Second in a SeriesPhysician Manpower Revisited in 1990

region for 1990. In 1988, an analysis of estimated physician supply and demand was performed by the Center for Health Policy Research of the Oklahoma Medical Research Foundation.<br><br> 2 The OMRF study suggested that other factors, especially those related to economic markets and the availability of physician support services are more predictive of physician location in Oklahoma than is the GME production or the need for services of a population. This study will examine past estimates of physician manpower compared to actual 1990 counts. The period of the "Oil Boom" of 1975-84 provided data for the Duffy et al.<br><br> projections. It was one of the most prosperous periods in post-WWII Oklahoma. The period to which the estimates were applied was the "Oil Bust" of 1984-90.<br><br> This was a period of flat economic growth and population decline that began in Oklahoma in 1982. Thus the comparison of predictions made during growth, with the actual outcomes during economic stagnation, provides an ideal model for examining the impacts of a state economy upon physician professional choices. The historical data used to formulate the Duffy et al.<br><br> projections assumed continued economic growth. The actual outcomes occurred during a period of economic stagnation. Additionally, the Oklahoma Board of Medical Licensure and Supervision greatly restricted the entrance of foreign medical graduates into Oklahoma practice during the mid-1980s.<br><br> 1 Duffy, F. Daniel, MD, Lewis, C.S. , MD, and Miller, MS, Deborah A., Estimated Physician Manpower Requirements for 1990, Journal of the Oklahoma Medical Association, Vol 78, No 6, pages 183-190, June 1985.<br><br> 2 Lapolla, MHA, Michael P., A Perspective: Physicians for Oklahoma, OMRF Center for Health Policy Research, 1988. October 1990Michael Lapolla, MHA; F. Daniel Duffy, MD; and C.S.<br><br> Lewis, Jr., MDPage 2-1 Second in a Series ...Physician Manpower Revisited in 1990 Methods The methodology of the 1984 projection study by Duffy, Lewis and Miller was replicated during February 1990. The actual six-year data was substituted for the 1984 assumptions. Physician Manpower The 1990 physician manpower was calculated from source documents provided by Oklahoma Board of Medical Licensure and Supervision (allopathic physicians) and the Oklahoma Osteopathic Association (osteopathic physicians).<br><br> The allopathic and osteopathic manpower count was as of February 1990. The source document were custom printouts produced for this study. The 1990 physician manpower includes :The 1990 physician manpower excludes : Active licensed physiciansLicensed physicians in GME Programs Licensed semi-retired physiciansLicensed retired physicians Licensed federal physiciansUnlicensed physicians in internships and PGY-1 years Licensed faculty/research physiciansLicensed physicians practicing out-of-state Licensed physicians in administrative positionsPhysicians with suspended licenses Licensed SMD physicians (supervised medical doctors - interns) Population Estimates Physician-to-population ratios calculated between official Bureau of the Census population counts must rely upon estimates.<br><br> State population estimates undergo constant revision as predictor variable values change. In 1984, Duffy et. al.<br><br> used the population estimate for 1990 of 3,569,842. This study used 3,309,700 as provided by the Oklahoma State Department of Commerce in March 1990. That estimate has since been reduced to 3,224,000 in July 1989.<br><br> Preliminary census data shows a population of 3,123,799. Licensed Physicians in GME Programs There were 567 licensed physicians in GME residency or fellowship programs in 1990. The Oklahoma Board of Medical Licensure and Supervision provided the count of 468 licensed physicians in allopathic training programs.<br><br> 3 The Office of the Dean, University of Oklahoma College of Medicine (OU-CM) provided the count of 41 licensed DO physicians in allopathic GME programs 4 and the Oklahoma Osteopathic Association Directory 5 showed 58 licensed DO physicians in DO and other GME programs in Oklahoma. Physicians in the initial year of postgraduate training or internships are not licensed and therefore not included in the census of licensed physician manpower. Categorization of Specialties General physicians refer to those with one year of GME and family physicians refer to those with three years of GME.<br><br> All physicians were categorized by specialty in accordance with the 85 officially designated AMA classifications 6 We regrouped the individual physician specialties into seven specialty groups: Family/General, Internal Medicine, Pediatrics, Obstetrics & Gynecology, Hospital- Based, Psychiatry and Surgery. The grouping aggregate specialties which share common first years of training. The specialties within a group have a certain degree of overlap in their capacity for providing medical services.<br><br> This categorization differs from the classifications used by Duffy, Lewis and Miller. We believe this specialty grouping provides a better analysis tool that examines physician groups by common professional training and function. 3 Oklahoma Board of Medical Licensure and Supervision, custom report, February 11, 1990.<br><br> 4 Custom report as of January 1990, Office of the Dean, University of Oklahoma College of Medicine, Oklahoma City, OK. 5 1989-1990 Annual Directory, The Journal of the Oklahoma Osteopathic Association, September 1989. 6 Physician Characteristics and Distribution in the United States, 1987 edition, American Medical Association.<br><br> October 1990Michael Lapolla, MHA; F. Daniel Duffy, MD; and C.S. Lewis, Jr., MDPage 2-2 Second in a Series ...Physician Manpower Revisited in 1990 Family and General Physicians The data tables and text will specify either family of general physicians.