect to the latter, possible composition changes among graduates in coming years could very well alter separation estimates for a number of occupations. For example, growing proportions of both females and Blacks may result in somewhat different death and retirement patterns than those applied here. This may be particularly true for the pharmacy profession where a significant increase in female pharmacists is expected over the coming years. 2. The separation patterns in existence today are likely to be different from those that will prevail over the next 20 years, both as to patterns experienced by the general working population and by workers in individual occupa- tions. Increasing trends to greater leisure time, for example, may have a significant impact on retirement patterns. 3. As indicated above, the projection methodology generally did not make allowances for the possible reentry of workers into the active manpower pool. In view of the fact that most health professions except nursing have relatively small proportions of females—a segment of the work force that generally exhibits high turnover—the assumption was made that reentry into these professions (except for pharmacists) would tend to have only a slight effect upon the overall supply projections. Here too, however, compositional shifts which may occur in certain occupations over the next two decades might alter the validity of this assumption. DEVELOPMENT OF SPECIALTY PROJECTIONS FOR MEDICINE In general, most projections of health manpower supply in the literature have largely been confined to providing an aggregate measure of supply. Despite continued concern about ‘‘shortage’’ problems, little attention has been di- rected to projecting such distributional aspects of supply as the degree of specialization among health workers. This consideration is critically needed in order to evaluate the relationship between the composition of supply and re- quirements in the years ahead. Supply projections of specialties, furthermore, are not only useful in analyzing the dimensions of problems of maldistribution but also serve to shed further insight into the projected estimates of overall supply. In addition to providing basic and alternative projections of total active supply to 1990, this report presents projections for a selected number of medical specialties. These projections have been controlled to the independent projections of total active supply discussed earlier (specifi- cally M.D.’s). The general approach undertaken was first to project the distribution of the supply of health profes- sionals who were active in 1970 and were estimated to survive to 1975, 1980, 1985, and 1990. In this approach, no intercategory shifts were assumed for the projection period. Specialty distributions were then estimated for the graduate entrants over the 20-year period. Any evaluation of the numerical findings of these projections must be undertaken cautiously, with full awareness of the assump- tions and caveats outlined above and in Chapters 3 and 4. POPULATION ESTIMATES AND RATIOS Where applicable, the projections of supply have been related to population projections in order to provide an easy and simple means of assessing the implications of the projections. As indicated earlier, an effort was made to provide a consistent framework for the population ratios used with the supply projections. The supply projections of total numbers active in each of the health professions (as well as historical estimates within the same tables and discussion?), are related to projections of the total resident population developed by the Bureau of the Census.’ ® It is important to note that the primary rationale for the use of a single set of population projections was to provide the % In chapters for individual health professions, tables and discussions of current characteristics and historical trends utilize population ratios that employ denominators generally covering the same geographic areas as the manpower data in the numerators. In those sections where projected population ratios are compared to ratios for 1960 and 1970, the population denominators of the 1960 and 1970 ratios conform to the series used for the projections in order to provide comparability in the estimates. 10 U.S. Bureau of the Census. Current Population Reports. Series P-25, No. 477. 11 most reasonable and comparable framework for trend evaluations. Although ratios for any given year are affected to some degree by the population base adopted (either total or civilian resident population), the trends over the projec- tion period are little affected. The choice of the specific population series was largely determined by the desirability of obtaining consistent population projections for both the Nation overall and for States. Although the Bureau of the Census has published a number of population projections for the entire United States, only two are available by State. Of these, the Series I—E projection was selected on the basis that its assump- tions about fertility rates more closely approximate the current pattern. As indicated in Table 1, population estimates obtained from Series |—-E are somewhat lower than other population projections published by the Bureau Table 1. ALTERNATIVE PROJECTIONS OF U.S. POPULATION: JULY 1, 1975-90 [in 1,000’s] Total population, including Resident Armed Forces overseas Year population Series I-E Series B | Series C | Series D | Series E 1975..... 214,883 218,177 217,375 216,561 215,703 1980..... 226,934 236,725 233,798 230,855 227,765 1985.5. 55 239,329 257,903 252,093 246,265 240,153 1990. 4:4 250,630 278,570 269,673 260,762 251,431 Source: Resident population: U.S. Bureau of the Census. Current Population Reports. Series F-25, No. 477. Total population, including Armed Forces abroad: U.S. Bureau of the Census. Current Population Reports. Series P-25, No. 470. Note: Resident population series shown above (column 1) is used for the projected population ratios presented in this report. of the Census. The use of this series in this report thus results in higher population ratios than would be derived by applying any of the other series. Table 2 provides the projected population figures for individual geographic areas'!. Mhese population estimates are currently being used in exploratory projection activities undertaken by BHRD concerned with the geographic distribution of health manpower supply. Table 2. Table 2. PROJECTIONS OF THE RESIDENT POPULATION OF GEOGRAPHIC REGIONS, DIVISIONS, AND STATES: JULY 1,1975-90—Continued PROJECTIONS OF THE RESIDENT POPULATION OF GEOGRAPHIC REGIONS, DIVISIONS, AND STATES: JULY 1, 1975-90 Region, division, and state] 1975 | 1980 | 1985 | 1990 Region, division, and state | 1975 | 1980 | 1985 | 1990 UNITED STATES ...... 214,883 226,934 239,329 250,630 NORTH CENTRAL— G Continued NORTHEAST......... 51,187 53,499 55,927 58,152 WEST NORTH NEW ENGLAND ... 12,534 13,252 13,997 14,682 CENTRAL ....... 16,828 17,385 17,995 18,555 Connecticut .... 3,283 3,551 3,825 4,082 lowa .......... 2,861 2,908 2,962 3,009 Maine. ......... 1,003 1,016 1,031 1,044 Kansas. ........ 2,287 2,334 2,386 2,432 Massachusetts ... 5,977 6,277 6,588 6,869 Minnesota ...... 4,021 4,245 4,483 4,703 New Hampshire. . 807 878 950 1,019 Missouri ....... 4,866 5,070 5,288 5,491 Rhode Island. ... 985 1,027 1,068 1,104 Nebraska....... 1,525 1,570 1,620 1,664 Vermont . ...... 474 504 535 563 North Dakota ... 607 600 597 594 MIDDLE ATLANTIC 38,653 40,246 41,930 43,470 South Dakota ... 660 658 660 662 New Jersey ..... 7,725 8,300 8,906 9,481 WEST.....ovvvvnnennn 38,126 41,449 44,825 47,952 New York ...... 18,964 19,789 20,660 21,461 MOUNTAIN....... 8,956 9,617 10,286 10,894 Pennsylvania.... 11,964 12,157 12,364 12,529 Arizona........ 1,974 2,164 2,352 2,523 SOUTH. vii wmivinss ies 66,327 69,927 73,539 76,784 Colorado........ 2,423 2,636 2,848 3,042 SOUTH ATLANTIC. 32,757 34,860 36,942 38,817 Idaho. ......... 735 761 790 817 Delaware. ...... 601 655 709 758 Montana ....... 706 2 739 757 District of Nevada ........ 584 673 759 836 Columbia. ..... ) ) ) ®) New Mexico. .... 1,052 1,088 1,126 1,160 Florida. ........ 7,557 8,280 8,980 9,626 Utah .......... 1,146 1,234 1,322 1,400 Georgia ........ 4,887 5,191 5494 5,761 Wyoming....... 336 342 351 360 MALY Iai ve x ves 4348 4782 5225 5.637 PACIFIC. ......... 29,171 31,832 34,539 37,059 North Carolina .. 5,277 5,482 5,682 5,852 Alaska......... 328 352 374 392 South Carolina. . . 2,658 2,731 2,800 2,855 California ...... 22,077 24,226 26,429 28,496 Virginia........ 4,936 5,229 5512 5,755 Hawaii ........ 828 874 908 933 West Virginia. .. . 1,681 1,634 1,598 1,565 Oregon. ........ 2,257 2,421 2,591 2,749 EAST SOUTH Washington ..... 3,682 3,958 4,236 4,489 CENTRAL ....... 13,106 13,440 13,793 14,100 : Alabama ....... 3,500 3,565 3,634 3,692 Projection methodology does not yield reasonable estimates Kentucky ...... 3,290 3,372 3,461 3,540 for the District of Columbia but the estimates for this area have Mississippi... .. . 2,227 2,245 2,268 2,288 been included in totals for division, region, and the United States. Tennessee. ...... 4,089 4,259 4,430 4,581 Source: U.S. Bureau of the Census. Current Population Reports WEST SOUTH Series P-25, No. 477. CENTRAL ....... 20,464 21,627 22,804 23,867 Arkansas . . ..... 1,986 2,052 2,126 2,195 Note: Figures may not add to totals and subtotals due to Louisiana. ...... 3,807 3,975 4,141 4,285 independent rounding. Oklahoma... .... 2,669 2,787 2,912 3,029 Texas ......... 12,002 12,812 13,625 14,358 NORTH CENTRAL.... 59,242 62,059 65,037 67,741 EAST NORTH CENTRAL ....... 42,415 44,674 47,042 49,186 inois......... 11,666 12,256 12,885 13,464 Indiana ........ 5,483 5,782 6,093 6,370 Michigan ....... 9,445 10,031 10,639 11,193 Ohio vvrennn.. 11,152 11,675 12,218 12,693 Wisconsin. ...... 4,669 4,930 5,207 5,466 See footnote at end of table. 12 Chapter 2 ¢ PROJECTIONS OF HEALTH MANPOWER SUPPLY—A SUMMARY The Nation's health manpower profile has changed significantly over the past decade. In 1970, the overall supply of active health professionals and allied workers totaled about 4 million. (See Tables 3 and 4.) This number was about 56 percent (or 1.4 million) higher than the level of 10 years earlier. Slightly more than three-fourths of this growth was concentrated among allied health personnel, reflecting their increased utilization, as well as greatly increased employment opportunities that resulted from changes in the health care delivery system. Between 1960 and 1970, the allied health work force rose from 1.5 million to approximately 2.7 million (an increase of about 80 percent), as compared with the 30 percent rise in the number of health professionals, whose numbers increased from 1.0 to 1.3 million. It should be remembered that the supply projections presented in this report generally sugge.t a continuation of these rapid growth patterns over the next two decades. As indicated earlier, however, projections of the supply of allied health workers, owing to the severe data weaknesses which currently exist, have been undertaken only for selected allied groups, with the coverage of the 1970 active base confined to credentialed personnel and new entrants limited to graduates of “approved” educational programs. As a result, a comprehensive profile of the total health manpower pool has not been provided here. Nevertheless, the detailed estimates of the future supply of all health professionals, when coupled with the selected allied health estimates, provide valuable insights into the Nation’s future health manpower situation. SUPPLY OF HEALTH PROFESSIONS For health professions, the overall supply of active workers is projected to increase from 1.3 million in 1970 to 1.9 million in 1980 and to 2.5 million in 1990. (See Table 5.) This represents a gain of 87 percent over the 20-year period, or an average annual rate of growth of 3.3 percent Table 3. SUPPLY OF ACTIVE HEALTH PROFESSIONALS: DECEMBER 31, 1970 Health profession Number active Health profession Number active All health professions. .......... 1,329,130 PHYSICIANS, 1. 4 v0 ¢ mua ® wuki & ow © 40 © with & ck 5 Wok #ion wim 323,210 DOS titi iii iia 12,000 MoDS 0s sis wns wim 2 win 0 wins mn 6 916 5 win 3 05w 5a 311,210 General practice sve ivnivesvmivesswsn 56,260 Medical specialties... ......oovinvennn. 66,380 Dermatology ... +.viieiinenannnn 4,000 Family practice «.ovovvevrvevevnes 1,690 Internal medicine. ........c000eue. 41,870 Pediatrics’. ...ovieiiiiiieann. 18,820 Surgical specialties «..uiswsnvsnsenmen 85,390 General surgery ......ovvviennnnn. 29,760 Neurological surgery .............. 2,580 Obstetrics and gynecology « ...o.vun 18,880 OphthalmOoIOgY «+ vv « sw s xix ssw enim sw 9,930 Orthopedic surgery. ....oeoveeennnn 9,620 Otolaryngology ......covvvennennn 5,410 Plastic SUFEry ..vvvvurnnnnececnns 1,600 THOTaCICiSUIBRLY. + vv «wins wiv www wiv www 1,810 Urology ss ssc nwe mrs wesweve EN 5,800 Other specialties . ....cvcoeenvens ve 103,190 Anesthesiology. .....covvenuunnn 10,860 Child psychialty + vuv vives ones 2,100 INEUrOIOBY «is vos wus vim swim «ww wi 3,070 PSYChIAtIY wisi qin « iw ¢ wiv v wim pinin v 21,150 PathOlOgY:: «cs vv ¢ min + win 3 iw wwe #0 10,280 Physical medicine and rehabilitation .............. 1,480 Radiology... vvvvvvnnnnnnn., 10,520 Therapeutic radiology .......... 870 Miscellaneous ................ 42,860 Dentists « woo wos vm e vm swine ww eos sme vw 102,220 OPLOMELrIStS vivo vin 55 + wiv 3 vie winie wins + 18,400 Pharmacists, « viv » sive win & wo « is winie Gal 59 129,300 POGIRELISIS: vo 0.6: & 5idt 2 ne 3000 3008 Vimict Buea 99 7,100 Veterinarians. . .....coovvnnninnnnannn 25,900 Registered nurses ......ve vss evess 723,000 1 Also includes pediatric allergy and pediatric cardiology. Source: For sources of data in this table, see tables in chapters on each occupation. Note: Figures may not add to total and subtotals due to independent rounding. Table 4. SUPPLY OF TOTAL ALLIED HEALTH MANPOWER, BY OCCUPATION: DECEMBER 31,1970 Allied health occupation Number active Total allied sv vovivesvvevevnenernns 2,743,000 Medical RUIEd «oi sviv simi 0 00 § 918 8 ws vin ¢ ses woo 1,073,000 Medical laboratory personnel ............ 140,000 Radiologic technology personnel ......... 100,000 Medical record personnel ............... 53,000 Dietetic and nutritional personnel ........ 47,000 Physical therapy personnel .............. 24,000 Occupational therapy personnel .......... 16,000 Other personnel ......ccvvveeienaeanees 693,000 Dental allied. + vos 55 ¢ wn + mic» mix 2:90 vin 009 0 158,000 Dental hygienists .....ccovueveenenannnee 15,000 Dental assistants... .o ei sss no sss swerve 112,000 Dental technicians ......ccvevvennennns 31,000 Environmental allied ........ccvvevinennn 242,000 Environmental engineers .......cceeeeen 35,000 Environmental scientists ........ccc00ene 25,000 Environmental sanitarians .............. 12,000 Environmental technicians .............. 69,000 Environmental aides. .......ooviinen.n 101,000 Nursing allied ......covvvvvnnteinennnns 1,270,000 Licensed practical nurses ............... 400,000 Nursing aides, orderlies, attendants ....... 848,000 Home health aides .........c...e0vvuenn 22,000 Source: Dental allied: BHRD, Division of Dental Health All other occupations: National Center for Health Statistics. Health Resources Statistics. Health Manpower and Health Facilities, 1971. DHEW Pub. No. (HSM) 72-1509. U.S. Government Printing Office, 1972. (compounded), somewhat above that registered between 1960 and 1970. The gain in the 1970's is projected to be somewhat faster than in the 1980's, for health professions as a group, as well as for individual fields. It should be reiterated at this point that these aggregate estimates (as well as the figures for individual occupations discussed later), have been developed under a basic assump- tion about the future direction of Federal legislation and overall financing of education in health fields. In general, this assumption states that upon expiration of current legislation, the amount of overall public and private funding provided would be such as to maintain at least the current level of professional school enrollment. More detailed discussions of specific assumptions, methodologies, and findings are presented in subsequent chapters of the report. Although the overall supply of active health professions is projected to increase by nearly 90 percent between 1970 14 and 1990, growth patterns are expected to vary consider- ably among the individual professions. (See Table 5.) Over the 20-year period, for example, increases in supply are projected to range from a high of about 100 percent for registered nurses to a low of approximately 40 percent for pharmacists. In general, the compositional changes in the overall health professions pool that were in evidence during the 1960’s are expected to continue. The professions which registered the sharpest increase in supply during the 1960’s—registered nurses, veterinarians, and physicians—are projected generally to post the sharpest gains during the 1970-90 interval. In 1990, these three occupations combined are projected to account for 85 percent of all active health professions, compared with 78 percent in 1960 and 81 percent in 1970. PHYSICIANS The Nation’s supply of active physicians has grown substantially over the past two decades and is projected to rise at a somewhat sharper pace over the next two. The supply of active M.D.’s and D.O.’s rose from 220,000 in 1950 to 251,900 in 1960 and to 323,200 in 1970, an increase of about one-half over the 20-year period. (See Table 5.) This expansion has been particularly marked in recent years, reflecting both the greater output from U.S. medical and osteopathic schools and increased entry into the United States of M.D.’s trained abroad. The increase in the output of U.S. medical and oste- opathic schools in large part reflected the impact of Federal legislation, beginning with the Health Professions Educa- tional Assistance Act of 1963. Since academic year 1963-64, for example, the number of medical schools rose from 87 to 103 (in 1970-71), and first-year enrollment grew from 8,800 to 11,348. In addition to developments such as these, immigration of M.D.’s trained abroad has doubled the Nation’s pool of foreign-trained physicians since the early 1960’s. In 1971, active foreign-trained M.D.’s (excluding graduates from Canadian medical schools) numbered 59,600, or 18.5 percent of all active M.D.’s, as compared with 30,300, or 11.6 percent of the total active in 1963. Under the basic methodology utilized in this report, the supply of active physicians (M.D. and D.O.) is projected to grow from 323,200 in 1970 to 593,800 in 1990. This increase represents an average annual growth rate (com- pounded) of 3.1 percent, somewhat above the rate of 2.5 percent posted between 1960 and 1970. The gain is projected to be slightly more rapid in the 1970 decade than in the 1980's. As a result of these substantial increases, the ratio of active physicians to total resident population is projected to rise substantially. In 1970, there were 159 physicians for each 100,000 population; the ratio is expected to reach 197 by 1980 and 237 in 1990. In evaluating these figures, it is important to recognize several key assumptions that underlie them: Assumption 1. Upon expiration in FY 1974 of the Comprehensive Health Manpower Training Act of 1971, aggregate public and private funding will be adequate to at least maintain (though not necessarily to increase) the productive capacity of professional schools needed to ensure the continuation of enrollments at the level resulting from this Act. This assumption accounts in part for the projection of a slightly lower rise in physician supply for the 1980's. Since the current legislation concerns itself with enrollment increases through academic year 1974-75, the impact of the legislation (unless altered) upon the Nation’s supply of M.D.’s and D.O.’s will be felt through the latter 1970’s. Enrollment increases upon expiration of the current legislation are still assumed to occur, but at a reduced pace. The assumed enrollment growth for the remainder of the projection period, consequently, results in a slightly slower expansion of the M.D. and D.O. pool in the 1980-90 period. Under the basic methodology, consequently, first-year enrollment in U.S. medical schools is projected to grow from 11,348 in academic year 1970-71 to 14,339 in 1974-75; 15,321 in 1979-80; and 16,811 in 1986-87. With assumptions about attrition among students (See Chapter 3), the projections of first-year enrollment result in a total graduate input of approximately 270,000 M.D.’s over the next two decades. The number of M.D.’s graduating is projected to rise from 8979 in 1970-71 to 15,920 in 1989-90, an increase of 77 percent. This compares with an increase of 28 percent between academic years 1960-61 and 1970-71. Similar increases for osteopathic graduates are also proiected for the next 20 years. Assumption 2. U.S. medical and osteopathic schools will be financially able to maintain the projected output of graduates. Projections for first-year enrollments and sub- sequently for graduates become meaningful only to the extent that existing and assumed new schools remain financially able to accommodate these numbers. Compared to that for most health professions, however, private and non-Federal public funding for medical and osteopathic schools promises to represent a presence that will be most Table 5. SUPPLY OF ALL ACTIVE HEALTH PROFESSIONALS, USING BASIC METHODOLOGY: ACTUAL 1960 AND 1970; PROJECTED 1980 AND 1990 All health Physicians Registered Y M.D. . ei . Beh : : ear professions ( Yau Dentists i Optometrists| Pharmacists | Podiatrists |Veterinarians Number active 1960 ...ovnvvvnnnnnrsnens 1,029,620 251,900 90,120 527,000 16,100 117,800 7,000 19,700 1970 oc svvpimsnimsnmonim nines 1,329,120 323,200 102,220 723,000 18,400 129,300 7,100 25,900 1980 ..o.vvvvnnenrnevones 1,885,370 446,800 126,170 1,099,600 21,800 146,100 8,500 36,400 1990 ....coiininnnnrinnns 2,484,410 593,800 154,910 1,466,700 28,000 179,900 13,000 48,100 Percent distribution 1960 .....oonvnnnnnnnnnes 100.0 24.5 8.8 51.2 1.6 11.4 0.7 1.9 1970 c.invvinnnnnnnnnnnns 100.0 24.3 1.7 54.4 1.4 9.7 0.5 1.9 1980 .onvrmsvnsvmsmesnnes 100.0 23.7 6.7 58.3 1.2 7.9 0.4 1.9 1990 ...0 000s onium. vey 100.0 23.9 6.2 59.0 1.1 7.2 0.5 1.9 Rate per 100,000 population’ 1960 voor unravevrsrn reeves 572.1 140.0 50.1 292.8 8.9 65.5 3.9 10.9 1970 x vain vive sins siwsnnonans 652.1 158.6 50.2 354.7 9.0 63.4 3.5 12.7 1980 sve vusnnramunnenss . 830.8 196.9 55.6 484.5 9.6 64.4 3.8 16.0 1990 covnvnvenaarrvnnnnns 991.3 236.9 61.8 585.2 11.2 71.8 5.2 19.2 ! Resident population as of July 1. Source: For sources of manpower data in this table, see tables in chapters on each profession. Note: Figures may not add to totals due to independent rounding. 15 supportive to educating and producing future streams of physicians into the existing pool. In recent years there has been a substantial increase in the number of young people expressing interest, and actively seeking careers, in health occupations. The pressure thus exerted on enrollment in health professions and allied educational programs, specifically in the area of physicians, is likely to be forceful. For example, applications for admission to medical school now approximate three times the number of first-year places available. In addition, the whole set of dynamics surrounding the increased role of the female and racial-ethnic minorities in the functioning of our society provides a strong forcing function to encourage continued and perhaps sharply increased non-Federal finan- cial support to medical education. Assumption 3. Foreign trained M.D.’s will continue to increase the U.S. supply annually in approximately the same numbers as they did in 1970-71. If so, the projected growth in their number would account for slightly less than two-fifths of the total growth in physician supply over the 1970-90 period, similar to the substantial input accounted for by foreign medical graduates (FMG’s) during the 1960's. This means that foreign trained physicians (includ- ing the Canadian trained),’ would represent almost one- third of all active physicians in 1990, compared to about one-fifth in 1970. More specifically, the supply of active U.S. trained physicians alone is projected to increase by 166,600, or by over 60 percent, over the projection period—from 263,200 in 1970 to 429,800 in 1990. In contrast, the supply of all active FMG’s in the United States is projected to nearly triple by 1990, growing from about 60,000 in 1970 to 164,000 in 1990. This rapid growth among the FMG population represents an average yearly gain of about 8 percent (compounded), corresponding quite closely to the 9 percent yearly increase registered during the 1963-70 period. Assumption 4. The supply flow will be generally unaffected by any significant changes in the health care delivery system. ideally, it would be most desirable if this document could present throughout separate data on U.S. trained physicians and medical graduates from foreign schools, including Canadian schools. This would be consistent with the legislative mandate of the Bureau of Health Resources Development (BHRD) for funding professional education only in U.S. schools. Unfortunately, such separation cannot be fully achieved because certain published data on physicians, such as internship and residency statistics, often com- bine statistics on U.S. trained M.D.’s with counterpart data on graduates of Canadian schools. In these instances, it is not possible to separate out the relevant information for U.S. trained M.D.’s alone. 16 MEDICAL SPECIALISTS Although the overall supply of physicians is projected to increase rapidly to 1990, this expansion may not signif- icantly alter the current specialty distribution. In 1970, for example, the supply of active M.D.’s was distributed unevenly among specialties, and this pattern had not been significantly changed by the growth in supply over the past decade. The largest numbers of M.D.’s (both U.S. and foreign- trained) are in general practice and in the five traditional specialties: internal medicine, general surgery, psychiatry, obstetrics and gynecology, and pediatrics. There have been only small changes in the composition of specialty man- power since the early 1960s, with the exception of physicians in general practice, whose numbers declined by about 15 percent between 1963 and 1970. However, the decline in the number of general practitioners does not necessarily represent a decline in the number of M.D.’s providing primary care. In many instances, the functions of general practice have partially shifted to specialists in internal medicine and pediatrics. In addition, the most recent specialty to be recognized is that of family practice, which had its specialty board established in 1970, and there are indications of rapid growth for this specialty in the coming years. At the present time, one-half of the Nation’s medical schools have programs of family practice either started or in the planning stages, and indications are that many medical students are interested in this specialty. The basic projections developed in this report suggest variations in growth patterns among individual specialties, with the medical and surgical specialties growing the most rapidly. (See Table 6.) Among the 22 specialties analyzed, neurology is projected to demonstrate the largest annual average growth rate in the next 20 years—6.8 percent (compounded) between 1970 and 1980 and 4.7 percent (compounded) between 1980 and 1990. Otolaryngology, in contrast, is projected to exhibit the slowest growth rate (about 2.8 percent compounded) over the projection period. For general practitioners, the numerical declines of recent years are projected to continue through 1990, with the supply falling from 56,260 in 1970 to 36,700 in 1990. However, substantial growth in the primary care specialties of family practice, internal medicine, and pediatrics and minimal growth in obstetrics and gynecology should serve to largely offset the decline in general practice. As outlined later, developments in medical specialties relate closely to the impact of foreign-trained physicians and the assump- tions about FMG’s used for the projection. A number of alternative projections were also developed to show the projected distribution of physicians among Table 6. SUPPLY OF ACTIVE PHYSICIANS (M.D.), BY MAJOR SPECIALTY GROUP: ACTUAL 1963 AND 1970; PROJECTED 1975-90 Specialty group’ 19632 1970 1975 1980 1985 1990 Number of active physicians TORE | v0 nnrin wobetinsss 5ehict kb oak 3 0k 3 93 &prhicd 261,730 311,210 363,870 430,240 499,440 571,030 General practice vv ussnnisnsvmsnns vr vues 66,870 3 56,260 51,910 47,210 42,110 36,700 Medical specialties... ous sivas oi swims via sina» 46,520 66,380 86,210 110,750 136,490 163,240 Surgical specialties. ......coovviiiiiieenn. 67,010 85,380 106,750 133,550 161,660 190,870 Other specialties vucveervrrvsvmsvnswnrwns 81,330 103,190 119,000 138,720 159,180 180,210 Percent distribution Totals voi ii iie iii iii iin iene 100.0 100.0 100.0 100.0 100.0 100.0 General practice. « «.vxs vie sin evweniveviwsives 25.5 18.1 14.3 11.0 8.4 6.4 Medical specialties .....ovvveenniennnns 17.8 21.3 23.7 25.7 27.3 28.6 Surgical specialties. vu viv amr emi vv srwenas 25.6 27.4 29.3 31.0 32.4 33.4 Other specialties «oun s wie sms 2s vive sin 5m v 314 33.2 32.7 32.2 31.9 31.6 1 A more detailed listing of the specialties included within each group can be found in table 30. 2 See table 30 for explanation of adjustment of these figures. 3 Excludes 1,690 diplomates in family practice who have been included in figure for medical specialties. Source: 1963: Theodore, C. N. and Sutter, G. E. Distribution of Physicians in the U.S., 1963. Chicago, American Medical Association, 1967. 1970: Haug, J. N.; Roback, G. A.; and Martin, B. C. Distribution of Physicians in the United States, 1970. Chicago, American Medical Association, 1971. Note: Figures may not add to totals due to independent rounding. individual specialties. On balance, however, the resulting distributions did not appear to differ substantially from the pattern shown using the basic methodology. Despite this consideration, it should be noted that all of the projections undertaken here for the specialties are limited by lack of available data on physicians who spend their time and work efforts among a number of different specialties. In other words, in accordance with available published data, a physician has been designated to only one specialty on the basis of that area in which he reports most hours of work. The absence of information on functional distributions of time, and the corresponding implications for the supply projections, are described in greater detail in Chapter 4. REGISTERED NURSES Registered nurses form by far the largest group of health professionals. In 1970, the active supply of R.N.’s numbered 723,000, or more than half of the total health professional work force, a substantial increase (37 percent) 565-118 O - 74 - 3 17 over the 527,000 active R.N.’s in 1960.2 (See Table 5.) The projections provided here indicate further substantial growth in the supply of R.N.’s over the next 20 years, at an average annual growth rate (3.6 percent compounded) somewhat above the experience of the 1960’s (3.2 percent). A slowing down in the rate of growth is expected to occur during the latter 10 years of the period. In the 1970-80 decade, the supply of nurses is expected to increase by more than one-half, or at a greater rate than during the 1960-70 decade. The slower pace projected for the 1980-90 decade reflects assumptions about the future course of admissions to nursing programs, which are discussed in detail in Chapter 10. During the middle and latter 1960’s, the effects of the Nurse Training Acts of 1964 and 1971 and the Health Manpower Act of 1968 on nursing education were significant. Prior to enactment of the Nurse Training Act in 2Since the preparation of this chapter, revised estimates of the 1970 supply of active R.N.’s have been developed. See p. /30 for a brief explanation of this change. 1964, for example, total enrollment in programs preparing registered nurses was approximately 129,000. By 1970, total enrollment had grown to nearly 165,000, an increase of 27 percent. This compares with 9 percent growth between 1960-61 and 1964-65. The number of programs, furthermore, rose from 1,137 in 1960-61, to 1,158 in 1964-65, and to 1,355 by 1970-71. Continued increases in admissions and, subsequently, in the supply of registered nurses seem inevitable given the current indication of the attraction of the occupation to young people. In this regard, the increased recognition of the numerous ways in which R.N.’s can and do contribute to the provision of health care has, in part, resulted in this development. In addition, the attractiveness of this field may continue to be enhanced as the increased employment of other health workers serves to allow R.N.’s to utilize their professional skills. DENTISTS Between 1960 and 1970, the supply of active dentists rose from 90,120 to 102,220. (See Table 5.) Since this increase represented an average growth rate below that evidenced for all health professions as a group, the proportion that dentists comprise of the total health professions fell from 8.8 to 7.7 percent. The projections provided here for this group indicate further declines in the proportion to 6.2 percent in 1990. Nevertheless, the supply of active dentists is projected to rise from 102,220 in 1970 to 154,910 in 1990—an average annual growth rate of 2.1 percent (compounded). Although this growth rate is somewhat slower than that for all health professions combined (2.6 percent compounded), it is nearly twice as fast as the growth in supply during the 1960-70 period (1.3 percent). Overall, the ratio of dentists to population is projected to increase from 50 per 100,000 in 1970 to 62 per 100,000 in 1990. An examination of dental school enrollment over the past two decades reveals striking evidence of the substantial impact upon enrollment of the formula and special project grant provisions of the Federal legislation in recent years. During the past decade, for example, the average rate of increase in total dental school enrollment was about 2.3 percent, compared to annual gains of 1.2 percent experienced through the 1950's. Since 1965, however, coincident with the initiation of Federal legislation, this average annual gain has approximated 3.6 percent. These developments in enrollment have, in turn, resulted in similar trends among graduates of dental schools over the historical period. Although enrollment is projected to increase substan- tially in the next few years, the picture over following years 18 will in all likelihood witness a dramatic slowdown in the rate of growth (under the legislative assumption posed earlier). Historical evidence suggests strongly that the growth of dental school enrollment may very well be somewhat slow in the absence of Federal funding for enrollment increases assumed for the period after academic year 1974-75. The reader should keep in mind, however, that the basic assumption is that aggregate funding after 1974-75 be such as to at least maintain the level of dental school enrollment resulting from the current Federal legislation and efforts by non-Federal public agencies and private sources. PHARMACISTS As with active dentists, pharmacy manpower is projected to increase more rapidly in the 1970-90 period than during the 1960’s—at a 1.7 percent annual rate as compared with a 1.0 percent rate. However, pharmacists as a proportion of the overall health professional work force are expected to continue to decline somewhat, as they did in the 1960-70 period. Between 1960 and 1970, the proportion that active pharmacists represented of the overall professional work force fell from 11.4 percent to 9.7 percent. Although the active supply is projected to increase from 129,300 to 179,900 over the 20-year period, the proportion they represent of the overall professional supply is projected to decline to about 8 percent in 1980 and 7 percent in 1990. (See Table 5.) As with other health professions enrollment trends of pharmacists have reflected the impact of Federal legislation upon the course of health professions education. In the last decade, for example, third-to-last year enrollment® rose from 4,145 in academic year 1962-63, to 4,491 in 1964-65, znd to 5,864 by 1970-71. Between academic years 1970-71 ind 1971-72, furthermore, the number of these enrollees ‘ose by over 600 students, or by 11 percent. Under the oasic methodology (and assumptions) used in this report, the number of third-to-last year students is projected to rise sharply by 1974-75 (to about 7,300) and then to continue increasing over the projection period, reaching 8,854 by 1987-88. Continued enrollment and supply increases in pharmacy are virtually assured by several factors that, although not unique to the occupation, pose prominent attractions to 3Enrollments are reported for only the last 3 years of pharmacy school programs leading to the B.S. and B.Pharm. degrees, but figures include students who are studying for the Pharm.D. as their first degree. These are the most meaningful figures which can be obtained on a national basis because many pharmacy colleges admit students after 2 collegiate years and enroll them for 3 professional years. the field. The profession provides considerable oppor tunities for part-time employment and scheduling flexibili- ties that offer appealing work conditions for a continued influx of female professionals. Furthermore, the increased role of pharmacists as consultants to physicians and the general public regarding use of drugs also may appeal to greater numbers of young people interested in this aspect of health and in the general functioning of our society. In accordance with some of these considerations, the basic methodology used here projects an increase in the supply of active female pharmacists from 11,700 in 1970 to 20,700 in 1980 and 35,200 in 1990. In effect, the supply of female pharmacists is projected to triple over the next two decades, increasing the proportion of all active pharma- cists accounted for by females from 9.0 percent in 1970 to 19.6 percent by 1990. VETERINARIANS, OPTOMETRISTS, PODIATRISTS Among the remaining health professions, the greatest relative increases in supply are anticipated for veterinarians. Compared with a 31-percent growth in supply during the 1960’s, the supply of these professionals is projected to grow by 41 percent during the 1970's and 32 percent during the 1980’. By 1990, the supply of active veter- inarians is projected to reach 48,100, an 86-percent in- crease over the 25,900 active supply in 1970. The supply of optometrists is projected to increase from 18,400 in 1970 to 28,000 in 1990, somewhat more rapidly than during the 1960-70 period. For podiatrists, the supply is projected to grow rapidly, increasing from 7,100 in 1970 to 13,000 in 1990. The ratio to population for both op- tometrists and podiatrists will rise substantially. ALTERNATIVE PROJECTIONS In addition to the projection for health professionals utilizing the basic methodology, a number of alternative projections were developed for several professions that reflected different educational responses to the basic "assumption that underlay the projections. Although the basic assumption was that enrollment resulting from current legislation would at least be maintained through the projection period, it was further assumed that, given these enrollment levels as a base, additional increases might occur in the absence of Federal funding specifically targeted at increasing enrollment. The basic methodology, con- sequently, assumed that any further enrollment increases or construction of new schools could be approximated by the experience of the respective professional schools prior to the initiation of massive Federal legislation. For a number 19 of occupations, consequently, alternative projections were developed that assumed either (a) an absence of further enrollment growth after 1974-75 or (b) a growth pattern after 1974-75 that exceeded the gains experienced prior to the legislative impact yet remained at a pace below that evidenced during the time when Federal legislation ap- parently exerted its greatest impact. Two alternative projections were developed for the overall supply of physicians, for example. Compared to the basic supply projection for physicians discussed above (593,800 in 1990), the “high” projection showed an sstimate of 637,100 for 1990, while a “low” projection resulted in a supply projection of 552,000 for that year. The divergence in the supply estimates projected by these alternatives, consequently, would be about 85,000 by 1990, with the “low” or most conservative estimate being about 15 percent below the “high” projected figure. The variation in these supply figures reflects, in part, differences in the number of projected first-year enrollees in U.S. medical and osteopathic schools, which result in corresponding differences among the number of graduates projected. The basic methodology projects, for example, a total gross graduate input (before deaths and retirements) of 268,083 M.D. graduates over the projection period; the low alternative projects a total input of 253,237, the high alternative projects an input of 284,496. In brief, the variations in domestic production of physicians, as pro- jected, account for somewhat more than one-third of the 85,000 difference in supply (1990) shown by the low and high alternatives. Variations in the projected growth pattern of the FMG population account for the remainder and the bulk of the difference. As indicated earlier, the basic methodology projects the number of active foreign-trained physicians in the United States to rise from about 60,000 in 1970 to 164,000 by 1990, an increase of 173 percent or about 8 percent annually (compounded). The high and low alternatives project a 1990 active supply of FMG’s of 191,000 and 137,000 respectively. Even under the conservative alterna- tive, significant growth in the FMG population is projected—more than doubling over the next two decades. Physicians represent the only health professional group in this report for which alternative projections were undertaken for two segments of the professional popula- tion—namely, U.S. medical and osteopathic school grad- uates and the FMG population. A total of nine combina- tions of alternate projections can be shown. In this report, the low alternative shown represents the combination of low projections for both segments of the physician popula- tion; the high alternative represents, correspondingly, a combination of the two high projections. (See Table 7.) No additional analysis has been undertaken concerning the other possible combinations. Considerations used in developing these alternative projections for physicians and for other health professional groups, as well as comparative findings, are presented in greater detail in subsequent chapters. In summary, the overall projections developed for health professions show a sharp expansion in the supply of these groups over the 1970-90 period, generally at a more rapid pace than during the 1960 decade. These projections, however, are contingent upon the basic assumption about productive capacity advanced earlier. Actual growth patterns could vary considerably from the projections shown if the aggregate level and composition of support in the coming years were to be substantially different from that assumed in this report. Table 7. ALTERNATIVE PROJECTIONS OF THE SUPPLY OF ACTIVE PHYSICIANS (M.D. AND D.O.) IN THE UNITED STATES: 1990 Type of alternative projection of physicians Projected number Trained in the of active physicians Fane dn i 1 | (M.D. and D.O. United States Foreign trained ( an ) Low Low 2 552,000 Low Basic 578,600 Low High 605,200 Basic Low 567,200 Basic Basic 2 593,800 Basic High 620,400 High Low 583,900 High Basic 610,500 High High 2 637,100 ! Includes physicians trained in Canada. 2 Represents projections shown and discussed in this report. SUPPLY OF ALLIED HEALTH PERSONNEL Among allied health professions and occupations, the supply projections developed for this report utilize as estimates of future entrants into the supply only graduates of approved programs. This reflects the fact that data available on the training of allied health workers are 20 extremely sparse and limited to only a few occupations.’ Furthermore, in only a relatively small number of allied health fields are all or most workers formally trained in: educational institutions. In order to assess fully the meaning of the projections of allied health workers, it will be necessary to determine what additional supply will result from those entering the field from other than approved programs. Such supply projections are now being developed by BHRD. Projections of allied health manpower supply have been developed in this report for 16 occupational groups, generally those where information on supply, graduates, and training programs is available and reasonably reliable. /t should be noted by the reader, however, that these projections were developed for the active supply of formally trained persons in the respective allied health professions and occupations, not for the total supply of workers. In all of the projections (as summarized in Table 8), the initial starting supply point in 1970 represented the best estimate available of the active credentialed work force. Over the projection period, subsequently, additions, to the work force consisted only of graduates of approved programs. The rationale for this approach was partly based on the current inadequacies in the data base for allied health manpower which, in turn, precluded what could be’ considered meaningful projections of the total supply, including persons now in the work force and future entrants into these occupations who have not gained entrance through formal training. This approach, in view of the growing trend in many occupations to have formal training as a minimum requirement for entrance, permitted an examination of current and future profiles for those persons who had received or were projected to obtain formal training. Given such considerations, nonetheless, the projections for these selected allied health occupations did reveal considerable variation in growth patterns. This is illustrated in Table 8 and presented in greater detail in Chapter 11. * * * * * * The overall findings presented above for health profes- sions and allied health projections provide a brief overview of the material presented in this report. Detailed informa- tion, and additional background data, are provided in the following chapters. Table 5. SUPPLY OF ACTIVE FORMALLY TRAINED SELECTED ALLIED HEALTH PERSONNEL: 1970 AND PROJECTED 1975-90 Occupation 1970 1975 1980 1985 1990 Basic educational preparation at least baccalaureate in level Dietitians ........... » UR EE SOE CE VE GE CEE OE 15,300 16,140 18,170 20,470 22,340 Medical record administrators ......coeevvenenen.. 4,200 4,500 5,140 5,850 6,430 Medical technNOIOZISIS: six. viv s aw 4 was 0s vse wiv 500 + we 45,000 60,160 80,620 103,010 123,520 Occupational therapists «vo vvvveieerneeennnnnnns 7,300 9,270 11,760 14,500 16,880 Physical therapists ..o« ves vv « sin ¢ vio + ws vais su wigs ie 11,550 16,640 23,030 30,080 36,570 Speech pathologists and audiologists . . . .vvuvuuunn. 13,300 23,560 37,070 53,720 70,930 Basic educational preparation less than baccalaureate in level Certified laboratory assistants . ......ocu0vuae wo 6,700 13,590 22,260 31,950 41,160 CytotechnOlOgIStS us +i vivre vive Minis swe wiv » ww vm wie 2,400 3,400 4,670 6,090 7,400 Dental assistants... «vu 55:0 + 5iv owe wists sis Wie» 574 3434 20 9,200 23,490 39,110 55,880 71,530 Dental hygienists ......o0uvuunn Fok Sima § iss Vai 15,100 23,310 34,190 46,320 57,650 Dental laboratory technicians ...... $e WIN wi aie. 1,600 3,970 7,070 10,670 14,290 Respiratory therapists ....... HSB SEE GONE SSE 3,850 6,800 10,510 14,720 18,810 Licensed practical nurses ......... SHG TTS BNE 400,000 464,680 565,890 693,410 819,790 Medical record technicians ........ VE Wn vis wee 3,800 4,160 4,900 5,720 6,460 Occupational therapy assistants. .......oceueuunn. 600 2,320 4,360 6,620 8,820 Radiologic technologists .....eovveuenennnnnnns 41,000 63,570 93,560 127,770 161,280 Source: 1970 dental allied: BHRD, Division of Dental Health 1970 all other occupations: National Center for Health Statistics. Health Resources Statistics. Health Manpower and Health Facilities, 1971. DHEW Pub. No. 72-1509. U.S. Government Printing Office, 1972. Note: These estimates are for the supply of formally trained personnel only, and consequently should not be viewed as representing total active supply. Additions to 1970 supply include only graduates of approved programs. 21 PART II DETAILED OCCUPATIONAL PROFILES Chapter 3 This chapter provides a wide variety of information— current, historical, and projected—on physicians in the United States. It describes current characteristics and trends, as well as projections of the total supply of physicians. Also included are data sources used, a discussion of the assumptions and methodology used in developing the projections, and an analysis of the projection findings. The data on physicians (M.D.), largely drawn from data published\ by the American Medical Association (AMA), generally cover all active non-Federal physicians in the 50 States, the District of Columbia, Puerto Rico, and other outlying areas of the United States, as well as Federal physicians in the United States and abroad. Excluded from coverage are inactive physicians, those with address un- known, and those identified as “temporarily foreign.” The American Osteopathic Association (AOA), which maintains a master file of osteopathic physicians in the United States, is the source of all primary data descriptive of the osteopathic physician population. The AOA file was recently updated on the basis of a survey of osteopathic physicians conducted by the AOA in June 1971. While preliminary data are available, the results from the survey are not included in this report, since further analysis will be required before using the data. Therefore, 1970 characteris- tics data shown in this report for osteopathic physicians have been estimated on the basis of distributions observed in 1967. There is probably more extensive and better quality information on the M.D. population than on any other health profession. There are, however, a number of prob- lems in utilizing the historical data on M.D.’s. In the early 1960’s, the AMA made a major effort to improve its data on the M.D. population, including changes in definitions and coverage which created discontinuities in the statistics. Among significant changes made by the AMA were: (1) a shift of the annual reference point from mid-year to year-end; (2) omission of non-Federal physicians with temporary foreign addresses from tabulations of physician data; (3) the inclusion of foreign-trained physicians taking internship or residency training in the United States, without regard to the physician’s intention to remain here after completing training; and (4) inclusion of un- licensed foreign-trained physicians identified for the first time when they obtained standard certificates from the Education Council for Foreign Medical Graduates.’ 'A detailed discussion of these modifications and the reasons for them appears in: Pennell, Maryland Y. Statistics on Physicians, 1950-63. Public Health Reports 79: 905-910, October 1964. 25 PHYSICIANS In 1968, furthermore, the AMA made several major changes in its classification system and questionnaire format which substantially affected the activity and spe- cialty classification of physicians and created a discon- tinuity in the historical series of M.D.’s between 1967 and 1968. Although the data on M.D.’s as a whole remained relatively consistent over this period, there was disconti- nuity for active M.D.’s. Under the new classification system, the identification of inactive physicians became a priority. Largely reflecting the definitional change, as well as the impact of improved and computerized record keeping, the number of physicians listed as inactive rose from 13,000 in 1967 to 19,000 in 1968. Significant changes are also apparent in the ‘“‘not classified” category in 1970 through 1972. In 1970 this category represented only 0.1 percent of all physicians, but in 1972 it increased to 3.5 percent. This anomaly is due largely to the high non- response rate to recent AMA procedures to update its files. Further information on the effects of these changes is given in subsequent sections of this report. These problems notwithstanding, the historical coverage of the M.D. population is considerably more extensive than that of osteopathic physicians. Historical data for D.O.’s are very limited, and the figures shown here are largely estimates. In order to provide an improved data base on D.O.’s, the Bureau of Health Resources Development (BHRD) has contracted with the American Osteopathic Association to process the data from its 1971 survey of osteopathic physicians. Efforts are also being undertaken by BHRD to gain further insights into the supply profile of the M.D. population. For example, BHRD is currently exploring a number of alternative approaches to improving and expand- ing the current data base on foreign-trained physicians. As indicated later in this chapter, the limited statistical information now available for this group represents perhaps the most significant and critical gap in the information system on physicians. Furthermore, BHRD is currently engaged in a number of contracts to provide additional supply, requirements, and utilization information for se- lected specialties. CURRENT CHARACTERISTICS AND TRENDS There were approximately 323,200 physicians—311,200 M.D.’s and 12,000 D.O.’s—actively engaged in medical practice in the United States as of December 31, 1970. About 54 percent of all active physicians were under 45 years of age, according to estimates based on 1967 AMA data. (See Table 9.) Thus, at least one-half of the active Table 9. NUMBER OF ACTIVE PHYSICIANS (M.D. AND D.O.), BY AGE GROUP AND SEX: DECEMBER 31,1970 Both sexes Male Female Age group Percent P N ercent Percent umber | gistribution | NUP | gisibution | UMP | icwibution ANE: wiv + ww ¢ $19 8 Fwd wie $30 496 FiwE6 io 323,200 100.0 301,000 100.0 22,200 100.0 25-44 years 4 BATE 3 WR RR SAE A a 173,340 53.6 160,090 53.2 13,260 59.9 25529" iy dru vine wow wines Bras win are si ses wi 37,980 11.8 33,910 11.3 4,070 18.4 30:34: wu sins win 4 wins mn 5 wns miwin wow ¢ iw eH wy 46,360 14.3 43,130 14.3 3,230 14.6 B5539 ii wind wins 2 5 BH0 00 BES WINE B98 Bie #0 44,970 13.9 42,110 14.0 2,850 129 BOMB. 5.0 0 «Givi 3:43 init ak d B20 § WHE id SS 0 44,040 13.6 40,930 13.6 3,110 14.0 A564 YORIS 445 wins wins wis 0 5:84 90s 4iw 4 41% 3 05% 58 120,200 37.2 113,120 37.6 7,080 31.9 ASB os oi00 wiv + Win 0 WEES FW 0 B00 § WR SBE SEW 38,440 11.9 35,940 11.9 2,500 71.3 S0:54 aia o vi 2 ws wins S00 § 9583 900 wa www wie 31,650 9.8 29,700 9.9 1,960 8.8 B5u89 sain a wince wewin pinin Sit # 0k 5a § sk Bick 0 28,560 8.8 27,070 9.0 1,500 6.7 [10 21,540 6.7 20,420 6.8 1,120 53 65 years and OEY... vis vivid iv & wis + 5k + #i% ¢.4/% wie 29,660 9.2 27,830 9.2 1,830 8.3 G88 5k via 0 0 3 ik 4 Tk 5 Bk & wed HOT BR Ri 13,880 4.3 13,010 4.3 870 3.9 70-74. 0.0 00:0 vivo v0 0 wins viv 90m 0 ww shrews 8,130 25 7,560 25 570 2.6 75 ANA OVRY: wv i vos wis + 510s vin + ww + 50 wwe wie 7,650 2.4 7,260 2.4 390 1.8 ! Includes all those reported as ‘‘under 30 years of age”. Source: Female physicians: Based on percent of women among active M.D’s as shown in: Pennell, Maryland Y. and Renshaw, Josephine E. Distribution of Women Physicians, 1970. Journal American Medical Women’s Association 27: 197-203, April 1972. Age distribution of physicians: Based on 1967 age distribution of active M.D.’s as shown in: Theodore, C. N. and Haug, ]. N. Selected Characteristics of the Physician Population, 1963 and 1967. Chicago, American Medical Association, 1968. Note: Figures may not add to totals and subtotals due to independent rounding. Preliminary data from the 1971 American Osteopathic Association Survey of Osteopathic Physicians suggest that active osteopaths are somewhat older than active M.D.’s. physician supply in 1970 was accounted for by those who graduated during the past two decades. Among the young- est age groups, a considerably larger percentage of female physicians (one-third) were under the age of 35 than were male physicians (one-fourth). Looked at in another way, nearly half of all physicians were 45 years of age or over in 1970, and nearly all of these physicians will have left the profession through death or retirement by 1990. Female physicians accounted for 6.9 percent (or 22,200) of the total active supply in 1970.2 Although this propor- 21t should be noted, however, that according to the 1970 Census of Population, 9.2 percent of physicians were female. The discrepancy in these figures might, in part, be accounted for by (1) the standard errors inherent to proportions from a sample, as is the case in both the figures in Table 9 and the 1970 census results, (2) the general mobility of females in and out of the labor force and most important, (3) the fact that the Table 9 figure is based on a stringent AMA classification of activity (new classification), where Census data rely on self-reporting. 26 tion was up slightly from 1967 (5.7 percent), recent developments in medical school enrollment suggest sharper increases in female representation in coming years. For example, in 1968-69, women accounted for 9.1 percent of the total first-year enrollments in U.S. medical schools; in 1969-70, 9.3 percent; in 1970-71, 11.1 percent; and in 1971-72, 13.5 percent.? According to the 1970 Census of Population*, Blacks accounted for 2.2 percent of the physician supply in 1970; and M.D.’s of Spanish heritage accounted for about 3.7 percent. Although current information on the racial-ethnic composition of physicians is generally rather limited, data 3pubé, W.F. US. Medical Student Enrollments, 1968-69 through 1972-73. Journal of Medical Education 48: 293-297, March 1973. 4U.S. Bureau of the Census. United States Census of Popu- lation: 1970. Detailed Characteristics. United States Summary. PC(1)-D1. U.S. Government Printing Office, 1973. from the Current Population Survey (CPS) indicate that the representation of Black and other minority groups was about 8 percent in 1970.° It should be recognized, however, that CPS definitions of racial-ethnic groups are not totally consistent with Census classifications; further- more, separate data on Black representation are not available from the survey. To remedy this lack of racial-ethnic data, BHRD has contracted with the National Medical Association Founda- tion, Inc., to conduct a survey of Black physicians. This survey is shortly expected to provide data on the geo- graphic distribution, types of practice, specialties, and other professional and personal characteristics of Black physicians in the United States. The number of Black physicians more than likely will soon be increasing, since Black enrollments in medical schools have been rising in the past few years. In the 1968-69 academic year, Blacks accounted for 2.7 percent of first-year enrollment; in 1969-70, for 4.2 percent. Other minorities, such as Orientals and Puerto Ricans, have also shown small increases in enrollment in recent years, and two very underrepresented minorities—Mexican-Americans and American Indians—have shown relatively sharp in- creases, though their total representation continues to be virtually negligible. Among the Nation's geographic regions, physicians are disproportionately located in the Northeast and West, areas that have ratios of active physicians per 100,000 population significantly above those in the South and North Central States. On a geographic division basis, physician/population ratios in 1970 ranged from 196 and 190 per 100,000 population in the Middle Atlantic and New England States respectively, to 132 and 105 per 100,000 population in the West South Central and East South Central States, respec- tively. Individual State ratios ranged from a high of 236 per 100,000 population in New York, to a low of 89 per 100,000 population in Mississippi. (See Table 10.) This geographic pattern largely reflects the continued movement of physicians to States having large urbanized areas. For example, although physicians were under- represented in the South, the physician/population ratio for the South Atlantic States was virtually at the national average in 1970—largely resulting from heavy physician concentrations in the District of Columbia and Maryland (Baltimore). Of the 10 States with the largest number of cities with populations over 100,000 in 1970, furthermore, only one State (Indiana) had a physician/population ratio lower than the median ratio for all States (134 per 100,000 population). SUnpublished data from the Current Population Survey of the Bureau of Labor Statistics, U.S. Department of Labor. 6Dubé, op. cit. 27 Contributing to this development has been the rapidly increasing demand for physician services in large metro- olitan areas, as well as the greater attraction presented to physicians to practice in urban rather than rural settings. To some extent, the locational patterns of physicians appear to reflect the distribution of medical schools in the Nation. More significantly, however, available evidence suggests strongly that State of practice tends to be related to State of internship and residency. These training programs tend to be concentrated in metropolitan areas, where facilities are generally more adequate to further educate large numbers of doctors. The geographic distribution of osteopathic physicians differs somewhat from that of M.D.s. In 1970, for example, ratios among regions ranged from 3.3 per 100,000 population in the Southern region to 9.6 per 100,000 population in the North Central region. In contrast to M.D.’s, it has only been during the last decade that virtually all States have begun to license D.O.’s for unlimited practice, a situation that is partially responsible for the current skewed geographic distribution of D.O.’s. Pre- liminary AOA survey results indicate that at the end of 1971, two-thirds of all active non-Federal osteopathic physicians were located in the East North Central, West North Central, and Middle Atlantic divisions. The largest concentration of active D.O.’s in the Federal service was located in the North Central region. Direct care of patients is the primary activity of the overwhelming proportion of physicians. As of December 31, 1970, 290,300 physicians (or 90 percent of all active physicians) were involved in the direct care of patients as their primary activity. (See Table 11.) About two-thirds of all active physicians were in office-based practice (203,200), while slightly less than one-third (87,100) were in hospital-based practice. Of this latter group, 52,000 were interns or residents. The remaining active physicians were engaged in administration (12,200), research (11,900), medical teaching (5,700), and other activities (2,700). Of physicians in patient care, 70 percent were in office-based practice. Over 98 percent of the active osteopathic physicians have patient care as their primary activity, with the remaining 1 percent recorded in teaching. About 90 percent were in office-based practice and 9 percent in hospital- based activity. As explained earlier, the American Medical Association recently introduced new criteria for establishing a physi- cians’s primary activity. The physician no longer merely indicates his primary activity, but rather reports the average number of hours worked during a typical week in each activity. The primary activity is defined (and assigned by computers) as that in which the physician indicates that he spends the greatest number of hours. Table 10. NUMBER OF ACTIVE PHYSICIANS (M.D. AND D.O.) AND PHYSICIAN/POPULATION RATIOS, BY GEOGRAPHIC REGION, DIVISION, AND STATE: DECEMBER 31,1970 Region, division, and State Resident popula- Number of active tion July 1,1970 Number of physicians per Number of active Number of active physicians (in 1,000) [100,000 population M.D.s Do/s All locations ........ 323,200 209,539 154 311,200 12,000 UNITED STATES ....... 317,200 203,805 156 305,300 12,000 NORTHEAST ...ivvivnnrnnnnnn. 95,730 49,150 195 92,520 3,210 New Englands. sie vos ss vies oe 22,530 11,873 190 21,940 590 Connecticut. «vivecsvssosne 5,730 3,039 189 5,690 50 Maine. .....ovivinnennnns 1,240 995 125 1,060 180 Massachusetts ......co0uu.. 12,120 5,699 213 11,890 240 New Hampshire............ 1,010 742 136 990 20 Rivode Islands ov seis vies wins oie 1,600 951 169 1,530 80 Vermont «oveveveeennnnnns 820 447 184 790 30 Middle Atlantic. «s+ sv s 0 5 0m 0 0 73,210 37,272 196 70,580 2,630 New Jersey ....coovvnennse 10,900 7,195 152 10,300 600 New York voovvvvnvnnnnnnn 43,080 18,260 236 42,560 520 Pennsylvania «.vcsuvuerans nn 19,270 11,817 163 17,720 1,510 SOUTH iunsvsumevnen wo WE BE 83,750 62,990 133 81,630 2,110 South Altantic ......ooveuen.. 45,690 30,773 149 44,880 810 DEIAWALE +s coos vv viniw vu +50 780 550 141 740 40 District of Columbia ........ 3,950 753 525 3,940 20 Florida: + sic +500 wis ¢ wis «0 4 we 9,980 6,845 146 9,490 480 Georgia. « sis wns wn suns pp 5,360 4,602 117 5,280 80 Maryland... ss 5 5 5s Give » we 9,150 3,937 232 9,130 20 North Carolina ............ 5,790 5,091 114 5,760 30 South Caroling «vesaw swe van 2,520 2,596 97 2,520 10 VHBINIA 5 os « wis vi 0 970 3 50 3 i 6,240 4,653 134 6,200 40 West Virginia... covesnssnsnn 1,930 1,746 111 1,830 100 East South Central ............ 13,460 12,823 105 13,370 90 ALBAN: vz i vn skis sw ne wins 3,200 3,451 93 3,200 0 RENIUCKY is + on +50 sain 5 win 4 0 3,440 3,224 107 3,410 40 MISSISSIDPN « «wi oie 4.0 3 ik Sk 1,970 2,216 89 1,970 0 Tennessee . . vu « vu sve vive» win 4,850 3,932 123 4,800 60 West South Central ........... 24,590 19,396 132 23,380 1,210 ALRANSAS 3:4 + ws vii v.00 3 ww ivi 1,830 1,926 95 1,820 20 Louisiana. . «a. sss vs 06d 00s 4,600 3,644 126 4,590 10 Oklahoma ...ceveunnns Kare 3,140 2,572 122 2,730 410 TEXAS 4 » wiv wie » wows 900 wig wy 15,030 11,254 134 14,250 780 NORTH CENTRAL ........c..n.. 76,500 56,730 135 71,060 5,440 East North Central ............ 54,430 40,368 135 50,730 3.900 UNOS. « wa wins wns iw «win + ws 135,770 11,737 142 15,490 280 Indiana ....oovvvnenennnen 5,360 5,208 103 5,180 180 Michigan ss « vies wins ww cme von 12,810 8,901 144 10,770 2,040 OMIO wu + wiv 3 wiv 5 00 & wis + win sine 15,060 10,688 141 14,020 1,040 WISCONSIN... « wis + ws + 00s v.00 wine 5,430 4,433 123 5,270 160 28 Table 10. NUMBER OF ACTIVE PHYSICIANS (M.D. AND D.0.) AND PHYSICIAN/POPULATION RATIOS, BY GEOGRAPHIC REGION, DIVISION, AND STATE: DECEMBER 31, 1970—Continued 3 Number of active Region, division, and State b f Resident popula- tion July 1, 1970 Number of physicians per Number of active Number of active physicians (in 1,000) | 1,000 population M.D.s B.0% NORTH CENTRAL—Continued West North Central. ........... 22,070 16,367 135 20,340 1,740 lowa oovviiiniinnnnnnn., 3,260 2,830 115 2,880 380 KANSAS vy v:oi0 swe wan winie isin wis 2,910 2,248 129 2,740 180 Minnesota «. «uv nies vies sive 530 5,860 3,822 153 5,810 50 MiSSOUFL. + vis 50000 neve en 7,020 4,693 150 5,970 1,050 Nebraska ................ 1,760 1,490 118 1,730 40 North Dakota ............. 630 618 102 620 10 South Dakota: vu se same vs sie 630 666 95 600 30 WEST one woo vim 4 wins Wins + 50 5 0k 9.9000 0 61,330 34,930 176 60,090 1,230 Mountain ....oovvvvvnnnnnnn. 12,550 8,345 150 11,840 710 ALIZONE 0.5 tina wow 3 wns ave wwe 4% 2,860 1,792 160 2,610 250 Colorado ..........co.... 4,380 2,225 197 4,140 240 $ARNG! iire wins tere wows pn vierw wines 700 717 97 670 30 Montana .........covvvunnn 770 697 111 740 30 NEVALR iv sr vine sive ws wine + 570 493 116 550 30 New Mexico. .....0000venes 1,420 1,018 139 1,300 120 Utah oo wi om 4 500 4 is 20k oe 1,500 1,069 141 1,480 20 Wyoming. ...oovivnnnnnnn. 350 334 103 340 10 Pacific vovvvunnnnnnnnnnnn... 48,780 26,589 183 48,260 520 AlBBKA , vue pv viun ses wins es 320 305 106 320 0 CAlIFOrNIA + vv u win + wiv + wim 4 we + 38,780 19,994 194 38,590 190 Hawall covsnvumenessmenns 1,170 774 151° 1,150 20 OPBBON. wi1.s vin 30:4 wows ivin worn 3,105 2,102 148 2,960 140 Washington ............... 5,400 3,414 158 5,240 170 PUBTED RICO wiv « wiv » wie « win & 010 wie 8 wis 2,480 LL om 2,480 = OULIYING areas: » we + wie o wis 5% 4 win » v 3,420 — —- 3,420 - Sources: M.D.’s: Haug, J. N.; Roback, G. A.; and Martin, B. C. Distribution of Physicians in the United States, 1970. Chicago, American Medical Association, 1971. D.O.’s: Based on data in: American Osteopathic Association. A Statistical Study of the Osteopathic Profession, 1967. Chicago, The Association, 1968. Population: U.S. Bureau of the Census. Current Population Reports. Series P-25, No. 468. Note: Figures may not add to totals and subtotals due to independent rounding. According to the AMA, the impact of the reclassification has been greatest (in percentage terms) upon the medical teaching component, as many physicians on medical school staffs spend more time in nonteaching functions (e.g., research or patient care) than they do in teaching. Thus, in 1970, the AMA reported approximately 5,600 physicians primarily engaged in medical teaching; whereas for the same year, the Association of American Medical Colleges (AAMC) reported 16,100 M.D.’s holding full-time faculty positions in American medical schools. 29 Overall, the number of active physicians in the United States has increased substantially in the past two decades, rising from 219,900 in 1950, to 251,900 in 1960 and to 323,200 in 1970, an increase of approximately 47 percent over the 20-year period. (See Table 12.) It should be noted, however, that these figures understate slightly the growth of active physicians, because of the change in the AMA classification system in 1968. Although the number of inactive physicians was fairly constant since the early 1960's, a change in definition used by the AMA in 1968 Table 11. NUMBER OF ACTIVE PHYSICIANS (M.D. AND D.O.), BY MAJOR PROFESSIONAL ACTIVITY: DECEMBER 31,1970 Total active physicians MD. D.0. Major professional activity Percent Percent Percent Number distri- Number distri- Number distri- bution bution bution All activities . . . . . 323,200 100.0 311,200 100.0 12,000 100.0 Patientcare ........... 290,300 89.8 278,500 89.5 11,800 98.3 Officebased .......... 203,200 62.9 192,400 61.8 10,800 89.8 Hospital based . . . ..... 87,100 27.0 86,100 27.1 1,000 8.5 Interns . ......... 11,900 3.7 11,400 3.7 400 35 Residents . ......... 40,100 12.4 39,800 12.8 400 29 Full-time staff . ..... 35,100 10.9 34,900 11.2 200 1.8 Medical teaching. ......... 5,700 1.8 5,600 1.8 100 1.1 Administration .......... 12,200 3.8 12,200 3.9 (1) - Research + sev www v vmm 11,000 3.7 11,900 3.8 0 — Other . . . w.osumesssunn 2,700 0.8 2,600 0.9 (1) — Not classified. . . . ....... 400 0.1 400 0.1 0 —- 1 Less than 50. Source: M.D.'s: Haug, ).N.; Roback, G. A.; and Martin, B. C. Distribution of Physicians in the United States, 7970. Chicago, American Medical Association, 1971. D.O.’s: Based on data in: American Osteopathic Association. A Statistical Study of the Osteopathic Profession, 71967. Chicago, The Association, 1968. Note: Similar data for M.D.’s for 1972 appear in Appendix C, table C2. Figures may not add to totals and subtotals due to independent rounding. resulted in raising its count of inactive physicians by about 6,000 between 1967 and 1968. As indicated above, the growth of the overall physician supply has been especially rapid since the mid-1960’s. Blumberg estimates that about half of the gain from 1966 to 1970 reflected the moderate increase in enrollment in U.S. medical schools beginning in the fall of 1960.” The remainder of the increase was largely accounted for by the continued entry of foreign-trained physicians into the U.S. supply. Increases in medical school enrollments in recent years give clear indications of continuing sharp increases in physician supply in the years ahead. In the last decade, total student enrollment in U.S. medical and osteopathic schools rose about one-third, from 32,232 in academic year "Blumberg, Mark S. Trends and Projections of Physicians in the United States, 1967-2002. Berkeley, Calif. Carnegie Commission on Higher Education, 1971. 30 1960-61 to 42,638 in 1970-71. Reflecting the impact of health manpower legislation since the mid-1960’s, enroll- ment growth has been especially rapid in recent years. Among medical schools, for example, first-year enrollment in academic year 1971-72 numbered 12,361, a 49 percent rise over first-year enrollment in 1960-61. Between 1966-67 and 1971-72, furthermore, the number of U.S. medical schools rose from 89 to 108, as compared with a total of 86 medical schools in 1960. (See Table 13.) FOREIGN MEDICAL GRADUATES About one out of every six M.D.’s in the United States is a foreign medical graduate (FMG).® There were 54,418 active FMG’s in the United States as of December 1970, representing the medical schools of 84 foreign countries. 81n this section of the chapter, “FMG’s” do not include Canadian trained physicians, unless otherwise stated. See footnote 1 in Chapter 2. Table 12. TREND IN NUMBER OF ACTIVE PHYSICIANS (M.D. AND D.O.) AND PHYSICIAN/POPULATION RATIOS: SELECTED YEARS DECEMBER 31, 1950-72 Number of Total Active Number of Number of Year active population physicians per active active physicians! (in 1,000’) 100,500 M.D.’s D.0.’s> population 1950 vc co vvwmns sa 219,897 156,472 141 208,997 10,900 V955 ww ssvwmmupn ss 240,153 170,499 141 228,553 11,600 960 wis +s snmmmin +» 251,933 185,370 136 239,757 12,176 198) wis s mwimmna s » 259,267 188,303 138 246,689 12,578 1962 ............. 264,947 191,236 139 254,316 10,631 I963 wvnis slvrmmmubin 5 » 272,502 194,169 140 261,728 10,772 1964: on vi vsnmmnn ss 280,461 196,858 142 269,552 10,909 1965 ...:esvwemass 288,671 199,278 145 271575 11,096 1966 woos os vn nmumnns 297,097 201,585 147 285,857 11,240 1967 ............. 305,453 203,704 150 294,072 11,381 J968 univ spies» 307,882 205,758 150 296,312 11,570 1969 svn is smnmnnies 314,706 207,863 151 302,966 11,740 1970 sna s sommmmn » 323,203 209,539 154 311,203 12,000 1971 sec ss mamma N.A. _— N.A. 4 (318,699) N.A. 1972 oii. N.A. - N.A. % (320,903) N.A. ! Excludes physicians with address unknown and those with activity status not reported. Includes civilians in 50 States, District of Columbia, Puerto Rico, and other outlying areas; U.S. citizens in foreign countries; and the Armed Forces in the U.S. and abroad. 3 The decline in the number of active D.O.’s between 1961 and 1962 reflects the granting of some 2,400 M.D. degrees to osteopathic physicians who had graduated from the University of California College of Medicine at Irvine when it was the College of Osteopathic Physicians and Surgeons. These physicians are included in the count of M.D.’s beginning in 1962. 4 Excludes 3,529 physicians “not classified”. If the percent active among all physicians is applied to the “not classified” physicians, the estimated number of active physicians would be 322,026. 5 Excludes 12,356 physicians “not classified”. If the percent active among all physicians is applied to the “not classified” physicians, the estimated number of active physicians would be 332,530. Source: All data for 1950, 1955; population for 1960-70: National Center for Health Statistics. Health Re- sources Statistics. Health Manpower and Health Facilities, 1971. DHEW Pub. No. (HSM) 72-1509. U.S. Government Printing Office, 1972. 1960-62 active physicians: Pennell, Maryland Y. Statistics on Physicians, 1950-63. Public Health Reports 79: 905-910, October 1964. 1963-67 active D.O.’s: National Center for Health Statistics. Health Resources Statistics. Health Manpower and Health Facilities, 1968. Public Health Service Pub. No. 1509. U.S. Government Printing Office, 1968. 1963-72 active M.D.’s: Roback, G. A. Distribution of Physicians in the U.S., 1972. Chicago, American Medical Association, 1973. Also prior annual editions. 1968, 1969 active D.O.’s: Interpolated by BHRD, Division of Manpower Intelligence. 1970 active D.O.’s: Unpublished data provided by the American Osteopathic Association. This group comprised 17.5 percent of the active M.D. population. In addition, active Canadian graduates in the United States numbered 5,539, or 1.8 percent of the active M.D. population. Historical data on total active FMG’s are very limited. Data on the total numbers are available for a number of years, but detailed data on age, sex, activity, and State of practice are available for only a few years. Where possible, 31 data on active FMG’s are presented here, although many of the characteristics data refer only to the total group—active, inactive, and address unknown. (A more detailed discussion of these and other weaknesses of the data on FMG’s is presented in the section on projections.) According to the limited data available, the FMG population in the United States has expanded at a rapid rate in recent years, while the number of Canadian Table 13. TREND IN NUMBER OF SCHOOLS, ENROLLMENTS, AND GRADUATES FOR MEDICAL AND OSTEOPATHIC SCHOOLS: ACADEMIC YEARS 1960-61 THROUGH 1971-72 Medical schools Osteopathic schools Academica Number Total First-year Number Total First-year of Graduates of Graduates enrollment enrollment enrollment enrollment schools schools 196061 nie: 86 30,288 8,298 6,994 6 1,944 496 506 1961-621... .. 87 31,078 8,483 7,168 5 1,555 439 363 1962-63 ..... 87 31,491 8,642 7,264 5 1,581 433 367 1963-64 ..... 87 32,001 8,772 7,336 5 1,594 441 355 1964-65 ..... 88 32,428 8,856 7,409 5 1,661 472 394 1965-66 ..... 88 32,835 8,759 7,574 5 1,681 464 360 1966-67 ..... 89 33,423 8,964 7,743 5 1,763 480 405 1967-68 ..... 94 34,538 9,479 7,973 5 1,823 509 427 1968-69 ..... 99 35,833 9,863 8,059 5 1,879 521 427 1969-70 ..... 101 37,669 10,401 8,367 6 1,997 577 432 1970-71 ..... 103 40,487 11,348 8,974 7 2,151 623 472 197172 wwe v » 108 43,650 12,361 9,551 4 2,304 670 485 i College of Osteopathic Physicians and Surgeons in Los Angeles became the University of California College of Medicine at Irvine in 1961-62. The latter school granted its first M.D. degrees to senior students who were to graduate in June 1962. Source: Medical schools: Medical Education in the United States, 1971-72. Journal of the American Medical Association 222: 961-1076, Nov. 20, 1972. Osteopathic schools: American Osteopathic Association, Office of Education. Educational Supplement March 1973. Also prior annual editions. graduates has remained relatively stable. As of Decem- ber 31, 1963, there were 30,925 FMG’s in the United States, comprising approximately one-ninth of the total M.D. population. By December 31, 1970, the number of FMG'’s had almost doubled, to approximately one-sixth of the total M.D. population. This near-doubling of FMG’s contrasts sharply with the 13 percent increase in U.S. trained M.D.’s and a 9 percent increase in Canadian trained M.D.’s between 1963 and 1970. By December 31, 1972, the number and percentage of FMG’s had risen even further. (See Table 14.) The rapid increase in total FMG’s in recent years is further illustrated by the increases in annual FMG immi- grants and exchange visitors, FMG licensure, and FMG- filled internships and residencies. In FY 1963, FMG immigrants and exchange visitors totaled 6,739%; by FY 1972, the number had risen by 65 percent to 11,080. Similarly, the annual number of newly licensed FMG'’s has risen rapidly, from 1,451 in 1963 to 3,016 in 1970, or from Stevens, Rosemary and Vermeulen, Joan. Foreign Trained Physicians and American Medicine. DHEW Pub. No. (NIH) 73-325. U.S. Government Printing Office, 1972. 32 one-sixth to one-fourth of the total new licentiates. By 1972, the number had risen to 6,661 or nearly one-half of all newly licensed additions to the medical profession.'® About one-half of the FMG’s in the United States were fully licensed as of December 31, 1970.'? The growing proportion of internships and residencies being filled by FMG’s also serves to illustrate the rising importance of this group. In 1962-63, 19 percent of all interns were FMG'’s; by 1970-71, the proportion was 35 percent. Residencies filled by foreign medical graduates increased from 24 percent of the total in 1962-63 to 32 percent in 1972-73. Almost two-fifths of all FMG’s in the United States in 1970 had graduated from medical schools located in Europe, while one-third had graduated from schools in Asia. (See Table 15.) Over 60 percent of all FMG’s in the 10 American Medical Association, Council on Medical Education. Medical Licensure 1972. Journal of the American Medical Associa- tion 225:299-310, July 16, 1973. There were wide variations among States in the proportion of FMG’s who were licensed. For example, more than two-thirds of the FMG’s in California were licensed, the largest percentage of licensed FMG’s in any State. This compares with only 6 percent in Louisiana. Table 14. TREND IN SUPPLY OF TOTAL PHYSICIANS (M.D. AND D.O.) IN UNITED STATES, BY COUNTRY OF GRADUATION: SELECTED YEARS DECEMBER 31, 1959-72 Other foreign trained United i Year h Tol 1 States Canadian Percent of total physicians tained traine Number a 1959... ii. 255,170 234,595 5,421 15,154 59 VIG! pti mls vim 289,188 252,619 5,644 30,925 10.7 1967 + i sinvwme ss von 322,045 270,179 6,050 45816 14.2 1969 i vuwwmuwss wan 338,942 N.A. N.A. 53,352 15.8 1920) +s sn nwwnm.s ss sou 348,328 284,937 6,174 57,217 16.4 VI?1 cinnuwmmd a3 nti 359,373 290,923 2 6,236 62,214 17.3 T1972 sna w ss mia N.A. N.A. N.A. 68,009 —- ! Includes both active and inactive physicians. 2 Unpublished data from the American Medical Association. Source: M.D.’s 1959: Stewart, William H. and Pennell, Maryland Y. Health Manpower Source Book 11. Medical School Alumni. U.S. Government Printing Office, 1961. M.D.’s 1963, 1967: Theodore, C. N. and Haug, J. N. Selected Characteristics of the Physician Population, 1963 and 1967. Chicago, American Medical Association, 1968. M.D.’s 1969-72: American Medical Association. Profile of Medical Practice. 1973 and prior annual editions. Chicago, The Association, 1973. D.0.’s 1959, 1971: Estimated by BHRD, Division of Manpower Intelligence. D.O.’s 1963-70: National Center for Health Statistics. Health Resources Statistics. Health Manpower and Health Facilities, 1971. DHEW Pub. No. (HSM) 72-1509. U.S. Government Printing Office, 1972. Table 15. NUMBER OF FOREIGN-TRAINED PHYSICIANS (M.D.) IN THE UNITED STATES, BY GEOGRAPHIC REGION OF GRADUATION: DECEMBER 31,1970 Region of graduation Number! Percent distribution ANTERIONS + suv ims 3 + EF FR BI FRAT RAR IE HE OTEE SF WE 63,400 100.0 ATCA sod viento s ims Passi sma B Ad ERAGE WY 1,130 1.8 BBIR com on 50 dim tiom von eon Bh wa ww eon ae nee oh 21,000 33.1 CRATE. 4 al 0. 0 mmm ikon » aims wyghin o' a slBsaimwichon o & semeoimmonld oli h 6,170 9.7 EUrOpe oi i ee ee ee ee ee ee eee eee 24,760 39.1 Latin AMErICR wv v vss sven tassssmsnsnnssnnmemns vas 9,930 15.7 470 1 TTT Im TY 400 0.6 ! Includes both active and inactive physicians. Source: Haug, ). N. and Martin, B. C. Foreign Medical Graduates in the United States, 1970. Chicago, American Medical Association. 1971. NOTE: Figures may not add due to independent rounding. same year were from 13 countries: Philippines, India, West Germany, Italy, Cuba, United Kingdom, Switzerland, South Korea, Mexico, Spain, Austria, Argentina, and Iran. (See Table 16.) Although about half the FMG’s were from developed countries, there has been a substantial increase in 565-118 O - 74 - 4 33 recent years in the number of FMG’s coming from the developing countries. The latter tend to be more recent graduates than those from the developed countries. As of 1970, approximately 60 percent of the FMG’s from developed countries had graduated prior to 1955. But a vast Table 16. PERCENT DISTRIBUTION OF FOREIGN-TRAINED PHYSICIANS (M.D.) IN THE UNITED STATES FOR SELECTED COUNTRIES OF GRADUATION: 1967 and 1969-72 Country of graduation 1967 1969 1970 1971 1972 All countries (excluding Canada): NUMBEE" 5 4 2 sobitmm 5 mammons +4 gs 46,300 53,600 57,200 62,200 68,000 PEICENE www 2 + nomad ss nmmmmas oa 100.0 100.0 100.0 100.0 100.0 Philippines . . . . «eee. 12.8 12.8 12.3 12.8 13.0 IR vpn rr ERIE FL NEES EE 8.2 6.9 6.8 5.1 23 WeSt Germany ...isisaswavesomnommmuss 5.6 6.1 6.0 7.1 52 BBY wives mm mwmie ds REE 5 a bem weno 53 5.6 55 6.4 5.1 CUBR wx os nnmmims mnmmmen s mw mn nn s 4.6 4.8 4.8 5.1 4.4 United Kingdom. . . ........ 000. .... 4.3 4.6 4.6 5.2 4.1 Switzerland... ..... LL... 4.1 4.4 4.4 53 3.8 SouthKorea . ...........0'iiveunenu.. 3.8 3.7 3.6 29 3.2 MEXICO vv ttt ea 3.2 3.2 3.0 3.4 3.1 SPAIN vous vs nsmpmss pv mn sr REE 32 3.1 3.1 2.8 3.2 AUSHIE oy cv ummn mn s smmanms s ous es 279 3.0 3.0 3.8 25 AD vn s s r mp a as ES REE 5.8 hE 3.0 29 2.8 25 3.1 ATSENEING: x « 1 5s ums ws s sno EH HG § bn l ww 23 2.3 2.2 2.3 23 L111, Et IT LE ET 36.9 36.5 37.5 35.3 37.7 ! Includes both active and inactive physicians. Source: 1967: Theodore, C. N.; Sutter, G. E.; and Haug, ). N. Medical School Alumni, 1967. Chicago, American Medical Association, 1968. 1969, 1971, 1972: American Medical Association. Profile of Medical Practice, 1971, 1972, and 1973 editions. Chicago, The Association. 1970: Haug, J. N. and Martin, B. C. Foreign Medical Graduates in the United States, 1970. Chicago, American Medical Association, 1971. majority (88 percent) of the FMG’s from developing countries (predominantly from Asia) had graduated after 1955.12 FMG’s tend to be younger than their U.S. counterparts. In 1970, slightly more than one-third of the United States graduates and slightly less than one-third of the Canadian graduates were under 40 years of age. Among FMG’s, in contrast, almost one-half were under 40. Over 75 percent of the FMG’s, furthermore, were under 50 years of age, compared with 61 percent of the U.S. graduates, and only 55 percent of Canadian graduates. (See Table 17.) FMG’s are also more often women. Females numbered 6 and 7 percent of U.S. and Canadian graduates respectively, but more than twice that proportion of the FMG'’s. Because many FMG’s enter the physician pool as “trainees,” relatively small numbers were in office-based practice in 1970. Over one-third of the active FMG’s were 12Based on data in: Haug, J. N. and Martin, B. C. Foreign Medical Graduates in the United States, 1970. Chicago, American Medical Association, 1971. 34 office-based, as compared with about two-thirds of active Canadian and U.S. trained physicians. Almost another third of all active FMG’s were interns or residents, about two and a half times the proportion of U.S. and Canadian graduates. Adding to the FMG interns and residents those who were full-time physicians on hospital staffs, one-half of all FMG’s were hospital-based, as contrasted with over one-fifth of U.S. and Canadian physicians. Since FMG’s tend to be younger than their U.S. and Canadian counterparts, it is to be expected that more of the FMG’s would be in training, and thus in hospital-based practice. FMG’s were also more likely to be engaged in research than U.S. trained physi- cians. (See Table 18.) Within the FMG aggregate, however, there were substan- tial differences in the activity distribution of those from developed and developing countries. FMG’s from the former had an activity distribution more nearly like that of U.S. trained physicians. On the other hand, FMG’s from the developing countries tended much more to be hospital- based. Almost two-thirds of all FMG’s from the developing countries were interns, residents, or hospital physicians. Table 17. NUMBER OF PHYSICIANS (M.D.) IN THE UNITED STATES, BY AGE GROUP AND COUNTRY OF GRADUATION: DECEMBER 31,1970 Number! by country of graduation Percent distribution Age group United . United 3 States Foreign Canada States Foreign Canada All.ages ......... 