Health Manpower Distribution in Pennsylvania GEORGE K. TOKUHATA, DrPH, PhD PAULINE NEWMAN, PhD EDWARD DIGON, MPH LINDA A. MANN, BA THOMAS HARTMAN, BA KRISHNAN RAMASWAMY, MSc, MS(Hyg)
The distribution of physicians and other licensed health personnel in the state of Pennsylvania is analyzed with regard to adequacy of personnel supply for the population served.
Introduction Recently there has been a growing concern over the distribution of health care services in the United States and elsewhere. This concern rests primarily upon the problems and questions related to the supply of health manpower. More specifically, the basic issues that have been raised include shortages in supply of health personnel,1-5 how to determine "need" for health personnel,6 7 basic principles of manpower utilization,8'9 advantages and disadvantages of allied health personnel,1 01 5 special needs of health personnel for the poor and deprived,16'1 7 and manpower strategy as a new dimension in public health.1 8-2 0 The first medical licensure laws in the United States were enacted more than a century ago2 1 when the provision of health services was very different from the delivery of care today. In 1900, physicians constituted 35 per cent of all health workers,22 but today state licensing laws regulate at least 25 other health professions and The authors are with the Bureau of Program Evaluation, Pennsylvania Department of Health, Harrisburg, Pennsylvania 17120. Dr. Tokuhata is Bureau Director and is also Professor of Epidemiology and Biostatistics (adjunct), University of Pittsburgh Graduate School of Public Health, and Associate Professor of Community Medicine, Temple University College of Medicine. This article was presented at the American Public Health Association Annual Meeting (Statistics Section), November 14, 1972, Atlantic City, New Jersey.
occupations.23 The numbers of allied and auxiliary health personnel have so increased that physicians now constitute only 9 per cent of those employed in health services.22 New functions have emerged for existing kinds of personnel, and new kinds of personnel are being developed to meet the needs of modern health care. In the Commonwealth of Pennsylvania medical and other health professions and related occupations are licensed through the Bureau of Professional and Occupational Affairs, Department of State. During 1970 we undertook a special investigation of licensed health personnel because of the pressing need for accurate documentation of such data to better organize all public health programs including planning and evaluation.
Objectives Major objectives of the present study were 6-fold: (1) to determine the overall distribution of each group of the licensed health personnel in Pennsylvania; (2) to derive some practical, numerical criteria with which "relative adequacy" of personnel supply may be determined; (3) to identify counties and minor civil divisions where the supply of health personnel may be considered "unfavorable"; (4) to analyze the pattern of personnel distribution according to the size of the population served; (5) to determine how various health professions are geographically correlated HEALTH MANPOWER DISTRIBUTION 837
with one another; (6) to evaluate certain characteristics of physicians including specialty, patient care status, age, and their relationship to hospital beds.
1971, approved by the Office of Medical Services and Facilities, Pennsylvania Department of Public Welfare.
Results Methods Composition of Licensed Health Personnel The basic data used for the present study were derived from the licensure records maintained by the Pennsylvania Bureau of Professional and Occupational Affairs. The Bureau maintains current information regarding the name and address of each licensee by professional category, license number, date, and zip code; these items of information are routinely coded for computer listing. From the computer printouts each licensee was identified with regard to the county where address was given as of July 1, 1970. It was not clear whether the given address represented the place of residence or that of office. For medical doctors each licensee was further identified by smaller geographic units, specifically by postal service areas. Since the computer printouts, although complete in total counts of licensees in Pennsylvania, contained no information on physician's specialty, age, or patient care status, we decided to employ 1969 summary data published by the American Medical Association24 in order to make appropriate estimates of such characteristics for Pennsylvania physicians as of 1970. The American Medical Association data were not 100 per cent complete in terms of enumeration of all of the licensed physicians, but did prove to be useful for this purpose. In relating location of hospitals to that of physicians we used the Directory of General and Special Hospitals,
Licensed health personnel in Pennsylvania is composed of 16 categories including medical doctor, osteopath, dentist, dental hygienist, registered nurse, practical nurse, pharmacist, physical therapist, podiatrist, chiropractor, optometrist, veterinarian, assistant pharmacist, midwife, drugless therapist, and medical professor. Federal physicians were not included in the present study. As of July 1, 1970, there were a total of 218,227 persons in the health profession who were licensed to practice in the Commonwealth of Pennsylvania (Table 1). However, 49,259 of this total were not residents of Pennsylvania. This indicates that 168,968 or 77 per cent of the total licensees were potentially available for health care and other related activities within the state. The proportion of licensees who actually resided in Pennsylvania varied considerably from one profession to another. Among major categories, those with relatively more in-state addresses were practical nurses and dentists whereas those with relatively fewer in-state addresses were physicians, registered nurses, dental hygienists, pharmacists, and optometrists. By far the largest proportion of the total number of licensees was represented by registered nurses (55 per cent); the next largest group was practical nurses (22 per cent);