<br><br> For the purposes of this analysis family physicians are those MD and DO physicians successfully completing an accredited three year residency training program in Family Practice. General physicians are those MD and DO physicians entering practice upon the completion of a single internship year, or prior to the completion of a multi-year residency training program. The difference is important as professional and public policy encourages additional graduate medical education for all physicians.<br><br> GME Production 1984-89 The Oklahoma GME production by specialty was reported by the sponsoring academic institution or hospital. Some GME programs (Internal Medicine and Pediatrics) have graduates who routinely pursue additional GME sub-specialty (fellowship) training. The reported residency program output was reduced by those pursuing fellowships or training in another residency.<br><br> This was done to eliminate over-counting graduates of preliminary GME experiences. To provide the true output of General Practice DO physicians, those completing internships in Oklahoma were similarly reduced by those pursuing residency training . Data for College of Osteopathic Medicine - Oklahoma State University (COM- OSU) graduates completing internship training and directly entering practice was provided by the COM-OSU.<br><br> Interns and residents from other schools were determined from reports provided by the sponsoring hospital's GME programs. Additional data was collected for practice sites and other GME experience for the specialties of Family Practice, Obstetrics & Gynecology, Psychiatry and General Surgery to compare both campuses of the University of Oklahoma College of Medicine. The GME production of all other residencies at the University of Oklahoma College of Medicine-Oklahoma City was obtained from the individual programs through the Office of the Dean.<br><br> Attrition Rates Duffy et al. assumed the rate of physicians leaving practice due to retirement, out-migration, or death was 1.6% per year, and revised this estimate upward in 1986 to 2%. Unfortunately, reliable sources do not exist to provide a true count of physician attrition rates.<br><br> The membership secretaries at the OSMA and OOA estimate that 70-80 (MD) and 10-15 (DO) physicians lapse membership each year. This is 2% per year. The Center for Health Policy Research conducted an age analysis of Oklahoma physicians, by specialty, in 1988 7 .<br><br> This study indicated that an average of 143 physicians will reach age 65 annually during 1988-1998. If all these physicians retired, an attrition rate of 2.9% of the practicing physician manpower would result. In this paper we used the 2.9% attrition rate.<br><br> Net Migration In & Out of Oklahoma The net migration is a calculated number. It represents the net number of licensed physicians moving into or from Oklahoma during 1984-90. It is the net result of the change in manpower during 1984-90 plus the Oklahoma GME graduates practicing in Oklahoma and less the estimated physicians lost to practice through attrition.<br><br> 7 Lapolla, MHA, Michael P., Age Analysis of Oklahoma Physicians, OMRF Center for Health Policy Research, 1988. October 1990Michael Lapolla, MHA; F. Daniel Duffy, MD; and C.S.<br><br> Lewis, Jr., MDPage 2-3 Second in a Series ...Physician Manpower Revisited in 1990 Results The summary findings shown at Table 2-1, and the detailed tables in Appendix 2-1 and Appendix 2-2, demonstrate the actual physician manpower changes that occurred during 1984-90, and provides an overview, by specialty group, of the components of physician manpower change. The table uses the same specialties used in the Duffy et al. paper but groups them into the seven specialty groupings developed by the authors in this analysis.<br><br> Table 2-1 Abbreviated Oklahoma Physician Manpower Production Model for 1984-90 * The projections By Duffy, Lewis and Miller estimated physician in-migration by specialty group, not by specialty. This table (column 8) allocates the assumed in-migration to each specialty estimate proportionately. In column 9, positive numbers are over-projections; negative numbers are under-projections 123456789 Oklahoma Physician Changes for 1984-90Projection Variation 19841984-90OK Grads inPhysician19901984-90*ProjectedProjection Manpower Attrition OK Practice Migration Manpower Gain/Loss for 1990 Variation Family/General1,348-302217531,316-321,604288 Obstetrics & Gynecology257-342822273162741 Medicine Specialties834-123215239491151,087138 Pediatric Specialties292-4059-182931410117 Hospital Specialties659-1049210274990917168 Surgical Specialties814-15572112843291,122279 Psychiatric Specialties207-6934532251827954 Other Physicians 39 -8 23 22 76 37 95 19 Total Practitioners4,450-8337403674,7242745,7851,061 Projection totals in column 8 off slightly due to rounding.<br><br> Column 1 is the specialty group. Column 6 is the sum of columns 2-5. Column 7 equals column 6 minus column 2.<br><br> Column 8 is the 1990 manpower projection for the specialty group as estimated by Duffy, Lewis and Miller in 1985. Column 9 is the difference between column 8 and column 6. Total Physician Manpower Change There were 4,450 MD and DO licensed physicians (excluding physicians in GME training programs) in Oklahoma in 1984.<br><br> By 1990, the census grew to 4,724 practicing licensed physicians. This was a 6.2% increase over the six year period; or a rate of 1% annually. Inputs and Outputs of the Manpower Change The change in physician manpower was increased by the 740 Oklahoma GME graduates practicing in Oklahoma and 367 physicians moving to Oklahoma from elsewhere.<br><br> Decreases occurred from 833 physicians leaving practice due to retirement, death or other reasons. Changes by Specialty Categories The Duffy, Lewis and Miller study projected physicians in three specialty categories They were primary, secondary and tertiary care. During the six year period of 1984-90, primary care specialties increased by 7 physicians (0.3%); secondary care physicians by 208 (11.8%); and tertiary care physicians by 22 (6.4%).<br><br> October 1990Michael Lapolla, MHA; F. Daniel Duffy, MD; and C.S. Lewis, Jr., MDPage 2-4 Second in a Series ...Physician Manpower Revisited in 1990 Changes by Individual Specialty The only overall loss within a specialty group occurred in family and general practice.