270,600 57,200 6,200 100.0 100.0 100.0 25-44 years ........... 130,560 36,260 2,750 48.2 63.4 44.6 25-292... ........ 32,830 5,370 370 12.1 9.4 6.0 3034 conus ts mim s 33,380 11,900 670 12.3 20.8 10.9 3539 sowuwins ra mune 33,320 9,760 871 12.3 17.1 14.1 4044. sus seus was 31,020 9,220 840 11.8 16.1 13.6 45-64 years ........... 104,070 16,880 2,290 38.5 29.5 37.1 45-49 . Loo... 33,530 6,830 650 12.4 11.9 10.6 50-54... 26,440 3,720 590 9.8 6.5 9.5 55-539 cons nr snmnwnins 24,050 3,110 580 8.9 5.4 9.4 6064 vvise ss vmmuni 20,040 3,210 470 1.5 5.6 7.6 65 yearsand over . ....... 36,010 4,090 1,130 133 1.1 18.3 6569 ............. 14,410 1,500 430 53 2.6 6.9 70-74 vvnnn ss nme 6,790 1,290 430 25 23 6.9 75andover . sawn 14,810 1,300 280 55 23 4.5 ! Includes both active and inactive physicians. 2 Includes all those reported as ‘under 30 years of age’. Source: Haug, J. N. and Martin, B. C. Foreign Medical Graduates in the United States, 1970. Chicago, American Medical Association, 1971. Note: Figures may not add to totals and subtotals due to independent rounding. Geographically, foreign medical graduates were dis- proportionately located in the New England, Middle Atlan- tic, and East North Central divisions. (See Table 19.) Well over one-third of all FMG’s were located in New York, New Jersey, and Pennsylvania, with New York being the State most heavily populated with foreign trained physicians. (See Table 19.) Although FMG’s comprised only 17 percent of all physicians in the United States, over 25 percent of the physicians in New York, Rhode Island, New Jersey, Illinois, and Delaware were FMG’s. This means that the physician/population ratios in these five States would be substantially lower without the FMG’s. In New York, for example, the ratio of total physicians (including Canadians and FMG’s) to population was 245 per 100,000 in 1970; without the inclusion of Canadians and FMG’s however, the ratio would have been 152 per 100,000. With the recent increase in the number of unsuccessful applicants to U.S. medical schools, the role of American citizens trained in foreign medical schools becomes in- 35 creasingly important. In 1970-71 alone, nearly 13,500 applicants were turned away from American medical schools. Given continued large increases in applicants, along with unabated interest among rejectees in seeking a medical education and the opportunity to study in foreign schools, the number of Americans studying medicine abroad may evidence sharper growth patterns in the coming years. The Institute of International Education estimated that in 1969-70 there were more than 3,300 Americans in foreign medical schools.!® Americans are currently believed to be enrolling in schools outside the United States and 13 American Medical Association, Council on Medical Education. Medical Education in the United States 1970-71. Journal of the American Medical Association 218: 1199-1286, November 22, 1971. 14 nstitute of International Education. Open Doors, 1971. Report on International Exchange. New York, The Institute, 1971. Table 18. NUMBER OF ACTIVE PHYSICIANS (M.D.), BY MAJOR PROFESSIONAL ACTIVITY AND COUNTRY OF GRADUATION: DECEMBER 31, 1970 Number of active physicians by country of graduation Percent distribution Major professional activity United Foreign Canada United Foreign Canada States States AN activities wu wv: s symm ws vss 251,240 54,420 5,550 100.0 100.0 100.0 Patient Care ss samsmpms ss amon & o3 225,620 48,190 4,720 89.8 88.6 85.0 Officebased i: , ovwmuws ss samme s vb 167,950 20,980 3,510 66.8 38.6 63.2 Hospital based ................. 57,670 27,210 1,210 23.0 50.0 21.8 Interns, residents. . . . ........... 33,970 16,650 610 13.5 30.6 11.0 Full-timestaff . . .............. 23,700 10,560 600 9.4 19.4 10.8 Medical teaching + vows swe ss pu mmm s ss 4,450 1,010 140 1.8 1.9 25 AdMINIStration: , , vs sues ss wavs ini ss 10,670 1,190 300 4.2 2.2 5.4 ReSEArCN www os s nomena s 4s Nmwns £55 8,320 3,290 320 33 6.0 5.8 ONY 0 smb 53 hm BB Eos 5s ob iogm cw ®ve 2,110 470 60 0.8 0.9 1.1 Notclassified. . . .................. 70 280 10 (1) 0.5 0.2 ! Less than 0.05 percent. Source: Haug, J. N. and Martin, B. C. Foreign Medical Graduates in the United States, 1970. Chicago, American Medical Association, 1971. Note: Figures may not add to totals and subtotals due to independent rounding. Canada at a rate of 500 per year.!® It is further estimated, however, that less than one-half of these students actually finish the full course requirements and return to the United States with acceptable credentials.'® These figures are conservative, however, since the licensure statistics in the United States depict a steady inflow of American graduates at magnitudes of 200-400 per year. In total, 5972 U.S.-born FMG’s were identified in the United States in 1970, almost three-fourths having graduated from schools in Italy, Switzerland, the United Kingdom, Spain, or Mexico.!” With increased concerns about physician shortages and maldistribution in this country, programs have recently been created for the transfer of U.S. students studying abroad to United States medical schools. In this direction, 15Mason, Henry R. Foreign Medical Schools as a Resource for Americans. Journal of the National Association of College Adminis- trative Counselors 5:16-20, November 1970. 16 Mason, Henry R. A Profile of 314 Americans Graduating from Foreign Medical Schools. Journal of the American Medical Association 209: 1196-1199, August 25, 1969. Haug and Martin, op. cit. 36 for example, such pathways as COTRANS'® and what is generally referred to as the “Sth pathway”'® have been established. As seen in the following sections, projections have not been developed separately for U.S.-born M.D.’s trained abroad. This reflects the fact that, despite the distinct possibilities of significant increase in their numbers, these 1815 1970, the Association of American Medical Colleges (AAMC) established a “coordinated transfer application system,” or COTRANS, to assist in the evaluation of U.S. citizens seeking transfer from foreign medical schools to medical schools in this country, basically through participation in Part | of the National Board of Medical Examiners. Transfer applicants apply directly to U.S. medical schools, and acceptance decisions are made by the admissions committee of each school. The AMA has liberalized requirements for entrance into graduate medical education for U.S.-born graduates of foreign medical schools. As of July 1971, U.S.-born FMG’s are being allowed to substitute a year of supervised clinical training under the direction of a U.S. medical school approved by the Liaison Committee on Medical Education for the internship or social service required by a foreign school of medicine. As of 1972, 14 U.S. medical schools were participating in this program, which is known as “the fifth pathway.” Table 19. NUMBER OF PHYSICIANS (M.D.), BY LOCATION AND COUNTRY OF GRADUATION: DECEMBER 31, 1970 Region, division, and State Number! by country of graduation Percent by country of graduation Percent distribution United | Foreign | Canada United Foreign | Canada | United Foreign Canada States States States All locations . . . .. 270,600 57,200 6,200 81.0 17.1 1.9 100.0 100.0 100.0 United States. . . .... 264,240 54,620 5,980 81.3 16.8 1.8 97.6 95.5 96.5 NORTHEAST, . coon visas 69,580 26,030 2,260 71.1 26.6 2.3 25.7 45.5 36.9 New England. . . ...... 18,440 4,150 840 78.7 17.7 3.6 6.8 7.3 13.9 Connecticut . . ..... 4,620 1,270 190 76.0 20.9 3.1 1.7 2.2 3.1 Maing «... cv 05 2 shin s 900 170 110 76.1 14.7 9.2 0.3 0.3 1.8 Massachusetts . ..... 10,230 2,000 350 81.3 15.9 2.8 3.8 3.5 57 New Hampshire . .... 860 150 100 78.1 13.2 8.7 0.3 0.3 1.6 Rhode Island. . . .. PR 1,080 500 60 66.2 30.2 3.6 0.4 0.9 1.0 Vermont . ........ 760 70 40 87.1 6.2 4.7 0.3 0.1 0.7 Middle Atlantic . ...... 51,140 21,880 1,420 68.7 29.4 1.9 18.9 38.2 23.0 New Jersey . . . ..... 7,570 3,220 130 69.3 295 1.2 2.8 5.6 22 New York. . ....... 27,800 15,950 1,060 62.0 35.6 2.4 10.3 27.9 17.2 Pennsylvania . . ..... 15,780 2,710 220 84.3 14.5 1.2 5.8 4.7 3.6 SOUTH ..cunnssssnnnn 76,440 10,010 770 87.6 1.5 0.9 28.2 17.6 12.6 South Atlantic . . sv v4 40,850 7,220 550 84.0 14.9 13 15.1 12./ 8.9 Delaware « » + + 0.5 v4» 540 220 20 69.3 27.7 2.9 0.2 0.4 0.4 District of Columbia. . . 3,250 780 40 79.9 19.1 1.0 1.2 1.4 0.7 Florida + vono ams +s 9,510 1,770 170 83.1 15.4 1.5 33 3.1 2.7 Georgia . . ........ 5,090 430 20 91.7 7.8 0.4 1.9 0.8 0.4 Maryland . . ....... 7,140 2,250 130 75.0 23.6 1.4 2.6 3.9 2.1 North Carolina ..... 5,700 310 60 93.9 5. 1.0 21 0.5 1.0 South Carolina... . 2,560 100 10 95.9 3.7 0.4 1.0 0.2 0.2 Virginia ..conwmin 5,590 900 70 85.4 13.7 1.0 2.4 1.6 1.1 West Virginia. . . .... 1,470 460 20 753 23.8 0.9 0.5 0.8 0.3 East South Central . .... 13,110 870 60 93.4 6.2 0.4 4.8 1.5 1.1 Alabama ......... 3,220 150 10 95.3 4.4 0.3 1.2 0.3 0.2 Kentucky. ........ 3,190 350 20 89.7 9.7 0.6 1.2 0.6 0.4 Mississippi +... .... 2,000 70 10 96.3 3.2 0.4 0.7 0.1 0.2 Tennessee «. «uv s+ 4,700 310 20 93.5 6.1 0.4 1.7 0.5 0.3 West South Central . . . .. 22,480 1,930 160 91.5 1.9 0.7 8.3 3.4 2.6 Arkansas . ........ 1,920 30 10 98.4 1.3 0.3 0.7 (2) 0.1 Louisiana. ........ 4,480 260 30 93.9 5.5 0.7 1.7 0.5 0.5 Oklahoma + evwwswas 2,780 110 20 95.7 3.6 0.7 1.0 0.2 0.3 Texas s vovmmimins #3 13,310 1,540 110 89.0 10.3 0.7 49 27 1.7 NORTH CENTRAL ...... 59,750 14,030 1,280 79.6 18.7 1.7 22.3 24.5 21.0 East North Central ..... 41,070 11,550 930 76.7 21.6 1.7 15.2 20.2 13.7 Hlinois . ......... 11,610 4,540 170 11.1 27.8 1.1 4.3 7.9 2.8 Indiana «ovo ses wn 4,950 470 40 90.6 8.6 0.8 1.8 0.8 0.7 Michigan «. cu 545 8,560 2,380 430 75.3 20.9 3.8 3.2 4.2 7.0 OhIO. 2 vawn ev saws 11,000 3,520 230 74.6 23.9 1.5 4.1 6.2 3.7 Wisconsin. . . ...... 4,890 640 50 87.6 11.5 0.9 1.8 1.1 0.9 See footnotes at end of table. 37 Table 19 NUMBER OF PHYSICIANS (M.D.),BY LOCATION AND COUNTRY OF GRADUATION: DECEMBER 31, 1970—Continued Number? by country of graduation Percent by country of graduation Percent distribution Region, division, and State United Foreign Canada United Foreign Canada United Foreign Canada States States States NORTH CENTRAL—Continued West North Central . ..... 18,740 2,480 360 86.9 11.5 1.7 1.3 4.3 59 Jowa . i. evvawn sas 2,710 320 30 88.5 10.6 1.0 1.0 0.6 0.5 Kansas vovwwine ss 2,580 300 30 88.7 10.3 1.0 1.0 0.5 0.5 Minnesota ......... 5,300 650 200 86.3 10.5 3.2 2.0 1.1 3.2 Missouri... ....... 5,280 980 50 83.7 15.6 0.8 2.0 1.7 0.8 Nebraska .......... 1,780 70 10 95.8 3.8 0.4 0.7 0.1 0.1 North Dakota ....... 530 90 40 80.0 13.8 6.2 0.2 0.2 0.7 South Dakota ....... 560 70 0 88.4 11.1 0.5 0.2 0.1 0.1 WEST csv a ss nnmimans sos 58,480 4,550 1,670 90.4 7.0 2.0 21.8 8.1 27.0 Mountain + cvs sw .é » 0 m0 a 11,780 780 190 92.4 6.1 1.5 4.5 1.4 3a Arizona .......... 2,610 280 50 88.8 9.6 1.6 1.0 0.5 0.8 Colorado . ......... 4,080 260 50 929 59 1:2 15 0.5 0.8 Waho .. cum mw sss saw 700 10 10 97.1 1.5 1.4 0.3 (2) 0.2 Montana . ss +: sus 740 30 10 94.4 3.8 1.8 0.3 0.1 0.2 Nevada .. cov vu 560 10 20 93.6 24 4.0 0.2 (2) 0.4 New Mexico ........ 1,240 130 20 89.4 9.1 1.5 0.5 0.2 0.3 Utah .onamw ass ons 1,510 40 20 96.1 27 | 0.6 0.1 0.3 Wyoming . . ........ 350 10 10 95.1 3.6 1.4 0.1 (2) 0.1 Pacific. . ............ 46,700 3,770 1,470 90.0 7.3 2.8 173 6.7 239 Alaska. . .......... 300 20 0 93.5 5.2 1.2 0.1 (2) 0.1 California. . ........ 37,480 2,980 1,180 90.0 72 2.8 13.9 5.2 19.2 Hawaii. . .......... 1,000 200 30 80.9 16.4 2.3 0.4 0.4 0.5 Oregon « «sc 093s + ns 2,980 140 60 93.7 4.4 1.9 11 0.3 1.0 Washington ........ 4,940 430 190 88.8 73 3.5 1.8 0.8 3.1 POSSESSIONS: ... . wis sss ois 1,410 1,410 10 49.8 49.9 0.4 0.5 2.5 0.2 other® . ... ........... 4,980 1,180 190 78.4 18.6 3.0 1.8 2.1 3.4 ! Includes both active and inactive physicians. Includes physicians with APO-FPO addresses and with address unknown. 3 Less than 0.05 percent. Source: Haug, J. N. and Martin, B. C. Foreign Medical Graduates in the United States, 1970. Chicago, American Medical Association, 1971. Note: Figures may not add to totals and subtotals due to independent rounding. graduates will undoubtedly remain a small segment of the overall population of physicians trained abroad who enter the United States physician pool. PROJECTIONS OF THE SUPPLY OF PHYSICIANS TO 1990 Projections of the supply of active physicians to 1990 presented in this section have been developed on the basis of different assumptions as to the future input of newly trained U.S. physicians and the foreign medical graduate 38 population. Three different projections are provided for each group. Projection methodologies and findings are shown sepa- rately for (1) U.S.-trained M.D.’s and D.O.’s; (2) foreign trained physicians (including graduates from Canadian medical schools); and (3) all active physicians. This ap- proach has been adopted for several reasons. First, although foreign trained physicians play a key role in the total profile of the physician supply, there is substantial interest in what the physician supply would be if only U.S. graduates were considered. Second, BHRD, which has a major Federal responsibility for support of U.S. medical and osteopathic schools, and DHEW, which has as its goal the maintenance and improvement of the Nation’s health care, are both vitally concerned with the future supply of all types of physicians. Third, and perhaps most important a considerable disparity exists between the quantity and quality of the information on U.S. trained physicians and that on foreign medical graduates. Information available on foreign trained physicians is often quite sketchy and, in general, of limited value for purposes of projections. For these reasons, it was considered essential that separate projections be developed for the two groups. PROJECTIONS OF THE SUPPLY OF UNITED STATES TRAINED PHYSICIANS Projections of the supply of U.S. trained physicians for the 1970-90 period were based on: (1) the number of active U.S. trained physicians practicing as of December 31, 1970 and separations from that pool over the 1971-90 period; and (2) new graduates from U.S. medical and osteopathic schools and separations from the pool of new graduates. Data on active M.D.’s in 1970 were obtained from the annual publication of the American Medical Association.?® The American Osteopathic Association provided the esti- mate of active D.O.’s for the same date. Data on graduates of U.S. medical and osteopathic schools in 1971 were obtained from school reports on FY 1972 capitation grant applications filed by the schools with BHRD.?' Estimates of graduates for the first projected year, 1972-73, were those prepared by schools on the BHRD capitation grant applications. Information on actual and projected first-year enrollments in these schools (through academic year 1974-75) was also provided on the applica- tions and largely formed the basis for the graduate projections. Methodology and Assumptions. In developing the enroll- ment data needed to estimate graduates over the projection period, it was recognized that capitation grant data by themselves did not adequately reflect the number of first-year students that would be enrolled in schools beginning operation in academic years 1973-74 and 1974-75. A considerable number of States, localities, universities, or citizen groups have expressed an intent to establish new medical schools in the future; many, further- more, have completed feasibility studies, drawn up exten- sive plans, and obtained backing by State legislatures. 20Haug, J. N.; Roback, G. A.; and Martin, B. C. Distribution of Physicians in the United States, 1970. Chicago, American Medical Association, 1971. 21pata for U.S. medical schools include figures for graduates of the medical school in Puerto Rico. 39 In order to ascertain which of the potential new schools were close to actuality and appeared most likely to open during the 1973-75 period, a budgetary projection of startup grants (prepared by the Division of Physician and Health Professions Education, BHRD) was examined, along with publications of the Association of American Medical Colleges (AAMC). On the basis of this information, it.was concluded that, apart from Southern Illinois University, which was included in the capitation data, only one new medical school seemed firm enough to include in the projections for this period. The average initial class size for medical schools established during the 1952-70 period (33.5) was used to estimate first-year enrollment for the new medical school. A similar procedure was followed for potential osteopathic schools. This resulted in adding three new schools to the projections for 1973-75, one of medicine and two of osteopathy. The methodology also takes into account enrollments in accelerated programs (those less than 4 years in duration). These were assumed to reflect the same share of total graduates in the years ahead as was reported by the schools for the academic year 1971-72. The assumption that there would be no greater flow of 3-year medical students through existing schools is in line with the overall assump- tion as to Federal funding.?? Although the grant applica- tions did provide graduate projections through 1974-75 of 3- and 4-year graduates, these figures were felt to be unrealistic estimates for projection purposes. Most medical schools in the United States conduct 4-year academic programs which, with the addition of summer and other vacation time, result in a total of 45 months. However, with rethinking concerning the need for programs of 4 years’ duration, focus has been placed on the acceleration of M.D. and D.O. training as a method of producing additional physicians. Accelerated programs have been defined by Blumberg to be “those which require less calendar time to complete than current (or conventional) programs at U.S. medical schools.”?® There are, in general, two basic methods of implementing the acceleration: (1) a reduction in the number of total credit hours of instruction required or a reduction in the specific content of instruction so that only 3 academic years are needed; and (2) compression of the time needed to complete the presently required program. 227s assumes that the future direction of curriculum shorten- ing will not continue the trends in evidence in recent years. A discussion of curriculum shortening can be found in: American Medical Association, Council on Medical Education. Medical Edu- cation in the United States 1970-71. Journal of the American Medical Association 218: 1204, November 22, 1971. 23Blumberg, Mark S. Accelerated Programs of Medical Edu- cation. Journal of Medical Education 46: 643-651, August 1971. The first method would result in dramatic changes in requirements for medical licensure and large-scale changes in the format of undergraduate as well as medical educa- tion. The latter method, as generally proposed, involves changing the 45-month program to a 36-month program by reducing nonstudy time. Freshmen would enter medical school in July and graduate in June 3 years later.24 During World War 11, accelerated programs were adopted in most U.S. medical schools in an attempt to meet the increasing demand for physicians imposed by war. These programs reduced the years to graduation from four to three by utilizing summers and vacation time for classes. In addition, a freshman class was admitted every 9 months, permitting two classes to graduate in 1 calendar year, 3 years after the initiation of the program. However, owing to an immediate post-war return to 4-year programs, along with subsequent reduction in admissions to permit schools to return to a conventional schedule, the war-induced acceleration programs produced only temporary increases in the supply of physicians. Shortly after the war, however, the University of Utah pioneered in the development of an accelerated 3-year program which graduated one class each calendar year.?® This program was favorably received by the students, although the faculty was less enthusiastic about the extra teaching burdens. In general, very few accelerated programs were de- veloped until the late 1960's. By November 1972, the American Medical Association reported that a total of only 28 schools had some form of 3-year program.?$ Eight of these schools were ‘“‘conducting or planning for an edu- cational program in which all, or essentially all, medica! students will complete their medical school training in 36 successive calendar months or less.” Six other schools reported that at least 10 percent of their students were enrolled in programs of 36 months or less. An additional 14 schools stated that 3-year programs were available, but that few students were enrolled. Some criticism has recently been raised concerning accelerated programs, such as the increased burden upon the faculty because of the elimination of summer vacations and general objections to the alteration of the medical curriculum. However, the number of schools adopting these 3-year programs is increasing and is projected by the AMA 24Methods such as doubling freshmen each year by taking in 2 classes would eventually increase the supply of physicians. However, under the strict definition of “accelerated programs,” this method would not apply and will not be considered in this report because of its controversial nature. 25Blumberg, Mark S. Accelerated Programs of Medical Edu- cation. Journal of Medical Education 46: 643-651, August 1971. 26 American Medical Association, Council on Medical Education. Medical Education in the United States 1971-72. Journal of the American Medical Association 222: 961-1048, November 20, 1972. 40 to continue to increase. The Association reported that, as of November 1972, at least 20 additional schools (in addition to the 28 previously mentioned) indicated the possibility of incorporating a 3-year program. A total of 101 degree-granting schools reported that a student could obtain an M.D. degree in 36 months (not counting students with advanced standing), thus creating an accelerated capability for most schools. Furthermore, the Association estimates that one-half (approximately 56 schools) of the U.S. medical schools may be providing a 3-year program by 1973.27 Because of these developments, for purposes of this report, it was felt necessary to evaluate what the possible impact on graduate output (and consequently on physician supply) would be if accelerated programs took hold in a major and comprehensive way. To determine the maximum impact of such shifts, it was assumed that a// medical schools would convert to a 36-month program in 1 year. Of course, past trends indicate a gradual changeover, if indeed the direction of the current trends does continue. In a recent article, Blumberg undertook a hypothetical conversion of medical school programs over a 16-year period, assuming that all schools converted at the earliest opportunity during this period.?® Applying a similar analysis to this report’s basic methodology for M.D. graduate projections, the results show an approximate 16,000 increase in the number of graduates over the projection period. A “windfall” of an extra graduating class occurs in the third year after the year of conversion. (See Table 20.) In effect, such a conversion to accelerated programs would result in one additional graduating class by 1990. Without conversion, students projected as entering medical schools over academic years 1970-71 to 1986-87 would total 253,053. (See Table 21.) Under the 4-year program, and assuming an attrition rate of 5.3 percent over the 2"In a related development, a study of the modification of the curriculum in schools of osteopathy has resulted in the “spiral curriculum,” which emphasizes a 3-year program leading to the D.O. degree with an incorporation of the fourth year with the internship. Although the time for adoption of such a program has not been determined, the emphasis and direction implied by this program exists. See: Kabara, Jon J. and Jacobson, Lawrence E. The Spiral Curriculum: For Training Osteopathic Physicians. The D.O. 12: 93-101, July 1972. In addition to the Blumberg article cited above, the following 2 studies examine the impact of shortening the physician cur- riculum: U.S. General Accounting Office. Report to the Congress: Program to Increase Graduates from Health Professions Schools and Improve the Quality of Their Education. Washington, U.S. General Accounting Office, 1972; and Rittenhouse, C. H. and Weiner, S. A Study of the Semi-Annual Admissions System at the University of Tennessee College of Medicine. Menlo Park, Cal., Stanford Research Institute, March 1971. Table 20. PROJECTED ANNUAL NUMBER OF GRADUATES OF MEDICAL SCHOOLS IN THE UNITED STATES UNDER PROPOSED ACCELERATED PROGRAMS COMPARED WITH NUMBER OF GRADUATES IN CONVENTIONAL PROGRAMS: ACADEMIC YEARS 1970-71 THROUGH 1989-90 Graduates® from: Academic year Flisevenr, Conventional Accelerated Difference enrollment (4-year (3-year program) program) Total ssn mmm ne vom wo 239,642 255,776 16,134 1970-71 ,:svmemwes sons 11,348 — —- —- 1971-72 sc ssmmms s wae 12,375 - - - 1972-73 is vnb@m i 3 mH wR 13,390 - —- 1973-74... ooo. 13,857 10,747 22,466 11,719 TIT4T5 svn armin + vwimw 14,339 11,719 12,680 961 197576 sv wwimes + vowom 14,530 12,680 13,123 443 1976-77 cinwmins svnwwe 14,724 13,123 13,579 456 197778 vonwnes sunwme 14,921 13,579 13,760 181 1978-79 svuna es smaninn 15,120 13,760 13,944 184 1979-80 owas ss vnvwes 15,321 13,944 14,130 186 1980-81 ............. 15,526 14,130 14,319 189 198182 sive ermunmne 15,733 14,319 14,509 190 198288 sums snunwms 15943 14,509 14,703 194 198384 sums vnmmmmes 16,155 14,703 14,899 196 198485 ............. 16,371 14,899 15,098 199 198586 ............. 16,589 15,098 15,299 201 198687 sos ss vemewess 16,811 15,299 15,503 204 1987-88 usc smmunie ses 17,037 15,503 15,710 207 198889 i: iivwnwims us — 15,710 15,920 210 198990 ............. - 15,920 16,134 214 ! The attrition rate for 4-year programs (5.3 percent) has also been applied to the 3-year programs. 2 These figures are those used in the basic methodology projections. In this table it is assumed that all schools convert to 3-year programs beginning with the 1st-year class of 1971-72. length of the program, the projected enrollment figures result in a total of 239,642 graduates for the projection years 1973-74 to 1989-90 (Table 20). Although the conversion of all schools to an accelerated program would not change the projected number of first-year enrollees in any year of the 1970-71 to 1986-87 period,’ the conversion to a 3-year program would allow an entering class in academic year 1987-88 to graduate in 1990, the end point of the projection period for graduates. As shown in table 20, a projected freshman class of 17,037 in 1987-88 (also assuming a 5.3 percent attrition experience) would 29A 4-year attrition rate (5.3 percent) used for the graduate projections has not been changed for the 3-year program. Little is known about 3-year attrition rates. Furthermore, the AMA has eliminated calculations of attrition rates from its reports because of their inaccuracy due to increased flexibility of the M.D. curriculum. 41 result in a graduating class of 16,134 in 1989-90, a number equal to the overall gain in the number of graduates over the projection period that occurred due to the conversion. In sum, given the basic figures and projections used in this report, the maximum impact of a complete adoption of accelerated programs would increase the total number of projected graduates from 239,642 to 255,776. Although this increase is significant, it is important to note again that the assumption implicit in this estimate represents a maximum condition. In more realistic terms, however, if medical schools in the United States continue to explore and adopt conversion programs, a continuation of recent trends suggests a very gradual process. For each year in the projection period, estimates of graduates were computed from earlier first-year enroll- ments, utilizing an attrition rate of 5.3 percent, the same as Table 21. FIRST-YEAR ENROLLMENTS AND GRADUATES IN MEDICAL SCHOOLS IN THE UNITED STATES UNDER BASIC AND ALTERNATIVE ASSUMPTIONS: ACTUAL 1970-71 AND PROJECTED 1971-72 THROUGH 1989-90 First-year enrollment Graduates Academic year Alternative assumptions Alternative assumptions Basic Basic methodology methodology Low High Low High 197071 , , vunmwimrs vmome ss wussss 11,348 11,348 11,348 8,979 8,979 8,979 1B70T2 cv wnpuns is nOERARE SS HESS BE 12,375 12,375 12,375 9,617 9,617 9,617 1972-73 ss uamunas sna us sv uw Es 13,390 13,390 13,390 9,850 9,850 9,850 197374 ss unuwnm is sng @Hm A 85 bmmms 13,857 13,857 13,857 10,747 10,747 10,747 VITATE si sn nnd das mmmmmee 5 8 ¥en 14,339 14,339 14,339 11,719 11,719 11,719 1975-76 . «iii ite eee ee 14,530 14,339 14,722 12,680 12,680 12,680 1976-77 ov vie ee ee ieee 14,724 14,339 15,115 13,123 13,123 13,123 1977-78 © ii ee eee 14,921 14,339 15,519 13,579 13,579 13,579 1978-78 ,s vuvswns sumpREES 5 8%» 15,120 14,339 15,933 13,760 13,579 13,942 197980 ©: sows ss sommuine 658 8xw0 15,321 14,339 16,359 13,944 13,579 14,314 VOBOBY i vunmina ssa mmma nis wmoow 15,526 14,339 16,796 14,130 13,579 14,696 TIBI82 iii tinnntarmmanesosrmmma 15,733 14,339 17,245 14,319 13,579 15,089 1982-83... i eee 15,943 14,339 17,705 14,509 13,579 15,492 1983-84 . . LL. eee 16,155 14,339 18,178 14,703 13,579 15,906 198485 .., vovnumssrmummnss vanes 16,371 14,339 18,664 14,899 13,579 16,331 198586 i: vans nnisnusmunds wasn 16,589 14,339 19,163 15,098 13,579 16,767 198687 i: snsvnnissmpasnsssnmne 16,811 14,339 19,676 15,299 13,579 17,215 TIBTBE intima s ow smamis vv mmmin —- — — 15,503 13,579 17,675 1988-89... iii eee - — — 15,710 13,579 18,147 198990 + vvvvnun sss ummpmns s nism —- —- - 15,920 13,579 18,633 Source: 1970-71 first-year enrollment: Medical Education in the United States, 1970-71. Journal of the American Medical Association 218: 1199-1316, Nov. 22, 1971. 1971-72 through 1974-75 first-year enrollments: Applications for capitation grants submitted to BHRD. 1970-71 graduates: Applications for capitation grants submitted to BHRD. that reported for the entering class of students in 1967.3° An examination of historical data on attrition among medical students revealed a gradual rise from 5.5 percent for entering students around 1950 to about 13 percent for the entering class of 1957. For several years thereafter, attrition ranged narrowly between 12 and 14 percent. Beginning with the 1961 entering class, however, attrition has declined continously, returning in 1967 to the propor- tion in evidence virtually two decades earlier. The projec- tion methodology for this report assumes that the attrition rate of 5.3 percent will be maintained for the entire projection period. Although projected estimates of supply will vary as attrition rates differ, slight variations in the attrition 30 American Medical Association, Council on Medical Education. Medical Education in the United States 1970-71. Journal of the American Medical Association 218: 1199-1286, November 22, 1971. 42 patterns of medical students have only a minor impact on the overall supply estimates. Under the basic methodology, for example, if the attrition rate were reduced from 5.3 to 3 percent, only about 6,100 additional graduates would Fr. expected over the entire projection period. Yet, although this effect is relatively minor when compared to total graduates, it nonetheless represents the output of two to three medical schools over this period. It should be noted that the use of single-point attrition rate estimates is not without limitations. For example, in the derivation of the attrition figure, the number of medical school graduates in a particular year is reported as of June. The attrition estimate is overstated somewhat by not including as graduates those students who graduate later than June. Furthermore, the expansion of combined degree programs, aided in part by Federal funding, affects the derivation of attrition estimates. As part of recent develop- ments in curriculum “tracks,” for example, a small but growing number of first-year students are entering com- bined M.D.-Ph.D. programs which total 6 years in length. Moreover, some students are choosing to take M.S. or M.P.H. degrees before graduation. Although a number of such programs exist, information on their extent and coverage is rather limited. The AAMC, with the assistance of Federal funds, is currently seeking to obtain such information. Another recent development has also altered the appar- ent meaning of published attrition rate estimates. Although attrition occurs in U.S. medical schools, recent encourage- ment of U.S. citizens studying abroad to transfer to U.S. schools has, in a number of instances, filled gaps created by the attrition of U.S.-trained students. In some schools, for example, this situation has resulted in an increase in the number of sophomores over freshmen for a specific class cohort. Without data on such transfers, the computation of attrition rates for these schools would actually produce negative figures. In addition to estimating the inflow of graduates over the 20-year period, the projection methodology estimated the losses to the profession through deaths and retirements. To develop these estimates on an age-specific basis, it was first necessary to develop a detailed age composition of U.S.-trained physicians as of December 31, 1970. Although an age distribution for active U.S. M.D.’s was unavailable, a distribution was calculated based on the 1967 age data for all active M.D.’s®!, and the resulting distribution was also utilized for D.O.’s. As indicated in Chapter 1, adjusted age-specific death and retirement rates were applied to yearly estimates of the physician population to derive estimated losses to the profession. In addition to providing such information, this methodology also permitted an examination of shifts in the age distribution of active physicians over the projection period. A number of studies of the mortality of physicians suggest strongly that M.D.’s tend to live somewhat longer than the overall male population. Furthermore, there is convincing evidence that physicians remain in practice considerably beyond the average age of retirement of the general population. For example, AMA data suggest that, in 1970, 63 percent of all physicians aged 65 and over were still “active”. This compared with a total labor force participation rate of 27 percent for similarly aged males in the general population. For these reasons, it was felt necessary to modify separation rate statistics for all working males to bring them more in line with the apparent 31Theodore, C. N.and Haug, J. N. Selected Characteristics of the Physician Population, 1963 and 1967. Chicago, American Medical Association, 1968. 43 physician experience rhe following paragraphs briefly state the assumptions and methodology employed for this conversion process. (For a detailed description of further background and a more definitive statement of assump- tions, corresponding rationale, and methodology, see Appendix A.) For purposes of this report, it was assumed that physicians tend to live, on the average, approximately 2.5 years longer than did the average U.S. male worker in 1968 (66.6 years). Given this assumption, age-specific death rates published for the overall male population were modified based on information obtained from published Model Life Tables.>? A subsequent comparison between (a) the pro- portion of active physicians to total physicians (by age) and (b) male labor force participation rates (by age) was utilized to convert published retirement rates for the overall male working population to a derived series for physicians. Evaluation of the use of this methodology was accom- plished, in part, by applying the derived separation rates to actual published data on the supply of physicians. The converted (and unadjusted) age-specific separation rates were applied to mid-year 1959 M.D. supply figures (AMA data), which were brought forward to 1970. Compared to 1970 published supply data (adjusted to mid-year), the converted rates resulted in an estimate 1 percent lower, as compared with an estimate 7 percent lower using un- adjusted rates. By far the most critical determinant of the future supply of U.S.-trained physicians, however, is clearly the number of graduates of U.S. medical and osteopathic schools. The following discussion treats this subject in some detail and provides the background and rationale used in projecting the future stream of M.D. and D.O. graduates. It goes without saying that Federal funds are important determinants of the level of enrollments in U.S. medical and osteopathic schools. Federal support for construction, research, training, student assistance, and other medical school activities comprises a significant portion of their total support. Although public medical schools receive over 50 percent of their income for operating expenditures from appropriations by State legislatures (a proportion that has remained constant over the period fiscal year 1960-61 to fiscal 1970-71 33) a significantly large percentage of their income also comes from Federal appropriations. Conse- quently, enrollments in a// medical schools, public or private, are clearly affected by shifts or changes in Federal Government support. 32Coale, A. J. and Demeny, P. Regional Model Life Tables and Stable Populations. Princeton, N.J.: Princeton University Press, 1966. 33Comparisons of Patterns of Financing for Private and Public Medical Schools. Datagram. Journal of Medical Education 47: 579-583, July 1972. Detailed statistical information has not yet been de- veloped to measure the precise impact of specific Federal programs upon enrollments. Many Acts of Congress and sections of Acts provide for support of medical schools and students, and only now are attempts being made to measure their impact in a systematic way. Nonetheless, the experi- ence of recent years provides clear evidence of the overall importance of Federal programs on the course of medical education. In the academic year 1963-64, at the time when the Health Professions Education Assistance (HPEA) Act was passed, the United States had a total of 87 medical schools. The entering class of these schools numbered 8,722 while graduates numbered 7,336. By the academic year 1971-72, less than a decade later, the number of medical schools had grown to 108, with a total entering class of 12,361 (an increase of 42 percent) and a total graduating class of 9,551 (an increase of 30 percent). Although many factors obviously were at work to produce such an increase, it is quite apparent that sharply increased Federal support played a major role. In developing the projections of U.S. medical school graduates, three assumptions were made about the impact of assumed future support patterns on medical school enrollments. This was done in order to allow for several possible reactions of the medical education system to the assumed level of Federal and non-Federal support. An examination of trend data on enrollments in U.S. medical schools provided the major insights into the possible course of future enrollments and into possible alternative assump- tions. This analysis showed that during the 1952-66 period, prior to any significant impact from Federal legislation, increases in first-year medical school enrollment occurred through both the building of new schools and the expan- sion of existing schools. Trends in freshman enrollment of schools already established in 1952 were examined for the entire period, as were trends in freshman enrollment among the 11 new schools opened during the 14-year period. Under the first (or ‘basic’’) assumption concerning medical school enrollments, it was assumed that increases in first-year enrollments from the year 1975-76 to the mid-1980’s would occur at the same yearly rate as that experienced in the 1952-66 period. Implicit in this method- ology is the assumption that, even in the absence of massive Federal stimuli to increase enrollments, the number of first-year students in medical schools would continue to increase, although at a more moderate pace than during the 1966-72 period of substantial Federal funding. This in- crease would be accomplished both through expansion of enrollments within existing schools and construction of new schools. On this basis, annual enrollment increases of about 1.3 percent for M.D.’s and 0.6 percent for D.O.’s were used. (See Tables 21 & 22.) 44 Under the second assumption—termed the “low” alter- native, which is the most conservative of the three—the total number of first-year students enrolled per year in the 1975-76 to 1986-87 period would remain at the 1974-75 level. This means that funds from sources other than the Federal Government, when combined with Federal funds, would be adequate to support the enrollment level of the mid-1970’s but not to bring about any further increases in enrollments. There is some evidence, however, that recent developments such as the increased public awareness of physician ‘“‘shortages” and increased public demand for improved health care would bring forth the necessary non-Federal funds to continue to increase medical school enrollments. Nevertheless, such a “low” projection serves to indicate one possible realistic boundary of student enrollments. In the third assumption—the most liberal of the three—it was assumed that freshman enrollment would increase at a greater rate than in the pre-Federal funding period (as used in the basic methodology) but at a less rapid rate than that observed in the latter 1960s and early 1970's when Federal funds for medical schools and students were increased sharply. For this assumption, an arbitrary annual rate of increase twice as great as the 1952-66 experience was employed; i.e., enrollments were projected to rise at annual rates of about 2.7 percent for M.D.’s and 1.2 percent for D.O.%. The growing awareness of health care needs in this Nation could very well result in such a further expansion in enrollments. Potential manpower shortages and/or mal- distributions resulting in health care delivery problems have become a political and social issue. As the wealth of this country rises within the next two decades, enabling more people to purchase more extensive health care, the need for support of M.D. and D.O. schools may be increasingly recognized by the public, resulting in further increases in funding and possibly in enrollments. There are, however, two considerations that provide some rationale for not setting this “high” assumption any higher than it is. First, it seems reasonable to assume that each established school possesses an internal capacity level and that a school’s educational efficiency and effectiveness are lessened when that capacity is exceeded; thus, increases in enrollments could not easily continue to rise as they did in the late 1960’s and early 1970s without a large number of new schools being set up or existing ones greatly expanded. Second, part of the large increase in the supply of young people entering medical school in the 1960's reflected the post-war “baby boom” and the sharp rise in college-age population in the late 1960's. This phenomenon will not recur during the late 1970's and 1980's. In fact, the reduction in the birth rate observed in the 1960's will Table 22. FIRST-YEAR ENROLLMENTS AND GRADUATES IN OSTEOPATHIC SCHOOLS UNDER BASIC AND ALTERNATIVE ASSUMPTIONS: ACTUAL 1970-71 AND PROJECTED 1971-72 THROUGH 1989-90 First-year enrollment Graduates Academic year Basic Alternative assumptions Basic Alternative assumptions methodology methodology | Low High Low High 1970-71 cnn ss spnmmue s samme n 33 Be 623 623 623 472 472 472 197172 sav si snap ma ss sipRGNE 2 8 BE 670 670 670 491 491 491 POITTB viv vs wmmmimtls 3 mmm EE 28 Wd 767 767 767 546 546 546 1973-74 ii ieee eee eee ee 823 823 823 590 590 590 19745718 wns san uve ss pagans ov ws 916 916 916 634 634 634 1975-76 cn s wisn wma s ys HERS» $0 F 922 916 927 726 726 726 1976-717 vii nomad iis nw mmm es vue 927 916 939 779 779 779 PITTI wos vm mmr sss nmmak s 5 5a 933 916 951 867 867 867 1978-79 i i i i te eee eee 939 916 963 873 867 878 197980 vis sssmmumpsppummns ves 945 916 975 878 867 889 T9808] vo cvvwmmow ss Nm BES HUES 951 916 987 884 867 901 1981-82 «ii vom mad ss nmamimes uns 957 916 999 889 867 912 TOB2BB vu vv vvmww ss ssnmmmmes mans 963 916 1,012 895 867 923 TOB3BE «is vvonn vss vos mu ss rewy 969 916 1,024 901 867 935 1984-85 . ..comemeis so wmme vv oss 975 916 1,037 906 867 946 JOBE-BE vin sini om mvs m nik iO® olin ® S00 981 916 1,050 912 867 958 1986-87 ...vovevissnmgames vavm® 987 916 1,063 918 867 970 TJOBTMBE. vw + co imwnin 0 4 sldemmmmn » 3m ios 0 - — - 923 867 982 1988-89 . . iii ee ieee -_ — — 929 867 994 98990 .. sosvinm ws so vr mma bowie - — - 935 867 1,007 Source: 1970-71 first-year enrollment: American Osteopathic Association, Office of Education. Educational Supplement January 1971. 1971-72 through 1974-75 first-year enrollments: Applications for capitation grants submitted to BHRD. 1970-71 graduates: Applications for capitation grants submitted to BHRD. decrease the number of college-age youths available for medical school in the 1980's. PROJECTION FINDINGS. The basic methodology projec- tion for U.S. medical school graduates results in a total gross®* graduate input of 268,088 over the entire 1971-90 period. The number of M.D. graduates is projected to rise from 8,979 in 1970-71 to 15,920 in 1989-90, an increase of 77 percent. (See Table 21.) This compares with an increase of 28 percent (from 6,994 to 8,974) during the previous 10 years (1960-61 to 1970-71). The low alternative projects a total gross M.D. graduate input of 253,242; the high alternative, a total of 284,501. The three alternatives used consequently produce total gross M.D. graduate inputs approximately 15,000 graduates apart. However, it is essential to note that if the Federal spending assumption proves to be in error and the rate of increase is that of the 34Before deduction of death and retirement losses. 1966-72 experience—nearly 7 percent a year for freshman enrollment for M.D.’s alone—a total gross graduate input (1971-90) of about 350,000 would result, and the number of M.D. graduates would be around 30,000 by 1990. It is important to interpret the projected number of enrollees and graduates in terms of a capacity-per-school measure. Such an examination provides an additional test of the reasonableness of the projections. Under the basic methodology, the number of medical schools is projected to increase from 103 in academic year 1970-71 to 114 as of 1974-75, and to 126 by 1986-87. These projections would give an average of 133 first-year students per medical school by 1986-87, compared to an actual average of 110 per school in 1970-71 and a projected 126 per school for 1974-75. The slowdown projected for the 1974-75 to 1986-87 period appears consistent with the assumption about funding support underlying these projections. Simi- larly, using the basic methodology, the projections result in an average of 126 graduates per medical school as of 1989-90. This ratio appears to compare reasonably with 45 that of medical schools in 1974-75 producing graduates 4 years later (119 per school). In line with these projections, corresponding estimates derived by the high methodology also appear to reflect realistic expectations under the assumptions advanced—139 medical schools and 142 first- year students per school by 1986-87 and 134 graduates per school by 1989-90. Two separate, but brief, analyses were undertaken to further ascertain the reasonableness of the basic projec- tions. The first analysis compared the number of 22-year- olds in the overall population to entering medical school freshmen for selected historical, as well as projected years. The rationale for this comparison involved an implicit assumption that enrollees in medical schools should be relatively closely related to population trends for this age cohort. An examination of the data indicated that the ratios of medical school freshmen to 22-year-olds remained relatively constant between 1960 and 1970, though with noticeable dips in 1966 and 1970. (See Table 23.) The relationship in the late 1960's reflects the fact that the number of 22-year-olds was increasing at a faster rate than freshman enrollment. This phenomenon, in part, could be Table 23. attributed to: (1) the impact of the post World War Il “baby boom,” which was not in evidence in the late 1950's and early 1960’s; and/or (2) the fact that enrollees are being compared here to population groups, rather than the number of applicants. The ratio of freshman medical students to 22-year-olds is projected to remain relatively constant to 1990 at about the same level as was evident in the early 1960's, when the “baby boom” was not a factor. A slight increase in the ratio, however, is projected to occur in the middle 1980s, largely reflecting a showdown in the rate of population growth for the 22-year-olds. The second analysis, in contrast, considered the ratio of freshman medical students to bachelor’s degrees. The historical data reveal that the ratios declined somewhat between academic years 1960-61 and 1970-71, implying that the number of B.A. degrees have been increasing at a faster yearly rate than entrants into medical schools. This phenomenon has been projected to continue. This means that if B.A. figures were the sole determinant of freshmen in medical schools, the projection figures would appear conservative if anything. FIRST-YEAR MEDICAL STUDENTS,BACHELOR’S DEGREES, AND 22-YEAR OLDS: SELECTED YEARS ACTUAL 1960-61 THROUGH 1972-73; PROJECTED 1974-75 THROUGH 1980-81 . First-year medical students per 1,000: First-year , Number of 22-year medical Bachelor's olds® (in 8 ed 4 Academic year students’ degrees 1,000’) Be av asguss By ’ (1) (2) (3) (4) (5) TOBOBL sowwms s siniwwms 8,298 389,183 2,238 213 3.7 196263 .iuvviivi ovum 8,642 414275 2,303 20.9 3.8 196465 cnn omavniims 8,856 494,174 2,642 17.9 34 1966-67 . ............ 8,964 551,040 2,810 16.3 32 1968-69 ............. 9,863 666,710 2,809 14.8 35 1970-71 «oo iii 11,348 827,234 3,528 13.7 3.2 1972973 .vvwmwss nmews 13,390 903,000 3,548 14.8 3.8 197478 ,venwp es vnnws 14,339 990,000 3,753 14.5 3.8 1976-77 , vuvunw v.39 simu 14,724 1,100,000 3,981 13.4 3.7 TIIBTY . sow mmwes s aww 15,120 1,207,000 4,098 12.5 3.7 198081 iv evinsssanmn 15,526 1,300,000 4,237 11.9 3.7 1 Projections are by basic methodology. Include 1st-professional degrees. Degrees shown are those granted in academic year preceding medical school year. 3 Asof July 1 in year specified as beginning of academic year. Source: 1960-61 through 1970-71 first-year medical students: Medical Education in the United States, 1970-71. Journal of the American Medical Association 218: 1199-1316, Nov. 22,1971. Bachelor’s degrees: Simon, Kenneth A. and Fullam, Marie G. Projections of Educational Statistics to 1979-80. Office of Education Pub. No. 10030-70. U.S. Government Printing Office, 1971. 22-year olds: U.S. Bureau of the Census. Current Population Reports. Series P-25, Nos. 311,314,441, and 470. 46 It should be noted that dissimilar projected results in the two analyses occur primarily because the number of B.A. degrees is projected to increase at a faster rate than 22-year-olds. These projections imply an increase in the number of college-educated 22-year-olds, thus confirming the reasonableness of the M.D. freshman enrollment projections. Adding these projected M.D. graduate inputs, as well as those for D.O.’s, to the existing pool of U.S. physicians (after allowance for separations from both groups) provides an estimate of the total supply of U.S.-trained physicians. Under the basic assumption, the supply of active U.S. trained physicians is projected to grow from 263,200 in 1970 to 334,800 in 1980, and to 429,800 in 1990, as shown in Table 24. Over the entire 20-year projection period, the number of these physicians is projected to increase by 166,600, or by approximately 60 percent. Although these estimates appear striking at first glance, they are not far out of line with the experience of recent years. Between 1963 and 1970, for example, the number of active U.S.-trained physicians rose at an average yearly rate (compounded) of 1.6 percent; this compares with projected yearly changes (compounded) of 2.4 and 2.5 percent in the 1970-80 and 1980-90 periods, respectively. During the 1960's, increases in the physician/population ratio for all physicians could be attributed largely to the heavy influx of foreign trained M.D.’s. Counting U.S.- trained physicians alone, the ratio rose only from 125 to 129 per 100,000 population in the 1963-70 period. Under the basic methodology, this ratio is projected to rise to 148 per 100,000 population in 1980 and to 172 per 100,000 population by 1990, as shown in Table 24. It should be noted that the population projection series utilized to calculate these future ratios is a very conserva- tive one. Using a higher population series would lower these ratios somewhat. For example, the projected ratio for 1990 would be lowered from 172 to 154 per 100,000 popu- lation, if a very liberal population projection were used. Given the supply projections developed with the basic methodology and the conservative population series adopted, the projected population ratio for 1990 shows an interesting phenomenon. In effect, the 1990 ratio projected for U.S.-trained physicians alone (172 per 100,000) is almost the same as the ratio that is projected to prevail in 1975 for all physicians—foreign and U.S.-trained combined (Table 25). Although not intended to negate the efficacy of using population ratios to indicate levels of medical care, this phenomenon does raise some interesting questions Table 24. SUPPLY OF ACTIVE PHYSICIANS (U.S. TRAINED M.D. AND D.O.) AND PHYSICIAN/POPULATION RATIOS, USING BASIC METHODOLOGY AND ALTERNATIVE ASSUMPTIONS: ACTUAL 1960 and 1970; PROJECTED 1975-90 Projection series 1960 1970 1975 1980 1985 1990 Number of active physicians (U.S. trained M.D.’s and D.O.’s) Basic methodology . ..........¢ooiveen.n N.A. 263,200 291,500 334,800 381,100 429,800 Alternatives: LOW simwmi vs vu sme de £14 eld ime od voi domly N.A. 263,200 291,500 334,200 375,800 414,600 High sven pupossscsmpmmrse wpnme N.A. 263,200 291,500 335,400 386,700 446,500 Rate per 100,000 population’ Basic methodology . . . . «vv ivi viii — 129.2 135.7 147.5 159.2 171.5 Alternatives: LOW se mins ts s s ie sais ss VBE Re 3 8 wom — 129.2 135.7 147.3 157.0 165.4 High svsciisnssssm is bh ames es onoesm - 129.2 135.7 147.8 161.6 178.2 ! Resident population as of July 1 for 50 States and the District of Columbia. Source: 1970 U.S. trained M.D.’s: Haug, J. N. and Martin, B. C. Foreign Medical Graduates in the United States, 1970. Chicago, American Medical Association, 1971. 1970 D.O.’s: Unpublished data provided by the American Osteopathic Association. Population: U.S. Bureau of the Census. Current Population Reports. Series P-25, Nos. 468,477, and 483. Note: Figures in this table may differ from the sum of M.D.’s and D.O. in Table 25 due to independent rounding. 47 Table 25. SUPPLY OF ACTIVE PHYSICIANS (U.S. TRAINED M.D. AND D.O.), USING BASIC METHODOLOGY AND ALTERNATIVE ASSUMPTIONS: ACTUAL 1960 AND 1970; PROJECTED 1975-90 Projection series 1960 1970 1975 1980 1985 1990 Number of active U.S. trained M.D.’s Basic methodology . . . .. «voi viii tii N.A. 251,200 277,900 318,300 361,500 407,100 Alternatives: LOW ina ss sain mms 8 8 50 HAW E SAFE EE buss N.A. 251,200 277,900 317,700 356,300 392,300 BigZh .. :cessaees smpingis humemyi oe N.A. 251,200 277,900 318,800 367,000 423,400 Number of active D.O.’s Basic methodology . .. ...... 00a. 4 12,000 13,600 16,500 19,600 2 22,700 Alternatives: LOW + s sinmm is s 5a Mmeie + s Saves ss pun { ) 12,000 13,600 16,500 19,500 22,700 High ::sansnsispssswss samupes epws (1) 12,000 13,600 16,600 19,800 23,200 ! There were approximately 12,200 active D.O.’s in 1960. The number declined between 1961 and 1962 because the California College of Medicine (formerly the College of Osteopathic Physicians and Surgeons) granted about 2,400 M.D. degrees to D.O.’s who had received the latter degree from that school. Beginning in 1952 these physicians have been included in the count of M.D.’s. 2 Using the age distribution of D.0.’s from the preliminary findings of the 1971 American Osteopathic Association Survey of Osteopathic Physicians, the projected number of D.O.’s in 1990 would be about 1,000 less than shown in this table. Source: 1970 U.S. trained M.D.’s: Haug, J. N. and Martin, B. C. Foreign Medical Graduates in the United States, 1970. Chicago, American Medical Association, 1971. 1970 D.O.’s: Unpublished data provided by the American Osteopathic Association. about the profile of physician supply. U.S. self-sufficiency in producing M.D.’s has been described by some as a very desirable goal. According to the projections, the “level of medical care” implied by the 1975 ratio for all physicians would be reached by the supply of U.S.-trained physicians by about 1990. The projections of the supply of U.S. trained physicians largely mirror the findings revealed by the projections of all physicians in active practice. Under the basic methodology, the supply of active U.S.-trained M.D.’s is projected to grow from 251,200 in 1970 to 318,300 in 1980 and to 407,100 in 1990 (Table 25). The average yearly changes (com- pounded) for this group are virtually identical to those projected for all U.S.-trained physicians. The supply of active osteopathic physicians, however, is projected to grow at a somewhat faster pace—relative both to the recent experience of D.O.'s as well as to the projected increase among M.D.’s. Between 1963 and 1970, for example, the number of active D.O.’s rose from 10,800 to 12,000—an average yearly increase (compounded) of 1.6 percent, the same as that for U.S.-trained M.D.’s. The supply of active D.O.’s, however, is projected to grow to 48 16,500 by 1980 and to 22,700 by 1990%°, an average yearly increase (compounded) of 3.2 percent in 1970-80 and 3.2 percent in 1980-90. (See Table 25.) Hence the ratio of active D.O.’s to all U.S.-trained physicians is projected to increase slightly over the next two decades—from 4.6 percent in 1970 to 5.3 percent in 1990. This finding does not seem to be inconsistent with the trends over the past decade towards greater professional acceptance and in- creased public awareness of the role of osteopathic physicians. In addition to the basic projection, alternative projec- tions were developed of the future supply of U.S.-trained physicians, for M.D.’s and D.O.’s combined. It should be noted, however, that given the assumptions on enrollment growth stated earlier, the supply estimates projected by the alternatives begin to show significant divergences from the basic supply estimates only during the last 10 years of the 35Using the D.O. age distribution available from the preliminary findings of the 1971 AOA survey, the projected number of D.O.’s in 1990 is reduced by about 1,000 from findings reported in Table 25. projection period. This results from the fact that the same graduate estimates were used for all three projections through academic year 1977-78. Under the high alternative projection, the supply of U.S.-trained physicians is projected to grow to 446,500 by 1990--a 70-percent increase over the 1970-90 period, compared with an increase of 63 percent in the basic projection. Under the low alternative, in contrast, the supply is projected to reach 414,600 in 1990, a 58-percent growth over the next two decades. For the 1980-90 period, the basic, high, and low assumptions project increases of 28.4, 33.1 and 24.2 percent, respectively. (See Table 24.) The divergence in the supply estimates projected by the high and low alternatives would be 31,900 physicians by 1990, with the low estimate being about 8 percent below the high figure. This difference approxiates the output of 16 medical schools over a 20-year period. Compared to the ratio of 172 U.S.-trained physicians per 100,000 population projected for 1990 by the basic methodology, the low alternative projects a ratio of 165 per 100,000, while the high alternative projects a ratio of 178 per 100,000. Over the 1970-90 period, the basic method- ology projects the number of U.S.-trained M.D.’s and D.O.’s to increase by 62 and 89 percent, respectively. The high alternative projects increases of 69 and 93 percent, respec- tively; while the low alternative shows projected growth at 56 and 86 percent. PROJECTIONS OF THE SUPPLY OF FOREIGN MEDICAL GRADUATES This section provides projections to 1990 of the supply of foreign medical graduates (FMG’s), also under three different assumptions. For an adequate understanding of the projections presented here, it is important for the reader to keep in mind the gaps and weaknesses in the data on foreign medical graduates. The primary source of data on FMG’s is the master file of the American Medical Association and the numerous AMA publications based on that file. The AMA defines an FMG as “anyone graduating from a medical school outside the United States, its possessions, and Canada.” Theoreti- cally AMA records provide data on the number and characteristics of all FMG’s in the United States, at a point in time, as well as on trends in FMG’s over time. However, in practice, difficulties in locating and recording FMG’s as they enter or leave the country or find employment here have created numerous problems in terms of both current and historical data. Although the following section briefly describes some of these problems, it is by no means meant to cover the full scope of the FMG data difficulties. In order to be included in the AMA records, as of 1961, an FMG had to (1) have passed the examination given by 565-118 O - 74 - 5 49 the Educational Council for Foreign Medical Graduates (ECFMG) and received a standard ECFMG certificate and/or (2) have received a full license from his State of residence to practice.>® Most FMG’s in the United States are believed to have passed the examination and thus appear in the AMA files, but an unknown number are thought to be missing from AMA records for one reason or another. The ECFMG examination can be taken by a medical graduate prior to or upon entry into the United States. After passing the examination, the FMG is eligible for a number of approved training and other activities, but he cannot provide direct patient care unless he is fully licensed. An unknown number of FMG’s never take or pass the ECFMG examination or that of a State licensing board after entry into this country. Those who do not return to their country of origin may find employment here as technicians, in limited-practice situations, or in nonmedical activities. Furthermore, an FMG who wishes to be em- ployed in certain activities, such as in a State mental hospital, may receive a temporary license to practice even though he has not passed the ECFMG examination, and such FMG’s are not easily located or counted. Similarly, those in nonapproved training programs may not be included in the AMA files. Moreover, an FMG who is engaged in administration, research, or teaching is not obligated to have a license or to have passed the ECFMG examination. In addition to proble’.is of possible underreporting of the FMG population, no precise information exists as to their patterns of immigration or emigration. FMG’s entering the country are recorded by the Immigration and Naturali- zation Service (INS) and may be on the records of the ECFMG or the AMA37, but no accurate records are available on individual FMG’s who temporarily or perma- nently leave the country. A recent study by Haug and Stevens®®, which utilizes unpublished AMA data, indicates that approximately 80 percent of the FMG’s who were in the United States in 1963 were also in this country in 1971. In addition, the study reports that approximately 70 36Gince 1961, two ways of entering the United States have been created for U.S.-born FMG’s. COTRANS and the “fifth pathway,” which are described in footnotes 18 and 19 above, have facilitated the reentry of Americans studying medicine abroad into U.S. medical schools and AMA-approved internships and residencies, respectively. The immigration figures are for self-designated “physicians,” with no check upon the accuracy of this designation. More significantly, however, the INS counts provide no information on whether the entrants are actually practicing as physicians upon entry into the United States. 38Haug, James and Stevens, Rosemary. The Physician “Brain Drain’; A Follow-up Study of Foreign Medical Graduates Located in the United States in 1963 and in 1971. (Unpublished) percent of those FMG’s who were in the United States in 1963 for “temporary” training (interns and residents) were located in the AMA files in 1971. It should be noted, however, as stated by the authors, that these findings may be somewhat biased owing to limitations in the AMA data and the fact that no information exists as to the number of FMG’s who were here in 1963 and 1971 but emigrated and then returned sometime within that period. In addition, the data are not necessarily representative of the situation for FMG’s who are newly entering the United States. Since many of those in the United States in 1963 may already have been here for a number of years, their 1963-71 experience is not necessarily the same as those who entered the country during that period. With the sparsity of data on emigration and incomplete immigration, training, and employment information, it is also difficult to develop or assess trend data on the total number and composition of FMG'’s, especially on the discrete components of the FMG work force; i.e., those who enter, leave, or remain in this country. Although changes in total FMG’s over time can be observed from AMA figures, little can be said concerning movements and tendencies of, say, older FMG’s, new entrants, or emigrants. Although the AMA has published some limited data on the FMG work force at various points in time, these total numbers represent a net concept, with little information available on the specific FMG’s entering or leaving that total in the year. For example, although the total number of FMG’s in the United States reported by the AMA increased by about 5,000 in 1971, this would appear to really reflect many more than 5,000 FMG’s actually entering the United States in that year. The reader should keep in mind these conceptual and statistical considerations when assessing the projections presented here. For purposes of the remainder of this report, it should also be noted that Canadian graduates are included within the FMG component unless specified to the contrary. METHODOLOGY AND ASSUMPTIONS. Since the most critical aspect of the projection methodology is obviously that relating to the future increase in FMG'’s, three different assumptions were made as to the size of the annual FMG increment; i.e., the net increase in the number of FMG’s who will be added to the physician manpower supply each year over the next two decades. According to the limited available data from AMA files, an average net change of approximately 3,800 FMG'’s per year occurred from 1963 through 1970. In 1971, the net increment rose to 5,200. This sharp 1-year increase in the AMA count of FMG'’s, along with the sharp increases in immigration reported by INS in both 1971 and 1972, has 50 posed important questions about the future supply of FMG’s. Without adequate emigration data, unfortunately, relatively little can be said about the pool of FMG's in the United States at different points in time. Although the net changes in the FMG population were analyzed to determine overall FMG manpower growth, little was gleaned about the characteristics, age, IQcation, etc., of those who entered or left the pool in these years. Several views concerning the future growth in the FMG supply have been expressed by manpower experts, but no consensus appears to have emerged. This lack of agreement reflects a combination of several factors, among them, questions as to the reliability of current and historical information on FMG’s; differing viewpoints as to the implications for the future of the 1970-72 experience; different views as to what has drawn FMG’s to the United States; and the impact of changes in immigration or licensing laws. It is believed by some that the recent sharp increases reflect little more than a diminution of the backlog of FMG’s in this country resulting from the recent changes in U.S. immigration laws. In 1965, an amendment terminated the national quota system and assigned prior- ities to technicians and professionals with skills considered in short supply in this country. At that particular time, a physician shortage was declared. In addition, a 1970 change in the immigration laws eliminated the 2-year mandatory emigration of FMG’s on exchange visas before permitting their reentry. At present, unless an FMG “. . .is sponsored by the U.S. Government or his own government (and the vast majority are not sponsored), or unless the Department of State determines that his services are needed at home, an FMG can now have his visitor visa converted to permanent resident status.”>® A careful consideration and analysis of the immigration and exchange-visitor data must be made in order to evaluate their implications for future FMG supply. Although the number of immigrants rose substantially in 1971 and 1972, the number of exchange visitors declined, reaching its lowest level in 7 years. Furthermore, data from INS indicate that a substantial number of the immigrants reported in the past few years are in reality exchange visitors already in the United States who have shifted to immigrant status. Even so, taken together, the increase in exchange visitors and immigrants combined is much less sharp than among immigrants alone; the 1972 increase was only about 500, the smallest annual increase in 3 years (after the sharp rise in 1970). (See Table 26.) In addition, the observed yearly increments in the FMG supply reported 39publin, T.D. The Migration of Physicians to the United States. The New England Journal of Medicine 286: 870-877, April 20, 1972. Table 26. PHYSICIANS ADMITTED TO THE UNITED STATES, BY IMMIGRATION CLASSIFICATION: FISCAL YEARS 1968-72 : . Sew Total Immigration classification 1968-72 1968 1969 1970 1971 1972 Total physicians admitted . ........... 47,537 9,125 7,515 8,523 10,947 11,427 Immigrant physicians: Totaladmitted ........¢00000010000s 21,942 3,128 2,756 3,158 5,756 7,144 Occupational preference: Total ws ss roammmus ss vpmmnss rows 6,027 1,036 996 840 1,484 1,671 Third preference, admissions ............ 3,101 692 761 544 564 540 Third preference, adjustments . . . ......... 1,870 181 126 166 557 840 Sixth preference, admissions ............ 415 128 69 84 90 44 Sixth preference, adjustments . . . ......... 641 35 40 46 273 247 All other immigrants admitted. . . ........... 15915 2,092 1,760 2,318 4,272 5473 Nonimmigrant physicians: Total admitted . cw vs nos amuses sou nem 25,595 5,997 4,759 5,365 5,191 4,283 Distinguished merit and ability. . . ........... 615 61 62 83 178 231 Othertemporary . ........oo ov eeseennns 199 7 20 100 47 25 Trainees ss vuwwmav ss pwr wimes sve wu 874 228 217 174 173 82 Exchange ViSiOIS wim s+ s mw mmo 4 8 » a1 9 i@ oo 23,888 5,701 4,460 5,008 4,784 3,935 Transferees .: vows ats soup nw o # wR EE®.4 19 0 0 0 9 10 Source: Annual Reports of Immigration and Naturalization Service, tables 8A and 16B. by AMA during the past 10 years may overstate the increase and might have been partially due to improve- ments in data collection rather than ‘true’ increases in the FMG population. Each of the three alternative projections of FMG’s presented here views the recent experiences in a somewhat different light, resulting in basic, low, and high projections. The figures include American citizens trained abroad; no separate analysis of this group is made. It must be emphasized that in all the projections, the yearly change in the FMG supply represents net, not gross, inputs to the physician supply. They do not represent entrants alone (as do the immigrant and exchange visitor figures) but rather represent the net difference between any 2 years in the total active supply of FMG’s. As such, they have already allowed for deaths and retirements among existing and new FMG’s, as well as emigration of these two groups. Under the first assumption (termed the basic projec- tion), it was assumed that the 1971 increase in FMG’s (as reported by the AMA) did not entirely represent a 1-year phenomenon but was rather a step increase in the FMG increment that would continue into the years ahead. The accelerating increase in new foreign-trained medical licen- tiates during the past 3 years, together with the increase in the number of FMG’s taking the ECFMG examination, 51 helps to support the assumption that the 1970-71 experi- ence initiated a new FMG incremental supply trend. Under this basic assumption, it was assumed that the active 1970 base of FMG’s would experience a net yearly increase of 5,200 through 1990 (including Canadians).*® The second set of projections (the high estimate) assumed that the 1970-71 experience marked the beginning of a new trend in FMG supply. With the relaxing of immigration laws, the specific evidence of FMG’s migrating to the United States because of (1) a lack of job opportunities in their home countries, (2) the higher American standard of living, and (3) the potential relaxing of licensure requirements in rural States, an even further step increase in FMG supply could possibly be expected. As a high alternative, therefore, it was assumed that the active FMG base (including Canadians) of 59,966 in 1970 would increase by 5,200 in 1971 (as it actually did) but would then rise subsequently by an arbitrarily chosen increment of 6,600 a year through 1990. 40The 1971-72 experience with FMG estimates supports this assumption. Taking into account the adjustments made in this report for AMA “active” totals, the number of FMG’s increased from 59,525 in 1971 to 64,788 in 1972, an increase of 5,267. Canadians are excluded from these figures. Under the low projection, it was assumed that the foreign trained physician supply in the United States would increase by the same average yearly net increment observed in the 1963-1970 period, as shown by the limited historical data. The active FMG’s (including Canadians) in 1970 (59,966) would therefore increase by the already achieved 5,200 increment of 1971 but thereafter would increase by only 3,800 a year through 1990. Part of the rationale for this alternative is the consideration of the proposed abolition of the free-standing internship and the tightening of requirements for approval of residency training pro- grams. This reduction in training programs, along with the increase in U.S. medical school graduates, might very well hamper the future entry of FMG’s into U.S. training programs. PROJECTION FINDINGS. The basic projection of the supply of foreign medical graduates (including graduates of Canadian medical schools) results in a total net graduate input of 104,000 FMG'’s over the 1971-90 period. The total number of practicing FMG’s is projected to rise from about 60,000 in 1970 to 164,000 by 1990, an increase of 173 percent or about 8 percent a year (compounded). This is not substantially different from the 9-percent increase from 1963 to 1971, when the number of FMG’s grew from 36,965*' to 59,966. The low alternative projects a total net graduate input of 77,400; the high alternative, a total (net) of 130,600. The high and low projections thus result in a 53,200 spread in a net foreign-trained graduate input over the 20-year period. (See Table 27.) The influx of foreign-trained M.D.’s has been largely responsible for the increase in the overall physician/ population ratio during the 1960's. Under the basic methodology, foreign-trained M.D.’s would play an in- creasingly important role in the delivery of health care, despite continued increases in U.S. graduates. The ratio of FMG'’s to population is projected to increase from 29 to 49 per 100,000 population during the 1970-80 period, and to 65 per 100,000 population by 1990, more than twice the 1970 ratio (Table 27). In addition, FMG’s would increase from one-fifth of the total active physician population in 1970 to somewhere around one-third of all physicians in 1990. Even under the low alternative, significant growth in the FMG population is projected. Their numbers would in- crease from about 60,000 in 1970 to 99,000 in 1980 and to 137,000 in 1990. Under the high alternative, FMG’s would more than triple in numbers between 1970 and 1990, reaching 191,000 by the latter year. 41includes inactive foreign trained physicians. 52 The alternative projections, as presented, do not esti- mate the future supply of foreign-trained physicians if the sharp upward trends of the past year or two were simply to be extrapolated to 1990. Such calculations were under- taken, but the subsequent findings were rejected as being highly unlikely. However, they are reported here for information purposes only. For example, if the average annual percent increase in FMG supply (excluding Cana- dians) over the 1967-71 period were simply extrapolated on a straight-line basis (approximately 8 percent a year increase), the supply of active FMG’s would number about 250,000 by 1990—a magnitude roughly equaling the 1970 active supply of U.S.-trained M.D.’s. Unlike the three alternatives shown above (in which net yearly increases were assumed to remain the same over the projection period), if the net changes were assumed to rise incre- mentally in line with the 1969-71 experience, the supply of active FMG’s would be projected to be about 400,000 by 1990. This calculation assumes that the net annual change over the projection period would increase each year by 1,300, the difference between the net annual change of 1969-70 (3,665) and of 1970-71 (4,997). By 1989-90, for example, such an approach would result (unreasonably) in a net increase in that year of around 30,000. There is strong justification for rejection of an accel- erated rate of increase of FMG'’s. 1. The fact that the number of immigrants and ex- change visitors combined who entered the United States did rise in 1971 does not necessarily reflect the beginning of a sharp upward trend. For example, a more rapid increase actually occurred between 1966 and 1968, followed by a sharply reduced number of entrants in 1969; in 1970 the number of total entrants barely equaled the inflow experi- enced 3 years earlier. A somewhat similar situation oc- curred in the 3 years following a spurt in 1963. Although these figures have, on balance, been increasing, the rise has been by no means a steady and persistent one. If one were to extrapolate the recent experience of exchange visitors, their incoming numbers would be reduced to negligible amounts over the projection period. 2. It appears unlikely that foreign countries could long permit or afford to have their physicians leaving their countries in the numbers implied by the immigration figures. For example, the immigrant statistics show about 965 Korean physicians entering the United States in FY 1972; this represents about 10 percent of their entire physician population. Obviously, such increases could not continue for very long. It is evident from the above, however, that regardless of the alternative chosen, FMG’s will play an increasingly important role in the U.S. medical care system. To assess the desirability of this development is beyond the scope of Table 27 SUPPLY OF ACTIVE FOREIGN TRAINED PHYSICIANS, USING BASIC METHODOLOGY AND ALTERNATIVE ASSUMPTIONS: ACTUAL 1970; PROJECTED 1975-90 T Projection series 1970 1975 1980 1985 1990 Number of active foreign trained physicians® BasicmethodologY . ...... cit tienen snnnnenannns 60,000 86,000 112,000 138,000 164,000 Alternatives: LOW &+ ct ttt tsetse sssssansasessanssnssasannen 60,000 80,000 99,000 118,000 137,000 HIBN i sanammus si 0am e@ ee wee ss o vue mn wee vod 60,000 92,000 125,000 158,000 191,000 Rate per 100,000 population? Basic Methodology . «vv vv vv tt tit ee ieee eee 29.4 40.0 49.3 57.7 65.4 Alternatives: BOW. .covminn si Mmm BEE SHIM B IE SEH EE IE 0 29.4 37.4 43.8 49.5 54.8 HIZR © vvvvns sr nssiassssasenmss nansmns seams 294 42.6 54.9 65.8 76.0 ! Includes Canadian trained physicians. 2 Resident population as of July 1 for 50 States and the District of Columbia. Source: 1970 foreign trained physicians: Haug, J. N.and Martin. R C. Foreign Medical Graduates in the United States, 1970. Chicago, American Medical Association, 1971. Population: U.S. Bureau of the Census. Current Population Reports. Series P-25, Nos. 468,477, and 483. this report, although other reports of Project SOAR will deal with this topic. PROJECTIONS OF THE TOTAL SUPPLY OF PHYSICIANS The previous two sections have presented a number of alternate projections to 1990 of U.S. and foreign trained physicians. As indicated earlier, these projections were developed independently in order to show what the future physician supply would be considering only U.S. graduates, as well as to minimize the deficiencies of the data on foreign trained physicians. This section combines the two components and discusses the projected supply profile for all active physicians in the United States. Between 1960 and 1970, the number of all active physicians rose from 251,900 to 323,200, an increase of 28 percent. (See Table 28.) Over this same period, the number of active physicians per 100,000 population rose from 140 to 159. These increases in large part reflect the growing input of FMG’s to the overall physician supply. Under the basic methodology used to project both components of the total supply, the number of all active physicians is expected to increase to 446,800 in 1980 and 593,800 in 1990. The supply is thus projected to grow by 123,600 (or 38 percent) over the 1970-80 period, and by 53 147,000 (or 33 percent) over the 1980-90 period. The growth in the physician supply over the next two decades would not only be numerically large, but would also be at a faster annual rate than during the past 10 years. The basic projection also indicates that the overall physician/population ratio will increase to 197 per 100,000 population in 1980, and to 237 per 100,000 population in 1990. This compares with a ratio of 159 physicians per 100,000 population in 1970. For active U.S.-trained physi- cians alone, the 1990 ratio would be 172 per 100,000 (Table 24), much the same as the 1975 ratio for all physicians. The country of training of the overall physician supply is projected to change significantly over the 20-year period. In 1970, for example, physicians trained in Canada and abroad accounted for nearly one-fifth of the total supply of active physicians practicing in the U.S. Under the basic method- ology used for both components of the supply profile, this proportion is projected to increase to 25 percent by 1980 and to 28 percent by 1990. Thus the ratio of foreign- trained to all active physicians is projected to rise by virtually 50 percent over the 1970-90 period. Although this represents a striking increase, it should be recalled that the ratio of foreign trained to total physicians in 1970 was double the level registered 10 years earlier. The projections reveal further developments of interest. Under the basic methodology, the supply of all active Table 28 SUPPLY OF ACTIVE PHYSICIANS (M.D. AND D.O.) AND PHYSICIAN/POPULATION RATIOS, USING BASIC METHODOLOGY AND ALTERNATIVE ASSUMPTIONS: ACTUAL 1960 AND 1970; PROJECTED 1975-90 Projection series 1960 1970 1975 1980 1985 1990 Number of active physicians (M.D. and D.O.) Basic methodology ............. Bt 88 9 I 3 100 251,900 323,200 377,500 446,800 519,100 593,800 Alternatives: LOW ovviimmsswmmmnns taimasns assesses 251,900 323,200 371,900 433,600 494,100 552,000 HIgh cvnsinnssmnmmmme romans sonny en 251,900 323,200 383,100 459,900 544,300 637,100 Rate per 100,000 population’ Basic methodology . ...................... 140.0 158.6 175.7 196.9 216.9 236.9 Alternatives: BOW 5 4 5 5.0ibiio wv oie www wisn 8 8% #0 @ idk. & 5 3% 140.0 158.6 173.1 191.1 206.5 220.2 High 140.0 158.6 178.3 202.7 227.4 254.2 ! Resident population as of July 1 for 50 States and the District of Columbia. Rate for 1970 differs from that shown in table 10 because of exclusion of Puerto Rico and outlying areas from population base in this table. Source: 1960 active physicians: Pennell, Maryland Y. Statistics on Physicians, 1950-63. Public Health Reports 79: 905-910, October 1964. 1970 active physicians (M.D.): Haug, J. N.; Roback, G. A.; and Martin, B. C. Distribution of Physicians in the United States, 1970. Chicago, American Medical Association, 1971. 1970 active physicians (D.0.): Unpublished data provided by the American Osteopathic Association. Population: U.S. Bureau of the Census. Current Population Reports. Series P-25, Nos. 468,477, and 483. physicians is projected to grow to 400,000 by 1977. The supply of U.S.-trained physicians alone, however, is not projected to reach that level until 1987. This finding again serves to dramatize the numerical impact of foreign-trained physicians. As indicated earlier, alternative projections (high and low) were developed separately for both U.S.-and foreign- trained physicians. Although a matrix of possible combina- tions could be examined, the following discussion concerns itself with only two alternative projections of all active physicians—one consisting of the high projections for the two components and one consisting of the respective low projections. Under the high methodology, the supply of all active physicians is projected to increase from 323,200 in 1970 to 459,900 in 1980 (a 42-percent increase) and then to 637,100 in 1990 (a 39-percent increase). Compared to results from the basic methodology, the high series projects an additional 43,300 physicians by 1990, of which approxi- mately three-fifths are projected to result from the in- 54 creased entry of foreign-trained physicians. The high methodology projects the proportion of foreign-trained to all active physicians to be 30 percent in 1990, compared to 28 percent in the basic projection. In contrast, the low methodology projects the overall physician supply to reach 552,000 by 1990—a figure about 42,000 below the basic projection for that year and approximately the same number as in the 1985 high projection. Over the entire 20-year projection period, the low methodology projects the overall supply of physicians to grow by 71 percent, in contrast to a 84-percent increase in the basic approach, and the 97-percent increase under the high methodology. Another means of assessment is afforded by an examina- . tion of the physician/population ratios projected by the basic methodology and the two alternatives. Under the basic approach, the ratio is projected to reach 237 per 100,000 population by 1990. This compares with a ratio of 254 per 100,000 population under the high alternative, and 220 per 100,000 under the low approach. NOTE ON ESTIMATES OF “ACTIVE” M.D.S As noted in Table 12, as well as in certain other tables presented in this report, BHRD estimates of the number of active M.D.’s in 1971 and 1972 vary substantially from numbers published by the AMA*?2; Active physicians (M.D.) Year BHRD estimate ~~ AMA figure Difference 1971...... 322,026 318,699 3,327 1972...... 332,530 320,903 11,627 In evaluating this apparent discrepancy, note should be made of the different definitions for “active’’ employed by the two organizations. The AMA active figure is defined as the number of professionally active M.D.’s whose address is known. Excluded from this number are those M.D.’s identified by the AMA in its information system as inactive, address unknown, or not classified. In brief, the category “not classified” accounts for the BHRD-AMA differences in numbers of active M.D.’s. In 1971 and 1972, according to the AMA this category accounted for 3,529 and 12,356 M.D.’s, respectively. The AMA, to update its files between AMA census years, utilizes its weekly Periodic Survey of Physicians to obtain information on those M.D.’s that have been brought to the attention of AMA as evidencing some signs of change in 42Roback, G. A. Distribution of Physicians in the U.S., 1971. Chicago, American Medical Association, 1972. _______. Distri- bution of Physicians in the U.S., 1972. Volume 1. Regional, State, County. Chicago, American Medical Association, 1973. 