TABLE 1-Pennsylvania Licensed Health Personnel, 1970: In-State and Out-of-State and Percentage In-State*
Licensed Health Personnel
Total Licensed in State
Licensees with In-State Addresses
Licensees with Out-of-State Addresses
Physicians (MD) Osteopaths (DO) Dentists (DMD, DDS) Dental hygienists (DH) Registered nurses (RN) Practical nurses (LPN) Pharmacists (RP) Physical therapists (PT) Podiatrists (DPM, DSC) Chiropractors (DC) Optometrists (OD) Veterinarians (DVM, VMD) Assistant pharmacists (AP) Midwives (MW) Drugless therapists (DT) Medical professors (LL)
23,897 2,576 8,125 2,338 124,140 39,078 11,050 1,357
16,645 1,629 6,525 1,553 92,614 36,471 8,348 964
7,252
928 923
800 878
2,101 1,399
1,314
7
Total
218,227
89 40 179
Percentage In-State
177 7
393 128 45 787 471 7 7 2 0
69.7 63.2 80.3 66.4 74.6 93.3 75.5 71.0 86.2 95.1 62.5 66.3 92.1 82.5 98.9 100.0
168,968
49,259
77.4
928 82 33
947
1,600 785
31,526 2,607 2,702
Data based on July 1, 1970, Bureau of Management Information Systems computer printouts. *
838
AJPH AUGUST, 1975, Vol. 65, No. 8
TABLE 2-Licensed Health Personnel: Number, State Average Population Ratio, and Range of Average County Population Ratios for Counties with Health Personnel: Pennsylvania, 1970
Licensed Health Personnel Registered nurses Licensed practical nurses Physicians, total Medical doctors Doctors of osteopathy Pharmacists Dentists Dental hygienists Optometrists Physical therapists Chiropractors Podiatrists
Total No. in State
92,614 36,471 18,274 16,645 1,629 8,348 6,525 1,553 1,314 964 878 800
State Average Ratio: Population/Health Personnel
Range of Population/Personnel Ratios for Counties with Health Personnel Highest (least favorable)
127 323 645 709 7,240 1,413 1,807 7,594
288 1,419 2,981 3,841 105,438a
8,976 12,234 13,433 14,742
36,090d 127,175e
22,634b 5,961
36,090c
37,770f 79,451g
Lowest (most favorable) 43 84 134 134 2,446 878 1,342 3,301 5,030 5,494 4,771 7,409
Ratio Highest/Lowest 6.7 16.9 22.2 28.7 43.1 25.8 4.4 10.9 7.2 23.1 7.9 10.7
a Eight counties (4,926 to 37,721 inhabitants) have no doctors of osteopathy. b One county (4,926 inhabitants) has no pharmacists. c Five counties (4,926 to 39,108 inhabitants) have no dental hygienists. d Three counties (4,926 to 11,818 inhabitants) have no optometrists. e Fifteen counties (4,926 to 99,190 inhabitants) have no physical therapists. f Four counties (5,961 to 16,712 inhabitants) have no chiropractors. g Eleven counties (4,926 to 36,090 inhabitants) have no podiatrists.
and then in decreasing order physicians (11 per cent), pharmacists (5 per cent), dentists (4 per cent), dental hygienists (1 per cent), optometrists (1 per cent), and others. Population to Health Personnel Ratio
Differences in the number of available professional personnel by category will influence the population to personnel ratio, i.e., the average size of population being served by a given professional person. Sometimes such ratios are expressed in reciprocals, i.e., the number of personnel per 100,000 population. These ratios are probably the most widely used yardstick to estimate the extent of health care provided in a population. We computed, for each professional category, state average ratio as well as county average ratios. The results of this analysis are presented in Table 2. During 1970, 11,793,909 Pennsylvanians were served by a total of 168,968 health personnel including 18,274 physicians, 6,525 dentists, 1,553 dental hygienists, 92,614 registered nurses, 36,471 practical nurses, 8,348 pharmacists, 964 physical therapists, 800 podiatrists, 878 chiropractors, 1,314 optometrists, and others. On the average, 645 people were served by a physician (MD and DO combined), 1,807 people by a dentist, 127 people by a registered nurse, 323 people by a practical nurse, and 1,413 people by a pharmacist. The population to personnel ratio was much greater for dental hygienist (7,594 people), optometrist (8,976 people), physical therapist (12,234
people), chiropractor (13,433 people), and podiatrist (14,742 people). The average number of people served by one professional person varied exceedingly from one county to another, indicating uneven distribution of such personnel. For example, population to registered nurse ratios varied from the most favorable, 43, to the most unfavorable, 288, a 7-fold difference. For practical nurses the ratio fluctuated from 84 to 1,419, a 17-fold difference. Population to physician ratios ranged from 134 to 2,981, indicating a differential of as much as 22-fold. Variations were much greater for osteopaths than for medical doctors. Pharmacists were distributed with ratios ranging from the most favorable, 878, to the most unfavorable, 22,634, with a 26-fold difference. The distribution of dentists was not as skewed as other professionals, but there still was a 4-fold difference between the most favorable (1,342) and most unfavorable (5,961) ratios. For dental hygienists the most favorable ratio was 3,301 as compared with the most unfavorable ratio of 36,090, a difference of 11-fold. Optometrists were also unevenly distributed with a maximum ratio differential of 7-fold, 5,030 compared with 36,090. The distribution of physical therapists was markedly skewed with a maximum ratio differential of 23-fold, 5,494 compared with 127,175. Chiropractor ratios fluctuated from the most favorable, 4,771, to the most unfavorable, 37,770, an 8-fold difference. Likewise, podiatrists ratios varied from 7,409 to 79,451, an 11-fold difference between the two extreme counties. In a number of counties certain professional categories were completely nonexistent as of 1970. To be specific, HEALTH MANPOWER DISTRIBUTION
839
there were no osteopaths in eight counties with a population to be served ranging from 4,926 to 37,721 per county. In one county no pharmacists were listed. In five counties with a population ranging from 4,926 to 39,108 there were no dental hygienists. Optometrists were missing in three counties having a population up to 11,818 per county. No physical therapists were listed in as many as 15 counties having a population up to 99,190 per county. In four counties there were no chiropractors, and podiatrists were missing in 11 counties including one having 36,090 inhabitants.
