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Careers in
A/I: Allergy/Immunology
Workforce Needs
 The best career decisions are those informed by
objective analyses of the options that one is considering. The following are
slightly edited and excerpted conclusions, recommendations, methodologies and
figures from the A/I Physician Workforce Report (June 2000), the most
thorough-going assessment of workforce needs conducted on the specialty. It
was prepared for the American Academy of Allergy, Asthma and Immunology
by SUNY-Albany’s Center for Health Workforce Studies and reflects two years of
health workforce research:
Conclusions:
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It appears that the demand for allergist/immunologists is
likely to rise over the next several years driven in part by the increasing
prevalence of allergy and asthma related conditions and the increasing
complexity of treatment interventions. The expansion of managed care is
unlikely to reduce demand for services by formally trained allergists.
Although the demand for allergy and immunology services in
the future is difficult to predict, the signals pointing to increased demand
appear stronger than those pointing to a decrease in demand.
Allergist/immunologists report patient volumes have been increasing over the
past two years. For example, 59% of allergists report an increase in the
volume of sinusitis cases, 58% report an increase in the volume of asthma
cases, and 51% report an increase in the volume of urticaria cases they treat.
Allergist/immunologists also report that they expect that the incidence of
these and other allergy and immunology conditions will drive demand higher
over the next five years. While new medications and treatments are likely to
influence demand, most allergists expect these interventions will lead to an
increase demand for their services over the next five years.
When asked about the impact of managed care on their
practices over the last two years, a similar percentage of
allergist/immunologists report increased patient volume as report decreased
patient volume. While managed care could moderate demand for
allergist/immunologists in the future, a very high percentage of core
allergists report that the increase in managed care has led to an increase in
the complexity of the cases that they are seeing. Fifty three percent (53%) of
allergist/immunologists report managed care has led to a more complex case
load compared with only 3% believing it has led to a less complex case mix.
The remainder report no impact on case mix. Encouraging the less complex cases
to be treated by the primary care physician and the more complex cases to be
treated by the allergist/immunologists would appear to be the role played by managed care
plans.
Thus, while allergist/immunologists report an increasing
percent of their patients are in managed care plans, this is likely to have
less of a negative impact on demand than might have been expected in the past.
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There are two distinct groups of physicians providing
allergy related services: those whose practice is devoted exclusively or
almost exclusively dedicated to providing allergy and asthma related services;
and physicians who provide these services on a part time basis and/or provide
non-allergy related services as well.
Core Allergists (defined as physicians providing 30
or more hours per week in allergy and immunology patient care or 20 – 29
hours per week if those hours represent a majority of a physician’s patient
care time per week) account for 88% (3,335) of the current allergist FTEs and
86% of the estimated patient visits to allergist/immunologists. These
physicians are the backbone of the allergist workforce.
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In light of the decrease in the number of new
graduates of allergy and immunology fellowship programs over the past decade
and the aging of the current supply of allergist/immunologists, it is expected
that the absolute number of allergists practicing in the U.S. and the per
capita ratio of allergists, will begin to decrease within the next few years,
leading to a decrease in access for Americans to physicians with formal
training in allergy and immunology.
Fifty-four new allergist FTEs added to the supply each year
is not enough to keep up with the retirement of currently practicing
allergist/immunologists. The Center’s projection model which incorporates
the current effective production rate, age distribution, proportion completing
a formal allergy and immunology training program, retirement and death rates
projects that there will be a significant decline in the supply of
allergist/immunologists if current trends continue. This downward trend is
already underway.
Under the assumptions that demand stays constant and
current supply is slightly higher than demand, the conclusion drawn from the
model is that there will be a shortage of allergist/immunologists within the
next ten years. Because current effective production cannot keep up with the
current retirement rate of practicing allergists, the supply of
allergist/immunologists will begin to drop below demand for allergy and
immunology services in the near future. Figures ES-1 and
ES-2 show this likely
scenario in terms of the number of physicians providing allergy and immunology
services (Figure ES-1) and the allergist FTE to 100,000 population ratio
(Figure ES-2). If demand increases, as is likely, the shortage is likely to
occur even sooner.
-
There are some encouraging signs that the interest in
allergy and immunology fellowship programs by US Medical Graduates (USMGs) may
be increasing and that the number of allergy and immunology fellows may have
bottomed out.