55 their status—such as a termination of intern, residency, or Government service contract, or a notification of address change. If after three follow-up surveys the AMA receives no response, apparently the M.D.’s in question are placed in the “not classified” category. This procedure was initiated with 1970 AMA statistics and was still in effect by late 1973. In 1970, the number of M.D.’s in this category was only 358. Given the objectives of this repc:.—namely, to develop new or improved estimates of available manpower re- sources—the AMA definition of active M.D.’s was deemed too restrictive. According to AMA definitions, for example, the number of M.D.’s rose by only 2,200 between 1971 and 1972; yet, available data on medical school graduates and entry of foreign-trained physicians suggested a much larger increase. BHRD'’s estimate was, however, derived from AMA data. The AMA's categories of “active” and “inactive” M.D.’s were used to calculate a proportionate active figure (i.e. roughly 94 percent). This proportion was applied to the “not classified” totals for 1971 and 1972, respectively, and the resultant figures were then added to the AMA “active” estimate to arrive at the BHRD figures. Technically, this procedure should have been undertaken for 1970 but, in view of the small number of physicians who were “not classified” (358), the entire “not classified” category was simply added to the AMA “‘active” figure. The AMA recognizes the fact that a number of M.D.’s in the category “not classified” are indeed actively working; but the Association has no means at present of determining the magnitude of this group. Admittedly, the active proportion used by BHRD is an arbitrary assumption. Hopefully, later information collected by the AMA on M.D.’s generally and those currently “not classified” specifically will assist in resolving this apparent discrepancy. Chapter 4 « MEDICAL SPECIALISTS (M.D.'S) This chapter provides estimates and projections of the supply of M.D.’s engaged in particular specialties. Largely because of limitations in the available data, osteopathic physicians are not included in the analysis except at an occasional point. The basic sources of data on the specialties of M.D.’s are the published reports of the American Medical Association (AMA), based on its master file of physicians and its periodic surveys of their activities. The AMA records classify physicians according to the specialty in which they spend the largest portion of their time. The physician is asked to designate his specialty or specialties from a given listing and to indicate the “number of hours spent per week” in each. The published categorizations reflect an allocation of each physician to the specialty in which he spends the greatest number of hours. Thus, a physician who designated his primary specialty as general practice would nonetheless be classified as an internist if he also indicated that he devoted the largest number of hours to internal medicine. As a result, the data may overestimate the number of specialists and, conversely, may underestimate the number of physicians engaged in general practice. Similarly, the reporting of a physician in a particular specialty does not necessarily mean that he spends all his time in that specialty. The identification of M.D.’s by specialty may be done in various ways. One method of categorizing specialists is according to whether or not they are board-certified. The certified diplomate is one who has completed 1 to 5 years of residency training and has passed a specialty board examination. He may or may not be actively working, or even spending most of his time, in his field of certification. Noncertified specialists are those who have acquired a specialty as a result of training or experience. This may come as the result of a physician being appointed to a particular service in a hospital which accords him increasing experience and responsibility in a specialty. Or, it may reflect his having worked as a specialist in one or another department of a hospital and then carrying over into his private practice the “specialist” status obtained through his earlier association with the hospital. Some specialists may also have spent 1 or 2 years in a particular service as a resident but failed to complete the residency requirements for certification. Other physicians may call themselves specialists even though they have had no hospital experi- ence in a particular specialty. However, since detailed comprehensive and comparable data are available only under the AMA classification system, those data are used in this section. It should be noted further, that many 57 physicians with completed residency training in a particular specialty are not board-certified. Thus, board certification alone is not a realistic guide to specialty designation. The Bureau of Health Resources Development (BHRD) is sponsoring a number of studies on the specialty fields, particularly for use in developing requirement and supply projections. Anesthesia practices are being studied by a team at Case Western Reserve University to determine what types of manpower mixes are being or could be utilized. Harvard Medical School is conducting a major study on surgical services in the United States, funded in part by BHRD, to determine the types and frequency of all surgery being performed and the training and background of manpower involved. A study at the University of Washing- ton is related to manpower in orthopedic surgery. CURRENT CHARACTERISTICS AND TRENDS Although there are more than 60 officially recognized specialties, only 21 have been included here for analysis. These were chosen either because of their numerical importance or for their potential growth. As can be seen in Table 29, the largest number of M.D.’s are in general practice and in the specialties of internal medicine, general surgery, psychiatry, obstetrics and gyne- cology, and pediatrics. The smallest number are in thera- peutic radiology, physical medicine and rehabilitation, thoracic surgery, and plastic surgery. Foreign medical graduates (FMG’s)! are distributed in much the same specialties as U.S. trained physicians; that is, largely in general practice and in the five major specialties cited above. However, there are proportionately fewer FMG’s than graduates of American and Canadian schools in dermatology, ophthamology, and orthopedic surgery, and proportionately more FMG’s in anesthesiology, pediatric cardiology, pathology, and physical medicine and rehabili- tation. It is worth noting that FMG’s tend to be more represented in the specialties that have high proportions of unfilled residency positions (excluding FMG’s from such proportions) and to be less represented in the specialties with a small proportion of unfilled residency positions. Specialists are distributed unevenly by geographic loca- tion, with States such as New York, Massachusetts, 1 In view of the AMA inclusion of Canadian graduates with U.S. graduates in internship and residency data, all references to FMG’s in this chapter exclude Canadians. Table 29. PERCENT DISTRIBUTION OF ACTIVE PHYSICIANS (M.D.) AND OF FIRST-YEAR RESIDENTS, BY SPECIALTY AND COUNTRY OF GRADUATION FROM MEDICAL SCHOOL: 1970 Active physicians (M.D.) (December 31) First-year residents (September 1) . Other U.S. and Other Specialty us, Canadian foreign Canadian | foreign Total medical medical y Total ‘ i graduates graduates medical medical medical graduates graduates graduates All active M.D.’s: Number ................. 311,203 251,237 5,548 54,418 14,556 10,199 4,357 Percent .............0.... 100.0 100.0 100.0 100.0 100.0 100.0 100.0 General practice’ PHAR RS HEE 18.6 20.1 13.9 12.4 1.9 0.5 2.1 Medical specialties ............. 20.8 21.2 15.6 194 31.1 31.2 28.6 Dermatology . + os vss cw ss vans 1.3 14 1.5 0.7 1.4 1.9 0.3 Internal medicine . ........... 13.5 139 9.4 11.7 20.9 21.6 19.3 Pediatrics? |. « wsninws ss naman 6.1 59 4.7 7.0 8.1 7.8 11.2 Surgical specialties ............. 275 28.1 28.6 229 36.3 38.1 32.8 General surgery . ............ 9.6 9.6 8.3 9.7 173 16.5 19.1 Neurological surgery. . . ........ 0.8 0.8 1.4 0.8 1.0 1.0 0.8 Obstetrics and gynecology . ...... 6.1 6.1 6.1 5.6 59 53 7:2 Ophthalmology . «ev trv vas nune 3.2 35 3.8 1.5 3.2 4.3 0.6 Orthopedic SUrgery . . « + + vos 5s + 3.1 34 3.7 1.6 3.6 4.7 1.2 Otolaryngology «sev w sc evs wwe 1.7 1.6 2.3 1.2 1.6 2.0 0.6 PlastiCSUrgery «esis ss vwmawes 0.5 0.5 0.6 0.4 08 0.9 0.6 Thoracicsurgery ........ce..+. 0.6 0.6 0.5 0.7 0.9 1.0 1.0 Urology «vv viii itive ean 1.9 2.0 1.9 1.4 2. 2.3 1.8 Other specialties .............. 33.3 30.6 41.9 45.4 30.6 29.2 36.0 Anesthesiology ............. 33 29 4.7 6.1 4.7 33 8.0 Child psychiatry, ws + » ssn i » # 0.7 0.6 1.4 08 1.2 1.3 1.0 NEUroIOgY ss wwmu ss ummm 6» & 1.0 0.9 1.6 1.2 1.9 24 1.7 Psychiatry ................ 6.8 6.2 10.2 9.2 9.5 10.3 1.7 Pathology ................ 3.4 2.7 4.5 58 5.1 32 9.6 Physical medicine and rehabilitation . 0.5 0.4 0.5 09 0.7 0.3 1.5 RadiOIOBY vs wines monies ws 3.4 3.6 3.2 2.6 6.2 73 3.8 Therapeutic radiology ......... 0.3 0.3 0.3 0.4 0.2 0.3 0.2 Miscellaneous . ............. 13.7 13.0 15.5 18.3 0.9 13 0.5 } 1 Includes family practice. 2 Includes pediatric allergy and pediatric cardiology. Source: Active physicians: Haug, J. N. and Martin, B. C. Foreign Medical Graduates in the United States, 1970. Chicago, American Medical Association, 1971. First-year residents: American Medical Association. Director of Approved Internships and Residencies, 1971-72. Chicago, The Association, 1971. Vermont, Rhode Island, California, Connecticut, and Mary- land having disproportionately large numbers. Examples of the variation in geographic distribution can clearly be seen in an examination of the physician/population ratios for California and Alaska. In California, there is 1 internist for every 3,500 persons, whereas in Alaska there is 1 per 14,400 persons. Similarly, there is 1 general surgeon per 7,100 persons in California compared to 1 per 12,500 persons in Alaska, and 1 pediatrician per 10,000 persons in 58 California compared to 1 per 20,000 persons in Alaska. Studies have also shown that internists, surgeons, and certain other specialists (particularly pediatricians, obstetri- cians and gynecologists, pathologists, and radiologists) tend to locate in larger cities, whereas these specialties are 2 Mason, Henry R. Manpower Needs by Specialty. Journal of the American Medical Association 219: 1621-1626, March 20, 1972. urdgerrepresented in other areas. There is somewhat less variation in the physician/population ratios for general practitioners. Major contributing factors to location choice appear to be the presence or absence of hospitals and training facilities, the degree of urbanization, and per capita income levels in the area. There is evidence that the availability of residences has a strong positive relationship to the specialist supply because a substantial number of physicians remain in the area in which they receive their training. Studies on future practice locations of medical students indicate that there is also a direct relation between the attachment a student has to a particular area—for example, place of birth, education, or residency training— and the likelihood of locating in that area®. Not surpris- ingly, medical centers, hospitals, training facilities, and the like are heavily located in populous States, namely, New York, California, and Massachusetts—all of which have a disproportionately large number of physicians compared to the more sparsely populated States such as Idaho, Wyoming, Montana, Maine, and Alaska. Individual specialties have shown very different growth patterns over time, evolving and growing in response to the particular scientific and intellectual interests of groups of individuals at particular points in time, rather than to any set plan. The oldest specialty is ophthalmology which developed around the ophthalmoscope in the 1850's and established the first certifying board in 1916. The specialty of radiology developed around the invention of the X-ray machine about 1900. Pediatrics grew out of individual interest in child care which was reinforced by the maternal and child welfare movements of the early 1900's. Overall, the AMA listed only 20 approved specialty fields in 1920. This original list of 20 specialties has more than tripled, and specialty boards now offer certification in about 65 different specialties, subspecialties, and special divisions. In 1931, only 10 percent of all physicians were engaged in specialty practice; by 1970, over 80 percent of all physi- "cians were reported to be in a specialty. There have been only relatively small changes in specialty distribution in recent years. Table 30 shows the specialty classification of M.D.’s over the 1963-72 period. In viewing the table, it should be kept in mind that the system used by the AMA to classify specialists was changed in 1968. In the pre-1968 classification procedure, the physician assigned himself to a particular specialty; in the new system, the specialty classification is determined by the number of hours the physician spends in a given specialty. For this 5 Weiskotten, H. G.; Wiggins, W.S.; Altenderfer, M.E,; Gooch, M.; and Tipner, A. Trends in Medical Practice. Journal of Medical Education 35: 1071-1121, December 1960. 59 report, the pre-1968 data have been adjusted (according to the percent difference between the two sets of data existing in 1968) so that the data shown are believed to be internally consistent. Data prior to 1963, are not pre- sented here because of other noncomparabilities, including the separation of specialists into full- and part-time cate- gories. As shown in Table 30, with the exception of general practice there has been little change in the composition of specialty manpower during the past 10 years, despite a net increase of nearly 71,000 active physicians over this period. The only specialties in which there has been an increase of more than 1 percentage point have been internal medicine and pediatrics. The proportion of all active physicians in internal medicine increased from 11.6 percent in 1963 to 15.0 percent in 1972. In pediatrics the proportion has changed from 4.9 percent to 6.4 percent. The growth of pediatrics and internal medicine, which are often considered to be a part of primary care, has served to partially offset the decline in general practice, which fell from 26 percent of all physicians in 1963 to 17 percent in 1972. In absolute numbers, general practice has also declined (by about 2 percent a year), whereas the special- ties as a group have grown by about 4 percent a year (compounded). Of all the specialties shown, the subspecial- ties of therapeutic radiology and child psychiatry have demonstrated the largest annual compounded growth rate (25 percent and 16 percent respectively); otolaryngology has shown the smallest annual growth rate (1 percent). The medical specialties as a group have grown faster than the surgical and other specialties. In the surgical group, the surgical specialties have grown more rapidly than general surgery. In recognition of the decline in general practice in the face of continued needs in this field, the medical profession has recently attempted to encourage this type of medical care by developing the specialty of family practice, which was formally recognized in 1969. Family practice was originally conceived of as a specialty concerned with comprehensive, continuing health care of the individual in the context of his family, community, and society. In the past most general practitioners were trained in rotating internship programs. Some received an additional 1 to 2 years of graduate training in general practice resi- dencies. Their training was oriented toward episodic, hospital-based health care for the individual, rather than to a continuity of care for the individual as a member of the 4 Thedore, C. N.; Haug, J. M.; Balfe, B. E.; Roback, G. A.; and Franz, E. ). Reclassification of Physicians, 1968. Chicago, American Medical Association, 1971. QQ o Table 30 TREND DATA ON NUMBER OF ACTIVE PHYSICIANS (M.D.),BY SPECIALTY: DECEMBER 31, 1963-72 Specialty 1963 1964 1965 1966 1967 1968 1969 | 1970 | 1971 1972 All active MDs... ...... 261,728 269,552 277,575 285857 294,072 296,312 302,966 311,203 1 (318,699) 2 (320,903) General practice® ............ 66,874 65,861 64,943 63,903 61,605 61,578 58,919 57,948 (56,358) (55,348) Medical specialties ........... 46,518 49,175 51,762 54,032 56,761 59,796 60,054 64,694 (70,269) (72,728) Dermatology ............ 3,156 3,279 3,407 3,538 3,656 3,775 3,870 4,003 (4,149) (4,227) Internal medicine ......... 30,434 32,230 33,892 35315 37,077 38,532 38,258 41,872 (46,202) (47,994) Pediatrics .............. 12,928 13,666 14,463 15,179 16,028 17,489 17,926 18,819 (19,918) (20,507) Surgical specialties ........... 67,005 69,687 72,473 75,466 78,316 81,113 82,246 85,375 (89,125) (90,409) General surgery ........... 23,607 24 564 25,644 26,628 27,490 28,433 28,603 29,761 (30,897) (30,989) Neurological surgery. . ....... 1,818 1,933 2,041 2,185 2,310 2,419 2,484 2578 (2,721) (2,753) Obstetrics and gynecology . . . . . 15,296 15,866 16,379 16,973 17,478 18,017 18,084 18,876 (19,770) (20,202) Ophthalmology ........... 7,833 8,092 8,380 8,718 9,065 9,368 9,578 9,927 (10,252) (10,443) Orthopedic surgery . ........ 6,827 7,207 1,557 7,990 8,434 8,869 9,227 9,620 (10,121) (10,356) Otolaryngology ........... 4,724 4776 4,852 4,946 5,086 5,195 5272 5,409 (5,592) (5,662) Plasticsurgery ............ 1,023 1,090 1,167 1,243 1,342 1,414 1,503 1,600 (1,688) (1,786) Thoracic surgery. . ......... 1,296 1,374 1,474 1,622 1,720 1,822 1,857 1,809 (1,928) (1,927) Urology ............... 4581 4,785 4,979 5,161 5,391 5,576 5,638 5,795 (6,156) (6,291) Other specialties. . . .......... 81,331 84,829 88,397 92,456 97,390 93,825 101,747 103,186 (102,947) (102,418) Anesthesiology ........... 7.593 8,124 8,592 9,055 9572 10,112 10,434 10,860 (11,557) (11,853) Child psychiatry . . ......... 151 980 1,154 1,353 1,525 1,702 1,898 2,090 (2,171) (2,268) Neurology. . . «voor... 1,822 2,037 2,198 2,320 2,493 2,675 2,850 3,074 (3317) (3,494) Psychiatry. . ............. 15,551 16,377 17,333 18,290 19,137 19,907 20,328 21,146 (22,279) (22,570) Pathology” .............. 7,016 7,557 8,106 8,560 9,090 9,696 10,023 10,483 (11,103) (11,218) Physical medicine and rehabilitation. . . ........ 991 1,096 1,162 1,222 1,294 1,407 1,415 1,479 (1,563) (1,551) Radiology ............. 7.211 7,530 7,949 8,396 8,963 11,718 12,367 13,360 (14,339) (14,917) Miscellaneous? ........... 40,396 41,128 41,903 43,260 45,316 36,608 42,432 40,694 (36,618) (34,547) ! Excludes 3,529 physicians “not classified”. If the percent active among all physicians is applied to the “not classified” would be 322,026. 2 Excludes 12,356 physicians “not classified”. If the percent active among all physicians is applied to the “not classified” physicians would be 332,530. 3 Includes family practice in 1970-72. 4 Includes pediatric allergy and pediatric cardiology. 5 Includes forensic pathology. 6 Includes therapeutic radiology and diagnostic radiology. 7 Includes physicians with unspecified specialty. physicians, the estimated number of active physician physicians, the estimated number of active Source: Roback, G. A. Distribution of Physicians in the U.S., 1972. Chicago, American Medical Association, 1973. Also prior annual volumes. Note: Due to a change in the A.M.A. classification procedure in 1968 1968-72. In this report the figures for 1963-67 have been adjusted to 1968. Chicago, American Medical Association, 1971. , there exists a discontinuity in the published series between the figures for 1963-67 and those for provide a comparable series using comparative data in: Theodore, C. N. et al. Reclassification of Physicians, family. Thus, prior to the introduction of the concept of family practice, these programs traditionally placed mini- mal emphasis on health maintenance and comprehensive care. Since its formal recognition, family practice has grown rapidly. As of September 1972, there were 151 approved residency training programs in the field, with approxi- mately 1,040 residents in training. Thus, 59 percent of the available 1,755 openings were filled. Foreign medical graduates accounted for 12 percent of the filled residencies. At the present time, half of the Nation's medical schools have programs in family practice that are either operational or in the planning stages. However, concurrent with the growth of family practice, there has been a further decline in the numbers of physicians who indicate that they function as general practitioners. This decline has been reflected in the decrease in the number of filled general practice residencies. On July 1, 1970, there were 145 approved general practice residency training programs, with a capacity of 925 physicians. By July 1971, the number had dropped to only 133 programs with a capacity of 818 physicians. A high proportion of these residency positions were filled by FMG’s. Although some of the general practice training programs have been converted to family practice programs, others have been terminated. General practitioners who wish to become board-certified in family practice must meet stated eligibility criteria and pass the certification examination. As in other specialties, informa- tion on the number of M.D.’s in family practice is collected by the AMA. Up to the present time, however, family practitioners have been included under ‘‘general practice” in the AMA's Distribution of Physicians series. According to data published by the AMA, 348 family practitioners were included in this broader designation in 1970 and 2,344 in 1971.5 In the future, however, family practice will be listed as a separate specialty in the AMA's annual professional activity questionnaire, and consequently the number of family practitioners will appear as a separate line item in the Distribution of Physicians for 1973. At this time, there is a discrepancy between the AMA statistics on family practice and those provided by the American Board for Family Practice. According to the latter, 1,690 physicians became board-certified family practitioners in 1970 (109 FMG’s and 1,581 graduates of U.S. and Canadian medical schools), and 1,595 were so certified in 1971.5 The difference between the Board and the AMA figures may reflect the mechanism used by the 5 American Medical Association. Profile of Medical Practice. 1972 edition. Chicago, The Association, 1972. Personal communication to Dr. Robert Knouss, Division of Physician and Health Professions Education, DHEW, NIH, BHME.. 61 AMA in classifying practitioners according to the number of hours they report as being worked within a specialty. For example, an M.D. reporting 23 hours a week worked in internal medicine and 17 hours in family practice would be listed by AMA in internal medicine. Despite the growth in popularity of family practice in recent years, its future remains uncertain. Factors that have contributed to its growth and potential for success include medical student interest, the further organization of ambu- latory care with the continued development of health centers, and the demand by the public for a clearly identifiable point of entry into the health care system and personal health services. However, among the possible offsetting concerns that may limit the growth in family practice are the public's tendency toward self-referral to specialties, conflicting attitudes of the practicing and academic community, and large numbers of hospitals that are oriented more towards curing than preventing. The growth of specialization at the expense of general practice is the result of many influences. One major factor is the vast increase in medical knowledge which has made it virtually impossible for any single individual to be skilled in all phases of applied medicine. Furthermore, newly emer- ging fields of knowledge are often attractive areas of study for both young and experienced physicians. The changing economic and social conditions have also provided incen- tives for specialty practice. Physicians beginning practice after World War Il entered an era in which the rising expectations of the population created a demand for a more sophisticated level of medical care than had previ- ously been available. A number of physicians who started in general practice have shifted to practice in newer specialties as a result of these factors. Another reason for growth in the specialties is that specialization allows some physicians to maximize their income and minimize the demands on their time. The growth of medical specialization may also be attributed to factors inherent, in part, in the organization of medical education. For example, it is the responsibility of medical schools to select their students, determine their curricula, and ultimately graduate M.D.’s. During their training, these students receive a considerable amount of instruction from laboratory-oriented specialists on a sample of patients not totally representative of the general popula- tion. Few medical school faculty members have been general practitioners themselves; consequently, there often tends to be less emphasis on general practice and more on hospital practice. The patients utilized for the training of medical students tend to be indigent and to have multiple social and emotional problems; thus most patients seen by students are not broadly representative of medical practice in the community. Available data indicate that many Table 31. CHANGES IN THE SUPPLY OF ACTIVE PHYSICIANS (M.D.), BY SPECIALTY: SELECTED YEARS 1963-90 1963-70 1970-80 1980-90 Specialty Number of Yearly Number of Yearly Number of Yearly physicians percent physicians percent physicians percent (M.D.) change’ (M.D.) change’ (M.D.) change! Total active physicians . . . ........ 49,480 2.5 119,030 33 140,790 29 General practice . . . ................ —10,620 -2.1 —9,050 =hs —10,510 —2.0 Medical specialties . ................ 18,180 4.8 44,370 5.2 52,490 39 Dermatology . . . ................ 850 3.4 1,660 3.5 2,090 3.2 Family practice? , ..u sc usan es ves — 1,230 5.6 1,530 4.2 Internal medicine ............... 11,440 4.6 29,150 54 34,600 4.0 Pediatrics3 ................... 5,890 5.5 12,320 5.1 14,270 2.7 Surgical specialties . ................ 18,370 35 48,170 4.5 57,320 3s General surgery . ................ 6,150 3.3 25,250 6.3 29,570 4.4 Neurological surgery .............. 760 5.1 1,220 3.9 1,460 33 Obstetrics and gynecology . . ......... 3,580 3.0 6,970 3.2 8,120 2.8 Ophthalmology . ................ 2,090 3.4 3,520 3.0 4,480 29 Orthopedicsurgery . .............. 2,790 5.0 4,430 3.8 5,530 3.3 Otolaryngology . ................ 680 2.0 1,760 2.8 2,190 2.7 Plasticsurgery . ................. 580 6.5 1,140 5.5 1,380 4.1 Thoracicsurgery. . ............... 510 4.8 1,200 5.1 1,390 39 Urology . ...... inn... 1,210 3.4 2,660 3.8 3,200 3.2 Other specialties. . . ................ 23,550 3.7 35,530 3.0 41,490 2.6 Anesthesiology ...........000... 3,270 5.2 6,650 4.9 7,450 3.6 Child psychiatry . . ............... 1,340 15.7 1,760 6.3 2,110 4.4 Neurology ............00uu.... 1,250 7.7 2,870 6.8 3,410 4.7 Psychiatry .................... 5,600 4.4 12,920 4.9 15,410 3.8 Pathology .................... 3,310 5.7 7,520 5.6 8,350 39 Physical medicine and rehabilitation . . . . . 490 59 1,020 53 1,110 37 RadIOIOBY. «x ¢ « svn ss memuniss 3,360 5.6 8,910 6.3 10,780 4.5 Therapeutic radiology. . . ........... 690 25.0 260 2.6 310 24 Miscellaneous . . ................ 4,240 1.4 —6,400 1.4 —17,440 -1.9 1 Average annual compound change rate. Family practice not reported before 1970. 3 Includes pediatric allergy and pediatric cardiology. Source: 1963 physicians: Theodore, C. N. and Haug, J. N. Selected Characteristics of the Physician Population, 1963 and 1967. Chicago, American Medical Association, 1968. 1970, 1980, and 1990 physicians: Table 34. Note: Figures may not add to totals and subtotals due to independent rounding. students do show interest in general practice at the onset of their training period, but this interest gradually diminishes as their training progresses. With the advent of family practice, these aspects of medical education are becoming somewhat ameliorated. Looked at another way, however, the decline in the number of general practitioners does not necessarily repre- sent a decline in the number of physicians providing 62 primary care. The functions of general practice have shifted partially to the specialties of internal medicine, pediatrics, and obstetrics, perhaps by default. According to limited data assembled by the National Disease and Therapeutic Index (NDTI), it appears that about 80 percent of the work of internists and pediatricians is similar to that of general practitioners. Referred patients constitute only about 8 percent of pediatric practice, 26 percent of internal medicine practice, and 19 percent of obstetric-gynecologist practice.” If the groups mentioned above are combined into a primary care category, the picture vis-a-vis general practice changes substantially. On this basis, the number of “pri- mary care’’ physicians (those in general practice, family practice, internal medicine, pediatrics, and obstetrics and gynecology) actually increased between 1963 and 1970 (from 125,530 to 137,520), although the proportion they make up of all physicians fell from 48 to 44 percent. Another contribution to the divergent growth rates of medical specialties and a major aspect of the health care system in the United States is the system of providing hospital residencies. There are far more residency training positions available in hospitals than there are medical school graduates to fill them. In effect there are few barriers to a medical school graduate entering the specialty of his choice. As can be seen in Tables 32 and 33, there were only minor changes in the distribution of physicians in first-year residencies and in all residencies during the period 1960-71. This is especially noteworthy in view of the fact that there were 12,800 more physicians in residency training in 1971 than in 1560. Three specialties, however, have shown a different pattern. The proportion of residents in general surgery decreased from 20 percent of all residents in 1960 to 15 percent in 1971. (See Table 33.) A decline also took place in obstetrics-gynecology; in 1960, 9 percent of all residents in training were in obstetrics and gynecology, whereas in 1971 the percentage was 7 percent. In contrast, radiology residents increased as a proportion of the total, from 5 percent in 1960 to 8 percent in 1971. This trend is even more interesting in view of the fact that radiology residencies are not entered by FMG’s in large numbers. Only one out of every five radiology residents in 1971 was an FMG, whereas more than one out of every three general surgery residents was an FMG. The pattern of residencies shows the marked impact that FMG'’s have had on specialty training. Between 1965, the earliest year for which detailed data on FMG’s are available, and 1971, the number of FMG’s in residency training grew from 9,121 to 13,520, or from 29 percent of the total to 32 percent. Four specialists show especially marked 7 Kozlow, D. A. ed. Specialty Profile. National Disease and Therapeutic Index. Ambler, Pa., 1972. The NDT] is a service of Lea, Inc. and is a continuing study of private medical practice in the United States, begun in 1965. Data are obtained from a representa- tive panel of physicians, who report case history information on private patients over a given period of time. All information is recorded on tapes by Lea, Inc., and both monthly and quarterly reports are generated. 63 changes for FMG’s—general practice, psychiatry, internal medicine, and general surgery. In 1965, 4 percent of all FMG residents were in general practice, but by 1971 the proportion (including family practice) dropped to 1 per- cent. Similarly, the percentage of all FMG residents in general surgery dropped from 21 to 18 percent during the period, and the proportion of all FMG residents who were in psychiatry fell from 10 percent to 8 percent. On the other hand, FMG residents in internal medicine increased from 17 percent of total FMG residents in 1965 to 20 percent in 1971. (See Table 32.) PROJECTIONS OF THE SUPPLY OF M.D.’S BY SPECIALTY TO 1990 METHODOLOGY AND ASSUMPTIONS The basic methodology used to project the future supply of active specialists was to determine the number of specialists active in December 1970 who would still be active in 1975, 1980, 1985, and 1990, and then to estimate the specialty of the new additions to the active supply during the 20-year period. In all instances, the projections were controlled to the independently derived “basic” projection of active M.D.’s described in Chapter 3. The following sections describe the projection methodology in more detail. The basic projection of M.D.’s provided estimates of the total number of active M.D.’s in 1970 who would still be active by 1975, 1980, 1985 and 1990. These “1970- survival” estimates were developed separately for two groups—graduates of U.S. and Canadian medical schools, and foreign medical school graduates. The survivor total was then distributed according to the 1970 specialty distribution of active M.D.’s for each 5-year interval over the 1970-period; the distribution was made separately’ for U.S. and Canadian M.D.’s and for foreign medical graduates. In the case of family practice, the data from the American Board of Family Practice providing 1970 esti- mates for family practitioners were used in lieu of AMA data, largely because the Board’s numbers appeared to reflect more realistically the current situation in family practice. Because most of these newly certified diplomates of family practice were originally general practitioners, the 1970 estimate of general practitioners used in these projections was the AMA total of general practitioners minus the family practice diplomate estimate. This pro- vided an estimate of the number of active M.D.’s in individual specialties in 1970 who would still be active in each of the relevant future time periods. This approach implicitly assumes that separation rates utilized for all Table 32. TREND IN FIRST-YEAR RESIDENTS, BY SPECIALTY: SELECTED YEARS SEPTEMBER 1, 1960-71 Specialty 1960 1961 1962 1967 1968 1970 1971 Total first-year residents . ...... 11,070 10,923 10,627 12,581 12,721 14,556 15,181 General practice . . . .............. 364 316 242 265 256 \ 144 146 Medical specialties ............... 3,188 3,267 3,191 3,706 3,853 4,664 5,050 Dermatology . . ............... 102 128 135 183 166 205 207 Family practice! . . ............. —- — — — —- 131 301 Internal medicine .............. 2,193 2,284 2,171 2,417 2,589 3,044 3,166 Pediatrics? . ................. 893 855 885 1,106 1,098 1,284 1,376 Surgical specialties . .............. 4,274 4,227 4,151 4,790 4,748 5,290 5,225 General surgery . .............. 2,122 2,057 2,039 2,406 2,394 2514 2,400 Neurological surgery. . . .......... 101 121 103 116 119 141 141 Obstetrics and gynecology . . ....... 917 859 793 783 759 857 911 Ophthalmology . .............. 288 312 356 397 418 460 454 Orthopedic surgery . ............ 353 368 256 421 403 528 515 Otolaryngology . .............. 153 155 167 208 206 234 245 Plasticsurgery ............... 47 53 70 77 90 120 134 Thoracicsurgery. . . ............ 89 102 101 126 137 125 133 Urology. . . ................. 204 200 207 256 222 311 292 Other specialties. . . .............. 3,244 3,113 3,043 3,820 3,864 4,458 4,760 Anesthesiology . .............. 550 550 515 612 677 688 769 Child psychiatry . . . ............ 28 65 79 147 118 178 214 Neurology .................. 149 177 163 233 249 283 338 Psychiatry . ................. 1,090 1,082 1,121 1,246 1,209 1,388 1,396 Pathology. . ................. 757 655 607 704 661 744 802 Physical medicine and rehabilitation . . . 55 61 52 109 95 101 110 Radiology3 ................. 544 514 498 755 849 941 852 Miscellaneous . . .............. 71 9 8 14 6 135 279 1 Family practice residencies not reported before 1970. 2 Includes pediatric allergy and pediatric cardiology. Includes therapeutic radiology. Source: American Medical Association. Directory of Approved Internships and Residencies, 1972-73. Chicago, The Association, 1972; also prior annual issues. active M.D.’s are representative of the patterns for individ- ual specialists, an assumption which was necessary in the absence of detailed data for the specialties. The basic M.D. projection also provided estimates of the net additions to the active supply of physicians in the coming 20 years—graduates from U.S. and Canadian schools and from foreign medical schools. To obtain the specialty distribution of new entrants to the physician pool, the 1970 percentage distribution of first-year residents by specialty—again separately for the two groups of M.D.’s—was applied to the number of net entrants for each 5-year period over 1970-90.® This approach implicitly 2 American Medical Association. Directory of Approved Intern- ships and Residencies, 1971-72. Chicago, The Association, 1971. 64 assumed that the 1970 distribution of residents would represent their ultimate specialty choice and that the 1970 pattern of residences would continue into the future. The first step described above estimated the number of survivors over the 20-year period, while the second step estimated the number of new additions to the supply over the period. These two sets of figures were then aggregated to provide the overall projections of the future supply of active M.D.’s by specialty. In any evaluation of this methodology, several concerns should be noted: 1. The simplified methodology used to develop the specialty projections largely reflects the lack of sufficient and consistent trend data on residency training in all of the specialties. Ideally, each specialty should be projected Table 33. TREND IN TOTAL RESIDENTS AND OF FMG RESIDENTS, BY SPECIALTY: SEPTEMBER 1, 1960, 1965, AND 1971 Number of residents Percent distribution Foreign medical Foreign medical Specialty Hox) —_—— Tord a 1960 1965 1971 1965 1971 1960 | 1965 1971 1965 | 1971 Total residents ......... 28,356 31,700 42,293 9,121 13,520 100.0 100.0 100.0 100.0 100.0 General practice . . . .......... 549 494 246 326 171 1.9 1.6 0.6 3.6 1.3 Medical specialties ........... 7,245 8,145 12,191 2,482 4,041 25.6 25.7 28.8 27.2 29.9 Dermatology + « su + + + saivinnis 298 420 621 50 52 1.1 1.3 1.5 0.5 0.4 Family practice®. . . . . vv vu. —- - 632 — 68 —- — 1.5 - 0.5 Internal medicine . ......... 5,197 5,600 7,869 1,564 2,771 18.3 17.7 18.6 17.1 20.5 Pediatrics . ............. 1,750 2,125 3,069 868 1,150 6.2 6.7 1.3 9.5 8.5 Surgical specialties ........... 12,115 13,487 16,370 3,399 4,619 42.7 42.5 38.7 373 34.2 General surgery®. . ......... 5,640 6,024 6,435 1,953 2,431 19.9 19.0 15.2 21.4 18.0 Neurosurgery ........... 369 482 595 81 129 1.3 1.3 1.4 0.9 1.0 Obstetrics and gynecology . . . . . 2,517 2,526 2,800 682 1,114 8.9 8.0 6.6 75 8.2 Ophthalmology ........... 807 1,054 1,403 97 116 2.8 33 3.3 0.9 Orthopedic surgery ......... 1,262 1,501 2,572 194 234 4.5 4.7 6.1 2.1 1.7 Otolaryngology ........... 525 680 960 80 158 1.9 2.1 23 0.9 1.2 Plastic surgery ........... 135 184 279 39 59 0.5 0.6 0.7 0.4 0.4 Thoracic surgery. . . ........ 179 226 277 85 119 0.6 0.7 0.7 09 0.9 UICIOgY « vv vnwuwms somman 681 810 1,049 188 259 2.4 2.6 2.5 2.1 1.9 Otherspecialties. . . . . «. v0 vss 8,447 9,574 13,486 2914 4,689 29.8 30.2 319 319 34.7 Anesthesiology . .......... 1,244 1,185 1,844 550 992 4.4 37 4.4 6.0 7.3 Child psychiatry . . . ........ 79 334 528 75 134 0.3 1.1 1.2 0.8 1.0 Neurology .............. 342 562 854 137 252 1.2 1.8 2.0 1.5 1.9 PathologyS ............. 1,985 2,098 2,554 832 1,409 7.0 6.6 6.0 92.1 10.4 Physical medicine and rehabilitation .......... 153 199 31 87 185 0.5 0.6 0.7 1.0 1.4 PSYCHIRLIY. » « vown me ss noma 3,107 3,565 4,085 945 1,098 11.0 11.2 9.7 10.4 8.1 Radiology® ............. 1,557 1,631 3,310 288 619 5.4 5.1 7.8 3.2 4.6 ! Excluding Canadian graduates. Family practice residencies were not reported before 1970. 3 Includes pediatric allergy and pediatric cardiology. Includes rectal and colon surgery. 5 Includes forensic pathology. 5 Includes diagnostic and therapeutic radiology. Source: Directory of Approved Internships and Residencies 1972-73. Chicago, American Medical Association, 1972. Also 1961 and 1965 editions. Note: Figures may not add to totals and subtotals due to independent rounding. separately, taking into account the trends in residencies and the relationship of residency training to specialty entered. However, the technique of utilizing the current percentage distribution of residencies to develop individual specialty totals was necessary because of time and data constraints. It is true, however, that increasing numbers of physicians may choose specialties which are relatively undersupplied, re- 565-118 O - 74 - 6 65 sponding perhaps to their own as to where their services are needed, government inducements, and/or economic self- interest. The experience of family practice is a good case in point. In 1965, with the declining number of physicians entering general practice, it would have been hard to predict the popularity family practice is experiencing in 1970, 1971 and 1972. 2. Data on the number of first-year, rather than total, residencies were used, even though specialties differ in the amount of residency training required; years of training vary from one to five. 3. The use of first-year residency distribution may involve some double counting. For example, a physician may complete a residency program in pediatrics in 1965 and be counted as an active practicing physician in 1970, even though he may also at that time be acquiring a year of residency training in pediatric cardiology (thereby being counted again as a first-year resident). 4. Another possible double counting may occur in some of the subspecialties (namely, neurosurgery, plastic surgery, thoracic surgery, child psychiatry, and therapeutic radiol- ogy) because first-year residencies in general surgery, psychiatry, and radiology can be used for meeting certifica- tion requirements in the subspecialties. For example, physicians intending to become thoracic surgeons are counted at two points in their training: at the point of their first-year residency in general surgery and at the point of their first-year residency in thoracic surgery. 5. There are virtually no data on the number of FMG’s who complete particular types of residency training and then leave the country. Since FMG’s are more likely to fill vacant residency training positions than those of their choice, there is a greater likelihood that their specialty field of practice after residency may not be the same as their residency field. Furthermore, many FMG’s enter the United States after having completed specialty training in their home country. 6. The methodology fails to account for those medical school graduates who do not enter residency training programs at all, although this is a very small number. 7. Nonapproved residency and internship programs are not listed in basic reference sources on first-year residencies and consequently are excluded from these projections. Among the individual specialties, psychiatry is expected to be most affected, since considerable numbers of FMG’s are in unapproved psychiatric training programs in State mental hospitals. 8. Detailed and definitive data on the relationship between residency training and type of practice are lacking. For example, of 1,900 aerospace medicine physicians, only 5 percent have completed formal residency programs in aerospace medicine, and only 18 percent are board- certified.’ ? Ellingson, H.V. Training in Aerospace Medicine. Aerospace Medicine. Vol. 39, No. 9, Section II, pp. 1-28, September 1968. 66 PROJECTION FINDINGS Utilizing the basic methodology, the number of active M.D.’s is expected to increase by about three-fourths between 1970 and 1990, or by about 2.8 percent a year (compounded). As can be seen in Table 34, general practitioners will continue the numerical decline already in evidence in recent years; their numbers are expected to fall from 56,260 in 1970 to 36,700 in 1990, with a somewhat faster decline in the second decade of the period. However, the primary care needs of the population should not be affected as much as this decline implies, since the primary care specialties of internal medicine, family practice, and pediatrics are all expected to grow. Limited data exist as to how much time physicians in these particular specialties devote to primary care. As previously noted, a conservative estimate would be at least 80 percent. D.O.’s must be added to M.D.’s in primary care, however, to get a better picture of the total manpower involved. As of December 31, 1970, there were about 12,000 active D.O.’s in practice, with at least 75 percent estimated to be delivering primary care. In recent years, the number of States licensing D.O.’s has increased from 35 in 1965 to 49 in 1972. Given this development, it is likely that the geographic distribution of D.O.’s will become somewhat more dispersed during the next two decades. Recently there has been a dramatic increase in the number of osteopathic physicians who are pursuing speci- alty training through two routes. First, the number of specialty training positions in osteopathic hospitals has been increasing sharply. Second, young physicians with D.O. degrees can now enter the approved training programs which were formally reserved for those with M.D. degrees. As of April 1972, there were about 1,380 specialists certified by the AOA; 1,400 osteopaths who spent part of their time in specialty practice; and 1,646 who were full-time specialists. Despite these considerations, however, the frequency with which D.O. graduates enter general practice will in all likelihood remain considerably greater than that for M.D. graduates. Over the next two decades, the medical specialty fields are projected to continue to grow more rapidly than the surgical or other specialties. The growth in family medicine and internal medicine is projected to be especially rapid in the years ahead, with internal medicine increasing from 41,870 in 1970 to 105,620 in 1990 and family practice increasing from 1,690 in 1970 to 4,450 in 1990. (See Table 34.) However, since the future of family practice is still somewhat in doubt, these projections must be viewed carefully. Table 34. NUMBER OF ACTIVE PHYSICIANS (M.D.) ENGAGED IN PRIMARY CARE: ACTUAL 1963 AND 1970; PROJECTED 1980 AND 1990 Number of physicians (M.D.) Percent distribution Activity and specialty 1963! 1970 1980 1990 1963 1970 1980 1990 Total active physicians . . ....... 261,730 311,200 430,240 571,030 100.0 100.0 100.0 100.0 Physicians in primary care . .......... 125,530 137,520 178,140 226,150 48.0 44.2 41.2 39.3 Generalpractice - = « « + s.assaw as suo 66,870 2 56,260 47,210 36,700 25.6 18.1 10.9 6.4 Family practice . .............. N.A. 1,690 2,920 4,450 - 0.5 0.6 0.7 Internal medicine ............. 30,430 41,870 71,020 105,620 11.6 13.5 16.5 18.4 Pediatrics3 . ................. 12,930 18,820 31,140 45,410 4.9 6.0 7:2 79 Obstetrics and gynecology . . ....... 15,300 18,880 25,850 33,970 59 6.1 6.0 59 Physicians in all other activities ....... 136,200 173,680 252,100 344,880 52.0 55.8 58.8 60.7 ! See table 30 for explanation of adjustment of these figures. 2 Excludes 1,690 diplomates in family practice who have been shown separately. 3 Includes pediatric allergy and pediatric cardiology. Source: 1963: Theodore, C. N. and Sutter, G. E. Distribution of Physicians in the U.S., 1963. Chicago, American Medical Association, 1967. 1970: Haug, J. N.; Roback, G. A.; and Martin, B. C. Distribution of Physicians in the United States, 1970. Chicago, American Medical Association, 1971. For reasons previously mentioned, the 1970 active base for family practice was determined by the 1970 number of family practice board certifications, rather than by the AMA statistics. A drawback to this approach is the fact that this active base is increasing not only because there are more graduate additions but also because there is an increase in the number of practicing physicians receiving board certification in family practice. This number in- creased from 1,690 in 1970 to 3,250 in 1971 and to 4,542 in 1972.1° Most of these physicians are general practi- tioners who are converting to family practice. Conse- quently, the 1970 active base for general practice is decreasing not simply through deaths and retirements but also through conversions. Furthermore, the graduate addi- tions for family practice may be underestimated using this methodology because increasing numbers of physicians are electing to do residency training in family practice. For example, between 1970 and 1972, the number of first-year residents increased from 131 to 494. If these increases continue our projections for family practice will be too low. However, for reasons previously mentioned, we are not sure that family practice will maintain its current popular- ity. 10 American Medical Association. Profile of Medical Practice. 1973 edition. Chicago, The Association, 1973. 67 Obstetrics-gynecology is projected to show the slowest growth of the primary care specialties. (See Table 34.) This may be partially a reflection of the recently declining birth rate. However, it should be noted that the trend data in obstetrics-gynecology show marked fluctuations in numbers of physicians. Taken together, consequently, these four specialties, plus general practice, are projected to increase by nearly 90,000 by 1990, although as a proportion of all M.D.’s they will still drop from 44 percent to 39 percent. Although the projections in table 35 suggest a sharp increase in the number of M.D.’s in surgical specialties, from 85,380 to 190,870 over the projection period, the inclusion of some implied assumptions might not argue for such an increase. In this regard, different opinions and concerns have recently been expressed concerning the possible ‘“‘overcrowdedness” of the field, a factor which largely formed the rationale for the ongoing Study of Surgical Services in the United States mentioned above. The projections are strongly influenced by the different medical specialty choices of U.S. and Canadian physicians and of foreign medical graduates. As can be seen in Table 36, six specialties most clearly illustrate the FMG impact. In 1970, 12 percent of all FMG’s were in general practice, whereas only 4 percent of the FMG’s are projected to be in this field in 1990. Internal medicine demonstrates an opposite movement, with 12 percent of the FMG’s in the Table 35. SUPPLY OF ACTIVE PHYSICIANS (M.D), BY SPECIALTY: ACTUAL 1970; PROJECTED 1980 AND 1990 Number of physicians (M.D.) Percent distribution Specialty 1970 1980 1990 1970 1980 1990 Total active physicians . . . .......... 311,210 430,240 571,030 100.0 100.0 100.0 General practice . . . . «coche ieee 1 56,260 47,210 36,700 18.1 11.0 6.4 Medical specialties . . .. ... o.oo 66,380 110,750 163,240 21.3 25.1 28.6 Dermatology « « vv vv vv hee eee 4,000 5,660 7,750 1.3 1.3 1.4 Family practice . . ..... o.oo 1,690 2,920 4,450 0.5 0.7 0.8 Internal medicine . . ooo 41,870 71,020 105,620 133 16.5 18.5 Pediatrics”, +. + vv vv hee eee 18,820 31,140 45,410 6.0 7.2 8.0 Surgical specialties . . .. o.oo 85,380 133,550 190,870 27.4 31.0 33.4 General SUFBEry . . . «ovo vv sv vn vs aso 29,760 55,010 84,580 9.6 12.8 14.8 Neurological surgery . . ............ 2,580 3,800 5,260 0.8 0.9 0.9 Obstetrics and gynecology . . . . . «vc ov. 18,880 25,850 33,970 6.1 6.0 519 Ophthalmology . . . o.oo vv vnn 9,930 13,450 17,930 3.2 3. 3] Orthopedic Surgery . . ....... «o.oo. 9,620 14,050 19,580 i | 33 3.4 Otolaryngology . . «vv vv vv ive ven nn 5,410 7,170 9,360 1.7 1.7 1.6 Plastic SUFBEIY + + vv a vv vv vo ve a vss 1,600 2,740 4,120 0.5 0.6 0.7 Thoracic SUFBErY « « « « vv evo wo av vv ns 1,810 3,010 4,400 0.6 0.7 0.8 Urology «vv vv vee eivveee anna 5,800 8,460 11,660 1.9 2.0 2.0 Other specialties. . . . «cco vv evo oven 103,190 138,720 180,210 33.2 32.2 31.6 Anesthesiology . . ... coo 10,860 17,510 24,960 3.5 4.1 4.4 Child psychiatry . . . «ovo ei 2,100 3,860 5,970 0.7 0.9 1.0 Neurology . « «vv vv vv vv vom noe e nn 3,070 5,940 9,350 1.0 1.4 1.6 Psychiatry . ..........coovvnnn 21,150 34,070 49,480 6.8 7.9 8.7 Pathology . «vv vv vv ieee ee omen es 10,280 17,800 26,150 33 4.1 4.6 Physical medicine and rehabilitation . . . .. 1,480 2,500 3,610 0.5 0.6 0.6 RAMOIOPY: + vam s » smmmumme ss Bn 10,520 19,430 30,210 3.4 4.5 5.3 Therapeutic radiology . . . .......... 870 1,130 1,440 0.3 0.3 0.3 Miscellaneous . . . «ce vv svn sea e ne 42,860 36,460 29,020 13.8 8.5 5.1 ! Excludes 1,690 diplomates in family practice who have been shown separately. 2 Includes pediatric allergy and pediatric cardiology. Source: 1970 physicians: Haug, American Medical Association, 1971. 1970 diplomates in family practice: Directory of Approved Internships and 1971. J.N.; Roback, G. A; and Martin, B. C. Distribution of Physicians in the United States, 1970. Chicago, Residencies, 1971-72, Chicago, American Medical Association, Note: Figures may not add to totals and subtotals due to independent rounding. specialty in 1970 compared with 18 percent in 1990. In pediatrics, the proportion is projected to increase from 7 percent to 10 percent. There will be an increase in the proportion of all FMG’s who are general surgeons, from 10 percent in 1970 to 17 percent in 1990. (It should be kept in mind, however, that the general surgery numbers are influenced by the problem of double counting previously indicated.) Pathology is also projected to increase in proportion, from 6 percent to 9 percent. Finally, psychi- atry is projected to exhibit a small decline in popularity among FMG’s, with the proportion of all FMG’s in 68 psychiatry decreasing from 9 percent in 1970 to 8 percent in 1990. For U.S. and Canadian trained physicians, the changes in distribution among specialties will be less dramatic than that evidenced by foreign medical graduates, although in essentially the same fields. The proportion of all U.S. and Canadian trained physicians who engage in general practice is projected to decline from 19 percent in 1970 to 7 percent in 1990. (See Table 37.) This means that there will be almost 20,000 fewer U.S. and Canadian general practi- tioners in 1990 than in 1970. As was true in the case of Table 36. SUPPLY OF ACTIVE FOREIGN TRAINED PHYSICIANS (M.D.), BY SPECIALTY: ACTUAL 1970; PROJECTED 1980 AND 1990 Number of foreign trained” physicians (M.D) Percent distribution Specialty 1970 1980 1990 1970 1980 1990 Total active physicians . . ........... 54,420 104,420 154,420 100.0 100.0 100.0 General practice . . . . vv vv viv vin. 2 6,630 6,900 6,900 12.2 6.6 4.4 Medical specialties . ................ 10,660 27,080 43,810 19.4 259 28.3 Dermatology « ov cs sv mma 3 » www mie 390 500 610 0.7 0.4 0.3 Familypractice + « : c vives as ssnmen 110 250 400 0.2 0.2 0.2 Internal medicine . so uvo vas seins 6,370 16,610 27,060 11.7 15.9 172.5 Pediatrics® oo vote eee 3,790 9,710 15,750 7.0 9.3 10.1 Surgicalspecialties « . . . vo oss ss rwune 12,410 29,630 47,120 229 28.3 30.5 Generalsurgery ..... v.00 0senus 5,290 15,570 26,100 9.7 14.9 16.8 Neurological surgery . ............. 410 790 1,210 0.8 0.7 0.7 Obstetrics and gynecology . . ......... 3,060 6,790 10,560 5.6 6.5 6.8 Ophthalmology . ................ 810 1,020 1,210 1.5 0.9 0.7 Orthopedic SUIEErY « + + vuoi ¢ » 2s wm» 880 1,430 1,970 1.6 1.3 12 Otolaryngology «ov +s sc sv vn wim s swine 640 920 1,180 1.2 0.8 0.7 Plastic SUIBerY wus oss muvamu ss mune 210 500 790 0.4 0.4 0.5 Thoracicsurgery. . . .........0.... 370 910 1,460 0.7 0.8 0.9 Urology. . . «vo viii ieee ieee 740 1,640 2,660 1.4 1.6 1.7 Otherspecialties , « o..o « s sv www s 500m 24,720 40,800 56,590 45.5 39.0 36.6 Anesthesiology «uv: ss evuoimis snus 3,300 7,460 11,670 6.1 1.4 7.5 Child psychiatry . . ............... 430 930 1,450 0.8 0.8 0.9 INBUIOIORY: 5. 5. 5. 6 wie 0 4 a lt ao sm 2c eco 620 1,500 2,400 1.2 1.4 1.5 Psychiatry .................... 5,030 8,770 12,480 9.2 8.4 8.0 Pathology . woes sc vupwmn ss mows 3,130 8,230 13,440 58 7.8 8.7 Physical medicine and rehabilitation . . . . . 500 1,320 2,150 0.9 1.2 1.3 RadIOIOBY « sos civ ssa mado t so oimen 1,410 3,400 5,420 2.6 3.2 35 Therapeutic radiology . ............ 210 300 380 0.4 0.2 0.2 Miscelaneous , «cv us sv awmes s pose 10,090 8,880 7,190 18.5 8.5 4.6 ! Excludes Canadian trained physicians. . 2 Excludes 110 diplomates in family practice who have been shown separately. Includes pediatric allergy and pediatric cardiology. Sourre: 1970 foreign trained physicians: Haug, J. N. and Martin, B. C. Foreign Medical Graduates in the United States, 1970. Chicago, American Medical Association, 1971. 1970 diplomates in family practice: Directory of Approved Internships and Residencies, 1971-72. Chicago, American Medical Association, 1971. Note: Figures may not add to totals and subtotals due to independent rounding. FMG'’s, the proportion of all U.S. and Canadian physicians in internal medicine is projected to increase from 14 percent in 1970 to 19 percent in 1990. A smaller increase is also projected to occur in another primary care specialty, pediatrics. The increases in these primary care specialties may partly reflect the gradual replacement of general practitioners by the specialists in internal medicine, pediat- rics, and family practice. The proportion of all U.S. and Canadian physicians who are in general surgery is also 69 projected to rise, from 10 percent in 1970 to 14 percent in 1990. (However, it should be remembered that the surgery figures may be somewhat inflated due to the double- counting problem.) In radiology, the proportion is pro- jected to increase from 4 percent in 1970 to 6 percent ir. 1990. Finally, in psychiatry, an interesting shift of U.S. and Canadian graduates vs. FMG physicians is projected to occur, Offsetting a decline in the popularity of psychiatry Table 37. SUPPLY OF ACTIVE UNITED STATES AND CANADIAN TRAINED PHYSICIANS (M.D.), BY SPECIALTY: ACTUAL 1970; PROJECTED 1980 AND 1990 Number of United States and Canadian : CL. Percent distribution trained physicians (M.D.) Specialty 1970 1980 1990 1970 1980 1990 Total active physicians . » as + s ss wns ss sss mo wis s +4 256,790 325,820 416,610 100.0 100.0 100.0 General Practice sic + + LS RF RW AL > mB Fo E+ i mmm mn. vn ! 49,630 40,310 29,800 19.3 12.4 72 Medical specialties . . ....... viii i 55,720 83,670 119,420 27 253 28.7 Dermatology . . ov voi eee ee 3,620 5,160 7,140 1.4 1.6 1.7 Family practice « : s su vwmow s som ®im t 3 sa soe 51s 58 1,580 2,670 4,050 0.6 0.8 1.0 Internal medicine ¢: vunun ss is nm sss naman sis 35,500 54,410 78,570 13.8 16.7 18.9 Pediatrics” ©. uti 15,030 21,430 29,670 5.9 6.6 0 Surgical specialties... ...... ee 72,970 103,920 143,760 28.4 31.9 34.5 General SUFEry . . . ov i i iit i et ee ee eee 24,480 39,440 58,480 9.5 12.1 14.0 Neurological surgery. . . . . . . oii iii ii ie ieee 2,170 3,010 4,100 0.8 0.9 1.0 Obstetrics and gynecology + «vw + + s ssw w os ss psp wim vs 35 15,810 19,060 23,410 6.2 5.8 5.6 Ophthalmology : « ss sis wmm Ens HERA Hs 4 BES EHE +5 5 6 9,120 12,430 16,720 3.6 3.8 4.0 OrthopediC SUIBEYY ; s mainwme ss modus £5 pmBmmm s » » » 8,740 12,620 17,610 3.4 3.9 4.2 OOIaryNZOIOBY + 5 + 5.50 BBs +5 » am sidid +» Mmmm wrt va 4,770 6,250 8,170 1.9 1.9 20 Plasticsurgery .... viii eee 1,390 2,240 3,330 0.5 0.7 0.8 Thoracic SUFgery . . . ov vv i tt tee eee eee eee eee as 1,440 2,100 2,940 0.6 0.6 0.7 Urology «viii ee eee 5,060 6,770 9,000 2.0 241 22 Otherspecialties . . . . . cc viv t i t ttt eee eee 78,480 97,920 123,620 30.6 30.1 29.7 Anesthesiology . . ..... Le 7,560 10,050 13,290 2.9 3.1 3.2 Child psychiatry. . : sv svn ses ss no nimim ss saimaimme & 5s 1,670 2,930 4,520 0.7 0.9 1.1 NEWOIOZY: wovivs s pons mmims ss aamod s Hanwoe 2 vb 2,450 4,440 6,950 1.0 1.4 1.7 PSYCHIBIIY cnt ¢ 1 HH BER I PERNA FREESE. oa 16,120 25,300 37,000 6.3 7.8 8.9 PAthOlOgY: wun : 12 BREF RSG 3 RHE TAS BR § 7,150 9,570 12,710 2.8 2.9 3.1 Physical medicine and rehabilitation . . . .............. 980 1,180 1,460 0.4 0.4 0.4 RAGIOIOZY. vn iid t bmamnidwns v smmnms « mw mmm » oo 9,120 16,040 24,800 3.6 4.9 6.0 Therapeutic radiology . . . .... iii 660 830 1,060 0.3 0.3 0.3 MiSCRIANBOUS i» v.v « s vrs wm ss FHS HDS sO UENCE £3 58 32,770 27,580 21,830 12.8 8.5 5.2 ! Excludes 1,580 diplomates in family practice who have been shown separately. 2 Includes pediatric allergy and pediatric cardiology. Source: 1970 physicians: Haug, J. N. and Martin, B. C. Foreign Medical Graduates in the United States, 1970. Chicago, American Medical Association, 1971. 1970 diplomates in family practice: Directory of Approved Internships and Residencies, 1971-72. Chicago, American Medical Association. 1971. Note: Figures may not add to totals and subtotals due to independent rounding. among FMG’s, there will be an increase in the proportion of U.S. and Canadian physicians, from 6 percent of their total numbers in 1970 to 9 percent in 1990. Another way of assessing the projections of specialists is through an examination of the M.D./population ratios implied by the projections. In Table 38, it can be seen that the overall M.D./population ratio is projected to increase from 153 per 100,000 population in 1970 to 190 per 100,000 in 1980 and to 228 per 100,000 in 1990. The foreign medical graduate component is projected to in- 70 crease at a more rapid pace than either U.S. or Canadian graduates. These relative differences have implications for many of the specialties. In general practice, the ratio of M.D.’s to population is projected to decline from 28 per 100,000 in 1970 to 15 per 100,000 in 1990. The decline is projected to be much more dramatic among U.S. and Canadian physicians, however, with the ratio decreasing from 24 U.S.-Canadian M.D.’s per 100,000 population in 1970 to only 12 per 100,000 in 1990. Partially offsetting the impact of the decline in Table 38. RATIOS OF ACTIVE PHYSICIANS (M.D.) TO POPULATION, BY SPECIALTY AND COUNTRY OF GRADUATION: ACTUAL 1970; PROJECTED 1980 AND 1990 Active physicians (M.D.) per 100,000 population’ Specialty Total physicians us. Bd Gariadian trained Foreign trained physicians 1970 1980 1990 1970 1980 1990 1970 1980 1990 Total active physicians .............. 152.7 189.6 227.8 126.0 143.6 166.2 26.7 46.0 61.6 General practice. «occu sav ss vans svn sna in 27.6 20.8 14.6 24.4 17.8 11.9 3.3 3.0 2.8 Medical specialties « wu «wiv e560 wes wi 4 wim d sins 32.6 48.8 65.1 27.3 36.9 47.6 3.2 11.9 i715 Dermatology. viv s wis s wins sis ssa sw enw s sins o 2.0 2.5 3. 1.8 2.3 2.9 0.2 0.2 0.2 Family practice. ......covviviniennnn. 0.8 1.3 1.8 0.8 1.2 1.6 0.1 0.1 0.2 Internal MediCINg +c vuv cawsvs sus sus emes 20.5 31.3 42.1 17.4 24.0 31.3 3.1 73 10.8 Pediatrics? ov ve eee 9.2 13.7 18.1 7.4 9.4 11.8 1.9 4.3 6.3 Surgical specialties «...cvvvieriiriiiiannn 41.9 58.8 76.2 35.8 45.8 57.4 6.1 13.1 18.8 General SUFBErY.v «ve vine wiv s iw wiv 4 0ow 200 3 14.6 24.2 33.7 12.0 17.4 23.3 2.6 6.9 10.4 Neurological SUrgery...csvvivsvcarnnnes 1.3 1.7 2.1 1.3 1.3 1.6 0.2 0.3 0.5 Obstetrics and gynecology. «cv vvevuevenns 9.3 11.4 13.6 7.8 8.4 9.3 1.5 3.0 4.2 Ophthalmology... verve ririnennnnnn. 4.9 5.9 1.2 4.5 3.5 6.7 0.4 0.5 0.5 Orthopedic SUrBerY .. suw sav sv ¢ via 3 win 4 55 » 4.7 6.2 7.8 4.3 5.6 7.0 0.4 0.6 0.8 O1O1aryNOBOIORY : + ui + wis v9.45 4.0% 2:0 # wiv #50 4 2.7 32 3.7 23 2.8 3.3 0.3 0.4 0.5 PIaSLIC SUFBREY + aix vive sie wind sais wine wins aids 0.8 1.2 1.6 0.7 1.0 1.3 0.1 0.2 0.3 Thoracic SUrgery..... eevee useennnnns 0.9 1.3 1.8 0.7 0.9 1.2 0.2 0.4 0.6 UIOIOBY: + « win v wie sie» ww wis wots ww a wine wim 8 2.8 3.7 4.7 23 3.0 3.6 0.4 0.7 1.1 Other SPECIRILIEs: + ww s wiv 5 wis « wv 2.05 win 4 #58 + 53 8 50.6 61.1 71.9 38.5 43.1 49.3 12.1 18.0 22.6 Anesthesiology « «vc vvivevrreenrencnanns 5.4 2.7 10.0 37 4.4 53 1.6 33 4.7 Child psychiatry . co vvviivennnennnnnas 1.0 1.7 2.4 0.8 1.3 1.8 0.2 0.4 0.6 INEUFOIOBY « vv + wis vwiv v 2x v wre wears wim & www win # 1.5 2.6 3.7 1.2 2.0 2.8 0.3 0.7 1.0 Psychiatry «os + wis sew win ow ¥ ve wi oe wey 10.4 15.0 19.7 7.9 11.1 14.8 2.5 3.9 5.0 PAthOIOBY « wiv «win 8 9s pnw # wie 2 950 4 0.4 wai wins 5.0 7.8 10.4 3.5 4.2 5: 1.5 3.6 5.4 Physical medicine and rehabilitation. ..... 0.7 1.1 1.4 0.5 0.5 0.6 0.2 0.6 0.9 RAAIOIOBY « ww +50 ¢ 53% + wiv 4.004 3.500 6.08 Bik $i 5 5.2 8.6 12.1 4.5 7.1 92.9 0.7 1.5 2.2 Therapeutic radiology. ...vvvviiennniens 0.4 0.5 0.6 0.3 0.4 0.4 0.1 0.1 0.2 Miscellaneous . .« evens revs rnin rns 21.0 16.1 11.6 16.1 12.2 8.7 5.0 3.9 29 ! Resident population as of July 1. Includes pediatric allergy and pediatric cardiology. Source: U.S. and Canadian trained physicians: Table 37. Foreign trained physicians: Table 36. Population: Bureau of the Census. Current Population Reports, Series P-25, Nos. 468, 477, and 483. Note: Figures may not add to totals and subtotals due to independent rounding. general practice, however, are the aforementioned projected increases in the related primary care specialties of internal medicine and pediatrics. The surgical specialties are projected to increase their M.D./population ratio substantially, rising from 42 per 100,000 in 1970 to 76 per 100,000 in 1990. The increase among U.S. and Canadian graduates, however, is projected to be proportionally less than among FMG’s. The U.S. Canadian M.D./population ratio in surgery is projected to rise from 36 to 57 per 100,000; while the FMG ratio is 71 projected to rise from 6 to 19 per 100,000. Similarly, the increase in the FMG/population ratio in the other speci- alties is projected to be proportionally greater than that for the U.S.-Canadian graduates. However, it is important to note that in nearly every specialty field (with the exception of general practice, physical medicine and rehabilitation, and anesthesiology) the 1990 population ratio of U.S. M.D.’s alone is projected to exceed or equal the ratio for all physicians (including Canadian graduates and FMG'’s) that prevailed in 1970. The anticipated specialty increases among U.S. medical school graduates over the next 20 years may have a major impact on residency training of FMG’s, By 1990, the U.S. graduating class is projected to be nearly 7,000 larger than it is today, and with this rise in the number of U.S. graduates seeking residency training, substantial pressure will be extended on residency positions in the future. The possible impact of increased numbers is partially obscured by the reservoir of unfilled first-year residency positions reported each year. For example, in 1970, first-year residency positions were filled by 10,199 U.S. and Cana- dian graduates and 4,357 foreign trained graduates, leaving 2,350 positions vacant. The projected 7,000 increase in U.S. graduates alone will more than fill those vacant positions, not to mention the projected 5,200 annual increase of FMG’s. There is also substantial variation among the specialties in the proportion of unfilled positions. For example, in 1971 there were 690 unfilled first-year resi- dency positions in pathology and psychiatry, but only 1 unfilled position in dermatology. It is difficult to foresee how the increased U.S. graduate demand for residency positions will affect the flow of FMG'’s. Increased competition among U.S. trained physi- cians for training appointments may mean that the pool of U.S. graduates who do not obtain their first choice of training position will increase, thereby making it necessary for many to move into the less popular residency programs—those now often filled by FMG’s. In addition, a dropping of the free-standing internship, coupled with a possible tightening of requirements for approval of resi- dency training programs, might reduce substantially the number of available approved training programs. Another new development which may have a significant effect on graduate medical education in the future is the increasing demand, particularly on the part of female physicians, for part-time residencies. Until recently, only the specialty of psychiatry provided for this, but an increasing number of training programs in other specialties are now willing to consider it on an individual basis. Altogether, these trends may alter substantially the resi- dency situation and hence the specialty distribution of the physician population. ALTERNATIVE PROJECTIONS The second approach utilized to project specialty dis- tributions was quite similar to the basic methodology except for the fact that a distribution of total, rather than first-year, residencies was used to project specialty choices of future graduates from medical schools. The primary merit of this methodology over the basic approach is the fact that it reduces the double-counting problem that 72 occurs particularly in the surgical specialties. The primary disadvantage of this methodology lies in the implicit assumption that all residents in any 5-year cohort will have completed their training by the onset of the second 5-year cohort, when in fact many may still be in training, since periods of residency training vary from 1 to 5 years. Another disadvantage of this methodology is the fact that it reflects the “less recent” experience of residency pref- erences among medical school graduates. That is, it reflects the choices of 1965-70 graduates, whereas the basic methodology primarily reflects the preferences of 1970 graduates. Another alternative methodology employed to project the number of physicians by medical specialty was based largely upon the extrapolation of trends in the specialty distributions of first-year residents. The trend data ex- amined consisted of the total number of first-year residents by specialty as of Sept. 1, 1961, 1962, 1967, 1968, 1970, and 1971"! (the only years for which published data were available). Given the marked fluctuations in these time intervals, trend data were not computable for three specialty classifications—obstetrics and gynecology, pathol- ogy, and miscellaneous. In these instances, the extrapola- tions were done somewhat arbitrarily, given the data available. The extrapolated projections for family practice were based on the 1970 and 1971 data. The advantage of this methodology over the previous two projections is that it is not based on the perhaps unrealistic assumption that the residency distribution by specialty will remain constant from 1970 through 1990. Historical trend data substantiate the fact that there are varying growth rates among the specialties, although these are minor differences for the most part. The primary disadvantage of this methodology is the lack of sufficient trend data, both in terms of previous years’ experiences of residents and the specialty distribution patterns of U.S.- trained M.D.’s and FMG’s. Hence, for example, this methodology is not able to disaggregate its projected numbers by country of education. Nonetheless, given an assumption that these trends may be more reflective of the future developments, this approach also provided useful insights into projected specialty patterns. As can be seen in Tables 39 and 40, the three separate methodologies project remarkably similar numbers for each group of specialties. This reflects in part, the fact that the three methodologies treat only graduate input differently; the future specialty distribution of those M.D.’s active in 1970 remains the same under each method. Some differ- 1 American Medical Association. Directory of Approved Intern- ships and Residencies, 1972-73. Chicago, The Association, 1972. Also earlier issues. Table 39. COMPARISON OF TWO ALTERNATIVE SPECIALTY PROJECTIONS OF PHYSICIANS (M.D.) WITH THE BASIC METHODOLOGY PROJECTIONS: 1980 AND 1990 1980 1990 Specialty Basic | Il Basic | 1 All active physicians (M.D.).....ovvriiennnnnn. 430,240 430,240 430,240 571,030 571,030 571,030 Genera) PractiCR., «vs wis s wv sw s w15 www sit 5 ww 4 is #28 § $00 47,210 46,580 46,940 36,700 35,380 34,490 Medical specialties «caus 5109 499 dum uns H0E ee Es EE 110,750 103,040 110,910 163,240 146,140 163,600 DerMAatOIORY + vs wiv: 4 556 551% 5 5127 ik WR § 9804 Buk 4 How # Bows 5,660 5,960 5,760 7,750 8,300 7,970 Family practice. .....coviniiiniinnnnrnnennnnn, 2,920 2,560 5,150 4,450 3,660 11,050 Internal medicine ........ciiiiiiiiiiiiiiie. 71,020 66,520 69,130 105,620 95,510 99,580 Pediatrics’ uur teen 31,140 28,000 30,870 45,410 38,590 45,000 Surgical specialties... vv sire cos wis ¢ 5% v2 390 sine wivie Bn 133,550 139,910 131,390 190,870 204,840 181,390 General. SULBETY.. i suis o 3.5 ois 4 40 + wiv wank okie + 9d Sui # Sane 55,010 53,780 52,870 84,580 81,800 76,070 Neurological SUrBery ....ve eens nennenneennns 3,800 4,710 3,600 5,260 7,280 4,770 Obstetrics and gYNECOIOBY «us vs x4: 5:5 + #5 4 wiv 4.514 0 9iw 25,850 27,320 26,440 33,970 37,130 37,360 OphthalMOIOBY sv 44a 540% vivié sinis sic $16.4 wins 0 % $l £m 13,450 14,210 13,550 17,930 19,590 15,350 Orthopedic SUIery...oouoveenreeeseenenennnnnan 14,050 16,950 13,760 19,580 26,020 18,760 OLOBBLYNZOIORY 1«: « wis « wn x wig sims #inip om + wow win + wie www 7,170 8,510 7,130 9,360 12,350 9,350 Plastic SUFBBIYs vss sss wn smn sms swe wow eon ¢ wits wn v ww 2,740 2,470 2,740 4,120 3,510 4,400 Thoracic SUIBErY.« vv + wis s9in + wis #1810 ¥ 4 wiv $ vw o 9% © 4% 3,010 2,700 3,120 4,400 3,730 4,520 UrOIOBY. is. & 5:00 50 5 50% 340k wives wii Si Ws S100 Wk 0 S00 8,460 9,280 8,190 11,660 13,440 10,810 Other SPECIAILIES. iv sais « cits wis wok vime wns win # din & Hin 2 ace 138,720 140,650 141,130 180,210 184,620 191,870 ANeStNESIOIOZY , vv 4:0 ¢ viv tr cus sma vine su Sun vw swe 17,510 16,470 17,310 24,960 22,770 24,420 Child psychiatry. sui » weve ems vive oi8 8 wae Sewn + 98 3,860 3,640 4,190 5,970 5,490 7,300 INCUIDIORY « +4 « aut 4 00k a it sink 5.000 wikis 4k #in # 0's # Wok» 00 5,940 6,030 6,240 9,350 9,560 10,380 PSYCHIAEIY « sin sine cme o 04 ‘svn wine ows wong wie « ww wont wine 34,070 34,800 33,020 49,480 51,050 45,390 PAtROIORY «iv + iv vn vais 6.500 3.98 $418 $04 57% ¢ m6 $0¢ 358 17,800 18,960 17,100 26,150 28,730 24,150 Physical medicine and rehabilitation. .............. 2,500 2,610 2,620 3,610 3,860 4,040 RadiOIOgY «cv tevrerernnrencenenssssanannnnnas 19,430 20,370 2 20,350 30,210 32,300 23 ,640 ‘Therapeutic radiology. vu « wi + wiv wiws vm win « wins we swe 1,130 1,160 — 1,440 1,510 = MISCRUANREOUS « ois »0i0 4 508 300s id $784 wk + 50 + iso wi 200 36,460 36,620 40,320 29,020 29,370 44,560 ! Includes pediatric allergy and pediatric cardiology. 2 Includes therapeutic radiology. Source: Basic: Based on distribution of first-year residencies. I: Based on distribution of total residencies. 11: Based on extrapolation of the trends in first-year residencies. Note: Figures may not add to totals and subtotals due to independent rounding. ences appear by 1990, however, particularly among family practice and the surgical specialties, with the numbers for family practice evidencing the greatest variation. This variation is most probably due to the fact that its annual growth rate is among the highest of the specialties, particularly in their most recent experience. It is also interesting to note the variation that occurs among the different projections for the surgical specialties. The num- bers for general surgery projected in the alternative method- 73 ologies show reduced numbers of general surgeons vis-a-vis the other surgical specialties, thus minimizing the double- counting problem that occurs in the basic methodology. The estimates for the miscellaneous specialists projected by trend data should be viewed with particular caution. These figures were based on very rough estimations derived from data that exhibited considerable fluctuation from year to year (as was the case, although to a lesser degree, for obstetrics-gynecology and pathology). Table 40. PERCENT DISTRIBUTION OF TWO ALTERNATIVE SPECIALTY PROJECTIONS OF PHYSICIANS (M.D.) WITH THE BASIC METHODOLOGY PROJECTIONS: 1980 AND 1990 1980 1990 Specialty Basic | 1 Basic | 1 All active physicians (M.D.). ov vvvuiieeneriiieeerennnnnnnnns 100.0 100.0 100.0 100.0 100.0 100.0 General PraCtiCe. uve eet us anes seen nnseneenseneeesnensnsnsnns 11.0 10.8 10.9 6.4 6.2 6.0 MEAICR-SPECIAILIES + viv + 1 0s #01 sion Waid wim» 20 0.5 2 5% #30 5 0k 490k & 1000 Sue 25.7 24.0 25.8 28.6 25.6 28.7 DErMAtOORY civ: + sive 30 5 550.0 #18. 300k 2d Hit 5050.3 905% wows + wintwinans Wie 3 1p 400% 1.3 1.4 1.3 1.4 1.5 1.4 FAM: PIRCLICE. «p10 & 51s 5 750.5 0:5 3 5061 5 wok women wow v0 mie son # 20s 008 4 2u0 #4700 8 70 0.7 0.6 1.2 0.8 0.6 1.9 Internal Medicine ,\...covnvruesvrerieerrinnvenerenssennnens 16.5 15.5 16.1 18.5 16.7 17.4 Pediatrics’ Lo. 7.2 6.5 7.2 8.0 6.8 7.9 SUIZICal SPECIAINIES:, vin vias win « win 4 03 013; aii #008 wis Hi 4.000 WINN Siw & Adore 31.0 32.5 30.5 33.4 35.9 31.8 General SUFSEIY. 1.0 swt wins viv » viv 5 wis bE RTs WN GA SR Se RAL le # we 12.8 12.5 12.3 14.8 14.3 13.3 NGUrOIOZICAl SURBETY 05 ses wins wins 53 4 5k 5 Fit 33 5 9.500 Abele Rcvie wracs 0n & woe 0.9 | 0.8 0.9 1.3 0.8 Obstetrics and BYNECOIORY + vin + sin + 210: & viv 2.30% 014 4inos siuss since Simis aes wie 6.0 6.4 6.2 59 6.5 6.5 OPIHAIMOIORY + wii sii vine sins divi wins 2 olptaiane iv & Sw wenn boucw wan woals win 34 3.3 3.2 3.1 3.4 2.7 Orthopedic SUFBBIY « « +4 sus sat sree renerresvernsenesus ens susan 33 3.9 3.2 3.4 4.6 3.3 Otolaryngology. ..voeveennrnnennnn. OE 1.7 2.0 1.7 1.6 2.2 1.6 Plastic SUMBeIY. ov vv t tit iitineeneoneneneenesnennennennennns 0.6 0.6 0.6 0.7 0.6 0.8 THOFRCICSULERIY ‘vous ww s wins wiv 0a s Wi wine sie Givi 435 » Siw 000 & 6580 & 450 00 0.7 0.6 0.7 0.8 0.7 0.8 Urology « cis wine sims wu os wins ow 5 030 3 EH SNR RE BIE SE AE 0 eee 2.0 2.2 1.9 2.0 2.4 1.9 OLher SPECIAIHIBS: ote vinv wins on « sins ala 50k 2000 Dish Bs Fob whieh wos iw $miw win 32.2 32.7 32.9 31.6 32.3 33.6 Anesthesiology ..... B04 A Was Sib #aowginie pecs Sie win» Hiei wine vies aT we 4.1 3.8 4.0 4.4 4.0 4.3 Child psychiatry «vv viiieiiiniiitieennennneeeenenenennnnnnns 0.9 0.9 1.0 1.0 1.0 3.3 INGUFOIORY « vv «wiv sina win wim wins wins wins win » 970.3 is B1008 608 #0 4 C408 $008 & 1.4 1.4 1.3 1.6 1.7 1.8 Psychiatry. ov sus suis sun o wis Sie WHY BE «WIR % HE SWE RE SR SE ie 7.9 8.1 7.7 8.7 8.9 8.0 Pathology + vv savas ih AAS HH $0 We SATE FE SE REE CREE SEE Ae 4.1 4.4 4.0 4.6 5.0 4.2 Physical medicine and rehabilitation. « «ee ee vee ve rneenennennnnnn. 0.6 0.6 0.6 0.6 0.7 0.7 RACIOIORY + 55 5.550 4 08 508 » wet 40k $0on Hower 338% 0% 50 800 £0 48 30s 43000 9 4.5 47 243 5.3 5.7 255 Therapeutic radiology. «ove vueeeeneeneneneneneneennnenennnens 0.3 0.3 -_ 0.3 0.3 — MISCEHIANCOUS + »:v 4 is + wiv + 000 + wi +018 sims + AIT ITTY. 8.5 8.5 9.5 5.1 5.1 7.8 Y Includes pediatric allergy and pediatric cardiology. Z Includes therapeutic radiology. Source: Table 39. Note: Figures may not add to totals and subtotals due to independent rounding. REVISED SUPPLY PROJECTIONS The projections of specialty distribution shown above utilized 1970 residency data as the basis for all three of the alternate approaches. In the first two series, 1970 first-year residency patterns and 1970 total residency patterns, respectively, were used as proxies for future career choices of new entrants to the profession. For the third series residency trend data through 1970 were used. Projections developed by BHRD subsequent to the preparation of this report, apply the 1972 residency data as specialty choice indicators within the respective methodologies. For a group such as general practitioners, where residency numbers are 74 virtually negligible, such a change in the methodology data base makes little difference in the final outcome. In contrast, for a specialty such as family practice, where residency growth has been especially rapid in recent years, the change of base year in the methodology brings recent developments into the analysis. According to the supply projections developed under the revised basic series (i.e., using 1972 first-year residency patterns for estimating future career patterns), general practitioners are projected to continue their declining trend, falling from 56,300 in 1970 to 36,500 in 1990. (See Table 40a.) This largely reflects the fact that current residencies in this area are negligible and that the future Table 40a. SUPPLY OF ACTIVE PHYSICIANS (M.D.), BY SPECIALTY: ACTUAL 1970; PROJECTED 1980 AND 1990 Number of physicians (M.D.) Percent distribution Specialty 1970 1980 1990 1970 1980 1990 Total active phySICIaNS «+ evs vv 20s sus sine swe wae 311,210 430,240 571,030 100.0 100.0 100.0 3eneral practice, ........ce0vvvennennerennnnnnnes 1 56,260 47,140 36,510 18.1 11.0 6.4 Medical SpecAlLIBS «.u.aivis 4. + visi s ato # ok winie winin Sime woe Sinse 66,380 116,010 174,960 21.3 27.0 30.6 Dermatology. «coves renrnnensecasncenannnnas 4,000 5,610 7,620 1.3 1.3 1.3 Family practice... vue vet vive wins wie Say a Se Se Peis 1.690 6,610 12,630 0.5 1.5 2.2 Internal MBUIGING 5.0: sive wiv « ww s div » wis » iw « wie wie ww 41,870 71,650 106,880 13.5 16.7 18.7 POUIBLIESE covsiin bis 0 4 5.0 2000 Bibi» 000 5.050 5 0 5 938 5 18,820 32,150 47,830 6.0 7.5 8.4 Surgical specialties ......vveriiiiiiiriiiiaeiianaan 85,380 128,970 180,810 27.4 30.0 31.7 GENCIAl SUIBRTY.. wis wie sin ons vive i 3 wu % 2% 408 wen 38a 29,760 52,450 78,890 9.6 12.2 13.8 Neurological SUPBRIY « sv csv v cas viv env eins vin vain sain 2,580 3,440 4,500 0.8 0.8 0.8 Obstetrics and gynecology «cv vvvvenereaccennnnas 18,880 26,110 34,590 6.1 6.1 6.1 Ophthalmology. ..oeveveeennnns wa a sy 9,930 12,920 16,730 3.2 3.0 29 Orthopedic SUFEETY «uv rev ismivmsvecswevus vs sve 9,620 13,350 18,030 3.1 3.1 3.2 Otolaryngology. + sce sve eveeness #08 WE SE Se 5,410 6,800 8,520 1.7 3.6 1.5 PIaSEiC SUIBBIY wa i.oin 4.50 2.50 « wii 4 vin « win + Bin bwin 2 iuin wivin 1,600 2,860 4,360 0.5 0.7 0.8 Thoracic SUIBEIY « cov vevvrerceeesstessssennnnes 1,810 3,020 4,430 0.6 0.7 0.8 UrOIOZY + cessvcnsstnrscinnetnsvsicasensvnnes 5,800 8,030 10,740 1.9 1.9 1.9 Other SPecialties «ec eovecesserrerserssscnnnannsas 103,190 138,120 178,760 33.2 32.1 31.3 ANEStheSIOIOBY vv wus 30s ww 3 ins vw + w:0 p0n swine miu » .. 10,860 17,360 24,560 3.5 4.0 4.3 Child DSYCHIAIIY « vias wins wins sins wiv v wins bw wwin wise since 2,100 4,270 6,870 0.7 1.0 1.2 NGUrolOgY: =« view 4m: ¢ wie Tab. 55e ¢ wie Vow wise LEE pois wy 3,070 6,500 10,580 1.0 1.5 1.9 PSYCHIREY «uv vv tind pins vm sinie wiv a uie a wie § ww we 21,150 32,780 46,550 6.8 7.6 8.2 PatholOgY + ct euvtstscrtrtecsvecensvenovsvanes 10,280 16,770 24,000 3.3 3.9 4.2 Physical medicine .......vevvevevensnsnnacannes 1,480 2,550 3,720 0.5 0.6 0.7 Radiology «vo sgns win ww roms om » ww sins #0 SE ee 10,520 14,740 19,730 3.4 3.4 3.5 Therapeutic radiology ..... ww. SH SIE SW EE Se 870 1,760 2,790 0.3 0.4 0.5 MisCellaneouUS «vv vv tenn rsennsenesssnnseannenns 42,860 41,400 39,960 13.8 9.6 7.0 ! Excludes 1,690 diplomates in family practice who have been shown separately. 2 Includes pediatric allergy and pediatric cardiology. Source: Projections developed by RAS, BHRD, HRA, (April, 1974). These projections update earlier projections for medical specialties developed by RAS. See text of this report for explanation. Note: Figures may not add to totals and subtotals due to independent rounding. supply will be almost completely determined by survivors of those practicing now. Among the remaining specialty areas, in contrast, all are projected to increase over the coming years, but at differing rates of growth. The primary care specialties (general practice, family practice, internal medicine, pediatrics, and obstetrics/ gynecology) as a group are now projected under the basic series to increase from 137,500 in 1970 to 183,700 by 1980 and to 238,400 by 1990. Among individual com- ponents, the most rapid growth rate is projected for the recently recognized specialty of family practice (from 1,690 in 1970 to 12,630 by 1990, or an increase of 647 percent). The numbers of physicians in both internal medicine and in pediatrics are projected to increase 75 substantially over the 1980 and 1990 period. As a result of these increases among individual specialties, the projected decline in general practice will be partially offset. Nonethe- less, the proportion of all physicians that are in primary care activities is projected to edge down over the projection period, from 44 percent in 1970 to 42 percent by 1990. The results from all three projection series developed are shown in Table 40b. In all instances, as indicated earlier, the projections of individual specialties have been con- trolled to overall M.D. projections derived independently by RAS. For most specialties, the revised projection findings are roughly comparable when either first-year residency positions or extrapolated trend data on resi- dencies are considered (i.e., the basic series and series 11). Table 40b. COMPARISON OF TWO ALTERNATIVE SPECIALTY PROJECTIONS OF PHYSICIANS (M.D.) WITH THE BASIC METHODOLOGY PROJECTIONS: 1980 AND 1990 1980 1990 Specialty Basic 1 1 Basic 1 1 All active physicians (M.D). vvvvn niin ennnnnn. 430,240 430,240 430,240 571,030 571,030 571,030 General practice. ....oocvenvvnsnerenrererrcenennns 47,140 46,460 45,990 36,510 35,090 33,460 Medical specialties «ov vvv vee inin inne iin nnn 116,010 107,280 121,500 174,960 155,580 195,860 DEFMAIBIORY x ont vinrs. wins wine win: 4 418.4 5% wi1w $008 HIE $i6k 5,610 5,800 5,770 7,620 8,050 7,880 Family Practice. ve vies sus 45 4 in + on + 5055004 4500 600 & 6,610 5,480 15,320 12,630 10.120 42,710 INEErnal MediCINe «iv « 4:4 wvit ain vive wiv vai adie sui ae z 71,650 66,840 69,350 106,880 96,160 100,040 Pediatrics’. «ouverte eee eens 32,150 29,170 31,060 47,830 41,250 45,230 Surgical specialties. «cov vue rennet renereenennnnns 128,970 135,660 125,800 180,810 195,550 167,310 GENBTALSUYERIVA « viv + 60 im +0 3 0i 597% S3% BITE H1% 4 21% 4 52,450 51,300 50,600 78,890 76,420 71,440 NeUrolOZICal SUPBEYY «iu suv sow sain vies sivis sins sins $78 & 3,440 4,500 3,400 4,500 6,830 4,340 Obstetrics and gynecology + ...... swe ieie Baie wins Be 26,110 27,230 23,920 34,590 36,950 27,920 Ophthalmology... vveeunnannn. 3 Rnkiiaiihy Sevsyivingy 4 .. 12,920 13,820 13,290 16,730 18,720 17,020 Orthopedic SUTBery . ove viene ensnnneneenennn 13,350 16,500 13,600 18,030 25,010 18,220 Otolaryngology. seu sos sus sins vnes w HIE § Win SW 6,800 8,220 6,930 8,520 11,670 8,790 PIaStIC SUIBRIY" wiv wins wis 30:3 Wins Sine wale is 508 Finis Sims 2,860 2,530 2,930 4,360 3,650 4,680 Thoracic SUMBEIY cs veo vse vsenavsevees ¥.8 A Be Sine 3,020 2,600 3,060 4,430 3,530 4,340 Urology. ..... Aa hi ini 9s 3 Sion SEN BoB aT ete were 8,030 8,960 8,090 10,740 12,780 10,560 Other specialties. «cover eenererenenenenennnnnns 138,120 140,840 137,000 178,760 184,810 174,490 ANESINESIONOBY wis + win + win 5 wi 8 wie 3 w0 ive ain & 30. & win wi 17,360 16,660 17,040 24,560 23,090 23,760 Child DSYCHIRLIY « « 4:0 4 wis « 5% 4.3.5 + 2is wind wie.s #00 # 4a § wie 4,270 3,730 4,600 6,870 5,670 7,940 INEUPOIORY: iss sini a win 4 40 3 00 3 is 4 iw 3itw win 20 + 0m 2oais 6,500 6,240 6,580 10,580 10,000 10,910 Psychiatry ..iuiiiiniiiin tintin ineeneennnnnns 32,780 33,600 31,970 46,550 48,410 43,170 PRENOIOBY: « wiv ww # iv 0 410 # wis $08 #078 $00 95008 S106 970% #18 16,770 18,610 15,880 24,000 27,910 21,130 Physical medicine and rehabilitation .............. 2,550 2,580 2,670 3,720 3,800 4,110 RATIOIORY ws 3.55 00 bit 5 905 os 90d 5 90 4 i Bik vik es 14,740 15,670 18970 219,730 21,830 227,580 Therapeutic radiology. «ooo iiiei iin ieenneenns 1,760 1,850 - 2,790 3,000 — Miscellaneous «vv vv vein inner ereneneennnnnnn 41,400 41,910 39,280 39,960 41,110 35,860 i Includes pediatric allergy and pediatric cardiology. 2 Includes therapeutic radiology. Source: Projections developed by RAS, BHRD, HRA (April 1974). These projections update earlier projections for medical specialties shown in Table 39. Basic: Based on distribution of first-year residencies. I: Based on distribution of total residencies. 