Unfavorable Population to Personnel Ratio For the purpose of our discussion a set of arbitrary criteria was developed defining, only in relative terms, what may be considered "unfavorable" supply of health care personnel in relation to the size of the population to be served. These numerical criteria, therefore, should not be regarded as a definite set of standards or empirically proven indicators of real needs for more health personnel. Currently, there are no such standards in any category of the health profession. However, we did employ some practical orientation in formulating these criteria. Having observed the actual pattern of population to health personnel ratios by county in Pennsylvania, and giving recognition to the fact that training of most of these health professionals is not only time-consuming but also influenced by numerous constraints, we felt that any criteria which could be used as a general guide for estimating the need for more health personnel must somehow be realistic. As summarized in Table 3, we considered 1,500 or more people to be served by one physician as being unfavorable as far as physician supply is concerned. The federal government also uses this same criterion in some of its health programs. For dentists we used 3,000 or more people to be served as a criterion for a county to be labeled as having an unfavorable supply. Likewise, the following numerical criteria were developed: 20,000 or more people per dental hygienist, 200 or more per registered nurse, 500 or more per practical nurse, 3,000 or more per pharmacist, 30,000 or more per physical therapist, 40,000 or more per podiatrist, 20,000 or more per chiropractor, and 15,000 or more per optometrist. Using these arbitrary criteria we developed, some interesting patterns emerged in the distribution of health personnel in Pennsylvania. The result of this analysis is summarized in Table 4. Of 67 counties within the state, 15 may be considered unfavorable in the supply of physicians, 11 may be so labeled for dentists, 13 for dental hygienists, and seven and nine counties for registered nurses and practical nurses, respectively. According to our criteria, 16 of the Pennsylvania counties were unfavorably supplied with pharmacists, 20 counties with physical therapists, and 18 counties with podiatrists. Chiropractors and optometrists were in short supply in 13 and 12 counties, respectively. The data in Table 4 also indicate two interesting characteristics: (1) In general, the relative number of 840 AJPH AUGUST, 1975, Vol. 65, No. 8
TABLE 3-Criteria Used for Defining Unfavorable* Population to Health Personnel Ratios: Pennsylvania, 1970
"Unfavorable" Population/ Health Personnel Ratio
Health Personnel
Physicians Dentists Dental hygienists Registered nurses Practical nurses Pharmacists Physical therapists Podiatrists Chiropractors
1,500 3,000 20,000 200 500 3,000 30,000 40,000 20,000
or more persons/physician or more persons/dentist or more persons/hygienist or more persons/nurse or more persons/nurse or more persons/pharmacist or more persons/therapist or more persons/podiatrist or more persons/chiropractor
Optometrists
15,000
or more
persons/optometrist
The definition of "unfavorable" ratio was arbitrary. These criteria were established to aid in identifying the relative supply of various health personnel in Pennsylvania's counties. *
counties with an unfavorable supply of health personnel decreased as the size of the county population increased, suggesting that health personnel shortage exists more in counties with a smaller population. (2) In counties with a population of less than 25,000, short supply of health personnel was indicated in all categories of the profession; in fact, in more than 50 per cent of such small counties the supply of physicians, dentists, physical therapists, podiatrists, and optometrists was unfavorable. In contrast, in a small proportion of large counties with a population of 250,000 or more, shortage was indicated only in four categories, i.e., registered nurses, practical nurses, chiropractors, and optometrists.
Geographic Clustering of All Health Categories In order to assess the degree to which any two of the 11 selected health personnel categories and hospital beds may be related geographically, we developed a 12 by 12 correlation matrix. As can be seen from Table 5, all of these 12 items, without exception, were highly correlated with one another. This observation clearly indicates (1) that all of the 11 categories of health profession-medical doctors, osteopaths, dentists, dental hygienists, registered nurses, practical nurses, pharmacists, physical therapists, podiatrists, chiropractors, and optometrists-tend to aggregate in the same geographic locations for practice of their professions, and (2) that they also tend to be located where hospital beds are also available.
Distribution of Physicians
COUNTY DISTRIBUTION Of all categories of health professionals, none has attracted more attention than the physician. Therefore, we have analyzed physician data in further detail. First, we computed a population to physician (MD and DO combined) ratio for each of the 67 counties and ranked them according to such ratios.
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As shown in Table 6, the geographic distribution of physicians in Pennsylvania was extremely skewed. Five counties-Sullivan, Cameron, Fulton, Clarion, and Perryhad such a short supply of physicians that as many as 2,000 to 3,000 people had to be served by one physician. In contrast, in another five counties, Montour, Montgomery, Philadelphia, Delaware, and Dauphin, the supply of physicians was very favorable where only 134 to 561 people were to be served by one physician. It should also be noted that as many as 43 per cent of all physicians in Pennsylvania were actually located in only three adjacent counties centered around Philadelphia. Furthermore, a total of 38 per cent of all physicians and 36 per cent of all hospital beds in Pennsylvania were located in the two largest cities, Philadelphia and Pittsburgh, where 21 per cent of the state population actually lived.
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Pennsylvania is divided into six administratively delineated regions. As data in Table 7 indicate, Region I had the most favorable ratio, 440 persons per physician; the most unfavorable ratio, 1,030 persons per physician, was found in Region VI. The data also indicate that the number of persons to be served by one hospital bed fluctuated considerably; the ratio ranged from the most favorable, 194 persons per bed in Region I, to the most unfavorable, 237 persons per bed in Region III. On the other hand, the average number of hospital beds available per physician likewise differed from the lowest, 2.3 beds in Region I, to the highest ratio, 5.4 beds in Region VI. A careful review of these data further revealed that, while the geographic pattern of population to physician ratios generally agreed with that of hospital beds to physician ratios, population to hospital beds ratios were distributed differently. In Region VI the supply of hospital beds was most favorable, but the supply of physicians was most unfavorable. In Region III the supply of hospital beds was most unfavorable, but the supply of physicians was better than three other regions. Region I had the most favorable supply of both physicians and hospital beds, but the availability of hospital beds per physician was least favorable among the six regions being compared. These observations suggest that each region has different needs for the supply of health resources.