There have been a number of signs that interest in the
specialty by USMGs may be increasing. Many training program directors report
that pediatric and internal medicine residents hold positive views about the
specialty and that these views have become better in recent years. There have
also been a number of anecdotal reports of improved job prospects for
physicians completing allergy and immunology training programs. This could
further spur interest in the specialty in the future.
While some program directors (22%) report that their
graduates had some difficulties finding practice positions, many (41%) of
fellowship program directors report that there will be more opportunities and
fewer difficulties finding full-time positions for new graduates in the
future. Recent graduates, on the other hand, do not report many difficulties
finding positions.
-
The supply of allergist/immunologists is undergoing
demographic changes that have a number of significant implications for the
future of the specialty. This includes an increase in the number of women in
the specialty and an increase in the average age of allergists.
There are significantly more women in the specialty now
than in the past. Since 1990, the proportion of practicing
allergist/immunologists that are female has increased from 10% to 18%; the
percent of fellows that were female in 1999 was 47%, indicating that the
percent of women in the specialty will continue to rise in the coming years.
This is consistent with the increased representation of women in medicine over
the past 30 years. While the increase in the proportion of allergists that are
women is a positive development reflecting increased equity and opportunities
for women and a greater choice for patients, the increase could also lead to a
decline in the availability of services. Female physicians, on average, work
fewer hours over the course of their professional lives. Previous research has
shown that women may work 10% to 20% fewer hours than their male counterparts
over their careers. Thus, as the percentage of allergists that are women
continues to grow over the coming years, there could be a decline in the
availability of allergy and immunology services.
In terms of age, the allergy workforce is already older, on
average, than the general physician population in the United States. Because
the production of new allergist/immunologists is at a very low level, the age
of the allergist workforce becomes an important issue. An older average age
indicates that a larger proportion of the allergist workforce will retire over
the next decade or two. In fact, 37% of core allergists report that they plan
to stop providing allergy and immunology services (effectively retiring)
within the next 10 years (Non-core allergists will retire at an even quicker
pace). The current level of production cannot keep up with this rate of
retirement.
| Note: These findings are not
meant to take issue with the importance of continued gender and
racial diversity for the health of the subspecialty. Findings on
future workforce supply are meant to place in sharp focus the
serious shortage that the subspecialty may be confronting. The fact
that women physicians tend to take on greater responsibility for
family and child-rearing responsibilities does mean that their
projected productivity rates over a career affect the overall
workforce supply. That finding and any attendant projections are not
meant to imply that this is a negative development.
The current report assesses the known empirical
trends on female vs. male productivity rates and extrapolates from
them to future workforce needs as a whole. It is recognized that
future projections may need to be readjusted if greater empirical
evidence is gained which substantiates how male physicians opt for a
more balanced work/home life, sharing in greater domestic
responsibilities that affect productivity rates over a career. |
-
Unlike older age cohorts of allergist/immunologists, a
majority (54%) of the youngest allergists are internists, indicating a major
shift from the historical dominance of pediatricians in the specialty.
Another significant evolution in the allergy workforce is a
shift toward initial residency training in internal medicine rather than
pediatrics. This finding may imply that allergy and immunology may be drawing
fellows from a different pool of candidates now than in the past.
-
The practice patterns of allergist/immunologists are
changing and there are significant differences in the practice patterns of
older and younger allergists.
Traditionally, allergist/immunologists, like other
physicians, were solo practitioners. While solo practitioners still make up a
large proportion of the allergist workforce, like the general physician
population, group practice settings are becoming more common amongst
allergists. This is especially true among younger allergists who are much more
likely to be in group practice than older allergists.
Another place where changes in allergy practice can be seen
is in the use of immunotherapy. Older allergist/immunologists are more likely
to report that higher percentages of their patients are treated with allergy
shots. Moreover, allergists who have not completed a formal allergy and
immunology fellowship program (especially those who training derives solely
from an otolaryngology fellowship or short courses in allergy and immunology)
are much more likely to employ this treatment option than those who have
completed a formal allergy and immunology training program. As the number of
non-formally trained allergist/immunologists decreases, it is likely that the
use of immunotherapy may also decrease. Determining whether this development
is positive or negative in terms of patient outcomes is beyond the scope of
this study.