11: Based on extrapolation of the trends in first-year residencies. Note: Figures may not add to totals and subtotals due to independent rounding. This reflects the fact that, in general, the first-year residency patterns, reflecting recent developments, are more consistent with trend expectations than are total residency patterns. Among the individual specialty groups considered for this analysis, the most notable exception to this generalization is family practice. Previous discussions have noted the exceptionally rapid growth in family medicine residency positions in recent years. The use of trend data for projection purposes (Series I), consequently, results in exceptionally high supply 76 estimates for the projection period, particularly by 1990. As shown in Table 40b, for that matter, a trend extrapola- tion for this specialty results in a 1980 supply estimate (15,320) that is 20 to 50 percent above that estimated for 1990 by the other two projection series. A continuation of the recent pace of residency growth in family practice uninterrupted over the next two decades, however, seems somewhat questionable and, therefore, the supply projec- tions developed in this manner should be viewed with particular caution. Chapter 5 ¢ DENTISTS The basic sources of information on dentists are publica- tions of the American Dental Association (ADA)! and preliminary results from the Second National Survey of Licensed Dentists, 1967-70, conducted by the Division of Dental Health in the Bureau of Health Resources Develop- ment (BHRD). Data cover all civilian dentists located in the 50 States and the District of Columbia. In addition, dentists in the Armed Forces both in the United States and abroad are included in the statistics shown, unless indicated otherwise. It should be noted at the outset that data on active dentists presented in this report are estimates based essentially on the ratio of active to total dentists derived from data in the 1950 Census of Population and the number of graduates from U.S. dental schools less separa- tions. Since virtually all dentists practicing in the United States have graduated from dental schools located in this country and since losses of U.S. graduates through migra- tion to foreign locations are negligible, the active dentist supply represents the net balance between the total number ever graduated from American schools and the number lost through deaths and retirement. The numbers of deaths each year were estimated from death rates for white males only, given the very small proportion of women dentists and Black dentists in the profession. Since death rates for women are lower than for men and higher for Blacks than for whites, the net error incurred is believed to be very small. The basic data on deaths were drawn from life tables issued by the National Center for Health Statistics.? In order to estimate dentist deaths from these tables, an average age was assigned to each dental graduating class. According to the ADA, the median age at graduation was 25 years prior to World War |l, 28 years in the period 1950-54, and currently 26 years. Using these figures, an estimate was obtained of the total number of dental Y Annual Report on Dental Education, 1972-73. Chicago, American Dental Association, 1973. Also prior annual issues. 2 National Center for Health Statistics.Vital Statistics of the United States, 1967. Vol. Il Section 5. Life Tables. Rockville, Maryland, Health Services and Mental Health Administration, 1970. Once each class had been assigned an average age, it was then possible to use the life tables to estimate the number of deaths. Life tables for 1901-09 were used for the period 1900 to 1925, tables for 1928-31 for years 1925 to 1935, tables for 1937-41 for the years 1935 to 1945, tables for 1949-51 for the years 1945 to 1955, tables for 1959-61 for the years 1955 to 1965, and the table for 1967 for the years 1965 to 1990. 717 graduates surviving to any given year, including 1970. To derive estimates of active dentists, conversion ratios of active dentists to total dentists based on data from the 1950 Census of Population were used. These conversion ratios were derived by comparing the number of dentists included in the 1950 census counts for each 5-year age interval with the total number of living dentists in that age interval. The resulting values were then plotted and a smooth curve created with approximate values interpolated for each 5-year interval of age.* These “percentage active” values were then applied to the relevant age group of dentists in all graduating classes. Using these ratios, a historical series of active dentists was developed through December 31, 1970. At present, the Register of Licensed Dental Manpower contains 48 States and the District of Columbia. When active rates for 1968-69 from the Division of Dental Health's Second National Survey of Licensed Dentists are applied to the number of licensed in-State dentists in the Annual Register, the number of active dentists is less than 1 percent greater than the number of active dentists as projected in this report as of the end of 1971. The same comparisons by State showed less than 10 percent differ- ence in most States, with the noticeable exceptions of the District of Columbia (38 percent) and the State of Washington (25 percent). These figures, consequently, tend to reinforce most of the projected methodology used in this chapter. In order to provide an improved and current data base, the Division of Dental Health is establishing a Biennial Register of Licensed Dental Manpower under contract with the American Association of Dental Examiners. With the cooperation of the 51 Boards of Dentistry, the first annual register will include the name, address, and license number of all dentists and hygienists licensed by the 50 States and the District of Columbia as of August 1971. Future registers of dentists will also include year of birth, school of graduation, and year of graduation. Both the dentist and hygienist registers will be updated each year through the American Association of Dental Examiners and the 51 Boards of Dentistry. 4 By age group, the “percentage active’’ figures were as follows: under 44 years—100 percent; 45-49 years—98 percent; 50-54 years—91 percent; 55-59 years—83 percent; 60-64 years—75 per- cent; 65-69 years—66 percent; 70-74 years—57 percent; 75-79 years—47 percent; 80-84 years—35 percent; 85-89 years—22 per- cent; and 90 years and over—10 percent. CURRENT CHARACTERISTICS AND TRENDS The Division of Dental Health estimates that there were approximately 102,220 active dentists in the U.S. in 1970.° Of these, 95,680 were civilian dentists located in the 50 States and Washington, D.C., and 6,540 were dentists in the Armed Forces. Active dentists are a relatively young group. In 1970, the median age was estimated to be 43 years, with approxi- mately 30 percent of the active supply less than 35. At the other end of the age spectrum, slightly more than 10 percent, or 11,420 active dentists, were estimated to be 65 years old or over. (See Table 41.) 5 This estimate of active dentists is essentially the same as that listed for dentists under 68 years of age (102,500 in 1970) in: American Dental Association. American Dental Directory, 1972. Chicago, The Association, 1972, Table 41. NUMBER OF ACTIVE DENTISTS, BY SEX AND BY AGE GROUP: DECEMBER 31, 1970 Number of Sex and age group active Percent ; distribution dentists Bothsexes ....... 102,220 100.0 Male: woem cov mmm sss 98,950 96.8 Female ............ 3,270 3.2 Allages ..wew oss 102,220 100.0 Less than 25 years ...... 2,500 2.4 A544 years , . von nwvies 53,000 51.8 2529 sss sum n mas 11,580 11.3 3034 cv cs nm unm as 8 15,590 15.2 3539 us ss mmm a a 13,560 13.3 40-44 . LL... 12,270 12.0 45-64... LL... 35,300 34.6 4549 css srw mms» 14,530 14.2 50-54 .. cs nova m ses 9,370 9.2 5589 os vpn wmns a 5,910 58 6064 , , wow sry 5,490 54 65 yearsand over. . . ..... 11,420 11.2 6569 ou ts wen ming is 5,100 5.0 20:74 2 ss naman io» 3,400 3.3 75-and over ........ 2,920 29 Source: Estimates by sex: Sex distribution of active dentists from 1970 Census of Population was applied to the estimated number of active dentists. Estimates by age: Percentage active factors were applied to the total number of living dentists at each year of age. According to information from the 1970 Census of Population, there are very few females in the dental profession—only about 3 out of every 100 civilian dentists in 1970. Although current information is relatively sketchy, a recent report published by the American Dental Association suggests that the number of female dental students and dentists will probably rise in the coming years.” This prediction is based largely on the fact that in academic year 1971-72, over 40 percent of the women enrolled in denta! schools were first-year students, and they constituted 2 percent of freshman enrollment. Blacks also make up only a small part of the dental work force. According to data from the 1970 Census, Blacks accounted for only 2.3 percent of the civilian dentists in 1970, about the same as in 1960. This proportion is expected to rise, however, as the result of recent increases in enrollment of Blacks in dental schools. Between the 1963-64 and 1971-72 academic years, for example, first- year enrollment of Blacks rose from 2.3 percent of total first-year enrollment to 5.0 percent. In current first-year enrollment, Blacks account for 4.6 percent, Orientals for 2.6 percent, Spanish- or Mexican-Americans for 1.1 per- cent, and American Indians for about 0.1 percent. Almost all active dentists (97 percent) in 1970 were primarily engaged in providing direct patient care, as shown in Table 42. Two percent of the total, or 1,900 active dentists, were engaged principally in teaching, with the remaining few in research and administrative activities. 5 U.S. Bureau of the Census. United States Census of Popula- tion: 1970. Detailed Characteristics. United States Summary. PC(1)-D1. U.S. Government Printing Office, 1973. 7 Annual Report on Dental Education, op. cit. Table 42. NUMBER OF ACTIVE CIVILIAN DENTISTS, BY MAJOR PROFESSIONAL ACTIVITY: DECEMBER 31, 1970 Number of Major professional activity active Percent civilian distribution dentists All activities . . ........ "wi oui iy 95,680 100.0 Coe sons issvponds sinwnns 92,380 96.6 Administration ............. 1,100 1] Teaching . . . ssn aves ss nmmaa 1,900 20 Research and other . .......... 300 0.3 Source: BHRD, Division of Dental Health based on data from 1965-66 survey of licensed dentists and other sources. Between 1950 and 1971, the number of active dentists is estimated to have grown from 79,190 to 103,750, an increase of nearly 31 percent. There was relatively little difference in the growth patterns of the 1950's or the 1960's. (See Table 43.) Despite the increase in the number of dentists during the 1950's, the ratio of active dentists to population declined slightly between 1950 and 1960. Although the downward trend in the ratios leveled off after 1960, the 1971 ratio was still below that of 1950. In 1950, there were 52 active dentists per 100,000 civilians; in 1971, the ratio was 50 per 100,000. (See Table 43.) As indicated earlier, the supply of active dentists in the United States consists almost completely of Americans who have graduated from U.S. dental schools. In 1970, 0.7 percent of active dentists were graduates of foreign dental schools. Canadian schools furnished two-thirds of all foreign graduates. ® The distribution of active civilian dentists varied widely in 1970 among States, ranging from a high of 69 per 100,000 civilian resident population in New York State to a low of 25 per 100,000 in South Carolina. In general, States 8 Derived from data in: American Dental Association. American Dental Directory, 1972. Chicago, The Association, 1972, Table 43. TREND IN NUMBER OF ACTIVE DENTISTS AND DENTIST/ POPULATION RATIOS: SELECTED YEARS DECEMBER 31, 1950-71 Number of Population! Active dentists Year active (in 1,000’) per 100,000 dentists ’ population 1950 ..... 79,190 153,622 51.5 1955 0 ven 84,370 167,513 50.4 1960 . + 44 90,120 182,275 49.4 1961 4s nmw 91,390 185,214 49.3 1962 «4 + ue 92,730 187,974 49.3 1963 ..... 93,750 190,618 49.2 1964 ..... 94,900 193,162 49.1 1965 ..... 95,990 195,468 49.1 1966 . oe 97,050 197,656 49.1 1967 swine 98,320 199,721 49.2 1968 ..uvo 99,480 201,678 49.3 1969 ..... 100,720 203,777 49.4 1970 ..... 102,220 206,017 49.6 1970) on inwie 103,750 208,056 49.9 ! Total population including Armed Forces overseas. Source: Active dentists: BHRD, Division of Dental Health. Population: U.S. Bureau of the Census. Current Population Reports. Series P-25, Nos. 465 and 475. 79 in the Northeast and West had higher dentist-to-population ratios than the national average (47 per 100,000), while those in the North Central and South had lower ratios. (See Table 44.) For States with ratios greater than the national average, two of every three had a dental school; for States below the national average, in contrast, the proportion was two of five. As might be expected, self-employment predominates among dentists who are active in the profession—about 88,000 (86 percent) were engaged primarily in private practice. Of the remaining number, 2.1 percent were teaching at schools of dentistry, 1.5 percent were State or local government employees, and 7.8 percent were em- ployed by the Federal Government. (See Table 45.) In 1971, some 10,700 dentists were recognized by the American Dental Association as specialists in one of eight areas of dentistry. Over two-fifths, or about 4,420 of the specialists, limited their practice exclusively to orthodon- tics. The next largest group, 2,570 specialized in oral surgery, followed by 1,200 in pedodontics and 1,040 in periodontics. Relatively few specialists engaged in one of the other recognized areas—prosthodontics, endodontics, public health dentistry, and oral pathology. (See Table 46.) Dental specialists were about equally distributed among the four geographic regions, with the West having the highest specialist-to-dentist ratio. The West had 12.5 spe- cialists per 100 dentists, followed by the South with 10.7, the North Central 9.4, and the Northeast 9.4. Among individual States, specialist/dentist ratios ranged from a high of approximately 14.2 specialists per 100 dentists in California to a low of 3.9 per 100 in Mississippi. PROJECTIONS OF THE SUPPLY OF DENTISTS TO 1990 Projections of the supply of active dentists are presented here along with a discussion of how these projections were developed. The first part of the discussion relates to the basic methodology utilized to project the overall supply of active dentists. Additional information is also provided on the impact on the projections of different assumptions as to graduate input. METHODOLOGY AND ASSUMPTIONS Projections of the number of active dentists for the 1971-90 period were calculated using essentially the same methodology described earlier for estimating active dentists in 1970 and earlier years. Data on 1971 graduates of dental schools were obtained from school reports on 1972 capitation grant applications; these applications also pro- vided estimates of first-year enrollments through 1974-75. Table 44. NUMBER OF ACTIVE CIVILIAN DENTISTS AND DENTIST/POPULATION RATIOS, BY GEOGRAPHIC REGION, DIVISION, AND STATE: DECEMBER 31, 1970 . Civilian population Rate per Region, division, and State Numb or setivg July 1,1970 100,000 civilian dentists . i . (in 1,000’s) population UNITED STATES ...uvuu es vn 95,680 201,717 47.4 NORTHEAST ......... i... 28,820 48,945 58.9 New England. . ................. 6,120 11,782 519 Connecticut . vv vu vomamnivss 1,850 3,024 61.0 Maine vs vomsmas ponmmEm sss 360 984 36.2 Massachusetts . . .............. 3,000 5,674 529 New Hampshire . . ............. 310 738 41.5 Rhodelsland. . . .............. 430 916 46.9 Vermont . . ....... 0... 170 447 38.5 Middle Atlantic... .............. 22,700 37,164 61.1 New Jersey. « o.oo nov vv v vomwaie ns» 4,090 7,134 57.3 New York .................. 12,520 18,229 68.9 Pennsylvania . . ............... 6,090 11,801 51.6 SOUTH. .uanwusnsnanndisaunssss 21,850 61,962 35.3 SOUth AHANtC ; . + ov ons vs 5 5.5% 000s 10,790 30,126 35.8 Delaware . . ................. 210 544 38.6 District of Columbia ............ 650 736 88.3 Florida . ................... 2,570 6,743 38.2 Georgia... 1,330 4,521 29.4 Maryland . . ................. 1,560 3,869 40.3 North Carolina . .............. 1,480 4,974 29.8 SouthCarolina , vumv uns s summa 640 2,522 25.4 Virginia sum sss mnmimmes s avian 1,760 4,470 39.4 West Virginia. , « s sos wme ss nainme 590 1,746 34.0 East SouthCentral ............... 4,140 12,703 32.6 ADAGE + vr ummm a ss Howe 1,000 3,419 29.4 Kentucky's s o's s somuws ts mewn. 1,120 3,182 35.2 MISSISSIPPI = + ¢ « commis 5 5 ai men 610 2,195 27.9 Tennessee . ....vovwmveerenmnea 1,410 3,907 36.0 West South Central . .............. 6,920 19,134 36.2 Arkansas . . ... Lie. 600 1,918 31.4 Louisiana. . ................. 1,250 3,602 34.8 OKIBhOMA, v4 + ss puma ws 4s REEER 930 2,535 36.6 TEXAS « win win v4 +3 BE 65 2% bwin 4,140 11,080 37.4 NORTHCENTRAL. ................ 26,190 56,529 46.3 East North Central . .............. 18,490 40,272 45.9 HINOMS. ov woww s+ suvmame + + n@nE 5,540 11,085 50.0 Indiana 0 unis ss ammnser wins 2,040 5,201 39.2 Michigan . «vc ovinmmmnnen nnn 4,280 £,886 48.1 Ohio... iii. 4,430 10,669 41.5 Wisconsin. . ................. 2,200 4,431 49.6 West North Central . . + vvowvm ss vous 7,700 16,257 47.4 IOWA: ssn m ss pan E ES 4 £5 me 1,320 2,829 46.7 Kansas . : cuww sso vommmme vo v0 am 920 2.211 41.6 Minnesota. . . ................ 2,220 3,818 58.1 See footnotes at end of table. 80 Table 44. NUMBER OF ACTIVE CIVILIAN DENTISTS AND DENTIST/POPULATION RATIOS, BY GEOGRAPHIC REGION, DIVISION, AND STATE: DECEMBER 31, 1970—Continued Number of active Civilian population Rate per Region, division, and State in ; July 1, 1970 100,000 civilian dentists . . (in 1,000’s) population NORTH CENTRAL—Continued West North Central—Continued Missourl «ozs smmmv isi mmm 1,970 4,655 42.3 Nebraska « 2 vo svt me tvs vm wm 810 1477 35.0 North Dakota . ............... 230 606 38.0 South Dakota . ............... 230 661 34.8 WEST csi rommmmis sniummes s snmumn 18,820 34,280 54.9 MOUNTAIN +. 25 Fk 4 Baw iio bo 40 mb msn 3,740 8,224 45.5 Arizona . LL... 690 1,764 38.1 Colorado»... «c's ss omma sz 13 poawws 1,130 2,176 51.9 IANO 2 wow ss s su mmm so 5» 69 wwe 320 712 44.9 MONIANA vist vo sums » £5 Bois sme 310 691 44.3 Nevada .iwisssvmnsiimurnews 200 483 41.4 NeW MEXICO: « s suimww bt 85 mmmmmns 360 1,001 36.4 LL RT PEE EIN ITTY, 580 1,065 54.8 Wyoming . . . .... iii. 150 33 46.2 PACHIC: wivcw omnia » wcmmibimle ols onion om co im oe 15,080 26,056 57.9 Alaska. . ..... i ie 80 274 28.1 California. . . ...... ovo. 11,270 19,623 57.4 Hawall ooo ss sv mmmes ss wane 460 720 63.8 OreEON oon cis snow @ + 3 2 Amn HE o 1,370 2,098 65.2 Washington ...seewe ss v3 meiwmss 1,900 3,341 57.0 Source: Active dentists: BHRD, Division of Dental Health based on data from the Second National Survey of Licensed Dentists, 1967-70. Population: U.S. Bureau of the Census. Current Population Reports. Series P-25, No. 468. Note: Figures may not add to totals and subtotals due to independent rounding. Graduate projections for the 1972-78 period were com- puted from the number of first-year students reported 4 years earlier, utilizing the attrition rates (for each school) that were in evidence during the 1965-69 period. In 1950, the average attrition rate in dental schools was 4 percent; the ratio climbed to 12 percent in 1960, then declined to 4 percent in 1971.° For losses to the profession resulting from deaths, survival rates for white males were used, as described earlier in the chapter. As with most other health professions, the future supply of dentists largely reflects the growth of enrollments in dental schools. From the early 1950s through 1971, the number of graduates from U.S. dental schools rose at an average annual rate of approximately 1.8 percent. However, %In 1973, however, the attrition rate was 6 percent. 565-118 O - 74 - 7 81 from 1953 to 1964, the annual rate of increase averaged only 1.2 percent. From 1965 through 1971, it averaged 3.1 percent.! © The latter spurt in graduates results in large part from the impact of Federal support provided through basic improvement and special project grants. Between 1965 and 1971, dental school enrollment rose at an average annual rate of about 3.6 percent, as compared with 2.3 percent for the 1960-71 period. (See Table 47.) Students enrolled in dental schools rose from 13,580 in 1960 to 17,300 in 1971, an increase of 27 percent. Construction provisions in the Health Professions Educa- tional Assistance (HPEA) Act have had a noticeable impact in recent years. In the academic year 1960-61, a total of 47 10 Annual Report on Dental Education, 1971-72. Chicago, American Dental Association, 1972. Table 45. NUMBER OF ACTIVE DENTISTS, BY TYPE OF PRACTICE: DECEMBER 31, 1970 Number of | Percent Type of practice active distri- dentists bution All types of practice. . . .... 102,220 100.0 Selfemployed .......co00... 87,780 85.9 Individual practice ......... 80,780 79.0 Partnership ............. 6,000 59 Shareholder in incorporated Practice uu w% 4 3 8 mm ims + + 1,000 1.0 Other dentist or dental group . .. .. 1,800 1.7 Dental school .............. 2,100 2.1 State and local government. . . .... 1,500 1.5 Federal Government. . . ........ 8,040 7.8 Armed Forces . ........... 6,540 6.4 Other . ................ 1,500 1.4 Other . ........ i... 1,000 1.0 Source: BHRD, Division of Dental Health based on data from various sources. dental schools were in operation, and in 1963-64 there were 48. By the end of the decade, the number had risen to 53. One school closed in 1971. (See Table 47.) Four new schools opened in 1972-73, and two more in 1973-74, making a total of 58 schools in the current academic year. For purposes of this report, the projections assumed that when the current legislation expires in FY 1974, there would be no extension of Federal legislative inducements to increase enrollments and the level of support from the public and private sectors combined would be sufficient only to maintain enrollment levels resulting from earlier Federal legislation. Given this framework, the basic meth- odology used to project future inputs of graduates main- tained the total number of first-year students enrolled per year in the 1979-80 to 1986-87 period at the level reached in 1978-79. (See Table 48.) Although this is a conservative approach, examination of historical information on enrollments and graduates sug- gests that it represents a reasonable assumption. As noted earlier, increases in dental enrollments prior to the HPEA period were very slight, at least during the years back to 1953. Even this slow growth resulted entirely from the opening of a number of new dental schools during these years, for combined enrollment in existing schools actually showed a slight decline. Table 46. TREND IN NUMBER OF ACTIVE DENTAL SPECIALISTS, BY SPECIALTY: 1952-71 Public Year! All Endo- Oral Oral Ortho- Pedo- Perio- Prostho- ear Tobi tebe ; : . . . health specialists dontists pathologists | surgeons dontists dontists dontists dontists dentists 1952 . . vamsn 2,584 _- 13 684 1,251 86 366 173 11 1958 ...00wn 2,747 — 22 725 1,359 127 302 192 20 1954 ..: vim 2,843 - 24 779 1,443 141 220 212 24 T9588 sis man 3,034 — 24 844 1,521 148 245 225 27 1956 «.:aou. 3,098 — 29 843 1,637 151 194 214 30 1957 ....... 3,552 —- 34 976 1,820 177 270 245 30 1958 ....... 3,787 — 37 1,089 1,925 184 283 239 30 1959 iv is nus 3,916 A 40 1,104 2,008 195 290 249 30 1960 vis + 5 mvs 4,170 — 42 1,183 2,097 229 307 278 34 1961 4.05 sa 4,405 — 43 1,266 2,209 244 320 285 38 1962 cvs viv 5,121 — 41 1,338 2,818 257 328 296 43 1963 ....... 5,662 —- 40 1,434 3,073 415 345 309 46 1964 ....... 5,985 - 45 1,502 3,261 447 361 317 52 1968 +ivv ss v5 6,462 — 52 1,636 3,437 568 376 336 57 1968 «uv sus 9,705 439 89 2,262 4,128 1,106 929 654 98 1969 uu. ss 10,060 478 97 2,383 4,216 1,129 951 704 102 1970 civ vv 10,315 497 97 2,406 4,335 1,159 1,003 715 103 197% wv inin + us 10,697 536 111 2,567 4,415 1,195 1,042 715 116 ! Data not available for 1966 and 1967. 2 Endodontics was not recognized as a dental specialty prior to 1965 and data are not available for 1965. Source: Bureau of Economic Research and Statistics. Facts About States for the Dentist Seeking a Location, 1970. Chicago, American Dental Association. Also prior annual issues. 82 Table 47. TREND IN NUMBER OF SCHOOLS, ENROLLMENTS, AND GRADUATES FOR DENTAL SCHOOLS: ACADEMIC YEARS 1960-61 THROUGH 1971-72 Academic year Number of Total First-year Graduates schools enrollment | enrollment 1960-61 ... novi vsmmmus ss smommme 32 nm 47 13,580 3,620 3,290 FOBTEOD" ion wesw wisnkis on 0 ses sas 00k wd anodes own or tole 03 9 47 13,510 3,600 3210 196263 . cvvwsms ss wnpms sso rmpEET £3 08 48 13,580 3,680 3,230 TIED . : x wns sspmume ssp maw sd s550 48 13,690 3,770 3,210 196465 ; so vn vm sss mma ss RETR BA SLs 0 @ 49 13,880 3,840 3,180 VTIGS-DBB : innit ss nmima ts mmmmeadd is no 49 14,020 3,810 3,200 BHEGEBT = ite wdsne si cies ln non che hes est pilin he oie os shake #4 wale 49 14,420 3,940 3,360 1967-68 © vv tee 50 14,960 4,200 3,460 196869 , ssn mwp es snmmme coduimmmnios 43 95 52 15,410 4,200 3,430 TH6D-TO : ssa mms s so FHRRR ER IRBARAE 5 0b 53 16,010 4,360 3,750 1970-71 Lotte tt ee ee eee eee 53 16,550 4,560 3,780 TOTTI + vnniin's s smmimmwhs to Wedmimwis 2 5 ww 52 17,300 4,740 3,960 Source: Dental Students’ Register, 1966-67. Chicago, American Dental Association, 1967. Also prior annual editions. Annual Report on Dental Education, 1972-73. Chicago, American Dental Association, 1973. Also prior annual editions. Note: Data for University of Puerto Rico are included in this table. A different assumption also was examined: that in- creases in enrollments after the expiration of the current legislation would occur at the same yearly rate as that experienced in the 10-year period prior to enactment of the HPEA Act. In view of the slow growth during this historical period (only about 1 percent annually), this alternative assumption would result in a supply estimate by 1990 less than 2 percent above that derived from the basic methodol- ogy. Because the difference between the two projections is so small, no detailed data for the second assumption are presented here. A growing awareness of dental care needs in this Nation, along with continued Federal legislation, could conceivably motivate expansion in enrollments beyond that assumed and result in further increases in supply. However, it seems rather unlikely, on the basis of historical experience, that enrollment within existing schools would show a marked increase or that many new dental schools would come into being. With respect to this latter point, it should be noted that dental schools, unlike medical schools, must have their clinical work performed within the existing plant; in medical schools, in contrast, clinical work is generally undertaken outside of the school. This situation adds a considerable financial burden to the building of new dental schools. Furthermore, gifts, grants, endowment income, and income from regional organizations are of only nominal importance as income sources to dental schools—which 83 means that these institutions must often seek public support for financing. During the HPEA period, for example, two private dental schools closed and five others had to ask States for support. PROJECTION FINDINGS The basic projection indicates that there will be a total gross graduate input of 101,690 over the 1971-90 period. If graduating classes were to grow at the same rate as during the decade before Federal spending, the graduate total would be 103,390—only 1,700 more graduates than the basic projection. However, if Federal support were to continue at the high levels of the late 1960’s and early 1970’s and the projected rate of increase in enrollments were to match the recent experience (a 6.5 percent average yearly rate of increase), a total gross graduate input of 123,580 would result for the 1971-90 period. (See Table 48.) Under the basic methodology the number of dental schools graduating dentists is projected to increase from 53 in academic year 1970-71, to 54 as of 1974-75, and to 59 by 1975-76. This represents a net increase in the number of schools, as 10 new schools are assumed, along with the termination of one existing school. The total number of 59 schools is further assumed to remain constant through the remainder of the projection period. Table 48. FIRST-YEAR ENROLLMENTS AND GRADUATES IN DENTAL SCHOOLS USING BASIC METHODOLOGY: ACTUAL 1970-71 AND PROJECTED 1971-72 THROUGH 1989-90 Academic year Fisstyear Graduates enrollment 1970-71 ........... 4,560 3,760 1971272 vc vmwms s 5mm 4,710 3,920 197273: wv ovinn iss anne 5,280 4,220 1973-74 + vn vws ¢ «mw 5,380 4,570 1974-75... ........ 5,490 4,740 1975-76 ........... 5,540 5,060 1976577 ov ww wmv vs mus 5,690 5,140 1977-78 i wun sensing 5,830 5,210 1978-79 . vo viv ve van 5,850 5,290 197980 ........... 5,850 5,370 198081 ........... 5,850 5,440 198182 ........... 5,850 5,440 T982:83 , cowie sus 5,850 5,440 Y98384: . uw mwm ei sin 5,850 5,440 1984-85 ........... 5,850 5,440 198586 ........... 5,850 5,440 1986-87 ........... 5,850 5,440 1987-88 ........... - 5,440 1988-89 ........... - 5 440 1989-90 ........... = 5,440 Source: 1970-71 through 1974-75 first-year enrollments: Appli- cations for capitation grants submitted to BHRD. 1970-71 graduates: Applications for capitation grants sub- mitted to BHRD. Note: Data for the University of Puerto Rico are excluded from this table. As indicated earlier, the level of first-year enrollment is projected to level off by 1978-79 (graduates by 1981-82) and remain at that level through 1986-87 (graduates through 1989-90). These school projections result in an average of 92 graduates per school by 1980-81, compared 84 to a 1970-71 average of 75 per school, and a projected ratio of 88 per school for 1974-75. This slowdown in graduates per school after 1974-75 appears consistent with the basic assumption explicit in the projection methodology. Under the basic assumption, the supply of active dentists is projected to grow from 102,220 in 1970 to 126,170 in 1980 and to 154,910 in 1990. The increase in active dentists is thus projected at 23,950 between 1970 and 1980, nearly twice the increase of 12,100 from 1960 to 1970, or 23 percent as compared with 13 percent. Between 1980 and 1990, growth is projected to be about the same—a 28,740 increase (also 23 percent). The ratio of active dentists to population, which had edged up between 1960 and 1970, is projected to rise sharply in the future. The ratio is projected at 56 dentists per 100,000 population in 1980 and 62 per 100,000 in 1990; this coripares with a ratio of 50 in 1970. (See Table 49.) Table 49. SUPPLY OF ACTIVE DENTISTS, USING BASIC METHOD- OLOGY: ACTUAL 1960 and 1970;PROJECTED 1975-90 Number of active | Rate per 100,000 Year dentists population 1960 «ss + svwni + + 90,120 50.1 1970 «ss sninnmm +» 102,220 50.2 1978 ..iivwwimass 111,990 52.1 1980 ics nnwmas za 126,170 55.6 1985 ........... 140,950 58.9 1990 ........... 154,910 61.8 ! Resident population as of July 1. Source: 1960 and 1970 active dentists: BHRD, Division of Dental Health. Population: U.S. Bureau of the Census. Current Population Reports. Series P-25, Nos. 468, 477, and 483. Note: Graduates of University of Puerto Rico have been ex- cluded from projected additions to the supply. Chapter 6 © OPTOMETRISTS Optometrist data cover all active optometrists in the 50 States and the District of Columbia. Those few U.S. optometrists who may be overseas or in the territories are excluded. Although current estimates cover both Federal and non-Federal optometrists, historical data provided for years prior to 1960 relate only to civilian workers. However, since there were few military optometrists prior to 1960, this has little effect on the data. The primary sources of information on active optom- etrists which are used here are (1) the 1968 Vision and Eye Care Manpower Survey conducted by the National Center for Health Statistics (NCHS) and (2) data from the 1960 and earlier Censuses of Population. The 1968 survey, which is the most recent comprehensive survey of optometrists in the United States, provides the basic data for most of the estimates presented in this report. The age distribution obtained from the survey was assumed to be as of December 31, 1968. To derive 1970 estimates used for characteristics data and as the base for the projections, it was necessary to build upon the 1968 NCHS data for December 31, 1968. Estimates were thus made of new entrants to and separa- tions from the active supply of optometrists for the period January 1, 1969 through December 31, 1970. Entrants to optometry were based on graduates of optometry schools for the 1968-70 period, which were obtained from school reports on FY 1971 institutional grant applications. These new graduates were added to the base-year age distribution of optometrists active as of January 1, 1969. Age-specific separation rates were then applied to the total number of active optometrists and to new entrants for 1969 and 1970.! The estimated “losses’’ (deaths and retirements) were then subtracted by age group from the active pool, to derive a December 31, 1970 figure. The historical supply trends shown represent a combina- tion of both estimates and actual counts and should be used with caution. Individual tables provide detailed explana- tions and sources for specific items. In order to improve the data base, the Bureau of Health Resources Development (BHRD) contracted with the American Optometric Association (AOA) to make recom- mendations on how best to improve the base and is now supporting the AOA in collecting base data on optom- etrists. The AOA-BHRD survey of all active optometrists in the United States, which began in September 1972 and will continue through early 1974, is being conducted through "Fullerton, Howard N. A Table of Expected Working Life for Men, 1968. Monthly Labor Review 94: 49-55, June 1971. 85 State licensing boards. In addition to basic demographic items, the survey is obtaining information on principal form of employment, type of activity, continuing education, auxiliary utilization, and patient load. Upon completion of data collection, this survey will become the data base for the profession. Survey results for several States have already been published. CURRENT CHARACTERISTICS AND TRENDS In 1970, there were approximately 18,400 optometrists actively engaged in practice in the U.S. Optometrists are relatively old compared to the total labor force, with more than three out of five optometrists 45 years of age and older, and thus expected to retire over the next 20 years. Only about 15 percent were between 30 and 39 years of age. This relatively older age distribution reflects the large number of optometrists who completed their education immediately after World War Il and the Korean War, as well as a subsequent drop off in enrollment in optometric schools. (See Table 50.) In 1970, only about 400 optometrists, or 2 percent of the total active number, were women. This is expected to rise somewhat in the future, however, as a result of the recent increases in enrollment of females in optometry schools. The survey of health professions student finances con- ducted by the Bureau of Health Manpower Education in 1970, shows that 3 percent of optometry students were women. Blacks and other minority groups are also underrepre- sented in optometry according to data from the 1970 Census of Population. Census figures for 1970 indicate that Blacks accounted for less than 1 percent of active optometrists and persons of Spanish heritage for slightly less than 2 percent. Although current and more comprehen- sive data on racial-ethnic distribution will not be available until results of the current survey are known, the census data are believed to indicate reasonably well the proportion of selected minority groups in the optometric profession. The East and West North Central, New England, and Pacific geographic divisions had higher ratios of active optometrists per 100,000 population than the United States average. The New England and Pacific States had the highest ratio, 11 per 100,000 each, with the lowest (6 per 100,000) being found in the South Atlantic division. 2U.S. Bureau of the Census. United States Census of Population: 1970. Detailed Characteristics. United States Summary. Final Report PC(1)-D1. U.S. Government Printing Office, 1973. Table 50. NUMBER OF ACTIVE OPTOMETRISTS, BY SEX AND BY AGE GROUP: DECEMBER 31, 1970 Number of Sex and age group active Percent . distribution optometrists Bothsexes sswis.ss vo unas 18,400 100.0 Male ................... 18,050 97.9 Female ,.. cvovwmus ss simmen 390 2.1 ANABES suv animes ss mumi 18,400 100.0 Lessthan25 years .....3.v5 220 1.2 25 48.yRArS: + + pam mn i Bw 6,730 36.3 2529 cus nnunsae si npER 1,230 6.6 BOBS civ contnmma vi mimmn 1,040 5.6 B5 BY wns sn mmmm ss ww 1,630 8.8 4044 . , .. nmin nn 2,830 15.3 45-64 years ............... 9,890 53.4 45-89 , , cs ssn niv ims ws 3,630 19.6 50:54 conv s nun aas i bus 3,140 17.0 55:89 suns ssn mum ena 1,990 10.7 60-64 ................. 1,140 6.1 65 yearsandover ............ 1,600 8.6 6569 ,onimnisnimmanm sens 720 3.9 POL inom bnammod vo ms 450 2.4 75andover ............. 430 2.3 Source: Based on data in: Mount, Henry S. and Hudson, Bettie L. Optometrists Employed in Health Services. DHEW Pub. No. (HSM) 73-1803. U.S. Government Printing Office, 1973. Note: Figures may not add to totals and subtotals due to in- dependent rounding. Among individual States, optometrist/population ratios ranged from a high of approximately 14 per 100,000 population in Illinois, Rhode Island, and South Dakota to a low of about 5 per 100,000 population in Maryland and Alabama. There appears to be a tendency for optometry students to locate in the areas where they went to school, as 8 out of 12 schools of optometry are located in three geographic divisions with large numbers of optom- etrists—the East North Central, Middle Atlantic, and Pacific divisions. (See Table 51.) Nearly all optometrists (96 percent) classify themselves primarily as being in general practice. The remaider were in the contact lens specialty (2 percent) or had major professional activities in developmental vision, visual train- ing, or other fields. (See Table 52.) It should be noted, however, that many optometrists have secondary activities in which they spend some time. Furthermore, there appears 86 to be an increasing trend toward specialization, as 9 percent of optometrists graduating in 1965-68 reported their major professional activity to be in an area other than general practice, while only 4 percent of those who graduated in 1961-64 reported such major activities. As Table 53 shows, about three-fourths of the total supply of optometrists were in solo practice in 1970, 13,600 out of 18,400. About one out of eight were in a partnership with other optometrists. Of the remainder, approximately 1,000 were employed by another optom- etrist. There appears to be a definite trend away from solo practice; the 1968 survey showed 68 percent of the optometrists who graduated in 1961-64 as being in solo practice, compared with only 46 percent of those who graduated in 1965-68. Over the past four decades, the number of active optometrists has more than doubled, increasing from 8,400 to 18,400 (See Table 54.) The largest part of the increase took place in the 1930-50 period, when the number grew by three-fourths from 8400 to 14,750 and the ratio of active optometrists to population rose from 6.8 per 100,000 to 9.8 per 100,000. However, during the decade of the 1950's, the ratio dropped, reaching 9.0 per 100,000 in 1960, and has remained relatively stable since that time, even though the number of optometrists increased some- what during this period, from 16,100 in 1960 to 18,400 in 1970. It should be noted that this analysis used historical data from the decennial censuses of population and the 1968 NCHS survey of optometrists. Supply estimates for inter- vening years between 1960 and 1968 were interpolated. Taken together, the historical series shows an increase in the ratio of active optometrists to population through 1950, a decrease in the ratio to the mid-1960’s, and a subsequent increase to 1968. In contrast to the series shown, the American Optomet- ric Association utilizes the Blue Book of Optometrists® as the source of its historical estimates of active optometrists. Taking actual counts of listings from this directory, the AOA assumes 90 percent of all optometrists listed in the Blue Book are active. The 90 percent figure was developed from various State studies of optometrists in the 1960's, and it was assumed that the same percentage could be applied nationally and to earlier historical data. Using this method, the AOA shows decreasing ratios of active optome- trists from 1950 to 1968 (11.8 optometrists per 100,000 population in 1950; 11.0 in 1960; and 9.3 in 1968). In evaluating this discrepancy, it should be noted that a number of optometrists may have been located in jewelry 3 American Optometric Association. Blue Book of Optometrists. St. Louis, Mo., The Association, Annual issues. Table 51. NUMBER OF ACTIVE OPTOMETRISTS AND OPTOMETRIST/POPULATION RATIOS, BY GEOGRAPHIC DIVISION AND STATE: DECEMBER 31,1970 Number of Resident population Rate per Division and State active July 1,1970 100,000 optometrists (in 1,000’s) population UNITED STATES ........... 18,400 203,805 9.0 NEWENGLAND .................. 1,330 11,873 11.2 CONREEHCUL « ¢ + sv v mics bagi on 260 3,039 8.6 MANE + oni ssissennrs mannose 110 995 11.1 Massachusetts . . ................ 720 5,699 12.6 New Hampshire . ................ 70 742 9.4 RADAGISIAAG.. 0 + + cv nha dk 5 nom oom or 130 951 13.7 VRIMONE vv vnin is v3 mwnnis ovum mnie 40 447 8.9 MIDDLE ATLANTIC ............... 3,420 37272 9.2 New Jersey . ................... 680 7,195 95 New York ..cuvinissnnnneenss oes 1,610 18,260 8.8 Pennsylvania. . ................. 1,140 11,817 9.6 SOUTH ATLANTIC ................ 1,940 30,773 6.3 Delaware . . . .. CEASE Ls ERG EE he 40 550 7.3 District of Columbia. . . ............ 70 753 9.3 FIOTHIR wis 4 su aimm@s o om mien n 500 6,845 7.3 GROIGIA «v4 ss vam Haid 6.8 summons es 260 4,602 5.6 Maryland +50 05 50m cwns ode owne 180 3,937 4.6 North Carolina . ................ 310 5,091 6.1 South Carolina . ................ 150 2,596 5.8 Virginia ..................... 27¢ 4,653 5.8 West Virginia. . ................. 150 1,746 8.6 EAST SOUTH CENTRAL . . ooo oon. 850 12,823 6.6 AldDama , : a nuiviv «iv nmmnis sou viw wa 180 3,451 5.2 Kentucky. .................... 240 3,224 7.4 Mississippi... ................. 130 2,216 59 Tennessee. . . ........... 20 8 BF 290 3,932 7.4 WEST SOUTHCENTRAL . ............ 1,370 19,396 7.1 Arkansas . .................... 150 1,926 7.8 Louisiana .................... 220 3,644 6.0 Oklahoma .................... 240 2,572 9.3 TEXAS vv wien is 020 mh BB or eck nn 760 11,254 6.8 EASTNORTHCENTRAL . ............ 4,190 40,367 10.4 BANOIS «of alas agi vv vv cin aes anna 1,620 11,137 14.5 Indiana ..................... 510 5,208 9.8 Michigan . .................... 700 8,901 7.9 ORIG i: sr mmmmamis main din « vwwwm 940 10,688 8.8 Wisconsin. . ................... 420 4,433 9.5 WEST NORTH CENTRAL. . ........... 1,670 16,367 10.2 JOWE Jovy vr mummies 58m T ome coun 330 2,830 11.7 RADNER fogs 4s s mE EE h 5 mmm imme » va 240 2,248 10.7 Minnesota . ................... 350 3,822 9.2 MISSOLIIE © 2% 4 oo mentions oooh m5 Mae 420 4,693 8.9 See footnotes at end of table. 87 Table 51. NUMBER OF ACTIVE OPTOMETRISTS AND OPTOMETRIST/POPULATION RATIOS, BY GEOGRAPHIC DIVISION AND STATE: DECEMBER 31, 1970—Continued Number of Resident population Rate per Division and State active July 1, 1970 100,000 optometrists (in 1,000’s) population WEST NORTH CENTRAL—Continued Nebraska . . . .................. 150 1,490 10.1 NorthDakota . ................. 70 618 113 SouthDakota , «vv ssnonnmsess wn 90 666 13.5 MOUNTAIN . . . comme s snmuwd 4.85 uw 720 8,345 8.6 Arizona... eee 130 1,792 23 Colorado . . ..... iii iii innnn 180 2,225 8.1 JIANO ysis 5s smmsinm +s sommmmin 3 0 pun 90 717 12.6 Montana ...cecuvesvrvsmnmess vim 90 697 12.9 Nevada . , csv umes vmwmmwsss nue 40 493 8.1 NewMeXiCo . ssn css vmnmesssvna 70 1,018 6.9 LA 70 1,069 6.5 Wyoming . . «oo titi eee eee eee 40 334 12.0 PACIFIC . ; : vsisaen ss nnagsne 2 sv Hu ® 2,950 26,589 11] ALASKA: ssn wds FREER ET Es BEES 20 305 6.6 California. . . ..... oii. 2,240 19,994 11.2 Hawaii. . . ......... 60 774 7.8 Oregon : s suvwmn s vamos ss vows 270 2,102 12.8 Washington ..acws sssimsms 0 poem 350 3,414 10.3 Source: Active optometrists: Based on data in: Mount, Henry S. and Hudson, Bettie L. Optometrists Em- ployed in Health Services. DHEW Pub. No. (HSM) 73-1803. U.S. Government Printing Office, 1973. Population: U.S. Bureau of the Census. Current Population Reports. Series P-25, No. 468. Note: Figures may not add to totals and subtotals due to independent rounding. stores in earlier years ana consequently may not have been reported as optometrists in the censuses of population. This might account in part, for variations between the respective census and AOA series reflecting possible census underesti- mates of active optometrists during this period. In line with other historical series presented in this report, trend estimates presented for active optometrists are generally consistent with series shown in other publications of the Department of Health, Education, and Welfare. However, the problem of inconsistencies between the sources of information is being studied more intensively, in order to isolate other factors which may have accounted for the discrepancies. Such an examination may result in a subsequent revision of the historical series provided in this chapter. Although there was relatively slow growth in active optometrists in the 1960’s, enrollments in optometry schools began to increase sharply during this period. Over 88 the last decade, total enrollment in optometry schools increased by more than 160 percent, from 1,181 in the 1961-62 academic year to 3,094 in 1971-72. (See Table 55.) The number of graduates more than doubled, from 321 in 1961-62 to 683 in 1971-72. Two new schools were opened during the decade, in Alabama and New York. PROJECTIONS OF THE SUPPLY OF OPTOMETRISTS TO 1990 Projections of the supply of active optometrists to 1990 are presented here, using several different assumptions as to graduate input. METHODOLOGY AND ASSUMPTIONS Estimates of the number of active optometrists for 197190 were calculated using essentially the same methodology used to estimate the December 31, 1970 v Table 52. NUMBER OF ACTIVE OPTOMETRISTS, BY MAJOR PROFESSIONAL ACTIVITY: DECEMBER 31,1970 Table 54. TREND IN NUMBER OF ACTIVE OPTOMETRISTS AND OPTOMETRIST/POPULATION RATIOS: SELECTED YEARS 1930-70 Number of i ; di . Percent . Major professional activity aciive distribution Number of Resident Active optometrists Year active population? optometrists optometrists’»2 | (in 1,000%) | Per 100,000 population All activities . . ........ 18,400 100.0 General practice . . « « «+... 17,800 96.5 1930°. . .. 8,377 122,775 6.8 Contactlenses . . « + + « + + vu 5» 370 2.0 1940° "i 10,450 131,669 7.9 Visual training . . . . . . .. CL 60 0.3 1950% . . . . 414,750 150,697 9.8 Developmental vision . . .. ... 90 0.5 1960 .... $ 16,081 179,323 9.0 Low vision aids .......... 10 (1) 1963 .... 16,700 189,922 8.8 Industrial vision . . ........ 40 0.2 1965 ; .0 5 17,200 194,578 8.8 Other ws. s smswmn s3 smu 90 0.5 1967 . .xw 17,900 198,492 9.0 1968 .... 18,426 200,415 9.2 1 Less than 0.05 percent. 1970 . ... 618,400 205,056 9.0 Source: Based on data in: Mount, Henry S. and Hudson, Bettie L. Optometrists Employed in Health Services. DHEW Pub. No. (HSM) 73-1803. U.S. Government Printing Office, 1973. Note: Figures may not add to totals due to independent rounding. Table 53. NUMBER OF ACTIVE OPTOMETRISTS BY TYPE OF PRACTICE: DECEMBER 31, 1970 Number of Type of practice active Percent . distribution optometrists Alltypes . ............ 18,400 100.0 Solopractice. « swum 5 4 + sun 13,560 73.5 Partnership. . swiv nme 35 vs 2,190 11.9 Group practice . i .s.ce3 2959 530 29 Government . .....c.0 000 40 0.2 For optometrist . . . ........ 960 5.2 For ophthalmologist. . . ...... 130 0.7 Forotherphysician . . . « . . «4 40 0.2 Firm or corporation. . ....... 630 3.4 Nonprofit organization/institution. 200 1.3 Other « .. » covivinss waa 170 0.9 Source: Based on data in: Mount, Henry S. and Hudson, Bettie L. Optometrists Employed in Health Services. DHEW Pub. No. (HSM) 73-1803. U.S. Government Printing Office, 1973. Note: Figures may not add to totals due to independent rounding. ! For 1930, data are for civilian gainful workers; for 1940-60, data cover experienced civilian labor force; figures for 1963-70 cover all licensed optometrists in the United States. 2 Data for 1930-60 are as of April 1, data for 1963-70 are as of December 31. 3 Excludes data for Alaska and Hawaii. The American Optometric Association has estimated active optometrists at 17,796, which would yield 11.8 per 100,000 population. 5 The American Optometric Association has estimated active optometrists at 19,688, which would yield 11.0 per 100,000 population. 6 The 1970 Decennial Census of Population provides a figure of 17,219 active optometrists, which would yield 8.4 per 100,000 population, Source: 1930, 1940 active optometrists: Kaplan, David L. and Casey, M. Claire. Occupational Trends in the United States 1900 to 1950. Bureau of the Census Working Paper No. 5. U.S. Department of Commerce, 1958. 1950, 1960 active optometrists: U.S. Bureau of the Census. United States Census of Population: 1960. Detailed Characteristics. United States Summary. PC (1) - 1D. U.S. Government Printing Office, 1963. 1963-67, 1970 active optometrists: BHRD, Division of Man- power Intelligence. 1968 active optometrists: Mount, Henry S. and Hudson, Bettie L. Optometrists Employed in Health Services. DHEW Pub. No. (HSM) 73-1803. U.S. Government Printing Office, 1973. 1930-60 population: U.S. Bureau of the Census. Statistical Abstract of the United States 1966. U.S. Government Printing Office, 1966. 1963-70 population: U.S. Bureau of the Census. Current Popu- lation Reports. Series P-25, No. 475. Table 55. TREND IN NUMBER OF SCHOOLS, ENROLLMENTS, AND GRADUATES FOR OPTOMETRY SCHOOLS: ACADEMIC YEARS 1960-61 THROUGH 1971-72 Academic | Number of Total First-year Graduates year schools enrollment | enrollment 1960-61. . 10 1,118 401 321 1961-62. . 10 1,181 427 295 1962-63. . 10 1,284 466 347 1963-64. . 10 1,372 516 336 1964-65. . 10 1,547 593 377 1965-66. . 10 1,745 643 413 1966-67. . 10 1,882 669 481 1967-68. . 10 1,962 646 477 1968-69. . 10 2,203 771 441 1969-70. . 1 2,488 786 445 1970-71. . 11 2,831 884 528 1971-72. . 12 3,094 906 683 Source: 1960-61 through 1963-64: Pennell, Maryland Y. and Delong, Merrill B. Optometric Education and Manpower. Journal of the American Optometric Association 41: 941-956, November 1970. 1964-65 through 1971-72: Bernstein, Stuart. Optometric Ed- ucation Statistics. Journal of the American Optometric Association 43: 869-872, August 1972. figure (described earlier). Data on graduates of optometry schools for 1971 were obtained from school reports on FY 1972 capitation grant applications; these applications also provided estimates of projected enrollments and graduates through 1974-75. Graduate data for 1976-78 were com- puted from the number of firsi-year students reported 4 years earlier, utilizing an attrition rate of 10 percent (in both the basic and the alternative supply projections), based on the experience of recent years. Thus, 90 percent of entering optometry students are expected to graduate 4 years later.* Although the projected estimates of supply would differ according to the attrition rates used, slight variations in the attrition patterns of optometric students have only a minor impact on the overall supply estimates. Under the basic methodology, for example, if the attrition rate used was 9 percent, there would be only about 200 additional graduates over the 20-year period. Separation rates (i.e., death and retirement rates) used in the basic methodology and in the alternative approaches were largely based on age-specific rates for males developed by the Department of Labor.’ Unlike physicians, as “Pennell, Maryland Y. and Delong, Merrill B. Optometric Education and Manpower. Journal of the American Optometric Association 41: 941-956, November 1970. Fullerton, Howard N. A Table of Expected Working Life for Men, 1968. Monthly Labor Review 94: 49-55, June 1971. 90 v indicated earlier, there was no evidence to suggest that optometrists, on the average, tend to live longer than males in the general working population. For this reason age- specific mortality rates developed by the Department of Labor were applied in this report to the optometrist population. In contrast to the mortality experience, however, infor- mation does exist that suggests variations in retirement patterns between optometrists and all working males. For example, in comparing total male labor force participation rates with age-specific proportions of optometrists that are active (1968 NCHS Survey data), it was found that, in general, a higher proportion of optometrists were ‘active’ for each age group. Based on these findings, published age-specific retirement rates for all male workers were adjusted to better reflect the apparent experience, indicated for optometrists. Over the projection period use of the adjusted series reduced estimated retirements of optome- trists 25 percent below that obtained by not undertaking such a modification. (See Appendix A for further detail on assumptions, rationale, and methodology utilized to esti- mate losses to the profession resulting from deaths and retirements.) The most critical assumption underlying the future supply of optometrists is very clearly the future enrollment in schools of optometry. As indicated earlier, optometry enrollments have increased rapidly since the early 1960's. Current Federal legislation encourages continued increases in enrollment in optometry schools to 1974-75, and therefore a concomitant increase in graduates to 1978. In projecting the total supply beyond 1978, certain assump- tions were made as to the output of graduates of optometry schools after that period. The assumption utilized to develop the “basic” projec- tion of optometrists to 1990 assumes an increase in first-year enrollment after 1975 similar to the increase achieved by the schools prior to the initial Federal legislation. The assumption was made that first-year enroll- ment beginning in the 1975-76 academic year would increase annually at a rate equivalent to that experienced in the 12-year period prior to enactment of the Health Professions Education Assistance Act of 1963 (about 3.4 percent annually). This period was adopted as a reasonable estimate for enrollment growth in the absence of massive Federal programs targeted specifically at increasing enroll- ment in optometric schools. Two alternative assumptions as to graduate additions were also made. First, under a “low” assumption, the number of graduates after 1978 was held constant. The assumption was that there would be no further increase in first-year enrollment after 1974-75 (following expiration of the Comprehensive Health Manpower Training Act of 1971). Public and private support would continue in such a form to maintain the level of enrollment achieved under the Act but not to further increase the level. The second or “high” estimate assumes that the rate of increase in first-year enrollment beyond 1974-75 would be midway between the average rate of increase in first-year enrollment experienced by existing optometry schools from 1964-65 to 1971-72 (excluding the two new schools opened during this period) and the average annual rate of increase under the basic methodology. Under this alterna- tive, an average annual increase in first-year enrollment of 5.4 percent was assumed. This assumption, in contrast to that in the basic methodology, reflects increases in enroll- ment greater than that experienced in the 12-year period prior to the initial legislation. However, the rate of increase would still be less than the increases achieved under legislation since 1963. (See Table 56.) The projected number of enrollees can be interpreted in terms of an enrollee-per-school measure. The reasonableness of the projections, consequently, can be evaluated by examining the implications of this measure. Under the basic methodology, an increase is projected in first-year enroll- ment per schocl from 80.4 in 1970-71 to 127.8 in 1986-87 (a 59-percent increase over a 16-year period). It should be noted that first-year enrollment in 1960 for 10 schools averaged 40 students per school (all schools being at normal enrollment for that time, having classes at all levels of the educational program). Thus an increase of 100 percent in first-year enrollment per school took place in the 1960's, considerably greater than the projected increase. If one excluded from this analysis the school at the University of Alabama, which opened in 1969-70, this increase in first-year enrollment in existing schools during the 1960’s would even be somewhat higher. In evaluating these changes, it is difficult to determine whether the schools in existence in 1960 were operating at full capacity at that time or whether the projections imply full capacity in the future. It should be noted, however, that modifications in curricula or the utilization of existing facilities over a longer period of time during the year could take place, a situation which would permit the schools to serve more students without necessarily increasing plant size. Table 56. FIRST-YEAR ENROLLMENTS AND GRADUATES IN OPTOMETRY SCHOOLS UNDER BASIC AND ALTERNATIVE ASSUMPTIONS: ACTUAL 1970-71 AND 1971-72; PROJECTED 1972-73 THROUGH 1989-90 First-year enroliment Graduates Academic year Alternative Alternative Basic assumptions Basic assumptions methodology methodology Low High Low High 197071 . oc vv ve vn 884 884 884 528 528 528 197172 & i ihn vn vv vn 906 906 906 683 683 683 1972-73 i i inner vn 990 990 990 691 691 691 1973-74 is ommnme us 1,005 1,005 1,005 775 775 735 1974-75 ..: vio nmww vs us 1,027 1,027 1,027 817 817 817 VO75-78 . ci smi vs a 1,062 1,035 1,082 891 891 891 1976-77 . . oo... 1,098 1,035 1,140 904 904 904 1977-78... .......... 1,135 1,035 1,202 924 924 924 1978479 us smmume «5 00 1,174 1,035 1,267 956 930 974 1979-80 ...:i:s50 005 v5 1,214 1,035 1,335 988 930 1,026 1980-81 ...:.:cnmwa vn 1,255 1,035 1,407 1,022 930 1,082 1981-82 ..:i:iivivivewn 1,298 1,035 1,483 1,057 930 1,140 TJ982+83 . i. ivi vn 1,342 1,035 1,563 1,093 930 1,202 1983-84 ............. 1,388 1,035 1,647 1,130 930 1,266 1984-85 ............. 1,435 1,035 1,736 1,168 930 1,335 198586 wus sv mmmus v5 © 1,484 1,035 1,830 1,208 930 1,407 198687 vs so muwnwens 1,534 1,035 1,929 1,249 930 1,482 1987-88 ..: is wawsma rs - - — 1,292 930 1,562 1988-89 ...:co0www sss - — — 1,336 930 1,647 198990 . ...i:svwiwe sss -_ - — 1,381 930 1,736 Source: 1970-71 through 1974-75: Applications for capitation grants submitted to BHRD. 91 PROJECTION FINDINGS The projection developed using the basic methodology results in a total gross graduate input of 20,093 for the 1970-90 period. The low alternative projects a total gross graduate input of 17,373, and the high alternative, 22,072. The high and low alternatives consequently produce total gross graduate inputs approximately 4,700 graduates apart. However, it is essential to note that if Federal support should continue at the high levels of the late 1960’s and early 1970's and the projected rate of increase were to match the 1967-72 experience (about 7.5 percent a year), a total gross graduate input of 24,528 would result for the 1971-90 period. Using the basic methodology, the supply of active optometrists is projected to grow from 18,400 in 1970 to 21,800 in 1980, and to 28,000 in 1990. (See Table 57.) The growth in active optometrists is thus projected at 3,400 between 1970 and 1980, a somewhat larger increase than the 2,300 gain from 1960 to 1970. However, in percentage terms, this is only slightly larger than the increase experi- enced in the 1960 to 1970 period—18 percent as compared with 14 percent. Between 1980 and 1990, growth is projected to be more rapid—a 6,200 increase, or 28 percent. The ratio of active optometrists to population, which was relatively constant between 1960 and 1970, is pro- jected to begin to rise in the years ahead. The ratio is projected at 9.6 per 100,000 population in 1980, and 11.2 per 100,000 in 1990; this compares with a ratio of 9.0 in 1970. Under the high alternative projection, the supply of active optometrists is projected to increase to 21,900 in 1980 and to 29,900 in 1990. This represents a 19-percent increase between 1970 and 1980, and a 36-percent increase between 1980 and 1990. Under the low alternative, the supply of active optometrists is projected at 21,700 in 1980 and 25,300 in 1990. The percentage increase would be 17 percent in the 1970-80 period and 18 percent in the 1980-90 period. The supply projection of active optometrists in 1990 under the basic methodology yields a supply that is 2,700 or 11 percent more than the low estimate, and 1,900 or 6 percent fewer than the higher estimate. The low alternative yields 6,900 (38 percent) more optometrists in 1990 than in 1970, while the high alternative projects 11,500 or 62 percent more optometrists than in 1970. Under the basic methodology, the supply is projected to increase by 9,600 or by 52 percent. The low alternative yields a population ratio of 10.1 optometrists per 100,000 in 1990, compared with 11.9 per 100,000 in the high estimate and 11.2 per 100,000 under the basic methodology. Table 57. SUPPLY OF ACTIVE OPTOMETRISTS AND OPTOMETRIST/POPULATION RATIOS, USING BASIC METHODOLOGY AND ALTERNATIVE ASSUMPTIONS: ACTUAL 1960 AND 1970; PROJECTED 1975-90 Projection series 1960 1970 1975 1980 1985 1990 Number of active optometrists Basic methodology . ...................... 16,100 18,400 19,700 21,800 24,500 28,000 Alternatives: LOW suuwd is smmmimmn se vonamn is men sn 16,100 18,400 19,700 21,700 23,600 25,300 High 16,100 18,400 19,700 21,900 25,100 29,900 Rate per 100,000 population’ Basic methodology . ...... ............... 8.9 9.0 9.2 9.6 10.2 11.2 Alternatives: Low. oe 8.9 9.0 9.2 9.6 9.9 10.1 High... 8.9 9.0 9.2 9.6 10.5 11.9 ! Resident population as of July 1 for 50 States and the District of Columbia. Source: 1960 active optometrists: Bureau of the Census. United Census of Population: 1960. Detailed Characteristics. United States Summary. PC(1)-1D. U.S. Government Printing Office, 1963. 1970 active optometrists: Based on data in: Mount, Henry S. and Hudson, Bettie L. Optometrists Employed in Health Services, DHEW Pub. No. (HSM) 73-1803. U.S. Government Printing Office, 1973. Population: U.S. Bureau of the Census. Current Population Reports, Series P-25, Nos. 468, 477, and 483. 92 Chapter 7 « PHARMACISTS Data on pharmacists cover all active pharmacists in the 50 States, the District of Columbia, Puerto Rico, and the Virgin Islands. Those few U.S. pharmacists who may be overseas are excluded. Although current estimates include both Federal and non-Federal pharmacists, historical data provided for years prior to 1950 relate only to civilian workers. The primary sources of information on active phar- macists used here are: the 1966 Survey of Pharmacists conducted by the National Center for Health Statistics (NCHS); the 1970 Licensure Statistics Census of the National Association of Boards of Pharmacy (NABP); and censuses of population. The 1966 NCHS Survey and the NABP licensure statistics provide the basic data for most of the estimates presented. Although data from the NABP Census are not consistent with data from the censuses of population, trend data on active pharmacists from NABP appear to be internally consistent. Nevertheless, historical trends shown represent a combination of both estimates and counts and should be used with caution. Individual tables provide detailed explanations and sources. The Bureau of Health Resources Development (BHRD) has contracted with the American Association of Colleges of Pharmacy (AACP) to make recommendations on how best to improve the data base and is now supporting the AACP in improving the data on pharmacists. The AACP- BHRD survey of all active pharmacists in the United States, which began in September 1972 and will continue through mid-1974, is being conducted through State licensing boards. In addition to basic demographic items, detailed data are being collected on principal form of employment, type of activities, equipment used, auxiliary utilization, and persons served. Upon completion of data collection, this survey will become the most recent data base for the profession. Survey results for several States have already been published. CURRENT CHARACTERISTICS AND TRENDS In 1970, there were approximately 129,300 pharmacists actively engaged in practice in the United States. Phar- macists are a relatively young group, with nearly two out of three under 50 years of age and thus expected to continue in the profession for at least the next 15 years. Over 40 percent of all pharmacists in 1970 were less than 40 years old. This relatively young age distribution reflects the increasing enrollments in schools of pharmacy over the past decade. (See Table 58.) Compared with other health professions (except regis- tered nurses), pharmacy has a high proportion of women. 93 According to the National Association of Boards of Pharmacy, as seen in Table 58, 11,700, or 9 percent, of active pharmacists were women. This proportion is ex- pected to rise in the future as a result of the recent increases in enrollment of females in pharmacy schools. The American Journal of Pharmaceutical Education shows that 24 percent of pharmacy students in 1971 were women." Blacks comprised slightly more than 2 percent of active pharmacists in 1970, according to data from the 1970 Population Census.? The proportion of persons of Spanish heritage was also relatively small, slightly less than 2 percent. Current and more comprehensive data on racial- ethnic distribution will not be available until results of the current AACP-BHRD survey are known. In 1970, pharmacists were disproportionately located in the Northeast—the Middle Atlantic and New England divisions had the highest ratios, 76 per 100,000—with the lowest (54 per 100,000) being found in the South Atlantic division. (See Table 59.) Among individual States, pharmacist/population ratios ranged from a high of 85 per 100,000 population in Pennsylvania and Massachusetts to a low of 27 per 100,000 in Hawaii. Unlike other health fields, pharmacists are not found in greatest numbers in geographic divisions where there are the most schools of pharmacy. The Middle Atlantic division, which has the highest ratio of active pharmacists to population, and the South Atlantic, which has the lowest ratio, have the same number of schools of pharmacy —12. More than four out of five active pharmacists in 1970 were working in community pharmacies, with 35 percent being owners or partners and 47 percent employees. Slightly fewer than 1 in 10 active pharmacists were employed in hospital pharmacies. Four percent were in manufacturing and wholesale activities, and 5 percent were in teaching, government, or other activities. (See Table 60.) Over the past four decades, the number of active pharmacists rose by about 45,000. or an increase of 50 percent. However, the ratio of active pharmacists to population decreased during this period from 68 per 100,000 in 1930 to 62 per 100,000 in 1971. (See Table 61.) ! American Association of Colleges of Pharmacy. Report on Enrollment in Schools and Colleges of Pharmacy, First Semester, Term, or Quarter, 1971-72. American Journal of Pharmaceutical Education 36: 120-130, February 1972. 2U.S. Bureau of the Census. United States Census of Population: 1970. Detailed Characteristics. United States Summary. Final Report PC(1)-D1. U.S. Government Printing Office, 1973. Table 58. NUMBER OF ACTIVE PHARMACISTS, BY AGE GROUP AND SEX: DECEMBER 31, 1970 Both sexes Male Female Age group Percent Percent Percent Numb Co mbes distribution Number distribution Number distribution All ages’ PP 129,300 100.0 117,620 100.0 11,670 100.0 Lessthan25vears : vw osson ss sanmiss se 3,860 3.0 3,150 27 710 6.1 2549968 suv si mE mE EE Es Ema sb 79,610 61.6 70,930 60.3 8,680 74.4 2520 chs s HET ERE AE REESE 21,270 16.4 17,910 15.2 3,360 28.8 BOB umuwit i mmimmmin se mmm» 31,630 24.5 28,470 24.2 3,160 27.1 40-49 . LL. eee eee 26,720 20.7 24,560 20.9 2,160 18.5 50-64 years uci nannma ss ums ey 34,660 26.8 32,880 28.0 1,780 15.3 S059 suum iss wammnd ss Wa muds» 8 22,170 17.1 20,950 17.8 1,220 10.4 60-64 . . eee 12,500 9.7 11,930 10.1 570 4.8 65yearsandover . ...... ieee. 11,150 8.6 10,650 9.1 500 4.3 B56 uum is rom nmEE ts HE EEE EE 5,770 4.5 5,520 4.7 260 2.2 F094 ;vviv sss mmwnwmis ss BEBE Ens 4 3,260 23 3,110 2.6 150 1.2 75nd Over , oo wnwmms sa simmun sos 2,120 1.6 2,020 17 100 0.8 ! Includes active pharmacists in 50 States, District of Columbia, Puerto Rico, and the Virgin Islands. Source: Total active pharmacists: National Association of Boards of Pharmacy. 1971 Proceedings. Licensure Statistics and Census of Pharmacy. Chicago, The Association, 1972. Age and sex distribution based on data in: Reinhart, George R. Pharmacy Manpower. Public Health Service Pub. No. 1000-Series 14 - No. 2. U.S. Government Printing Office, 1969. Note: Figures may not add to totals and subtotals due to independent rounding. While there was relatively slow growth in the supply of active pharmacists in the 1960’s, enrollments in pharmacy schools began to increase sharply. In the last decade, total enrollment increased by 77 percent, from 10,730 in the 1962-63 academic year to 18,956 in 1972-73. The annual number of graduates has increased by more than one-third, from 3,728 in 1962 to 4,858 in 1972. (See Table 62.) PROJECTIONS OF THE SUPPLY OF PHARMACISTS TO 1990 Projections of the total supply of active pharmacists are shown here under several assumptions as to graduate input. In addition, projections of the supply of active pharmacists are presented on the basis of sex and full-time equiva- lencies. METHODOLOGY AND ASSUMPTIONS Estimates of the number of active pharmacists for 1971-90 take into account the estimates of active phar- macists (by age) as of January 1, 1971, new pharmacy graduates, and attrition to both groups. Beginning with the base-year age distribution of pharmacists, new graduates were added year by year to those pharmacists active as of January 1, and age-specific separation rates were applied to the number of active pharmacists each January 1, including new graduates. Estimated “losses” (death and retirements) were then subtracted, by age group, from the active pool, with the pool being aged by 1 year each time. Data on graduates of pharmacy schools for 1971 were obtained from school reports on FY 1972 capitation grant applications. These applications also provided estimates of projected third-to-last-year enrollment through 1974-75. (Third-to-last-year enrollment was used in order to stand- ardize pharmacy programs of varying lengths.*) Graduate ‘data were computed for both the basic methodology and the alternative supply assumptions up to 1978 from the number of third-to-last-year students reported 3 years earlier. 3Fullerton, Howard N. A Table of Expected Working Life for Men, 1968. Monthly Labor Review 94: 49-55, June 1971. 45ee footnote 3, Chapter 2. 94 Table 59. NUMBER OF ACTIVE PHARMACISTS AND PHARMACIST/POPULATION RATIOS, BY GEOGRAPHIC DIVISION AND STATE: DECEMBER 31, 1970 Number of Resident popula- Rate per Division and State active tion July 1, 100,000 pharmacists 1970 (in 1,000’s) population Allocations . . . ..... oven... 129,300 206,579 62.6 United States. «+ s vow wn s os simwmma ss 128,200 203,805 62.9 NEWENGLAND: .c..vvsenmatssmummmds 8,990 11,873 75.7 Connecticut . . . ... viii ii 2,450 3,039 80.5 MAING , s vuowpms sama wwe s wwsnmewmss 470 995 46.7 Massachusetts «« « s ssw wns 3 2.4 vw & #2 : 4,840 5,699 84.9 New Hampshire . ............. 5d 330 742 45.0 Rhodelsland ................ ..... 700 951 73.7 VEMIORL + vv wnss vrmemsn gs pr oEee sy 210 447 45.9 MIDDLE ATLANTIC . ss vewinin sonwwmm ess 28,300 37,211 75.9 New Jersey ..vwa svsnmsms nun m@mms» 4,330 7,195 60.1 NewYork .ccons wrmnasme ss mmm ss 13,930 18,260 76.3 Pennsylvania cc cv san iims ss stn mimws » 10,050 11,817 85.0 SOUTH ATLANTIC ........ iii. 16,500 30,772 53.6 DelaWale vavsws svnsmmis sn pummmess 250 550 45.1 District of Columbia , a3 sss sss nwsmis 4 2 620 753 82.1 Florida ; s ves nas spss aE s nna nm@e & 3 4,290 6,845 62.7 Georgia ..invissnnsn@atsmmaimim vd 2,870 4,602 62.3 Maryland . . . o.oo ie 2,220 3,937 56.4 North Carolina .................... 2,040 5,091 40.0 South Caroling +... so ssnizis sss swims s 1,520 2,596 58.4 VIrginld + osneamsvsasmnssnnasmeds 1,990 4,653 42.7 West Vinginlas so wis sasnmassssnwamas b 720 1,746 41.2 EASTSOUTHCENTRAL ................ 7,420 12,823 57.3 Alabama . ............ 0... 2,120 3,451 61.5 Kentucky. s vom ss sommes sain mises s 1,620 3,224 50.2 MISSISSIPPI ss svn ra imRBR ss RE amER +» 1,130 2,216 51. Tennessee ...s.vvovvvevsnssmeness 2,550 3,932 64.9 WESTSOUTH CENTRAL . ............... 11,860 19,397 61.1 AIRANSES + sv vv ws mn smes ¢ 3 SH simm sess 1,010 1,926 52.5 Louisiana. sown s cd sameness shu mwas 3% 2,350 3,614 64.4 Oklahoma ........... 0.0... 2,120 2,572 82.5 TEXAS + c von ommn snmp nies ss mvmmm ss » 6,380 11,254 56.7 EASTNORTHC CENTRAL .. coon s sons muimnss 23,720 40,368 58.7 HHNOIS, « so msm nwa ss amEmma sa 6,020 11,137 54.1 INGIANA. woo nmes sma iho.sn na Ragheb 8 3,120 5,208 59.9 Michigan . . ........ 0. i... 5,640 8,901 63.4 Ohio oii eee 6,550 10,688 61.3 WISEONEIRY. +. yn nic vir mewn vs my apgaies ox 2,390 4,433 53.8 WEST NORTH CENTRAL , vous ts av wows ss 9,680 16,367 59.1 Jowa: i shes rue mE rs He be 1,520 2,830 53.6 Kansas ..onecisvensmisnmusnmiis 1,440 2,248 63.8 Minnesota. + a cvs s sass s samp nm £4 3 2,310 3,822 60.4 95 Table 59. NUMBER OF ACTIVE PHARMACISTS AND PHARMACIST/POPULATION RATIOS, BY GEOGRAPHIC DIVISION AND STATE: DECEMBER 31, 1970—Continued Number of Resident popula- Rate per Division and State active tion July 1, 100,000 pharmacists 1970 (in 1,000’) population WEST NORTH CENTRAL —Continued MISSOUI] 53s hmmmn ss RAE BE ess ama 2,600 4,693 555 Nebraska . . ......s.............. 1,030 1,490 68.9 North Dakota . ................... 340 618 545 SouthDakota .................... 450 666 67.3 MOUNTAIN . ; c comsvawsssmmnn rss women 5,440 8,345 65.2 Arizona . LL... eee 1,060 1,792 59.1 Colorado . . ..................... 1,600 2,225 7.9 Maho . . cov vss vs srr rer see 510 717 71.1 Montana . ...................... 420 697 60.8 Nevada ..................0.0.... 340 493 68.0 NeW MeRICO: + 5 » suimms vss REE FE Ls 06 570 1,018 55.9 Utah: omwin ss psa sss wo BmE es « as 730 1,069 67.9 WYOMING cu is + s sams sss ans a® s4 8 bine 220 334 64.4 PACIFIC «5s. vomm min vv simmonnins v2 wa 16,330 26,589 61.4 Alaska ............. i... 100 805 31.8 California. . . .................... 12,000 19,994 60.0 Hawaii. . . ...................... 210 774 26.6 Oregon von si sans ss nmaEw om +8 0.8 1,390 2,102 66.1 Washington wu. : sssss sis bbu@GEss & 8 nn 2,640 3,414 77.3 PUertoRICO. win vm ss samme ss maama 55 5a 1,030 2,712 37.8 Virginlslands . ..................... 30 62 41.9 Source: Active pharmacists: National Association of Boards'of Pharmacy. 1971 Proceedings. Licensure Statistics and Census of Pharmacy. Chicago, The Association, 1972. Population: U.S. Bureau of the Census. Current Population Reports. Series P-25, No. 468. United States Census of Population: 1970. Number of Inhabitants. Puerto Rico, Virgin Islands. PC(1)-53A, 55A. U.S. Government Printing Office, 1972. Note: Figures may not add to totals and subtotals due to independent rounding. In order to incorporate into the projections the trend toward increasing enrollment of females in pharmacy schools, male and female third-to-last-year students were independently projected by simple linear regression from 1960-71 AACP enrollment figures to 1988. The derived proportions of male and female students were applied to distribute total third-to-last-year enrollment figures accord- ing to sex. Based on the experience of recent years, differential attrition rates of 16.3 percent for males and 13.7 percent for females were utilized to generate respec- tive male and female graduate components to 1990. Under this attrition assumption, 83.7 percent of the male and 86.3 96 percent of the female third-to-last year-students are ex- pected to graduate 3 years later.’ Although projected estimates of supply would vary with different attrition rates, slight variations in the attrition patterns of pharmacy students would appear to have a negligible impact on the overall supply estimates. However, were an undifferentiated (by sex) 10 percent attrition rate applied to third-to-last-year students, under the basic SProgress Report, Pharmacy Manpower Information Project. American Journal of Pharmaceutical Education 36: 396-401, August 1972. Table 60. NUMBER OF ACTIVE PHARMACISTS, BY TYPE OF EMPLOYER: DECEMBER 31,1970 Number of Type of employer active Percent . 1 | distribution pharmacists ALYpes « + 2 sommes me voame 129,300 100.0 Community pharmacy owner or partner . . ..... ove. 45,890 35.5 Community pharmacy employee . . . 60,510 46.8 Hospital pharmacy ........... 11,840 9.2 Manufacturing and wholesale . . . .. 4,750 3.6 Teaching, government, and other . . . 6,310 4.9 ! Includes active pharmacists in 50 States, District of Columbia, Puerto Rico, and Virgin Islands. Source: National Association of Boards of Pharmacy. 1971 Proceedings. Licensure Statistics and Census of Pharmacy. Chicago, The Association, 1972. methodology used in this report, an additional 8,000 graduates could be expected over the 20-year projection period. Also, graduate supply would be affected somewhat by the assumed increase in the proportion of female third-to-last-year students (to 32 percent in 1987-88), since a continuing lower attrition rate for females is anticipated. But the differences, as presently seen, are small. Under the basic methodology, for example, if the proportion of female third-to-last-year students were maintained at 24 percent (the 1970-71 rate), and the above differential attrition rates were observed, a decrease of only about 500 graduates would be expected over the projection period. Separation rates used in the basic methodology and alternative approaches were derived from age-specific rates for males developed by the Department of Labor® and from unpublished data for women in the labor force developed by the Bureau of Labor Statistics. These age- specific separation rates are for the general labor force. Although separation patterns are not currently available for pharmacists, it should be noted that their experience may not be identical with that of men and women in the general labor force. Male pharmacists, for example, may tend to stay in the labor force longer than the general population. The death rate of the general population was assumed to be representative of that of pharmacists. A brief literature search for this group uncovered no empirical evidence suggesting longer life. spans than the general population. However, to the extent that life expectancy of pharmacists may be longer than the national average, the death rates 6 Fullerton, Howard N. op. cit. 565-118 O - 74 - 8 97 used here somewhat overstate losses to the profession. Similarly, if male pharmacists’ retirement patterns were lower than those of the total labor force, then the projected supply of active pharmacists would be understated some- what. For example, if the retirement rates of male pharmacists more closely approximate those of opto- metrists (about 50 percent lower than the general labor force for those over 50 years of age), the projected total active supply of pharmacists would increase by nearly 6,200 for 1980 and 6,500 for 1990 under the basic methodology—to 152,300 and 186,400 respectively. But studies substantiating such a trend are lacking. Indeed, there is evidence suggesting that the retirement patterns of male pharmacists may more closely approximate those of the general labor force; the proportion of pharmacists em- ployed in community pharmacies (those who are probably more representative of the general labor force) is increasing, while the proportion of self-employed pharmacists, those more likely to retire at a later age, is decreasing. This observation and its implications are reinforced by a comparison between data from the 1960 and 1970 Census of Population showing the proportion of pharmacists as private wage and salary workers to have increased by about 12 percent, while self employed pharmacists dropped by about 13 percent. Although no definitive data exist on the separation or reentry patterns of female pharmacists, the separation rates presently used for females may somewhat underestimate losses. Allowing a 7-percent higher separation rate of females would decrease the total active supply of females shown in Table 66 by about 900 for 1980 and 2,200 for 1990, under the basic methodology, to 19,800 and 33,000 respectively. The overall proportion of females in the total active supply, however, is only slightly affected. The basic determinant of the future supply of phar- macists is very clearly the enrollment in colleges of pharmacy. As indicated earlier, pharmacy enrollments have increased rapidly since the 1960's, and current legislation encourages continued increases in enrollment in pharmacy schools to 1974-75, and thus a concomitant increase in graduates to 1977. In projecting the total supply to 1980 and 1990, the basic assumptions relate entirely to the output of graduates of pharmacy schools after 1977. The basic projection methodology assumes an increase in third-to-last-year enrollment after 1974-75 that would be similar to the increase achieved by the schools prior to the initial Federal legislation. The assumption was made that third-to-last-year enrollments beginning in 1975-76 would increase annually at a rate equivalent to that experienced in the 6-year period prior to enactment of the Health Professions Education Assistance Act of 1963 (about 1.5 percent annually). This period was adopted as a reasonable approximation of enrollment growth that might occur Table 61. TREND IN NUMBER OF ACTIVE PHARMACISTS AND PHARMACIST/POPULATION RATIOS: SELECTED YEARS 1900-71 Number of Resident Active pharmacists Year active population? per 100,000 pharmacists! »2 (in 1,000’s) population 19002. 46,200 75,995 60.8 19102. Le 54,300 91,972 59.0 1920. 64,200 105,711 60.7 19303. 83,800 122,775 68.2 HOT 1-0 in sini iis 008 ur shin £37 got Bonito 82,600 131,669 62.7 19503. 489,200 150,697 59.2 1960 © vv vee ee $117,800 181,668 64.8 1964 © ee 118,800 192,468 61.7 1968 + vv eee 123,500 200,415 61.6 1970 + te ee 6 128,200 205,056 62.5 1971 eee 129,700 207,336 62.6 ! For 1900-30, data are for civilian gainful workers; for 1940-50, data cover experienced civilian labor force; figures for 1960-71 cover licensed pharmacists in 50 States and District of Columbia. 2 Data for 1900 are as of June 1; 1910, April 15; 1920, January 1; 1930-50, April 1; 1960-71, December 31. 3 Excludes data for Alaska and Hawaii. # The 1950 Decennial Census of Population provides a figure of 90,307 active pharmacists, which would yield 59.0 per 100,000 population. 5 The 1960 Decennial Census of Population provides a figure of 92,700 active pharmacists, which would yield 51.0 per 100,000 population. 6 The 1970 Decennial Census of Population provides a figure of 109,642 active pharmacists, which would yield 53.5 per 100,000 population. Source: 1900-40 active pharmacists: Kaplan, David L. and Casey, M. Claire. Occupational Trends in the United States 1900 to 1950. Bureau of the Census Working Paper No. 5. U.S. Department of Commerce, 1958. 1950 active pharmacists: U.S. Bureau of the Census. United States Census of Population: 1960. Detailed Characteristics. United States Summary. PC(1)-1D. U.S. Government Printing Office, 1963. 1960-71 active pharmacists: National Association of Boards of Pharmacy. 1972 Proceedings. Licensure Statistics and Census of Pharmacy. Chicago, The Association, 1973. 1900-50 population: U.S. Bureau of the Census. Statistical Abstract of the United States 1966. U.S. Govern- ment Printing Office, 1966. 1960-71 population: U.S. Bureau of the Census. Current Population Reports. Series P-25, No. 475. t despite the absence of massive Federal programs aimed at increasing enrollments. Two alternative assumptions as to graduate additions were also made. First, as a low projection, the number of graduates after 1978 was held constant. The assumption here is that there will be no further increases in third-to- last-year enrollment after 1974-75 (coincident with expira- tion of the Comprehensive Health Manpower Training Act of 1971), since public and private support would be continued in such a form that increases in enrollment achieved under the Act through 1974-75 would be main- tained, but no further increases in enrollment encouraged. (See Table 63.) 98 The second or igh estimate assumes that the rate of increase in third-to-last-year enrollment beyond 1974-75 would be midway between the average rate of increase experienced by existing pharmacy schools from 1964-65 to 1971-72 and the average annual rate of increase under the basic methodology. Under this alternative consequently, an average annual increase in third-to-last-year enrollment of 3.7 percent was used. This alternative, in contrast with the basic methodology, assumes increases in enrollment greater than that experienced prior to the period of major Federal support. However, the rate of increase would not be of the magnitude achieved since 1963, given the absence of further massive Federal support to increase enrollment. Table 62. TREND IN NUMBER OF SCHOOLS, ENROLLMENTS, AND GRADUATES FOR PHARMACY SCHOOLS: ACADEMIC YEARS 1960-61 THROUGH 1972-73 Enrollment i Number of Academic year Stools Total! Third-to-last Graduates year 1960-6] .insisssnsnasivnvummn 76 2 13,556 2 5,797 3,445 198162 vv nvivs sv undid ds Lbs CE ES 76 10,893 3 2,181 3,728 1962-63 . .. iit i iii 76 10,730 4,145 4,188 1963-64 + vv vee 76 210,291 2 4,390 2,32,195 196465 ..n si ssamunssonmpwnns 75 12,104 4,491 3,393 1965366 «vs is pons msivanmmwuns 74 12,495 4,647 3,704 1966-67 suns veinnmatruumeny 8 74 13,221 5,234 3,782 1967-68 . oo. onan siisnmmeibs ss 74 14,274 5,616 4,035 1968-69 . . vv viii 74 14,932 5,469 4,291 1969-70 . oo iii it eee 74 15,323 5.532 4,766 1970-71 sus ssmnpomnes rommenss sy 74 15,626 5,864 4,746 1971-72 nas sess ms cr MmumeEm £42» 74 16,808 6,532 4858 1972-713 wos ssa sd ss sms we® £8 95 73 18,956 7,546 N.A. ! Includes enrollments in the last 3 years of pharmacy programs leading to degrees of B.S., B. Pharm., and Pharm.D. 2 Excludes data for University of Puerto Rico which were not available. 