<br><br> The decrease of 32 physicians is the net result of a large gain of 83 family practice physicians, the gain of one preventive medicine physician, and a loss of 57 MD general physicians and 59 DO general physicians. The largest gains were in the medical specialties with 215 Oklahoma GME graduates and 23 physicians moving to Oklahoma that offset 123 physicians lost to attrition. This provided a net gain of 115 medical physicians or a 14% increase.<br><br> The hospital specialty group also had a large proportional gain of 14% by adding 90 physicians. The pediatric specialty group remained static with a net gain of one practicing physician. The largest decrease in individual specialties occurred in DO General Practice and MD General Practice.<br><br> Few new MD physicians will be one-year trained general practice physicians. The manpower in these two specialties declined by 116 physicians during 1984-90. This represented over a 15% decrease.<br><br> The largest gaining specialties were Family Practice (increase of 83 or 15%) and Cardiology (increase of 56 or 95%) P hysician-to-100,000 Population (PTP) Ratio Change The projections for 1990 Oklahoma physician manpower made in 1984, and revised in 1986, were overestimates compared to 1990 reality. The 1984 estimates were for a 1990 PTP ratio of 167 by 1990.The PTP ratio in 1984 was 141 physicians per 100,000 population; it increased to 155 in 1986 and declined to 149 in 1990. This represented a 5.7% increase over the six year period, or less than 1% per year.<br><br> All of the physician manpower growth for the six year 1984-90 period occurred during 1984-86. Between 1986 and 1990 the absolute number of physicians declined 2% and the physician to population ratio fell 4% as both the numbers of practicing physicians and state population decreased. The period of 1984-86 demonstrated the last attributes of the "oil boom" and 1986-90 reflected the effects of the "oil bust." Figure 2-1 Estimates of 1990 Physicians-to-100,000 Population Compared to Actual Ratio 141 1984 Estimated 1990 Actual 167 149 155 1986 Changes in Primary Care Specialties The "primary care" specialties, as defined by the Oklahoma Physician Manpower Training Commission, include family and general practice as well as pediatrics, internal medicine and obstetrics & gynecology.<br><br> The 1984 estimates suggested that Oklahoma would add 440 (revised in 1986 to 329) primary care physicians by 1990. During 1984-90 the number of primary care physicians increased by 7. October 1990Michael Lapolla, MHA; F.<br><br> Daniel Duffy, MD; and C.S. Lewis, Jr., MDPage 2-5 Second in a Series ...Physician Manpower Revisited in 1990 1990 Physician Manpower Compared to Projections The estimates of Duffy, Lewis and Miller projected that physician manpower would grow 30% from 4,450 in 1984 to 5,785 physicians in 1990. The actual 1990 manpower was 4,754.<br><br> They also projected that the PTP ratio would grow 18% from 141 physicians per 100,000 population in 1984 to 167 per 100,000 population in 1990. The actual 1990 ratio was 149 physicians per 100,000 population, and the actual growth rate was 5.7%. The predictions of the Bureau of Health Professions of the Department of Health and Human Services were not accurate either.<br><br> It projected that the PTP ratio in Oklahoma would be 159. The population was estimated to increase 9% from 3.3 million to almost 3.6 million. Finally, The physicians per 100,000 population were projected to grow 18% from 141 to 167.<br><br> Over 600 physicians were assumed to migrate into Oklahoma during 1984-90 when only an estimated 367 did. Finally, an estimated 548 physicians were estimated to leave practice but an estimated 833 did so. The population grew at less than one-half percent, the physician manpower increased by 6.1%, and the physician to 100,000 population ratio increased 5.7% from 141 to 149.<br><br> And a significant out-migration of physicians occurred. During the prosperous economic period of 1975-84, Oklahoma was a net gainer of physicians. During 1985-90, Oklahoma became a significant loser.<br><br> The specialties most over-estimated for Oklahoma were DO General Practice (233), General Surgery (111), Pediatrics (89), MD General Practice (81), Radiology (67) and Internal Medicine and Anesthesiology (both 62). The two specialties most under-estimated were Family Practice (-33) and Cardiology (-22). Annual Growth Rates The annual rate of Oklahoma physician manpower growth during 1984-90 was 1%.<br><br> The equivalent rate of growth for the United States was 3.2% for 1984-87 8 . In perspective, the national rate of physician growth was approximately three times that of Oklahoma during the past six years. At least during this period, any perceived national "surplus" was not overflowing into Oklahoma.<br><br> Figure 2-2 demonstrates the Oklahoma manpower changes. During the same period Oklahoma GME programs produced 740 physicians who selected an Oklahoma practice. The estimated attrition of practicing physicians was 833.<br><br> The Oklahoma programs did not provide for Oklahoma enough practicing graduates to offset the estimated attrition. There were 649 Oklahoma GME graduates who left Oklahoma for an out-of-state practice. Their out-migration was partially offset by an in-migration of 367 physicians.<br><br> 8 Persoanal Correspondence with the American Medical Association and American Osteopathic Association. October 1990Michael Lapolla, MHA; F. Daniel Duffy, MD; and C.S.