-
Allergist/immunologists are
generally satisfied with their professional practice and see the future as
having more opportunities for allergists.
Allergist/immunologists…are more optimistic about
practice opportunities outside their local areas and future practice
opportunities. That allergists report more opportunities outside their local
area is indicative of the slight pressure they reportedly feel from
competition with other physicians and suggests that they are not concerned
greatly that demand will shrink below supply levels or that supply will swell
above demand levels.
Recommendations:
The following recommendations were made by the Center for
Health Workforce Studies upon completion of their final comprehensive workforce
report:
-
The community of health professionals involved in care for
individuals with allergic and asthmatic conditions should take steps to
maintain and to encourage an increase in the number of physicians formally
trained in accredited allergy and immunology fellowship programs.
The rising incident of allergic and asthmatic conditions as
well as the increasing sophistication of medical interventions to treat these
conditions, requires a well-trained medical workforce. Physicians with formal
training in allergy and immunology are critical to efforts to expand and treat
patients with allergies and asthma. Therefore, in light of the finding that
the supply of allergists will be decreasing and is likely to fall below demand
within the next few years, it is strongly recommended that steps be taken to
encourage internists and pediatricians to consider sub-specializing in allergy
and immunology.
A program of active recruitment
of pediatric and internal medicine 2nd year residents (who are
making decisions about whether to subspecialize) needs to be implemented to
ensure that all positions in all programs are filled by qualified candidates.
Allergy and immunology fellowship program directors report that allergy and
immunology is looked upon favorably by these residents, so actively recruiting
them should be possible. Moreover, it is recommended that any program of
active recruitment should be focused on USMGs and permanent resident IMG
medical residents. IMGs with temporary visas have a greater likelihood
of leaving the country after training for a variety of reasons, including lack
of job opportunities and visa restrictions. Thus, in order to maximize the
likelihood of successfully increasing the effective production of FTE
allergists, temporary visa holding IMGs should be excluded as targets of
active recruitment.
It has been documented that loss in the production of
allergist/immunologists in the United States has been driven by the drop in
USMGs entering the specialty. This trend must be reversed if the supply of
allergist/immunologists is to remain roughly balanced with demand for allergy
and immunology services...
The American Academy of Allergy, Asthma, and
Immunology and others involved in the field should explore enhanced public
support for allergy and immunology fellowship programs.
Over the past decade, the federal government through the
Medicare program and several state governments through the Medicaid program
have provided incentives for teaching hospitals and residency programs to
increase their production of primary care physicians. This reflected a
national consensus that there was a need for additional primary care
physicians. Given the documentation provided in this report, as well as the
growing number of federal and state initiatives to diagnosis and treat asthma,
a case should be made to federal and state policy makers to provide incentives
to increase the production of allergists. The most common factor reported by
training program directors for reducing the size of their programs is reduced
financial support for the program.
AAAAI and program directors should also work together to
lobby the appropriate institutions to ensure that financial support for
allergy and immunology fellowship programs is maintained, at the very least,
and increased in the very near future.
The American Academy of Allergy, Asthma, and
Immunology should take steps to publicly circulate the likelihood of a
potential shortfall in the supply of allergist/immunologists over the next 15+
years.
The American Academy of Allergy, Asthma, and Immunology is
dedicated to the advancement of the knowledge and practice of allergy, asthma
and immunology. As such, it is imperative that the AAAAI share the findings
of this report with interested allergy and immunology stakeholders and the
general medical community. This publicity and information circulation may also
support efforts to increase production of new allergist/immunologists as news
about potential shortages of allergists filters down to internal medicine and
pediatric residents.
It is imperative that efforts aimed at reversing the
trends reported here begin immediately. The decline in the supply
of allergist/immunologists has already begun. The effects, while they
have not been seen as yet, will come shortly, as the slight surplus of
allergists declines to a shortage within the next 10 years. There is the
potential, if the supply of allergists declines too far, that the specialty
will lose viability. Signs of a potential viability problem can be seen in the
recent sharp decline in total fellows in training and fellows completing
training. This becomes particularly problematic if demand for allergy and
immunology services increases over the next 10 years, accelerating any
potential viability issues.