PHYSICIAN CHARACTERISTICS For doctors of medicine we further analyzed their professional activities. The numbers of doctors in various activity statuses were estimated by applying various proportions derived from the 1969 AMA data to the actual numbers of doctors enumerated in Pennsylvania as of July, 1970. These analyses are presented in Tables 8 and 9. Of 16,645 nonfederal MDs licensed and residing in Pennsylvania, 14,076 (85 per cent) are assumed to have been providing patient care, 1,499 (9 per cent) engaged in such activities as teaching, administration, or research, and the remaining 1,070 (6 per cent) retired. This indicates HEALTH MANPOWER DISTRIBUTION
841
TABLE 5-Correlation Matrix: County Distribution of Licensed Health Personnel in Pennsylvania, 1970
Category of Health Personnel
MD
DO
1
0.87 1
MD DO Dentist Dental hygienist RN LPN Pharmacist Physical therapist Podiatrist Ch iropractor Optometrist Hospital beds
Dental Dentist hygienist 0.89 0.73 0.89 1
0.98 0.80 1
RN
LPN
0.88 0.59 0.94 0.90 1
0.96 0.85 0.97 0.80 0.87 1
Phar- Physical macist therapist 0.99 0.85 0.99 0.84 0.87 0.98 1
0.96 0.74 0.99 0.91 0.95 0.94 0.96 1
Podia- Chiro- Optom- Hospital beds trist practor etrist
0.96 0.94 0.92 0.77 0.75 0.96 0.97 0.87 1
0.77 0.52 0.85 0.80 0.93 0.81 0.79 0.85 0.67 1
0.97 0.91 0.95 0.79 0.81 0.98 0.98 0.91 0.99 0.74 1
0.97 0.83 0.98 0.80 0.87 0.98 0.99 0.95 0.96 0.80 0.98 1
TABLE 6-Population, Total Physicians, and Number of Persons per Physician by County: Pennsylvania, 1970
11 Total Physicians
(MD, DO)
County Total Adams Allegheny *Armstrong Beaver
*Bedford Berks Blair Bradford Bucks Butler Cambria *Cameron Carbon Centre Chester *Clarion *Clearf ield Clinton Columbia Crawford Cumberland
Dauphin Delaware Elk Erie
56,937 1,605,016 75,590 208,418 42,353 296,382 135,356 57,962 415,056 127,941 186,785 7,096 50,573 99,267 278,311 38,414 74,619 37,721 55,114 81,342 158,177 223,834 600,035 37,770 263,654 154,667 4,926 100,833 10,776 36,090 39,108 79,451 43,695 16,712
1,294.0 595.1 1,718.0 1,248.0 1,512.0 767.8 846.0 644.0 960.8 1,453.9 893.7 2,365.3 1,032.1 1,141.0 728.6 1,920.7 1,658.2 1,450.8 1,172.6 1,178.9 728.9
90 4 28 27 49 36
Huntingdon
842
44 2,697 44 167 28 386 160 90 432 88 209
4
*Indiana Jefferson *Juniata Persons
645.4
30
Forest Franklin *Fulton Greene
*
11,793,909
316 113
Fayette
11
per
Persons/ (Final Count) Physician Rank
18,274
3 49 87 382 20 45 26 47 69 217 399 1,335
Total Physicians
1970 Population
561.0 449.5
1,259.0 834.3
1,368.7 1,231.5 1,120.4 2.694.0 1,288.9 1,448.4 1,621.4 1,213.8 1,519.3
physician ratio of 1,500 or greater.
AJPH AUGUST, 1975, Vol. 65, No. 8
County
Lackawanna Lancaster Lawrence Lebanon Lehigh Luzerne Lycoming McKean Mercer Mifflin Monroe Montgomery Montour Northampton
45 6 61 40 53 12 21 8 27 51 25 65 29 33 10 64 59 50 34 35
Northumberland
*Perry Philadelphia *Pike Potter Schuylkill *Snyder *Somerset *Sullivan
11 5 4 41 20 47 39 32 66 44
*Susquehanna *Tioga Union Venango Warren
Washington Wayne Westmoreland Wyoming York
49 56 37 54
III
(MD, DO)
283 371 85 113 418 411
136 36 162 47 63 1,930 123 267 74 15 4,713 7 11 154
19 43 2 21 24 31 60 59 177 34 307 15 331
1970 Population Persons/ (Final Count) Physician Rank
234,107 319,693 107,374 99,665
255,304 342,301 113,296 51,915 127,175 45,268 45,422 623,799 16,508 214,368 99,190 28,615 1,948,609 11,818 16,395 160,089 29,269 76,037 5,961 34,344 39,691 28,603 62,353 47,682 210,876 29,581 376,935 19,082 272,603
827.2 861.7 1,263.2 882.0 610.8 832.8 833.1 1,442.1 785.0 963.1 721.0 323.2 134.2 802.9 1,340.4 1,907.7 413.5 1,688.3 1,490.5 1,039.5 1,540.5 1,768.3 2,980.5 1,635.4 1,653.8 922.7 1,039.2 808.2 1,191.4 870.0 1,227.8 1,272.1 823.6
17 22 42 24 7 18 19 48 13 28 9 2 1 14 46 63 3 60 52 31 55 62 67 57 58
26 30 15 36 23 38 43 16 -
TABLE 7-Interregional Distribution of Hospitals, Hospital Beds, and Total Physicians: Pennsylvania, 1970* Ratios Physicians
Population/ physician
Beds/
Hospitals
Hospital beds
Population/
Population
bed
physician
1 11 III IV V VI
3,865,810 1,796,985 1,260,357 1,031,363 2,874,984 964,410
91 53 26 31 62 35
19,931 8,727 5,317 5,223 13,980 5,021
8,792 2,224 1,580 1,072 3,670 936
439.7 808.0 797.7 962.1 783.4 1,030.4
194.0 205.9 237.0 197.5 205.6 192.1
2.3 3.9 3.4 4.9 3.8 5.4
Total
11,793,909
298
58,199
18,274
645.4
202.6
3.2
Region
* The 21 state-operated mental hospitals, totaling 24,799 beds, and the nine state schools and hospitals for the mentally retarded, totaling 10,621 beds, have been excluded from this table.