<br><br> Lewis, Jr., MDPage 2-6 Second in a Series ...Physician Manpower Revisited in 1990 Figure 2-2 Oklahoma Physician Manpower Changes for 1984 to 1990 4,724 740 367 4,450 1990 Oklahoma Physician Manpower Estimated Physicians Lost to Practice Through Attrition 1984 Oklahoma Physician Manpower In-Migration of Licensed Practicing Physicians Oklahoma GME Graduates Oklahoma Practice Oklahoma GME Graduates Out-of-State Practice 833 649 Analysis of Projections Projections of physician manpower for the United States result directly from medical school enrollments since very few US graduates seek practice opportunities out of the country. However, projections of physician manpower for a state are quite different since physicians may freely move in and out of states seeking practice opportunities. The three major sponsors of national physician manpower projection models are the Bureau of Health Professions of DHHS (BHPr), the American Medical Association (AMA), and the Graduate Medical Education National Advisory Committee (GMENAC).<br><br> The GMENAC model is an adjusted needs based model that is specialty specific. The BHPr model is a demand based model. The AMA model projects based upon current utilization adjusting for demographic changes, and projects supply of MD/DO physicians by most specialties and demand for all specialties.<br><br> 9 National supply prediction models can be fairly accurate when dealing with the United States as a closed system. Within a particular state, there is inherent risk in applying a national model or relying upon state-specific projections from a national model. Short-term projections, much less long-term ones, are difficult to make when examining physician manpower trends within states and regional areas.<br><br> As shown in Table 2-2, both the Duffy et al., and national estimates, projected much higher Oklahoma physician numbers for 1990 than actually occurred. The Duffy et al. model projected 5,978 practicing physicians in Oklahoma in 1990.<br><br> The Bureau of Health Professions of the Department of Health and Human Services projected Oklahoma to have 5,560 active MD physicians in 1990 10 and did not include the approximately 700 practicing osteopathic physicians in Oklahoma. 9 Weiner, Jonathan P., Forecasting Physician Supply: Recent Developments, Health Affairs, Winter 1989. 10 Projections of Physician Supply in the U.<br><br> S., Bureau of Health Professions, U. S. Department of Health and Human Services, March 1985.<br><br> October 1990Michael Lapolla, MHA; F. Daniel Duffy, MD; and C.S. Lewis, Jr., MDPage 2-7 Second in a Series ...Physician Manpower Revisited in 1990 These projections for Oklahoma, coupled with national debate concerning physician oversupply, occurred at the same time that the University of Oklahoma College of Medicine Admissions Committee reduced their medical school enrollment.<br><br> (See the first paper in this series, Medical Education in Oklahoma). The Oklahoma State Medical Association Council on Medical Education recognized that the state population and economy were leveling in the mid-decade of the 1980s. 11 Nonetheless, the Council assumed that Oklahoma would attain a physician-to-100,000-population ratio of 185 by 1999 given 1984 medical school enrollments.<br><br> Concern about the potential oversupply of physicians, nationally and locally, formed the basis for the recommendation to reduce the University of Oklahoma class size to 15% less than the 1984 enrollment. The recommendation assumed there would be a linear relationship between medical school class size in Oklahoma and the number of practicing physicians in the state. It failed to recognize the large cohort of aging primary care physicians and the free choice of movement in and out of state seeking practice opportunity.<br><br> The various projections are summarized in the tables below: Table 2-2 Physician-to-Population Ratio Projections for 1990 12 Physician to 100k Projections for Oklahoma Population 1990 Duffy, Lewis and Miller in 1984167 Duffy, Lewis and Miller revised in 1986161 Bureau of Health Professions, DHHS159 Actual 1990 Manpower149 Table 2-3 Physician Growth Projections for 1990 13 1984-901984-901984-90 Growth Projections for U.S. MD Growth DO Growth Overall Growth Bureau of Health Professions, DHHS15.4%33.7%16.1% Projections for Oklahoma Duffy, Lewis and Miller in 198427.1%37.8%28.8% Actual (for Oklahoma)6.2%0.0%5.8% The actual number of practicing physicians in Oklahoma in 1990 was 1,056 physicians less than that projected by the Duffy, Lewis and Miller and 1,548 less than projected by the DHHS-BHP. The projections were over-estimated by a factor of 3.9-5.6 compared to actual 1990 data.<br><br> The largest physician manpower component in Oklahoma are family and general practice physicians. They represented 30% of all practicing physicians in 1984 and lost 32 physicians for a net loss rate of 2.4% during 1984-90. 11 Physician Manpower Production Critique: State of Oklahoma, Oklahoma State Medical Association Council on Medical Education, Journal of the Oklahoma State Medical Association, pages 191-194.<br><br> June 1985. 12 Projections of Physician Supply in the U. S., Bureau of Health Professions, U.<br><br> S. Department of Health and Human Services, March 1985. Duffy, F.<br><br> Daniel, MD, Lewis, C.S. , MD, and Miller, MS, Deborah A., Estimated Physician Manpower Requirements for 1990, Journal of the Oklahoma Medical Association, Vol 78, No 6, pages 183-190, June 1985. 13 Ibid.<br><br> October 1990Michael Lapolla, MHA; F. Daniel Duffy, MD; and C.S. Lewis, Jr., MDPage 2-8 Second in a Series ...Physician Manpower Revisited in 1990 1985 Conclusions Compared to 1990 Outcomes Listed below are the conclusions as presented in the 1985 analysis "Estimated Manpower Requirement for Oklahoma in 1990." 14 A short discussion of the 1990 outcome is to the right.<br><br> 1984 Predictions Physician Manpower for 1990 Oklahoma will have 167 physicians per Using the same computation, Oklahoma had 149 100,000 population in 1990.physicians per 100,000 population in 1990. Foreign Medical Graduates will represent an increasingBeginning in 1985, modified licensure regulations, number of physicians in practice in Oklahoma. coupled with state economic and demographic factors, resulted in a precipitous decline of the FMG's practicing in Oklahoma.<br><br> The FMG census will be essentially driven by Oklahoma allopathic GME programs accepting FMG applicants in order to fill positions. The ratio of DOs in Oklahoma's physician populationThe percentage of DOs in the 1990 physician will increase from 1973's 15% to 19% in 1990. population is less than 15%.