-
The American Academy of Allergy, Asthma, and
Immunology should develop a workforce tracking system to monitor the important
trends identified in this series of reports.
In light of the uncertainties around supply and demand, the
Center for Health Workforce Studies recommends that better monitoring of the
issues identified over the course of this project in order to better assure
access to needed allergy and immunology services for Americans as well as
ensure the viability of the specialty. The specialty of allergy and
immunology, like the whole field of medicine and the health care delivery
system, is changing rapidly. There are some ominous signs that the supply of
allergist/immunologists is beginning a long-term decline that could lead to
reduced access to needed allergy and immunology services. An ongoing
monitoring system is needed to assess developments and trends impacting on
both supply and demand and this information needs to reach not only the
allergy and immunology community, but also the general medical education and
training community…
Methodology:
The data used in this report were obtained from several
sources. First, historical data on trends in graduate medical education were
derived from the American Medical Association’s Graduate Medical Education
database. The AMA collects these data each fall directly from all graduate
medical programs accredited by the Accreditation Council for Graduate Medical
Education and one year later issues summary data in the early fall Medical
Education theme issue of the Journal of the American Medical Association.
Second, data on currently practicing physicians who provide
allergy and immunology services were obtained from the Survey of Physicians
Providing Allergy and Immunology Services in the United States, 1999
(henceforth, the practitioner survey) conducted by the Center in
the spring/summer of 1999. The survey was mailed to 6,570 physicians who were
believed to provide allergy and immunology services. The overall response rate
for the practitioner survey was 56.3%. Responses were found to be representative
of the population of physicians who provide allergy and immunology services.
The practitioner survey consisted of a detailed battery of 75
unique questionnaire items. These items were designed to collect information on
a host of physician characteristics, attitudes, and experiences, including:
demographics, practice activities, characteristics, and recent change, as well
as thoughts about future changes in allergy practice.
Third, 1998-1999 data on allergy and immunology fellowship
training programs and their directors were obtained from the 1999 Survey of
Directors of Allergy and Immunology Fellowship Programs (henceforth, the
program director survey) conducted by the Center from the spring through
the fall of 1999. The survey was mailed to the directors of 85 fellowship
programs believed to currently train physicians in the practice of allergy and
immunology. Through correspondence with several programs and AAAAI, it was
determined that there existed only 77 at the time of the survey. The overall
response rate to the survey was 92%. Responses were found to be representative
of the universe of allergy and immunology fellowship training programs.
The program director survey consisted of a series of
questions ranging from objective items about the number of positions,
applicants, fellows, and fellows completing the program, to more subjective
items on the job market for recent program completers and general sentiment
about allergy and immunology in the medical community as a whole.
Fourth, data on physicians who recently completed their
fellowship training were obtained from the 1999 Survey of Allergy and
Immunology Fellows Completing Training (henceforth, the exit
survey) conducted by the Center in the late spring/summer of 1999. The
survey was initially distributed through the allergy and immunology program
directors, but eventually was handled completely by the Center. Some 53 of the
estimated 84 fellowship program completers responded to the survey, generating a
63% response rate.
The exit survey consisted of a battery of questions intended
to collect information on demographics, the plans of fellows completing
training, and their assessments of their experiences in searching for a practice
position. The exit survey was designed to help the Center better understand the
current supply and demand for physicians practicing allergy and immunology, as
well as develop a profile of the newest members of the allergist supply.
Finally, data on the general United States population were
obtained from the U.S. Bureau of the Census. Specifically, state, regional, and
national estimates and projections of resident populations were taken from a
variety of sources to use in the calculations of physician to population and
population to physician ratios.