3 The sharp drop from the preceding year reflects the transition from a 4-year to a 5-year post-high school program in 1960 by those pharmacy schools which were not already on a 5-year program. Source: Report on Enrollment in Schools and Colleges of Pharmacy First Semester, Term, or Quarter, 1972-73. American Journal of Pharmaceutical Education 37: 138-153, February 1973. Also prior annual reports. Report of Degrees Conferred by Schools and Colleges of Pharmacy for the Academic Year 197 1-72. American Journal of Pharmaceutical Education 37: 126-137, February 1973. Also prior annual reports. Data for the University of Puerto Rico for 1964-65 through 1970-71 were obtained from: Applications for institutional and capitation grants submitted to BHRD. Note: The last 3 years of pharmacy programs are used in order to have comparable data for pharmacy schools with different types of programs. Pharmacy schools with 3-year programs require 2 years of college for admission. Other pharmacy schools have 5-year programs and accept students directly from high school. Hampton College (an unaccredited school) is omitted from all data. Projection Findings. The basic projection of the size of future graduating classes results in a total gross graduate input of 126,931 for the 1971-90 period. The low alternative projects a total gross graduate input of 118,394 and the high alternative, 151,139. The high and low alternatives consequently produce total gross graduate inputs approximately 32,745 graduates apart. However, if Federal support were to continue at the high levels of the early 1970’s and the projected rate of increase were to match the 1967-72 experience (about 6 percent a year), a total gross graduate input of 169,500 would result for the 1971-90 period. A measure of the reasonableness of the projections can be derived by examining the implications of the increase in the projected numbers of third-to-last-year enrollees per 99 pharmacy school. An increase in third-to-last-year enroll- ment after 1975, similar to the increase achieved by the schools prior to the initial legislation, is assumed under the basic methodology. In line with this assumption, an increase is projected in third-to-last-year enrollment per pharmacy school from 76.9 in 1970-71 to 121.3 in 1987-88 (a 58 percent increase over a 17-year period). During the 1962-63 academic year, third-to-last-year enrollment aver- aged 53.8 enrollees per school. The increase to 1970-71 was 43 percent over an 8-year period. The projection period is twice as long as the 1962-63 to 1970-71 period. In the projection methodology utilized in this report, no new pharmacy schools are assumed to be opening during the 1970-90 period. This is consistent with the fact that new pharmacy schools were not established during the Table 63. THIRD-TO-LAST YEAR ENROLLMENTS AND GRADUATES IN PHARMACY SCHOOLS UNDER BASIC AND ALTERNATIVE ASSUMPTIONS: ACTUAL 1970-71 AND 1971-72; PROJECTED 1972-73 THROUGH 1989-90 Third-to-last year enrollment Graduates ; Alternative Alternative Acaueripyese Basic assumptions Basic assumptions methodology methodology Low High Low High 1970-71 © i ee 5,914 5914 5914 4,746 4,746 4,746 1971-72 tt ii ree ea 6,633 6,633 6,633 4.573 4,573 4,573 197278 Li vrnpn ss mupmp@s LENGE E LE 6,908 6,908 6,908 4,985 4,985 4,985 197374 , : vvann sss bitinmm ss bhw@ans 7,117 7,117 7,117 5,592 5592 5,592 VIATE svn wm 8 HABREA SL 8 5 ha Bomrats a 7,297 7,297 7,297 5,826 5,826 5,826 1975476 : i cvnmis a 23 Bama vv v mamme » 7,406 7,333 7,567 6,002 6,002 6,002 IIVBTT i i nih 2% vmmmnmin +s mmm» 7,517 7.333 7,847 6,156 6,156 6,156 1977-78 itt tt tee tee 7,630 7.333 8,137 6,249 6,187 6,385 1978-79 i. iii i eee 7,744 7.333 8,438 6,344 6,189 6,622 1979-80 Lie 7,860 7.333 8,750 6,440 6,189 6,868 19808BT |. uswwn sss wa RRE LE I EBER 7,978 7,333 9,074 6,538 6,191 7,124 198782 is nswms isi vERFER LIS HR 8,098 7,333 9,410 6,637 6,191 7,388 198283 i i i cna H a ER mms 8,219 7.333 9,758 6,738 6,192 7,664 1983-84 ........¢iiiirrr iii 8,342 7,333 10,119 6,840 6,194 7,948 1984-85 . ee 8,467 7,333 10,493 6,943 6,195 8,243 1985-86 «vv iii 8,594 7,333 10,881 7,048 6,196 8,549 198BB7 wus susmum sis sRamits usmis 8,723 7,333 11,284 7,155 6,197 8,867 198788 i va 0a FT as 5 5 mamorm ov acon 8,854 7,333 11,702 7,263 6,197 9,196 1988-89 ....... iii ie - _ —- 7.372 6,198 9537 1989-90 . . . Le —- - — 7,484 6,198 9,892 Source: 1970-71 through 1974-75 third-to-last year enrollments: Applications for institutional and capitation grants submitted to BHRD. 1970-71 graduates: Applications for capitation grants submitted to BHRD. Note: Figures shown above for 1970-71 through 1972-73 differ from those in table 62. These discrepancies reflect in part the different sources used for the tables. study period preceding Federal legislation. The assumption is advanced, consequently, that all projected enrollment increases will take place among existing schools. It is difficult to determine whether pharmacy schools are now operating at capacity or will be at capacity during the projection period. However, it is entirely possible that changes in the pharmacy curriculum or utilization of existing facilities throughout the year would permit existing schools to serve a greater number of students than are presently enrolled. Under the basic methodology outlined earlier, the supply of active pharmacists is projected to grow from 129,300 in 1970 to 146,100 in 1980, and to 179,900 in 1990, as shown in Table 64. The growth in active pharmacists is thus projected at 16,800 between 1970 and 1980, compared with a 11,500 increase from 1960 to 1970. The projected increase represents a larger percentage gain in 1970-80 than that experienced between 1960 and 1970-73 100 percent as compared with 10 percent. Between 1980 and 1990, growth in supply is projected to be more rapid—a 23,800 increase, or 23 percent. The ratio of active pharmacists to population, which was relatively constant between 1960 and 1970, is projected to rise sharply. The ratio is projected at 64 per 100,000 population in 1980, and 72 per 100,000 in 1990. This compares with a ratio of 63 per 100,000 in 1970. Under the high alternative projection, the supply of active pharmacists is projected to increase to 146,900 in 1980 and 194,200 in 1990. This represents a 14 percent increase between 1970 and 1980, and a 32 percent increase between 1980 and 1990. Under the low alternative, the supply of active pharmacists is projected at 145,600 in 1980 and 171,800 in 1990. The projection of active pharmacists in 1990 under the basic assumption yields a supply that is 8,100 (or 5 percent) more than the low estimate and 14,300 (or 8 Table 64. SUPPLY OF ACTIVE PHARMACISTS AND PHARMACIST/POPULATION RATIOS, USING BASIC METHODOLOGY AND ALTERNATIVE ASSUMPTIONS: ACTUAL 1960 AND 1970; PROJECTED 1975-90 Projections series 1960 1970 1975 1980 1985 1990 Number of active pharmacists’ Basic MethodolOgY + vs su iss animes so um mmin ss 117,800 129,300 133,800 146,100 161,800 179,900 Alternatives: LOW mus ss mmm v1 oid immed 11s wmmal ole « 117,800 129,300 133,800 145,600 158,700 171,800 High coc ssnnsmumsssmmnmin es pusmmnsys 117,800 129,300 133,800 146,900 167,100 194,200 Rate per 100,000 population? Basic methodolOBY + vw ss sms wines summons sey 65.5 63.4 62.3 64.4 67.6 71.8 Alternatives: LOW ovis bomsms ss pa mBiesmBu@n es ss 65.5 63.4 62.3 64.2 66.3 68.5 HEHE ts wasabi side o 2mm den 24% Brandi A 4 IRR 65.5 63.4 62.3 64.7 69.8 71.5 ! Includes licenced pharmacists in practice in 50 States and the District of Columbia; for 1970-90 also includes those in Puerto Rico and the Virgin Islands. 2 Resident population as of July 1 for 50 States and the District of Columbia. Rate for 1970 differs from that shown in table 59 because of exclusion of Puerto Rico and the Virgin Islands from population base in this table. Source: 1960 and 1970 active pharmacists: National Association of Boards of Pharmacy. 1961 and 1971 Proceedings. Licensure Statistics and Census of Pharmacy. Chicago, The Association, 1962 and 1972. Population: U.S. Bureau of the Census. Current Population Reports. Series P-25, Nos. 468,477, and 483. percent) fewer than the high estimate. The low alternative yields a population ratio of 68 pharmacists per 100,000 in 1990, compared with 78 per 100,000 in the high estimate and 72 per 100,000 under the basic assumption. As noted earlier, a definite upward trend in the proportion of women enrolled in pharmacy schools is evident, and there is no reason to believe that this trend is temporary or sporadic. Also noted was the fact that the attrition rate of female students is lower than that of males, resulting in an even greater proportion of female graduates over time. The increasing proportion of women in pharmacy is important because of the much shorter work-life- expectancy of female professionals and thus their lower professional productivity per pharmacist.” There are indi- cations that women pharmacists have a work-life- expectancy about one-half that of the average male pharmacist.® Further, women pharmacists have been shown to practice full-time, on the average, about half and "Ohvall, R.A. and Sehgel, K.S. Practice Continuity and Lon- gevity of Women Pharmacists. Journal of the American Pharma- ceutical Association NS9: 518-520, October 1969. 8Tash, R.H.; Dickson, W.M.; and Rodowskas, C.A., Jr. Women in the Professional Work Force. Journal of the American Pharma- ceutical Association NS13:622-624, November 1973. 101 part-time about one-fourth of their professional lives. It is therefore reasonable to assume that two part-time phar- macists are approximately equivalent to one full-time pharmacitt, based on a 40-hour work week. Converting the projected active supply of female pharmacists to full-time equivalents yields the estimate of active full-time phar- macists to 1990 under the basic methodology shown in Table 65. A comparison of this table with the projected total active supply of pharmacists shown in Table 64 (basic methodology) reveals that the full-time equivalency con- version lowers the 1990 supply estimate by about 5 percent. This procedure reduces the projected 1980 esti- mate by about 4 percent while the 1970 estimate would be lowered by about 2 percent. If the alternative separation patterns that were men- tioned earlier are examined in terms of numbers of full-time equivalent pharmacists, considerable differences in the above totals are possible. To illustrate, if female separation rates remain as adopted under the basic methodology, but male death and retirement patterns are lower, e.g., closer to those of optometrists, the 1980 and 1990 projected total full-time equivalent pharmacists would be 147,100 and 177,500 for 1980 and 1990 respectively. However, should female separation rates be 7 percent higher than those presently full-time equivalent pharmacists for 1980 and 1990 would assumed, and male separation rates approximate those of be 140,300 and 169,400 respectively, departing only the general labor force (as assumed), the resultant total slightly from the figures presented in Table 64. Table 65. SUPPLY OF ACTIVE PHARMACISTS AND FULL-TIME EQUIVALENTS, BY SEX, USING BASIC METHODOLOGY: ACTUAL 1970 AND PROJECTED 1975-90 Number of active pharmacists’ Active full-time equivalents? Year Male | Female Both sexes | Female 970) vv tvs van m ams i SEBEL 2 3 mo 117,600 11,700 126,400 8,800 1875 vv tis mmnos ov smn ns son 118,700 15,100 130,000 11,300 1980 cine s v5 wbinmwmns vmsmwas spe 125,400 20,700 140,900 15,500 1985 134,400 27,400 155,000 20,600 1990 © iv er mmm st Ems ss 144,700 35,200 171,000 26,400 Includes active pharmacists in 50 States, District of Columbia, Puerto Rico, and Virgin Islands. Equals full-time workers plus 50 percent of part-time workers. Source: 1970 active pharmacists: National Association of Boards of Pharmacy. 1971 Proceedings. Licensure Statistics and Census of Pharmacy. Chicago, The Association, 1972. Table 66. SUPPLY OF ACTIVE PHARMACISTS, BY SEX, USING BASIC METHODOLOGY AND ALTERNATIVE ASSUMPTIONS: ACTUAL 1960 AND 1970; PROJECTED 1975-90 Projection series 1960 1970 1975 1980 1985 1990 Number active male pharmacists’ Basic methodology . . .................... 111,300 117,600 118,700 125,400 134,400 144,700 Alternatives: LOW cus vmwmissmsmmmis sass is sme 111,300 117,600 118,700 125,000 132,100 138,800 HIZh © .ivenmrissmommmma vs 5 mnames sma 111,300 117,600 118,700 126,000 138,300 155,000 Number active female pharmacists’ Basic methodology . .. ................... 6,500 11,700 15,100 20,700 27,400 35,200 Alternatives: Low ee 6,500 11,700 15,100 20,600 26,600 33,000 High ................. ws BREE 6,500 11,700 15,100 20,900 28,800 39,200 ) Includes licensed pharmacists in practice in 50 States and the District of Columbia; for 1970-90 also includes those in Puerto Rico and the Virgin Islands. Source: 1960 and 1970 active pharmacists: National Association of Boards of Pharmacy. 1961 and 1971 Proceedings. Licensure Statistics and Census of Pharmacy. Chicago, The Association, 1962 and 1972. 102 Chapter 8 ¢ PODIATRISTS Data on podiatrists cover all active members of the profession in the 50 States and the District of Columbia, but not those few podiatrists who may be overseas or in the territories. The primary source of information on active podiatrists used here is the 1970 Survey of Podiatrists conducted by the National Center for Health Statistics (NCHS), which has an early 1970 reference point. To derive the December 31, 1970 estimates used for characteristics data and as the base for the projections, estimates were made of new entrants to and separations from the supply of active podiatrists during 1970. The methodology for making these estimates was the same as that used for optometrists and is described in Chapter 6. Because podiatrists were included with physicians in decennial census estimates up to 1970, there are few historical data on the profession. Historical trends shown here represent a combination of estimates and counts and should be used with caution. Individual tables provide detailed explanations and notes of sources. In order to provide an improved data base, the Bureau of Health Resources Development (BHRD) is cooperating with NCHS to conduct a survey of podiatrists in the United States in 1974. This survey will be based on an update of the mailing list developed by NCHS for conducting its 1970 survey. The survey instrument will be similar to the 1970 questionnaire, requesting basic information on demographic characteristics and such items as principal form of employ- ment, type of practice, use of auxiliaries, and patient load. CURRENT CHARACTERISTICS AND TRENDS In 1970, there were approximately 7,100 podiatrists actively practicing in the United States. Podiatrists as a group were older than some other health professions, with nearly two out of three podiatrists being 45 years of age or older. (See Table 67.) Only 14 percent were between 30 and 39 years of age. This age distribution reflects the large number of podiatrists who completed their education immediately after World War [I and the Korean War, and also the subsequent dropoff in enrollment in podiatry schools. In 1970, 300 or 4 percent of active podiatrists were women. This proportion may decrease somewhat in the future, as a result of recent decreases in enrollment of females in podiatry schools. The survey of health pro- fessions student finances conducted by the Bureau of Health Manpower Education shows that less than 2 percent of podiatry students in 1970 were women. 103 Blacks make up a small proportion of podiatrists. According to data from the 1970 Census of Population®, Blacks accounted for slightly more than 4 percent of active podiatrists in 1970. The census indicates, furthermore, that only 1.3 percent of the total supply was accounted for by podiatrists of Spanish heritage. 1 U.S. Bureau of the Census. United States Census of Population: 1970. Detailed Characteristics. United States Summary. Final Report PC(1)-D1. U.S. Government Printing Office, 1973. Table 67. NUMBER OF ACTIVE PODIATRISTS, BY SEX AND BY AGE GROUP: DECEMBER 31,1970 Number of . Percent Sex and age group active Pe pi peiTh Eel distribution podiatrists BOthSexes iu: :cvcovwwe 7,100 100.0 Male ....:cssvessuvummes 6,800 96.0 Female ............00... 300 4.0 AU Ages owes vuvwmn ss 7,100 100.0 Lessthan25years ........... 120 1.7 25-44 years Lo... ieee 2,380 33.1 25:29 stv mar tk mma ho 670 9.4 30-34 LL hee 340 4.7 3539 ummm 14 mmm ts we 640 8.9 044 oivvivin sss mmm ts pe 730 10.1 ASGAYRAS oun sss wwaw svt HE 3,810 53.2 45-49 ; ov nna as sv mmEE i v2 mE 950 13.2 50:84 .ansassannmwn i sve 1,000 14.0 3889 anna pnonmEE ¢ we 950 13.2 60:64. .v0issanmas ines 920 12.8 65 yearsandover ........... 830 11.5 65-69 . . iii eee 400 5.5 P0794 vino vs va nmmin os vimmw 270 3.7 75-andover . ....... 0.0... 160 2.3 Source: Estimates by sex: Koch, Hugo K. and Phillips, Hazel M. Podiatry Manpower: A General Profile. United States - 1970. DHEW Pub. No. (HRA) 74-1805. U.S. Government Printing Office, 1973. Estimates by age: Based on unpublished data from 1970 survey. Note: Figures may not add to totals and subtotals due to in- dependent rounding. In 1970, podiatrists were disproportionately located in the New England and Middle Atlantic States which had higher ratios of active podiatrists per 100,000 population than the other geographic divisions, 5.7 and 6.1 respec- tively. The lowest ratio (0.9 per 100,000) is found in the East South Central States. Among individual States, podiatrist/population ratios ranged from a high of 7.0 per 100,000 in Massachusetts and New York, to a low of about 0.5 and 0.4 per 100,000 population respectively, in South Carolina and Mississippi. There appears to be a tendency for students to locate in the areas where they went to school, as all five schools of podiatry in 1970 were located in the three divisions with the largest number of podiatrists—the Middle Atlantic, East North Central, and Pacific divisions. (See Table 68.) Nearly all podiatrists in 1970 (90 percent) classified themselves as being in general practice, as shown in Table 69. The remaining podiatrists were in surgery (6 percent) or Table 68. NUMBER OF ACTIVE PODIATRISTS AND PODIATRIST/POPULATION RATIOS, BY GEOGRAPHIC DIVISION AND STATE: DECEMBER 31, 1970 Resident population Rate per Division and State Numivezof July 1,1970 100,000 active podiatrists (in 1,000’) ROpUlation UNITEDSTATES ....0ouvvvesvesnse 7,100 203,805 35 NEWENGLAND .................. 680 11,873 35.7 Connecticut . . . .... vie... 180 3,039 59 Maine . . .............. 20 995 2.2 Massachusetts . . . ............... 400 5,699 7.0 NeW Hampshire ..ovww cs ssmme 2.5 + 510 20 742 2.8 Rhode Island . , co vson ss ompmw isso 60 951 59 Vermont . . : s samis is vas nmes sae 10 447 1.3 MIDDLE ATLANTIC ............... 2,290 37,271 6.1 New Jersey ......... iin. 360 7,195 5.0 NewYork ....conssssnsimumesss 1,240 18,260 6.8 Pennsylvania. . ................. 690 11,817 5.8 SOUTH ATLANTIC ................ 600 30,772 1.9 Delaware . . ................... 20 550 4.0 District of Columbia .............. 60 753 7.6 FIBA «coms ss uname cs aummssss 190 6,845 2.8 BEOIBIA winiin i v6 5 HWE 2 85 mb minre eo 60 4,602 1.2 Maryland . . . ............. ..... 100 3,937 25 North Carolina ................. 60 5,091 1.1 South Carolina . ................ 10 2,596 0.5 Virginia . ...... 60 4,653 1.2 West Virginia. . . .. ovine ven. 40 1,746 2.5 EAST SOUTH CENTRAL cv. vcnuwnmss 110 12,823 0.9 EE RE lL TTT 20 3,451 0.6 Kentucky sv vw + 5s s» 6885.05 5 foo kines 60 3,224 1.7 Mississippi... o.oo 10 2,216 0.4 TENNESSEE = ini s 2 3 www vv 0mm aie e 30 3,932 0.7 WEST SOUTH CENTRAL . ............ 290 19,397 1.5 Arkansas . . . Lo... LLL... 20 1,926 0.9 Louisiana. . ................... 40 3,644 i OKIBhOma + uvus sss wmwmes sas mee 50 2,572 1.8 TEXAS . ss npono cs san mmme i Samume 190 11,254 1.7 Table 68. NUMBER OF ACTIVE PODIATRISTS AND PODIATRIST/POPULATION RATIOS, BY GEOGRAPHIC DIVISION AND STATE: DECEMBER 31, 1970—Continued Resident population Rate per Division and State Midshioh July 1, 1970 100,000 active podiatrists (in 1,000) population EASTNORTHC CENTRAL . . .svvuvsosun 1,690 40,368 4.2 MHNOIS, «wis 2 3 stig a 3 3 mbm ox wn 600 11,137 5.4 INdIANA . cs ome sme bk 150 5,208 2.8 Michigan . . ................... 270 8,901 3.1 OND curv: snusmntsnsammmss sp 530 10,688 5.0 WiSconsife c+ s saan a ds muna oo on 130 4,433 3.0 WEST NORTH CENTRAL. . ........... 370 16,367 2.2 OWA yun uo ssmmmnssamm@umis ss 90 2,830 33 Kansas voma ss svenms is bmmusds oon 50 2,248 2.0 Minnesota . ................... 80 3822 2.0 Missouri... ..... i. 90 4,693 1.8 Nebraska ....convmwvssnowmmesss 40 1,490 2.8 NorthDakota .................. 10 618 1.0 SouthiDakota .. .« ss viwnns swumwmm sv 20 666 2.3 MOUNTAIN . vs covmmmnssnsmamess 200 8,345 2.4 ARZODA. suai samedi names so 40 1,792 2.1 Colorado . .................... 70 2,225 32 Idaho . . . .................... 20 717 22 Montana . .................... 10 697 2.0 Nevada so umws soimmmims s soma nm os 20 493 3.2 New MEXICO: ows 5 siwmma 5 3 sismaims s+ 20 1,018 2.0 Utah nu sim dis msiadns st smmiunme +0 30 1,069 23 Wyoming . . . . oo ii ii 10 334 1.5 PACIFIC ,.ivvnivssnmmummus mmm ss 840 26,589 3.2 AVIRA oon v ss 6 GCE ECE RR (1) 305 _- California «uo + Sumani s soimndmme 3 740 19,994 3.7 Hawali cova snmmaas sb smmiime so 10 774 0.6 Oregon . . o.oo iii iii tiie 40 2,102 1.7 Washington ... ss sie nme so vmmms sy 60 3,414 1.9 ! Less than 5. Source: Active podiatrists: Koch, Hugo K. and Phillips, Hazel M. Podiatry Manpower: A General Profile. United States - 1970. DHEW Pub. No. (HRA) 74-1805. U.S. Government Printing Office, 1973. Population: U.S. Bureau of the Census. Current Population Reports. Series P-25, No. 468. Note: Figures may not add to totals and subtotals due to independent rounding. had primary activities in foot orthopedics or other fields. Many podiatrists, of course, have secondary activities in which they spend some time. Furthermore, there appears to be an increasing trend toward specialization, as 24 percent of the podiatrists under 35 years of age reported their primary activity to be in an area other than general practice, while only 6 percent of those 45 years and over reported such primary activities in 1970. 105 As Table 70 shows, about 86 percent of the supply of active podiatrists were in solo practice in 1970, 6,100 out of 7,100. Six percent (460) were in a partnership with other podiatrists. Here too, there appears to be a definite trend, as the 1970 survey showed 90 percent of podiatrists 45 years of age and over as being in solo practice, compared with only 62 percent of those under age 35. Table 69. NUMBER OF ACTIVE PODIATRISTS, BY MAJOR PROFES- SIONAL ACTIVITY: DECEMBER 31, 1970 Number of P t Major professional activity active . ercen so . distribution podiatrists All activities . ............ 7,100 100.0 General practice . . . .......... 6,430 89.9 Surgery LL... 410 5.7 Foot orthopedics . ........... 180 2.5 OEY. ovo nics srnmnses ne 130 1.8 1 SL — Includes podogeriatrics, podiatric dermatology, roentgenology, and other activities. Source: Based on unpublished prelimary data from 1970 Survey of Podiatrists by the National Center for Health Statistics. Note: Figures may not add to totals due to independent rounding. Table 70. NUMBER OF ACTIVE PODIATRISTS, BY TYPE OF PRACTICE: DECEMBER 31,1970 Number of Type of practice active Percent ot distribution podiatrists ANIYPES vuivss sn munnnssas 7,100 100.0 Solopractice . . .............. 6,110 85.5 Partnership ................ 460 6.4 Group practice .............. 130 1.8 Government organization. . ....... 140 2.0 Nongovernment organization, institution... ............. 160 2.2 Other . .......... uu... 150 24 Source: Koch, Hugo K. and Phillips, Hazel M. Podiatry Man- power: A General Profile. United States - 1970. DHEW Pub. No. (HRA) 74-1805. U.S. Government Printing Office, 1973. Note: Figures may not add to totals due to independent rounding. 106 Over the past two decades, the number of active podiatrists has grown from 6,400 to 7,100. During the 1960-70 period, the number of active podiatrists remained nearly constant, as the number of new graduates entering the profession was offset by deaths and retirements of active practitioners. The ratio of active podiatrists to population decreased from 4.2 per 100,000 in 1950 to 3.9 per 100,000 in 1960. It decreased further to 3.5 per 100,000 in 1970. (See Table 71.) Enrollments in schools of podiatry have recently begun to increase sharply. In the last decade, total enrollment at podiatry schools increased by nearly 170 percent, from 472 in 1961-62 to 1,267 in 1971-72. (See Table 72.) Table 71. TREND IN NUMBER OF ACTIVE PODIATRISTS AND PODIATRIST/POPULATION RATIOS: SELECTED YEARS 1950-70 Number of Resident Aces Year active population’ p 100.000 podiatrists (in 1,000%s) | Per 199) population 19502... .. 6,400 151,868 42 1960 . .... 7,000 179,975 3.9 1970 ..... 37,100 * 205,056 3.5 ! Data for 1950, 1960 are as of July 1, data for 1970 are as of December 31. 2 Excludes Alaska and Hawaii. 3 The 1970 Decennial Census of Population provides a figure of 6,026 active podiatrists, which would yield 2.9 per 100,000 popula- tion. Source: 1950, 1960 active podiatrists: U.S. Department of Health, Education, And Welfare; Public Health Service; Bureau of Health Professions Education and Manpower Training. Health Man- power Source Book 20. Manpower Supply and Educational Statis- tics for Selected Health Occupations: 1968. Public Health Service Pub. No. 263, Section 20. U.S. Government Printing Office, 1969. 1970 active podiatrists: Koch, Hugo K. and Phillips, Hazel M. Podiatry Manpower: A General Profile. United States - 1970. DHEW Pub. No. (HRA) 74-1805. U.S. Government Printing Office, 1973. Population: U.S. Bureau of the Census. Current Population Reports. Series P-25, No. 475. Table 72. TREND IN NUMBER OF SCHOOLS, ENROLLMENTS, AND GRADUATES FOR PODIATRY SCHOOLS: ACADEMIC YEARS 1960-61 THROUGH 1971-72 . Number of Total First-year Acadernic yeu: schools enrollment dev Graduates 1960-61 . .................... 5 478 N.A. 116 196162 . iv swmmwnmu os snes 5 472 120 96 196263 vows sommEpEE bb BEE Ge 4 496 N.A. 114 196364. .vuvims i imummm i eam mine 5 585 195 97 186465 i wumunis nmmnr iin hoswsnr 5 622 177 122 1965-66 ..........c¢ouiuveuunun. 5 707 223 135 1966-67 ..........niinennnn. 5 838 283 165 1967-68 . . . .. 5 926 291 162 T9686 | snvvnis s HEBERT 5 4 some 5 1,061 331 204 196970 .: in sssiinmonionm se same 5 1,097 293 251 1970-71 oo. 5 1,148 351 242 197172 i vvuv se mmwmms ss as 5 1,267 399 286 Source: 1960-61 through 1969-70: Pennell, Maryland Y. Podiatric Education and Manpower. Journal of Podiatric Education Vol. 1, No. 2, June 1970. 1970-71, 1971-72: Applications for capitation grants submitted to BHRD. PROJECTIONS OF THE SUPPLY OF PODIATRISTS TO 1990 Several projections of the supply of active podiatrists to 1990 are presented here, using different assumntions as to graduate input over the projection period. METHODOLOGY AND ASSUMPTIONS Estimates of the number of active podiatrists for 1971-90 were calculated by using essentially the same methodology as for estimating the December 31, 1970 figure. Data on graduates of podiatry schools for 1971 were obtained from school reports on FY 1972 capitation grant applications; the schools also provided estimates of first- year enrollments and graduates through 1974-75. Graduate projections to 1978 were computed from the number of first-year students reported 4 years earlier, utilizing an attrition rate of 10 percent in both the basic methodology and the alternative supply projections, in line with the experience of recent years.? Thus, 90 percent of entering podiatry students are projected to graduate 4 years later. If a different attrition pattern were used, of course, the graduate component would change somewhat, but the overall impact on the total supply estimates would be minor. Under the basic methodology, for example, if a 9-percent attrition was used, only about 100 additional graduates would be expected over the projection period. 2pennell, Maryland Y. Podiatric Education and Manpower. Journal of Podiatric Education 1:11-21, June 1970. 107 Separation rates used in the basic methodology and in the alternative approaches were derived largely from age- specific death and retirement rates for males developed by the Department of Labor.? In comparing age-specific data from the Department of Labor showing male labor force participation rates with information on the proportion of podiatrists that are inactive (as obtained from the 1970 NCHS Survey), it was found that a lower proportion of podiatrists were inactive for all age groups 60 years of age and above. This suggested that podiatrists tend to retire at a later age than does the general male labor force. Given this finding, adjustment factors were developed to convert the published age-specific retirement rates for males in the labor force to a series which would better approximate the apparent podiatrist experience. The overall consequence of the utilization of “podiatrist-specific’’ retirement rates is that retirements are reduced by approximately 15 percent over the 20-year period, compared with the number estimated to retire if the unconverted male labor force rates were used. Unlike retirement patterns, there is no evidence to suggest that podiatrists, on the average, live longer than persons in the general labor force. Therefore, age-specific mortality rates derived from those developed by the Department of Labor, were simply applied to the podiatrist population. Age-specific separation rates, consequently, represented the sum of individually computed retirement 3Fullerton, Howard N. A Table of Expected Working Life for Men, 1968. Monthly Labor Review 94: 49-55, June 1971. and mortality rates. (See Appendix A for detailed explana- tion of the methodology utilized to estimate deaths and retirements.) The basic determinant of the future supply of podiatrists is very clearly the enrollment in podiatry schools. As indicated earlier, podiatry enrollments have grown rapidly since the early 1960's, with new Federal legislation pro- viding much of the impetus for recent increases in enrollment. In projecting the total supply of podiatrists therefore, several different assumptions were made relating to the output of graduates of podiatry schools after 1978. The basic assumption utilized to develop the projections of podiatrists was that there would be an increase in first-year enrollment after 1974-75 similar to that achieved by the schools prior to the initial Federal legislation. On this basis, first-year enrollment beginning in 1975-76 was projected to increase annually at a rate equivalent to that experienced in the 12-year period prior to enactment of the Health Professions Education Assistance Act of 1963— about 5 percent annually. (See Table 73.) This period was adopted as a reasonable approximation of enrollment growth occurring in the assumed absence of massive Federal programs to increase enrollment. Two alternative assumptions as to graduate additions were made. First, as a low projection, the number of graduates after 1978 was held constant, on the assumption that there would be no further increases in first-year enrollment after 1974-75. This means that support from sources other than the Federal government, when combined with Federal funds, would be adequate to support the enrollment level of the mid-1970’s, but would not be sufficient to bring about further increases in enrollment. The second or high estimate assumed that the rate of increase in first-year enrollment beyond 1974-75 would be midway between the average rate of increase experienced by existing podiatry schools from 1964-65 to 1971-72, and the average annual rate of increase under the basic methodology. Under this alternative, consequently, an average annual increase in first-year enrollment of 6.5 percent was assumed. This alternative, in contrast to that of the basic methodology, assumed increases in enrollment greater than that experienced in the 12-year period prior to the initial legislation. However, the rate of increase would still not be of the magnitude achieved under legislation since 1963. Table 73. FIRST-YEAR ENROLLMENTS AND GRADUATES IN PODIATRY SCHOOLS UNDER BASIC AND ALTERNATIVE ASSUMPTIONS: ACTUAL 1970-71 AND 1971-72; PROJECTED 1972-73 THROUGH 1989-90 First-year enrollment Graduates Academic year Basic methodology Alternative assumptions Alternative assumptions Basic methodology Low High Low High 1970-71 oii 351 351 351 242 242 242 1971-72 oo iii ieee 399 399 399 286 286 286 1972-73 . i vnwamn ssimume vs 425 425 425 266 266 266 1973-74 . :: vuwnmns snmwm ss 461 461 461 309 309 309 TIVATE ss sommmis ss simmmis 506 506 506 368 368 368 1975-76 :. ven inivis mmamess 531 506 539 380 380 380 1976-77 ..:ivcninmus insane 558 506 574 420 420 420 1977-78 «ee 586 506 611 455 455 455 1978-79... iii. 615 506 651 478 455 485 197980 .., vonsnwi svuwnnmn 646 506 693 502 455 517 1980BY «i: vonmunsssnnsms 678 506 738 527 455 550 198182 i sannnmss nammme 712 506 786 554 455 586 TI98283 iui imma s mmimm oni 748 506 837 581 455 624 1983-84 ................. 785 506 891 610 455 664 1984-85 . ................ 824 506 949 641 455 707 198586 wun sss nncnasuwnunam 865 506 1,011 673 455 753 198687 wisi nummaa ii nuns 908 506 1,077 706 455 802 198788 iis sinmmmm vv mmm - —- — 742 455 854 1988-89 ................. — - — 778 455 910 198890 pn cs wmwmmis nmume — — - 817 455 969 Source: 1970-71 through 1974-75: Applications for capitation grants submitted to BHRD. 108 The reasonableness of the projections of podiatrists can be evaluated, in part, by examining changes in the number of enrollees per school. Comparisons of changes in this measure can be made between: (1) a period prior to the initial legislation; (2) the situation recently; and (3) the projection period. An increase of nearly 200 percent in first-year podiatry enrollment per school took place in the 9-year period between 1961-62 and 1970-71 (from 24 to 70). This compares with an increase of 159 percent in first-year enrollment per school in the 16-year projection period. As the projection period covers a time span 7 years longer than the observed period of enrollment increase yet projects a rate of increase considerably lower, it would appear that projected increases in enrollment are entirely reasonable in light of historical trends. In view of the fact that the number of podiatry schools (five) has been constant since the mid-1950’s and that there are no definite plans for new schools, the projections imply that enroll- ment increases would take place entirely within these five schools. The issue of whether existing schools are operating at capacity is very difficult to pinpoint. However, it should be pointed out that school capacity possibly could be substantially increased by more effective utilization of facilities as they now exist. This might include curriculum modifications, as well as increasing the yearly use of existing space within a school. PROJECTION FINDINGS The basic projection of the graduating classes of 1970-71 through 1989-90 results in a total gross graduate input of 10,325 for that period. The low alternative projects a total gross graduate input of 8,187 and the high alternative, 11,147. The high and low alternatives, consequently, produce total gross graduate inputs approximately 2,900 graduates apart. However, if Federal support continues at the high levels of the late 1960's and early 1970’s and the projected rate of increase matches the 1967-72 experience (about 8 percent a year), a total gross graduate input of 12,247 would result for the 1971-90 period. Utilizing the basic graduate projection outlined above, the supply of active podiatrists is expected to grow from 7,100 in 1970 to 8,500 in 1980 and to 13,000 in 1990. The number of active podiatrists is thus projected to rise 1,400 between 1970 and 1980, compared with an increase of only 100 from 1960 to 1970. Between 1980 and 1990, growth is projected to be more rapid—an increase of 4,500 or 53 percent, compared with 20 percent in the 1970-80 period and no gain between 1960 and 1970. The ratio of active podiatrists to population, which decreased between 1960 and 1970, is projected to increase slightly by 1980 (to 3.7 per 100,000) and then rise sharply to 5.2 per 100,000 population in 1990. (See Table 74.) Table 74. SUPPLY OF ACTIVE PODIATRISTS AND PODIATRIST/POPULATION RATIOS, USING BASIC METHODOLOGY AND ALTERNATIVE ASSUMPTIONS: ACTUAL 1960 AND 1970; PROJECTED 1975-90 Projection series 1960 1970 1975 1980 1985 1990 Number of active podiatrists BasicmethodolOogY . :: .nvemss i vmssims ss snnwms 7,000 7,100 7,500 8,500 10,300 13,000 Alternatives: LOW: wig ims elie 5.8 smimimns 8 8 imme Rh MEEHS 7,000 7,100 7,500 8,500 9,600 10,900 High Lo ee 7,000 7,100 7,500 8,600 10,500 13,800 Rate per 100,000 population” Basic methodology . .. ............ 0... 39 3.5 35 3.7 4.3 52 Alternatives: LOW wiih 2s 5 8 s si@ mms + 28 BEE 8 pomme s » 3.9 35 3.5 3.7 4.0 4.3 High: ec: ssnanamarsneser ss umsmmms 39 35 3.5 3.8 4.4 35 ! Resident population as of July 1 for 50 States and the District of Columbia. Source: 1960 active podiatrists: U.S. Department of Health, Education, and Welfare; Public Health Service; Bureau of Health Professions Education and Manpower Training. Health Manpower Source Book 20. Manpower Supply and Educational Statistics for Selected Health Occupations: 1968. Public Health Service Pub. No. 263, Section 20. U.S. Government Printing Office, 1969. 1970 active podiatrists: Koch, Hugo K. and Phillips, Hazel M. Podiatry Manpower: A General Profile. United States - 7970. DHEW Pub. No. (HRA) 74-1805. U.S. Government Printing Office, 1973. Population: U.S. Bureau of the Census. Current Population Reports. Series P-25, Nos. 468, 477, and 483. 109 Under the high alternative projection, the supply of active podiatrists would increase to 8,600 in 1980 and to 13,800 in 1990. This would represent a 21-percent increase between 1970 and 1980, and a 60-percent increase between 1980 and 1990. Under the low alternative, the supply of active podiatrists is projected at 8,500 in 1980 and 10,900 in 1990, or a 20-percent gain during the 1970-80 period and a 28-percent increase during the 1980-90 period. 110 The supply projection of active podiatrists in 1990 under the basic assumption yields a supply that is 2,100 (19 percent) more than the low estimate and 800 (6 percent) fewer than the high estimate. The low alternative yields a population ratio of 4.3 podiatrists per 100,000 in 1990, compared with 5.5 per 100,000 in the high estimate and 5.2 per 100,000 under the basic assumption. Chapter 9 © VETERINARIANS Data on veterinarians cover all active veterinarians in the 50 States, the District of Columbia, Puerto Rico, Virgin Islands, Canal Zone, and Guam. Those few American veterinarians who may be overseas are excluded. Although current estimates cover both Federal and non-Federal veterinarians, historical data provided for years prior to 1950 relate only to civilian workers. The primary sources of information on active veterinar- ians used here are the American Veterinary Medical Association (AVMA) and the 1960 and earlier population censuses. Not only are available trend data on active veterinarians severely limited, but the existing data base has serious gaps in coverage, since the AVMA collects data on its members only. Although some data on nonmembers has been collected, little or nothing is known about the location or activities of the estimated 15 percent of all active veterinarians not included in the AVMA data. All estimates by the Association and in this report are based on the known characteristics of those veterinarians in the AVMA master file. To derive the 1970 estimates used for characteristics data and as the base for the projections, it was necessary to build upon data published by the American Veterinary Medical Association on the age distribution of its members in 1965.) Nonmembers of the Association were assumed to have the same age distribution as members. The proportion of active veterinarians in each age group was assumed to be the same as the proportion of the total male population of the same age group who were in the labor force in that year.? Veterinarians 55 years of age and over were distributed into individual age groups on the basis of data on graduates (by year), which were also provided by the Association. In order to derive a December 31, 1970 estimate of active veterinarians, estimates were made of new entrants (i.e., graduates) and separations (i.e., deaths and retire- ments) to the active supply of veterinarians from the base period January 1, 1966 forward. Data on graduates of veterinary schools for each year were obtained from school reports on FY 1971 institutional grant applications. Begin- ning with the base year distribution by age, new graduates for each year were added to those veterinarians active as of January 1. Age-specific separation rates were then applied to the number of active veterinarians as of January 1, including new graduates. The estimated “losses” (deaths Age Distribution of Veterinarians with Projections to 1985. Journal of the American Veterinary Medical Association 146: 536-543, March 1, 1965. 2 Fullerton, Howard N. A Table of Expected Working Life for Men, 1968. Monthly Labor Review 94: 49-55, June 1971. 111 and retirements) each year were then subtracted by age group from the active pool, to bring the estimate up to December 31, 1970. Historical trends shown represent a combination o€ estimates and counts and should be used with caution. Individual tables provide detailed explanations and sources. The Bureau of Health Resources Development (BHRD) has contracted with the American Veterinary Medical Association to make recommendations on how best to improve the data base. The study will identify specific data gaps within the present veterinary manpower information system and recommend specific ways in which such gaps could be filled, including investigation of data available from resources such as State licensing boards, schools, and association membership lists. CURRENT CHARACTERISTICS AND TRENDS In 1970, there were an estimated 25,900 veterinarians actively engaged in practice in the United States. Veterinar- ians have a relatively young age distribution, with three out of five younger than 45 years of age in 1970, and thus expected to remain in practice over the next 20 years. One out of five veterinarians was under age 30, in contrast to only 4 percent 65 years of age and over. (See Table 75.) This relatively young age distribution reflects the large number of graduates of schools of veterinary medicine in the years after World War II. According to estimates based upon data from the 1970 Census of Population®, women accounted for 5 percent of the total active veterinarian work force in 1970. This is expected to rise substantially in the future, however, as a result of the recent increases in enrollment of females in veterinary medical schools. The American Association of Veterinary Medical Colleges reports that 9 percent of students enrolled in the 1970-71 academic year were women. Blacks are underrepresented in veterinary medicine, according to estimates based upon the 1970 Census of Population.* Slightly fewer than 2 percent of all active veterinarians were Black, about the same as in 1960. The proportion of persons of Spanish heritage was also rather small, fewer than 1.3 percent of the total active supply. Veterinarians are disproportionately located in the West North Central and Mountain divisions, which had higher 3 U.S. Bureau of the Census. United States Census of Popula- tion: 1970. Detailed Characteristics. United States Summary. Final Report PC(1)- D1. U.S. Government Printing Office, 1973. Ibid. Table 75. NUMBER OF ACTIVE VETERINARIANS, BY SEX AND BY AGE GROUP: DECEMBER 31, 1970 Number of Sex and age group active Percent gh distribution veterinarians Bothsexes ....«i5.+ +3 25,900 100.0 MIE oi v2 i im win elm m aie Sis Tow 24,600 94.9 Female ov vvs ss mmwmues ss 1,320 5.1 Alages ..amaimaesss 25,900 100.0 Less than 25 years ......... 580 2.2 25-44 years... 15,350 59.0 25:29 his hmmm. 4,940 19.0 3034 LL... 2,870 11.0 3539 vo ti creme an 4,180 16.1 40-44 LL 3,350 12.9 ASBAEYRAIS , + sc vv mnis 54 25 8,930 34.2 A549 os css swam vu pu 4,020 15.5 50:34 sv sss suwnmm ss ee 2,810 10.8 5559 suns smmmana vs vs 1,610 6.1 B064 us: pmmmas 55 oo 490 1.8 65 yearsandover . ......... 1,080 4.1 65-69 ........ 160 4.6 0:74... . + «wo wimwm v3 wa 260 1.0 75andover ........... 660 15 Source: Total active veterinarians: Based on data on members of American Veterinary Medical Association. Estimates by sex: Sex distribution of active veterinarians from 1970 Census of Population was applied to the estimated number of active veterinarians. Estimates by age: Based on data in: Age Distribution of Veter- inarians with Projections to 1985. Journal of the American Veteri- nary Medical Association 536,540-541,543; September 1, 1964. Note: Figures may not add to totals and subtotals due to in- dependent rounding. ratios of active veterinarians per 100,000 population than those in other geographic divisions, 25 and 19 per 100,000 respectively. The lowest ratio (8 per 100,000) was found in the New England division. However, veterinarian popula- 112 tion ratios should be used with caution. Veterinarians in many areas are much more proportional to large animals (herd counts) than to small animals, which can be viewed as essentially population-based. Among individual States, veterinarian/population ratios ranged from a high of 42 per 100,000 population in lowa to a low of 5 per 100,000 population in West Virginia and Rhode Island. In general, agricultural States with large numbers of farm animals served by veterinarians have the highest ratios of veterinarians to population. (See Table 76.) As shown in Table 77, more than two out of five veterinarians are primarily in small-animal practice, while one-fourth devote their practice to food animals. Nearly 8 percent are in meat inspection, 6 percent in teaching and research, and 5 percent in regulatory veterinary medicine. Although some veterinarians have secondary activities in which they spend some time, such splitting of practice would appear to be less than in some other health professions; veterinarians who devote their practice to small animals or to food animals do not often have an opportunity to cross over to another area of activity. Furthermore, there appears to be an increasing trend toward small-animal practice as the primary activity. Forty-seven percent of veterinarians who graduated in 1968-71 reported this activity to the Association, in contrast to 39 percent graduating 10 years earlier. Over the past four decades, the number of active veterinarians has more than doubled, increasing from 11,900 to 25,900. The largest part of the increase took place in the 1950’s when the number grew by 40 percent from 13,700 to 19,200. During this period, the ratio of active veterinarians to population rose from 9.1 per 100,000 to 10.7 per 100,000. By 1970, the ratio of active veterinarians to population had risen further to 12.6 per 100,000. (See Table 78.) As with the growth in active veterinarians in the 1960’s, enrollments in schools of veterinary medicine have in- creased sharply. In the last decade, total enrollment at veterinary medical schools increased by 50 percent, from 3,632 in 1962-63 to 5,439 in 1972-73. The number of graduates increased by 53 percent from 830 in 1963 to 1,271 in 1973. (See Table 79.) Table 76. NUMBER OF ACTIVE VETERINARIANS AND VETERINARIAN/POPULATION RATIOS, BY GEOGRAPHIC DIVISION AND STATE: DECEMBER 31, 1970 565-118 O - i Resident population Rate per Division and State Bilies of active July 1,1970 100,000 erinarians (in 1,000’s) population All locations . . . . o.oo vv ven. 25,900 206,708 12.5 United States, c sa wim s s sip mime es » 25,800 203,805 12.7 NEWENGLAND. . ........ coven 960 11,873 8.0 Connecticut . . . ov vv vv vit ce 250 3,093 8.1 Mang . «ons s sas sms ss mwwmmnn vw 100 995 929 Massachusetts « os wns +s s snwws sv os 390 5,699 6.8 New Hampshire . . . .. cc vv vv ven. 90 742 11.6 Rhodelsland. . conus snamuani sae 50 951 49 Vermont . . cv vv vv vv vt en een 90 447 19.7 MIDDLE ATLANTIC «vs savnwmmviss vn 3,120 37,271 8.4 New Jersey . . vs onm ss wwinwim sv eo % wi a 570 7,195 7.9 New YOrk. « vv vumassnanmas is nie 1,540 18,260 8.4 Pennsylvania . . . ........o vn. 1,010 11,817 8.5 SOUTHATLANTIC ,.....ccucssevws 3,530 30,772 11.5 Delaware . .c vs ss ss sansins ss nuns 80 550 14.2 District of Columbia .............. 80 753 10.8 Florida . .. vv viii ieee eee 850 6,845 12.4 Georgia ssw vp sm mun ¢ % vu bmn 620 4,602 13.4 Maryland : c so vss ssnwmpar s sauaes 640 3,937 16.3 NorthCarolina . . ; can ami ss nanos 410 5,091 8.0 SouthCarolind . .:. ovis vnssvnvenm 200 2,596 7.8 Virginia oo. 00 ieee eee 570 4,653 12.2 West Virginia. . . .. o.oo viii ono 90 1,746 51 EASTSOUTH CENTRAL ............. 1,350 12,823 10.5 AlRDAMA wv vn rs sums nm ss vomme an 440 3,451 12.8 Kemtuckys owns vs nmamn ss vmmmmne 350 3,224 10.9 MisSisSippl www + s ssn ems os sw mmww 210 2,216 9.7 Tennessee ...::savnmss nnpswias 340 3,932 8.7 WEST SOUTH CENTRAL . ............ 2,580 19,397 13.3 Arkansas . . oo. hie ieee ee eee 210 1,926 11.0 Louisiana wu ss sumwu vs swwmmmn +» 310 3,644 8.4 Oklahoma « + vs wns m es vammmmn vo 420 2572 16.3 TEXAS wv wnm es sn mamB es FH RBMBEE FE » 8 1,640 11,254 14.6 EASTNORTH CENTRAL . . ........... 5,010 40,368 12.4 HINOIS «vv ve ee ee ee eee eee 1,340 11,137 12.0 INDIANA © css mmmas cs ma mmmn ome 800 5,208 15.3 Michigan o + s sv sminm sp HCE E 555 vu 990 8,901 11.1 OhID ccc isnamamassvaemies es us 1,220 10,688 11.4 WISCONSIN. . : cosmos s prowess 28s By 670 4,433 15.0 WEST NORTHCENTRAL. ............ 4,100 16,367 25.0 JOWa «cs sume sa sume Em sss Puy 1,190 2,830 41.9 Kansas : . svsnvms sa vmees vs unm 610 2,248 27:1 MInHesolal Lesser snREwmns v4 CRED 780 3,822 20.4 113 74-9 Table 76. NUMBER OF ACTIVE VETERINARIANS AND VETERINARIAN/POPULATION RATIOS, BY GEOGRAPHIC DIVISION AND STATE: DECEMBER 31, 1970—Continued Nurmiber of active Resident population Rate per Division and State . July 1, 1970 100,000 veterinarians (in 1,000) population WEST NORTH CENTRAL —Continued Missouri, .. LL... LL... 760 4,693 16.2 NEDIaska « ais wv so a 5 sm mais « «0 ows 450 1,490 30.3 NorthDakota .................. 100 618 16.2 SouthDakota .................. 210 666 31.7 MOUNTAIN . . . Lin 1,620 8,345 19.4 Arizona... LL... ee 240 1,792 13.7 Colorado . .............¢civ... 590 2,225 26.6 1A2NO . & os ssn msm se smn EEE es nay 160 717 22.9 MONtana .; .xeuuimssniibianin es us 190 697 26.7 NEVAOR «a + s ss swio ss sms wme ss un 80 493 17.2 New Mexico . .................. 140 1,018 14.1 Utah ....... iii. 120 1,069 11.3 Wyoming... ...... iii... 90 334 26.0 PACIFIC , uve s ssamamas simsmmme sas 3,590 26,589 13.5 AlaSRE: ovis ¢ 2 3.88945 Bm ma cmd ss 20 305 7.9 California. . ................... 2,560 19,994 12.8 Hawaii ...................... 70 774 8.8 Oregon . .. oui i iii ee 320 2,102 15.3 WshINBION uv s sww sin 4.5 mE Emi do 610 3,414 17.9 PUBHIO RIC + voc vd 23 mm mmio wm s oo dein 60 2,712 2.2 Virginlslands . . . ................. (1) 62 - Canal Zone ........iiiiiinnnen.. 10 44 27 GUAM ttt tte te eee eee (1) 85 - ! | ess than 5. Source: Active veterinarians: American Veterinary Medical Associatior ) Population: U.S. Bureau of the Census. Current Population Reports. Series P-25, No. 468. United States Census of Population: 1970. Number of Inhabitants. Canal Zone, Guam, Puerto Rico, Virgin Islands. PC(1) - 53A, 54A, 55A,57A. U.S. Government Printing Office, 1972. Note: Figures may not add to totals and subtotals due to independent rounding. 114 Table 77. NUMBER OF ACTIVE VETERINARIANS, BY MAJOR PROFESSIONAL ACTIVITY: DECEMBER 31,1970 Number of 5 Number of : 2 Lo. f Percent i : ih , Percent Major professional activity active SStTiba tion Major professional activity active distribution veterinarians veterinarians All activities +... .... 25,900 100.0 Military veterinary medicine . . . 800 31 Regulatory veterinary medicine . 1,270 4.9 Food animal practice . ....... 6,430 24.8 Meat inspection . . . ... 1,940 7.5 Small animal practice . ....... 11,280 43.5 Industrial veterinary practice. . . 520 2.0 Equine practice ........... 830 3.2 Teaching and research. . . . . . . 1,660 6.4 Laboratory animal practice . . . .. 360 1.4 Other « cc cvvssseens oss 540 2.1 Publichealth ............. 280 1. Source: Based on data in: National Research Council, Committee on Veterinary Medical Research and Education. New Horizons for Veterinary Medicine. Washington, National Academy of Sciences, 1972. Note: Figures may not add to totals due to independent rounding. Table 78. TREND IN NUMBER OF ACTIVE VETERINARIANS AND VETERINARIAN/POPULATION RATIOS: SELECTED YEARS 1930-70 Your Number of active Population” A rare veterinarians” ’ (in 1,000’s) : ’ population 19302. 0 ta 11,863 122,775 9.7 THD, vam rE hE EE 11,068 131,669 8.4 19508 sv umm sr mmm ed BET EEE 13,679 150,697 9.1 1959 + te eee 419,200 179,386 10.7 1966 wvniws sss mnie ce vmwwmane § 5 22,900 197,656 11.6 1968 conn s srr mmEm re Fema oo 24,300 201,678 12.0 1969 ........ CEB BAER EE ee vy 25,100 203,777 12.3 TOTO wv «vv vam asn sts simmnin ss bv 5 25,900 206,017 12.6 ! For 1930, data are for civilian gainful workers; for 1940-50, data cover experienced civilian labor force; figures for 1959-70 cover Federal and non-Federal veterinarians in the United States. 2 Data for 1930-50 are as of April 1; 1959-70, December 31. 3 Excludes data for Alaska and Hawaii. 4 The 1960 Decennial Census of Population provides a figure of 14,906 active veterinarians, which would yield 8.3 per 100,000 population. 5 The 1970 Decennial Census of Population provides a figure of 19,435 active veterinarians, which would yield 9.4 per 100,000 population. Source: 1930-50 active veterinarians: Kaplan, David L. and Casey, M. Claire. Occupational Trends in the United States 1900 to 1950. Bureau of the Census Working Paper No.5. U.S. Department of Commerce, 1958. 1959 active veterinarians: U.S. Department of Health, Education, and Welfare; Public Health Service; Bureau of Health Professions Education and Manpower Training. Health Manpower Source Book 20. Manpower Supply and Educational Statistics for Selected Health Occupations: 1968. Public Health Service Pub. No. 263, Section 20. U.S. Government Printing Office, 1969. 1966-70 active veterinarians: Based on data on members of American Veterinary Medical Association. 1930-50 population: U.S. Bureau of the Census. Statistical Abstract of the United States 1966. U.S. Govern- ment Printing Office, 1966. 1959-70 population: U.S. Bureau of the Census. Current Population Reports. Series P-25, Nos. 368, 456, and 475. 115 Table 79. TREND IN NUMBER OF SCHOOLS, ENROLLMENTS, AND GRADUATES FOR VETERINARY SCHOOLS: ACADEMIC YEARS 1960-61 THROUGH 1972-73 Academic year Number of Total First-year Graduates’ schools enrollment enrollment 1960-61 ........ iii 18 3,497 983 824 1961-62... iii iii ee 18 3,528 1,001 819 1962-63... . 18 3,632 N.A. 830 M6368 , os vows ww SHB RE RE 53 23 18 3,727 1,059 834 196465 «1: svomames sown awd ss as 18 3,864 1,139 874 196566 « ss ssmmumis smomnamss se 18 -4,119 1,242 910 1966-67 ........¢0ovvvrvnunnnnn 18 4,388 1,305 963 1967-68 ......... ivi 18 4,623 1,315 1,064 1968-69 . ........ ii. 18 4,779 1,311 1,129 1969-70 . . oii ii 18 4,876 1,339 1,165 1970-71 «oo ee 18 5,006 1,430 1,239 197372 nn ss smmumas susie Ens s.0 18 5,149 1,453 1,258 1972-73 Litt i i ite eee 18 5,439 1,580 1,271 i Senior students. Source: Journal of the American Veterinary Medical Association 163: 36, July 1, 1973. Also prior annual issues. PROJECTIONS OF THE SUPPLY OF VETERINARIANS TO 1990 Projections of overall supply of active veterinarians are presented here under several different assumptions as to the graduate input over the projection period. METHODOLOGY AND ASSUMPTIONS Estimates of the number of active veterinarians fol 1971-90 were calculated using essentially the same method: ology as for estimating the December 31, 1970 figure; i.e., by adding new graduates and applying age-specific separa- tion rates to the veterinarian pool on a year-by-year basis. Data on graduates of veterinary medical schools for 1971 were obtained from school reports on FY 1972 capitation grant applications; the applications also provided estimates of projected first-year enrollments and graduates through 1974-75. Graduate data up to 1978 were computed from the number of first-year students reported 4 years earlier, utilizing an attrition (or dropout) rate of 7 percent (in both the basic methodology and the alternative supply projec- tions) as indicated by the experience of recent years.’ Thus 93 percent of entering veterinary students are assumed to 5 No separate adjustment was made for 2 schools with 3-year programs. 116 graduate 4 years later. Graduate projections for 1977 and beyond also include graduates of the Louisiana State Veterinary Medical School which opened in 1973. Although projected estimates of supply will vary with different attrition rates, slight variations in the dropout patterns of veterinary medical students have only a minor impact on the overall supply estimates. Under the basic methodology, for example, if attrition were reduced to 6 percent, only about 360 additional graduates would be expected over the entire projection period. Separation rates used in the basic methodology and in the alternative approaches were derived from age-specific rates for males developed by the Department of Labor.” In comparing Department of Labor data showing age-specific proportions of the total male labor force that are inactive to the age-specific proportions of veterinarians that are inactive, as obtained from the 1971 AVMA membership data, it was revealed that a lower proportion of veterinar- ians were inactive for all age groups. This suggested that the pattern of retirements for veterinarians is different than that of the general labor force. Hence, a series of adjustment factors was obtained by dividing the proportion of inactive veterinarians for each age group by the proportion of the total male labor force that is inactive for ¢ Unpublished material prepared by Maryland Y. Pennell and Willard H. Eyestone, Bureau of Health Professions Education and Manpower Training. Fullerton, Howard N., op. cit. corresponding age groups. These “conversion” factors were then applied to published age-specific retirement rates for males in the labor force in order to obtain age-specific retirement rates that seemed to be more representative for veterinarians. The overall consequence of the utilization of “veterinarian-specific’’ retirement rates was that retirements were reduced by approximately one-third over the projec- tion period, compared to the number estimated to be retiring if the unadjusted series were used. There was no evidence to suggest that veterinarians, on the average, live longer than does the general labor force. Consequently, age-specific mortality rates developed by the Department of Labor for all working males were applied to veterinarians. The final age-specific separation series repre- sented the sum of individually computed age-specific retirement and mortality rates. The basic determinant of the future supply of veterinar- ians is very clearly the enrollment in schools of veterinary medicine. As indicated earlier, veterinary enrollment has increased rapidly since the early 1960's. In projecting the active supply to 1980 and 1990, three assumptions related to the output of graduates of veterinary medical schools after 1978 were used. The basic assumption underlying the projections of veterinarians to 1990 is an increase in first-year enrollment after 1975 similar to the increase achieved by the schools prior to the initial Federal legislation. The assumption was made that, beginning in 1975-76, first-year enrollment would increase annually at a rate equivalent to that experienced in the 13-year period prior to enactment of the Veterinary Medical Education Act of 1966 (about 1.8 percent annually). The increase during this period was viewed as a reasonable parameter for a future period when it is assumed that there would be no massive Federal programs aimed at increasing enrollment in veterinary medical schools. Two alternative assumptions as to graduate additions were also made. First, as a low projection, the number of graduates after 1978 was held constant, on the assumption that there would be no further increases in first-year enrollment after 1974-75, coincident with expiration of the Comprehensive Health Manpower Training Act of 1971. This means that a combination of public and private funding would be continued in such a form that increases in enrollment achieved under the Act would be maintained but that no further increases in enrollment would be forthcoming. (See Table 80.) The second or high estimate assumed that the rate of increase in first-year enrollment beyond 1974-75 would be midway between the average rate of increase in first-year enrollment experienced by existing veterinary medical schools from the 1967-68 to 1971-72 academic years and the average annual rate of increase under the basic 117 methodology. Consequently, this alternative calls for an average annual increase in first-year enrollment of 3 percent. In contrast to the basic methodology, this alterna- tive assumes increases in enrollment greater than that experienced in the 13-year period prior to the initial legislation. However, the rate of increase would not be of the magnitude achieved under legislation since 1967. In order to better interpret increases in the projected number of enrollees, one can view the projections in terms of an enrollees-per-school measure. The basic methodology assumes increases in first-year enrollment at levels com- parable to those achieved by schools before the initial legislation relating to veterinary medicine. An increase in first-year enrollment per school of 39 percent from 1970-71 to 1986-87 is projected under the basic method- ology (from 79.4 to 110.5 enrollees per school). This would appear realistic when historical trends are considered. The first-year enrollment per veterinary school in 1960-61 averaged 54.6. The increase to the 1970-71 academic year was 45 percent over the 10-year period. (See Table 79.) It should be noted that all 18 veterinary schools were at “normal” enrollment throughout the period, having classes at all levels of the educational program. The projections include the opening of only one new school in 1970-80; namely, Louisiana State University during the 1973-74 academic year. On the basis of historical trends prior to the advent of Federal legislation it was assumed that no other schools of veterinary medicine would open during the projection period. To determine whether schools in exist- ence in 1960 or earlier were operating at full capacity at that time or whether the projections of future enrollment imply full capacity, is difficult. It should be noted, however, that the utilization of existing facilities over a greater part of the calendar year and certain modifications in the curriculum would permit the existing schools to serve a greater number of students without necessarily having to increase the physical size of the school. PROJECTION FINDINGS The basic methodology projection for the graduating classes of 1970-71 through 1989-90 results in a total gross graduate input of 32,423 for that period. The low alternative projects a total gross graduate input of 30,044 and the high projects 33,987. The high and low alternatives consequently produce total gross graduate inputs approxi- mately 3,900 graduates apart. If Federal spending should continue at the high levels of the late 1960’s and early 1970’s and the projected rate of increase were to match the 1967-71 experience (about a 5 percent increase yearly), a total gross graduate input of 37,100 would result for the 1971-90 period. Table 80. FIRST-YEAR ENROLLMENTS AND GRADUATES IN VETERINARY SCHOOLS UNDER BASIC AND ALTERNATIVE ASSUMPTIONS: ACTUAL 1970-71 AND 1971-72; PROJECTED 1972-73 THROUGH 1989-90 First-year enrollment Graduates Alternative Alternative Academic year Basic assumptions Basic assumptions methodology methodology Low High Low High THI07T nis vis nwnmumnmis spwmmne « 3 Huw 1,432 1,432 1,432 1,239 1,239 1,239 WTTT2 vain is sin TmBan + oka m Rin 40 gigi m 1,453 1,453 1,453 1,252 1,252 1,252 197273 suns vonomnnssuuvnn id nase 1,575 1,575 1,575 1,266 1,266 1,266 1973-74 © oo ee 1,657 1,657 1,657 1,381 1,381 1,381 197478 cuninsssnamim is hmmmmas pone 1,695 1,695 1,695 1,412 1,412 1,412 1975576 oun ss numunmss busses oss 1,726 1,695 1,746 1,465 1,465 1,465 1976-77 © ot eee ee 1,757 1,695 1,798 1,541 1,541 1,541 1977578 inmin 5 3 Siam GES so mE isin» nan 1,789 1,695 1,852 1,576 1,576 1,576 19787 tv vinv ss maT am» «mw «aa 1,821 1,695 1,908 1,605 1,576 1,610 197980 cvuv sv nnnnvn rr smn es aa 1,854 1,695 1,965 1,634 1,576 1,659 1980-81 «viii ee 1,887 1,695 2,024 1,664 1,576 1,708 19BIBY vn ss ppm maim ¢.6 5 8% 5ie 6 § 58 1,921 1,695 2,085 1,694 1,576 1,759 1983283 .vunuv ts navn miss enw ais ua 1,956 1,695 2,148 1,724 1,576 1,813 198384 ununissmamnmmes snnmmns os 1,991 1,695 27212 1,755 1,576 1,867 1934-85 , innit ss mmimmmuis vimmmin ws on 2,027 1,695 2,278 1,787 1,576 1,923 1985-86 . viii ee 2,063 1,695 2,346 1,819 1,576 1,981 1986-87 . oie 2,100 1,695 2,416 1,852 1,576 2,041 VIBTBB , vohuwws rpm nmme ss nuEmas ss — wo - 1,885 1,576 2,101 19888Y . .uwumsssnsiommmeis nmmuas ss — — — 1,919 1,576 2,164 19BID0 ss mamwo vs osname Vomwinni os — - — 1,953 1,576 2,229 Source: 1970-71 through 1972-73 first-year enrollments: Applications for capitation grants submitted to BHRD. 1970-71 through 1974-75 graduates: Applications for capitation grants submitted to BHRD. Under the basic assumption outlined earlier, the supply of active veterinarians is projected to grow from 25,900 in 1970 to 36,400 in 1980 and to 48,100 in 1990, as shown in Table 81. The growth in active veterinarians is thus projected at 10,500 between 1970 and 1980 compared with a 6,200 increase between 1960 and 1970. This is a somewhat larger percentage increase than that experienced in 1960 to 1970—41 percent as compared with 31 percent. Between 1980 and 1990, growth is projected to be less rapid—a 11,700 increase, or 32 percent. The ratio of active veterinarians to population, which rose between 1960 and 1970, is projected to continue to rise sharply. The ratio is projected to reach 16 per 100,000 population in 1980 and 118 19 per 100,000 in 1990, as compared with a ratio of 13 in 1970. Under the high alternative projection, the supply of active veterinarians is projected to increase to 36,400 in 1980 and 49,600 in 1990. Under the low alternative, the supply of active veterinarians is projected to be 36,300 in 1980 and 45,700 in 1990. The supply projection of active veterinarians in 1990 under the basic assumption thus yields a supply that is 2,400 more than the low estimate, and 1,500 fewer than the high estimate. The low alternative yields a population ratio of 18 veterinarians per 100,000 in 1990, compared with 20 per 100,000 in the high estimate and 19 per 100,000 under the basic assumption. Table 81. SUPPLY OF ACTIVE VETERINARIANS AND VETERINARIAN/POPULATION RATIOS, USING BASIC METHODOLOGY AND ALTERNATIVE ASSUMPTIONS: ACTUAL 1960 AND 1970; PROJECTED 1975-90 Projection series 1960 1970 1975 1980 1985 1990 Number of active veterinarians Basic methodology . sisamsss ss snma® sv 8 60 ® ew 19,700 25,900 30,700 36,400 41,100 48,100 Alternatives: LOW. ube mie co sphumnmshoh on » 31 0a bs ioldish: 0 22% edn ver 9 19,700 25,900 30,700 36,300 41,300 45,700 Higho vomwes so prammes s sms vws se enw ss 19,700 25,900 30,700 36,400 42,600 49,600 Rate per 100,000 population’ Basic methodology . .........¢c. iin 10.9 12.7 14.3 16.0 17.6 19.2 Alternatives: LOW summsssmuammass Sammme ss smn 10.9 12.7 14.3 16.0 17.3 18.2 Bigh sommes ss mnmaad sss nmmss ss siemens 10.9 12.7 14.3 16.0 17.8 19.8 ! Resident population as of July 1 for 50 States and the District of Columbia. Source: 1960 and 1970 active veterinarians: Based on data from the American Veterinary Medical Association. Population: U.S. Bureau of the Census. Current Population Reports. Series P-25, Nos. 468,477, and 483. 119 Chapter 10 ¢ REGISTERED NURSES This chapter presents data on active registered nurses in the 50 States and the District of Columbia; registered nurses who may be overseas or in the territories are excluded. Historical data cover all registered nurses in practice, including both Federal and non-Federal personnel, although data prior to 1960 exclude Alaska and Hawaii. Biennial national estimates of active registered nurses have been developed by the Interagency Conference on Nursing Statistics for 1954 and 1965, based largely on counts made by the employers of nurses (in contrast to the self- enumeration questionnaire method of the periodic inven- tories!. When it became evident that annual estimates were needed for planning purposes, the Conference agreed to make such estimates by subtracting net attrition from, and adding new graduates to, the previous year’s supply. Following release of data? from national inventories and from current surveys of the various fields of nursing, the current estimates are reexamined, differences analyzed, and adjustments made if necessary. The full-time and part-time components of the nursing supply are based on the results of hospital nursing surveys®, public health nursing counts?, nurse-faculty census reports’, State surveys®, and special studies. The Interagency Conference estimates refer to January 1 of each year, but for purposes of this report, the reference date is noted as December 31 of the previous year; e.g., January 1, 1972 = December 31, 1971. Data on age distribution and distribution by location of active registered nurses were obtained directly from the lus. Department of Health, Education, and Welfare; Public Health Service; National Institutes of Health; Bureau of Health Professions Education and Manpower Training; Division of Nursing. Health Manpower Source Book 2. Nursing Personnel, Public Health Service Pub, No. 263, Section 2. U.S. Government Printing Office, revised 1969. American Nurses’ Association. RN’s 71966. An Inventory of Registered Nurses, New York, The Association, 1969. 3 us. Department of Health, Education, and Welfare; Public Health Service; National Institutes of Health; Bureau of Health Professions and Manpower Training; Division of Nursing. Nursing Personnel in Hospitals - 1968. U.S. Government Printing Office, May 1970. 4 us. Department of Health, Education, and Welfare; Public Health Service; National Institutes of Health; Bureau of Health Professions and Manpower Training; Division of Nursing. Nurses in Public Health. Public Health Service Pub. No. 785. U.S. Government Printing Office, revised 1969. National League for Nursing. Nurse-Faculty Census, New York, The League, 1970. Biennial editions. Sus. Department of Health, Education, and Welfare; Public Health Service; National Institutes of Health; Bureau of Health Manpower Education; Planning for Nursing Needs and Resources. DHEW Pub. No. (NIH) 72-87. U.S. Government Printing Office, 1972 121 1966 Inventory of Registered Nurses. These distributions were not applied to the 1970 total estimate of registered nurses. To derive the 1970 estimate of fields of employ- ment, the percent distributions of nurses in private duty, office, and occupational health fields obtained from the 1966 inventory of registered nurses were applied to the 1970 estimate of active registered nurses as obtained from the Interagency Conference. Other field-of-employment categories were estimated from employer counts. Although some differences undoubtedly exist between the patterns of location and employment of newly registered nurses (1966-70) and those registered in earlier years, no data are available specifically on patterns of location and employ- ment of registered nurses entering the labor force since 1966. The Division of Nursing, Bureau of Health Resources Development, has contracted with the American Nurses, Association to conduct a current inventory of registered nurses in conjunction with the license renewal procedure. However, since licensure renewal dates cover a 2-year period, data from the inventory are not expected to be available until late 1974. Proposed contracts to develop a nurse manpower data collection capability for Puerto Rico, Virgin Islands, and Guam are expected to produce reliable baseline data from which estimates and projections can be made by 1975. Furthermore, a number of projects are being developed to explore ways of improving the current data base for R.N.’s. CURRENT CHARACTERISTICS AND TRENDS In 1970, there were approximately 723,000 registered nurses actively engaged in practice in the United States. According to the 1966 Inventory nearly one-half of all R.N.’s were under 40 years of age, and 15 percent 55 years of age and older. The median age in 1966 was 40.3 years. (See Table 82.) According to the 1966 Inventory, only about 7,000 active registered nurses, or 1 percent of the total, were men. However, recent increases in enrollment of males in initial programs of nursing suggest that this proportion is expected to rise somewhat in the future. The National League for Nursing reports that in academic year 1971-72, 5.5 percent of admissions in programs of registered nursing were men.’ 7 American Nurses’ Association. Facts About Nursing, A Statisti- cal Summary. 1970-71 edition. New York, The Association. Table 82. PERCENT DISTRIBUTION OF ACTIVE REGISTERED NURSES BY SEX AND BY AGE GROUP: 1966 Sex and age grou Percent ge group distribution Bothsexes ,uuwwassovmane iss 100.0 MAE i viind ssn sammemmn » ma 1.1 Female ....................... 98.9 Aages .,.sosmussssuvmmmes ss 100.0 Lessthan25 years ................. 11.0 25-44 years Lo. uous 49.3 2529 vvwn ss vmE RE TE tr HEE EE AE 14.5 3034 svn ss num v as is MEE EF 11.4 B53 wuinin sb smu mak em mie» xb 10.8 40-44 . . .. cirri resis 12.6 45-64 years... . ieee eee 335 45-49 LL Lee 10.9 BOB4 ovine susimema ts HUBEEA SS 9.4 5589 soins sansa s si ur mms dss 8.4 BOB ivini vi nvmta sa mmm 4.8 65yearsandover ............ 0.0... 3.1 Notreported . . . .................. 3.1 Source: American Nurses’ Association. RN’s 1966. An Inventory of Registered Nurses. New York, The Association, 1969. Blacks comprised less than 6 percent of employed professional nurses in 1960, according to the 1960 Census of Population.® As Blacks accounted for only 7.5 percent of the admissions in initial programs of nursing in 1971-72 and only slightly more than 5 percent of nursing graduates in that year, it is not believed that the proportion of Blacks in the nursing profession has changed significantly since 1960.° In 1966 the inventory showed that registered nurses were disproportionately located in the New England and Middle Atlantic divisions which had ratios of 509 and 395 respectively. The lowest ratio (176 per 100,000) was found in the East South Central division. Among individual States, registered nurse/population ratios ranged from a high of 536 per 100,000 population in Connecticut to a low of 133 per 100,000 population in Arkansas. (See Table 83.) In 1970, it was estimated that over 500,000 registered nurses, or 7 out of every 10, were employed in hospitals, 5 U.S. Bureau of the Census. United States Census of Popula- tion: 1960. Detailed Characteristics. United States Summary. Final Report PC(1)-1D. U.S. Government Printing Office, 1963. 9 Facts About Nursing, op. cit. 122 nursing homes, and related institutions, as shown in Table 84. Seven percent were in public health, 4 percent in nursing education, and 3 percent were in occupational health. Approximately 113,000 nurses, or nearly 16 per- cent of the total, were in private duty, office nursing, or fields of employment not separately identified. Over the last two decades, the number of active registered nurses increased by more than 90 percent, from 401,600 in December 1953 to 777,000 in December 1972. The growth in registered nurses was substantially faster than the population growth, and the ratio of active registered nurses to population rose from 250 to 372 per 100,000 population in that period. (See Table 85.) During the 1960's, enrollments in initial programs of nursing increased sharply, corresponding to the growth in active registered nurses during the period. As shown in Table 86, total enrollment increased from 118,800 in 1960-61 to 213,100 in 1972-73, or by 79 percent. The number of graduates increased by more than 70 percent during this period, from 30,300 in 1961 to 51,800 in 1972. PROJECTIONS OF THE SUPPLY OF REGISTERED NURSES TO 1990 Three projections of the supply of active registered nurses (R.N.’s) are presented here, using different assump- tions relating to graduate input over the projection period as well as some variation in the techniques utilized. Two major variables were used for these projections: (1) the numbers of new graduates from U.S. nursing schools which prepare students for licensing examinations (includes 50 States and the District of Columbia for purposes of these projections); and (2) withdrawal rates from the profession. It should be noted that a few terms used in the remainder of this chapter may differ in meaning from those found in other chapters of this report. Specifically, attrition of nursing students is described in terms of ‘completion rates,” and separation rates are described in terms of “withdrawal and net attrition rates’. The numbers of graduates from initial nursing programs for academic years 1970-71 and 1971-72 were obtained from the National League for Nursing’s annual survey of nursing schools.'® Estimates of graduates from diploma programs for 1972-73 and from baccalaureate programs for 1972-73 and 1973-74 were derived from prior admissions reported in the annual surveys, utilizing completion rates specific to each program. 10 National League for Nursing. State-Approved Schools of Nursing—RN, 1973. New York, The League, 1973. Table 83. NUMBER OF EMPLOYED REGISTERED NURSES AND NURSE/POPULATION RATIOS, BY GEOGRAPHIC DIVISION AND STATE: 1966 Number of Resident population Rate per Division and State employed July 1, 1966 100,000 registered nurses’ (in 1,000’s) population UNITED STATES . .:vovunsssnvamans 613,188 195,936 313 NEWENGLAND .. ic iiivsannissnnmensrsnnnmnn 57,262 11,244 509 Connecticut . ......... 000i nnsvrrnnnnnssas 15,438 2,878 536 MEINE «ov + vo msm Lr MERE PEE EEE LE BRE 4,051 978 414 Massachusetts + vous ss nora mss nama ma ss nmmei 28,743 5,403 532 NeWHampshite sv usw ss summa sta mamues 30 umm 3,521 676 521 Rhodelsland ............ 0. nenenn 3,673 898 409 VeIMORL « s vocnmmnin ss mimmmos 2s mmwmms ess sews 1,836 411 447 MIDDLE ATLANTIC iv. ssvmunsssomwmmwans 145,031 36,705 395 New Jersey ..uvwas sss snonms ss no nahaes oumams 24,942 6,899 362 NEW YOK vt vs tmnnd 48 so mmaimdd bn brimmed 4 ni 74,280 18,205 408 Pennsylvania . . . . . .. ci ii eee 45,809 11,601 395 SOUTH ATLANTIC . ........ iin. 78,450 29,105 270- Delaware . . . oo vv tt ete ee ee ee eee 2,098 513 409 Districtof Columbia « + + sso wes ss vo wmis os» 3,662 806 454 Florida . cs sana ss avssems snneains sss mens 21,760 5,893 369 Georgia. +: sv nanBn ds 3s HAMAR ELAN BE ES GEES 6,956 4,445 156 Maryland : c comand + 4M oB EAR FRR ERETS 605 E EB 10,005 3,611 277 North Carolina . .......... iii irennnenns 12,126 4,974 244 SouthCarolina ........... iii iii. 5,625 2,589 217 VIBINR comumme ss sommes s ¢ o/s ®ws 08 9500 ees 11,511 4,465 258 WestVirginla coun s es ssvsnsssomnien ses npnens 4,707 1,809 260 EASTSOUTH CENTRAL sav smasssamama ss 22,634 12,894 176 AlaDAMA. ; i isimir ss PMA BRR Es RRA r rs RnB Tw 5912 3,511 168 KENIUCKY » vm miso v2 Bim F ER 5 mm Ro a a ow down § 6,297 3,181 198 MISSISSIPPI «vv vv ht ee ee ee ee ee ee eee eee 3,670 2,337 157 TENNESSE . vv wv ts spn wms es sw mwas es bmw 6,755 3,866 175 WEST SOUTH CENTRAL ; s sas ww +s sp ainmnmm os 34,184 18,795 182 ArTKansas : «ss amn ii nhs FFAS LBA ERR TARE ARES 2,609 1,956 133 Louisiana. . «vv vv tit ti ee i ee eee 6,758 3,617 187 Oklahoma . oo vit iti ee eee 4,650 2,477 188 TeXaS o ; s sevmws ss PEvmE Ts FEMURS £5 be BEB HE EF 20,167 10,747 188 EAST NORTH CENTRAL ; + cova i avummi sss 118,555 38,736 306 HHINOIS 4 ont dino o smmmBion s pismo a ss nbmiain os 35,552 10,786 330 Indiana... eee 12,829 4,951 259 Michigan «sas es cs snnmwmmes ssnmmsssenmnmnss 23,441 8,468 277 ONO tsvmuwnwms ss names s HEN E 35 PaO gous § + 32,649 10,364 315 WISCONSIN: vv s5 ss ss Ss BEB s oo ABE E 2 2a TERETE F § 14,084 4,167 338 WEST NORTHCENTRAL. . .xuvevosnnnnss ns 51,541 15,933 323 JOWA" ( vvnimnnm sv bwwmmun sv onmuies ¢ veywemy «ly 9,981 2,760 362 Kansas. . «ov vt it te eee 6,895 2,275 303 MINNeSOta +. uv s srr mss s vu Rss ss Hmm EET S $y 14,441 3,572 404 MiSSOUrl + vues 550 nu EE 11,291 4,564 247 See footnote at end of table. 123 Table 83. NUMBER OF EMPLOYED REGISTERED NURSES AND NURSE/POPULATION RATIOS, BY GEOGRAPHIC DIVISION AND STATE: 1966—Continued Number of Resident population Rate per Division and State employed July 1, 1966 100,000 registered nurses’ (in 1,000’s) population WEST NORTH CENTRAL —Continued Nebraska «+ « save ns ss np EsE I yRARARE 2 EL 020 4,730 1,439 329 NorthiDakota, : suns not 1s as md 33 BARBRA L 8 0 HO HD 2,114 643 329 SOUthDaKOta ; suswms ssi Lams Es LREME 5S + & 0a os 2,089 679 308 MOUNTAIN © Le tt et ee te et ee eee eea oe 25,738 1.717 334 AFiZONa oie ee ee ee eee 5,862 1,603 366 Colorado . . out vite ee ee eee 8,312 1,955 425 JAAN + vv vs sss CE mE ETE Ss BBE ES EF SEE 1,954 697 280 MONIANA , uss snus ns s memos sss Ha mnis sss name 2,483 702 354 Nevada vv vss rmimw RE FLUE RAE 9? RAMEN EE LTE 1,060 431 246 NeW MEXICO « + ovum 2 FREE 43 HU BATHE 3 $3 HE 25M 1,002 250 Utah commis sanaum irs RAnnm 14 REA RE AE 3 RHE S 2,347 1,007 233 WYOMING « « « « sais wimms ss naman sss anand sss sins 1,209 319 379 PACIFIC . oe ieee ee 79,793 24,807 323 Alaska, ovo cc npn sme + I HERR EEA NEE BEES SEE 590 265 223 Callfornia, « s + vss RB PR + LER ERA IS HERE R IES BETES 58,694 18,802 312 Hawalle vox : 4 Sop B BF 3 2 MEANS 3 bo ES Tad bmn a 2,334 727 32 Oregon . .... titi titi tres eres serenennnen 6,814 1,973 345 Washington . .. .. iii ite 11,361 3,040 374 i Adjusted for nonresponse. Source: Employed registered nurses: American Nurses’ Association. RN’s 1966. An Inventory of Registered Nurses. New York, The Association, 1969. Population: U.S. Bureau of the Census. Current Population Reports. Series P-25, No. 380. Note: Figures may not add to totals and subtotals due to independent rounding. The withdrawal rate from the profession (or the annual Taie:34, net separation-attrition rate) represents a combination of NUMBER OF ACTIVE REGISTERED NURSES, BY FIELD OF gains and losses to the supply in one figure. The rate EMPLOYMENT: DECEMBER 31, 1970 accounts for losses during the year due to resignation, retirements, death, or inactive status, as well as gains Number of Pelcent through the return to practice of nurses formerly inactive Field of employment registered | distribution and through the addition of foreign-educated nurses nurses licensed in this country by endorsement. Reported as “inactive” are those R.N.’s who are continuing their’ education on a full-time basis. The numbers of foreign- Al Bolds ov 42s 3 wnat ais ——foo 00 educated nurses working in this country (a gain included in Hospital, nursing home, and the net attrition rate) could be estimated from the numbers is gion oll 0 as 30500 yi of new licenses issued where individual States do not Nursing education ne schoo! A 31,000 43 require all applicants to pass the State Board examination. Occupational health. . . . . ...... 20,000 2.8 This group represents only about 4 percent of the total Private duty, office nurse, and other. . 113,000 15.6 active R.N. supply. It should be noted, however, that more Source: BHRD, Division of Nursing. 124 Table 85. TREND IN NUMBER OF ACTIVE REGISTERED NURSES AND NURSE/POPULATION RATIOS: SELECTED YEARS DECEMBER 31, 1953-72 Number of Resident Active registered Year active registered population nurses per 100,000 nurses (in 1,000’s) population 1053, im vimts EAE EE REBT REE 401,600 160,492 250 Y955 vas mma MEERA Ph ME 430,000 166,725 258 VIET Le ve ns pwr nk maka EERE 460,000 172,809 266 5 2 1 A 504,000 178,729 282 FOB). iin ie 8 § www Wwe ewe a a a 550,000 184,480 298 1968. vi vis snmsaB FINEST RES EB OLS 582,000 189,922 306 53, TNE J J J Ep pgp png gg 621,000 194,578 319 1968: vvv + + sms wmnin rs ummnas v5 LHR BED 640,000 196,516 326 | 1-7 J 659,000 198,492 332 1968. vss ss vans iem « Bu ww mas o bor 680,000 200,415 339 LL EE ES TELE 700,000 202,617 345 VOTO: cv cv vmmmits fs RE RHE EES HM EWE 723,000 205,056 353 197 ics + tran ts mE RE AE ERE EEE 748,000 207,336 361 YGT2e vo so vwm mw sss mma vo wm EEE 777,000 209,123 372 1 Excludes Alaska and Hawaii. Source: 1953-70 active registered nurses: American Nurses’ Association. Facts About Nursing. A Statistical Summary. 1970-71 edition. New York, The Association, 1971. 1971, 1972 active registered nurses: BHRD, Division of Nursing. Population: U.S. Bureau of the Census. Current Population Reports. Series P-25, Nos. 465, 475, and 509. and more States are requiring the examination, which may account for some of the decrease in numbers of licenses issued by endorsement of a certificate from a foreign country. In this report, the net annual attrition rate is computed at intervals from actual supply figures at two points in time, according to a formula developed by Dr. Nathan Jaspen.'* In a 1968 article, Folk and Yett discuss this formula and also compare the results of applying various projection methods to the fields of engineering and nursing.! 2 Between 1950 and 1956, the estimated net attrition rate was approximately 5 percent.!® In the next 4 years, when the supply estimates included groups of R.N.’s not counted before, the net attrition rate was considerably lower. Taking both rates into account, the overall net losses from active supply during 1950-60 amounted to about 4 percent H Meyer, Burton. Development of a Method for Determining Estimates of Professional Nurse Needs. Nursing Research 6: 24-28, June 1957. 12 Eolk, Hugh and Yett, Donald E. Methods of Estimating Occupational Attrition. Western Economic Journal V1: 297-302, September 1968. 13 Meyer, Burton, op. cit. 125 a year. On the basis of data from the inventories of registered nurses in 1962 and 1966, the net attrition rate from active supply in recent years has been 3 percent. Inactive nurses constitute a sizable proportion of those who graduated from schools preparing for practice as registered nurses. Actually there are two types of inactive nurses: those who maintain a license to practice, and those who do not. The maintenance of a license is not dependent upon employment. At the present time, a nurse can continue licensure through the payment of a renewal fee to the State issuing the license, provided that the license had not been revoked for violations. While no information is available on the inactive nurses who do not maintain licenses to practice, data are available on those who do maintain licenses, when inventories of registered nurses are conducted. However, when considering the inactive nurse as a potential source of supply, it may not be remiss to look at the latter group as they have indicated retaining an interest in nursing through the maintenance of a license. The 1966 Inventory of Registered Nurses estimated that about 296,000 of the nurses holding current licenses to practice at the time of the study were not employed in Table 86. TREND IN NUMBER OF PROGRAMS, ENROLLMENTS, ADMISSIONS, AND GRADUATES FOR REGISTERED NURSING SCHOOLS: ACADEMIC YEARS 1960-61 THROUGH 1972-73 Number of Total _ i 1 Academic year SORA ervolment Admissions Graduates September 1 - August 31 1960:61. : s conn es spnwmes vanes 1,137 118,849 49,487 30,267 1961962; i s nun wim st a RB EEE 8 2 686 50 1,126 123,012 49,805 31,186 196263; : cs viv st HEBERT & BOWS 0 1,136 123,861 49,521 32,398 106364: i suv mails VRS BE AS Lh 5 Fo 1,148 124,744 52,667 35,259 1964-65. . «co iii eee 1,158 129,269 57,604 34,686 196566. . . «vi iii i eee 1,193 135,702 60,701 35,125 196687. : « vovwmwn i vapmmmme vs ww ww 1,225 139,070 58,700 38,237 196768. : : vovumnns s Bumapms s sume ws 1,269 141,948 61,389 41,555 196B169., i wo imw wn ts bn maw® oma inmw 1,293 145,588 64,157 42,196 1969-70. . «ov itt eee 1,339 150,795 70,428 43,639 August 1 - July 31 T9707): s vous ss sanER Ee pa Baw S 1,355 164,545 79,282 47,001 TIT 1-72: i 5 2.0. BRT a4 3 BHAA RE TS 1,363 187,551 94,154 51,784 T9727B. ct vvvmr as s mnmmwns ss nwa 1,377 213,127 N.A. N.A. Programs and total student enrollments are counted as of October 15; admissions (first year enrollments) and graduations are for the academic years as noted. Change in the academic year reporting dates resulted in overlapping counts of admissions and graduations during the transition period so that the 1970-71 figures for these items are not comparable to the figures for prior years. Numbers of programs and total enrollments are not affected by the change. Data include 50 States, District of Columbia, Guam, Puerto Rico, and the Virgin Islands. Source: National League for Nursing. State-Approved Schools of Nursing - R.N. 1973. New York, The League, 1973. Also prior annual editions. nursing.'