that, on the average, 838 persons in Pennsylvania were provided medical care by one medical doctor in 1970 with the population to MD ratio ranging from 142 (most favorable) to 4,802 (most unfavorable) by county. If we define ratios of 1,500 persons or more per MD as "disadvantaged," 25 of the 67 counties of Pennsylvania may be considered in need of more medical doctors. Of 14,076 MDs in patient care, 10,272 probably had officebased practice and 3,804 worked in hospitals either as an intern, resident, or a member of full-time house staff. Of 10,272 MDs in office-based practice, 3,229 were general practitioners, 2,172 medical specialists, 3,068 surgical specialists, and the remaining 1,803 were other specialists. Within the group of medical specialties, the largest number, 1,737 (1,536 in patient care), was represented by internal medicine and then in decreasing order pediatrics, cardiovascular disease, dermatology, allergy, pulmonary disease, gastroenterology, pediatric allergy, and pediatric cardiology. Nearly twice as many medical specialists were engaged in research as in administration. The largest subspecialty in surgery was general surgery which included 1,360 physicians, of whom 1,312 were estimated to be in direct patient care. In decreasing order there followed obstetrics and gynecology, ophthalmology, orthopedic surgery, urology, neurological surgery, thoracic surgery, plastic surgery, and colon-rectal surgery. The number of surgeons engaged in research was nearly 3 times as great as that of surgeons who were teaching or holding an administrative position. Other specialties with relatively large memberships include psychiatry, radiology, pathology, anesthesiology, occupational medicine, child psychiatry, and neurology. Of these groups, a relatively large proportion of psychiatrists were found in health administration whereas relatively more pathologists were pursuing research activities. Of the four counties with more than 1,000 MDs in each, relatively more physicians in Delaware and Allegheny were providing patient care than in Montgomery or Philadelphia. In contrast, both Philadelphia and Montgomery counties had relatively more physicians who were
engaged in activities other than direct patient care. The proportion of physicians already retired, however, was higher in Montgomery and Delaware counties than in Philadelphia or Allegheny (includes Pittsburgh) counties suggesting that physicians may choose to retire in suburban counties. Age distribution of Pennsylvania physicians (MD) active in office-based practice during 1970 is illustrated in Table 10. Of 10,272 physicians in this category, 2,044 or 20 per cent were estimated to be under 40 years of age, 2.983 or 29 per cent between 40 and 49 years of age, 2,589 or 25 per cent between 50 and 59 years of age, and the remaining 2,656 or 26 per cent in the oldest age group, 60 years or over. It should be noted that more than one-half (51 per cent) of all active physicians with office practice in Pennsylvania are now already 50 years of age. DISTRIBUTION BY POSTAL SERVICE AREA Since physicians were identifiable only through their mailing addresses, it was not possible to determine the exact number of physicians practicing in any given city, township, or borough. For this reason we analyzed detailed geographic distribution of physicians (MD and DO combined) according to the "postal service area." This was the only practical way in which 1970 census population could be related directly to the number of physicians in a smaller geographic area. For each postal service area representing one municipality or a group of municipalities we listed the size of population served and the number of physicians and then computed a population to physician ratio. The number of postal service areas with at least 1,500 population without any physician or with an "inadequate" (more than 1,500 people per physician) supply of physicians by county is summarized in Table 11. Of 1,353 postal service areas in Pennsylvania with at least 1,500 inhabitants, 195 had no physicians at all whereas in an additional 266 such areas the supply of physicians was considered inadequate. The population to physician ratios where there was at least one physician HEALTH MANPOWER DISTRIBUTION 843
TABLE 8-Estimated Number of Active Medical Doctors by Specialty Groups and Major Professional Activity: Pennsylvania, 1970*
Major Professional Activity
Patient care
Total
Officebased
Hospitalbased
Other professional activity
15,575
14,076
10,272
3,804
1 ,499
General practice
3,454
3,413
3,229
184
41
Medical specialties Allergy Cardiovascular diseases Dermatology Gastroenterology Internal medicine Pediatrics Pediatric allergy Pediatric cardiology Pulmonary diseases
3,385 104 357 184 98 1 ,737 765 19 18 103
2,964 94 301 171 82 1 ,536 676 16 13 75
2,172 89 256 135 69 1,088 471 13 5 46
792 5 45 36 13 448 205 3 8 29
421 10 56 13 16 201 89 3 5 28
Surgical specialties General surgery Neurological surgery Obstetrics and gynecology Ophthalmology Orthopedic surgery Otolaryngology Plastic surgery Colon and rectal surgery Thoracic surgery Urology
4,171 1 ,360 105 964
4,007 1,312 101 911
3,068 907 67 745
939 405 34 166
164 48 4 53
553 411 292 66 50 84 286
535 395 283 66 49 81 274
446 285 241 54 42 58 223
89
18 16 9
Other specialties Aerospace medicine Anesthesiology Child psychiatry Diagnostic roentgenology Forensic pathology Neurology Occupational medicine Psychiatry Pathology Physical medicine and rehabilitation General preventive medicine Public health Radiology Therapeutic radiology Other specialty Unspecif ied
4,565 7 453 154 76
3,692 5 409 132 68 5 107 122 815 389
1,889 2 172 41
72
1,803 3 237 91 43 4 64 116 504 134 32
1 43 6 311 255 40
873 2 44 22 8 3 29 40 165 134 8
28
13
10
3
15
96 614 44 470 734
25 567 38 239 686
18 286 20 168 73
7
281 18 71 613
71 47 6 231 48
Total Active Medical Doctors
Total active MDs
Specialty
8 136 162 980 523 80
110
42 12 7 23 51
25
1 3 12
* Estimates based on the distribution of nonfederal physicians (Pennsylvania) by specialty and other professional activity presented in the American Medical Association publication, Distribution of Physicians, Hospitals, and Hospital Beds in the U.S., 1969, Vol. 1, p. 1 1 1 .2 4
844
AJPH AUGUST, 1975, Vol. 65, No. 8
TABLE 9-Estimated Number of Medical Doctors in Selected Specialty and Other Professional Activity Groups: Pennsylvania, 1970*
No.