<br><br> There will be more one-year trained physiciansThere are fewer one-year, and more three-year, (in Oklahoma) by 1990, and fewer three-year trainedtrained physicians in 1990 than in 1984. primary care physicians than the GMENACThis occurred not so much as the result of new study recommends unless there are changesprograms for students, but rather because more in DO GME emphasis and programs.individual DO students selected multi-year GME programs. .<br><br> The other conclusions of the original paper were concerning the application of GMENAC need ratios to various specialties and geographic areas. These issues will be discussed in subsequent studies. There was essentially no change in the number of primary care physicians per population during 1984- 90.<br><br> However, the mix of primary care specialties did change. The number of one-year (MD & DO) physicians decreased by 116 (15%), and the number of three-year residency-trained physicians (allopathic and osteopathic) increased by 123 (8%). In 1984, 33% of primary care physicians had one year of post graduate training; in 1990, the percentage dropped to 28%.<br><br> Graduate Medical Education Inputs to 1990 Manpower There were 1,576 graduates of Oklahoma-based graduate medical education programs during 1984-89. Of these graduates, 1,389 entered the practice of medicine; 740 into an Oklahoma practice and 649 into a practice elsewhere. There are 187 physicians still in the GME pipeline.<br><br> In the table below, MD programs include preliminary and transitional programs as well as residencies and fellowships. The DO programs include osteopathic internships and residencies. 14 Duffy, F.<br><br> Daniel, MD, Lewis, C.S. , MD, and Miller, MS, Deborah A., Estimated Physician Manpower Requirements for 1990, Journal of the Oklahoma Medical Association, Vol 78, No 6, pages 183-190, June 1985. October 1990Michael Lapolla, MHA; F.<br><br> Daniel Duffy, MD; and C.S. Lewis, Jr., MDPage 2-9 Second in a Series ...Physician Manpower Revisited in 1990 Table 2-4 Graduate Medical Education Inputs to Oklahoma Physician Manpower for 1984-89 OklahomaOut-of-StateStill in1984-89 GME Practice Practice GME Program Graduates MD GME Programs582473741,129 DO GME Programs 158 176 113 447 All Oklahoma-based Programs7406491871,576 Physician Migration Patterns In 1984 it was assumed that out-migrating graduates of Oklahoma primary care GME programs would be offset by an in-migration of out-of-state GME graduates and other practicing primary care physicians. An essential component of the assumption was that the osteopathic internship programs in Oklahoma would produce 246 general practice DO physicians.<br><br> In fact, there were 357 graduates of these programs, but only 177 entered general practice (108 in Oklahoma and 69 out-of-state including military). The other 180 internship graduates entered GME programs (71 in Oklahoma and 109 out-of-state), Many (113) were still in these programs as of January 1990 including 51 in Oklahoma programs and 62 in out-of-state programs. The six year production of general practice DO physicians was overestimated by 75.<br><br> Foreseen Problems with 1984 Projection Methods Duffy, Lewis and Miller identified five potential problem areas within their study. Three of the five did cause problems, the fourth concerned the Oral Roberts University medical school which closed in 1989 and did not affect this analysis, and the fifth (health care system organization) is difficult to measure and not discussed in this analysis. The potential problem areas were: Physician Attrition Rate The Duffy, Lewis and Miller study assumed an annual attrition rate of 1.6% or 548 physicians lost to practice over the six year projection period.<br><br> It was discussed within the study that this was a very conservative estimate. The aging of the general physician population, with the associated effects upon attrition, was probably underestimated. Accurate attrition rates are almost impossible to accurately analyze from existing data bases.<br><br> The attrition rate for practicing physicians was probably closer to 3% based upon age alone. In 1987 it was calculated that approximately 143 physicians would reach age 65 annually between 1988-1997. The numbers would vary by specialty.<br><br> 15 The 3% attrition rate would have yielded over 800 physicians lost to practice due to retirement during 1984-90 compared to the assumed 548 in the study. Interviews with physician association membership staff suggest the attrition would be a minimum of 110 per year, or at least 660 during the six years of 1984-89. Population Growth The best population growth estimates at the time were based upon retrospective calculations using historical (1981-83) employment data.<br><br> These estimates proved very inaccurate due to the rapidly declining state economic situation. They were corrected in the latter part of the decade. 15 Age Analysis of Oklahoma Physicians, OMRF Center for Health Policy Research, unpublished, 1988.<br><br> October 1990Michael Lapolla, MHA; F. Daniel Duffy, MD; and C.S. Lewis, Jr., MDPage 2-10 Second in a Series ...Physician Manpower Revisited in 1990 Physician In-Migration to Oklahoma The 1984 study assumed an in-migration of 624.<br><br> The migration variable is the net sum of GME graduates leaving/returning to Oklahoma, and physicians trained outside of Oklahoma, entering practice in Oklahoma. The 1975-84 trends suggested a continued net importing of physicians. However, during 1984-90 there occurred a net out-migration of 282 causing an overprojection of 906.<br><br> Oral Roberts University These medical school graduates were not included in the 1984 projections. The school closed in 1989. October 1990Michael Lapolla, MHA; F.<br><br> Daniel Duffy, MD; and C.S. Lewis, Jr., MDPage 2-11 Second in a Series ...Physician Manpower Revisited in 1990 Summary The projection efforts by Duffy, Lewis and Miller used a methodology that was sound, logical and based upon empirical data. Given that the predictions were made for the period of the next six succeeding years, there was every reason to believe that they would be accurate.