® They represented almost a third of the total supply of registered nurses. Almost 87 percent of these inactive nurses were married and more than 50 percent were under the age of 40. Of course, there were a number of the inactive nurses who were from older segments of the population; about 17 percent were at least 55 years old. Nevertheless, the presence of a large group of relatively young married women, would suggest that a segment of these inactive nurses may intend to return to work. The inventories do not include data on the job-related intentions of the inactive nurses. However, some studies of inactive nurses conducted at the time of the 1966 Inven- tory provide some clues as to their intentions. The studies varied in scope and therefore could not be used for an intensive analysis. They did for the most part cover those inactive nurses who maintained licenses to practice. Some proportion of the respondents to these surveys, although 14 American Nurses’ Association. RN’s 1966. An Inventory of Registered Nurses. New York, The Association, 1969. less than half, indicated that they intended to return to work at some time in the future. Of those who did return to work, it was most frequently in a part-time position. These data tended to confirm the findings of a 1961 study of inactive nurses made by the Division of Nursing, BHRD. In that study, 44 percent of the respondents indicated they planned to return to active practice. Of those planning to return, the largest proportion indicated that they intended to work on a part-time basis.!® METHODOLOGY AND ASSUMPTIONS Estimates of the number of active registered nurses for the 1971-90 period were calculated using the Interagency Conference on Nursing Statistics January 1, 1971 (Decem- ber 31, 1970) estimate as the base. For each projected year, Ls Reese, Dorothy E.; Siegel, Stanley; and Testoff, Arthur. The Inactive Nurse. American Journal of Nursing 64:124-128, November 1964. 126 the graduates of nursing programs during the year were added to the active supply at the beginning of the year. Subtracted from this total were estimates of losses derived by applying the net attrition rate to the supply at the beginning of the year. This procedure yielded the active supply of registered nurses at the end of the year, and the cycle was then continued for all subsequent years of the projection period. Estimates of graduates were computed by applying completion rates for each type of program (baccalaureate, diploma, associate degree) to total admissions for that program. The lag time for completion was 2 years for the associate degree program, 3 years for the diploma program, and 4 years for the baccalaureate program. As with most other groups of health professionals, the future supply of registered nurses is largely a reflection of the course of enrollment in schools of nursing. From 1958-59 through 1971-72 the number of graduates of initial programs of nursing (R.N.) rose at an average annual growth rate of 3.9 percent. More significantly, however, the annual rate of increase averaged only 1.9 percent from 1958-59 through 1965-66 (prior to the influx of Federal support), but was 6.9 percent from 1965-66 through 1971-72. (See Table 86.) This latter spurt in enrollment in large part reflects the impact of Federal support provided through construction grants, special project grants for improvement in nurse training, institutional grants, and traineeships and other assistance to students. To illustrate the impact of the nursing legislation, the Progress Report of Nurse Training 1970'¢ stated that without the assistance under provisions of the Nurse Training Act, enrollment in the Nation's nursing schools would have been about 13,200 (8.8 percent) fewer in 1969 than it actually was. Similarly, without nurse training funds, admissions in that academic year would have been 5,800, or 9 percent, less than actual admissions. Between 1965 and 1971 admissions to schools of nursing rose by an annual rate of 7 percent, compared with a 5 percent annual increase during the 1958-71 period. For purposes of this report, the basic projection assumes that upon the expiration of current legislation, the com- bined level of Federal and non-Federal support would be such as to provide for the maintenance of enrollment levels resulting from earlier legislation. Given this framework, the basic methodology assumed that total admissions would increase only slightly, by 1 percent annually, from 103,100 in 1972-73, leveling off at 114,000 in 1982-83 and continuing at that level through the projection period. (See Table 87.) 16 ys. Department of Health, Education, and Welfare; Public Health Service. Progress Report on Nurse Training, 1970: Report to the President and the Congress. U.S. Government Printing Office, 1970. 127 In addition, under the basic methodology, it was assumed that the distribution of admissions among the three types of nursing programs would continue the trends of recent years; i.e., the proportion entering baccalaureate and associate degree programs would increase as those entering diploma programs decrease. Consequently, the assumption was made that the proportion of admissions in diploma programs would decrease from the 1972-73 pro- portion by 1 percent annually through the projection period, and the proportions entering baccalaureate and associate degree programs would increase by 0.7 percent and 0.3 percent a year respectively. Recent trends indicate that the average completion (retention) rates by type of program is 65 percent for baccalaureate, 74 percent for diploma, and 65 percent for associate degree ‘students. Under the basic methodology, graduate estimates through 1990 were derived by applying these rates to the appropriate admissions (allowing neces- sary lag time). The annual net attrition rate was held constant at 3 percent annually throughout the projection period. The rationale for this rate has been discussed earlier. Two alternative sets of assumptions were also made. First, as a low projection, it was assumed that the decrease in the proportion of admissions to diploma programs would not be as sharp as under the basic methodology. Under this alternative, it was assumed that the proportion of admis- sions in diploma programs as well as baccalaureate and associate degree programs would level off in the early 1980's. In this alternative, total admissions were assumed to be the same as under the basic methodology. The low projection also assumed that the completion rates by type of program would be somewhat lower than under the basic methodology over the projection period. It was assumed that baccalaureate completion rates would level at 60 percent, while diploma and associate degree completion rates would be 73 percent and 63 percent respectively. For this alternative projection, net attrition was again held at 3 percent through the projection period. The high alternative projection assumed that changes in total numbers of admissions to schools of nursing would reflect changes in total college enrollments over the projection period. Thus, it was assumed that the relation- ship of 2.4 R.N. program admissions to 100 total college enrollments established in recent years would continue at that level. College enrollment projections of the Bureau of the Census were utilized to develop projections of admis- sions under this alternative.! 7 Assumptions as to propor- tion by type of program were identical to that of the low alternative projection. 17 y.s. Bureau of the Census. Current Population Reports. Series P-25, No. 473. (Series E-2) Table 87. ADMISSIONS AND GRADUATES IN SCHOOLS OF NURSING UNDER BASIC AND ALTERNATIVE ASSUMPTIONS: ACTUAL 1970-71 AND 1971-72; PROJECTED 1972-73 THROUGH 1989-90 Admissions’ Graduates’ Academic year Basic Alternative assumptions Basic Alternative assumptions methodology Low High? methodology Low High? 1970-71. 0 0 vie eee eee 78,524 78,524 78,524 46,500 + 46,500 46,500 1971924 ss ss wmmnin s vo www 93,344 93,344 93,344 51,304 51,304 51,304 1972783: 4 ¢ s snmnms s L090 Fine 103,100 103,100 97,428 56,929 54,452 56,929 1973-78: c+ sc sv mnt: t sunmnn 104,100 104,100 101,388 61,951 59,186 60,476 197878. a + vam nin a 2 diane 105,200 105,200 105,504 66,864 63,895 64,916 1975-76. «vv viii ii ieee 106,200 106,200 109,764 70,077 66,348 67,789 1976-77. « «vv i i eee eee eee 107,300 107,300 113,484 70,671 66,813 70,344 1972784 s c sw nnis ss pr awwa 108,400 108,400 116,520 71,293 67,320 72,819 197879: 4 + ssn mun ts s ww wwmw 2 109,400 109,400 119,160 71,909 68,818 76,104 197980. 5 2 so mmpws s poismmes 110,500 110,500 121,500 72,518 69,453 78,156 198087. : s suv st sna m® ws 7 111,600 111,600 123,408 73,136 70,242 80,063 198182: is ssn ww is sn snmme 112,700 112,700 124,752 73,745 70914 81,589 198283. i ss ssn sss unm Ew 114,000 114,000 125,172 74,375 71,582 82,790 198384. ss amad is smmammas a 114,000 114,000 124,812 75,060 72,376 83,632 1984-85... . ii 114,000 114,000 123,780 75,404 72,635 83,692 1985-86. . . . oii iii 114,000 114,000 122,484 75,620 72,880 83,394 198687. : s wun ss sa mmn wey 114,000 114,000 121,368 75,517 72,880 82,787 198788. . csv ss pommwmns » 114,000 114,000 121,116 75,415 72,880 82,029 198889, + v siwmmine ds mm mans 114,000 114,000 121,416 75,312 72,880 81,476 198990 . c vows as nmnmwiss - - — 75,209 72,880 81,257 ! Includes baccalaureate, diploma, and associate degree programs in 50 States and District of Columbia. 2 Admissions in the “high” series are related to total college enrollments. The numbers of admissions and graduates are not always the high- est projections for a given year. Source: 1970-71, 1971-72: National League for Nursing. State-Approved Schools of Nursing - R.N. 1973. New York, The League, 1973. Also 1972 edition. As under the basic methodology, completion rates by type of programs for the high alternative were assumed to follow trends of recent years; i.e. baccalaureate and associate degree, 65 percent and diploma, 74 percent. Again, net attrition was held at 3 percent for this alternative through the projection period. It should be noted that for all projections, graduations were derived from projected admissions using appropriate completion rates and the 2-, 3-, and 4-year lag time appropriate to the type of program. Another projection method, not shown in this report, utilized the age-specific labor force participation rate model. Supply projections derived from stock estimates and age-specific labor force participation rates (LFPR) include numbers of graduates, survival rates, and participation rates estimated from census data on LFPR of all females. Where annual graduates and baseline supply data are the same, the basic method used in this chapter and the age-specific 128 LFPR method yield approximately the same supply projec- tions. Altman describes the latter method in detail.! 8 PROJECTION FINDINGS The projections developed using the basic methodology result in a total gross graduate input of 1,388,800 over the 1971-90 period. The low alternative projects a total gross graduate input of 1,336,200, and the high alternative, 1,468,000. The high and low alternatives, consequently, produce total gross graduate inputs approximately 132,000 graduates apart. Under the basic methodology, the supply of active registered nurses is projected to grow from 723,000 in 1970 8 Altman, Stuart H. Present and Future Supply of Registered Nurses, DHEW Pub. No. (NIH) 73-134. November 1971, reprinted August 1972. to 1,099,600 in 1980, and to 1,466,700 in 1990, as shown December 1981 and remain at this level through the in Table 89. Part-time nurses are projected to grow from 29 projection period. (See Table 90.) percent of the total in December 1972 to 30 percent in Table 88. TREND IN NUMBER OF ACTIVE FULL- AND PART-TIME REGISTERED NURSES: SELECTED YEARS DECEMBER 31, 1955-72 Year Number of active registered nurses Percent distribution : Total Full time | Part time Total Full time Part time F958) ie php mith sek sii 430,000 388,000 42,000 100.0 90.2 9.8 1957) 460,000 384,000 76,000 100.0 83.5 16.5 1959s. vomin + 1 s HERE Fs 4 vy UWL IE 504,000 414,000 90,000 100.0 82.1 17.9 196)i vs dts nama sss s BRB 550,000 433,000 117,000 100.0 78.7 21.3 TOBBas wiv v0 4 demnmine 5% #3 iF 582,000 450,000 132,000 100.0 77.3 22.7 HOBBS: win 000 pm mrlimmm no 4 wii 621,000 466,000 155,000 100.0 75.0 25.0 1966. «vv vv ieee 640,000 474,000 166,000 100.0 74.1 25.9 V6: 50 vv sw mmue st 2/8 Pa mw 659,000 483,000 176,000 100.0 73.3 26.7 1968. vs ts sais mwi s 48 pu wun 680,000 493,000 187,000 100.0 72.5 27.5 1969. «on vs sin pmmp ts 2 3 Ho @RE 700,000 503,000 197,000 100.0 71.8 28.2 1970: vw ss sang w a ss Mma wwe 723,000 515,000 208,000 100.0 71.2 28.8 17). svn vs nummm es s ADHERE § 748,000 524,000 224,000 100.0 70.1 29.9 1972. cv 4 + 3 UREA T+ F BRS RE 2 8 777,000 551,000 226,000 100.0 70.9 29.1 ! Excludes Alaska and Hawaii. Source: 1955-70 active registered nurses: American Nurses’ Association. Facts About Nursing. A Statistical Summary. 1970-71 edition. New York, The Association, 1971. 1971, 1972 active registered nurses: BHRD, Division of Nursing. Table 89. SUPPLY OF ACTIVE REGISTERED NURSES AND NURSE/POPULATION RATIOS, USING BASIC METHODOLOGY AND ALTERNATIVE ASSUMPTIONS: ACTUAL 1960 AND 1970; PROJECTED 1975-90 Projection series 1960 1970 1975 1980 1985 1990 Number of active registered nurses Basic methodology . ..................... 527,000 723,000 889,400 1,099,600 1,294,500 1,466,700 Alternative LOW «vt tt ee eee eee 527,000 723,000 881,400 1,076,100 1,261,200 1,426,200 PBN vv vio os mm male wwe a wn 527,000 723,000 886,000 1,105,500 1,337,400 1,535,300 Rate per 100,000 population’ Basic methodology . . .................... 293 355 414 485 541 585 Alternative HOW ris 600s olor mw evar cule ni dd 0 vw ow 9 ove or vi 293 355 410 474 527 569 Higheus vs sronemen ss vnesens s HE w ss 293 355 412 487 559 613 ! Resident population as of July 1. Source: 1960 active registered nurses: BHRD, Division of Manpower Intelligence. 1970 active registered nurses: American Nurses’ Association. Facts about Nursing. A Statistical Summary. 1970-71 edition. New York, The Association, 1971. Population: U.S. Bureau of the Census. Current Population Reports, Series P-25, Nos. 468, 477, and 483. 129 565-118 O - 74 - 10 Table 90. SUPPLY OF ACTIVE FULL- AND PART-TIME REGISTERED NURSES, USING BASIC METHODOLOGY ACTUAL 1970-72 AND PROJECTED 1973-90 Number of active registered nurses Percent distribution eat Total Full time Part time Fulltime 1 Total Full time Part time equivalents 1970. . ........ 723,000 515,000 208,000 619,000 100.0 7.2 28.8 197Vs tnes vs wnm 748,000 524,000 224,000 639,000 100.0 70.1 29.9 1972... ....... 777,000 551,000 226,000 664,000 100.0 70.9 29,1 1973. vv uv s mem 810,300 573,700 236,600 692,000 100.0 70.8 29.2 1974: 500 ts van w 848,000 599,500 248,500 723,800 100.0 70.7 29.3 s V975. cu is ann 889,400 627,900 261,500 758,600 100.0 70.6 29.4 W9P6: 52 av 5 mnimi 932,800 657,600 275,200 795,200 100.0 70.5 295 1977. svete cr nn 975,500 686,800 288,700 831,200 100.0 70.4 29.6 1978. . csv vb tus 1,017,500 715,300 302,200 866,400 100.0 70.3 29.7 1979... .. ..... 1,058,900 743,300 315,600 901,100 100.0 70.2 29.8 1980. ......... 1,099,600 770,800 328,800 935,200 100.0 70.1 29.9 198%, cu ww sm muss 1,139,800 797,900 341,900 968,800 100.0 70.0 30.0 1982, cows awoms 1,179,300 825,500 353,800 1,002,400 100.0 70.0 30.0 1983. cnn snnme 1,218,300 852,800 365,500 1,035,600 100.0 70.0 30.0 1984, . oc’ conn 1,256,800 879,800 377,000 1,068,300 100.0 70.0 30.0 1985. . ........ 1,294,500 906,200 388,400 1,100,400 100.0 70.0 30.0 1986. vow +s vo mms 1,331,300 931,900 399,400 1,131,600 100.0 70.0 30.0 1982 voit +s punwan 1,366,900 956,800 410,100 1,161,800 100.0 70.0 30.0 1988. vc: vunan 1,401,300 980,900 420,400 1,191,100 100.0 70.0 30.0 1989. 4504 sn nm» 1,434,600 1,004,200 430,400 1,219,400 100.0 70.0 30.0 1990. 0 vv 0s sunny 1,466,700 1,026,700 440,000 1,246,700 100.0 70.0 30.0 ! Equals full-time workers plus 50 percent of part-time workers. Source: 1970 active registered nurses: American Nurses’ Association. Facts About Nursing. A Statistical Summary. 1970-71 edition. New York, The Association, 1971. 1971, 1972 active registered nurses: BHRD, Division of Nursing. The growth in active registered nurses is projected at 376,600 between 1970 and 1980, substantially more than the 196,000 increase from 1960 to 1970. On a percentage basis, however, the 1970-80 increase is 52 percent greater than that which occurred between 1960 and 1970 (37 percent). In the 1980-90 period, growth is projected to be at a less rapid rate, a 367,100 (33 percent) increase. The high alternative projection of active registered nurses in 1990 yields a supply that is 68,600, or 5 percent, more than the basic methodology projection while the low alternative yields a projection that is 40,500 or 3 percent less than that obtained using the basic methodology. Under the basic methodology, the number of registered nurses is projected to grow by 743,700 (a 103-percent increase) between 1970 and 1990. The high alternative yields an increase of 812,300 registered nurses between 1970 and 1990 while the low alternative yields an increase of 703,200 registered between these years. A population ratio of 613 registered nurses per 100,000 population in 1990 is: obtained from the high alternative projection. This com- 130 pares with ratios of 569 per 100,000 under the low alternative and 585 per 100,000 under the basic methodol- ogy. ADDENDUM Subsequent to the completion of this chapter, the Interagency Conference on Nursing Statistics (ICONS) aggregated data for all fields of employment from both special surveys and preliminary data from the 1972 Inventory to develop a revised January 1972 (December 1971) estimate of 780,000 active R.N.’s. The Conference advised that previous estimates be adjusted by using graduate figures for appropriate years and applying a new net attrition rate—the latter to be computed from the January 1972 estimate back to a date preceding the time when exceptional increases may have been noted in hospitals, public health, and nursing education, where 75 percent of R.N.’s are employed. Members also agreed that the revised net attrition rate should be carried to January 1974 (December 1973), and that intensive reexamination of estimating mechanisms would be necessary. Following the directives of ICONS, results were ex- amined of the 1966-72 biennial surveys of nursing person- nel in American Hospital Association registered hospitals, public health agencies (including boards of education), and schools of nursing in relation to the January 1972 total estimate and field distribution determined by the Confer- ence. The aggregated data from the surveys indicated that the greatest numerical increases in the three fields occurred in the late 1960's, but that there was little difference in the rates of increase between 1966-68 and 1968-70. Therefore, a revised net attrition rate for the period between January 1966 and 1972 was computed, with the ICONS estimates as the end points and graduations from 1965-66 through 1970-71 as “gross gain” in the formula. The rate computed was 2.1 percent a year. Reflecting this rate, the adjusted estimated numbers of employed R.N.’s are as follows: 131 Year Employed as of registered December 31 nurses T1966 .......coiviiiiiieiaraenn 643,000 1967 «eee 667,000 1968 «vie 694,000 1969 «oii 722,000 VOTO ovsmmivi won w wis mais mas woes ae 750,000 TOT on vvivns sii 50 ik 00 308 55 oe 908 Th 780,000 HOT 1 0 wed 0 won wis wie ms ls wins 815,000 It should be noted that these adjusted estimates are actually intended for January 1 of the following year. Given these considerations, the December 1970 supply of active R.N.’s presented earlier in this chapter and elsewhere in this report (i.e., 723,000) has now been revised upwards by 27,000 to 750,000. Revised supply projections, however, have not yet been developed. Chapter 11 o ALLIED HEALTH OCCUPATIONS Allied health manpower is defined broadly to include the professional, technical, and supportive workers in patient services, administration, teaching, and research who engage in activities that support, complement or supple- ment the functions of physicians, dentists, and registered nurses. In addition, personnel engaged in organized environ- mental health activities, such as environmental engineers, are included in the allied pool. CONCEPTUAL AND STATISTICAL CONCERNS The need for reliable statistical information on health manpower is nowhere more urgent than in occupations in the allied health field. Unfortunately, owing to the large and rapidly growing numbers and types of workers in this field and the inadequate data base, assessing current and future supply is extremely difficult. The process of building and maintaining a reliable data base has been greatly hampered by numerous problems, including the following: 1. Lack of consensus on the parameters of the allied health field and on definitions of allied health professions and occupations. Lack of reliable estimates of current and past supply for allied health professions and occupations. 3. Limited information on the characteristics workers. Limited knowledge about the impact of task delega- tion on current and future supply estimates. 5. Extensive use of crude estimates and professional judgment in assessing the past and present situation. of Defining allied health broadly enough to accommodate both existing professions and occupations and new and emerging ones contributed major problems for data collec- tion. First of all, it is not always clear what fields should be classified as allied health. For example, several decades ago environmental health was a public health responsibility, and the function of assuring a safe environment was largely the province of the sanitarian. Today the picture is very different, and environmentalists are now highly skilled specialists concerned with air, water, and noise pollution; solid waste management; radiation protection; and pesticide use. This results in a major dilemma as to whether environmental personnel should be viewed as a separate field of manpower in a highly industrial urban society or whether they should be considered as a part of public health or allied health. Any data collection effort which encompasses such diversity and numbers is a mammoth undertaking. 133 Furthermore, the proliferation of occupations has re- sulted in a multitude of titles and definitions utilized to describe the allied health manpower pool. To date, more than 125 health professions and occupations have been identified in allied health, with approximately 250 addi- tional or secondary titles which imply or define relation- ships between one type of worker and another. However, there are serious questions as to whether there are any real functional differences between and among some of these occupational titles. Because the allied health field is so broadly defined and has a multiplicity of titles, manpower analysts have been unable to devise a standard nomenclature or classification system, although attempts have been made. One approach has been to classify by professional or occupational title. A refinement of this approach has been to classify manpower by function; namely, the nature of the services rendered. The traditional approach of the Bureau of Health Resources Development (BHRD) has been to classify workers on the basis of appropriate basic educational preparation either at the technologist or technician level. Unfortunately, no classification system for allied health professions and occupations is free of ambiguities. Con- fusion exists between titles, functional definitions, and educational preparation. For example, a physician's assist- ant is one who works at the physician-patient interface, to whom the physician delegates tasks. Some physician’s assistant educational preparation programs, however, offer college credit, while others do not. Not all physician’s assistants perform the same type of work; some are being used in primary care, while others are being trained for duties related to specialties. The estimates of current and past manpower supply used in this report clearly reflect these problems, since they were developed through the use of numerous sources. As a result, they should be viewed strictly as rough estimates. A glossary of occupational titles and definitions for allied health manpower by major category has been prepared by the Association of Schools of Allied Health Professions, for use in a survey of health occupations educational programs in 2-year and 4-year colleges and universities. It is hoped that the various governmental agencies concerned will adapt the glossary to the labor force in surveys and related work, thus achieving greater consistency. A number of sources were investigated to obtain the data needed, including State licensing boards, registry or certifying boards, professional organizations, national re- ports and surveys, and State surveys. Although these sources were helpful in generating statistics on allied health manpower, numerous limitations and problems were en- countered in all of them, particularly ‘the problem of obtaining estimates of the total active supply vs. the total potential supply (active and inactive) for an occupation and then from these figures determining the number active who are formally trained. Licensure records have traditionally been utilized as a major mechanism for the collection of manpower data. To date, only four allied health occupations (dental hygienist, environmental engineer, licensed practical nurse and physi- cal therapist) are licensed in all 50 States. (See Table 91.) For only these four occupations is it possible to obtain the total number of potential workers through State licensure, and data are generally unavailable on the number active or on their detailed characteristics. Double counting may also result from the fact that an individual may be licensed in more than one State. Another source of available data is the records main- tained by certifying or registry boards. However, the nature of the certification or registry mechanism results in the exclusion of a proportion of the active pool. Requirements for registration or certification usually include a prescribed educational preparation and demonstration of a level of skill through testing. When certifying bodies are part of a professional organization, membership in the organization may also be a requirement. Thus, although useful, registries do not account for the total active supply or potential in an occupation, but yield information on only that segment of the manpower pool which at some point in time has qualified for, and has chosen to seek, registration or certification. Problems in coverage also occur in the use of profes- sional organizations and their membership. Again, double counting may occur. Membership totals in professional organizations cover a widely varying percent of all workers and often include both active and inactive workers. How- ever, associations do maintain information on items such as name, age, sex, income, and education which provide useful insights into the profile or characteristics of allied health workers. Numerous problems have also been encountered when utilizing data from the population census. First, occupa- tional data are collected through the use of a sample and the estimates derived from the sample are influenced by sampling error, thus weakening the reliability of the estimates. Second, since the census is conducted at 10-year intervals, the value of these estimates is negligible. Finally, classification of specific occupations, while useful for some purposes, is not as detailed and accurate as required for this purpose. Occupational titles are often combined, thus eliminating information on specific detailed allied health professions and occupations. Despite the insufficiency of the census figures for the purposes of this chapter, the data do provide an insight into the composition of the allied health labor force with regard to race and sex. Six occupations which are analyzed in this report were reported in the 1970 Census of Population: Table 91. NUMBER OF STATES REQUIRING LICENSING FOR ALLIED HEALTH OCCUPATIONS: 1971-72 Occupation Nuribst of Occupation Number of States States Dentallhygienist., «vs ver ews sie + wit o 29 8 sins we oom swe» 50 Physical therapy assistant .......cccevvuvrvrvreen 14 Dental laboratory technician ..................... 1 PhysSiCIan’s assistant... cus ev sno vin vam sun sus ses ae 1 Environmental engineer. .........coviiiiiiinn.. 50 Psychiatricaide .....ccvisncvneenvrnnrvnnsssness 3 Licensed practical NUISE. «uv «ves sve wns wins vv sown vinin » 50 Psychologist. «cco cvvvverrnnnrrennssenrennnsans 46 Medical technologist. «vc cer vssvm evn vessssnvenes 10 Radiologic technologist . .......cooviiniiinnnnn 3 UGWITE LIaYY + ov sv 6 sis 4 08 £909 8 910 5.95% 0 00 364 $F 4 B00 8 23 Respiratory therapist «. «ov viv soc ve wins vive wwe win ve wie 1 Nursing home administrator. . .......oocvvvvivnnnn. 49 Sanitarian . vie « vie s wie 2 35 Fwie Vie Bae BEE we wy 4 3 win 35 OpticaltechniClan .«.cccvvrvvrvncnecvnnnernsnnes 2 Sanitarian teChNICIAN +. vv cv vive sits xv s sus sims wiv + wis 1 OPLiCIAN. vote titi tii tania rnenneannnns 17 SOCIA) WORKEE i 5.0 + 95 +50 2.58 210% ins 0 4 856 4 41% 5 0% © 2i 9 Physical therapist. vue ov 3 wins vie 40m 3 wn swe 5 0 0 wwe » 50 Speech pathologist and audiologist ................ 5 Source: Licensed practical nurses, respiratory therapists, sanitarians, and sanitarian technicians: U.S. Department of Health, Education, and Welfare. Report on Licensure and Related Health Personnel Credentialing. DHEW Pub. No. (HSM) 72-11. U.S. Government Printing Office, 1972. All other occupations: National Center for Health Statistics. Health Resources Statistics. Health Manpower and Health Facilities, 1971. .DHEW Pub. No. (HSM) 72-1509. U.S. Government Printing Office, 1972. Also unpublished data from various associations. dental hygienists, dental assistants, dental laboratory tech- nicians, dietitians, licensed practical nurses, and radiologic technologists and technicians." The six occupations com- prise only 17 percent of the estimated total active supply of allied health manpower and do not necessarily represent a cross-section with regard to various levels of occupa- tional skills, necessary training, and experience, factors that may greatly influence the characteristics of workers. Based on the census data for the aggregate of the six occupations for 1970, it is estimated that Blacks and "persons of Spanish heritage represented 15 and 4 percent, respectively, within the six occupations. Females employed in these six occupations represented 89 percent. By race, females were most predominant among the Blacks, com- prising 92 percent of this group as compared with 77 percent for workers of Spanish heritage. Many States have conducted health manpower surveys, but most are fraught with problems related to the number of employers surveyed, format, basic method of data collection, and definitional differences. As a result, esti- mates are seldom comparable. In addition to the special considerations listed above, there are a number of general factors that necessarily enter into any assessment of allied health workers. These include characteristics such as age and sex, geographic mobility, education, and working environment. Analysis of some of these factors as they affect allied health manpower has proceeded slowly owing to the limited information cur- rently available. For example, the majority of allied health workers are women and a large proportion are young. Such workers often train and work during their teens and early twenties and retire from the labor force to raise families. Little is known about their reentry patterns—whether they return to work, at what age, and into what occupation. Surveys dealing with the characteristics of allied health workers have, nevertheless, been attempted at both the national and State levels. At the national level, studies have been done by the Bureau of the Census and the Bureau of Labor Statistics. However, these sources differ in the manner in which occupations are classified and the data items obtained, thus creating comparability problems that preclude their extensive use in this chapter. With respect to future data availability, numerous projects are in progress or are being developed by the staff of the Bureau of Health Resources Development (BHRD) in order to improve and expand the current data base. Such efforts are being directed towards the following projects: 1 U.S. Bureau of the Census, United States Census of Popula- tion: 1970. Detailed Characteristics. United States Summary. Final Report PC(1)-D1. U.S. Government Printing Office, 1973. 135 1. A comprehensive survey of allied health professions and occupations in hospitals. A survey of allied health professions and occupations in ambulatory care settings. A survey of selected characteristics of allied health personnel employed in hospitals. The development of a computer-oriented allied health manpower data base composed of data from available State surveys. CURRENT CHARACTERISTICS AND TRENDS In 1970, an estimated 2.7 million workers were in professions and occupations classified as allied health by BHRD. The 1970 figure represents an increase of 75 percent over 1960. The growth of this field may be attributed to a number of factors, including the greater utilization of allied health workers, increased employment opportunities resulting from the expansion of the health care delivery system, and the creation and expansion of training programs, especially at the junior college and technical education level. The allied health field is divided into four major categories: medical, dental, environmental, and nursing allied. The medical allied health category includes such workers as personnel in medical laboratories, medical rec- ords, and medical libraries; dietetic and nutritional person- nel; physical and occupational therapy personnel; radiologic personnel; and administrators. In 1970, medical allied health workers numbered 1,073,400, or 39 percent of the total. (See Table 92.) Dental allied health workers—hygienists, assistants, and technicians—accounted for 6 percent (or 157,800) of the total allied health manpower work force in 1970. The number of workers in dental allied occupations increased 32 percent in the 1960-70 period, while the supply of dentists increased 29 percent, possibly because of greater use of these allied health personnel. The number of environmental allied health workers in 1970 was estimated at 242,000, or 9 percent of the total. This category includes environmental scientists, engineers, technicians, and aides. Although a relatively small field, it accounted for the largest increase among the allied health categories between 1960 and 1970, doubling during that decade. Nursing allied personnel—licensed practical nurses, nurs- ing aides, orderlies, attendants, and home health aides—are the largest group, constituting 46 percent of the total allied health workers currently employed. Their numbers have increased sharply in recent years, virtually doubling from 681,000 in 1960 to 1,270,000 in 1970. For every active registered nurse in 1960, there were 1.3 nursing allied 2 Table 92. ESTIMATED SUPPLY OF ACTIVE ALLIED HEALTH MANPOWER: 1970 $ % . Estimated active Major category, profession, and occupation personnel Total allied health manpower ...........c.c0.n. SIE EE BR RE WE PW LEE 2,743,200 Medical allied. .....covviiinninneieeenennnnnnns ain dowh wh BR BEE REE GRA TT VE OE 1,073,400 Medical laboratory personnel . ,.....ccevvevssinssnsrssnssssncsnnes alm 8 Ri bie & 140,000 Clinical laboratory scientist A , eee ioe He Ree aR 5,000 Clinical laboratory technologist 3 § Win § EERE BE BR Fe 1 We 8 Wiel ip pray suv 65,000 Clinical laboratory technician and assistant. ............ooeiuunn. Cnn ve yee yw 70,000 Radiologic technology personnel ........cciiiiiiiiiinttintttacttnntssecasens 100,000 Radiologic technologist, technician and assistant. .. .......oeieiinrneinnnnnns 100,000 Medical library personnel . ......ceoeevirenaa. Bh We SH A ¥ wie Se Se 0 GE 9,500 Medical librarian ........ ah R08 DH I Sta Tay 2,200 Medical library technician ............. SE BER VRE SRE AE 3 Bi Bi ET a 7,300 Medical record personnel . + 4B IIIA N SES s se sy rw ss ssn ans ARES 53,000 Medical record administrator’ EY FESR SS $l # SE HIE Se IE § WI ee 11,000 Medical record tBChNICIAN + » vu 3 vis ain # #10 & ie » #35 $160 $0 Bin + IK & 08 8 X02 BI0 » wis Sisie oo 42,000 Dietetic and nutritional personnel .............ccciuunn SR SE ee Tp 47,000 Dietitian and nutritionist)... ooo uee tue erie ies 30,000 Dietary technician... ...ocevevvnvens a pe vv ve eww. Bie 0 Won # won 00d BRE GF € 20 EBT 10,000 Food service supervisor ........ SEH RET SEE Wi HEE wi EnTy Tress win wn sow eit min 7,000 Physical therapy personnel . ......cociiieiiiiiinnnnnn LY mpp———— 24,000 Physical therapist! «....veuenenerenenennns eas een I, 15,000 Physical therapy assistant ............... ain e wse mini ince witha BTR WEA VE E00 GE BE 9,000 Occupational therapy personnel ........... ee 2 Sale Wi Wey wine hese aia st riak 16,200 Occupational therapist’ Fon WR ER 5 % HE BOT SW EE a EBieBNE e E B ee Yhe 10,700 Occupational therapy assistant and zie “ob ATI “RE RES WEE BH #0 4 re WEE Bw 4 5,500 Other personnel «....vvveviierneneeennennneeoaeeeannsns HER + BER BVI LR BE Od 683,700 Administrator, program representative, management Oificer? onvamus mas ERE 30,000 Administrative assiStaNt «coi vvrrvevvrrsvrssssrrsrecenrsas pve ach Riad musi E Wi 19,000 Ward ClEIR « viv viv » wiv & Hie 8 96 » B80 2/010 FW BES 85 6 £10 #0 0% wah wiase oo FR 58,000 Biomedical engineer’ o 307 S00 BE BIE IE SE SE OR CO SE se FE STH ee wi STE vw 3,600 Biomedical engineering technician .........cciiiiiiiiiiiiiiiiittittinneens 7,200 Fei EAUTALONTs « viv #75 55.8 Sind 206 40% 59 5.40504 36 S030, $1610 $018 £08 NO 23,000 Orthotist and ProstheliSt. cccon sss sme vas vrs six dois Soe Tinie S00® 3m 5 $800 S10 ¢ $10 i010 ¢ 3,600 Orthotic-prosthetic technician and assistant .......... sie Sie © Bi Find GY PvE EE Eee 3,600 Pharmacy assistant and FL] ERR Se PE Fr Ee PA op Sep Cpr gn 10,000 Clinical psychologist Sb GI © ET SR ETE SE TE NE ee wi we ik SE BE 13,000 Research SCIBNTISEY + «vue esas eneeeenennenenneneenenenennnn s 208 Twigs Ramis ani 51,000 Medical social worker!.......... % £050 HI GE vi SES BE § EE SHEET § A 25,200 SOCIAL WOUK ASSISTANT wiv « vi + wiv » wi » #0 2.010 Si0is $00 010 § Hiw PHS» BL0 FFI § Ki § 00 $7000 wu 5 @ 4,300 Specialized rehabilitation services ....... » Li HE HE SE Se RE pg 11,300 Corrective therapist’ pune 4 oak wiv 0 § ime BEA BI SEE CAR LAS AE LU SIE BIR HE EE 1,200 Educational therapist win. wn be asi wiih BER Ri Wa AR EE SE LE BR SE EO SE 500 Manual arts therapist’ £7% WINN FIR weet wie w Sues Wb B08 Bini SR RATE BE BE 8 § BIO OE SE 900 Music therapist’. . ... JA SE rete Ww wie u wie wie» ie ime hid # pekinink 2A WEE RAE ® 2,200 See footnote at end of table. 136 Table 92. ESTIMATED SUPPLY OF ACTIVE ALLIED HEALTH MANPOWER: 1970—Continued i " " Estimated active Major category, profession, and occupation personnel Recreational therapist! 5 HR PIES GE RA Bi ii § Wher § Todt br ® wa hs wkend wens zone 6,000 Home economist in rehabilitation ...........oeeeerenennnn.. 3 3 we vee weg # 500 Speech pathologist and audiologist! He ee eed BEE SEE SEE EE SWE Rs we De 19,000 VISION CANE wv vio v wiv « 51 3 v8 tle $3000 5 0 4 6 160 8 16% S08 ios 950 4 000 3 79 3 478 SI ai SS mama ® 37,300 Optician cei uvsvossmsns ss FREE TART FSS We Kwak Bod Fd» wk + wk + i idan ew 11,000 Ophthalmicassistant . .....coovie iin inennennnnnn vv A a Ee EEE 20,000 OFtHOPUSE + vv wns vv swims vm ves wins wns Ww i € e 6 RS WG SR ER ST HE 500 OPLOMEIIIC ASSISLANL: « sv v0 + win + 0:5 & wim » win #010 8 504 $5918 #76 # 500 # bi8 % 0» wid & Wi% & M0 5 053 5,000 Optometric technician ....... + WEE SIS WG ATE ST WR 6 HIN WE BAUR § ATR 8 REE SR 4 el ee 8 800 Miscellaneous ....... F838 ol Bhs Hi 3 When hk wie Ror UTES? HTS § SSSA ES TR 8 364,600 Ambulance attendant ..... iii i i tiie ieee . 5,600 Electrocardiograph technician. «cov vii iii iii i iii i titties tenennannns 9,500 Electroencephalograph technician. .......... § Wie MRE RTE SIE a a Hie WIN 8 WB 3,300 RESPIratory therapists sc iw + wis sis ¢ 9: 910 5 350 3 35% $258 wEi% 3.00% 3:0 5 2000 3 & S10 % ow & 0a # 11,000 Respiratory therapy assistant ...........uiuuineennnnennenrnnenensennennns 3,600 MEAICAI ASSISIANIL © 7 510 2.507 4558 Buncs Susicn 2wsh ets 4.3004 wie.» wi #rwie 3 7wriy wsbin's wig, Wiech WHATS WIRE § HES 300,000 Operating room technician ....... « wiki Wine WT YATE SW EE EE 3 WE OEE Ce We 8 iw § 8,000 Physicians assistant .........oiiiiin neni enenenen nena $V RIE ER 200 Surgical and other aides .......... TE SUEY SAE WS BGS SR SWE 8 wi ES BE § WE BIE Bere 23,400 Dental allied ...eevisn. #18 SIR § BU § WIE AE 6 BIR WIRE eB Re Bs ER 3 hw [0 ove. wien ® wine 157,800 Dental hygienist ........... WIE BRI A WI A RHR WE We ee eke brid wi ody ol ier» wre © wid a 15,100 Dental assistant ......... H8 W0 % 0 RT 8 Bui 3 woh @ ine #8 ee + wy Te YY ES WR 112,000 Dental laboratory technologist. .............. a x a AE AEF we NEES 0 EE SAE 30,700 Environmental allied .......... wan: wel we we ple are TE . oe WT RE Se HIER ER 242,000 Environmental engineer’. iar ool Sime ossivgere wore FR wee WE 6 EE ® EE © RE WA vue 35,000 Environmental scientist’. ............ * $B % HE RW 8 BE ¥ We TR RIG ¥ RE 0E 7 ait 3 oh 25,000 Environmental sanitarian’, . .... * © E SN § eB Ti6 W100 BIH 5 BE A Bk © Ro Rk Bod aie 4765 wa 12,000 Environmental technician. .............. 3H BWR BW Ee WE we ee Sui arene: wis o widen win 69,000 Environmental aide ............ Si 2H Res we a tee rrererer testers 101,000 Nursing allied ............. Creer % % WI WEE GN EEE § AE REE EEE 1,270,000 Licensed practical Nurse: + se sims sv s wis + si ¢.civs 43% #455 3 Wie » Bh We PE TTT witcal sd ch 400,000 Nursing aide, orderly, and attendant. . ........vu tienen ine ene ee nnnennnnnnss 848,000 Home health aide ........... Wk WHEE BE WR RR Wa i San Snes ke WE SET Te 6 WEN § EE 22,000 1 Appropriate educational preparation at least baccalaureate. Source: Dental allied: BHRD, Division of Dental Health, Physician's assistant: BHRD, Division of Allied Health Manpower. All other occupations: National Center for Health Statistics. Health Resources Statistics. Health Manpower and Health Facilities, 1971. DHEW Pub. No. (HSM) 72-1509. U.S. Government Printing Office, 1972. 137 workers; in 1970, in contrast, for every active registered nurse there were 1.8 nursing allied workers. Allied health professions and occupations are also typically categorized according to their basic educational preparation: (1) at least baccalaureate preparation, and (2) less than baccalaureate preparation. In 1970, an estimated 387,000 allied health workers, or 14 percent of the total, were in the first group. Within the four major categories of allied health identified earlier, the percentage of workers for which at least baccalaureate preparation is appropriate varied from 25 to 30 percent among the environmental and medical allied health groups, to about 1 percent of the dental allied health group, and to virtually none in nursing allied. Any discussion of the group of workers who have less than a baccalaureate preparation is difficult. The less-than- baccalaureate identification includes associate degrees, awards, and certificates, and comprises training programs in junior colleges, vocational or technical training schools, and hospitals. The programs may or may not be approved by a recognized accrediting body. The length of programs may vary from a few weeks for some occupations to several years for others. It must also be recognized that many workers are trained on the job and thus have no formal period of preparation. PHYSICIAN'S ASSISTANTS, A RECENT DEVELOPMENT One of the recent and more significant developments in the field of allied health has been the introduction of the formally trained physician’s assistant. The distinction of formal training is the unique feature of this development, with the first educational program being initiated in 1965. The Office of Special Programs (OSP), Bureau of Health Resources Development is responsible for supporting physi- cian’s assistant training with the emphasis on the prepara- tion of physician's assistants for primary ambulatory medical care in underserved areas. In carrying out their administrative mission the following definition of physi- cian’s assistant has been developed: The term physician’s assistant refers to one who by training and experience is prepared to work under the supervision of a licensed physician to aid that physician in carrying out his patient-care responsibilities. The physician’s assistant is prepared to collect a “data base” through a medical history, general physical examination, and routine laboratory tests; to organize the information to aid the physician in diagnosis; and to administer treatments as prescribed by the physician. He may, on the basis of standing orders, treat a defined range of medical conditions and may provide emergency care in 138 keeping with his training and as permitted by his supervising physician. Although effective supervision is required, it need not in all cases be face-to-face. The assistant may be prepared and permitted to perform other technical or clinical tasks—laboratory, X-ray, etc.—as determined by the training program and the individual supervising physician.? The Council on Medical Education of the American Medical Association (AMA), the American Academy of Family Physicians, the American Academy of Pediatrics, the American College of Physicians, and the American Society of Internal Medicine jointly developed the Essential Requirements which state the minimum educational re- quirements for the training of assistants to the primary-care physician. Essentials of an Approved Educational Program for Orthopedic Physician’s Assistants and Urologic Physi- cian’s Assistants have also been developed and ratified by the AMA House of Delegates. Although both the AMA and the OSP have worked to establish standards and descriptions for the physician's assistant educational programs and functions, the concept has not escaped the lack of clarity in nomenclature and functional activities which has been typical of most emerging occupations in allied health. For example, pro- grams operate and educate students under a variety of titles, including those of physician’s assistant, physician’s associate, clinical associate, and MEDEX. Educational programs may be differentiated by the type of physician’s assistant being trained. Currently, there are 45 programs which have as their objective the training of assistants to the primary-care physician,® while 34 operat- ing programs are training assistants for a specialist. In addition, the Federal Government has five training pro- grams to prepare physician's assistants to work in the penal system, the Indian Health Service, and other settings.? Several other elements tend to reflect the diversity of educational preparation. The length of training may vary from 1 to 5 years. The settings in which the educational process takes place may be a medical school, hospital, college, or university. Entrance to some programs requires only high school graduation, while others stipulate health 2u.s. Department of Health, Education, and Welfare; Public Health Service; National Institutes of Health; Bureau of Health Manpower Education. Program Support for Physician's Assistants in Primary Care. Bethesda, Md., 1972. 3 Information obtained from the Office of Special Programs, BHRD. 4 American Medical Association and U.S. Department of Health, Education, and Welfare; Bureau of Health Manpower Education. Summary of Training Programs: Physician Support Personnel. DHEW Pub. No. (NIH) 73-318, September 1972. care experience as a prerequisite. There are programs which will accept only applicants with a bachelor’s degree. Awards vary from certificates to degrees. The Office of Special Programs, BHRD, has compiled summary statistics on programs which educate physician’s assistants for primary care. The 45 programs had graduated 363 persons by 1972, with 492 scheduled to graduate in 1973, making a cumulative total of 855 graduates by December 1973. The American Medical Association has conducted two surveys of training programs for physician support person- nel, one in 1971 and the second in 1972. The universe of programs identified by the AMA differs from the universe identified by the Office of Special Programs and the fact of nonresponse in the survey precludes comparison of the data for 1971, 1972, and 1973. In 1972, the AMA solicited information on physician’s assistants from the programs listed as operational in the June 1972 “Summary of Training Programs for Physician Support Personnel.” Fifty-one program directors were requested to estimate the total number of graduates as of December 31, 1972. The names and addresses of the employers of the graduates were also requested. Fifty directors responded, and of this number 30 reported graduates. The totals, reproduced from the AMA survey findings, include physician’s assistants from MEDEX pro- grams, specialty, and primary-care physician's assistant programs, graduates, and employment status as of Decem- ber 1972.% Number of programs reporting graduates. .......... 30 Total estimated graduates as of December 1972 ..... 585 Employment: As physician's assistant ...................... 461 In office practice .............cciiuin.. 236 INIASHIULION vouivusnsnsvnsmusmnsmmidnss 225 As other than physician’s assistant ............. 49 Notemployed ........ccoviniiniiniinnnennnn. 47 Status UNKNOWN . Lottie ieee eee 26 DRCOASEO vi is wim o 0s iv 518 0 wick 6 #10 90.38 812.8 0 91 010 90 74 2 It is of interest to compare these 1972 estimates with similar estimates collected in 1971 by the AMA. In July of 1971, 24 programs were identified as operational. Of the 20 programs which responded to the survey, 12 reported graduates. The total graduates for December 1971 were estimated to be 184. An estimated 113 were employed as physician’s assistants in August of 1971. Between 1971 and 5 American Medical Association, Department of Health Man- power. 1972 Survey of Operational Physician’s Assistant Programs: Numbers Graduated and Employed. Chicago, The Association, 1972. 1972 the number of responding programs reporting gradu- ates had increased one and one-half times, the number of graduates had approximately doubled, and the number employed had nearly tripled. The growth rate in the supply of physician’s assistants could only be a matter of speculation at this time. There is no reason to believe that there will not be growth, but there is also no evidence to support the assumption that the recent rate of growth will continue in the future. Much will depend on the acceptability of the physician’s assistant to physicians and consumers and on the economic benefits derived. PROJECTIONS OF THE SUPPLY OF ALLIED HEALTH PERSONNEL TO 1990 The 1970 supply estimate presented for each occupation and used as a base for the projections includes only those persons who are credentialed and are actively employed. The estimates of future entrants into allied health occupa- tions to 1990 consider only graduates of approved pro- grams. The reasons for this approach are: (1) data on the number of graduates of approved programs represent the most reliable data on educational preparation available; and (2) such an approach projects at least a prescribed minimum amount of knowledge of the subject matter in particular occupations and is assumed to be related to the estimated credentialed active base. Given the limited manpower data base for allied health professions and occupations, it was decided to develop projections focused on virtually the only “hard” data available. Considerations which are not incorporated into the projection methodology, due to lack of quantifiable meas- urement, are the effects of task delegation on the number and types of the supply of future health manpower, the effect of qualified entrants into health fields as a result of equivalency and proficiency testing, and the effect of formally-trained or credentialed reentrants. In recent years there has been increasing awareness of the ability of less-trained persons to perform competently tasks which were the function of the more highly trained. The avowed purpose in using less-trained persons is to utilize personnel more efficiently and economically and to increase services. The extent to which task delegation will affect the supply of health workers depends on several factors: the degree to which the more highly trained are willing to relinquish functions and assume new or different responsibilities; the degree to which the lesser trained are willing to assume additional responsibility; the degree to which the consumer is willing to accept the new approach; and the extent to which State laws allow for change in practice. Dentistry offers one of the best examples of past and potential effects of task delegation. For years, dental hygienists, dental assistants, and dental technicians have assisted dentists at chairside and in the laboratory. Now persons in these job categories are being trained in functions previously performed only by the dentist, while the dentist is being taught to utilize and manage this team of workers. The expanded-function auxiliary approach in dentistry may have an impact on the mix of workers offering dental services. As stated previously, the methodology utilized to project supply in this chapter estimates a total active credentialed work force in 1970 and projects the supply through 1990 with the addition of graduates of approved programs only. This approach to estimating future supply in the field has serious limitations because of the exclusion of other entrants: those who come into the occupation from preparatory programs which are not approved; and those who come into the occupation from preparatory programs for other occupations, both approved and un- approved. Furthermore, no provision has been made for the reentrance of formally-trained workers into an occupation, owing to lack of quantifiable data on this subject. More- over, workers in the field or entrants can become qualified through equivalency tests, which equate knowledge, experi- ence, and skill with prescribed levels of formal training, and through proficiency tests, which match workers with jobs on the basis of measurable ability to perform. [. ficiency and equivalency testing is not an entirely new concept and has been carried out in major allied health fields for several decades. However, the impetus to develop proficiency and equivalency testing for many of the allied health occupa- “tions is fairly recent, resulting from a recognition of the shortage of health manpower, a need for better utilization of existing personnel, the attempt to build career mobility into the existing health occupations, and the necessity to evaluate the competencies of existing workers to assure the quality of services being rendered. As these tests are developed and implemented, the number of credentialed active manpower could increase substantially, affecting both the number of entrants to be considered and the mix of workers within any one occupation. The mix includes those who are qualified and credentialed through formal training and/or examination; those who, although quali- fied, have not participated in any type of credentialing process; and those who have neither formal training nor competency demonstrated through examination. The sections which follow provide projections to 1990 for formally trained allied health workers in 16 occupa- tions. The occupations selected are those for which: (1) formal training of 1 year or more is predominant; (2) adequate trend data on graduates exist; and (3) reasonably 140 reliable credentialed active and total supply estimates are available. These occupations are further divided into those which primarily require a baccalaureate and those in which less than a baccalaureate is generally required. The method of projecting supply, which proceeded through two stages for both groups, is described below. METHODOLOGY AND ASSUMPTIONS Appropriate Basic Occupational Preparation at least a Baccalaureate (Six Occupations). Included in this group are dietitians, medical record administrators, medical tech- nologists, occupational therapists, physical therapists, and speech pathologists and audiologists. In the projections for this group, the estimate of credentialed active personnel in each occupation for December 1970 was obtained from Health Resources Statistics, 1971.6 The age distribution of the active 1970 credentialed supply for medical technologists’ and occupational therapists® was based on survey data. For the other four occupations, an age distribution of the active work force was unavailable. It was assumed, consequently, that these four occupations were distributed by age in a manner similar to the medical technologists and occupational therapists. An average age distribution was computed from the data on medical technologists and occupational thera- pists and applied to the other four occupations. The sex distribution for active credentialed medical technologists and occupational therapists was also based on survey data. For the other four occupations, however, the sex distribu- tion of the active workers in each occupation was obtained from one State study.’ New entrants (graduates of approved programs only) were estimated for each year of the projection period (1971-90). It was assumed that the sex distribution of the entrants for each occupation would be similar to the corresponding sex distribution for the active credentialed workers in the same occupation. The projections of new entrants were developed by first relating the number of graduates in each of the 6 occupations in 1970 (or in 1971 6 National Center for Health Statistics. Health Resources Statis- tics. Health Manpower and Health Facilities, 1971. DHEW Pub. No. (HSM) 72-1509. U.S. Government Printing Office, 1972. National Committee for Careers in the Medical Laboratory, Inc. Salary Survey. GIST No. 50, February 1972. Bethesda, Md., The Committee (newsletter). Jantzen, Alice, C. Some Characteristics of Female Occupa- tional Therapists, 1970. American Journal of Occupational Therapy 26: 19-26, January 1972. Employment Security Commission of North Carolina. Health Manpower Needs in North Carolina, 1967-1973. Raleigh, The Commission, 1967. where data were available) to the total number of bache- lor’s and first professional degrees conferred in that year. For five of the occupations, the number of graduates from respective approved programs was computed as a proportion of total bachelor’s and first professional degrees conferred for the current period. The proportion was then held constant and applied to the projected 1971-90 total degrees conferred in order to estimate future graduate additions. For speech pathologists and audiologists, the same general methodology was applied, except that the number of graduates was related to master’s degrees conferred. It was assumed that the number of allied health graduates was directly related to the total pool of gradu- ates. This methodology and assumption were supported to some extent by the limited historical data available for the 1960's. Projected estimates of bachelor’s and first professional degrees conferred through 1980 were developed by the National Center for Educational Statistics (NCES).!° Total degree estimates for the 1981-90 period were projected by BHRD, using the same methodology used by NCES in developing the 1971-80 projections. The method assumed that the number of total bachelor’s and first professional degrees conferred is related both to the total number of persons in the population and to the number of persons in the age strata who receive degrees. Separations from the projected manpower pool were estimated annually. Separations, for the purpose of this chapter, represent separations from the occupation for all reasons, including deaths, retirements, and temporary ab- sences. It was arbitrarily assumed for the first five occupa- tions that, for each year during the 1971-90 period, 40 percent of the estimated graduates for that year would enter employment at age 22, 40 percent at age 23, and 20 percent at age 24; the exception was speech pathologists and audiologists, where 60 percent of the graduates were assumed to enter the field at age 23, and 40 percent at age 24. Age and sex specific separation rates for the labor force,’ ! were applied to the number of active credentialed personnel (including graduates) each January 1. Estimated losses were then subtracted annually from the active pool. It was assumed that all workers would retire at 65 years of age. APPROPRIATE BASIC OCCUPATIONAL PREPARA- TION LESS THAN A BACCALAUREATE (TEN OCCUPA.- TIONS). Included in this group are cytotechnologists, 10 Simon, Kenneth A. and Fullam, Marie G. Projections of Educational Statistics to 1979-80. Office of Education Pub. No. 10030-70. U.S. Government Printing Office, 1971. H Fullerton, Howard N. A Table of Expected Working Life for Men, 1968. Monthly Labor Review 94: 49-55, June 1971. 141 dental assistants, dental hygienists, dental laboratory tech- nicians, certified laboratory assistants, respiratory thera- pists, licensed practical nurses, medical record technicians, occupational therapy assistants, and radiologic technolo- gists. In the projections for this group, the estimate of the credentialed active personnel in each occupation for December 1970 was obtained from several sources. The number of active formally trained cytotechnologists and certified laboratory assistants, as well as the number of credentialed occupational therapy assistants, represented a weighted average based on findings in three States.! 2 For medical record technicians, radiologic technologists, and respiratory therapists, the number of active and creden- tialed workers was obtained from Health Resources Statis- tics, 1971." Estimates for dental assistants and dental laboratory technicians were obtained from the Division of Dental Health, BHRD. All active dental hygienists and active practical nurses were assumed to be licensed and thus credentialed. Age distributions for credentialed cytotechnologists and certified laboratory assistants were available from the National Committee for Careers in the Medical Laboratory (NCCML); registered radiologic technologists from organi- zation membership files. It was assumed that these distribu- tions would apply to the active credentialed estimate for these three occupations respectively. It was also assumed that an average of the age distribution of cytotechnologists and radiologic technologists could be applied to the re- mainder of the 10 occupations, except licensed practical nurses’ and dental hygienists, for which age distributions were available. Data on sex distributions were available for the latter two groups and for radiologic technologists. The sex distribution for dental assistants and dental laboratory technicians was available from the 1970 Census of Popula- tion. The distribution for the remaining five occupations was assumed to correspond to the sex distribution of the active work force reported in one State study.'® New entrants (graduates of approved programs only) were estimated for each year, 1971-90. It was assumed that the sex distribution of entrants in each occupation would be similar to the sex distribution for the active credentialed 12 A weighted average percentage of the active credentialed vs. the non-active credentialed was computed from data in 3 State studies: 1) Unpublished data for Arizona; 2) Office of Comprehen- sive Health Planning. Allied Health Manpower in Texas, 1970. Austin, Texas, The Governor's Office, 1970; and 3) Coordinated Health Survey Committee. Virginia Health Manpower, 1971. Richmond, Va., The Committee, 1971. National Center for Health Statistics, op. cit. 19 Marshall, Eleanor D. and Moses, Evelyn B. LPN’s 1967: An Inventory of Licensed Practical Nurses, U.S. Government Printing Office, 1971. 15 Employment Security Commission of North Carolina, op. cit, workers in that occupation. For graduate estimates, the number of graduates in each of the individual occupations was related to the total number of organized occupational curriculum awards, similar to the methodology used for the baccalaureate group. Trend data for total awards conferred were available for 1965-70,'¢ as were trend data (1965-70) for total degree-credit enrollment in 2-year institutions; 1970-79 projections of enrollments were also available!” The data on enrollments were extrapolated from past trends to derive estimated total enrollment data through 1990. The proportion that awards comprised of enroll- ments in 1970 (23 percent) was applied to the projected estimates of total enrollment to project total awards conferred to 1990.8 For each of the 10 occupations, the number of graduates from the respective approved programs was computed as a percentage of the estimated total organized occupational curriculum awards conferred for the current period. The percentage was then held constant and applied to the projected 1971-90 total awards conferred to derive the graduate additions for each year. It was arbitrarily assumed that for each year, 1971-90, 40 percent of the estimated graduates for that year would enter the labor market at age 20, 40 percent at age 21, and 20 percent at age 22. To estimate annual death and retirements, age and sex-specific separation rates for the labor force'® were applied to the number of active credentialed personnel (including graduates) each January 1. Estimated losses were then subtracted from the active pool. It was assumed that for each occupation, with the exception of licensed practical nurses, all workers would retire by age 65. Age data available for L.P.N.’s, in contrast to the limited information obtained for the other groups, suggested an average retirement age of 70. Limitations of Methodology. The methodology utilized in this set of projections had one purpose—to estimate, on the basis of the 1970 credentialed active supply of selected occupations, the formally trained supply of workers in these occupations through 1990 if projected entrants to the occupations represented only graduates of approved pro- grams. The resultant figures, therefore, were not intended, nor should they be interpreted, as estimates of the total active supply for these occupations. In 1970, for example, 16 Hooper, Mary E. Associate Degrees and Other Formal Awards Below the Baccalaureate, 1969-70, DHEW Pub. No. (OE) 72-48. U.S. Government Printing Office, 1971. 17 Simon, Kenneth A and Fullam, Marie G. op. cit. 18 For each year of the 1965-70 period, the proportion of total awards to enrollments was calculated; the proportions fluctuated between 18 and 25 percent. In view of the interyear movements, the 1970 proportion was arbitrarily selected for this methodology. 19 Fullerton, Howard N., op. cit. 142 there were a considerable number of other active workers in some of these occupations. (See Table 92.) Furthermore, there exist many other sources of personnel that can be expected to enter the occupation over the projection period—graduates of other than approved programs, gradu- ates of diverse programs who migrate into the field, those who receive formal/informal on-the-job-training, and re- entrants, among other sources. Any projection approach which includes only “appropriately trained” workers, as presented here, obviously understates the total current and future active supply. Apart from this, however, the basic limitation of this and any other projection method is the weakness of the data available: 1. Supply estimates for the number of credentialed personnel in these occupations have been derived from a variety of sources and they reflect estimates of varying reliability. In addition, it should be noted that the assumption equating the credentialed supply with those persons formally trained cannot be sup- ported by empirical evidence. The presumption was made that for most occupations, recent graduates of approved programs have been credentialed or qualify for credentialing, and that, except for persons coming under ‘‘grandfather clauses,” most credentialed per- sons have received formal training. Although this presumption appeared reasonable, it must also be noted that the situation varies among occupations. As indicated earlier, limited age and sex data are available for allied health professions and occupa- tions. Assumptions advanced in this methodology concerning these characteristics, although seemingly reasonable on the surface, also cannot be supported by “hard” data. This consideration includes, where indicated, extrapolations of narrowly based survey findings to a national experience. 3. Educational data for the occupations, particularly those occupations for which personnel are trained at less than the baccalaureate level, are generally not available for a sufficient number of years to develop a meaningful time series. 4. The projections of total organized occupational curriculum awards are extremely weak. 5. The age- and sex-specific separation rates were derived from working-life tables of the general labor force. The separation rates used were based on all separations from the labor force, including deaths, retirements, and temporary absences from the occu- pation. It is unknown whether the separation pat- terns of allied health workers are similar to those of the general population. (See Appendix A.) In addi- tion, it was assumed from available data, that workers in the allied professions and occupations covered in the projections retire at age 65 with one exception; LPN’s were assumed to retire at age 70. PROJECTION FINDINGS In presenting the projections, it is essential to repeat the caveat that they relate only to formally trained or credentialed workers and not to the total active supply. Furthermore, there is considerable variation within occupa- tions as to the proportion that is indeed credentialed, a variation that is not necessarily caused by the level of formal training required for the occupation. Given the increased interest in training prerequisites, it is conceivable that some newly established occupations will have relatively high proportions of formally trained person- nel, especially those occupations which emerge within a highly organized group, such as clinical laboratory person- nel. Although data are rather fragmentary, limited available information indicates that the credentialed work force among the 16 occupations varies not only in the size and the proportion of the total active supply they represent but in their respective sex and age distributions as well. Such compositional differences account in part for variations evidenced in projected growth rates among the groups. Among the six occupations requiring at least a baccalaureate, for example, projected increases in the number formally trained range from over 400 percent for speech pathologists and audiologists to 46 percent for dietitians. It should be noted, once again, that such gains have been projected for the supply of the formally trained and may not be at all representative of corresponding percent increases expected for the total active supply. In fact, in most instances, it is likely that the actual growth of the total active supply will be somewhat less, since current indications suggest that the formally trained will represent a larger segment of the overall allied health work force in the coming years than is now the case. In this regard, speech pathologists and audiologists may very well represent a case in point. As indicated in Table 93, the supply of active formally trained professionals in Table 93. SUPPLY OF ACTIVE FORMALLY TRAINED SELECTED ALLIED HEALTH PERSONNEL AND PERCENT CHANGE: 1970; PROJECTED 1980 AND 1990 Number of active formally trained personnel Percent change Occupation 1970 1980 1990 1970-80 1980-90 Basic educational preparation at least baccalaureate in level Dietitians. . .....coiitvrineriterrnternnnennas 15,300 18,170 22,340 18.8 23.0 Medical record administrators ..........oe0ueeeun 4,200 5,140 6,430 22.4 25.1 Medical technologists. ........ovuveiennnennnn. 45,000 80,620 123,520 79.2 53.3 Occupational therapists . «. «ve ev i svn viv s wis vis s 35 + 7,300 11,760 16,880 61.1 43.6 Physical therapists: «vu sins sin ¢ wine #8 4 220 0.9% +000 » Wit 11,550 23,030 36,570 99.4 58.8 Speech pathologists and audiologists . ............. 13,300 37,070 70,930 178.8 91.4 Basic educational preparation less than baccalaureate in level Certified laboratory assistants ........cceescuesas 6,700 CytotechnolOgIStS vs wv snn svwsms sms umavns nes viva 2,400 Dental assiStANES oi + v0 v ov swim aim via 3.3 3.07% 3 #0 98 » 9,200 Dental hygienists . .ccciivsvsnsrvarsenasnsonme 15,100 Dental laboratory technicians. . ..........oovuu... 1,600 Licensed practical nurses ..........covvevennunn. 400,000 Respiratory therapists .... «sve wes ves vs rsrsvne ens 3,850 Medical record technicians. ..........ccc0civeenes 3,800 Occupational therapy assistants ...........cc0u0uuu. 600 Radiologic technologists «ve vissvsvsnvsvisvios 41,000 22,260 41,160 232.3 84.9 4,670 7,400 94.6 58.5 39,110 71,530 325.1 82.9 34,190 57,650 126.5 68.7 7,070 14,290 341.9 102.2 565,890 819,790 41.5 44.9 10,510 18,810 173.0 79.0 4,900 6,460 29.0 31.9 4,360 8,820 626.7 102.3 93,560 161,280 128.2 72.4 Source: 1970 dental allied: BHRD, Division of Dental Health 1970 all other occupations: National Center for Health Statistics. Health Resources Statistics. Health Manpower and Health Facilities, 71971. DHEW Pub. No. (HSM) 72-1509. U.S. Government Printing Office, 1972. Note: These estimates are for the supply of formally trained personnel only, and consequently should not be viewed as representing total active supply. Additions to 1970 supply include only graduates of approved programs. 143 this field is projected to increase from an estimated 13,300 in 1970 to a supply of about 70,930 in 1990—a fivefold increase, with graduate inputs during the projection period representing only those workers having at least a master’s degree. Assuming that the current proportion of formally trained to the total active supply (70 percent) for this occupation would remain constant over the next two decades, the total active supply of speech pathologists and audiologists would be approximately 101,300 by 1990. In light of the growing trend toward an M.A. degree as a minimum requirement for entrance into the field, however, it seems likely that the 70 percent represents a low estimate for future years. Following this logic one step further suggests that the illustrative estimate of the total active supply might indeed be on the high side. Without question, such a discussion represents only slightly more than speculation along with insights derived from limited available data. Nonetheless, such an exercise, given projections developed here for the formally trained work force, is of use in suggesting what might constitute the maximum growth to be expected in many of the allied health professions and occupations. One constraint to this approach, however, stems from the fact that the reliability of information on the current credentialed and total work force varies substantially among the occupations examined. The formally-trained supply of dietitians is projected to increase from 15,300 in 1970 to 22,340 in 1990, an increase of over 7,000 or 46 percent. (See Table 94.) Applying the 1970 proportion of formally-trained workers (53 percent) to the 1990 estimate of formally-trained dietitians, would result in a total active supply of slightly over 42,000 workers. The current data base for dietitians, however, is weak, particularly compared to that for speech pathologists and audiologists. Therefore, the projections shown, as well as the illustrative total supply possibility, must be viewed quite cautiously. The projections show interoccupational differences in the proportion of the total active work force that is formally trained.?® Supply estimates presented here for medical record administrators and medical technologists can be used to illustrate this point. The projections developed for medical record adminis- trators and shown in Table 95 suggest that it will take more than two decades for the supply of formally-trained 20 Percentages of formally-trained personnel in the various allied occupations represent the ratios of the formally-trained, as shown in Table 93, to the total estimated supply, as shown in Table 92, Table 94. ADDITIONS AND LOSSES TO THE SUPPLY OF ACTIVE FORMALLY-TRAINED DIETITIANS: 1970 AND PROJECTED 1975-90 Number of active Additions from Losses from Year formally-trained Interval graduates of approved deaths and dietitians programs reitrements VOD yrs wins bmw 0 win 4 90 3 5900 0 B75 5 56 5 Wik i 6 00 9 mc 00 15,300 1970-750 4 wi 0:05 » 4,770 3,930 VOLE on v0 0003 450 5 G0 00 ¥ ck www nem cur wr 3 esi 16,140 1975-80. ¢0u vss 6,040 4,000 TOBO. wins 5m 5 50k 5 90a 7 9 030k wane wick wie» owt 4 370 3 80 4 18,170 1980-85........ 6,970 4,670 VIBE | 0.30% 3 Wik & Tot 3 wu 4mm wom: iw wii wis & 406 5.93004 9 20,470 1985-90....... 7,080 5,210 TOGO 250i vis wir «rims wins 0 ivr 0 wes ww 4 5% 3 00 46 4 Bd 3 22,340 Table 95. ADDITIONS AND LOSSES TO THE SUPPLY OF ACTIVE FORMALLY-TRAINED MEDICAL RECORD ADMINISTRATORS: 1970 AND PROJECTED 1975-90 Number of active formally-trained Additions from Losses from Year . Interval graduates of approved deaths and medical record + administrators programs retirements 1970 oii ee eee 4,200 1970-75 ....... 1,430 1,130 VOUS wiv s vie vniv unis nian wii 0058 wie 01% 300 6 0% § mid 0 4,500 1975-80....... 1,810 1,170 V9BO wou vmw buna v 0p #00 3 98 $405 sas 4 2m ¥ bins Mik 3 5,140 1980-85 ....4 44: 2,090 1,380 VOBS' ows wm sm vim 4 i + i #500 3 560 5.350 5 0% ie % om n 5,850 198590, suv 55 + 2,120 1,540 FOOD + uivs wv wi 4 0h # ie 8 500 8 00 2 och #. 0m 50 0 Biwi wen 6,430 144 workers to equal the current number active in the field. In 1970, the supply of formally-trained medical record admin- istrators numbered 4,200, or less than two-fifths of the overall active supply (11,000). The number of formally- trained workers is projected to increase to 6,430 by 1990, or by 53 percent over the projection period. In 1970, an estimated 69 percent of the total active supply of medical technologists (65,000) were formally trained. Between 1970 and 1990, the supply of the for- mally-trained segment is projected to increase from 45,000 to about 123,520, or virtually a threefold increase. (See Table 96.) Given this projection, the estimated number of formally-trained medical technologists in 1990 represents a work force that is twice the supply currently active. Stated in other terms, the projections indicate that by 1978, the supply of formally-trained personnel alone will equal the total number of medical technologists presently active. In addition to the projections developed for these occupations, projections of the formally-trained work force were undertaken for two other allied health groups that require a minimum of a baccalaureate for entrance into the field. The supply of formally-trained occupational thera- pists is projected to increase from 7,300 in 1970 to 16,880 by 1990; more than doubling over the 20-year period. (See Table 97.) In 1970, the total active work force of occupational therapists (including graduates of non- approved programs, persons receiving on-the-job-training, etc.) numbered slightly less than 11,000. For physical therapists, it is estimated that the number of formally-trained personnel will more than triple, from 11,550 in 1970 to 36,570 in 1990. (See Table 98.) The projected 1990 supply of formally-trained workers repre- sents a work force that is approximately two and one-half times the 1970 total active supply of 15,000. Since physical therapists are now licensed in all 50 States, this 1990 projection may be relatively realistic, the majority of the active work force coming through formal training programs. As shown in Tables 100 to 109, projections of the formally-trained supply were also developed for 10 allied health occupations which require less than a baccalaureate ADDITIONS AND LOSSES TO THE SUPPLY OF ACTIVE FORMALLY-TRAINED MEDICAL TECHNOLOGISTS: 1970 AND PROJECTED Table 96. 1975-90 Number of active Additions from Losses from Year formally-trained Interval graduates of deaths and medical technologists approved programs retirements BOTW .« oovciinini © aia 3 03 4.30080 5 900% 900 © 40 8 0 0 45,000 1970-75 ....... 29,610 14,450 WITS vv ei om wii 24 #06 3.57008 0 © BIR 3 B00 60,170 VO7580 ovr viv vv 37,460 17,010 TOBO co: sora: 250s 4 950: 3 wim # ak 4 ini & wow & ome wimem: 8 80,620 J980-83 sev sive 43,270 20,880 TOBE. 10.0 ww ww 4 00: 4 000 3 00 0 ww: «worm wore mica 103,010 1985-90... cn. 43,960 23,450 VID) is win wiv 5 win ¢ ww 8 wiv 4 ew 3 wi, «wie + 00w 4 123,520 Table 97. ADDITIONS AND LOSSES TO THE SUPPLY OF ACTIVE FORMALLY-TRAINED OCCUPATIONAL THERAPISTS: 1970 AND PROJECTED 1975-90 Number of active Additions from Losses from Year formally-trained Interval graduates of approved deaths and occupational therapists programs retirements FOTO vv vo cms vino oid da 5 08 0h BR 4 S00 0 8 ww # lw 7,300 1970-75 ....... 4,240 2,270 VOTE uv on ernie winio» ut #iticn. & on 3.050 i 4 Hl & W000 § WK 8 50 9,270 1975-80. cv ces 5,360 2,870 FOBO! + vi 3 we «070 wicece wconw 20m woann wiki & Hicei ® Sikh mist $i 11,760 1980-85....... 6,190 3,460 1985 iii iii i i aes 14,500 1985-90....... 6,290 3,910 FOOD «4 vie sins specs mimes win 5 gonsn wos wey wunl » wie wach wae 16,880 565-118 O - 74 - 11 for minimum entrance into the field. Projections, for example, were undertaken for three types of dental auxiliaries: dental hygienists, dental assistants, and dental laboratory technicians. For these occupations, however, the development and use of expanded-function auxiliaries were not considered, owing to the lack of sufficient baseline data. The supply of formally-trained active certified labora- tory assistants is projected to increase from 6,700 in 1970 to 41,160 by 1990; an increase of more than six-fold over the 20-year period. (See Table 100.) No estimate is available for the total active work force of C.L.A.’s in 1970 and therefore no projections have been made for the total occupation. Not until 1967 did the American Medical Association, the American Society of Clinical Pathologists, and the American Society of Medical Technologists jointly develop the essential requirements for certification of educational institutions to provide programs for certified laboratory assistants and initiate procedures for approval of such programs. Thus, there are very little trend data on which to base any future speculations of the proportion of the total supply who will be formally trained. Projections were made for another type of clinical laboratory personnel, cytotechnologists. It was estimated that in 1970, 74 percent (2,400) of all active cytotech- nologists were formally-trained. More than three times as many formally-trained active cytotechnologists (7,400) are projected for 1990. (See Table 101.) It is difficult to speculate what proportion this figure will represent of the total active base for cytotechnologists in 1990 for several reasons. Between 1970 and 1971 there was a 20-percent decline in the number of graduates from approved programs of cytotechnology. Employment opportunities may not expand as readily in the next two decades (possibly affecting the production of cytotechnologists) as in the last decade due to the ever-increasing technological adaptations being made in the clinical laboratory setting and the possible breakthroughs which may result from research. Table 98. ADDITIONS AND LOSSES TO THE SUPPLY OF ACTIVE FORMALLY-TRAINED PHYSICAL THERAPISTS: 1970 AND PROJECTED 1975-90 Number of active Additions from Losses from Year formally-trained Interval graduates of approved deaths and physical therapists programs retirements VOTO ioc aoe 0 vie wie & wom 4 wos 0nd] soul ink $05 4 900 00 BB 11,550 1970-75 + + wiv ¢ wie 6 8,520 3,440 15° 1 J SN 16,640 1975-80........ 10,780 4,390 TOBO oan am wiv ain owes 9% 1 950,80 9% W000 40 4 Pw wim gv 23,030 1980-85........ 12,450 5,400 VIBE wiv v0 + 90 # win & 0g 8 000 3 50 § WIE WEE EEE 905 OW EW 30,080 1985-90........ 12,650 6,160 VIOO wip 5 0 0 5:9 0 in 5.950 3 00 © F006 DIRE § 90 190 6 000 ¥ 0 § 36,570 Table 99. ADDITIONS AND LOSSES TO THE SUPPLY OF ACTIVE FORMALLY-TRAINED SPEECH PATHOLOGISTS AND AUDIOLOGISTS: 1970 AND PROJECTED 1975-90 Number of ackive Additions from Losses from formally-trained Year Interval graduates of approved deaths and speech pathologists ‘ ti _ and audiologists programs retirements VOFO: vv nigin won s win v won 3 iovw o worm 0 0's wie, wiwin Sere: wuss 13,300 VI7075 vv v vin v wow 14,840 4,580 YO75! oiiv wwe viv s win vain s wis 00 4 W308 015 $950 Ww Siw 23,560 1975-80 v5 0:04 ws 19,960 6,450 WOBO: wiv wim orn ¢ on 5 900 + 900 & 900 4 W000 § iw & 0H 000 WIS 37,070 198085, ¢ vis « vn 25,150 8,490 VIBE aie winie win 4 50% » 30k £030 4 000 3 610) § 00 6 2008 000 iit 53,730 1985-90. c40iu 44s 27,620 10,420 WOO: sive vis 9 8 3 7 6» 30 4 Bil § Bik 550 mid] $10 iit 70,930 146 Dental assistants, in contrast to most occupations discussed in this section, have comparatively few formally- trained personnel in the work force. In 1970, the number of formally-trained was only 9,200; or less than 10 percent of the overall active supply (112,000). The number of formally-trained dental assistants is projected to reach 71,530 by 1990. (See Table 102.) Assuming that the supply of all active dental assistants is totally responsive to the supply of dentists, the Division of Dental Health (BHRD) has projected the overall supply of active dental assistants to reach 170,800 by 1990. These two projections, although derived independently and by noncomparable methods, suggest that the proportion of formally-trained assistants will rise substantially over the next two decades. Such an occurrence is indeed possible, since dental assistants, who historically have been largely trained on the job, are now evidencing a marked trend toward formal training. Illustra- tive of this recent trend is the growth of dental assistants programs in the past decade. The number of students in dental assistant programs has risen from about 1,000, in 1962 to over 5,000 in 1970, and over 7,000 in 1972. Since all dental hygienists practicing in the United States are licensed, a situation uncommon among allied health professions and occupations, the formally-trained base for 1970 was considered to be the same as the total active work force. In this regard, subsequently, the projections shown represent the overall active supply in the profession. As shown in Table 103, the number of active dental hygienists is projected to grow from 15,100 in 1970 to 57,650 in 1990, or an increase of 280 percent. This estimate appears to be reasonable in view of the noticeable growth in the number of programs and graduates over the past few years. The projected supply outlook for dental laboratory technicians is quite similar to that of dental assistants. In 1970, the supply of formally-trained workers numbered about 1,600; or 5 percent of the overall active supply (30,700). This compares with a projected formally-trained Table 100. ADDITIONS AND LOSSES TO THE SUPPLY OF ACTIVE FORMALLY-TRAINED CERTIFIED LABORATORY ASSISTANTS: 1970 AND PROJECTED 1975-90 umber rhb Additions from Losses from Year irs y Interval graduates of approved deaths and certified laboratory . , programs retirernents assistants VOTO i viovv wins aim 900 40's 10 3369 B00 $9200 S00 s 0406 5 910 6,700 1970-75 vs ve sn 11,520 4,630 VOTE: vies om mins ik $00 500 2,908 ¢ 0.6 16 4 #08 3 0 § Ww 13,590 1975-80 0c cvvss 15,570 6,910 VOBO! ; vive sin swim soon 4 win 4 5k 3 008 8 In 008 S00 2 ©F S09 22,260 1980-85 ....... 