Specialty and Activity
%
Total, medical doctors
16,645
100.0
Patient care
Office-based practice General practice Medical specialties Surgical specialties Other specialties Hospital-based practice
14,076 10,272 3,229 2,172 3,068 1,803 3,804
84.6 61.7 19.4 13.1 18.4 10.8 22.9
Other professional activity
1,499
9.0
Inactive
1,070
6.4
* Estimated number of physicians by specialty and activity based on Pennsylvania Medical Practice data shown in the American Medical Association publication, Distribution of Physicians, Hospitals, and Hospital Beds in the U.S., 1969, Vol. 1, p. 252.24
TABLE 10-Estimated Age Distribution of Medical Doctors Active in Office-Based Patient Care: Pennsylvania, 1970* Age Group All ages Under 30 30-39 40-49 50-59 60 and over
No.
%
10,272
100.0
82
0.8 19.1 29.0 25.2
1,962 2,983 2,589 2,656
tion and out-migration will determine the final count of physicians available for patient care and other related activities.
25.9
Estimated from the age distribution of medical doctors active in patient care, December, 1968 (AMA Tape File). *
varied from an extreme low of 76 persons per physician to an extreme high of 13,441 persons per physician. Medical Training in Pennsylvania
One of the major factors determining the supply and distribution of physicians in Pennsylvania is formal training of physicians within the state. As of 1970 there were seven medical colleges and one college of osteopathy in the Commonwealth of Pennsylvania (Table 12). At present approximately 4,000 students are enrolled in these professional institutions. During 1971, a total of 843 students graduated, but only 369 or 44 per cent actually interned in Pennsylvania. Relatively speaking, Pennsylvania contributes more than its share in the supply of physicians in the United States. While some physicians graduating from colleges in other states or interning in other states do move into Pennsylvania for practice, it is not known what proportion of those physicians trained in Pennsylvania will remain in Pennsylvania. The difference between in-migra-
Conclusions A careful analysis of the available data clearly indicates that the fundamental problem in the supply of health personnel is more that of maldistribution than that of available number. All of the categories of licensed health personnel in Pennsylvania are unevenly distributed in relation to the size of the local population. There is a clear trend of high concentration of vital health personnel in and near large metropolitan communities, particularly where large and more hospitals or economic resources are located. Furthermore, there is a substantial proportion of professional personnel who are licensed but do not reside in Pennsylvania. These nonresident professionals and inactive personnel, either retired or engaged in other activities, do not actually contribute to the direct medical and other health care services needed in the population. Considering nonfederal medical doctors, active or inactive, Pennsylvania had 16,645 or approximately 5 per cent of the total number of medical doctors (290,942) estimated in the United States around 1970. In terms of the average number of persons to be served, the supply of MDs in Pennsylvania was slightly better than the national average. In evaluating adequacy of the supply of physicians in a population, it is important to recognize that not all those who are licensed are available for patient care. For example, only 14,076 MDs in Pennsylvania were providing direct medical care in 1970 with a ratio of 838 persons per MD when, in fact, as many as 16,645 MDs were licensed in the state with a ratio of 709 persons per MD. The total number of active MDs in Pennsylvania in the same year was estimated to be 15,575 or 757 persons per MD. Ideally, the supply of physicians should be viewed in relation to the real need of the population rather than just the size of it. If Schonfeld's criteria26 for determining the real need for primary medical care are acceptable, the supply of medical doctors in Pennsylvania is far short, 838 per MD available as compared with 752 per MD needed. Even if all of the active physicians in Pennsylvania were providing direct patient care, the ratio still would not reach such a standard. The concept of "need" or "adequacy" is relative. In the absence of empirical documentation relating the supply of health personnel to the actual health status of a population, we discussed the pattern of geographic distribution of health personnel mostly in terms of "favorable" or "unfavorable" population ratios. An analysis of the crude mortality (all causes) data in relation to the population to health personnel ratios by counties in Pennsylvania indicated that only physicians as a whole were positively and significantly correlated. Obviously, such mortality data represent only one aspect of the health status of a population, and better morbidity indicators are needed to HEALTH MANPOWER DISTRIBUTION
845
TABLE 11-Number of Postal Service Areas with at Least 1,500 Population with No or Insufficient Supply of Physicians by County: Pennsylvania, 1970
Service Areas Used
No. of Areas with No Physicians
No.of Areas with Inadequate Supply of Physicians*
1,353
195
266
13 52 22 21 20 35 10 27 34
2 8 4 5 3 6
4 1 2 1 1 3 7
4 17 6 4 4 7 4 2 8 10 9 1 3 3 7 5 3 4 2 7 4 2 6 3 5 8
-
-
2
6
-
-
4 2 14 -
1 1 2 1
-
-
Total No. of
Postal County Total Adams Allegheny Armstrong Beaver Bedford Berks Blair Bradford Bucks Butler Cambria Cameron Carbon Centre Chester Clarion
Clearfield Clinton Columbia Crawford Cumberland Dauphin Delaware Elk Erie Fayette Forest Franklin Fulton
Greene Huntington Indiana Jefferson Juniata
-
2 -
28 33
5 9
4 13 20 35 21 33 16 10 19 15 21 29 10 19 27 4 14 10 19 29 28 19 9
-
4
8 2 8 1 1
County
Lackawanna Lancaster Lawrence Lebanon Lehigh Luzerne Lycoming McKean Mercer Mifflin Monroe Montgomery Montour No, thampton Northumberland Perry Philadelphia Pike Potter Schuylkill Snyder Somerset Sullivan
Susquehanna Tioga Union Venango Warren Washington Wayne Westmoreland Wyoming York
Total No. of Postal Service Areas Used
18 41 12 11 15 27 20 16 19 10 12 28 515 22 11 1 10 11 44 14 27 7 26 22 8 15 14 42 17 48 10 36
No. of Areas with No Physicians
No. of Areas with Inadequate Supply of Physicians*
11 3 2 5 2 6 4 2 1 4
3 8 1 5 3 7 3 -
4 2 1 9 -
2 1
5 5 4
-
-
-
1 1 5 2
-
-
7 1 4 -
-
2 -
2 1 8 2 10 1 5
6 1 3 3 1 2 5 9 -
8 -
10
* Population to physician ratio of 1 ,500 or greater.