<br><br> However, the dramatic changes to the Oklahoma economic infrastructure, combined with unforeseen changes in population patterns, caused a well constructed projection model to over-project the 1990 Oklahoma physician manpower. Some unexpected changes in the professional choices of physicians graduating from Oklahoma DO internships contributed to an overestimate. Some of the more significant observations are listed below: " There were 4,027 MD physicians and 697 DO physicians included as active physicians in the 1990 Oklahoma physician manpower count.<br><br> This compares to a 1984 count of 3,752 and 698 respectively. Primary care physicians, as defined by the Oklahoma Physician Manpower Training Commission, increased by 7 physicians. " Oklahoma-specific estimates by national forecasting models overestimated the Oklahoma physician manpower for 1990.<br><br> The Duffy, Lewis and Miller projections overestimated Oklahoma's 1990 physician supply by over 1,000 physicians. " The Oklahoma physician manpower grew at only one-third of the annual rate of the national supply. During 1984-90, Oklahoma physicians increased by only 1% per year as opposed to a national growth rate of 3.2%.<br><br> The perceived national "surplus" did not overflow into Oklahoma. Oklahoma-based GME programs produced 740 physicians choosing to practice in Oklahoma. These physicians replaced about 89% of the estimated 833 physicians leaving practice.<br><br> The remainder of the replacement and small growth of manpower was the result of 367 licensed physicians moving into Oklahoma to establish practice. " All of the physician manpower growth for the six year period occurred during 1984-86. Between 1986 and 1990 the absolute number of physicians declined 2% and the physician to population ratio fell 4% as both the numbers of practicing physicians and state population decreased.<br><br> Oklahoma Physician Manpower% Changes in Physician Manpower 1984 1986 1990 1984-86 1986-90 1984-90 Family/General Specialties1,3481,3991,3164%-6%-2% Obstetrics & Gynecology2572752737%-1%6% Medicine Specialties83493894912%1%14% Pediatric Specialties2922942931%0%0% Hospital Specialties65974474913%1%14% Surgical Specialties8148458434%0%4% Psychiatric Specialties2072232258%1%9% Other Physicians 39 82 76 Total Practitioners4,4504,8004,7248%-2%6% Adj Phys/100k Pop *14115514910%-4%6% * Adj Phys/100k Pop includes licensed physicians in GME programs; the count in the specialty table does not. " The largest absolute growth by individual specialty occurred in family practice (+83), cardiology (+56), and anesthesiology (+29). The largest proportional growth occurred in cardiology (+49%), child psychiatry (+41%), physical medicine (+36%) and hematology/oncology (+23%).<br><br> The most significant decrease occurred in general practice with a loss of 116 physicians or a loss of 15%. October 1990Michael Lapolla, MHA; F. Daniel Duffy, MD; and C.S.<br><br> Lewis, Jr., MDPage 2-12 Appendix 2-1Oklahoma Physician Manpower Production Model for 1984-90 The Physician Manpower Production Model is on the page following this text. Listed below are explanatory notes for each column of this model. Column 1 Includes physician specialties grouped in one of seven categories.<br><br> Column 2 The number, by specialty, of physicians in Oklahoma in 1984 as calculated by the Regents Advisory Committee. Some unlisted specialties not calculated by GMENAC are grouped with listed ones per the indexing methodology of the American Medical Association. Column 3 The OMRF Center for Health Policy Research performed a study of Physician Age Analysis in 1988.<br><br> The figure in this column represents the number of physicians, by specialty, that will reach age 65 during the period 1985-90. This calculation is used in lieu of less precise available data concerning physicians lost to practice. These figures are greater than those used by the Regents Advisory Committee.<br><br> The Committee assumed an annual loss of 1.6% of active physicians. Column 4 The number of graduates of 1984-89 Oklahoma-based GME programs, by final specialty, practicing in Oklahoma. Final specialty training may be achieved out-of-state after completing an Oklahoma program.<br><br> For example, DO interns graduating from Oklahoma programs may elect to directly enter practice as general physicians, or seek additional GME. It is calculated that 102 of the 347 intern graduates entered Oklahoma practice as general physicians. If they chose to pursue additional GME then establish a practice in Oklahoma, they will appear under their final specialty rather than as a general physician.<br><br> For example, if a DO intern graduate enrolled in a Surgery GME program, then returned to Oklahoma, that physician would be categorized as a GME graduate in Surgery practicing in Oklahoma. Column 5 This is the calculated in-migration of licensed physicians. The figure is defined as Column 6 - (Columns 2 + 3 + 4).<br><br> Column 6 The census of Oklahoma practicing physicians as of January 1990. See Column 1, above. Column 7 The difference between Columns 6 and 2 Column 8 - Estimated for 1990 The 1990 projections, by specialty, of the Advisory Committee for the State Regents.<br><br> The Committee calculated the estimated 1990 manpower by specialty, then assumed in-migration values in bulk by specialty groups. This column proportionately allocates the assumed in-migration to each specialty, then adds it to the individual specialty projection. Column 9 - Projection Variation The difference between Column 8 (Estimated for 1990) and Column 6.<br><br> October 1990Michael Lapolla, MHA; F. Daniel Duffy, MD; and C.S. Lewis, Jr., MDPage 2-13 Appendix 2-1Oklahoma Physician Manpower Production Model for 1984-90 Oklahoma Physician Manpower Production Model for 1984-90 * The projections By Duffy, Lewis and Miller estimated physician in-migration by specialty group, not by specialty.