18,640 8,960 TOBE von: #5 Swit dae Bimal 5 kl 5.7008 0.0 # 3.5009 Boi 5.5040 § Hid 31,950 1985-90....... 19,490 10,270 1 1 LP 41,160 Table 101. ADDITIONS AND LOSSES TO THE SUPPLY OF ACTIVE FORMALLY-TRAINED CYTOTECHNOLOGISTS: 1970 AND PROJECTED 1975-90 Number of active Additions from Losses from Year formally-trained Interval graduates of approved deaths and cytotechnologists programs retirements VOTO ions mins win 4 ais 46 » 050 3 555 4 40 2008 SAE 20 4 0 2,400 1970-75 ........ 1,990 990 YOT5 ries. 0.00 4 58 4.5007 Tow Win 7 00 6 odd Few oa iw: + we 3,400 1975-80. cosas 2,690 1,420 BOBO iwsce 5150: 4 amir 4 wigs » 10m Rg «why © wre) sume los + ws yi 4,670 1980-85 ........ 3,220 1,990 T985 wv ins nies vies mins wins win + 29 0 98 000 010 8 £90 8 WW 6,090 1985-80. ss 504 3,360 2,050 VII wv sone arm ove vo wiw 3 ww + 3a 0 iw © wine 8 6 BPW 9% 5 9% 7,400 147 Table 102. ADDITIONS AND LOSSES TO THE SUPPLY OF ACTIVE FORMALLY-TRAINED DENTAL ASSISTANTS: 1970 AND PROJECTED 1975-90 Number of active Additions from Losses from Year formally-trained Interval graduates of approved deaths and dental assistants programs retirements NOT0, oii wii ov # 5iw0 0 93: 0 600 + N00 % WIE & 00 0 B00 $00 Wine 9,200 1970-75 vis vv uns 23,130 8,840 VO75! 0 siaco 00s wins wine win» 0mm 30s 4 Ih 8 hip & ed Ridin Bik 23,490 1975-80 .4: 00045 31,260 15,640 VOBO ty wiurw wie's 2:0 « wiv 8 wre vive 4 0m 4 win & 40g © vin greene 39,110 1980-85........ 37,420 20,650 WIBS , srvin ice wim « wis + Bins 90» Wil ¥ Was #54 4 WR Wile wae 55,880 1985-90........ 39,110 23,460 TOI i wis vies ais shad win & wi + 90% » 919 F300 Sink Tee Ww y 71,530 Table 103. ADDITIONS AND LOSSES TO THE SUPPLY OF ACTIVE FORMALLY-TRAINED DENTAL HYGIENISTS: 1970 AND PROJECTED 1975-90 Number of active Additions from Losses from Year formally-trained Interval graduates of approved deaths and dental hygienists programs retirements VOTO ove v0.9 5/9 5 050 » 06 $000 Smid B00 4 00 IEE $10 6 WIN 4 15,100 1970-75 + « evs 01x + 16,800 8,590 VOTE dive 2m vuim # Wik 390% 2060 SH AE PIE 5905 B00 £ V0 02 23,310 JOT5-B00 ¢ 00 4 wi» 22,710 11,830 VOBO uii iv vi oi # id R000 B BEE 0H il & Bi # 3 6 000 4 6 34,190 1980-85. ; vos 0:0 0 27,180 15,040 TOBE. suri in 5 mses im 220m wien rinttlanank BiviaTa lees sin bE 0 46,320 1985-90. « viv svn 28,410 17,080 LIE 25 57,650 supply of 14,290 by 1990 (Table 104); and an estimated 46,600 overall active supply as projected by the Division of Dental Health. Here also, the suggested increase in the proportion formally-trained may very well be reasonable, given the greater emphasis towards formal training for these workers in recent years. The number of licensed practical nurses that are for- mally trained is not presently known. For the purpose of these projections, it is assumed that all L.P.N.’s are formally trained, as all are licensed. As shown in Table 105, the number of formally-trained active licensed practical nurses is projected to increase from 400,000 in 1970 to 819,790 by 1990, slightly over a 100 percent increase. This estimate appears to be somewhat conservative in light of the nearly threefold increase in the number of active L.P.N.’s between 1950 and 1970. The projected supply outlook for formally-trained active respiratory therapists is also heavily influenced by the 148 substantial increase in the number of approved programs and graduates in the past few years. In 1970, the supply of formally-trained workers numbered 3,850, or 35 percent of the overall active supply of 11,000. This compares with a projected formally-trained supply of 18,810 by 1990. (See Table 106.) Applying the 1970 proportion of formally- trained workers to the 1990 estimate of formally-trained respiratory therapists would result in a total active supply of almost 54,000 workers by 1990. However, the substan- tial increase in the number of approved programs for respiratory therapists (from 11 in 1964 to 82 in 1970) and the corresponding increase in the number of graduates (from 48 to 439 in the respective years) would indicate a trend toward formal training. This suggests that the overall active supply in 1990 may very well number less than 54,000. Although formal training for medical record technicians was instituted in 1953, the last two decades have not Table 104. ADDITIONS AND LOSSES TO THE SUPPLY OF ACTIVE FORMALLY-TRAINED DENTAL LABORATORY TECHNICIANS: 1970 AND PROJECTED 1975-90 Number of 3ctive Additions from Losses from Year formally-trained Interval graduates of approved deaths and dental laboratory , technicians programs retirements O70 2% une Sinnslanont wasnsl wine o asiiey Suse iow rns he opr lofi 1,600 1970-75 woo wove nwo 2,610 250 1975 i i i i eae 3,970 1975-80: sn sss 3,530 430 VIBO « «uv wnin sie wisia wim wiv sini waa iw + Win $iwiw + wo 7,070 1980-85 ....5:045. 4,230 630 VIBE «i aie niwio swum 2mm 91910 Hiv Wied Find B13 #050 8 WS So 10,670 1985-90......... 4,420 790 VINO! « «wis ninin win + wie s015 #100 Wwe wma in # 019 4.00% S00 14,290 Table 105. ADDITIONS AND LOSSES TO THE SUPPLY OF ACTIVE FORMALLY-TRAINED LICENSED PRACTICAL NURSES: 1970 AND PROJECTED 1975-90 ii of active Additions from Losses from Year ¥ y Interval graduates of approved deaths and licensed practical 2 programs retirements nurses VOF0 ov nn oars weirs wins sree wake where woans- ase wie » $38 Wises 400,000 197075 ico 500 uv 236,600 171,920 VOTE 100 win viwie 009 witch 3 00 390 $00 W50F 408 § 00 3 050 4 910 464,680 1975-80 0: 4 wise ww 319,730 218,520 VOBO iu; wiv vw ww 0 wie is wire 900 W100 6 Wid» 00: 6 00 B0 565,890 1980-85........ 382,800 255,270 UBS iv vaio ik 500 $1000 # Hi BE REE STIR CRE WR 693,420 1985-90........ 400,140 273,770 BODO! i. i aia eis ibink # 85k 5.00 § Wor iol Sn fos § Woh itl & wed 819,790 Table 106. ADDITIONS AND LOSSES TO THE SUPPLY OF ACTIVE FORMALLY-TRAINED RESPIRATORY THERAPISTS: 1970 AND PROJECTED 1975-90 Number of active Additions from Losses from Year formally-trained Interval graduates of approved deaths and respiratory therapists programs retirements 970 i 5:6 2.00 500500 BAERS 3 CRIS Si 0 RI SR 3,850 1970-75 cs view nvs 4,390 1,440 TODS: + 2:85 ros Brame 32S wages cyrwas) Se Wize doch Biel ¥ Bohablptind 6,800 1975-80. svc wins 5,930 2,220 VIBO op vin vm + ww wwe www wig sims wine win « won u wen 10,510 1980-85, «cco wre: 7,100 2,890 VIBE on cum wiwim vows © 90 SRIF $70 SEE4 IW SRT S Wie Rie b 17,720 1985-901. » 0:0 55:0 7,420 3,330 VO90 . avs mani s wine Sm § hia & 00 5 B00 BIE § R56 ¢ Wi 4 Mm 8 18,810 149 witnessed a sizeable growth in the number of credentialed workers in this occupation. It is estimated that in 1970, for example, approximately 9 percent (3,800) of the 42,000 active supply were classified as A.R.T.’s, accredited record technicians. A 70 percent increase of formally-trained workers is projected for 1990 (6,460). (See Table 107.) This figure might represent less than 10 percent of the total active supply in 1990, since undoubtedly the supply over the next two decades will be expanded by a considerable number of workers who have not received formal training. Although data are rather fragmentary relating to the supply of formally-trained occupational therapy assistants, projections based on the limited available information indicated that the credentialed supply of employed O.T.A.’s is to increase from 600 in 1970 to 8,820 in 1990, approximately a 15-fold increase. (See Table 108.) Assum- ing that the current proportion of formally-trained to the total active supply (25 percent) for this occupation would remain constant over the next two decades, the total supply of O.T.A.s would be approximately 36,740 by 1990. However, it is likely that the actual growth of the total active supply will be somewhat less, since current indica- tions suggest that the formally-trained will represent a larger segment of the overall work force in the coming years than is now the case. The last occupation considered that requires an educa- tion at less than the baccalaureate level is radiologic technology. The number of formally-trained active workers is estimated at 41,000 in 1970, or 55 percent of the 75,000 estimated total active supply. The projected number of formally-trained radiologic technologists was estimated to be 161,280 by 1990, approximately a fourfold increase over the projection period. (See Table 109.) This formally- trained estimate for 1990 is approximately 2.2 times larger than the total active figure for 1970. The estimated number active in 1990, when the same ratio of formally-trained to total active in 1970 is applied, would be approximately 295,000. Such a large number is not anticipated owing to the belief that the proportion of formally-trained radiologic technologists to the total active will increase over the Table 107. ADDITIONS AND LOSSES TO THE SUPPLY OF ACTIVE FORMALLY-TRAINED MEDICAL RECORD TECHNICIANS: 1970 AND PROJECTED 1975-90 Number of active . Losses from formally-trained Additions from Year Interval graduates of approved deaths and medical record : so programs retirements technicians TOTO was wiv wom & tan win #0k § meh §oaodh 8 Wok BHA ® i006 00 0 3,800 1970-78 + vee niv 1,580 1,220 T1975 vvinnnvnevnrsntansanenrensnnennennns 4,160 1975-80........ 2,130 1,390 VOBO wv ivi vin swim 8 4716 § hiw $108 SWE SME XBL ww 8 Ww x 4,900 1980-85........ 2,550 1,730 TOBE ins wins 30 8 wie # 5 SORE 5 B86 I 8 Bin & G0 www a 5,720 1985-90........ 2,660 1,920 TODD dis 5 mi 5 8 504 wm i % Ba 0 & RA 4 005 8 AE 8 204 3 0 6,460 Table 108. ADDITIONS AND LOSSES TO THE SUPPLY OF ACTIVE FORMALLY-TRAINED OCCUPATIONAL THERAPY ASSISTANTS: 1970 AND PROJECTED 1975-90 Number of active Additions from Losses from formally-trained Year . Interval graduates of approved deaths and occupational therapy i 2 programs retirements assistants BIT0, ... 2 ye # ves emi sb bein Bonne: zp » ter wisi on wtemssin on 600 1970-75 ........ 2,230 510 TOTS ww enimvupm ans 805 gio 0 80k 0904 5 Hin $08 © W081 # WHE 4 400 2,320 1975-80 coo vino 3,010 980 TIBO: is « vim iw 5 00 5.350 6 3 10s 2.900 B10 4 & B18 5% S30 & #10 © Wi 4,360 1980-85 . vis vies» 3,600 1,340 VIBE iii vias 5k 2 0 3 id 4 Wik 6 000 3 Well + 0k RHR 5 W 8 $00 4 8 6,620 1985-90, wos mun 3,770 1,570 1990 Loti eee eas 8,820 150 Table 109. ADDITIONS AND LOSSES TO THE SUPPLY OF ACTIVE FORMALLY-TRAINED RADIOLOGIC TECHNOLOGISTS: 1970 AND PROJECTED 1975-90 Number or active Additions from Losses from Year i Interval graduates of approved deaths and technologists programs retirements VOTO oo 50 sini 470 © 90008 HIRE 57% & $78 & B10 6 Sin 3 0: $000 0 41,000 1970-75 ........ 38,770 16,400 VOTE st vivct 2iv 400 5 000 4 40 5 RIE 50 # W003 00 Wie 63,570 1975-80, vip ve 52,650 22,670 TOBO oo + vrs sein sons guns woo wong Suki wien ik R00 BiaL0 B30 93,560 1980-85 cv wiws ie 63,020 28,810 VIBE io ios wren wim owes sve wimg woe 4 wig w owo onwen w swig wim 127,770 198580 vs vx ¢ we 65,880 32,370 1990 x ovo wins 45 + 91% 3 000 4 40 § 40 © WK 8 We SWE PW 8 wr 161,280 20-year period. It should be noted, however, that the number of programs in radiologic technology decreased slightly over the 1970-72 period. This decrease is not reflected in the graduate output at present but may be at a later date. The formally-trained active supply for which projec- tions are shown represent only a portion of the total active work force, present and projected, for most of the 16 occupations. Furthermore, the 16 occupations should not be considered representative of all allied health professions and occupations for two reasons. First, the variability in the percent formally-trained and the 151 projected differences in rate of increase for each occupation might differ from other occupations. Second, although occupations were discussed which cut across the various types of services and skills, e.g., therapists, clinical labora- tory assistants, and medical record technicians—this group of 16 should in no way be considered a cross-section of the total allied health field. Again, it is stated that these projections should be interpreted cautiously, given the conceptual framework, data limitations, and assumptions made. The projections represent estimates of the formally- trained work force when only graduates of approved programs are considered. a LS idl 1d APPENDICES RRs Milan ih lth ie wie oben ete Appendix A DERIVATION OF SEPARATION ESTIMATES (DEATHS AND RETIREMENTS) IN SUPPLY PROJECTION METHODOLOGY The estimation of projected losses to health professions through deaths and retirements represents an important aspect of the development of supply projections. As indicated in the text, however, information on separation patterns relating specifically to health occupations is rather limited. As a consequence, for most occupations for which projections are presented here, estimates of deaths and retirements have been computed utilizing age-specific sepa- ration rates for the general working population as an initial input, with adjustments for specific occupational groups made where supportive empirical evidence exists. The purpose of this Appendix is to discuss these techniques in greater detail than was presented earlier. In particular, the focus of the following discussion centers on the methodology used to estimate M.D. losses, given the existence of several important studies that provide useful information on the mortality and retirement experience of physicians. OVERVIEW The Bureau of Labor Statistics (BLS) has on a number of occasions published age-specific separation rates for the general male working population. These ‘“working-life tables” provide estimates, for each 5-year age cohort, of the number of persons per 1,000 workers who are expected to die or retire annually.! These age-specific rates have been developed for the general working population, however, and not for specific occupations, of which many may have mortality and retirement experiences different from those of the general population. In the case of physicians, for example, there is independent evidence that these profes- sionals have somewhat longer life spans than the general working population and a somewhat longer working life. Hence, estimates of M.D. deaths and retirements derived from working-life tables for the general work force would tend to overstate losses to the profession. In this report, M.D. losses were estimated by adjusting the generalized separation rates to reflect more closely the physician experience. This adjustment was separately ap- plied to death and to retirement rates. The resultant ] Fullerton, Howard N. A Table of Expected Working Life for Men, 1968. Monthly Labor Review 94: 49-55, June 1971, A number of rates shown in article are in error; see Table A1 for author’s suggested corrections. 155 modified rates for each age cohort were then aggregated to develop the occupation-specific separation rates.? ADJUSTMENT TO DEATH RATES Although a number of studies have been conducted on the subject of physician mortality, the findings of which are relatively consistent, most are concerned with the total, rather than the working, M.D. population. This posed difficulties in the development of quantifiable assumptions about death rates for the active M.D. population, despite the fact that several of the studies suggested that “physi- cians have a longer life span than white males in general.”® A further investigation of the literature in this area uncovered a table of working life for physicians in 1959 (based on AMA data), as well as a brief summary of a comparison between that table and a similar table for U.S. males in 1960. The comparison indicated, for example, that for ages 30 through 70, “the life expectancy of physicians at any age was up to 2 years longer than that for U.S. males.” Overall, the comparison suggested about a 3-year difference in average life expectancy from birth. Given this information and constraints posed by avail- able life tables, it was assumed that physicians have an average life expectancy from birth of about 2; years more than the average male population.’ Life tables were 2 Separation rates developed by this method are designed to be applied to a working, rather than a total population. This method would be roughly equivalent to applying death rates to a total population and then applying an ‘‘active/total ratio” to the estimated survivors, 3 Williams, S. V.; Munford, R. S.; Colton, T.; Murphy, D. A.; and Poskanzer, D.C. Mortality Among Physicians: A Cohort Study. Journal of Chronic Diseases 24: 393-401, June 1971; see also: Emerson, H. and Hughes, H. E, Death Rates of Male White Physicians in the United States by Age and Cause. American Journal of Public Health 16: 1088-1093, November 1926; and King, Haitung, Health in the Medical and Other Learned Professions. Journal of Chronic Diseases 23: 257-281, April 1970. For some evidence to the contrary, see: Dublin, L. I. and Spiegelman, M, The Longevity and Mortality of American Physicians, 1938-1942, Journal of the American Medical Association 134: 1211-1215, August 9, 1947. 4 Li, F.P. Working-Life Span of Physicians. Journal of the American Medical Association 206: 1308, November 4, 1968. % The exact difference in average life expectancy used in this method, 2.533 years, was in part chosen because of the availability of published model life tables using this difference. See: Coale, A. J. and Dement, P. Regional Model Life Tables and Stable Populations. Princeton, N.]J., Princeton University Press, 1966. available that provided mortality rates for populations having different average life expectancies—the two popula- tions examined having average life expectancies of 66.023 years (approximating the 66.6 years for all U.S. males), and 68.556 years (assumed to be representative of the physician population; 2% years longer than the U.S. male average). In line with the methodology referred to earlier, ratios of age-specific death rates obtained from these life tables were then applied to the BLS annual death rates for all working males. The resulting series was used in this report for estimating M.D. losses due to death. (See Table A-1.) For other occupations in which age-specific separation rates were used—optometrists, pharmacists, veterinarians, and podiatrists—the basis was the generalized labor force death rates. For the allied health professions and occupa- tions, age- and sex-specific generalized labor force deaths rates were used. A brief literature search uncovered no empirical evidence for these groups that suggested longer life spans than for the general population. It should be noted, however, that to the extent that life expectancies of workers in these occupations may indeed be longer than the national averages, the use of these generalized BLS rates may overstate losses to the professions incurred through death. ADJUSTMENT OF RETIREMENT RATES Empirical evidence suggests strongly that a number of health professional groups have a longer working life than that experienced by the general working population. For physicians, for example, a 1949 study of the number of “fully retired” M.D.’s revealed that approximately 64 percent of the physicians 65 years old and over worked at least several hours a week.® Of the surveyed M.D.’s in this age group, furthermore, the average (mean) weekly hours worked in private practice was approximately 25. Support- ing this evidence, 1967 AMA data indicate that approxi- mately 73 percent of M.D.’s in this 65-and-over age group were classified as “active” (old classification system), and that slightly more than three-fifths of this age group worked a minimum of 20 hours a week.” In contrast, data 6 Rusk, H. A; Diehl, H.S.; Barclay, R. W.; and Kaetzel, P. K. The Work Week of Physicians in Private Practice. The New England Journal of Medicine 249: 678-681, October 22, 1953. Beginning in 1968, the AMA changed its classification system for determining the professional activity of M.D.’s. The proportions of inactive M.D.’s used in the methodology (see Table A1) were derived by converting published AMA data on the old classification system to a distribution consistent with the new system. This procedure assumed that the 1967 age distribution of inactive M.D.’s applied to those M.D.’s converted to inactive status under the new AMA system; and that the reclassification of 1967 M.D.’s by activity would yield the same proportion of “new’ inactives as reflected in 1968 data (new AMA system). See: Theodore, C. N.; Haug, J. N.; Balfe, B. E.; Roback, G. A.; and Franz, E. ]. Recl/assifi- cation of Physicians, 1968. Chicago, American Medical Association, 1971. 156 available on labor force participation rates of all males aged 65 years old and over (1970) show only 27 percent in the labor force. Although these two data sets are not totally comparable conceptually, the evidence clearly illustrates the tendency for physicians to work longer years than the average male worker in the labor force. A comparison was also made between age-specific labor force participation rates of the total male noninstitutional population and the proportions of M.D.’s active in corre- sponding age groups. For analytical purposes, a further analysis was made of the inverse of these rates; that is, the “proportion inactive” in each age cohort. As in the methodology described earlier for adjusting death rates (abridging life tables by reference to a standard table), the ratios of age-specific inactive proportions were applied to the BLS retirement rates for all working males. The resulting series was used in this report for estimating M.D. losses due to retirements. (See Table A-1.) An identical methodology was utilized to develop an adjusted age-specific retirement series for optometrists, podiatrists, and veterinarians. For each group, reliable survey data were available that indicated a longer working life for these professionals than for the overall male labor force. For pharmacists, however, the BLS age-specific retirement rates were used with slight modification.® For allied health professions and occupations, the BLS retire- ment series was used without modification, primarily because a lack of data precluded any modification. A brief examination of the literature revealed no empirical evidence supporting a contention that pharma- cists tend to have a longer average working life than the general working male population. Available statistical data indicated the retirement patterns of this group to be somewhere between the general populace and other health professionals. Recent growth patterns of community phar- macist employees take into account the fact that many pharmacists are private wage and salary workers.” This suggests that a considerable number of these professionals may find it economically advantageous to retire at age 65. Nonetheless, to the extent that pharmacists may have a somewhat longer working life, the use of BLS retirement rates may overstate losses to the profession somewhat." ® SA separate adjustment was undertaken for separation rates for female pharmacists. In this procedure, separation rates by age cohort were reduced by accession rates to make allowance for reentry into the active work force of females. 9 Data from the 1970 Census of Population indicate that private wage and salary pharmacists account for over three-fourths of the total pharmacists employed. The 1960 Census indicates about 60 percent of all employed pharmacists were private wage and salary workers. 10 As an illustration, if the male pharmacist retirement pattern approximated that of optometrists, the total active supply of pharmacists would be projected to number 186,300 by 1990, or 3.6 percent above of the projected supply shown in this report. LS1 DERIVATION OF ADJUSTED SEPARATION RATE SERIES FOR ESTIMATING LOSSES TO THE WORKING PHYSICIAN (M.D.) POPULATION Table AT. Sua > romalation per Adjustment factor for deaths Adjustment factor for retirements A casio Feith Age Deaths per 100,000 in Proportion inactive group in population with Adjustment R ’ Adjustment Due to Due to Due to all Dens i Dueitos) life expectancy of: factor 1970 factor deaths retirements causes! (5) + (4) (8) +(7) (1) x(6) | (2)x(9) | (10)+ (11) 66.023 68.556 Males M.D.’s years years (1) (2) (3) (4) (5) (6) (7) (8) (9) (10) (11) (12) 25-29 .... .0020 —- .0020 906 693 .7649 0418 .0053 .1268 .0015 —- .0015 30-34 .... .0023 .0002 .0025 1,016 777 7648 .0246 .0073 2967 .0018 .0001 0019 35-39 .... .0032 .0012 .0044 1,277 994 7784 .0254 .0087 3425 .0025 .0004 .0029 4044 . . .. .0049 .0016 .0065 1,799 1,455 8088 .0351 0116 3305 .0040 .0005 .0045 4549 . . .. .0077 .0031 .0108 2,703 2,306 8531 .0496 .0127 .2560 .0066 .0008 .0074 50-54 .... .0124 .0060 .0184 4,045 3,597 8892 .0694 .0162 2334 .0110 .0014 0124 55-59 .... .0192 .0145 .0337 5,990 5,569 9297 .1053 .0261 2479 .0179 .0036 .0215 60-64 . ... .0306 .0635 .0941 8,461 8,091 9563 .2499 .0638 2553 .0293 .0162 .0455 65-69 .... .0446 1317 1763 11,341 11,21 9885 5841 .1681 .2878 .0441 .0379 .0820 70-74 . ... .0702 .1096 .1798 14,167 14,465 1.0213 7478 3344 4472 .0717 .0490 1207 75 and over. .1020 .0863 .1883 40,931 45,378 1.1087 .8802 6365 7231 1131 .0624 1755 1 resulting annual loss to the total supply (active and inactive) is 15 per 1,000. In terms of aggregate average annual active physician loss rate, these rates correspond to 17.6 per 1,000 population in 1970, decreasing to 15.8 per 1,000 in 1990. The Source: Cols. 1-3: Fullerton, H. N. A Table of Expected Working Life for Men, 1968. Monthly Labor Review 94: 49-55, June 1971. Some rates were corrected in con- sultation with the author. Cols. 4,5: Coale, A. J. and Demeny, P. Regional Model Life Tables and Stable Populations. Princeton, New Jersey, Princeton University Press, 1966. Col. 7: Unpublished data from Bureau of Labor Statistics. Col. 8: Based on data in: Theodore, C. N. and Haug, J. N. Selected Characteristics of the Ph 1968. ysician Population, 1963 and 1967. Chicago, American Medical Association, Information was totally lacking on retirement patterns for allied health occupations covered in this report. However, the use of generalized age sex-specific retirement rates for this group of workers, seemed reasonable, given their general characteristics (e.g. education, wage-and-salary vs. self-employment, etc.), which appeared to be relatively similar to the general work force. DEVELOPMENT OF ADJUSTED SEPARATION RATES On the basis of techniques discussed above, conse- quently, “occupation-specific’’ death and retirement rate series were developed. A simple addition of these series, by age group, for each of the occupations resulted in an adjusted age-specific total separation series. (See Table A-1.) As part of the overall analysis, an effort was made to validate the reasonableness of the adjusted separation series. Owing to constraints of data availability and time, however, this attempt at verification was confined solely to the series developed to estimate M.D. losses. One test consisted of utilizing 1967 as a base year and projecting the number of active surviving physicians over a 20-year period, using a number of separation rates. A total of four different projections were developed, using (a) the adjusted separation series described earlier; (b) separation rates for the general working male population; (c) a technique used by Blumberg;'! and (d) mortality rates developed by Dickinson.!? In the last year of the 20-year period, these projections estimated active surviving M.D.’s to number (a) 170,600; (b) 139,800; (c) 178,000 and (d) 171,500 respectively. As can be seen, all except the second approach were clustered at about the same level. Another test was also undertaken, one that applied the new separation series to 1959 AMA estimates of physicians in order to compare projected active survivors in 1970 with those actually reported by the AMA for that year. In effect, 1 Blumberg, Mark S. Trends and Projections of Physicians in the United States, 1967-2002. Berkeley, Cal., Carnegie Commission on Higher Education, 1971. 12 Dickinson, F.G. and Martin, L.W. Physician Mortality, 1949-71951. Bulletin 103. Chicago, American Medical Association, 1956. In both projections developed by BHRD, physician mortality rates from these studies were used on the total M.D. population, and then a reclassified 1967 ‘‘active”’ distribution derived from AMA data was utilized. 158 the application of the adjusted death and retirement series resulted in an estimate of 247,304 active U.S.-trained M.D.’s in 1970; a figure of 253,389 was actually indicated by AMA data.'® Using a generalized separation series for all male workers, the figure was 231,318. In sum, the two tests applied to the data suggested that estimates of M.D. losses derived by the adjusted series compared reasonably well with loss estimates indicated by other studies and suggested by AMA data’? and provided a relatively reasonable estimate on a retrospective basis. LIMITATIONS OF THE APPROACH In evaluating the results derived from the above method- ology, the reader should keep in mind that the separation patterns utilized are not based on precise longitudinal data on actual death and retirement experiences of health professionals. Therefore, until reliable cohort analyses are undertaken for large segments of these groups over time, the separation patterns shown here are very difficult to validate in a rigorous fashion.!$ In addition to the above considerations, several general limitations of the methodology (other than those noted in the text of the report) should be kept in mind. That is, the validity of the procedures used is dependent upon (a) conceptual adequacies of the abridgement technique ap- plied; (b) definitional problems in the estimate of ‘‘active” health personnel; and (c) the conceptual weakness of relating labor force participation rates with proportions of health professionals that are active. For mortality estimates, furthermore, the assumption of a 2l2-year longer average life expectancy for M.D.’s, although generally consistent with other study findings, nonetheless represents an as- sumption not entirely validated by detailed cohort analyses over time. 3 The 253,389 figure represents a 1970 mid-year value to correspond to the 1959 AMA estimate. In addition to excluding 17,330 inactives and 2,070 addressees unknown from the AMA estimate of 270,637 total U.S. trained M.D.’s, an estimated 2,152 losses were added to adjust figure to mid-year estimate. 1% When comparing the estimates obtained using the adjusted rates as opposed to the unadjusted series, it is important to note that virtually 75 percent of the difference results from using the retirement conversion factor. 15 See text in Chapters 5 and 10 for a discussion of methods of estimating losses to dentist and registered nurse populations respectively. Appendix B DETAILED TABLES Table number B1. B2. B3. BS. B6. B7. BS. B9. B10. B11. B12. Supply of active physicians (M.D. and D.O.), using basic methodology: actual 1970 and projected 1971-90 Annual additions and losses to the supply of active physicians (M.D. and D.O.), using basic methodology: actual 1970 and pro- jected 1971-90 Annual additions and losses to the supply of active dentists, using basic methodology: actual 1970 and projected 1971-90 Annual additions and losses to the supply of active optometrists, using basic methodol- ogy: actual 1970 and projected 1971-90 . .. Annual additions and losses to the supply of active pharmacists, using basic methodology: actual 1970 and projected 1971-90 Annual additions and losses to the supply of active podiatrists, using basic methodology: actual 1970 and projected 1971-90 Annual additions and losses to the supply of active veterinarians, using basic methodol- ogy: actual 1970 and projected 1971-90 ... Annual additions and losses to the supply of active registered nurses, using basic method- ology: actual 1970 and projected 1971-90 Annual additions and losses to the supply of formally-trained dietitians: 1970 and pro- jected 1971-90 Annual additions and losses to the supply of formally-trained medical record administra- tors: 1970 and projected 1971-90 Annual additions and losses to the supply of formally-trained medical technologists: 1970 and projected 1971-90 Annual additions and losses to the supply of formally-trained occupational therapists: 1970 and projected 1971-90 See sees sees estes ese es sete esses “eee eee “eee eee EERE Page 161 162 163 164 165 166 167 168 169 170 171 159 Table number B13. Annual additions and losses to the supply of formally-trained physical therapists: 1970 and projected 197190 ................ Annual additions "and losses to the supply of formally-trained speech pathologists and audiologists: 1970 and projected 1971-90 .. Annual additions and losses to the supply of formally-trained certified laboratory assist- ants: 1970 and projected 1971-90 ........ Annual additions and losses to the supply of formally-trained cytotechnologists: 1970 and projected 197190 ................ Annual additions and losses to the supply of formally-trained dental assistants: 1970 and projected 1971-90 Annual additions and losses to the supply of formally-trained dental hygienists: 1970 and projected 1971-90 .................... Annual additions and losses to the supply of formally-trained dental laboratory tech- nicians: 1970 and projected 197190 ..... Annual additions and losses to the supply of formally-trained licensed practical nurses: 1970 and projected 1971-90 Annual additions and losses to the supply of formally-trained respiratory therapists: 1970 and projected 197190 ................ Annual additions and losses to the supply of formally-trained medical record technicians: 1970 and projected 1971-90 Annual additions and losses to the supply of formally-trained occupational therapy assist- ants: 1970 and projected 1971-90 ........ Annual additions and losses to the supply of formally-trained radiologic technologists: 1970 and projected 1971-90 B14. B1S. B16. B17. eases ste es see eee B18. B19. B20. B21. B22. B23. B24. Page 173 174 175 176 177 178 179 180 181 182 183 Table B1. SUPPLY OF ACTIVE PHYSICIANS (M.D. AND D.O.), USING BASIC METHODOLOGY: ACTUAL 1970 AND PROJECTED 1971-90 M.D.’s All active , Year physicians T U.S. Foreign® D.O.’s otal 3 " trained trained JOTO cv cmme i Asmmen t9 PuwBm® sv ewe ws 323,205 311,203 251,237 59,966 12,002 17 I rT TE IIE IY 333,042 320,774 255,608 65,166 12,268 V972 vt ii an HEHE EI I HEROES BOP R Se 343,375 330,831 260,465 70,366 12,544 JOB cnn ns mad re FL EHEOE FS BERGE Ye 353,868 341,000 265,434 75,566 12,868 978 iv vv mmm tsa ER LF LAER 365,211 351,979 271,213 80,766 13,232 OTS cm dm ale mmm a0 + onion » 5 ln HEH I 5 377,504 363,867 277,901 85,966 13,637 HIZB ionic so Mmm Es 68 MBE cy Hmmm. yo 390,788 376,659 285,493 91,166 14,129 VOTT csi cs uamis s 8 HED EBT 6 swmmmns =» 404,408 389,741 293,375 96,366 14,667 VOTE vi sa T RRA SE RENE EOE PHM EE We 418,441 403,153 301,587 101,566 15,288 FOTO wv ve mmmmiidds bs RBER LES LEB 3 bE 432,557 416,647 309,881 106,766 15,910 BOBO! ois o « winnie als basmimmms 58 HEHE H TF oo 446,767 430,237 318,271 111,966 16,530 1981 vt et ee ee eee eee 461,087 443,936 326,770 117,166 17,151 VOB: i i s vim bd MEE EEE Bw x ww 475,454 457,684 335,318 122,366 17,770 1983. cs ins ER ss SH RE RR THREE pee 489,895 471,501 343,935 127,566 18,394 1984: ., . cvv mint i RRR ER AEROS Ee 504,435 485,417 352,651 132,766 19,018 TOBE: iy swt widimie s mmmmmes bis BABEL PHD 519,078 499,440 361,474 137,966 19,638 1986 vv vv i ti eee ee eee 533,833 513,574 370,408 143,166 20,259 T9B7 ii nwmm ss sp EmBE es s0 Hwmve & » wimmn 548,666 527,787 379,421 148,366 20,879 JOBE . ia c s sv HEARERS PEPER Ls BE 563,587 542,089 388,523 153,566 21,498 TOBY vive vs MEHR REF RRM YE EYE 578,619 556,502 397,736 158,766 22.117 1990 .vmmmunc sv mmm s nmamm ss FROEHD 593,759 571,026 407,060 163,966 22,733 ! Includes Canadian trained physicians. Source: 1970 M.D.’s: Haug, J. N. and Martin, B. C. Foreign Medical Graduates in the United States, 1970. Chicago, American Medical Association, 1971. 1970 D.0.’s: Unpublished data provided by the American Osteopathic Association. 161 565-118 O - 74 - 12 Table B2. ANNUAL ADDITIONS AND LOSSES TO THE SUPPLY OF ACTIVE PHYSICIANS (M.D. AND D.O.), USING BASIC METHODOLOGY: ACTUAL 1970 AND PROJECTED 1971-90 Changes in supply January 1 — December 31 Number Number Year active Net additions active January 1 | 1 some, | ottorn | Son tin | Becmbers gain additions’ medical 2 retirements’ graduates 1970 vs rs usnsms vamp umny — - - - - 323,205 TO? wuss mumwwmn ss sim emmy» 323,205 9,837 9,451 5,200 4814 333,042 1972 wo s sp nmE ss FUR BEY + © 333,042 10,333 10,108 5,200 4,975 343,375 1973: sss unsmms ss namEmn ed 343,375 10,493 10,396 5,200 5,103 353,868 1974 i: svmmn ss npammn ss 353,868 11,343 11,337 5,200 5,194 365,211 1975 ws ivsmnii nbavemmess 365,211 12,293 12,353 5,200 5,260 377,504 1976. + vw mass s mmmis ma é4 5s 377,504 13,284 13,406 5,200 3322 390,788 TOIT vs vv mms samme inin 2755 390,788 13,620 13,902 5,200 5,482 404,408 1978 vv vv sa mm man by 404,408 14,033 14,446 5,200 5,613 418,441 1979 oc sews ss smmmume so no 418,441 14,116 14,633 5,200 5,717 432,557 TBD spun ss vemmarns » uv 432,557 14,210 14,822 5,200 5,812 446,767 198) Lv suwis ss vmmnmms 2 ow 446,767 14,320 15,014 5,200 5,894 461,087 TOBY ss vnwmpm es vB ERE HSE CO 461,087 14,367 15,208 5,200 6,041 475,454 1983. i ovanms sma nB WRT CHE 475,454 14,441 15,404 5,200 6,163 489,895 1984 .. suri srnmmnmesi on 489,895 14,540 15,604 5,200 6,264 504,435 1985 ... iii iii ei 504,435 14,643 15,805 5,200 6,362 519,078 1986 «vv vite 519,078 14,755 16,010 5,200 6,455 533,333 1987 ssnewmisssnnnsmesrnens 533,833 14,833 16,217 5,200 6,584 548,666 1988 sinus ovr ws i nme 548,666 14,921 16,426 5,200 6,705 563,587 1989 sovinss amps wine 563,587 15,032 16,639 5,200 6,807 578,619 1990 wns s smn das bhmn® 578,619 15,140 16,855 5,200 6,915 593,759 ! Includes graduates of U.S. medical and osteopathic schools. 2 Includes graduates of Canadian medical schools. 3 Excludes losses among foreign medical graduate additions. These losses are already included in figures for net additions of foreign medical graduates. Source: 1970 active physicians (M.D.): Haug, J. N.; Roback, G. A.; and Martin, B. C. Distribution of Physicians in the United States 1970. Chicago, American Medical Association, 1971. 1970 active physicians (D.0.): Unpublished data provided by the American Osteopathic Association. 162 Table B3. ANNUAL ADDITIONS AND LOSSES TO THE SUPPLY OF ACTIVE DENTISTS, USING BASIC METHODOLOGY: ACTUAL 1970 AND PROJECTED 1971-90 Changes in supply January 1 — December 31 Number Number Year active Losses from active January 1 Net gains Graduate deaths and December 31 additions | retirements 1970 sn vwriis 21s RAR EAE BREE EF FREE —- - - 102,220 1 102,220 1,530 3,760 2,230 103,750 1972 comms 4 wu Minmeln os pdm momen & 3 woaniii ogo 103,750 1,650 3,920 2,280 105,400 1973 Lsvana ss namsmms a PHBE ¢ 4 vw 105,400 1,920 4,220 2,300 107,320 1978 swans sv mw st vs MEH E es 8 HOMES 107,320 2,250 4,570 2,320 109,570 19758 asm ss san mmm ss ss Ba gm ess Hues 109,570 2,420 4,740 2,320 111,990 1916 +o svid ss bm mBd 43 HR ABR EIS nw 111,990 2,720 5,060 2,340 114,710 BIT T ain wild b mimi 2 alae mmonsh oF # Bonde ohon 114,710 2,770 5,140 2,370 117,480 1978 eee 117,480 2,830 5,210 2,380 120,310 JI7T vu mms's summa tis powwwmle o www whe 120,310 2,890 5,290 2,400 123,200 19830 whvwussvonmmmes spemme ss snowy 123,200 2,970 5,370 2,400 126,170 IBY Lonms ss pases ew +3 VBE E ES s 0 HEWES 126,170 3,010 5,440 2,430 129,180 1982 suv ins sd snaps ts RTE RE LI Qa wEm 129,180 2,980 5,440 2,460 132,160 1988 vss si so BmAHAR Es SMEAR E56 HRB 4 132,160 2,960 5,440 2,480 135,120 MIB oar s sa mms E ad s SRM BR AE FE HAE 135,120 2,920 5,440 2,520 138,040 JOBS wine sv bmn mmr’s es mmm x 0 bw 138,040 2,910 5,440 2,530 140,950 1986 meme 83 vino ts nmammn's 2 sim 140,950 2,870 5,440 2,570 143,820 1987 canis vppemuss pmupamervosamss 143,820 2,840 5,440 2,600 146,660 1988 iv sn unmamai s PERRET Fr HERES + 8 146,660 2,790 5,440 2,650 149,450 1989 ivi ss nrmam ii + uBETH EL LDU EE £8 149,450 2,760 5,440 2,680 152,210 T9090 ov vt vs sommes 0 sm mmmn ss wwwmow sb 152,210 2,700 5,440 2,740 154,910 Source: BHRD, Division of Dental Health. 163 Table B4. ANNUAL ADDITIONS AND LOSSES TO THE SUPPLY OF ACTIVE OPTOMETRISTS, USING BASIC METHODOLOGY: ACTUAL 1970 AND PROJECTED 1971-90 Changes in supply January 1 — December 31 Number Number Year active Losses from active January 1 Net gains Graduate deaths and December 31 additions . retirements 1970 5s nvm + 4 sn BENEA dE 28 BGT «vom - - - wr 18,445 1071 isn mmnns bmn sm mma 18,445 85 528 443 18,530 1972 i vvsr rss ems wens x wma HE 18,530 237 683 446 18,767 1978. L vnn nnn ss amon am is b Smmin.g i bos 18,767 241 691 450 19,008 V8 oi i inns s somo ma Es GnmEw dona 19,008 322 775 453 19,330 1978 ci commis vi bmn mma kom ek rn 19,330 348 817 469 19,678 VI7B « c snimmit +2 4 ummm ve ww 19,678 409 891 482 20,087 TOIT ii wnt mas s sms vs mmm mes saw 20,087 411 904 493 20,498 1978 ivi inacss samninmnn svmmd aes s aia 20,498 420 924 504 20,918 1979 eee 20,918 443 956 513 21,361 1980 oii eee 21,361 458 988 530 21,819 1981 Lee 21,819 483 1,022 539 22,302 1982 ii vc vnwmam sr mE ERs BGR BS 22,302 507 1,057 550 22,809 1983 i vvunmnm rs mms nama EEE EE 22,809 533 1,093 560 23,342 TOBA. , , Lv cvmrw seman T bs Umm 8 4 8 23,342 562 1,130 568 23,904 1988 vr nmummumii snioumunss bainenissss 23,904 592 1,168 576 24,496 1986) su sc nnssowis peinmmme sx uremia ds» 24,496 621 1,208 587 25.117 1987 wns naam mE as am EERE F hn eee, 25,117 657 1,249 592 25,774 19BB ss bana mma ts mmmb ms rma mre e 25,774 697 1,292 595 26,471 VIB i sh nn tPF smn mie vy HG 26,471 732 1,336 604 27,203 1990 Le eee 27,203 775 1,381 606 27,978 Source; 1970 active optometrists: Based on 1968 Survey of Optometrists by National Center for Health Statistics. 164 Table BS. ANNUAL ADDITIONS AND LOSSES TO THE SUPPLY OF ACTIVE PHARMACISTS, USING BASIC METHODOLOGY: ACTUAL 1970 AND PROJECTED 1971-90 Number Changes in supply January 1 — December 31 Number Year active Net gains active January 1 Graduate additions oe Decanber Ss Male Female retirements 1970 covws ss mwawmn sy vumn - - - - - 129,287 197). wuinw is vnmamme ss mame 129,287 306 3,773 973 4,400 129,593 V972 wn sv iimamm ed nawnm 129,593 263 3,567 1,006 4,310 129,856 973 wwin vu da mmmmn sv wrmmio 129,856 758 3,842 1,143 4,227 130,614 1974 sv evs svnnwus ss suv 130,614 1,442 4,261 1,331 4,150 132,056 1873 wrt 63 9906 Wi 00% 40 HEE RW 132,056 1,771 4,393 1,433 4,055 133,827 1976 siwivris vummminis ¢ 3 HE RAN 133,827 2,055 4,481 1,521 3,947 135,882 1977 wae v0 sb mum wn iS REE BE 135,882 2,310 4,552 1,604 3,846 138,192 1978 .. iii tiie i ieee 138,192 2,471 4,579 1,670 3,778 140,663 1978 ww vs rummmnie 3 44a wwn 140,663 2,633 4,609 1,735 3,711 143,296 1980! vom ss swum its sop wwn 143,296 2,793 4,641 1,799 3,647 146,089 VOB wwe ss mmmmm sss numsms 146,089 2,936 4,674 1,864 3,602 149,025 TIB2 ive i 4 WRT HA FF F HCN ES 149,025 3,044 4,709 1,928 3,593 152,069 WOB3: tein cas. 0: wri mono bok Bod iu or Wk 152,069 3,154 4,747 1,991 3,584 155,223 TOBY. oy tie ovo bro or sank 4 ir io 155,223 3,263 4,786 2,054 3,577 158,486 1985 iii iii iii ei 158,486 3,368 4,826 2,117 3,573 161,854 986. vw vomummnts vow wen 161,854 3,463 4,868 2,180 3,585 165,317 1987 vue vommuminns vuwe wos 165,317 3,523 4,912 2,243 3,632 168,840 TIB8: wu ss smonim ov s mw nme 168,840 3,596 4,958 2,305 3,667 172,436 1989 Livi snwmmmin +4 bOmmuE 4 172,436 3,667 5,004 2,368 3,705 176,103 1990; pes vo mmm vd sb ABET EE 176,103 3,750 5,053 2,431 3,734 179,853 Source: 1970 active pharmacists: National Association of Boards of Pharmacy. 1971 Proceedings. Licensure Statistics and Census of Pharmacy. Chicago, The Association, 1972. 165 Table B6. ANNUAL ADDITIONS AND LOSSES TO THE SUPPLY OF ACTIVE PODIATRISTS, USING BASIC METHODOLOGY : ACTUAL 1970 AND PROJECTED 1971-90 Changes in supply January 1 — December 31 Number Number Year active Losses from active January 1 Net gains Graduste deaths and December 31 additions : retirements 1970) iv rv nvm rss PHT EH SE PEE Ee A - - —- —- 7,148 1971 wn is muppm is sv upmmE es 8 HEFL 7,148 15 242 227 7,163 1972 cx vs smuunus sss HEIR BF LHHS BEE 7,163 59 286 227 7,222 1973 wins ss memmpes vr npewm EE LEFEESY 3 7,222 34 266 232 7,256 1974. wis ss nivwoiCes st LBBB BESE LRT RE ES 7,256 79 309 230 7,335 1975 wos snawnminit sma mmmes namsime + 7,335 135 368 233 7,470 1976 ii i nvm rans es nmr HE. 7,470 147 380 233 7,617 P9727 ais 2 mms Bomaninis sa imma bie sim ms 7,617 186 420 234 7,803 TOPB “Sih 2 Boman bien 5 4 ma mmm iw a wow os le 7,803 218 455 237 8,021 1979 Goic cnmmmmine s romm Bun dic ywBOwE v 8,021 245 478 233 8,266 1980 wus vs wvmmwns sa mumsnet s swine bs 8,266 267 502 235 8,533 1981 wi vvsrnpunme si Sanus SHRESG 8,533 294 527 223 8,827 1982 enw ss mus mmes LGA RE BABE 8,827 324 554 230 9,151 1988 Lun cnvsmbas es aammmas samme 9,151 352 581 229 9,503 1984 Luisi innnamgitvnmmmipmes smmmmain o 9,503 384 610 226 9,887 1988 civ cv mtr sss nvm mre pm 9,887 418 641 223 10,305 1986 . . viv viii iiss aaa 10,305 452 673 221 10,757 1987 wns vnwwwme ss umm nes 3 Das aE so 10,757 490 706 216 11,247 TBS iwi svumsmmmisss imams huisen.s 11,247 53 742 211 11,778 1989 www sanmnaams sri mamas inrausns 11,778 567 778 211 12,345 | 1990 vhs ss Ram Bgmd os sm mony o 00mm rm 12,345 606 817 211 12,951 Source: 1970 active podiatrists: Koch, Hugo K. and Phillips, Hazel M. Podiatry Manpower: A General Profile. United States - 1970. DHEW Pub. No. (HRA) 74-1805. U.S. Government Printing Office, 1973. 166 Table B7. ANNUAL ADDITIONS AND LOSSES TO THE SUPPLY OF ACTIVE VETERINARIANS, USING BASIC METHODOLOGY: ACTUAL 1970 AND PROJECTED 1971-90 Changes in supply January 1 — December 31 Number Number Year active Losses rom active January 1 . Graduate December 31 Net gains o. deaths and additions A retirements 1970 uv vss pnmamos ss ammmessnmmum si —- - - - 25,935 VOT Gini 2s CRB EAS 8S SB Bah 5 Bown 0 of rw om d 25,935 909 1,239 330 26,844 HOTZ ii 5oiie 2 2 sci tdhtchbe 21a im mrowbe 2 v 9300 oer on ind 26,844 910 1,252 342 27,754 1 3 pap 27,754 912 1,266 354 28,666 1974 cucu nssnwonimn is nanan iss sums 28,666 1,018 1,381 363 29,684 1975 cnvmis snawmwd 36 BETS I-43 nublE eS 29,684 1,038 1,412 374 30,722 1976 vn iit sna bmmm v3 mama os owen mn 30,722 1,076 1,465 389 31,798 VTT alii + 4 ion ein nha o's wir unspsre @ 5iut W gow oi 31,798 1,129 1,541 412 32,927 1878 vn vw 1spunpwn is pups m ss s HMBWE 32,927 1,136 1,576 440 34,063 1979 wavmu ss vrmEem ss s MEME 5 35 HUGH 34,063 1,140 1,605 465 35,203 T9880 2 namin t 3 9.00 aE 55 5 Su inom on 8 woo mo oe oo 6 35,203 1,148 1,634 486 36,351 FOBT i vnies 4 smmmum sion vs somim a imin wv www mn 36,351 1,155 1,664 509 37,506 B98D fiddle o lismmisi doy s wine ww dow & $32 we 3p m0 ee 37,506 1,152 1,694 542 38,658 1983 cv nvussswnamms ss pwmuns io ave ms 38,658 1,155 1,724 569 39,813 1984 Lot nctsvmmummes sma HE ¥s Same Em 39,813 1,160 1,755 595 40,973 1985 sun na s sa BREE IF I MBE TAT 5 ow whom 40,973 1,165 1,787 622 42,138 1986 itivt ss vmmmuwm st smn a mm wom 42,138 1,172 1,819 647 43,310 VOBT isis incnlo bs weombriole o oho mown uw: oy 0 50: 0 43,310 1,179 1,852 673 44,489 1988 ee ee 44,489 1,190 1,885 695 45,679 1989 i vnmnts sma mans sa nwwn ts pom 45,679 1,204 1,919 715 46,883 V990 wvv um ss sncwmam ss Rasmus sd eens 46,883 1,217 1,953 736 48,100 Source: 1970 active veterinarians: Based on data from the American Veterinary Medical Association. 167 Table BS. ANNUAL ADDITIONS AND LOSSES TO THE SUPPLY OF ACTIVE REGISTERED NURSES, USING BASIC METHODOLOGY: ACTUAL 1970 AND PROJECTED 1971-90 Changes in supply January 1 — December 31 Number Number Year active Brad " active : raduate et December 31 January:1 Net gains additions attrition 3 1970 , sons wm ts sss Boiwmpb ss 3 FE Emimmes s — — - - 723,000 1971 csi snmmpas ss nmam ssi BOGE 486 723,000 24.810 46,500 21,690 747,810 1972 ic v0 ama is pam REA ER a mmA Esp 747,810 28,870 51,304 22,434 776,680 1973: i ov wv mwmio on mmm ss ww § 776,680 33,629 56,929 23,300 810,309 1974 ee ee ee ea 810,309 37,642 61,951 24,309 847,951 1975 4 vonvmrn ss vwamEn sss oe va ose 847,951 41,425 66,864 25,439 889,376 TIVE 4s sen mmms bs pammms va USmPw 30 889,376 43,396 70,077 26,681 932,772 1977 cs vvwwns ss smamaw isd Hams sss 932,772 42,688 70,671 27,983 975,460 1978 (iis umm rss REO ME HE BER EH 975,460 42,029 71,293 29,264 1,017,489 1979 ii sibwie ds s8 RbmBluws Fa hmmm s+ 8 5 1,017,489 41,385 71,909 30,524 1,058,874 TIBO, vo twins sn mmm ims mmm 1,058,874 40,752 72,518 31,766 1,099,626 1981 i vv nua ss pma Bm es s FRR ED EES 1,099,626 40,147 73,136 32,989 1,139,773 1982 (cu nnuntsrnssamnms sp wawEs ss 2 1,139,773 39,552 73,745 34,193 1,179,325 11 EE TTT III ITI YY 1,179,325 38,996 74,375 35,379 1,218,321 T1984 i insm isi nmpmais s b mma 4 bak 1,218,321 38,510 75,060 36,550 1,256,831 TOBE uo simwin as ambimm minnie + ain macs ss 1,256,831 37,699 75,404 37,705 1,294,530 1986 «oii eee 1,294,530 36,784 75,620 38,836 1,331,314 T1987 ..svummsssnvsammasi s Samm sss 1,331,314 35,578 75,517 39,939 1,366,892 TOBE usin mm@ rss Mawnan ISS FMAME Eb 1,366,892 34,408 75,415 41,007 1,401,300 TI8Y ; + san R ati I MPAA HES» AREAS BE 1,401,300 33,273 75.312 42,039 1,434,573 TOGO & 5. 5n o0 o wions osses om chin 0 ws 5 we ew #10 1,434,573 32,172 75,209 43,037 1,466,745 Source: 1970 active registered nurses: American Nurses’ Association. Facts About Nursing. A Statistical Summary. 1970-71 edition. New York, The Association, 1971. 168 Table B9. ANNUAL ADDITIONS AND LOSSES TO THE SUPPLY OF FORMALLY -TRAINED DIETITIANS: 1970 AND PROJECTED 1971-90 Changes in supply January 1 — December 31 Number Number Year active Additions from Losses from active January 1 Net gains graduates of deaths and December 31 or losses approved h retirements programs T0720 uv sv un mwmmes s Sn maiama sv nmmmonis 34 - — —- - 15,300 TI7T wn St amma dd vo vmmmmws ss pa HES 5 5 5m 15,300 -23 865 888 15,277 1072 vamvisnsaw vss bpneds i DELETE 3 5.8 15,277 122 905 783 15,399 1973 \ or i tc rt aE EEE 15,399 188 960 772 15,587 1974: wn in ys wnt ss HENCE RES Frm nn 15,587 241 992 751 15,828 JO7S wvwu os vas ms $5 BmSam es so mmm mins s 15,828 311 1,049 738 16,139 1976 wwwiv ¢ csimmmms 55 mmmmmn rs amma 16,139 363 1,103 740 16,502 977 sumo sm ER aco vo wntimenis s nem b 16,502 370 1,155 785 16,872 JOB. sma commons vs vw mE oS 16,872 400 1,210 810 17,272 1978 nani tle vinig wee SERN ETE PERERE LE § 17,272 443 1,266 823 17,715 1980 «Lo 17,715 459 1,303 844 18,174 JOB wn vis v2 pum mm ais 55 BREED 55 0b mie 18,174 471 1,337 866 18,645 TOBY wiv wim vo % 5 Ma mW m.5 % 5 BR Hon no aos om ow 18,645 454 1,371 917 19,099 VOB wwvmvme t v HMw mad Bos Fm s swore 19,099 457 1,398 941 19,556 19BE. | funni va sim Gam ns mms 2's EHS 19,556 463 1,429 966 20,019 1985 .umwii iss mmmmmr ve wummn sss mami 20,019 453 1,437 984 20,472 T9086 50 thn iid 2 mmm SP ERT TE 5 PE 20,472 447 1,447 1,000 20,919 1987 ee 20,919 394 1,433 1,039 21,313 TOBE ov vv rwmts rpm TRAE LE DRED 54 5 dn 21,313 367 1,418 1,051 21,680 TOBY | viv mss 5 PHM EL EX LR ems oo mma 21,680 340 1,400 1,060 22,020 T9090 us vhum vim 2 + AES vw mms sym 22,020 324 1,384 1,060 22,344 Source: 1970 active dietitians: National Center for Health Statistics. Health Resources Statistics. Health Manpower and Health Facilities, 7971. DHEW Pub. No. (HSM) 72-1509. U.S. Government Printing Office, 1972. 169 Table B10. ANNUAL ADDITIONS AND LOSSES TO THE SUPPLY OF FORMALLY -TRAINED MEDICAL RECORD ADMINISTRATORS: 1970 AND PROJECTED 1971-90 Changes in supply January 1 — December 31 Number Number Year active Additions from active January 1 Net gains graduates of Lissar tron December 31 approved retirements programs 1970 4 8 8 8 tL es ss se ess esses — - - - 4,200 197T wv vu s sms mins sr mmm Bk ERE 4,200 3 254 251 4,203 97D Gurminin vy ow ows win a acini nie 38: wo lie 4,203 47 271 224 4,250 1973 wu snmm ss mes aan ss RU EBES HVE mv 4,250 66 288 222 4,316 P74 cuvms s noma as +8 a MENTE Es SHE SEE 4,316 79 297 218 4,395 1978 vans nian n sds LEBER AL SEEEBEE 4,395 104 315 211 4,499 1976 www sv saimmmis v0 mmm F RRGERRL 4,499 115 330 215 4,614 HITT cnn vam din va sim mw § MGW SEE 4,614 120 346 226 4,734 1978 i eee eee eee 4,734 129 363 234 4,863 1979 wun ss momma ™ + 3s HEFUER HBL PEE.» 4,863 135 379 244 4,998 1980 ov ssnmaan ta ssa nEmF I DUB MBE Ey 4,998 139 390 251 5.137 198) ss bmn mas I ERE RA PETG ES 5,137 141 401 260 5,278 F982 ls nimi sr mmm i SREB ERE Sh 5,278 143 411 268 5,421 1983 ii ee eee eee 5,421 141 419 278 5,562 1984 © Li ee eee ee 5,562 146 428 282 S29 TOBE ss meme ins st $I HUBER £3 PREETI GY 5,708 143 431 288 535% TOBE . +i so mum ss +E HHREE 48 DEC EE Eo www 5,851 138 434 296 5,989 19B7 icv nnmmm sss a ¥am@me ts HEME ts wun 5,989 126 429 303 6,115 TO8B . is nna dst RES ENE REI RHEE LE 6,115 114 425 311 6,229 1 ER PE EEE LL AER 6,229 108 420 312 6,337 1990 . cs womens i soins madd LARNER E Ss HGS 6,337 97 415 318 6,434 Source: 1970 active medical record administrators: National Center for Health Statistics. Health Resources Statistics. Health Manpower and Health Facilities, 1971. DHEW Pub. No. (HSM) 72-1509. U.S. Government Printing Office, 1972. 170 Table B11. ANNUAL ADDITIONS AND LOSSES TO THE SUPPLY OF FORMALLY-TRAINED MEDICAL TECHNOLOGISTS: 1970 AND PROJECTED 1971-90 Changes in supply January 1 — December 31 Number Number Year active Additions from Losses From active January 1 Net gains graduates of deathe.and December 31 approved retirements programs 1970 i sma cis PRR Em ER ss HORSE BE HEP ES wo -— - - 45,000 71 oii is vs REPRE ve HEH BE I BORE 45,000 2,612 5,367 2,755 47,612 1972 vvnm ams aman ys bmn EAD REESE 47,612 2,771 5,617 2,846 50,383 JO78 wm Bmais rr mmmons sg «lum vo lw wen be oe ow 50,383 3,031 5,959 2,928 53,414 1974 cvimos v GBM BS $5 VHGE EE EL Hw in 53,414 3,224 6,158 2,934 56,638 1975 cnvw iis np GPR IE ANGER ESE am We 56,638 3,527 6,512 2,985 60,165 976 vw vmin ds + slmmbnd 33 HANBH IES HARE ¥ 4 60,165 3,769 6,842 3,073 63,934 5. 7 2 Fg I 63,934 3,905 7,165 3,260 67,839 JOT8 vas sswammn tr ra smmmn sv www wm vo 67,839 4,079 7,508 3,429 71,918 1979 vim is BREUER Eas HEBER EE FH HEER $b 71,918 4,298 7,856 3,558 76,216 1980 vv s a mBE RE is LER CER EE REE RE vy 76,216 4,399 8,086 3,687 80,615 BORA wvnin vs mmm bs HMA HERE I RB EHTS + 3 80,615 4,484 8,297 3,813 85,099 1982 vn vs mnmmmm ss mmm ss mums sss 85,099 4,430 8,509 4,079 89,529 TOBB wns ss smmm as sv smmuinn vv wwne es oo» 89,529 4,465 8,677 4,212 93,994 1984 Lui ss mamm sss HEGRE TES BME TE EL 0H 93,994 4,535 8,870 4,335 98,529 1988 vo is sn REN FI FR ANME ELE HEE Ee 98,529 4,478 8,919 4,441 103,007 1986 iv vs mmm rr sam EERE R BEE ES WY 103,007 4,450 8,982 4,532 107,457 1987 ite ee eee ea 107,457 4,269 8,895 4,626 111,726 TOBB viv smmmn vs slg mm nme « Sumo owokbn wis wow 111,726 4,102 8,801 4,699 115,828 TIBY iis mwa 1s Eu m mss vom » wun 115,828 3,921 8,689 4,768 119,749 1990 J's amams ss pepe mes Ep mEEmE Ls 119,749 3,769 8,590 4,821 123,518 Source: 1970 active medical technologists: National Center for Health Statistics. Health Resources Statistics. Health Manpower and Health Facilities, 1971. DHEW Pub. No. (HSM) 72-1509. U.S. Government Printing Office, 1972. 171 Table B12. ANNUAL ADDITIONS AND LOSSES TO THE SUPPLY OF FORMALLY-TRAINED OCCUPATIONAL THERAPISTS: 1970 AND PROJECTED 1971-90 Changes in supply January 1 — December 31 Number ge Number Year active Additions from Losses from active January 1 Net gains graduates of deaths and December 31 approved retirements programs 1970 cumin ss winsome fs nnBERE so BONE w a - - - —— 7,300 ITT Cu hd i 4 MRT FHT» mmm ow www owen on 7,300 310 769 459 7,610 W972 win sis vimmmuein 2s ww mmn ns owe www 7,610 389 804 415 7,999 1973 ee eee we 7,999 407 852 445 8,406 978 wun ss vs nnmme s Soa BmBE 5 5 80% E EE 8,406 417 881 464 8,823 1978 copra i aes um is sRERA 22 WR RTE 8,823 449 932 483 9,272 MOTB wnt on ET sk 3 5 wee om on wn ws ews ov iw om 9,272 473 979 506 9,745 PTT wumh ds s GWimbi thn 3 8 Baie rio im i fot vww 9,745 470 1,025 555 10,215 1978 ee eee 10,215 494 1,074 580 10,709 1979 nvm ss nvmmmins 55 HE mE DE 5855 EE 10,709 521 1,124 603 11,230 1980 cvvunsinuvawe is nanan is nasasee 11,230 531 1,157 626 11,761 £1 EL TIE ETL IIIT TIT 11,761 541 1,187 646 12,302 1982 nna iss unmmes mamma oon oimm in 12,302 545 1,218 673 12,847 1983 Le eee 12,847 550 1,242 692 13,397 1984 io.ivinlinns vnpmnnie od SR BETS bE 13,397 556 1,269 713 13,953 1985 vvwuws srmunm mms s ERE SEE 13,953 545 1,276 731 14,498 1986 vvnupmssnmmumnis s nanasm ii soudume 14,498 541 1,285 744 15,039 1987 sunninc ss maad nis vba RES L nay we 15,039 494 1,273 779 15,533 988 wu iuvimmw s.3 MRA RAs HPAES nn 15,533 471 1,259 788 16,004 OBO noid c a RTH 5 3 Sow 5 lh con mii owe 16,004 447 1,243 796 16,451 IFT stv d Ena Tahoe 2 vm om woh om wie 16,451 429 1,229 800 16,880 Source: 1970 active occupational therapists: National Center for Health Statistics. Health Resources Statistics. Health Manpower and Health Facilities, 1971. DHEW Pub. No. (HSM) 72-1509. U.S. Government Printing Office, 1972. 172 Table B13. ANNUAL ADDITIONS AND LOSSES TO THE SUPPLY OF FORMALLY-TRAINED PHYSICAL THERAPISTS: 1970 AND PROJECTED 1971-90 Changes in supply January 1 — December 31 Number Number Year active Additions from active January 1 graduates of Losses from December 31 Net gains deaths and approved © retirements programs 1970: i sovnsssssnmss bs smnmms s sion - - os - 11,550 5 7 4 TRE EAE CE SS AR SNR 11,550 899 1,547 648 12,449 YOZD cle dria oh ct 5 hres foveal ci 6 180 hike vere w6 cen ee 12,449 971 1,616 645 13,420 1973 eee 13,420 1,024 1,715 691 14,444 1974 4 vo nn wi ss swam sss uname ss vues 14,444 1,060 1,772 712 15,504 1975 saw ma a s DMF HEE 19 3 HWE 48 35 85D 15,504 1,135 1,874 739 16,639 1976 i vwm sss untnem is aawaRes wR 16,639 1,195 1,969 774 17,834 1977 cs onnmis $3 Sw RER EL HEHE SR 17,834 1,220 2,062 842 19,054 VOTE eon tin we 0 ik ch wr EE 19,054 1,274 2,161 887 20,328 VOTO pines om ir it Tachi tine o sit my * da 20,328 1,337 2,261 924 21,665 1980. vv wmss s prmwmnrrs st sa mEw ss os www 21,665 1,365 2327 962 23,030 198Y swans ss vumuimevras mmm sa sommes 23,030 1,390 2,388 998 24,420 1982 mmm s ARNE ES SRB WE ES Ow 24,420 1,397 2,449 1,052 25,817 1983 ican ss nosnmma ds bammmss bhai 25,817 1,410 2,497 1,087 27,227 FIBA roar 2 nah 3 helm r iR 1 sdb iin ™® + Fre 27,227 1,436 2,553 1,117 28,663 1985 suv srw mamss srs wwnis vena 28,663 1,420 2,567 1,147 30,083 1986 % sommes sadness s EOE EE ENE TE 30,083 1,411 2,585 1,174 31,494 TO? rvwumas vs Hanser navER Es HH a0 31,494 1,339 2,560 1,221 32,833 1988: vrais nm 5s mE EF wi 32,833 1,292 2,533 1,241 34,125 FOB92- 5: hi cries cide bw lurpgpon ihe b+ wgwemon oly ogo bem 34,125 1,245 2,501 1,256 35,370 1990 + vv wes cs suwwwns ss smwuins s v5 www 35,370 1,202 2,472 1,270 36,572 Source: 1970 active physical therapists: National Center for Health Statistics. Health Resources Statistics. Health Manpower and Health Facilities, 1971. DHEW Pub. No. (HSM) 72-1509. U.S. Government Printing Office, 1972. 173 Table B14. ANNUAL ADDITIONS AND LOSSES TO THE SUPPLY OF FORMALLY-TRAINED SPEECH PATHOLOGISTS AND AUDIOLOGISTS: 1970 AND PROJECTED 1971-90 Changes in supply January 1 — December 31 Number Number Year active Additions from active January 1 } graduates of Losses from | pecember 31 Net gains deaths and approved : retirements programs TO70 wns sss disap sd ss u@mpEss EaFLm Es - - —- — 13,300 V7] cand ss vps td a NFER R F FRET RES 4 13,300 1,745 2,585 840 15,045 1972 wove ss mma rs tm mon sham 15,045 1,902 2,747 845 16,947 WITS ‘emis 55 simmmimig's oo at ono in + 914 wos pig 20a 16,947 2,058 2,955 897 19,005 1974 su ww ss nmwww sss pv BEwE® 3 8 Bow wE so 19,005 2,198 3,162 964 21,203 1978 coms cs ppmpmets abuso smpnins ss 21,203 2,356 3,393 1,037 23,559 1976 ssn: is npnne ts BERAS ES hMEER Eb 3 23,559 2,457 3,578 1,121 26,016 1977 wns cs vnmma ss bmpaon ss saness is 26,016 2575 3,797 1,222 28,591 BOTB nicer hms thine» pimsmm whle Ra wn ah 28,591 2,709 4,005 1,296 31,300 T1979 wv s sv awmmn sr vmpmmass swmumms es 31,300 2,821 4,189 1,368 34,121 1980 ous svnvmmissswmmninssvumnossss 34,121 2,944 4,386 1,442 37,065 198] wuss ommmmmiss ss mun sss Susans sy 37,065 3,055 4,570 1,515 40,120 VI82 wns svinmume ba nue ma ts GMER ET ED 40,120 3,228 4,847 1,619 43,348 M1983 wn is innmiaesr anmma iss nmmmah ss 43,348 3,351 5,055 1,704 46,699 P9844: iv vs sn am@mu tos naman dsb Ma Gads ba 46,699 3,465 5,251 1,786 50,164 TOBE cin ln wus oi on io Fin #70 Bits min 475 ls Bo cnie na ms 50,164 3,561 5,424 1,863 53,725 1986 «ov i ee eee 53,725 3,583 5,517 1,934 57,308 TOBT wots amma 's sm mmm s snimaimn ss ow 57,308 3517 5,551 2,034 60,825 1988 LL eee ee 60,825 3,444 5,540 2,096 64,269 TOBY vs iswawns sss mama es smwnimn vs ae 64,269 3,375 5,528 2,153 67,644 1990 os cs ninmmms s so mpwme o 3 HET EN £3 68 67,644 3,281 5,482 2,201 70,925 Source: 1970 active speech pathologists and audiologists: National Center for Health Statistics. Health Resources Statistics. Health Manpower and Health Facilities, 1971. DHEW Pub. No. (HSM) 72-1509. U.S. Government Printing Office, 1972. 174 Table B15. ANNUAL ADDITIONS AND LOSSES TO THE SUPPLY OF FORMALLY-TRAINED CERTIFIED LABORATORY ASSISTANTS: 1970 AND PROJECTED 1971-90 Changes in supply January 1 — December 31 Number — Number Year active Additions from Losses from active January 1 Net gains graduatesiof deaths and December 31 approved . retirements programs 1970 nce ir nmmpmas ts amnnis s aS BmRS - - —- —- 6,700 197] sunt cs DRM EES 2 REET EER Rodrik 6,700 1,259 1,969 710 7,959 P72 Sand 56 LAUFER AR 5 mm Flo 5 & eww ww 7,959 1,313 2,131 818 9,272 IO7B Rak 5.5 sot mom nin + 0 women ou win ws wi wt 0 10 0 0 9,272 1,373 2,305 932 10,645 NOTA 1. ore de 8 nde ine bys dn vos re #0907 00 0 I PE 10,645 1,438 2,479 1,041 12,083 1975 wos rt vopusan ss numame s UNGER : 12,083 1,511 2,640 1,129 13,594 1976 sonnac snpswnm is nnwmads i LESTE. 13,594 1,601 2,801 1,200 15,195 P97 iim a % SBE Re oh 3 obi ow o 5 oe oo wer ci 15,195 1,675 2,962 1,287 16,870 AGTB inns smmmmate as smn wie x ww wy 16,870 1,725 3,109 1,384 18,595 979 twins sev drmm sy trme evs REE EE 18,595 1,781 3,257 1,476 20,376 19B0 cvs ss smmummus s mimmnins d Binimmes 20,376 1,885 3,444 1,559 22,261 TIBY wiwmmim oe ss MEH 40 8p Wms ds hasioan 22,261 1,928 3,565 1,637 24,189 1982 unt dt So am mE 58% Pimms «ble mw oni 24,189 1,934 3,659 1,723 26,123 1983 Le eee 26,123 1,951 3,752 1,801 28,074 MBA ii brie rmbt 2 EP oy EE 28,074 1,937 3,806 1,869 30,011 1985 uns tors nammrsmumnsms so amma 30,011 1,937 3,860 1,923 31,948 1986 ovum es nonumti ss SnEE ETE 6T a 31,948 1,910 3,886 1,976 33,858 987 nun md a nati mBmdc on mmm = we 33,858 1,888 3,913 2,025 35,746 LE 35,746 1,855 3,913 2,058 37,601 TOBY fo vpmnnn s pr hmsins vs HUBER 43 ERORE 37,601 1,808 3,900 2,092 39,409 990 , um nuw sss awmbneg ss nEmae dss &0En 39,409 1,753 3,873 2,120 41,162 Source: 1970 active certified laboratory assistants: National Center for Health Statistics. Health Resources Statistics. Health Manpower and Health Facilities, 1971. DHEW Pub. No. (HSM) 72-1509. U.S. Government Printing Office, 1972. 175 Table B16. ANNUAL ADDITIONS AND LOSSES TO THE SUPPLY OF FORMALLY-TRAINED CYTOTECHNOLOGISTS: 1970 AND PROJECTED 1971-90 Changes in supply January 1 — December 31 Number Number Year active Additions from active January 1 graduates of Losses fro December 31 Net gains deaths and approved : retirements programs 1970 © tt eee ee ee — - — = 2,400 197) sensi spmemen t 3s RERw ss www 2,400 189 340 151 2,589 1972 wun ns 3s BH GATE 23 SHH HWY YMRS 2,589 186 368 182 2,775 JOB cvs ss i mba ss id HAGE LE LAER & 2,775 196 398 202 29 3 i 2 AS 2971 208 428 220 3,179 BOZ3 www ts Powis ol wu in on ince 80 an gc ie 0 be: 8 3,179 219 455 236 3,398 TOTIB sons ts namie +3 6 PEBEDE # BH EE VE» 3,398 231 483 252 3,629 VOID wow s 3 aida Biss puss iso Ress 3,629 243 511 268 3,872 VO78. suas rraiv imme bs LHPRNB IE HOH LE 3,872 251 536 285 4,123 1979 cow ss na Sel s HDB RT HE HARE BR Eo 4,123 263 562 299 4,386 VIB: wines smn Bis #8 ww B as sndim Edd § 4,386 281 594 313 4,667 1981 te eee 4,667 286 615 329 4,953 T9882 wuss smummes ss mmmawn s pumwic sss 4,953 286 631 345 5,239 1983 wuvwsnsneme ins novus REmE mess 5,239 288 647 359 5,527 T1984. iss numms si snow mE +8 HHNGE #8 8 5527 282 656 374 5,809 TOBE vi sma mn ss HEATH RI RSNA I EE 5,809 280 666 386 6,089 1986 © vv ie eee 6,089 270 670 400 6,359 TOBY wus sn wmmwi ss pm mms st mmm bow 6,359 272 675 403 6,631 1988 i i ee eee ee 6,631 269 675 406 6,900 TOBY ws s mmm m sa ts pen fmm. y nn 6,900 256 673 417 1,156 TOO i + ssismwem sss mEE ens ss Bunny ¢ wy 7,156 244 668 424 7,400 Source: 1970 active cytotechnologists: National Center for Health Statistics. Health Resources Statistics. Health Manpower and Health Facilities, 1971. DHEW Pub. No. (HSM) 72-1509. U.S. Government Printing Office, 1972. 176 Table B17. ANNUAL ADDITIONS AND LOSSES TO THE SUPPLY OF FORMALLY-TRAINED DENTAL ASSISTANTS: 1970 AND PROJECTED 1971-90 Changes in supply January 1 — December 31 Number Number Year active Additions from rm active January 1 Netgading graduates of deaths and December 31 approved . retirements programs 1970 cuvn es svnuwwas ss vamaves as sum ss - - - - 9,200 1971 cover ramums sss smmum gt nw E® 83 9,200 2,925 3,954 1,029 12,125 1972 wnnmss saa mead 3 PEWTER £3 BRETE ¢ 4 12,125 2,866 4,277 1,411 14,991 TJ978 san mw ss vim ts s HAST R Es DREMEL 8 3 14,991 2,818 4,627 1,809 17,809 1974 sone ss whan Ba © 5s WHER FF BEETS 8 4 17,809 2,817 4,977 2,160 20,626 JI7E wv ss ms inw rs wrmdimatn £5 Soha 0d 20,626 2,866 5,299 2,433 23,492 FOTO 1: ot 2h wien dink le & #0 Busi swhe + Sram iwionbe & 4 23,492 2,966 5,622 2,656 26,458 2 26,458 3,050 5,945 2,895 29,508 1978 cons ss vwavn er sppnwmes eomemn ss 29,508 3,104 6,241 3,137 32,612 1979 ssw ss vnwmu ss s wna mE ts EuBHES? 2 32,612 3,171 6,537 3,366 35,783 TBD unin vs RENE IS SREP HARE LLM EHRW Eo 35,783 3,328 6,913 3,585 39,111 981 cust ss na mB id ra Flim d § hammde § 3 39,111 3375 2,155 3,780 42,486 1982 Lee 42,486 3,357 7,344 3,987 45,843 0988 lime 13 Prmmes v1 wading dudes gig 45,843 3,377 7.532 4,155 49,220 1984 wns ir nwnwn sss nnn sss uwmeas ss 49,220 3,336 7,640 4,304 52,556 1985 uns samummures pine mm st RAMBEL Ep 52,556 3,319 7,747 4,428 35875 1986 .cv:scsammuiiisnvmmsr i hanmmas ss 55875 3,262 7,801 4,539 59,137 T1087 ee eee 59,137 3,226 7,855 4,629 62,363 1988 wuss vnpwn srs Bmw lprmegy ck 62,363 3,150 7,855 4,705 65,513 1989 uw ssn upmmi sos POMBE Es HOE HT Eb 3 65,513 3,061 7,828 4,767 68,574 1990 2 sss ssmmnims tr saignma ks BABH@S 8.8 68,574 2,952 7,774 4,822 71,526 Source: 1970 active dental assistants: BHRD, Division of Dental Health. 565-118 O - 74 - 13 177 Table B18. ANNUAL ADDITIONS AND LOSSES TO THE SUPPLY OF FORMALLY-TRAINED DENTAL HYGIENISTS: 1970 AND PROJECTED 1971-90 Changes in supply January 1 — December 31 Number Number Year active RL ons fm Losses from active January 1 Net gains i deaths and December 31 programs retirements TOTO: wiv + ts dm vs ss mmmminie sammy —- - — -— 15,100 1977 wit ctv wma sss rman ts EE a. 15,100 1,402 2,872 1,470 16,502 1972 ves ssvsnwma es sppnmas ss pussies ss 16,502 1,548 3,107 1,559 18,050 TI73- wns ss ARUBA IIB BFBT RE $3 HEFCE 18,050 1,646 3,361 1,715 19,696 1974 suis issn nics 3 aREan@ ss nome .ae 19,696 1,749 3,615 1,866 21,445 1978 divs sw aimmma 1.9 + mimBiond ss wmmws ms 21,445 1,866 3,849 1,983 2331 VOTH: vin oie vim wimimonss we win igs ios im 2 Ty nen ihc vp 23,311 2,009 4,084 2,075 25,320 T1977 vt vv van wns ss mms ams st vasa 25,320 2,096 4,318 2,222 27,416 1978 ee ee eee 27,416 2,163 4,533 2,370 29579 1979 snc sanmuns i383 HARE ELS VAST FE. 29,579 2,235 4,748 2513 31,814 M1980 wus ssa a Fats LATHER E 2 RT HRA 31,814 2.372 5,022 2,650 34,186 VIBY wii s cain M iad damm Sad 2 5 mm Sle 34,186 2,432 5,198 2,766 36,618 TOBY Gnd ts mmm vrs mmm mie vs wwe 36,618 2,425 5,334 2,909 39,043 WOBD: cceisnin nies wisi cnr calls woion i wt oon ip 37 9 wn 1 wr Tm 39,043 2,449 5,471 3,022 41,492 1984 eee 41,492 2,421 5,549 3,128 43,913 T9885 wus smmumumms sss CamABIES + oie ewe 43913 2,411 5,628 3,217 46,324 TUBB. wiv v + ss HMUME Es A EHAB AIP 2 HME 46,324 2,375 5,667 3,292 48,699 1987 spies smamua ss v9 ARRA EI 10mm asds 48,699 2,337 5,706 3,369 51,036 TOBE win ik ss HARB SAT Sn BE sdb mm 51,036 2,283 5,706 3,423 53,319 TOBY wiv ks vs mmr as 88 Mmmm » ss mmma» 53,319 2,210 5,686 3,476 55,529 DOO 2c 253 515 ih ors cn oor iis 0 00 ia 0 30 co ® 50 i rn rin 55,529 2,125 5,647 3,522 57,654 Source: 1970 active dental hygienists: BHRD, Division of Dental Health. 178 Table B19. ANNUAL ADDITIONS AND LOSSES TO THE SUPPLY OF FORMALLY-TRAINED DENTAL LABORATORY TECHNICIANS: 1970 AND PROJECTED 1971-90 Changes in supply January 1 — December 31 Number Number Year active Additions from LOSTes FIOM active January 1 Net gains graduates of deaths and December 31 approved . vegas retirements 1970 ; inant ts PRINCE 49 $» HBEA LS 2S HBES —- - . —- 1,600 TOTT mmm #3 snowmen shion 8 Bolen a io 0 ines Bow on io 1,600 413 447 34 2,013 VOTT! onions win 4.9 weshmnonin why 4 wg 2 4 ¢ ls www 2,013 444 483 39 2,457 1973 cv wwmae sss mummies vse mums iss mums 2,457 473 523 50 2,930 1974 . cin i st sun Fa ms 3s BiGiBE 29 838 DRED 2930 503 562 59 3.433 978 so vinm ts ta mATAR 13% RAGED FF Bad 3,433 536 599 63 3,969 1976 © i ee ee eee 3,969 562 635 73 4,531 VOTT snmmrns swum 4s Tusgwd ils + gw wm 4,531 594 672 78 5,125 1978 commas sp mE mE ss + CUBE $3 FEE 5,125 620 705 85 5,745 1979 . coum is so mEmames pHa a® 5 65000» 3.745 643 739 96 6,388 T9880 cnn ves sa mapas od ARSE 3 00 BEE E 6,388 680 781 101 7,068 JOBY ions ts sodA BR REF bh BARES sb BRE 7,068 698 809 111 7,766 POB2 | vita 41F mi Biu ifn 2% momtion 2 8 Bron om oh ol 7,766 707 830 123 8,473 1983 LL eee 8,473 725 851 126 9,198 IBA simon 4 ¢ wim Dwr + 3 snp gemih + + len ow pe 9,198 730 863 133 9,928 1985 ee eee 9,928 738 876 138 10,666 TOBE umm 24 smmammes v2 Sw a we 20 wwe es 10,666 737 882 145 11,403 TORT cvs me ss samme v 8 ME GE® 28 #289 e6T 11,403 735 888 153 12,138 1988 so unnim is amaawme so wai Bam $8 #8040 12,138 730 888 158 12,868 1989 vorumss nun dams si RESRR IS RAST E 2 12,868 719 885 166 13,587 1990" cvs ss nati T ada 3 Ram 55 ams Bows 13,587 707 879 172 14,294 Source: 1970 active dental laboratory technicians: BHRD, Division of Dental Health. 179 Table B20. ANNUAL ADDITIONS AND LOSSES TO THE SUPPLY OF FORMALLY -TRAINED LICENSED PRACTICAL NURSES: 1970 AND PROJECTED 1971-90 Changes in supply January 1 — December 31 Number Number Year active Additions from active January 1 Net £3) graduates of Losses from December 31 gains approved deaths and programs retirements M70 vs sump s s 5 RE RER LS UE REEE £35 - - —- —- 400,000 TPT os np wn mE so 2 HEGHE F.8 bn Ba db son 400,000 11,017 40,383 29,366 411,017 TI72 wv cima s 33 BHMER SE % Dmmmmeis on» 411,017 11,848 43,801 31,153 422,865 1978 cc ci sm @mas vs bmmmiov es mm rns 422,865 12,672 47,345 34,673 435,537 974: cos s nn dws tes mmm ss rpm, ps 435,537 13,750 50,827 37,077 449,287 7 449,287 15,390 54,245 38,855 464,677 1976 «cv cv rm is BRENNER EERE Eg 464,677 17,401 57,536 40,135 482,078 IT wnrrvvrna i issiibwmss s PHISH LT 3 482,078 18,776 60,701 41,925 500,854 T8978. vis 1.0 winioinm 4.3 3 BEBE EE E58 HRH Ea ys 500,854 20,037 63,802 43,765 520,891 1979 tla v4 SHB HE 55 3 bam Dwd ames 8 520,891 21,446 66,967 45,521 542,337 T9BO: wis ts mn wmms ov mw mmr vx wwwmmn ss 542,337 23.550 70,726 47,176 565,887 1981 wiv i nnn REY ES BF EEEE SE 565,887 24,623 73,203 48,580 590,510 1982 eee 590,510 25,169 75,130 49,961 615,679 1983 nn rt HARE Rr NERC E SL PRE EE. 615,679 25,819 77,057 51,238 641,498 VIBE: wire 2s sR THEE 5% Br on A mm mn 641,498 25,855 78,157 52,302 667,353 HIBS nm s tt amma vn sx mmm Cn. 667,353 26,065 79,258 53,193 693,418 1088 ftv is vinsimmns vs smmwmns $Y § 693,418 25912 79,808 53,896 719,330 1987 ee 719,330 25,893 80,358 54,465 745,223 1988 Lee 745,223 25,484 80,358 54,874 770,707 1989 vuvin s+ nr ERNE as PAAR CF Ream 770,707 24.921 80,083 55,162 795,628 B90 54 08 3.0 BARES ES § mdm toe mw, 795,628 24,158 79,533 35,375 819,786 Source: 1970 active licensed practical nurses: National Center for Health Statistics. Health Resources Statistics. Health Manpower and Health Facilities, 1971. DHEW Pub. No. (HSM) 72-1509. U.S. Government Printing Office, 1972. 180 Table B21. ANNUAL ADDITIONS AND LOSSES TO THE SUPPLY OF FORMALLY-TRAINED RESPIRATORY THERAPISTS: 1970 AND PROJECTED 1971-90 Changes in supply January 1 — December 31 Number Number Year active Additions from active January 1 . graduates of Losses from December 31 Net gains deaths and approved . retirements programs 1970 0 pvr nn ts ssmamamenmemumwnss sn — — —- - 3,850 1971 us csr nam mss wnlmwm sr mE te 3,850 530 749 219 4,380 TOT css sma mins » pow mows « op 5s sla ss wn 4,380 568 811 243 4,948 1973 Wd snares rN BREE RE EE RE 4,948 590 878 288 5,538 1 PT TEE TT ETE 5,538 616 944 328 6,154 T1978 i cnsmmi ss pbs mmmin ss mmm vw 6,154 646 1,005 359 6,800 BOFB eo « vovmv minis snp won x ow ww re le 6,800 685 1,066 381 7,485 ITT ews wate s Tem mmm es vos r ss se 7,485 714 1,128 414 8,199 1978 vcr er ar rer Es ee. ky 8,199 738 1,184 446 8,937 (1 ee TT I TE TITY 8,937 766 1,240 474 9,703 1980“: it mommimim ss RoammEs s SEMEL E 2a 9,703 808 1,311 503 10,511 1981 iis manm ms s Hr GRETA SREB TAS & a 10,511 828 1,357 529 11,339 1982 i nr na R A RMT RES FR mm Fw wn 11,339 834 1,393 559 12,173 1983 wiv ama mi brs mmR ans s mmm» 12,173 847 1,428 581 13,020 TOBY ii vs nniiimmits Homme + wo mie «ly 13,020 847 1,449 602 13,867 TOBE wists msama ut ss mums sn mmn ss ws 13,867 849 1,469 620 14,716 TOBE! v3 vss swmmme ss immu ks MEUBMBE + © 14,716 840 1,479 639 15,556 1987 cu csvvnmassSsmmmume su mawe dese 15,556 837 1,490 653 16,393 T1988 ov rnun wm ss bURAERSE mE oe 16,393 824 1,490 666 17,217 TOBY iv d's a HEHE 4 3 4 REBT dr» mmm. vw 17,217 807 1,485 678 18,024 VIO. i fe sv piarrrs sanaimmnin s emm wun y we 18,024 784 1,474 690 18,808 Source: 1970 active respiratory therapists: National Center for Health Statistics. Health Resources Statistics. Health Manpower and Health Facilities, 1971. DHEW Pub. No. (HSM) 72-1509. U.S. Government Printing Office, 1972. 181 Table B22. ANNUAL ADDITIONS AND LOSSES TO THE SUPPLY OF FORMALLY-TRAINED MEDICAL RECORD TECHNICIANS: 1970 AND PROJECTED 1971-90 Changes in supply January 1 — December 31 Number Number Year active Additions from | | coc from active January 1 Net gains graduatesof | 4o.insand | December 31 approved retirements programs 1970 www ss sivmna 13s HART Es DOB MANE» - — — — 3,800 TITY mm ss « amavis v3 na @EEes 3 des vi. 3,800 23 269 246 3,823 WID2 Gk 205 5 heim nin o whi wove on ih omg wi les oF ss vom @ 3,823 58 291 233 3,881 1978 nv cs Fomine sss vmmnnss new wwe 3 3,881 71 315 244 3,952 JIVE cnr crv umm tts PEE SE 3,952 92 339 247 4,044 75 ww vs nnmams 3 FETE NEHER 4,044 112 361 249 4,156 1976 coic ts san tmnt 8 9 BFS HES nhl mmm 4 4,156 130 383 253 4,286 1977 sin st 2 ns a Tad Es ma BBE ES ho mm 4,286 142 405 263 4,428 ITB wc cvcs bmnmdr or sr mmm» nm. 4.428 147 425 278 4,575 1979 ve cs cnr mans ss raha ss be 4,575 154 445 291 4,729 TID, vv vs smwnmes ts pammEs s pH BSE EE & 4,729 171 471 300 4,900 198) wows snuimnmitss HonREs Le NEdnm 4,900 170 487 317 5,070 1982 vinci s aumBn sss mamas » mow mw » 5,070 162 500 338 5,232 BIBB. Gir 2 5 Thon sitir cs + mmm = wg. 5,232 162 513 351 5,394 1984 ee eee 5,394 162 520 358 5,556 1985 civ cs sv vn mms rm ve Es 5,556 161 527 366 5,717 1986. vows + s vu Mma 54 2 HEAT ES BRE 8 5,717 155 531 376 5,872 1987: vvw sss rs nmmmas 3s AMaman ens Gmsss 5,872 153 535 382 6,025 BOB viv ot + AUR E gf 4 5 boo #0 ow AAS wer 6,025 151 535 384 6,176 1989 wwued ss swmma sons oo ES SI: 6,176 144 533 389 6,320 1990 «vv ttt ttrtnr rer rare ss rae 6,320 139 529 390 6,459 Source: 1970 active medical record technicians: National Center for Health Statistics. Health Resources Statistics. Health Manpower and Health Facilities, 1971. DHEW Pub. No. (HSM) 72-1509. U.S. Government Printing Office, 1972. 182 Table B23. ANNUAL ADDITIONS AND LOSSES TO THE SUPPLY OF FORMALLY-TRAINED OCCUPATIONAL THERAPY ASSISTANTS: 1970 AND PROJECTED 1971-90 Changes in supply January 1 — December 31 Number Number Year active Additions from Losses from active January 1 Net gains graduates of deaths and December 31 Ee retirements T1970 ot ee ee ee ee ee ee eee - - - - 600 197) comumm iv s mmmiwas 8 8 ST WwE § + Po HB» 600 328 381 53 928 1972 (sas m ss ss NEWB s 43 BEBE S + 8 9% WEES 928 332 412 80 1,260 1973 sons sss swan BL Es FRA WS IS HEHE L 1,260 343 446 103 1,603 978 nu mw is v mmm LARTER VE BREW 1,603 333 480 127 1,956 TOIS nme 13 oS WEEE ss LBHABE LAP CEN 8 1,956 365 511 146 2,321 T9786 cov ss mmmudd®s mB Pa NWS 2.321 376 542 166 2,697 2 2 J 2,697 394 573 179 3,091 TOT8 vnc vs mmmn ly 4 wngals slimmmm o » 3,091 405 601 196 3,496 VI79 wows so pmmu css 38 TEs vars we 3,496 420 630 210 3,916 VI80 ui wwiv cis vmmmas v3 SR GEW 1 8 SHOWS TE? 3,916 439 666 227 4,355 198] coms os mummm es 3 RUE RE 4 8 HERES 5 8 § 4,355 445 689 244 4,800 1982 wun iss hmume sss pala Bm es a memo 8s 4,800 450 707 257 5,250 JOBE wn is sims mid #3 MBSR A Po LMT HEE R 5,250 457 726 269 5,707 TOBA vit v vm mmns son mmm moh 88 on Bea 5,707 456 736 280 6,163 JOBS ww s similis « sommmmon # # ssmmonbe + 4 » 6,163 458 746 288 6,621 TOBB wv ws s sy mmm ss s HBT HT § FMP WES 043 6,621 451 752 301 7,072 T9877 wom ss vaiw wm s 2 tS WERE Ls SEW MEE 6 8 3 7,072 452 757 305 7,524 VJ988 vv insane sss nasa esp GiMiom EEE 7,524 443 757 314 7,967 HOBY woviv von vmmnck vs mmm vb EH ER RR 7,967 431 754 323 8,398 FO90 wine 4'« wronmmin 2 5 » srigmmmie »lu tl mmon = ulin 8,398 419 749 330 8,817 Source: 1970 active occupational therapy assistants: National Center for Health Statistics. Health Resources Statistics. Health Manpower and Health Facilities, 1971. DHEW Pub. No. (HSM) 72-1509. U.S. Government Printing Office, 1972. 183 Table B24. ANNUAL ADDITIONS AND LOSSES TO THE SUPPLY OF FORMALLY -TRAINED RADIOLOGIC TECHNOLOGISTS: 1970 AND PROJECTED 1971-90 Changes in supply January 1 — December 31 Number Number Year active Additions from Losses from active January 1 Netaain —" deaths and December 31 programs retirements 1970 cn ss wma is sa BMBF 5 2 so mmwn oss —- - —- - 41,000 TOT oir iis DUBE RE So mM Aw ES vim rrr bw 41,000 3,769 6,661 2,892 44,769 VOID wins 4 a nF RHE 3 5 mmm vs sonnet 44,769 4,303 7,205 2,902 49,072 1973 iis vimmanms ss vmmmum ss 5 mE EHEE 88 49,072 4,546 7,794 3,238 53,618 1974 eee 53,618 4,824 8,383 3,559 58,442 LJ 58,442 5,126 8,926 3,800 63,568 1978 vv vs smmmns v4 HIRE RR LS UEES § 3 63,568 5,477 9,470 3,993 69,045 LL i TE ET Tra 69,045 5,742 10,014 4,272 74,787 IOTB vt 20 SEER 5 0 mim won cee 50h win 74,787 5,972 10,512 4,540 80,759 1 J 80,759 6,208 11,011 4,803 86,967 1980 simvic s « smimmumnin 5% wypmmm s+ 5.98 5500 86,967 6,588 11,645 5,057 93,555 1981 Lee 93,555 6,774 12,053 5279 100,329 1982 wn vin rss nun Mn ss SSR EEL 4 awe 100,329 6,763 12,370 5,607 107,092 1983 vniwmis tt sama ma S55 LEE er wwe 107,092 6,876 12,687 5,811 113,968 TOBA cvnicin #2 3.00 Bib vs meme 5s 113,968 6,887 12,868 5,981 120,855 1985 vinmmi s mbimmmuns vamimmme 5 888 0EE 120,855 6,915 13,050 6,135 127,770 1986 Lo i 127,770 6,875 13,140 6,265 134,645 1987 ee 134,645 6,843 13,231 6,388 141,488 1988 vv vim o 9 s HABE EE TS GRRE RAE 3 are 141,488 6,736 13,231 6,495 148,224 1989 . vv wmmit ss 5EmEEE 5 mmm Ens op 148,224 6,610 13,186 6,576 154,834 1930 .civcnnusssmmnmmns memes s puns 154,834 6,446 13,095 6,649 161,280 Source: 1970 active radiologic technologists: National Center for Health Statistics. Health Resources Statistics. Health Manpower and Health Facilities, 1971. DHEW Pub. No. (HSM) 72-1509. U.S. Government Printing Office, 1972. 184 Appendix C. UPDATED TABLES As indicated in Chapter 1, December 31, 1970 was adopted as the base year for the development of individual practitioner profiles and as a base year for the projections. However, in many occupations, more recent manpower statistics are available, some of which have been presented earlier in individual chapters. This appendix provides additional current statistics. The following material does not purport to represent an exhaustive current profile of health professions and allied health occupations. It is intended simply to assist readers by providing supplemental, more current information than that presented earlier. Data presented for M.D.’s have been taken directly from AMA publications and, as such, are not totally comparable with figures presented in Chapters 3 and 4, Table number Page C1. Number of non-Federal physicians (M.D.) providing patient care and physician/population ratios in the United States, by State: December 31,1972 187 C2. Number of active Federal and non-Federal physicians (M.D.), by major professional activity: December 31,1972. ©... . . ..... 189 C3. New licentiates representing additions to the medical profession, by place in which licensed and place of training: 1972. . . . . . . . . . . .. 190 C4. Number and percent distribution of active physicians (M.D.), by specialty: December 31, 1972 192 C5. Number and percent of active physicians (M.D.) engaged in primary care: December 31, 1972 193 C6. Number of civilian dentists and dentist/population ratios, by State: December 31,1972 . . . 194 185 Table number Page C7. Number of active pharmacists, by sex and by age group: December 31, 1971 i % #5 +» » 196 C8. Number of active pharmacists, by type of employer: December 31,1971 . . . . . . . . . . 197 C9. Number of full- and part-time employees and budgeted vacancies in selected categories of personnel in community hospitals in the United States, by geographic region: 1973 . . . 198 C10. Estimated supply of selected categories of public and community health personnel: 1970, 1971 199 C11. Distribution of active optometrists, by sex and by age group: 1973 . . . . . . . . ..... 200 C12. Distribution of active optometrists, by principal form of employment: 1973 . . . . . . . . . 201 Table C1. NUMBER OF NON-FEDERAL PHYSICIANS (M.D.) PROVIDING PATIENT CARE AND PHYSICIAN/ POPULATION RATIOS IN THE UNITED STATES,BY STATE: DECEMBER 31, 1972 Number of inh Civilian non-Federal Rate per . State physicians 100,000 Papuan providing population jue patient care United States... .......... 266,587 129 206,451 Alabama ................... 2,841 81 3,486 Alaska, . s ss umm sas mewn m ra vn 224 75 298 ANZONA sis vumanie ss ME EE 5s oY 2,466 129 1,915 ArKansas « + vomma st +s sowne si on 1,620 82 1,969 Califor: «cnmnvms sonmimm ss ha 33,606 167 20,131 Colorado , ... vans sv nmadivg so be 3,343 144 2,314 Connecticut . . ....... ov... 5,087 166 3,065 Delaware . . . ........ 00... 694 124 559 Districtof Columbia . + vv 20s 4: «5 2,508 340 738 Florida vss smmmps ss wawics +3 #3 9,181 128 7,163 Georgia, ss vnwma ss rE AH EY Es WS 4,633 99 4,665 Hawall, . ss snmmw ss anwda tao un 1,079 142 759 Idaho . . . . . Li iii 652 87 751 Hinois . .... viii. 13,539 121 11,212 INAIANA ovvvivs sr wnnm ss vewaee 4,921 93 5,283 JOWR: , so vnemms +s vo nEn ss same 2,609 91 2,882 Kansas '.ovswumms svissne saan 2,259 101 2,227 Kentubky .. vv msw ss nnsnw ss nua 3,078 94 3,268 Louisiana... ........c..vuv... 3,883 105 3,685 Mane ; vo vn mms sv siwmcnes neo 999 98 1,017 Maryland sss vim ns + sown ss pnw 6,224 156 3,995 Massachusetts . . . us vv vs canes ss 10,252 178 5,766 Michigan ...cnuws si snsvs it nnms 10,163 112 9,067 Minnesota . ................. 5,000 128 3,893 Mississippi. . «vie eee 1,685 75 2,241 MiSSOUri vv vee eee eee 5,388 114 4,724 Montana saws ws sv mmponn sv wma 694 97 713 Nebraska « cw uw ss sims nwa s wows 1,532 101 1,513 NeValR vp vn dud naswiEs wnuR@n 537 103 519 New Hampshire . .............. 920 120 767 New Jersey . .........c0ov.. 9,389 128 7,320 New Mexico . .... vv viii ven. 1,036 99 1,050 NewYork wun iesvvnsrss onsen 36,161 197 18,338 North Caroling J. i swen sss nmnmm 5,000 98 5,121 NorthDakota ............... 524 85 620 Ohio «viii et eee eee 12,682 118 10,768 Oklahoma. . ................. 2,339 90 2,607 Oregon + ov vv vi ieee ee ene 2,800 128 2,179 Pennsylvania. . ............... 15,735 132 11,915 Rhodelsland. . ............... 1,380 147 937 South Caroling . . sews ss vuwmas 2,218 85 2,597 SouthDakota . i; unwwin ss naumns 482 72 673 Tennessee i. s « « voww i +s we wmyw + 4,193 104 4,013 TeXAS canons sv Mpmms ss HEMTmE » 12,258 107 11,496 Uta coum snmma® $8 bn umma 1,429 127 1,121 Vermont . o.oo uv i ieee. 694 150 462 See footnotes at end of table. 187 Table C1. NUMBER OF NON-FEDERAL PHYSICIANS (M.D.) PROVIDING PATIENT CARE AND PHYSICIAN/ POPULATION RATIOS IN THE UNITED STATES, BY STATE: DECEMBER 31, 1972—Continued Number of pe Civilian non-Federal Rate per rm State physicians 100,000 p co po providing population (1,000) patient care Virgina soni snnmeamssnomngsss ines 5.217 113 +,604 Washington, . . ev su mmm 35 Ham ww & + 5 5 # ow 4,446 131 3,406 WestYIgInIR. . : s wonad s3 3 mowed ssw 1,692 95 1,780 WISCONSIN. 4a o + sn mmr vs mamma sss nbn 4,984 110 4,518 Wyoming . «vv iv vite ie ee eee 311 91 341 Source: American Medical Association. Profile of Medical Practice. 1973 edition. U.S. Bureau of the Census. Current Population Reports. Series P-25, No. 488. 188 Table C2. NUMBER OF ACTIVE FEDERAL AND NON-FEDERAL PHYSICIANS (M.D.), BY MAJOR PROFESSIONAL ACTIVITY: DECEMBER 31, 1972 Total active physicians Federal Non-Federal Major professional activity Number Percent Number Percent Number Percent Allactivities | : vu aww vss nmm as os ro 1 320,903 100.0 27,580 100.0 i; 293,323 100.0 Patientcare ...............0.0uuu... 292,210 91.1 23,115 83.8 269,095 91.7 Officebased . .................... 201,302 62.7 2,328 8.4 198,974 69.8 Hospital based ....counsssomunmwecss 90,908 28.3 20,787 75.4 70,121 23.9 ther professional activity . . . ............ 28,693 8.9 4,465 16.2 24,228 8.3 Medical teaching. . . ................ 5,636 1.8 499 1.8 5,137 1.8 Administration... ................ 11,074 35 2,197 8.0 8,877 3.0 Research . ...................... 9,290 29 1,361 4.9 7,929 27 OWE vi vivian s gem es Sanwa § 4 2,693 0.8 408 1.5 2,285 0.8 ! Excludes 12,356 physicians “not classified”. If the percent active among all physicians is applied to the “not classified”’ physicians, the estimated number of active physicians would be 332,530. Source: American Medical Association. Profile of Medical Practice. 1973 edition. Note: Figures may not add to totals and subtotals due to independent rounding. 189 Table C3. NEW LICENTIATES REPRESENTING ADDITIONS TO THE MEDICAL PROFESSION, BY PLACE IN WHICH LICENSED AND PLACE OF TRAINING: 1972 Yotal new New licentiates FMG'’s as percent Place in which licensed . " graduating from of total new licentiates i i : foreign schools licentiates United States. . . .......... 14,476 16,808 47.0 ARDAMA «oss vmnn Panes mina 51 1 2.0 Alaska. . . .. oii ee 26 10 38.5 ANZONE: oy ss pmmwm ess noma 2 85 33 38.8 AIKINSAS & « + s sms ns as pr mE mE 4 103 7 6.8 California, . s ss onswnc ss nmmwms + 1,370 172 12.6 COlOralg ., + « sows wns #3» RH WE 2 9 100 4 4.0 Connecticut . «os anvmms sr nmumes 81 45 55.6 Delaware .. « « : vosw ows oo nming a» 55 49 89.1 District of Columbia ........... 202 106 52.5 FIORE voc sn imminme 3 ono ide 406 257 63.3 Georgia . .. vv viii ieee 372 109 29.3 Hawaii ............. 0... 40 16 40.0 VARGO vc ss swmmmms ss wn wwe. 4 0 - JHNOIS, ows soma mmum es vmws ons s 826 638 771.2 Indiana .;:ovuwwemssvamee ss 223 15 6.7 OWE wwii ve nmwnmins bs bois he +8 132 23 17.4 Kansas... ss snwnon ssa hmnmm es 162 48 29.6 Kentucky. , coanvo vs snmmas és 192 34 17.3 Louisiana. ..........ououvuun.. 