more equitably assess the nature and extent of contributions being made by various health personnel. In the absence of "perfect" or "complete" health or well-being in reality, public health professionals may strive for a "best attainable state of health." Yet, what kinds and how many of health personnel are actually needed to attain even such a level of health in a population have not been determined. It should also be emphasized that, in addition to the supply of needed health care providers, there are many other factors which also influence the health status of a population, e.g., extent of consumer utilization of the available health services, motivation and education of general public as well as health professions, the method of health care delivery, and the cost and payment for services
rendered. The concept of "need" is also subject to many 846 AJPH AUGUST, 1975, Vol. 65, No. 8
misinterpretations; this is particularly true when it is applied to health services. Need is the kind and amount of health care believed necessary by medical authorities, which
is often different from actual "demand" for such care. Medically defined need, while it sounds obvious, has not been adequately documented, particularly when applied to a large population. Also, the definition of need in public health is congruent with the belief that health care is a right of every person and should be distributed as equally as
practical.
The composition of health personnel has changed remarkably during the past many decades. In 1900 there was one supportive person to each physician. Today, the ratio of supportive persons to physicians is estimated to be at least 13 to 1, and is expected to grow even greater in the future.2 7 While both advantages and disadvantages of
TABLE 12-Medical Schools of Pennsylvania
Medical School Pennsylvania State UniversityHershey Medical School Hahnemann Medical College Medical College of Pennsylvania
Interned
Percentage Interned
1971
in Pennsylvania
in Pennsylvania
243
33
14
42.4
475 267
107 51
53 21
49.5 41.8
594
131
48
36.6
810 617 465
185 134 96
85 68 53
45.9 50.7 55.2
575
106
27
25.5
4,046
843
369
43.8
Total No. of Students, 1971-1972
Total Graduating,
(Women's) University of Pennsylvania School of Medicine Jefferson School of Medicine Temple School of Medicine University of Pittsburgh School of Medicine Philadelphia College of Osteopathic Medicine Total
various allied health personnel are being recognized, one important consideration should be given with respect to the idea of "health team" which could help alleviate some of the problems associated with the short supply of essential health personnel, such as physicians. A recent study conducted by Latham and associates2 8 indicates that the distribution of health services and personnel is closely interrelated with the availability of health facilities, family income, and health insurance. The authors concluded that the health care markets (supply) are more sensitive to economic demand factors than to medically determined need. The actual distribution of health manpower in Pennsylvania, as we have presented in this paper, does seem to agree with their conclusions. Pennsylvania licensure data which we used for the present study lacked much of the qualitative information; for example, data on physicians regarding specialty, patient care status, and type and place of practice were not available. This is the most serious defect in the existing licensure data, not only in Pennsylvania but probably in most other states as well. In view of the vital importance of accurate and current health manpower data for public health programs, a new system of ascertaining such information is in order. The use of the state licensure mechanism for such purposes would be more effective in achieving complete cooperation of all of the health professionals licensed by the state.
References 1. Hoff, W. Resolving the Health Manpower Crisis: A Systems Approach to Utilizing Personnel. Am. J. Public Health 61:2491, 1971. 2. Editorial: The Medical Manpower Shortage. J. A. M. A. 217:1857, 1971. 3. Hudson, C. L. Medical Manpower Shortage-Fact or Fiction? Proc. Med. Sect. Am. Life Convention 55:13, 1967. 4. Schaefer, M., and Hilleboe, H. E. The Health Man-
5.
6.
7. 8. 9. 10. 11. 12. 13.
14. 15.
16. 17. 18.