<br><br> This table (column 8) allocates the assumed in-migration to each specialty estimate proportionately. In column 9, positive numbers are over-projections; negative numbers are under-projections 123456789 Oklahoma Physician Changes for 1984-90Projection Variation 1984EstimatedOK Grads inOther1990Actual*Physicians Census of1984-90OklahomaPhysicianCensus of1984-90ProjectedProjection Physicians Attrition Practice In-Migration Physicians Gain/Loss for 1990 Variation Family/General Family Practice (3 yrs GME)541-1161158462483591-33 MD General Practice (1 yr GME)252-11558195-5727681 DO General Practice (1 yr GME)501-56102-105442-59675233 Preventive Medicine 54 -15 0 16 55 1 62 7 Sub-totals1,348-302217531,316-321,604288 Obstetrics & Gynecology257-342822273162741 Medicine Specialties General Internal Medicine487-70103-135072056962 Allergy 23-50-117-6269 Cardiology59-1511601155693-22 Dermatology49-12595127019 Hematology/Oncology36-320-64711536 Endocrinology16-19-1014-22511 Gastroenterology46-118-756106812 Infectious Disease9011-128-1135 Nephrology17-15-21923011 Neurology43-51345512638 Pulmonary28-413-13685317 Rheumatology 21 -6 7 2 24 3 24 0 Sub-totals834-123215239491151,087138 Pediatric Specialties General Pediatrics264-3553-14268435789 Neonatology12-1401532813 Pediatric Allergy Pediatric Cardiology Pediatric Encocrinology Pediatric Hem/Oncology Pediatric Nephrology Pediatric Subspecialties: 16 -4 2 -4 10 -6 25 15 Sub-totals292-4059-182931410117 Hospital Specialties Anesthesiology177-3537272062926862 Emergency Medicine142-416101642219329 Pathology112-209241251314015 Radiology215-4029292331830067 Nuclear Medicine4-113736-1 Physical Medicine (Rehab) 9 -4 0 9 14 5 10 -4 Sub-totals659-1049210274990917168 Surgical Specialties General Surgery286-613117273-13384111 Neurosurgery34-7563844810 Ophthalmology132-26825139717738 Orthopedic Surgery153-2610321691621041 Otorlaryngology61-106197615793 Plastic Surgery30-4233114211 Thoracic Surgery35-70-721-146140 Urology 83 -14 10 17 96 13 121 25 Sub-totals814-15572112843291,122279 Psychiatric Specialties Child Psychiatry10-4101177225 Psychiatry 197 -65 24 52 208 11 257 49 Sub-totals207-6934532251827954 Other Physicians39-8232276379519 Total Practitioners4,450-8337403674,7242745,7851,061 October 1990Michael Lapolla, MHA; F. Daniel Duffy, MD; and C.S.<br><br> Lewis, Jr., MDPage 2-14 Appendix 2-1Oklahoma Physician Manpower Production Model for 1984-90 Oklahoma Physician Manpower Production Model for 1984-90 * The projections By Duffy, Lewis and Miller estimated physician in-migration by specialty group, not by specialty. This table (column 8) allocates the assumed in-migration to each specialty estimate proportionately. In column 9, positive numbers are over-projections; negative numbers are under-projections 123456789 Oklahoma Physician Changes for 1984-90Projection Variation 1984EstimatedOK Grads inOther1990Actual*Physicians Census of1984-90OklahomaPhysicianCensus of1984-90ProjectedProjection Primary Care Physicians Attrition Practice In-Migration Physicians Gain/Loss for 1990 Variation Family Practice (3 yr GME)541-1161158462483591-33 MD General Prac (1 yr GME)252-11558195-5727681 DO General Prac (1 yr GME)501-56102-105442-59675233 Internal Medicine487-70103-135072056962 Pediatrics264-3553-14268435789 Obstetrics & Gynecology 257 -34 28 22 273 16 274 1 Primary Care Totals2,302-427401332,30972,742433 Secondary Care Anesthesiology177-3537272062926862 Cardiology59-1511601155693-22 Child Psychiatry10-4101177225 Dermatology49-12595127019 Emergency Medicine142-416101642219329 General Surgery286-613117273-13384111 Hematology/Oncology36-320-64711536 Ophthalmology132-26825139717738 Orthopedic Surgery153-2610321691621041 Otorlaryngology61-106197615793 Pathology112-209241251314015 Preventive Medicine54-15016551627 Psychiatry197-6524522081125749 Radiology215-4029292331830067 Urology 83 -14 10 17 96 13 121 25 Secondary Care Total1,766-3502263321,9742082,426452 Tertiary Care Allergy 23-50-117-6269 Endocrinology16-19-1014-22511 Gastroenterology46-118-756106812 Infectious Disease9011-128-1135 Neonatology12-1401532813 Nephrology17-15-21923011 Neurology43-51345512638 Neurosurgery34-7563844810 Nuclear Medicine4-113736-1 Pediatric Subspecialties:16-42-410-62515 Pediatric Allergy Pediatric Cardiology Pediatric Encocrinology Pediatric Hem/Oncology Pediatric Nephrology Physical Medicine (Rehab)9-40914510-4 Plastic Surgery30-4233114211 Pulmonary28-413-13685317 Rheumatology21-672243240 Thoracic Surgery 35 -7 0 -7 21 -14 61 40 Tertiary Care Totals343-4990-193652252215 Other Physicians 39 -8 23 22 76 37 95 19 Total Practitioners4,450-8337403674,7242745,7851,061 Total Licensed Residents55056717550-17 Residents @ .35 FTE1931986193-5 Adj Phys/100k Pop141149816718 Note: These primary, secondary and tertiary specialty groupings are included for comparisons to previous projections.<br><br> October 1990Michael Lapolla, MHA; F. Daniel Duffy, MD; and C.S. Lewis, Jr., MDPage 2-15 Appendix 2-2Oklahoma Physician Manpower Changes for 1984-86-90 Oklahoma Physician Manpower% Changes in Physician Manpower 1984 1986 1990 1984-86 1986-90 1984-90 Family/General Specialties MD Fam/Gen Practice7938858194%-7%3% DO General Practice501455442-9%-3%-13% Preventive Medicine 54 59 55 9% -7% 2% Sub-totals1,3481,3991,3164%-6%-2% Obstetrics & Gynecology2572752737%-1%6% Medicine Specialties Internal Medicine4875025073%1%4% Allergy 2323170%-26%-35% Cardiology59123115108%-7%49% Dermatology49565114%-9%4% Endocrinology1616140%-13%-14% Gastroenterology4646560%22%18% Hematology/Oncology36434719%9%23% Infectious Disease910811%-20%-13% Nephrology1718196%6%11% Neurology4347559%17%22% Pulmonary28333618%9%22% Rheumatology 21 21 24 0% 14% 13% Sub-totals83493894912%1%14% Pediatric Specialties Pediatrics2642702682%-1%1% Neonatology1212150%25%20% Pediatric Subspecialties: Pediatric Allergy2220%0%0% Pediatric Cardiology654-17%-20%-50% Pediatric Encocrinology100-100% Pediatric Hem/Oncology533-40%0%-67% Pediatric Nephrology 2 2 1 0% -50% -100% Sub-totals2922942931%0%0% Hospital Specialties Anesthesiology17721720623%-5%14% Emergency Medicine1421471644%12%13% Nuclear Medicine45725%40%43% Pathology1121221259%2%10% Physical Medicine (Rehab)9151467%-7%36% Radiology 215 238 233 11% -2% 8% Sub-totals65974474913%1%14% Surgical Specialties General Surgery286268273-6%2%-5% Neurosurgery34383812%0%11% Ophthalmology1321381395%1%5% Orthopedic Surgery1531671699%1%9% Otorlaryngology61747621%3%20% Plastic Surgery30353117%-11%3% Thoracic Surgery353021-14%-30%-67% Urology 83 95 96 14% 1% 14% Sub-totals8148458434%0%4% Psychiatric Specialties Child Psychiatry10111710%55%41% Adult Psychiatry 197 212 208 8% -2% 5% Sub-totals2072232258%1%9% Other Physicians398276 Total Practitioners4,4504,8004,7248%-2%6% Total Licensed Residents550580567 Residents @ .35 FTE193203198 Adj Phys/100k Pop14115514910%-4%6% 1984 - as of September 1984; 1986 - as of September 1986; 1990 - as of February 1990 October 1990Michael Lapolla, MHA; F.