Exhibits:
From the 1999 Practitioner Survey:
- Figure 1. - Allergist to Population Ratios by Region, 1999
- Figure 2. - Initial Residency Training of Core Allergists by Age, 1999
- Figure 3. - Average Hours Per Week Spend in Selected Professional Activities of Core Allergists, 1999
- Figure 4. - Average Total Allergy and Immunology Patient Visits per Week to Core Allergists by Age of Allergist,
1999
- Figure 5. - Primary Practice Setting Distribution of Core Allergists, 1999
- Figure 6. - Average Number of New Allergy and Immunology Patient Visits per Week to Core Allergists, 1999
- Figure 7. - Average Number of Allergy and Immunology New Patient Visits per Week to Core Allergists by Age of Allergist, 1999
- Figure 8. - Allergy and Immunology Patients per Hour Rates by Age of Allergist, Core Allergists 1999
- Figure 9. - Average Wait for Appointment, New Patients, Core Allergists 1999
- Figure 10. - Average Wait for Appointment by Age of Allergist, New Patients, Core Allergists, 1999
- Figure 11. - Professional Satisfaction of Core Allergists, 1999
- Figure 12. - Professional Satisfaction by Age, Core Allergists 1999
- Figure 13. - Economic Satisfaction of Core Allergists, 1999
- Figure 14. - Economic Satisfaction by Age, Core Allergists 1999
- Figure 15. - Change in Case Complexity Over Prior 2 Years, Core Allergists 1999
- Figure 16. - Change in Case Complexity Over Prior 2 Years by Age, Core Allergists 1999
- Figure 17. - Recent Allergy and Immunology Practice Growth, Core Allergists 1999
- Figure 18. - Recent Allergy and Immunology Practice Growth by Age, Core Allergists 1999
- Figure 19. - Future Impact of the Incidence/Prevalence of Allergy and Immunology Conditions on Demand for Allergy and Immunology Services, Core Allergists 1999
- Figure 20. - Future Impact of the Incidence/Prevalence of Allergy and Immunology Conditions on Demand for Allergy and Immunology Services by Age of Allergist, Core Allergists 1999
- Figure 21. - Future Impact of New Medications and Treatments on Demand for Allergy and Immunology Services, 1999
- Figure 22. - Future Impact of New Medications and Treatments on Demand for Allergy and Immunology Services by Age of Allergist, Core Allergists 1999
- Figure 23. - Change in Managed Care Referrals to Core Allergists Over Prior 2 Years, 1999
- Figure 24. - Change in Managed Care Referrals to Core Allergists Over Prior 2 Years by Age of Allergist, 1999
- Figure 25. - Effect of Managed Care Expansion on Patient Volume in the Last 2 Years, Core Allergists 1999
- Figure 26. - Effect of Managed Care Expansion on Patient Volume in the Last 2 Years by Age of Allergist, Core Allergists 1999
- Figure 27. - Effect of Managed Care Expansion on Case Complexity in the Last 2 Years, Core Allergists, 1999
- Figure 28. - Years Until Stop Providing Allergy and Immunology Services, Core Allergists 1999
From the 1999 Training Program Directors
Survey:
From the 1999 Fellows Exit Survey:
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Figure 1. - Demographic Characteristics of Recent Allergy and Immunology Fellowship Graduates, 1999
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Figure 2. - Previous Specialty Training of Recent Allergy and Immunology Fellowship Graduates, 1999
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Figure 3. - Planned Activity After Completing Current Fellowship Training of Recent Allergy and Immunology Fellowship Graduates, 1999
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Figure 4. - Practice Settings of Recent Allergy and Immunology Fellowship Graduates Going on to Patient Care, 1999
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Figure 5. - Geographical Distribution of Recent Allergy and Immunology Fellowship Graduates Going on to Patient Care, 1999
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Figure 6. - Types of Practice Locations of Recent Allergy and Immunology Fellowship Graduates Going on to Patient Care, 1999
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Figure 7. - Type of Compensation of Recent Allergy and Immunology Fellowship Graduates Going on to Patient Care, 1999
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Figure 8. - Level of Satisfaction with Anticipated Level of Compensation/Salary of Recent Allergy and Immunology Fellowship Graduates Going on to Patient Care, 1999
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Figure 9. - Whether Recent Allergy and Immunology Fellowship Graduates Going on to Patient Care Would Recommend Allergy and Immunology to Other Physicians in Training, 1999
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Figure 10. - Number of Positions Applied for by Recent Allergy and Immunology Fellowship Graduates, 1999
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Figure 11. - Number of Offers Received by Recent Allergy and Immunology Fellowship Graduates, 1999
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Figure 12. - Assessment of Allergy and Immunology Practice Nationally, Recent Allergy and Immunology Program Graduates, 1999
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Figure 13. - Assessment of Academic Positions in Allergy and Immunology Nationally, Recent Allergy and Immunology Program Graduates, 1999
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