244 25 10.2 Maine . . ..... iii 85 70 82.4 Maryland , , cs cons esc snmmmn ss 354 116 32.8 Massachusetts: vue + s ps nmins ¢ » 343 152 44.3 Michigan , ss sums ws +s srsiwmms ss 901 659 73.1 Minnesota .....omvs vvnmes sna 220 20 —- MissisSippl : sav mawi i sna minma sa 114 6 5:3 MiSSOUFi vv vv vv eee ee eee eee as 557 337 60.5 Montana ................... 5 0 - Nebraska , + vo vwwes s voamamws +s 111 4 3.6 Nevada cs svwamsmss snorammed ss 2 1 50.0 New Hampshire . .............. 28 16 57.1 New Jersey . ........couvuu.. 174 116 66.7 NeW MexICO + vvzr vss prwmmns vy 77 25 325 NEW YOrK. « ov a oivies s #1000 % 50 0.8 2,136 1,129 52.9 North Carolina ............... 215 28 13.0 NorthDakota cows vs sonamas ws 67 62 925 ORIO vs snmmminm se mmminm o's 85 728 418 57.4 Oklahoma .................. 108 12 13.3 Oregon . «vv vi ii ee ee ee eee 51 4 7.8 Pennsylvania .. . «vss s s vn wwe s 25s 1,351 910 67.4 Rhode island. . «vu + s s snmasn 05 58 36 19 52.8 SouthCarolingd wc. esssvmumes ws 67 0 - SouthDakota: ..:«. son 0m sss 28 13 46.4 Tennessee. . . . .. vv v vv vv ine 244 44 18.0 TeXaS + vv vv vie eee eee 390 72 18.5 Utah ©... iii iin 68 10 14.7 Vermont . vos wma ss mvwmme son 213 180 84.5 Virginia : vuwmuwm ss pummmmns os 727 531 73.0 Washington .asvinsssavamns 20 ue 189 55 29.1 West Virginia, s aww ssiwmemo i'n 5s 99 60 60.6 See footnotes at end of table. 190 Table C3. NEW LICENTIATES REPRESENTING ADDITIONS TO THE MEDICAL PROFESSION, BY PLACE IN WHICH LICENSED AND PLACE OF TRAINING: 1972—Continued . Total New licentiates FMG'’s as percent Place in which licensed Fos ew graduating from of total new ljcentiates foreign schools licentiates WISCONSINa wis + 5s sam mm ® o 3 5 www 149 50 33.6 WYOMING + + « s ¢ sn vnin sss swiwnmis 7 2 28.6 GUAM & tot te eee 6 6 100.0 Puerto Rico cs sewn es vumwmnn 149 109 73.2 Virginlslands ; s wowuw ts snmnmmes 3 0 — ! Includes 147 graduates of Canadian medical schools. 2 Incomplete report. Source: American Medical Association, Council on Medical Education. Medical Licensure Statistics for 1972. Chicago, The Association, 1973. 191 Table C4. NUMBER AND PERCENT DISTRIBUTION OF ACTIVE PHYSICIANS (M.D.) BY SPECIALTY: DECEMBER 31,1972 Specialty Number of physicians | Percent Total golive PHYSICIANS «vv 0 s sm mmmm vs Bw wmmm + ow wmm ww 3 320,903 100.0 General practice? EEE EEE Er eI Erm, 55,348 17.2 Medical Specialties +... wow ws ss Ha SERA 2 SRBERF FEI DBE EES 72,728 22.7 Dermatology « «vv vit ee ee ee ee eee ee ee eee ees 4,227 1.3 Internal Medicine + « vo vv + ss maw ss vw 10s vty) on sn sen en re a oR 47,994 15.0 Pediatrics” © ov vee ee eee eee 20,507 6.4 Surgical specialties . .. ....... tiie 90,409 28.2 General SUTBEIY vv vv i et ee tee et eee eee ee 30,989 9.7 INGUrologICAI SUIBEIY «wv + s sv swim ss t www wm sx « sm mms soa 2,753 0.9 Obstetrics and gynecology . « «vv vv vv vv eee I 20,202 6.3 OphthalmOlOBY + vs wiv + 2 3 Ho Mies ¢ 4s VME E +s s vEB awn + + #» 10,443 3.3 OrthopediCiSurBerY +m + s » stim vie 1 1 $s SREP + BUBB ERD 5 8 #0 10,356 3.2 OIWIAIYNZOIOBY ou awim +s ss BW RT + LI UBEMES + b UST E EE 2 6 50 5,662 1.8 PlastiCSUIBOIY s vaimmw + 2 4 SHIRE LE 4 3 HHBS HE +5 AWE EB US 38 1,786 0.6 ThoraciC Surgery. . a + + » s sss re ss Hmm mB * $ PHB AR EL £8 5 57 1,927 0.6 Urology ... coum ssmmmmss ts mmav ss sn omnm ss nes 6,291 2.0 Other specialties . «vv vv viv vit tte eee eee 102,418 31.9 AnesthesiolOBY «vv ss s san m sss pov wmv cas mmmmn ss wwe 11,853 37 Child psychiatry vw s + sme ms 2 ss sume sv 2 pummme ov emu 2,268 0.7 NEUIOIOBY: + vam ss F 3s MF ® 3 3 3 HHMER FE SETS 83 pwn 3,494 1.1 Poychialry, .onmin bs + 2 As R s dL HUN WB $ FS HERB 2 HT HB EE 22,570 7.0 PALNOIOEY? en vtec siRNA EE AREER dS EEE 11,218 3.5 Physical medicine and rehabilitation . . ................... 1,551 0.5 RadiologyS © i eee 14,917 4.6 Miscellaneous® o.oo ie ee ee ee eee eee 34,547 10.8 ! Excludes 12,256 “not classified”. 2 Includes family practice. 3 Includes pediatric allergy and pediatric cardiology. # Includes forensic pathology. 5 Includes therapeutic radiology and diagnostic radiology. 6 Includes also physicians with unspecified specialty. Source: American Medical Association. Profile of Medical Practice. 1973 edition. Note: Figures may not add to totals and subtotals due to independent rounding. 192 Table C5. NUMBER AND PERCENT OF ACTIVE PHYSICIANS (M.D.) ENGAGED IN PRIMARY CARE: DECEMBER 31, 1972 Number of Specialty Percent physicians Total active physicians .....ovvve inne nnnnennnnns 320,903} 100.0 Primary care, total ....... Ww % WIm SII IRN WIE BAR ee 144,051 44.9 General practice” ............ Ceres 5008 5 0 5 ew crm ren a 55,348 17.2 Internal medicine ............... 8h eww ween wp 6 47,994 15.0 Pediatrics® ............... I een ee 20,507 6.4 Obstetrics, ByNecology «ov vv vve en enenneennnennas 20,202 6.3 All other ......oovvuvvnnn. Rr SE 8 PH AE REE eS 176,852 55.1 ! Excludes 12,256 physicians “not classified’. 2 Includes family practice. 3 Includes pediatric allergy and pediatric cardiology. Source: American Medical Association. Profile of Medical Practice. 1973 edition. 193 Table C6. NUMBER OF CIVILIAN DENTISTS AND DENTIST/POPULATION RATIOS, BY STATE: DECEMBER 31, 1972 Civilian Number of civilian Rate per 100,000 population dentists population State July 1, 1972 (in 1,000) Total Active Total Active UNITED STATES . . vv vans ww 6 win 5k 5 90h #060 3 Tf SHER bithh B06 ¥ Sime 206,451 112,270 97,970 54 47 AVABAINE 5 0 5:0: 2 5193 270 8 Wits B90 3 96 2 $50 8 ¥56 © 050 8 HER $2000 450 4 ws w wie: @ wigan 3,486 1,159 1,045 33 30 AVESRE ooo vivo vie 50% 5 970 7 00 8 950 8 Win # C105 550 2150 8 8 4 B40 © RK 4 HIS WI% § WHS 298 105 101 35 34 ATIZONA 4 on viv an 1 500 450 8 00 4 wih 0 000 «wow ki 0 20 8 wiki n wow 0 wow 0 wh # RE 1,915 810 731 42 38 ATKBNSAS wins wai 4 0:0 3 98 4 59% 6.475 © 070 § W500 § 908 $06 6 WER 0 wie g Ww wi w WH 1,969 682 604 35 3 Cal lio Eu wiv s wom 2.900 8 909 5500 2 008 $00 £8 00 40 4 wine won 8 wie x wie ® www iin 20,131 13,252 11,664 66 58 COVOPAT 500 4 win» win 2 Fi 8 550 B50 3 308 £0430 # 979 § W618 & 400 4 Wii 3 %50 # Aim 0 iw 0 2,314 1,306 1,174 56 51 CONNOULICUE wiv so vio s $e 3 00 S200 6 $0 800% 7 0 § £108 J00 § #45 & #50 410 ¥ Wie » Win 3,065 2,099 1,847 68 60 DEIaWATE sus ves vas vs ESHER EAE 48 FEES 4 O10 EH WES V0 WEEP 559 239 220 43 39 District of ColumbIR: vo sow sown a3 5 55 2 559 # 519 4 058 # 05% & 650 ¢ 00 8 @0 Siwow # 738 784 675 106 91 PAOTIAR «wiv 515m #5000 300 # 99 § 005 4.97%) 4 B00 8 W005 BUN # 470 8 00% 5 G58 $900 BPI 8 7,163 3,047 2,618 43 37 GROTBIA +o 5a a B30 405 9607 ¢ 40 2 00% 0 § R04 8 B04 #000 # wie 8.90% $00 3 4,665 1,583 1,421 34 30 BHAWAN © « wv en chi lis 5 ows # Bak 3 0 8 8 4 oh WLR 9 NIL BIE 0 WE 759 522 460 69 61 VOBIG wie «vi v0 co mins swims 4 cos #5 mr ces» cw & inl § mode 3 ik 3 00 8.00 5 B00 $000k Ai 751 369 327 49 44 VIIIIOUS. » 4 vie + 5 swine wr sna: o wins mie 0 ims 0 amas # wn 0 00 & 0008 X00 wich miowcn wi 11,212 6,568 5,573 59 50 Le LTV TY 5,283 2,399 2,104 45 40 VOWE io vsinsom spin dis wit £50 8 050 5 00 0 000 00% 8 3 6 300% 30% 4 00 6 winin wim 0 2,882 1,561 1,320 54 46 HCAIVEAS: ; wiv v is 4 50 0 Wik 4 ATR @ 00 ¥ 90 8 HEU 9 WI 400 UW 6 F808 WIN WI IE 6 wi ¥ 2,227 1,093 947 49 43 KeNMICKY . «ons in se pd i Bs Sa EDR AAP SVR N SES SS RS VR ERB ETRE» 3,268 1,310 1,176 40 36 LOUIBIANA. + wa vow 4 atv ioe 8 hi 6 ie 3 ak BEE BH BE LAW FRE SERA PRS HEB 3,685 1,452 1,296 39 35 Maine. svete iiieite ts ineeesesennseneseosnsesnenssnsssnnns 1,017 419 351 41 35 IBPYABING 0 5 aw 00 0 000 3 1070 0 050 4 10mm pgs mumsy wins = wasn win & seins mi» win» win 3,995 1,829 1,671 46 42 MaSEACHUSEILS. + 5iv 3 54 5 906 5 50 & 050 8 wi 50% 418: 4 00 8 WIR #900 4 00 4 BT 6 Ww 20w 5,766 3,598 3,147 62 55 MUCHIZAN 5 50 oma smi 6 95 5 Wik 8 050 $0 £ 470 5 910 3 E10 § B40 © 008 00% § 45% ioe #0 9,067 4,939 4,396 54 48 IINNCEOTA. 5 vio a 5 0 om 0 50 4 2300 3.300 00 6 S06 § 956 4 1008 4 00.8 14 $709 % 4) # iors #00 3,893 2,670 2,290 69 59 MISSISSIDDI «vo vv emmrvsr oss s a Fabs pF saw aN ABR Erm EMRE Ew 2,240 688 613 31 27 VUISSOUIEE «iv vik wit 4 0.000 3008 01% 4 950 8 00 8 950 § 46 § 1000 WIWHK #50 6 Wn 8 400 4 00) 8 wil 4,724 2,397 2,023 51 43 MONTANA «ott vee ti ee eteensnenseoneosonnsesnesnnansnns 713 363 315 51 44 INCDPASKE, + «vv vos ecw 0 min # wins wow oie 4 ce # wd $61 6 Wid § 300 8 2300 8 $6 ¢ $18 # $9 1,513 975 822 64 54 NEVA .5 4 vos wi 3 T0300 8 979 # WHE 3 UK 4 WI § HW BK Rie e BUR XK BEE Bw 8 856 4 958 519 239 223 46 43 INOW HEIDSNIIE 5. » win + 5000 770 2 07% 2 900 3 370 & 300 wwe win «wre 3 wow w win» wom own 767 358 314 47 41 NEW Jersey ....vitirvnrrinnrinesrensvsonesenssrasesannsen 7,320 4,700 4,102 64 56 NEW MEXICO. «vv teens tne ernussensasoessonesonnsesneennnos 1,050 412 372 39 35 WOW YORK 5iv ¢ min 5 00 3 9% 5 9:0 9.050 8 900 8 105% 31000 490 JE 3.950; # os 4 wie» wm: wwe 18,338 14,722 12,537 80 68 North Carolina. css smn svssimssvs ves vs ons ums wnswn sm swe sws 5,121 1,735 1,527 34 30 NOPLth Dako: ss suv rs mr sm as 38908358 PHEW § TF « 3 § Bin SE ww y eos 620 278 233 45 38 ONTO iis wis mn di oh A BHF HF 3H 45 4 0 § BIE © B00 § IW 90 51008 SW 6 BN: » 10,768 5,152 4,479 48 42 ORIANOMNT: viv 2 os 2H 60M d ww 45 0 4 80 4 000 § 60 § iw & 0 3 B76 BISHE S00 $81 % 6 & 2,607 1,079 960 41 37 OVROM vv.» wie: » couch cms 8 0 3 5005 4 000 6 180 8 0 8 700 Bile #7050 § Wk 7000 AO WIRE Bi # 2,179 1,603 1,415 74 65 PORNSYIVAIIR «cco vin + wn vain 000 0 vi 8 0in 0 0k 5 Wk § Wi 8 006 BWR BWR 0004 0 11,915 7,172 6,070 60 51 Rhode Island .....ciivviiiiinnienertennssnnersnnreneesnns 937 493 419 53 45 South Carolina. ..c.vuuve i vrsnnsssenresnrvncnsvennesnnsons 2,597 759 684 29 26 SOUTH DIAROIE + + viv s ww 1 00 + rw «win 3 050 5 950 4 win 4 von wim www 6 ime w win + wim 673 275 229 41 34 TOIIIIEEBOC 4 svn + wiv + 010 § $0 4 50 5 48 4 94 & 458 4 0 6 F008 JW 8 Hw # iw 8 iw wi 4,013 1,640 1,490 41 37 TOXAB sw win sss vue FRSA FHI RTS HAT HEF GBPS OT STW GH ME su 11,496 4,850 4,407 42 38 UBaN, sv isva vais Pos ans ums mm 8 DEI WRI HEEL 5 Wb MME TNs Bs HR sows 1,1 661 595 59 53 See footnotes at end of table. 194 Table C6. NUMBER OF CIVILIAN DENTISTS AND DENTIST/POPULATION RATIOS, BY STATE: DECEMBER 31, 1972—Continued Number of civilian Rate per 100,000 Civilian : ; Stale population dentists population July 1,1972 (in 1,000’) Total Active Total Active VEIIIONE «svn evrensenssmsspitussassnssnsssrssraervennse 462 198 176 43 38 VIFGINIA + vv vvve sense nanessnsssanassnsasssensessnnsnnnns 4,604 2,020 1,827 44 40 Washington. «vv ven evnernennnnseasuoenseoesosansnenonnns 3,406 2,219 1,990 65 58 West Virginia «.vovvvnrireraruinesesnctsastssscsesnsnsrsns 1,780 710 611 40 34 WISCONSHT + 5s 6 is 20/5 8 0 600 4 4X2 Hb v wn wud wins whens Bin shie sues 4,518 2,602 2,223 58 49 WYOMING + cvvvevnreornnesnnsnssnassinssssssassssansnnans 341 175 156 51 46 Source: Civilian dentists: BHRD, Division of Dental Health. Population: Bureau of the Census. Current Population Reports. P-25, No. 488. Note: State population figures may not add to United States due to independent rounding. 195 Table C7. NUMBER OF ACTIVE PHARMACISTS, BY SEX AND BY AGE GROUP: DECEMBER 31, 1971 Number of p : ercent Sex and age group ACUVe | distribution pharmacists BOLH SBX@S cv 4 vv vive & mix vivre win 130,740 100.0 MAIR cs: iv: 4.055 2.00 3m aimiw aiuid 2.08 S300 000 118,020 90.3 Fema... . vv vioie 3i0ie bins 20s 550 wind win 12,730 9.7 All ages ....oovvvvennnnnnns 130,740 100.0 Less than 25. years «. vei vw ec ven vive wine 3,960 3.0 D549 VRAIS: 4, wis wiv # iw Riv 4 45% ¥ wi + 41% 81,500 62.3 25529, un win x wim 2 wm 0 wie PIE We 8 21,830 16.7 BO-39, iis ww 5 win 5 ww Wik 6 EE 8 BE we 31,790 24.3 BORD ovo vini wns vis ww wn 3 wie & wa 27,880 21.3 50-64 years vu cansansnwrvmsinnns 33,790 25.8 50:59" 1c win o wok 4 0h + 0k 3 Bik 3 whi HS 22,240 17.0 60-64... cities 11,550 8.8 65yearsand OVer .......oveeeeeens 11,490 8.8 053-69 ois uns vn sun sus vam wn ws 5,940 4.5 F074. sv vivir wiv 5 00 3 ww yw swim 499 3,360 2.6 TSANG OVEL: ; ov + 516 s.5i0 winis dinis sin 2,180 1.37 Source: National Association of Boards of Pharmacy. 1972 Proceedings. Licensure and Census of Pharmacy. Chicago, The Association, 1973. Note: Figures may not add to totals and subtotals due to inde- pendent rounding. 196 Table C8. NUMBER OF ACTIVE PHARMACISTS, BY TYPE OF EMPLOYER: DECEMBER 31, 1971 Number of Type of employer active Percent + distribution pharmacists Al LYS. wns wns ems wmaenny rn 130,740 100.0 Community pharmacy owner or PAFINBL. vss vat svinmes wwe ime 45,720 35.0 Community pharmacy employee. ... 61,640 47.1 Hospital pharmacy ........... aie 12,970 9.8 Manufacturing and wholesale. ...... 5,080 3.9 Teaching, government, and other. ... 5,340 4.1 Source: National Association of Boards of Pharmacy. 1972 Proceedings. Licensure Statistics and Census of Pharmacy. Chicago, The Association, 1973. Note: Figures may not add to totals due to independent round- ing. 197 Table C9. NUMBER OF FULL- AND PART-TIME EMPLOYEES AND BUDGETED VACANCIES IN SELECTED CATEGORIES OF PERSONNEL IN COMMUNITY HOSPITALS IN THE UNITED STATES, BY GEOGRAPHIC REGION: 1973 United States Northeast North Central South West Total Total Total Total Total Total full-time Total full-time Total full-time Total full-time Total full-time Occupational full-time and full-time and full-time and full-time and full-time and category and part-time and part-time and part-time and part-time and part-time part-time | budgeted | Part-time | pudgeted | Part-time | pudgeted | Part-time | pudgeted | Part-time | budgeted employees | positions | employees | positions [employees | positions | employees | positions [employees | positions vacant vacant vacant vacant vacant Total hospital personnel ......... .. 2,350,664 73,524 645,310 16,512 686,398 18,260 670,554 26,563 348,402 12,189 Total selected categories ........... 535,794 21,620 113,675 4,879 167,349 5,891 175,633 8,007 79,137 2,843 Clinical laboratory echt i 1ECHNOIOGISES wvisiv vn sv sv viviminivin so 46,644 2,201 11,436 439 13,881 661 11,854 927 9,473 174 Cytotechnologists and cytotechnicians 2,234 163 797 49 521 37 683 61 233 16 Histologic technicians and aides. ..... 5,739 194 1,641 31 1,530 29 1,719 95 849 39 DICLIIANS + + + cocvivivimins # & & simwmnis » 9,377 479 2,350 109 2,991 142 2,485 180 1,551 48 Dietary technicians «.....ovvmvrsss 16,102 355 3,921 49 4,430 49 5,589 178 2,162 79 Medical record librarians {AdmInIStrators) «.o.vam « s suman s + 5,267 353 981 43 1,517 97 1,805 150 964 63 Medical record technicians. ......... 14,565 444 3,082 100 4,526 76 4,674 191 2,283 77 Aides, orderlies and attendants ...... 352,825 13,17 69,375 3,249 113,509 3,687 122,302 4,606 47,639 1,629 X-ray technologists and technicians . . . 36,819 1,466 10,248 363 10,020 292 11,051 594 5,500 217 Occupational therapists ............ 1,972 248 437 70 686 77 378 64 47 37 Occupational therapy assistants AN AIRS 4 « « vmmivieva s 8 v sre 1,577 89 237 4 714 25 310 29 316 31 Physical therapists ................. 7,978 694 2,164 98 2,445 203 1,707 263 1,662 130 Physical therapy assistants and aides . . 8,146 32 1,513 22 2,969 76 2,561 134 1,103 90 Inhalation therapists and aides. ...... 26,549 1,441 5,493 253 7,610 440 8,515 535 4,931 213 Source: U.S. Department of Health, Education, and Welfare; Public Health Service; Health Resources Administration; Bureau of Health Resources Development; Division of Manpower Intelligence. Survey of Selected Hospital Manpower February 1973. A Preliminary Report. 198 Table C10. ESTIMATED SUPPLY OF SELECTED CATEGORIES OF PUBLIC AND COMMUNITY HEALTH PERSONNEL: 1970, 1971 Supply with masters level Supply 1971 Category PPIY training or higher 1970 Total ovoivsimsnivs vivsnrs Hkh + Tks iE 4 Wk owe . 95,600 19,757 Environmental health, total ..... TT % 4 0% 8 Wie 15,000 2,200 State & local governments ....... 48 WH ge 12,000 NA Food manufacturers... swevss vi smssmsns ve 3,000 NA ‘Epidemiology .......iiiiiiiiinnnn. v iyoy gies 9 1,000 1,000 Health education .......covviiiiinnnnnen nnn 2,000 2,000 Health services administration, total ............. 2 48,000 8,500 Public health administration.................. 5,000 NA Hospital administration ....:.......... Fane 17,000 NA Nursing home administration ............. ah 16,000 NA Voluntary health agencies ............... oh 10,000 NA Health statistics ........ 2 this anes ete where Yas yan 3 1,100 11,100 Maternal health, family planning, and child health. ... 800 800 Mental health......... 40 ER # PE WS Ne 200 200 Public health dentistry ....... & SH FT GE GE Se 300 300 Public health nursing .............. NP 26,000 29,457 Public health nutrition. ...... 3s Sess ladon Hoel wanwhiins b 1,000 1,000 Public health veterinary medicine ......... Corns 200 200 ! Data are for 1971. 2 Data are for 1968. Source: 1971 total supply: Environmental health: U.S. Department of Labor. Occupational Outlook Handbook. 1972-73 edition. Sta- tistics Bulletin No. 1700. Epidemiology: estimates from American Epidemiological Society. Health education: American Public Health Association. Health services administration, health statistics: National Center for Health Statistics. Health Resources Sta- tistics. Health Manpower and Health Facilities, 1971. DHEW Pub. No. (HSM) 72-1509. U.S. Government Printing Office, 1972. Maternal health, family planning, and child health; mental health; public health dentistry; and public health veterinary medicine: Task Force on Professional Health Manpower for Community Health Programs, 1973 Report. Public health nursing: estimate based on projection of January 1967 data from Third National Conference on Public Health Training. Public health nutrition: Pennell, Maryland Y. and Hoover, David B. Health Manpower Source Book 21. Allled Health Manpower Supply and Requirements: 1959-80. Public Health Service Pub. No. 263, Section 21. 1970 supply with masters level training or higher: Task Force on Professional Health Manpower for Community Health Programs, 1973 Report. 199 Table C11. DISTRIBUTION OF ACTIVE OPTOMETRISTS, BY SEX AND BY AGE GROUP: 1973 Percent distribution Both sexes Male Female All ages Less than 30 years 30 - 44 years 30-34 35-39 40-44 45 - 64 years 45-49 50-54 55-59 60-64 65 years and over 65-69 70 and over 100.0 97.8 2.2 100.0 11.3 26.7 8.7 6.8 11.2 553 18.8 18.4 12.0 6.2 6.7 3.3 3:3 Source: Preliminary data from the National Census of Optometric Manpower Resources conducted by the American Optometric Association under contract with BHRD. Note: Percents may not add to totals and subtotals due to independent rounding. 200 Table C12. DISTRIBUTION OF ACTIVE OPTOMETRISTS, BY PRINCIPAL FORM OF EMPLOYMENT: 1973 Principal form of employment Percent distribution All active optometrists vow mow Www 100.0 Self-empioyed Vor Be Bw be 80.2 Solo practice Bok Homo homme a ww 64.2 Partnership sw hl wer a la ld wn we a 13.4 Group practice ~~. . . . . Cee ee 2.6 Employed PR MN EW EEE EW gw 19.8 Professional corporatio EFA 4.3 Federal Government (Armed forces, PHS) 2.6 Federal Government (other) . . . . . . . 0.2 State and local government Pom a ww 0.2 Otheroptometrist . . . + + + v « 5 = « 5.8 Ophthalmologist . . . . . . .. . ... 0.8 Other physician . . . . . . ook RB mow ow 0.1 Firm or manufacturer Cee ee ee 2.32 Nonprofit organization/institution y vom 20 Multidisciplinary group practice vw NW 1.0 Other SEE EE EE EEE EEE 0.5 Source: Preliminary data from the National Census of Optometric Manpower Resources conducted by the American Optometric Association under contract with BHRD. Note: Percents may not add to totals and subtotals due to independent rounding. 201 565-118 O - 74 - 14 Appendix D BIBLIOGRAPHY Page i. GRAAL & x « w+ v2 t+ 2 dow BE om won 205 i. Medicine . « « + 5 + « + + = & 3» = % » 208 il. Dentistry . . « & 5 4 2 + + + % « = % » 212 IV. Optometry . . . . . « +. « + + « + » 214 V. Pharmacy . . . . . . 215 VI. Podiatry . . . . . . . . 217 VII. Veterinary Medicine . . . . . . . . . .. 218 VHL Nursing . . . . «5 «+ 2 a + 4 0s vv» 219 IX. AlliedHealth ~~ . . . . .. . ...... 221 203 I. GENERAL™ Coale, A. J. and Demeny, P. Regional Model Life Tables and Stable Populations, Princeton, N.J.: Princeton Uni- versity Press, 1966. Presents statistical data on life expectancy by age group. Fullerton, Howard N. A Table of Expected Working Life for Men, 1968. Monthly Labor Review, Vol. 94, No. A, pp. 49-55, June 1971. Contains 1968 longevity estimates, and death and retirement rates for U.S. male workers at various ages, with explanation of methodology used to derive estimates and rates. Kaplan, David L., and Casey, M. Claire. Occupational Trends in the United States, 1900 to 1950. Bureau of Census Working Paper No. 5. Washington, D.C.: U.S. Department of Commerce, 1958. Presents statistical and other data on trends in various occupa- tions in the U.S. over a 50-year period. National Advisory Commission on Health Manpower. Re- port to the President. Washington, D.C.: U.S. Government Printing Office, 1967. Report consists of two parts. Part | covers supply, education, and needs in health manpower and health care systems, together with recommendations for improvement and change. Part Il consists of extensive, original reports of seven member panels: Consumer; Education and Supply; Federal Use of Health Manpower; Foreign Medical Graduates; Hospital Care; New Technologies; and Organization of Health Services. National Commission on Community Health Services. Health Manpower: Action to Meet Community Needs, Washington, D.C.: Public Affairs Press, 1967. Report of Task Force on Health Manpower, to National Commission on Community Health Services. Basic project (financed jointly by U.S. Public Health Service, Vocational Rehabilitation Administration, Commonwealth Fund, Kellogg Foundation, McGregor Foundation, and New York Foundation) studied community health needs, issues, and resources, Made recommendations to ‘‘achieve effective mobilization of the key resource of health manpower.” Task Force on Professional Health Manpower for Com- munity Health Programs. (Thomas H. Hall, Coordinator.) * In General Sources, “U.S. Government Printing Office” will be spelled out. After that, citation will be abbreviated to “U.S. GPO.” 205 Professional Health Manpower for Community Health Programs, 1973, Chapel Hill, N.C.: University of North Carolina, School of Public Health, Department of Health Administration, 1973. Contains descriptive material on schools of public health (enrollment, graduates, programs, student characteristics, etc.); discusses emerging Federal policies in health re. community health manpower; presents data on present situation and future perspectives for selected categories of community health man- power; presents data on sources and methods." U.S. Bureau of the Census. Current Population Reports. Population Estimates and Projections. Series P-25. Wash- ington, D.C.: U.S. Department of Commerce. (Seriatim.) Presents varying types of statistical data (including projections), on selected U.S. population by State, region, etc., based on Census reports, interpolations of Census data, surveys, etc. Reports issued as numbered separates in Series P-25, U.S. Bureau of the Census. Statistical Abstract of the United States, 1966. Washington, D.C.: U.S. Government Printing Office, 1966. (Also prior and later years.) Presents pertinent summary statistics on the U.S., based on Census data. Includes data on specific health occupations. U.S. Bureau of the Census. U.S, Census of Population: 1960. Detailed Characteristics. U.S. Summary. Final Report PC(1)-1D. Washington, D.C.: U.S. Government Printing Office, 1963. Detailed characteristics of U.S. population, based on 1960 Census—data on families, fertility, migration, employment, income, occupation, etc. (Similar summary for 1970 Census of Population: Final Report PC(1)-D1,1973.) U.S. Department of Health, Education, and Welfare; Office of Education; National Center for Educational Statistics. Projections of Educational Statistics to 1980-81, 1971 Edition. DHEW Pub. No. (OE) 72-99. Washington, D.C.: U.S. Government Printing Office, 1972. (Also prior annual issues.) ~ Contains statistical data on enrollments, graduates, earned degrees, teachers, and expenditures for elementary and second- ary schools and institutions of higher learning. Provides projec- tions of statistics to 1980-81 for such schools, and appends description of methodology. U.S. Department of Health, Education, and Welfare; Public Health Service. Health Manpower Source Book. PHS Pub. No. 263, Manpower in the 1960’s, Section 18 (1964); Location of Manpower in 8 Occupations, Section 19 (1965); Manpower Supply and Educational Statistics for Selected Health Occupations: 1968, Section 20 (1969); Nursing Personnel, Section 2 (Revised 1969); Allied Health Manpower, 1950-80, Section 21 (1970). Washington, D.C.: U.S. Government Printing Office. Contains historical and other data (including some projections) on manpower supply and educational statistics for selected health occupations: medicine, osteopathy, dentistry, optometry, podiatry, pharmacy, veterinary medicine, nursing, allied health, and others. (See also specific references below under pertinent health occupations.) U.S. Department of Health, Education, and Welfare; Public Health Service. Third National Conference on Public Health Training: August 16-18, 1967. Report to the Surgeon General. PHS Pub. No. 1728. Washington, D.C.: U.S. Government Printing Office, 1967. Presents summary data on conference, together with recom- mendations on modification of existing legislation re. trained public health personnel and the Nation’s public health services. U.S. Department of Health, Education, and Welfare; Public Health Service; National Center for Health Statistics. State Licensing of Health Occupations. DHEW Pub. No. 1758. Washington, D.C.: U.S. Government Printing Office, 1968. Discusses provisions of State licensure laws relating to health occupations in various States as of 1966, with presentation of licensure statistics. Includes discussion of composition, powers, and duties of State licensing boards, together with objectives of licensing policies and practices. U.S. Department of Health, Education, and Welfare; Public Health Service; National Center for Health Statistics. Vital and Health Statistics, Series 14: Data on National Health Resources. Washington, D.C.: U.S. Government Printing Office, beginning as PHS Pub. No. 1000 (1968) and continuing up to the present as DHEW Pub. No. (HSM) 1800s. Contains data from surveys and studies conducted by National Center for Health Statistics and published in its Vital and Health Statistics Series. Series 14 presents statistics on selected demo- graphic and professional characteristics of various health man- power occupations. U.S. Department of Health, Education, and Welfare; Public Health Service; National Institutes of Health. Health Profes- sions Capitation Grants, FY 72. DHEW Pub. No. (NIH) 73-460. Washington, D.C.: U.S. Government Printing Of- fice, 1973. Presents statistical data on first year of capitation grants program, based on grant applications submitted by health professions schools in FY 72, 206 U.S. Department of Labor, Bureau of Labor Statistics. Occupational Outlook Handbook, 1972-73 Edition. Bul- letin No. 1700. Washington, D.C.: U.S. Government Print- ing Office, 1973. (Also prior and later biennial issues.) Presents current data on outlook for employment, etc. in the U.S. by occupations, including health occupations. U.S. Department of Health, Education, and Welfare; Public Health Service; Bureau of Health Manpower. Health Man- power Perspective: 1967. PHS Pub. No. 1667. Washington, D.C.: U.S. Government Printing Office, 1968. Brings together significant information on supply and needs for health manpower, education and training for health services, and Federal aid. Makes estimates to 1975 for developments in health occupations: employment, admissions, enrollments, and grad- uates in health professions schools, etc. U.S. Department of Health, Education, and Welfare; Public Health Service; Health Resources Administration; Bureau of Health Resources Development. How Health Professions Students Finance Their Education. DHEW Pub. No. (HRA) 74-13. Washington, D.C.: U.S. Government Printing Office, 1973. Presents results of survey to determine how students of medicine, osteopathy, dentistry, optometry, pharmacy, podia- try, and veterinary medicine financed their education during 1970-71 school year. U.S. Department of Health, Education, and Welfare; Public Health Services; Health Resources Administration; Bureau of Health Resources Development. Survey of Selected Hospital Manpower, February 1973: A Preliminary Re- port, Washington, D.C. Survey of full-time and part-time employees, and budgeted positions vacant in community hospitals, 1973, in the United States and regions, by selected categories of personnel. U.S. Department of Health, Education, and Welfare; Public Health Service; Health Services and Mental Health Admin- istration. Report on Licensure and Related Health Person- nel Credentialing. DHEW Pub. No. (HSM) 72-11. Wash- ington, D.C.: U.S. Government Printing Office, 1971. Identifies major problems associated with licensure, certification, and other requirements for practice or employment of health personnel (including group activities), along with recommenda- tions by Secretary of Health, Education, and Welfare for steps toward solution of problems so identified. U.S. Department of Health, Education, and Welfare; Public Health Service; National Center for Health Statistics. Comparison of Two Methods of Constructing Abridged Life Tables by Reference to a ‘Standard’ Table. Vital and Health Statistics. Data Evaluation and Methods Research. Series 2, No. 4. Washington, D.C.: U.S. Government Printing Office, 1966. Presents comparative methods for constructing abridged life tables. U.S. Department of Health, Education, and Welfare; Public Health Service; Health Resources Administration; National Center for Health Statistics. Life Tables. Vital Statistics of the United States, Vol. Il, Section 5. DHEW Pub. No. (HRA) 74-1147. Rockville, Md.: NCHS, 1971. (Also prior annual issues.) Presents current data on life tables, and methodology for construction of such tables. 207 U.S. Department of Health, Education, and Welfare; Public Health Service; Health Services and Mental Health Admin- istration; National Center for Health Statistics. Health Resources Statistics. Health Manpower and Health Fa- cilities. 1972-73. DHEW Pub. No. (HSM) 73-1509. Wash- ington, D.C.: U.S. Government Printing Office, 1973. (Also prior editions.) Presents current data on education, licensure, accreditation and certification, association membership, activity status, etc., for all health occupations. Also presents current data on health facilities and health services. Original edition published for 1965. Il. MEDICINE (M.D.’s, D.O.’s, and Foreign Medical Graduates) American Medical Association. Directory of Approved .. Internships and Residencies, 1971-72. Chicago: The As- sociation, 1971. (Also prior and later issues.) Listing of approved residencies and internships by name of institution, location, specialty, etc. Includes summary tables, special studies, requirements for certification by specialty boards, etc. American Medical Association. Distribution of Physicians in the U.S., 1972. Chicago: The Association, 1973. (Also prior annual editions.) Detailed information on physicians in U.S. in 1972, including major professional activity and specialty. Data shown for non-Federal physicians, for geographic divisions and States. Some data for counties and SMSA’s, American Medical Association, Center for Health Services Research and Development. Profile of Medical Practice. Chicago, lll.: The Association, 1971, 1972, 1973 editions. Contains annual data on physicians by age, specialty, activity, income, hours of work, productivity, etc. Also contains limited analysis, bibliography of source data, and recent publications pertaining to physician manpower issues. American Medical Association, Council on Medical Educa- tion. Medical Education in the United States, 1972-73. Chicago: The Association, 1973. (Also prior annual issues.) Annual data on enrollment, graduates, internships, and resi- dencies, with information on new medical schools. Also includes synopses of recent studies on medical education. (Education issue of The Journal of the American Medical Association (JAMA) published annually in November. Reprinted as a separate above, with addition of statistical appendices.) American Medical Association, Council on Medical Educa- tion. Medical Licensure Statistics for 1972. Chicago: The Association, September 1, 1973. (Also prior annual issues.) Statistical review of National and State Board examinations, Fed- eral licensing examination, and Educational Council for Foreign Medical Graduates results, for M.D.’s and D.O.’s, by State, with description of State laws affecting licensure of physicians. (Licen- sure issue of JAMA published annually in June. Reprinted as a separate, above, with addition of statistical appendices.) American Osteopathic Association. A Statistical Study of the Osteopathic Profession, December 31, 1967. Chicago: The Association, 1968. Contains statistics for 1967 on State of practice, activity, and specialty of D.O.’s. 208 American Osteopathic Association, Office of Education. Educational Supplement, January 1971. Chicago: The Association, 1971. (Also prior and later annual issues.) Contains statistics on enrollment, etc. in osteopathic schools. Association of American Medical Colleges. Datagrams and Communications. Washington, D.C.: The Association. (Issued periodically.) Provide current descriptive statistics on applicants and students, and articles on pertinent issues such as “How Medical School Characteristics Affect Location of Physician Practice.” (Re- printed from Journal of Medical Education.) Blumberg, Mark S. Accelerated Programs of Medical Educa- tion. Journal of Medical Education. Vol. 46, No. 6, pp. 643-651, August 1971. Defines and discusses nature of accelerated medical school programs, and compares it with that of conventional programs. Blumberg, Mark S. Trends and Projections of Physicians in the United States, 1967-2002. Berkeley, Calif.: Carnegie Commission on Higher Education, 1971. In depth analysis of trends in total supply of physicians, and projections of supply to 2002, with description of projection methodology. Butter, Irene. Health Manpower Research: A Survey. Inquiry. Vol. IV, No. 4, pp. 5-41, December 1967. Presents results of survey of growth, diversification, and distribu- tion of health manpower over period of years in order to develop framework for health manpower research. Butter, Irene. The Migratory Flow of Doctors to and from the United States. Medical Care, Vol. IX, No. 1, pp. 17-31, January-February 1971. Estimates, based on American Medical Association data, of outflow and inflow of foreign-trained physicians in the U.S. between 1966 and 1968. Discusses migration patterns, and suggests possibility that many foreign doctors migrate several times. Crowley, A. E. and Nicholson, H. C. Negro Enrollment in Medical Schools. JAMA, Vol. 210, No. 1, pp. 96-100. October 6, 1969. Historical and current (1968-69) data on Negro medical school enrollment and graduates. Includes data on analytical studies, State of education, public vs. private institutions, background of students, recruitment, etc. Datagram: Comparison of Patterns of Financing for Private and Public Medical Schools. Journal of Medical Education, Vol. 47, No. 7, pp. 579-583, July 1972. Presents financial data on public and private medical schools: income, expenditures, etc. Datagram: Federal Support of Medical School Activities, 1950-1971. Journal of Medical Education, Vol. 46, No. 10, pp. 906-909, October 1971. History of Federal support to medical schools through institu- tional grants, student scholarships, student loans, construction grants, etc., 1950-1971. Dickinson, F. G. and Martin, L. W. Physician Mortality, 7949-71951. Bulletin 103, American Medical Association, Chicago: The Association, 1956. Presents results of study on physician mortality rates over a 2-year period. Includes data on causes of death, life-expectancy, working-life expectancy, and comparisons with white males of same ages. Dove, D. B. Minority Enrollment in U.S. Medical Schools, 1969-70, Compared to 1968-69. Journal of Medical Educa- tion, Vol. 45, pp. 179-181, March 1970. Presents figures on black, female, American Indian, Mexican- American, Oriental, Puerto Rican, and other minority medical students, 1968-70. (Journal presents minority data annually.) Dubé, W. F. U.S. Medical Student Enrollments, 1968-69 through 1972-73. Journal of Medical Education, Vol. 48, No. 3, pp. 293-297, March 1973. Presents statistical data on medical school enrollments for a 5-year period, through 1972-73. Dublin, L. I. and Spiegelman, M. The Longevity and Mortality of American Physicians, 1938-1942. JAMA, Vol. 134, No. 15, pp. 1211-1215, August 9, 1947. Presents statistics on life expectancy and mortality among U.S. physicians over a 4-year period. Dublin, T. D. The Migration of Physicians to the United States. The New England Journal of Medicine, Vol. 286, No. 16, pp. 870-877, April 20, 1972. Discusses immigration of foreign medical graduates to the U.S., by visa status, with reasons for the migration patterns. Also discusses problems inherent in present methods of data collec- tion. Ellingson, H. V. Training in Aerospace Medicine. Aerospace Medicine, Vol. 39, No. 9-Sect. Il, pp. 1-28, September 1968. Presents data on education and training in aerospace medicine. Report of conference held in Columbus, Ohio, September 1967, sponsored jointly by American College of Preventive Medicine, Aerospace Medical Association, and Ohio State University. 209 Emerson, H. and Hughes, H. E. Death Rates of Male White Physicians in the United States by Age and Cause. American Journal of Public Health, Vol. 16, No. 11, pp. 1088-1093, November 1926. Presents results of study of white physician mortality in the U.S. Fein, Rashi. The Doctor Shortage: An Economic Diagnosis. Washington, D.C.: The Brookings Institution, 1967. First in series, “Studies in Social Economics,” concerned with health, education, social security and welfare, supported in part by DHEW funds. Assesses ‘‘doctor shortage,” projects future demand for and supply of physician services; and discusses ways of meeting problems. Haug, J. N., and Martin, B. C. Foreign Medical Graduates in the United States, 1970. Chicago: American Medical Association, 1971. Data on foreign medical graduates practicing in U.S., by country of graduation, age, sex, specialty, activity, State of practice, and other descriptive criteria. Contains narrative description and bibliography. Haynes, M. A. Distribution of Black Physicians in the United States, 1967. JAMA, Vol. 210, No. 1, pp. 93-95, October 1969. Current and historical data on Negro physicians in the United States by type of practice, State, specialty, etc. Institute of International Education. Open Doors, 1970. Report on International Exchange. New York: The In- stitute, 1970. Presents statistical data on enrollment of Americans in schools (including medical schools), outside the United States. Kabara, Jon J. The Spiral Curriculum: Model for Health Science Educational Programs. The D.O., Vol. 12, No. 11, pp. 105-108, July 1972. Discusses recent developments and changes in osteopathic curriculum as model for other health science programs. Kabara, Jon J. and Jacobson, Lawrence E. The Spiral Curriculum: For Training Osteopathic Physicians. The D.O., Vol. 12, No. 11, pp. 93-101, July 1972. Analyzes current status of training for osteopathic physicians; presents data on recent developments in curriculum modifica- tions. King, Haitung. Health in the Medical and Other Learned Professions. Journal of Chronic Diseases. Vol. 23, No. 4, pp. 257-281, April 1970. Presents data on physician health and mortality in Great Britain and other countries; also data on other professions. Koehler, John E. and Slighton, Robert L. Activity Analysis and Cost Analysis in Medical Schools. Santa Monica, Calif.: The Rand Corporation, July 1972. Cost analysis study prepared by Rand Corporation, under contract, jointly for National Institutes of Health and the Department of Health, Education, and Welfare. Koehler, John E. and Williams, Albert P., Jr. Economic Implications of Changes in Financing Medical Education. Santa Monica, Calif.: The Rand Corporation, December 1973. Paper (19 pp.) prepared by Rand Corporation for staff use. Evaluates impact of sources of financing of medical education on growth of medical schools, particularly Federal financial sup- port. Kozlow, Doris A. (Ed.). The NDTI Specialty Profile. National Disease and Therapeutic Index. Ambler, Pa.: Lea, Inc. (now IMS America), 1972. Published every two years. Provides profile of physicians in private practice in U.S. in terms of specialty. Li, F. P. Working-Life Span of Physicians. JAMA, Vol. 206, No. 6, p. 1308, November 4, 1968. Letter to Editor on life-expectancy of physicians at any age as compared with that of U.S. males at same age. Working-life expectancy and expected length of retirement also compared. Margulies, Harold and Bloch, Lucille S. Foreign Medical Graduates in the United States. Cambridge, Mass.: Harvard University Press, 1969. Full discussion of supply and distribution of foreign medical graduates in the U.S. Covers both foreign and U.S. born M.D.’s. Mason, Henry R. A Profile of 314 Americans Graduating from Foreign Medical Schools. JAMA, Vol. 209, No. 8, pp. 1196-1199, August 25, 1969. Presents data on Americans graduated from foreign medical schools, including data on course completion and credentialing. Mason, Henry R. Foreign Medical Schools: Organization and Expenditures in 13 Schools Attended by More than 2,000 U.S. Students. JAMA, Vol. 217, No. 13, pp. 1845-1846, September 27, 1971. Financial data on foreign medical schools in terms of basic science departments, and comparison with similar financial data in U.S. schools. Mason, Henry R. Foreign Medical Schools as a Resource for Americans. Journal of the National Association of College Administrative Counselors. Vol. 5, No. 3, pp. 16-20, November 1970. Presents data on enrollment of Americans in medical schools outside the United States. 210 Mason, Henry R. Manpower Needs by Specialty. JAMA, Vol. 219, No. 12, pp. 1621-1626, March 20, 1972. Presents data, by medical specialty, on health manpower needs. Pennell, Maryland Y. Statistics on Physicians, 1950-63. Public Health Reports, Vol. 79, No. 10, pp. 905-910, October 1964. Article reviews history of American Medical Association’s data base of M.D. population, and discusses changes in coverage and definition made in early 1960's. Pennell, M. Y. and Renshaw, J. E. Distribution of Women Physicians, 1969. Journal of American Medical Women's Association, Vol. 26, No. 4, pp. 187-190, 1971. . Op. cit., 1970, JAMWA, Vol.27,No.4, pp. 197-203, 1972. Articles include descriptive characteristics of women physicians in the U.S.: by State, professional activity, and primary specialty. Rittenhouse, C. H. and Weiner, S. A Study of the Semi-Annual Admissions System at the University of Tennessee College of Medicine. Menlo Park, Calif.: Stanford Research Institute, March 1971. Presents results of study of impact of shortening curriculum in medical schools. Roback, G. A. Distribution of Physicians in the U.S., 1972. Vol. 1-—Regional, State, County. Vol. 2—Metropolitan Areas. Chicago: American Medical Association, 1973. (Also prior annual issues under varying authorship.) Presents detailed analysis of Federal and non-Federal physician distribution in U.S. as of 1972, together with statistical data on medical specialties and activity; hospitals and hospital beds; resident population and income. Ruhe, C. H. W. Present Projections of Physician Production. JAMA, Vol. 198, No. 10, pp. 168-174, December 5, 1966. Contains projections of physician population to 1975 (from 1965), and compares results to earlier projections. Rusk, H. A.; Diehl, H. S.; Barclay, R. W.; and Kaetzel, P. K. The Work Week of Physicians in Private Practice. The New England Journal of Medicine. Vol. 249, No. 17, pp. 678-681, Oct. 22, 1953. Discussion of physician working patterns in private practice. Smith, Louis C. Remund and Crocker, Anna R. How Medical Students Finance Their Education. PHS Pub. No. 1336-1. Washington, D.C.: U.S. GPO, January 1970. Presents data on medical and osteopathic student financing based on 1967-68 survey conducted by Public Health Service, in cooperation with Association of American Medical Colleges and American Association of Osteopathic Colleges. Smith, Melody A. Minorities and the Health Professions: An Annotated Bibliography. Washington, D.C.: Association of American Medical Colleges, October 1972. Contains annotations on more than 200 publications dealing with minority or disadvantaged groups. Designed as source of information on attitudes, characteristics, and academic and professional aspirations of minority and disadvantaged students seeking to enter the health professions. Stevens, Rosemary. Trends in Medical Specialization in the United States. /nquiry, Vol. VIII, No. 1, pp. 9-19, March 1971. Discusses past and current trends in medical specialization, proliferation of specialties, and need for manpower policy. Notes existing maldistribution of medical specialties, and prospects for the future, based on planning, numerical ceilings, etc. Alterna- tives suggested. Stevens, Rosemary, and Vermeulen, Joan. Foreign Trained Physicians and American Medicine. DHEW Pub. No. (NIH) 73-325. Washington, D.C.: U.S. GPO, June 1972. Presents data on immigration status, licensing, location, profes- sional activity, etc. of foreign trained physicians in U.S.; analyzes data in terms of physician manpower and policy. Stewart, William H. and Pennell, Maryland Y. Health Manpower Source Book 11. Medical School Alumni. PHS Pub. No. 263, Section 11. Washington, D.C.: U.S. GPO, 1961. Describes distribution, type of practice, schools attended, etc. of graduates of U.S. medical schools. Surgeon General’s Consultant Group on Medical Education. Physicians for a Growing America. U.S. Department of Health, Education and Welfare, Public Health Service Pub. No. 709. Washington, D.C.: U.S. GPO, October 1959. Publication known as “Bane Committee’’ Report. Contains history of supply of physicians from 1930, and projections to 1975. Financial aspects of medical school construction and operation, trends in student enrollment, and other variables relating to physician supply also given in historical perspec- tive. Theodore, C. N. and Haug, J. N. (assisted by Martin, B. C.). Selected Characteristics of the Physician Population, 71963 and 1967. Chicago: American Medical Association, 1968. Compares statistical data on selected characteristics of physician population in two given years. 211 Theodore, C. N.; Haug, J. M.; Balfe, B. E.; Roback, G. A.; and Franz, E. J. Reclassification of Physicians, 1968. Chicago: American Medical Association, 1971. Presents data on distribution of physicians, etc., by specialty, for year 1968. Theodore, C. N.; Sutter, G. E.; and Haug, J. N. Medical School Alumni, 1967. Chicago: American Medical Associa- tion, 1968. Describes distribution, type of practice, etc. of medical school alumni. U.S. Comptroller General. Report to the Congress: Program to Increase Graduates from Health Professions Schools and Improve the Quality of Their Education. Washington, D.C.: U.S. General Accounting Office, 1972. Review of programs administered by National Institutes of Health, Department of Health, Education, and Welfare. U.S. Department of Health, Education, and Welfare; Public Health Service; Health Resources Administration; Bureau of Health Resources Development. Medical Specialties: An Annotated Bibliography and Selected Ongoing Studies. DHEW Pub. No. (HRA) 74-10. Washington, D.C.: U.S. GPO, August 1973. Represents a selective listing of recent manpower studies in the major medical specialties, with brief annotations. U.S. Department of Health, Education, and Welfare; Public Health Service; National Institutes of Health; Bureau of Health Manpower Education. The Foreign Medical Grad- uate: A Bibliography. DHEW Pub. No. (NIH) 73-440. Washington, D.C.: U.S. GPO, November 1972. Bibliography, through September 1972, focuses on foreign medical graduates in U.S.: education, training, utilization, inflow and outflow, etc. Weiskotten, H. G.; Wiggins, W. S.; Altenderfer, M. E.; Gooch, M., and Tipner, A. Trends in Medical Practice—An Analysis of the Distribution and Characteristics of Medical School Graduates, 1915-1950. Journal of Medical Educa- tion, Vol. 35, No. 12, pp. 1071-1121, December 1960. Presents results of surveys of graduates of American medical colleges, over a period of selected years from 1915 through 1950. Covers age at graduation, method of practice, type of salaried position, type of practice, specialty, place of practice, graduate training, etc. Williams, S. V.; Munford, R. S.; Colton, T.; Murphy, D. A; and Poskanzer, D. C. Mortality Among Physicians: A Cohort Study. Journal of Chronic Diseases. Vol. 24, No. 6, pp. 393-401, June 1971. Presents results of study of mortality of medical school graduates as compared with that of U.S. white male population. Il. DENTISTRY American Association of Dental Schools. Directory of Dental Educators, 1973-74. Washington, D.C.: The Associa- tion, 1973. Lists dental faculty alphabetically, and by teaching area, schools, etc. Presents summary statistics on dental schools—number of faculty, academic rank, degrees earned, Specialty Board Cer- tification, etc. American Dental Association, Bureau of Data Processing Services. American Dental Directory, 1972. Chicago: The Association, 1972. Alphabetical listing of dentists, by city and State; geographical listing of dentists by type of practice; listing of dental schools, dental organizations and boards. Published since 1947. American Dental Association, Bureau of Economic Re- search and Statistics. Distribution of Dentists in the United States by State, Region, District and County. Chicago: The Association, 1971. (Also prior and later issues.) Contains data on population increase and per capita buying income by county and district, as well as dentist/population ratios. Published yearly since 1953. American Dental Association, Bureau of Economic Re- search and Statistics. Facts About States for the Dentist Seeking a Location, 1970. Chicago: The Association, 1971. (Also prior and later issues.) Gives necessary data on States (population, etc.) for dentists seeking to locate practice. American Dental Association, Bureau of Economic Re- search and Statistics. Facts About the Dental Market, 1971. Chicago: The Association, 1971. Contains dental manpower demographic data (such as number of dentists by region and State), and information on income by State, licensure by State, etc. Published annually. American Dental Association, Bureau of Economic Re- search and Statistics. 1971 Survey of Dental Practice |. Introduction. Journal of the American Dental Association, Vol. 84, No. 1, pp. 172-177, January 1972. 1971 Survey of Dental Practice Il, Income of Dentists by Location, Age and Other Factors. Journal of the American Dental Association, Vol. 84, No. 2, pp. 397-402, February 1972. Surveys primarily concerned with business aspects of dental practice. Part | includes a sample questionnaire used in the survey; Part 11 reports on the 1970 income of dentists by age, location, and mode of employment, e.g., independent and salaried dentists. 212 American Dental Association, Council on Dental Educa- tion. Annual Report on Dental Education, 1973-74. Chi- cago: The Association, 1974. (Also prior annual issues.) Directory of dental schools, including information on specific programs offered, tuition costs, and statistical data on students enrolled the previous year. Published annually since 1939. Until 1966-67, published as Dental Students Register. American Dental Association, Council on Dental Educa- tion. Annual Report on Dental Education, 1973-74. Sup- plement 4. Minority Report. Chicago: The Association, 1974. (Also prior annual issues.) Presents summary data from Annual Survey of Dental Educa- tional Institutions. Earlier annual issues appeared under title “Minority Student Enrollment and Opportunities in U.S. Dental Schools.” American Dental Association. Council on Dental Educa- tion. Dental Students Register, 1966-67. Chicago: The Association, 1967. (Also prior and later annual issues.) Directory of dental schools, including information on specific programs offered, tuition costs, and statistical data on students enrolled the previous year. Published annually since 1939. Name changed after 1966-67 to Annual Report on Dental Education. (See above.) Cole, Roger B., and Cohen, Lois K. Dental Manpower. Estimating Resources and Requirements. Milbank Memorial Fund Quarterly, XLIX, No. 3, Part 2, pp. 29-62, July 1971. Contains history of dentist and dental auxiliary manpower supply and requirements from 1950 to 1970, with information on demographic and income characteristics of dental patients. Also contains projections of supply and requirements to 1980, and bibliography. Douglas, Bruce L.; Wallace, Donald A.; Lerner, Monroe; and Coopersmith, Sylvia B. Impact of Water Fluoridation on Dental Practice and Dental Manpower. Journal of the American Dental Association, Vol. 84, No. 2, pp. 355-367, February 1972. Report contains results of study (using seven matched pairs of mid-Western communities as data source) on effect of fluorida- tion on dentists’ fees, income, treatment methods, and size of patient load. Feldstein, Paul J. Financing Dental Care: An Economic Analysis. Lexington, Massachusetts: D.C. Heath, Lexington Books, 1973. Comprehensive economic framework for dental sector developed to clarify costs and benefits of alternative financing programs. Initial econometric model constructed involving supply and demand for dental services, dental manpower, and dental training facilities; and providing forecasts for several financing alternatives. Johnson, Donald W. and Thompson, Mary B. Compilation of State Dentist Manpower Reports, 1965-67. U.S. Depart- ment of Health, Education, and Welfare; Public Health Service; Bureau of Health Professions Education and Manpower Training. Washington, D.C.: U.S. GPO, 1970. Report gives State-by-State licensure procedures for December 1964-July 1967 registration periods. Contains results of Nation- wide survey of dental profession conducted jointly by Federal Government, American Association of Dental Examiners, and State Licensing Boards. Compiled by Division of Dental Health. Johnson, Donald W. and Bernstein, Stuart. Classification of States Regarding Expanded Duties for Dental Auxiliaries and Selected Aspects of Dental Licensure—1970. American Journal of Public Health, Vol. 62, No. 2, pp. 208-215, February 1972. Contains State-by-State analysis of laws on licensure and duties of dental hygienists and assistants, as of 1970. Laws analyzed in terms of expanded functions for auxiliaries, licensure reciproc- ity, and specialty licensure. 213 Lotzkar, S., Johnson, D. W., and Thompson, M. D. Experimental Program in Expanded Functions for Dental Assistants: Phase 1 Base Line, and Phase 2 Training. Journal of the American Dental Association, Vol. 82, No. 1, pp. 101-122, January 1971. Op. cit.: Phase 3 Experiment with Dental Teams. Journal of the American Dental Association, Vol. 82, No. 5, pp. 1067-1081, May 1971. Study conducted by Division of Dental Health, Public Health Service, to investigate feasibility of expanding functions of chairside dental auxiliaries. Study carried out at the Dental Manpower Development Center in Louisville, Kentucky. O'Shea, R. M. and Cohen, L. K. Toward a Sociology of Dentistry. The Milbank Memorial Fund Quarterly, Vol. XLIX, No. 3, Part 2, July 1971. Contains series of articles (e.g., on aspects of dentistry in U.S., Great Britain, and Israel), dealing with institution of dentistry, and dental manpower supply and requirements, from macro- sociological perspective. IV. OPTOMETRY American Optometric Association. Blue Book of Optom- etrists. St. Louis, Mo.: The Association, Annual issues. Presents count of active optometrists in the United States, annually, with addresses, etc., by States. Bernstein, Stuart. How Optometry Students Finance Their Education. Journal of the American Optometric Associa- tion, Vol. 43, No. 7, pp. 770-773, July 1972. Summary of findings of survey to determine how health professions students financed their education during 1970-71 school year. Bernstein, Stuart. Optometric Education Statistics. Journal of the American Optometric Association, Vol. 43, No. 8, pp. 869-872, August 1972. Data on enrollment and graduates in schools of optometry, based on 1971 capitation grants applications received in Bureau of Health Manpower Education, National Institutes of Health. Birchard, Clifton H. and Elliott, Theodore F. A Re- evaluation of the Ratio of Optometrists to Population in the United States in the Light of Socio-Economic Trends in Health Care. American Journal of Optometry and Archives of American Academy of Optometry, Jan., Feb., and March 1966 issues. Reprinted by American Optometric Associa- tion. 47 pp. St. Louis, Mo.: The Association, 1967. Re-evaluation of desirable and optimum ratios of optometrists to population in the U.S., assuming a National health insurance plan in effect in 1980. Heath, Gordon. The Need for New Optometry Schools. Journal of the American Optometric Association, Vol. 42, No. 12, pp. 1143-1150, November 1971. Study relates optometric education to supply, and concludes that, to meet needs, doubling number of schools of optometry is realistic goal, since most existing schools are at maximum feasible capacity. Mote, Herbert G. A Statistical Survey of Optometric Manpower Needs. Journal of the American Optometric Association, Vol. 40, No. 12, pp. 1201-1203, December 1969. Analysis of optometric needs, by States, to 1980, based on population growth as estimated by Bureau of Census. 214 Mount, Henry S. and Hudson, Bettie L. Optometrists Employed in Health Services, United States—1968. DHEW Pub. No. (HSM) 73-1803. Washington, D.C.: U.S. GPO, 1973. Statistics presented on basic demographic and professional characteristics of 20,300 optometrists licensed to practice in 1968, and employed in health services. Myers, Raymond |. Optometric Manpower: An Analysis of the Supply. Journal of the American Optometric Associa- tion, Vol. 42, No. 12, pp. 1135-1139, November 1971. Analysis of optometric demand through 1980, based on current estimates of supply of optometrists, on attrition, and on the assumption that optimum ratio of optometrists to population is 14.3 per 100,000. Pennell, Maryland Y. and Delong, Merrill B. Optometric Education and Manpower. Journal of the American Opto- metric Association, Vol. 41, No. 11, pp. 941-956, Novem- ber 1970. Presentation of statistical information on education and distribu- tion of optometric manpower. Trend data presented in addition to detailed analysis of recent optometry school enrollment. U.S. Department of Health, Education, and Welfare; Public Health Service; Health Resources Administration; Bureau of Health Resources Development. State Reports on Survey of Optometrists. (Published seriatim, beginning in 1973.) Fifty-one individual reports, (each State and District of Colum- bia), giving basic data collected in 1972-73 Census of Optom- etrists by American Optometric Association under contract for Division of Manpower Intelligence in Bureau of Health Re- sources Development. Worrell, Burton E. Some Approaches to the Maldistribution of Optometric Manpower. Journal of the American Opto- metric Association, Vol. 47, No. 12, pp. 1157-1159, No- vember 1971. Evaluation of maldistribution of optometric manpower; reasons for maldistribution explored; and four approaches to the problem offered. V. PHARMACY Barker, Kenneth N., and Smith, Mickey C. Deficiencies of the Task Force Criteria for Identifying Subprofessional Tasks. American Journal of Hospital Pharmacy, Vol. 29, No. 9, pp. 734-742, September 1972. Authors discuss deficiencies in one set of criteria for identifying subprofessional tasks, and propose series of field studies designed to develop comprehensive set of work category definitions to describe work of pharmacist. Barker, Kenneth N.; Smith, Mickey C.; and Winter, Evans R. The Work of the Pharmacist and the Potential Use of Auxiliaries. American Journal of Hospital Pharmacy, Vol. 29, No. 1, pp. 35-53, January 1972. Study of utilization of pharmacist’s time in small hospital setting. Objective of study: determination of how much of pharmacist’s time might be saved by delegation or certain tasks to auxiliaries. Bliven, Charles W. Report of Degrees Conferred by Schools and Colleges of Pharmacy for the Academic Year 1971-72. American Journal of Pharmaceutical Education, Vol. 37, No. 1, pp. 126-137, February 1973. (Also prior annual reports.) Presents current statistics on graduates from schools of phar- macy, by numbers and types of degrees conferred, by sex and race of graduates, etc. Report covers period July 1, 1971 to June 30, 1972, and includes data from all 74 active member schools in United States. Froh, Richard B. The Up and Coming Roles of the Pharmacist. Journal of the American Pharmaceutical As- sociation, Vol. NS12, No. 8, pp. 404-407, August 1972. Article explains several categories of functions possibly involving future pharmacist. Given rapidity of change, three categories seen as minimum number of service activities for future pharmacist: (1) drug use control, (2) clinical pharmacy, and (3) physician surrogate. Kirk, Kenneth W. and Ohvall, Richard A. Women Phar- macists in Hospital and Community Practice. American Journal of Hospital Pharmacy, Vol. 29, No. 9, pp. 761-766, September 1972. Results of study of women pharmacists conducted during 1971. Report on 276 women pharmacists practicing in hospital pharmacy, and comparison with responses from 713 community women pharmacists. National Association of Boards of Pharmacy. 7977 Proceed- ings. Licensure Statistics and Census of Pharmacy. Chicago: The Association. (Also 7972 Proceedings, published in 1973, and annual proceedings prior to 1971.) Presents data on selected demographic and professional char- acteristics of pharmacists: age distribution, primary and second- 215 ary activities, place of activity, sex, education, and number of licentiates (classified by applicants, failure, reciprocity, reinstate- ments, and recalled licenses). All data by State. Ohvall, R. A. and Sehgal, S. K. Practice Continuity and Longevity of Women Pharmacists. Journal of the American Pharmaceutical Association. Vol. NS9, No. 10, pp. 518-520, October 1969. Presents data on women pharmacists and length of working life. Orr, Jack E. Report on Enrollment in Schools and Colleges of Pharmacy, First Semester, Term, or Quarter, 1972-73. American Journal of Pharmaceutical Education, Vol. 37, No. 1, pp. 138-153, February 1973. (Also prior annual reports.) Presents current statistics on students enrolled in schools of pharmacy, by numbers and year of study, by types of degree programs, by sex and race of students, etc. Report covers first semester, term, or quarter of academic year 1972-73, beginning in Fall 1972. Progress Report, Pharmacy Manpower Information Project. American Journal of Pharmaceutical Education, Vol. 36, No. 3, pp. 396-401, August 1972. Presents data on enrollment in pharmacy schools by sex, attrition rates, etc. Reinhardt, George R. Pharmacy Manpower, 1966. PHS Pub. No. 1000-Series 14, No. 2, Washington, D.C.: U.S. GPO, 1969. Presents data on basic demographic and professional character- istics of registered pharmacists in United States in 1966, based on about 170,000 questionnaires mailed by State Boards of Pharmacy. Rodowskas, Christopher A., Jr. The Pending Crisis in Professional Productivity. Journal of the American Phar- macy Association, Vol. NS10, pp. 196-199, April 1970. Study presents demand/productivity profile of community pharmacy in 1978, forecast from trend data through 1968. Alternative delivery system proposed in light of impending shortage of professionally-trained pharmacists. Rodowskas, Christopher A., Jr. and Dickson, W. Michael. A Task Analysis of the Community Pharmacist. Pharmacy Manpower Information Project. Feasibility Phase Report-1, Pub. No. 1014; Report-2, Pub. No. 1015. Silver Spring, Md.: The Association, April 1973. Report made under contract with U.S. Department of Health, Education, and Welfare, National Institutes of Health, Bureau of Health Manpower Education, Division of Manpower Intelligence, by American Association of Colleges of Pharmacy. Report-1 presents task analysis involving identification of ac- tivities for selected group of community pharmacists practicing in specified work setting. In-depth description of utilization of pharmacists in chain pharmacy population obtained by com- bining data on all variables in investigation. Report-2 examines current status and future supply of, and requirements for, pharmacy manpower, with consideration given to alternative delivery systems for more effective utilization of professional pharmacist. Rodowskas, Christopher A., Jr. and Gagnon, Jean P. Personnel Activities in Prescription Department of Com- munity Pharmacies. Journal of the American Pharma- ceutical Association. Vol. NS12, No. 8, pp. 407-411, August 1972. Study examines prescription department work activities in relation to total prescription department income, and relates productivity to demand for services. Tash, Rosalia H.; Dickson, W. Michael; and Rodowskas, Christopher A., Jr. Women in the Professional Work Force. Journal of the American Pharmaceutical Association, Vol. NS13, No. 11, pp. 622-624, November 1973. Based on presentation before American Pharmaceutical Associa- tion, Academy of General Practice in Houston, Texas, April 24, 1972. Concerned with career patterns of professional women in work force, with emphasis on women in pharmacy. 216 U.S. Department of Health, Education, and Welfare; Public Health Service; Health Resources Administration; Bureau of Health Resources Development. State Reports on Survey of Pharmacists. (Published seriation, beginning in 1973.) Fifty-one individual reports, (each State and District of Colum- bia), giving basic data collected in 1972-73 survey of all licensed pharmacists in United States, conducted by American Associa- tion of Colleges of Pharmacy under contract for Division of Manpower Intelligence in Bureau of Health Resources Develop- ment. U.S. Department of Health, Education, and Welfare; Public Health Service; Health Services and Mental Health Admin- istration; National Center for Health Services Research and Development. Challenge to Pharmacy in the 1970's. Pro- ceedings of Invitational Conference on Pharmacy Man- power. DHEW Pub. No. (HSM) 72-3000. Washington, D.C.: U.S. GPO, 1971. Proceedings of conference held by DHEW (HSMHA) jointly with School of Pharmacy, University of California, San Francisco. Conference topics included: (1) Future role of pharmacists in a system of comprehensive health care; (2) Interrelationships between medical education and pharmacy education; (3) Phar- macist/physician relationships; (4) Need of study and research; (a) role for pharmacist, (b) models for delivery, (c) innovation in pharmacy education, and (d) models for interdisciplinary pro- grams. VI. PODIATRY Bernstein, Stuart. Revised Data on Enrollment and Grad- uates. Journal of Podiatric Education, Vol. 3, No. 2, pp. 35-36, June 1972. Update of data on enrollment and graduates in colleges of podiatry, based on 1971 capitation grants applications received in Bureau of Health Manpower Education, National Institutes of Health. Blauch, Lloyd E. 1964 Survey of the Podiatry Profession. (Reprint No. 1:66:01, pp. 7-40. Journal of the American Podiatry Association.) Washington, D.C.: The Association, 1965. Presents data on selected demographic and professional char- acteristics of registered podiatrists from 7964 Survey of the Podiatry Profession by the Special Studies Division, American Podiatry Association. Blauch, Lloyd E. The Podiatry Curriculum. Washington, D.C.: American Association of Colleges of Podiatric Medi- cine, 1970. In-depth review of curriculum of podiatry colleges, undertaken to develop model program of instruction in podiatry, based on requirements of modern podiatric service. Report suggests series of guidelines for profession’s educational institutions. Gilbert, Arthur C. F. Report of the 1964 Survey of the Podiatry Profession. (Reprint No. 1:66:01, pp. 3-6, Journal of the American Podiatry Association.) Washington, D.C.: The Association, 1965. Presents summary data on responses to questionnaire used in 1964 Survey of all known registered podiatrists as of April 15, 1964 by the Special Studies Division, American Podiatry Association. 217 Koch, Hugo K. and Phillips, Hazel M. Podiatry Manpower: A General Profile, United States- 1970. DHEW Pub. No. (HRA) 74-1805. Washington, D.C.: U.S. GPO, 1973. Presents statistical data on podiatrists in the United States in 1970, by geographic distribution, selected characteristics, scope of activity, etc. Levine, Jerome |. 1967 Survey of the Podiatry Profession as Related to the Use of X-Rays. Journal of the American Podiatry Association, Vol. 58, No. 2, pp. 64-67, February 1968. Results of survey conducted by APA in March 1967. Survey included questions on podiatrist practices in general, and specific questions on use of radiation. Pennell, Maryland Y. Podiatric Education and Manpower. Journal of Podiatric Education, Vol. 1, No. 2, pp. 11-21, June 1970. Educational data presented for years 1960-61, through 1969-70, together with manpower statistics on supply (current and projected), and need for podiatrists estimated for 1980. Wepprecht, Kenneth R. and Baima, John A. Podiatric Practice in the United States—1969. Journal of the Ameri- can Podiatry Association, Vol. 61, No. 2, pp. 37-43, February 1971. Results of survey conducted by Armour Pharmaceutical Com- pany to determine way in which today’s podiatrist practices his profession: (1) conditions he treats; (2) his usage of drugs; (3) surgical procedures he performs; and (4) podiatric services he renders to his patients. Vil. VETERINARY MEDICINE American Veterinary Medical Association, Department of Membership Services. AVMA Directory 1972. Chicago: The Association, 1972 (Biennial). Directory lists AVMA members in the U.S., Canada and other countries, and certain non-members. Statistics reflect data on AVMA members, and a limited number of nonmembers who responded to questionnaire. Armistead, W. W. Veterinary College Organization and Curriculum: A Look at Alternatives. Journal of the American Veterinary Medical Association, Vol. 156, No. 15, pp. 1911-1916, June 15, 1970. Presents an analysis of impediments to changes needed in the veterinary curriculum, and offers methods of overcoming ob- stacles. Dorn, C. Richard. Veterinary Medical Services: Utilization by Dog and Cat Owners. Journal of the American Vet- erinary Medical Association, Vol. 156, No. 1, pp. 321-327, February 1, 1970. Examines several independent pet population studies, conducted in specific U.S. areas, for factors relating to dog and cat ownership and to use of veterinary services. Joint Committee on Education, American Veterinary Medi- cal Association and Association of American Veterinary Medical Colleges, Inc. Veterinary Medicine, Its Require- ments and Responsibilities. Chicago: Joint Committee, May 1973. (Also earlier issues, published periodically.) Contribution of veterinarians to Nation’s health and welfare examined. Requirements for veterinary services discussed and related to present scope of profession’s practice. February 1971 issue entitled “Veterinary Medicine, Its Requirements and Responsibilities in Relation to Public Health.” 218 May, William O., Jr.; Blenden, Donald C.; and McCulloch, William F. Public Health Aspects of Small Animal Veter- inary Medical Practice. A Time-Function Study. HSMA Health Reports, Vol. 86, No. 10, pp. 910-914, October 1971. Presents results of time-function study of practice time devoted to five categories of activities by “small animal” veterinarians in Missouri. National Research Council, Committee on Veterinary Medi- cal Research and Education. New Horizons for Veterinary Medicine. Washington, D.C.: National Academy of Science, 1972. Study concerned with (1) examining and evaluating veterinary medical research and education; (2) assessing manpower and facilities; (3) gauging National needs; and (4) formulating recom- mendations on how resources in veterinary medical research and education can be modified and developed to meet expected needs for veterinary manpower. Schnurrenberger, Paul R.; Martin, Russell J.; and Walker, James F. Characteristics of Veterinarians in Illinois. Journal of the American Veterinary Medical Association, Vol. 160, No. 11, pp. 1512-1521, June 1, 1972. Effort to secure high survey response rate by veterinarians in inois in 1967 resulted in 99% response. Follow-up interviews conducted in 1968 and 1969. Student Enrollment, 1972-73; Residence of First-Year Stu- dents. Journal of the American Veterinary Medical Associa- tion, Vol. 163, No. 1, pp. 36-37, July 1, 1973. (Also prior annual issues.) Presents annual statistical data on veterinary medical schools and students. VIII. NURSING Altman, Stuart H. Alternative Measures of the Regional Availability of Nursing Manpower. Economic and Business Bulletin, Vol. 24, No. 1, pp. 68-75, Fall 1971. Analysis of measures of adequacy of hospital nursing personnel and demand for nursing services on a regional basis. Altman, Stuart H. Present and Future Supply of Registered Nurses. DHEW Pub. No. (NIH) 72-134, November 1971. (Reprinted August 1972 as Pub. No. (NIH) 73-134.) Washington, D.C.: U.S. GPO. Comprehensive analysis of impact of economic factors on present nurse supply and projected supply through the 1970’. Study also examines non-economic factors influencing indi- vidual’s decision in such matters as choice of nursing career, type of educational program, and continued professional practice. American Nurses’ Association. Facts About Nursing, A Statistical Summary. 1970-71 edition. New York: The Association, 1971. (Also prior and later editions) Beginning with the first edition in 1935, Facts About Nursing makes available, from various sources, statistical data on nursing. Presents information on (1) distribution of registered nurses; (2) nursing education; (3) economic status of registered nurses; (4) allied nursing personnel; (5) related information; and (6) functions and purpose of nursing organizations. Cleland, Virginia; Bellinger, Arnold; Shea, Fredericka; and McLain, Sister Rosemary. Decision to Reactivate Nursing Career. Nursing Research, Vol. 19, No. 5, pp. 446-452, September-October 1970. Article examines factors influencing decision of married nurses to reactivate their nursing careers, in order to improve prediction on future employment patterns of married nurses. Folk, Hugh and Yett, Donald E. Methods of Estimating Occupational Attrition. Western Economic Journal, Vol. VI, No. 4, pp. 297-302, September 1968. Discusses various projection methods for estimating supply of personnel in fields of engineering and nursing. Knopf, Lucille. From Student to RN—A Report of the Nurse Career-Pattern Study. DHEW Pub. No. (NIH) 72-130. Washington, D.C.: U.S. GPO, 1972. Study, initiated in 1962, presents data on biographical character- istics of nursing students, occupational goals, and reasons for choice of nursing as career. Study also examines relation of these variables to students’ completion of nursing program, and subsequent work in nursing field. Levine, Eugene. Nurse Manpower: Yesterday, Today, and Tomorrow. American Journal of Nursing, Vol. 69, No. 2, pp. 290-296, February 1969. Examines characteristics of nurse manpower in early 1950's; factors influencing nursing since that time; and future expecta- tions of nursing profession. 219 Marram, Gwen D. An Untapped Source of Registered Nurses. Nursing Outlook, Vol. 17, No. 7, pp. 48-50, July 1969. Examines sizable fraction of potential nursing manpower in U.S. consisting of nurses who received their professional education in foreign countries, and are not eligible for registration and licensure. Suggests provision of specialized courses, with State or Federal funds or both, to enable them to qualify. Marshall, Eleanor D. and Moses; Evelyn B. LPN’s 1967: An Inventory of Licensed Practical Nurses. Washington, D.C.: U.S. GPO, 1971. Report of survey made under contract with American Nurses’ Association for Division of Nursing, Bureau of Health Manpower Education, National Institutes of Health, Public Health Service. Contains data on socio-demographic and employment character- istics of licensed practical nurses. Marshall, Eleanor D. and Moses, Evelyn B. RN's 1966... An Inventory of Registered Nurses. New York: American Nurses’ Association, 1969. Inventory of registered nurse manpower data, giving national data on personal characteristics of all registered nurses, and measuring Nation’s inactive registered nurse complement. Meyer, Burton. Development of a Method for Determining Estimates of Professional Nurse Needs. Nursing Research, Vol. 6, No. 1, pp. 24-28, June 1957. Discusses formula for estimating professional nurse supply from attrition rates, etc. National League for Nursing. Nurse-Faculty Census. New York: The League, 1972. (Also prior biennial editions.) Presents statistical data, personnel every 2 years. including count, on nurse-faculty National League for Nursing, Division of Research. State- Approved Schools of Nursing—LPN/LVN, 1972. New York: The League, 1972. (Also prior and later annual editions.) Directory of State-approved schools for licensed practical nurses and licensed vocational nurses. Includes data on admissions, enrollments, graduates, etc. National League for Nursing, Division of Research. State- Approved Schools of Nursing—RN, 1972. New York: The League, 1972. (Also prior and later annual editions.) Directory of State-approved schools for registered nurses. In- cludes data on admissions, enrollments, graduates, etc. Niles, Anne M. Recruiting inactive Nurses. Hospitals, Vol. 44, No. 17, pp. 86-89, September 1, 1970. Article discusses efforts to recruit inactive nurses back into professional practice, taking into account reasons for profes- sional inactivity, and expectations. Reese, Dorothy E.; Siegel, Stanley E.; and Testoff, Arthur. The Inactive Nurse. American Journal of Nursing, Vol. 64, No. 11, pp. 124-128, November 1964. Presents results of a 1961 study of inactive nurses—plans to return to active practice, type of active practice (i.e. part or full time), etc. Shetland, Margaret L. An Approach to Role Expansion— The Elaborate Network. American Journal of Public Health, Vol. 61, No. 10, pp. 1959-1964, October 1971. Explores role of nurse, as responsibility in health care expands into decision-making, etc. to meet changing health needs of Nation and to fulfill “role expectations,” as seen by both nurses and physicians. U.S. Department of Health, Education, and Welfare. Prog- ress Report on Nurse Training, 1970: Report to the President and the Congress. Washington, D.C.: U.S. GPO, 1970. Presents report by Secretary, DHEW, on administration of Nurse Training Act of 1964, including amendments of Health Man- power Act of 1968, Title Il, “Nurse Training,” as incorporated into Title VIII of Public Health Service Act. U.S. Department of Health, Education, and Welfare; Public Health Service; Health Resources Administration; Bureau of Health Resources Development. A Directory of Programs Preparing Registered Nurses for Expanded Roles 1973-74. DHEW Pub. No. (HRA) 74-31. Washington, D.C.: U.S. GPO, 1974. Contains listing of two types of expanded-role training programs for registered nurses: certificate and master’s degree; by institu- tion. Includes data on area of concentration, entrance require- ments, length of program, type of financial aid, etc. U.S. Department of Health, Education, and Welfare; Public Health Service; National Institutes of Health; Bureau of 220 Health Manpower Education. Planning for Nursing Needs and Resources. DHEW Pub. No. (NIH) 72-87. Washington, D.C.: U.S. GPO, 1972. Presents basic guidelines, including principles and procedures, to meet changing conditions in nursing. U.S. Department of Health, Education, and Welfare; Public Health Service; National Institutes of Health; Bureau of Health Professions Education and Manpower Training. Health Manpower Source Book 2, Nursing Personnel. PHS Pub. No. 263, Section 2. Washington, D.C.: U.S. GPO, (revised 1969). Presents data on nurses in States and Nation as of 1966. Revision reflects: (1) distribution, characteristics, national estimates, and educational preparation of RN’s; (2) nursing education; (3) prac- tical nurses’ characteristics and education; (4) RN’, LPN’s, aides, orderlies, and attendants in hospitals; (5) RN’s in public health and occupational health; and (6) projection of RN need and supply. U.S. Department of Health, Education, and Welfare; Public Health Service; National Institutes of Health; Bureau of Health Professions Education and Manpower Training. Nurses in Public Health, January 1968. PHS Pub. No. 785. Washington, D.C.: U.S. GPO, revised 1969. Report of census of nurses employed in public health conducted in 1968 by Division of Nursing. U.S. Department of Health, Education, and Welfare; Public Health Service; National Institutes of Health; Bureau of Health Professions Education and Manpower Training. Nursing Personnel in Hospitals—1968. Washington, D.C.: U.S. GPO, May 1970. Report contains data from 1968 survey conducted jointly by the U.S. Public Health Service and American Hospital Association. Survey estimates 445,000 RN’s and 815,000 LPN’s employed in hospitals in the U.S. in 1968. IX. ALLIED HEALTH American Medical Association, Department of Allied Medi- cal Professions and Services. Educational Programs for the Physician’s Assistant. Chicago: The Association, Fall 1973. (Published semi-annually.) Presents current list of approved educational programs for allied medical professions and services, with detailed data on phy- sician’s assistant programs. American Medical Association, Department of Health Man- power. 1972 Survey of Operational “Physician’s Assistant” Programs: Numbers Graduated and Employed. Chicago: The Association, 1972. (Mimeo, 7 pp.) Contains listing and analysis of number of physician’s assistants graduated, employment status, and place of employment. Coordinated Health Survey Committee. Virginia Health Manpower, 1971. Richmond: The Committee, 1971. Contains information on professional and technical health manpower employment and needs, by type of employer, for State and planning districts. Health manpower educational statistics also presented. Survey report compiled by Compre- hensive Health Planning, Virginia Council on Health and Medical Care, and Virginia Regional Medical Program. Dentistry in National Health Programs—A Report with Recommendations. Journal of the American Dental As- sociation, Vol. 83, No. 3, pp. 569-600, September 1971. Report of Task Force on National Health Programs of the American Dental Association. Provides summary of Nation's situation re. dental care. Projects supply and demand for dental occupations, and proposes needed dental school and dental auxiliary program expansion. Discusses demand under varying assumptions, such as: increased productivity, redistribution of personnel, increased utilization of auxiliaries, national dental insurance. Employment Security Commission of North Carolina. Health Manpower Needs in North Carolina, 1967-1973. Raleigh: The Commission, 1967. Contains information on National health manpower trends, State employment trends in surveyed facilities, and State trends by occupation. Survey conducted by Commission's Bureau of Employment Research, with cooperation of the U.S. Depart- ment of Labor’s Bureau of Employment Security and the N.C. State Board of Education, Department of Community Colleges. Hooper, Mary Evans. Associate Degrees and Other Formal Awards Below the Baccalaureate, 1969-70. DHEW Pub. No. (OE) 72-48. Washington, D.C.: U.S. GPO, 1971. . Contains trend data from 1965 on with respect to total awards and total enrollment in 2-year educational institutions. 221 Jantzen, Alice C. Some Characteristics of Female Occupa- tional Therapists, 1970. American Journal of Occupational Therapy, Vol. 26, No. 1, pp. 19-26, January 1972. Contains summary and analysis of socio-demographic and employment characteristics of female occupational therapists. Losee, Garrie J. and Altenderfer, Marion E. Health Man- power in Hospitals. Washington, D.C.: U.S. GPO, 1970. Contains estimates for 1969 of number of personnel employed, number of budgeted positions vacant, and number of additional positions needed to provide optimal care in hospitals, by occupation. National Committee for Careers in the Medical Laboratory, Inc. Salary Survey. GIST, No. 50, February 1972. Bethesda, Md.: The Committee, (Newsletter.) Contains survey information on salary, education, and place of employment of laboratory workers. Office of Comprehensive Health Planning. Allied Health Manpower in Texas, 1970. Austin: The Governor's Office, 1970. Contains detailed information on allied health manpower em- ployment and needs, by type of employer, for State planning regions, and counties. Allied health manpower educational statistics also presented. Survey report compiled by Texas Health Careers Program and Governor's Office. Pennell, Maryland Y. and Hoover, David B. Health Man- power Source Book 21. Allied Health Manpower Supply and Requirements: 1950-80. PHS Pub. No. 263, Section 21. Washington, D.C.: U.S. GPO, 1970. Contains supply and requirements estimates, and projections to 1980, for medical, dental, nursing, environmental, and allied health manpower. U.S. Department of Health, Education, and Welfare; Public Health Service; Health Resources Administration; Bureau of Health Resources Development. A Directory of Programs Training Physician Support Personnel, 1973-74. DHEW Pub. No. (HRA) 74-318. Washington, D.C.: U.S. GPO, 1974. Contains listing of physician’s assistant training programs by State and institution. Includes entrance requirements, length of training, date classes begin, class capacity, credentials awarded, and financial aid available. Prepared jointly by Division of Medical Practice, AMA, and Division of Manpower Intelligence, BHRD, HRA, as an update of DHEW Pub. No. (NIH) 73-318, entitled “A Summary of Training Programs—Physician Support Personnel, September 1972.” U.S. Department of Health, Education, and Welfare; Public Health Service; National Institutes of Health; Bureau of Health Manpower Education. Certification in Allied Health Professions—1971 Conference Proceedings. DHEW Pub. No. (NIH) 73-246. Washington, D.C.: U.S. GPO, 1972. Presents conference plan, resource papers by various allied health professional associations, recommendations, list of participants, selected references, etc. U.S. Department of Health, Education, and Welfare; Public Health Service; National Institutes of Health, Bureau of Health Manpower Education. Physician Support Personnel: 222 Selected Training Programs. DHEW Pub. No. (NIH) 72-183. Washington, D.C.: U.S. GPO. (Revised May 1972.) Presents results of survey made in April 1971 of training programs for all types of physician support personnel: Phy- sician’s Assistant, Pediatric Nurse Practitioner, Community Health Medic, etc. Contains summary tables. U.S. Department of Health, Education, and Welfare; Public Health Service; National Institutes of Health; Bureau of Health Manpower Education. Program Support for Phy- sician’s Assistants in Primary Care. Bethesda, Md.: March 1972. Brochure issued by Office of Special Programs giving program guidelines, scope of program, definitions, educational standards, financial support, etc. U. S. GOVERNMENT PRINTING OFFICE : 1974 O - 565-118 1, lute lh en. ’ let a ae ail and £ Ls DHEW PUBLICATION NO. (HRA) 75-38 U. S. DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE Public Health Service Health Resources Administration C02872739°7