<br><br> Daniel Duffy, MD; and C.S. Lewis, Jr., MDPage 2-16 Appendix 2-2Oklahoma Physician Manpower Changes for 1984-86-90 Oklahoma Physician Manpower% Changes in Manpower Primary Care 1984 1986 1990 1984-86 1986-90 1984-90 Fam/Gen Practice (MD)7938858194%-7%3% General Practice (DO)501455442-9%-3%-13% Internal Medicine4875025073%1%4% Pediatrics2642702682%-1%1% Obstetrics & Gynecology 257 275 273 7% -1% 6% Primary Care Totals2,3022,3872,3094%-3%0% Secondary Care Anesthesiology17721720623%-5%14% Cardiology59123115108%-7%49% Child Psychiatry10111710%55%41% Dermatology49565114%-9%4% Emergency Medicine1421471644%12%13% General Surgery286268273-6%2%-5% Hematology/Oncology36434719%9%23% Ophthalmology1321381395%1%5% Orthopedic Surgery1531671699%1%9% Otorlaryngology61747621%3%20% Pathology1121221259%2%10% Preventive Medicine5459559%-7%2% Psychiatry1972122088%-2%5% Radiology21523823311%-2%8% Urology 83 95 96 14% 1% 14% Secondary Care Total1,7661,9701,97412%0%11% Tertiary Care Allergy 2323170%-26%-35% Endocrinology1616140%-13%-14% Gastroenterology4646560%22%18% Infectious Disease910811%-20%-13% Neonatology1212150%25%20% Nephrology1718196%6%11% Neurology4347559%17%22% Neurosurgery34383812%0%11% Nuclear Medicine45725%40%43% Pediatric Subspecialties: Pediatric Allergy2220%0%0% Pediatric Cardiology654-17%-20%-50% Pediatric Encocrinology100-100% Pediatric Hem/Oncology533-40%0%-67% Pediatric Nephrology2210%-50%-100% Physical Medicine (Rehab)9151467%-7%36% Plastic Surgery30353117%-11%3% Pulmonary28333618%9%22% Rheumatology2121240%14%13% Thoracic Surgery 35 30 21 -14% -30% -67% Tertiary Care Totals3433613655%1%6% Other Physicians398276 Total Practitioners4,4504,8004,7248%-2%6% Total Licensed Residents550580567 Residents @ .35 FTE193203198 Adj Phys/100k Pop14115514910%-4%6% Note: These primary, secondary and tertiary specialty groupings are included for comparisons to previous projections. October 1990Michael Lapolla, MHA; F.<br><br> Daniel Duffy, MD; and C.S. Lewis, Jr., MDPage 2-17 Additional DataChanges in Mental Health Professions for 1975-90 Mental Health Professionals for 1975-85-90 1975 1985 1990 Psychiatrists26,00033,00036,000 Clinical Psychologists15,00033,00042,000 Clinical Social Workers25,00060,00080,000 Marriage/Family Counselors 6,000 28,000 40,000 Totals72,000154,000198,000 Psychiatrists26,00033,00036,000 Other Mental Health Professionals 46,000 121,000 162,000 Totals72,000154,000198,000 0 10 20 30 40 50 60 70 80 PsychiatristsClinical Psychologists Clinical Social Workers Marriage/Family Counselors 1975 1985 1990 26 15 25 6 33 33 28 36 40 60 42 80 Thousands Percent Growth of Mental Health Professionals for 1975 to 1990 Psychiatrists30% Clinical Psychologists82% Clinical Social Workers92% Marriage/Family Counselors121% Psychiatrists30% Other Mental Health Professionals96% Percent Distribution of Mental Health Professionals for 1975-85-90 1975 1985 1990 Psychiatrists36%21%18% Clinical Psychologists21%21%21% Clinical Social Workers35%39%40% Marriage/Family Counselors 8% 18% 20% Total100%100%100% Psychiatrists36%21%18% Other Mental Health Professionals 64% 79% 82% Total100%100%100% Sources: American Psychiatric Association; American Psychological Association; National Association of Social Workers; American Association of Marriage and Family Therapists. As reported in New York Times, May 17, 1990.<br><br> October 1990Michael Lapolla, MHA; F. Daniel Duffy, MD; and C.S. Lewis, Jr., MDPage 2-18 Additional DataChanges in Mental Health Professions for 1975-90 0 200 400 600 800 1,000 1,200 1,400 OtherPsychOb/GynPediatricHospitalSurgicalMedicalFamily General 76 225 273 293 749 843 949 1,316 Table 2-1 Oklahoma Physician Manpower Changes 1984-86, 1986-90 and 1984-90 Oklahoma Physician Manpower% Changes in Physician Manpower 1984 1986 1990 1984-86 1986-90 1984-90 Primary Care Totals2,3022,3872,3094%-3%0% Secondary Care Total1,7661,9701,97412%0%11% Tertiary Care Totals3433613655%1%6% Other Physicians 39 82 76 Total Practitioners4,4504,8004,7248%-2%6% Adj Phys/100k Pop14115514910%-4%6% Table 2-3 Estimates of Oklahoma Physician Manpower Compared to 1990 Data 1984 Manpower 1990 Estimate (1984) 1990 Estimate (1986) 1990 Manpower Primary2,3022,7242,6312,309 Secondary1,7662,4282,1601,974 Tertiary343522419365 October 1990Michael Lapolla, MHA; F.<br><br> Daniel Duffy, MD; and C.S. Lewis, Jr., MDPage 2-19 Additional DataChanges in Mental Health Professions for 1975-90 Table 2-6 1984 State Regents Projections and Actual 1990 Physician Manpower for Oklahoma 16 19841990Projected1990Actual Category Actual Census Projected Change Actual Census Change Primary Care2,3022,742+4402,309+7 Secondary Care1,7662,426+6601,974+208 Tertiary Care343522+179365+22 Other Physicians 39 95 +56 76 +37 Total Physicians4,4505,785+1,3354,724274 Residents @ 35% FTE19319301985 Total Adjusted Physicians 4,6435,978+1,3354,922+279 16 Duffy, F. Daniel, MD, Lewis, C.S.<br><br> , MD, and Miller, MS, Deborah A., Estimated Physician Manpower Requirements for 1990, Journal of the Oklahoma Medical Association, Vol 78, No 6, pages 183-190, June 1985. October 1990Michael Lapolla, MHA; F. Daniel Duffy, MD; and C.S.<br><br> Lewis, Jr., MDPage 2-20

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