19.
power Crisis-Cause or Symptoms? Am. J. Public Health 57:6, 1967. Estes, E. H., Jr. The Critical Shortage-Physicians and Supporting Personnel. Ann. Intern. Med. 69:957, 1968. Fahs, I. J., Choi, T., Barchas, K., and Zakariasen, P. Indicators of Need for Health Care Personnel: The Concept of Need, Alternative Measures Employed to Determine Need, and a Suggested Model. Med. Care 19:144, 1971. Kissick, W. L. Forecasting Health Manpower Needs: The "Numbers Game is Obsolete." Hospitals 41:47, 1967. Mace, D. J. Basic Principles in Manpower Utilization. Pediatr. Clin. North Am. 16:915, 1969. Kissick, W. L. Effective Utilization: The Critical Factor in Health Manpower. Am. J. Public Health 58:23, 1968. Fenninger, L. D. Where Do Allied Personnel Fit in Health Services? Milit. Med. 134:383, 1969. Sanazaro, P. J. Physician Support Personnel in the 1970's: The R. and D. Approach to Health Manpower. J. A. M. A. 214:98, 1970. Hatch, C. D. Allied Health Personnel: An Answer to the Manpower Crisis. Hosp. Prog. 51:69, 1970. Estes, E. H., Jr. Advantages and Limitations of Medical Assistants. J. Am. Geriatr. Soc. 16:1083, 1968. Yankauer, A. Allied Health Workers in Pediatrics. Pediatrics 41:1031, 1968. Stokes, J., 3rd. Physician's Assistants, More Physicians, More Highly Trained Nurses, or a New Health Worker? Am. J. Nurs. 67:1441, 1967. Lenzer, A. New Health Careers for the Poor. Am. J. Public Health 60:45, 1970. Cherkasky, M. Medical Manpower Needs in Deprived Areas. J. Med. Educ. 44:126, 1969. Ginzberg, E. New Dimensions of Public Health: Their Impact on the Evaluation and Selection of Health Personnel. II. A Manpower Strategy for Public Health. Am. J. Public Health 57:588, 1967. Forgotson, E. H., and Forgotson, J. Innovations and Experiments in Uses of Health Manpower: A Study of Selected Programs and Problems in the United Kingdom and the Soviet Union. Med. Care 8:1, 1970. HEALTH MANPOWER DISTRIBUTION
847
20. Hill, F. T. The Revolution in Health Care. J. Maine Med. Assoc. 60:21, 1969. 21. Shryock, R. Medical Licensing in America, 1650-1965. Johns Hopkins Press, Baltimore, 1967. 22. Pennell, M. Y., and Hoover, D. B. Health Manpower Source Book 21. Allied Health Manpower Supply and Requirements, 1950-80. PHS Publication No. 263. U.S. Government Printing Office, Washington, DC, 1970. 23. Roemer, R. Legal Regulation of Health Manpower in the 1970's. HSMHA Health Rep. 86:1053, 1971. 24. Distribution of Physicians, Hospitals, and Hospital Beds in the U.S., 1969. Vol. 1. Region, State, County. American Medical Association, Chicago, 1970.
25. Health Resources Statistics. Reported from National Center for Health Statistics. PHS Publication No. 1509. U.S. Government Printing Office, Washington, DC, 1970. 26. Schonfeld, H. K., Heston, J. F., and Falk, I. S. Numbers of Physicians Required for Primary Medical Care. N. Engl. J. Med. 286:571, 1972. 27. Perry, J. W. Trends in Allied Health. Presented at National Regional Medical Programs Conference for Allied Health Professions, Asilomar, CA, 1969. 28. Latham, R. J., Hu, T.-W., and Werner, J. L. The Distribution of Health Services in Pennsylvania. Pennsylvania State University, Institute for Research on Human Resources.
(Excerpts from letters received by the APHA Smoking and Health Project from former smokers.)
MAN'S BEST FRIEND I grew up in a rural county on the edge of the Missouri River. Like most rural children of those days we had little chance for supervised recreation. We thought it was smart to mimic older people. Most of the farmers smoked either a corn-cob pipe or roll-your-own cigarettes. Occasionally the of my so-called "tailor-mades" were bought by the. carton. We thought it was clever to sneak a pack picked we Sometimes the share and pack. older brother's Fatimas, meet as a group on the river bank, up what we called "snipes" on the railroad track-tossed away cigar butts. We would cut the burned end off the butt and would light up and puff away. In those days we never inhaled. Later, when I was 19 and attending a nearby business college, I thought I just HAD to learn to inhale because my peers were doing it. I kept up the smoking habit for 30 years! In 1960 I moved to Florida and started working for a county health department. My dog got an awful crop of fleas and I was offered a new kind of insect killer called chlordane to dustIton the dog. all It seemed innocuous enough until I lighted a cigarette 2 days later and "took a drag." burned irritated had chlordane The blood. of the way to my stomach, and I began to expectorate bright clots I my respiratory tract so much that even months after the incident whenever I would try to smoke,to said and wised I up a for finally smoke to year, After trying would raise pink-tinged sputum. myself: "Only a fool would persist in smoking and falling heir to lung cancer. I certainly have a head start on getting cancer and it's high time that I stop smoking." Now that I am a "reformed smoker" I sometimes carry a survival mask to meetings where I know in advance that everybody else will be lighting up and polluting my air. Laura Alice Lee Bureau of Drug Abuse Prevention Division of Mental Health Tallahassee, FL 32301
848 AJPH AUGUST, 1975, Vol. 65, No. 8
The distribution of physicians and other licensed health personnel in the state of Pennsylvania is analyzed with regard to adequacy of personnel supply for the population served.
Introduction Recently there has been a growing concern over the distribution of health care services in the United States and elsewhere. This concern rests primarily upon the problems and questions related to the supply of health manpower. More specifically, the basic issues that have been raised include shortages in supply of health personnel,1-5 how to determine "need" for health personnel,6 7 basic principles of manpower utilization,8'9 advantages and disadvantages of allied health personnel,1 01 5 special needs of health personnel for the poor and deprived,16'1 7 and manpower strategy as a new dimension in public health.1 8-2 0 The first medical licensure laws in the United States were enacted more than a century ago2 1 when the provision of health services was very different from the delivery of care today. In 1900, physicians constituted 35 per cent of all health workers,22 but today state licensing laws regulate at least 25 other health professions and The authors are with the Bureau of Program Evaluation, Pennsylvania Department of Health, Harrisburg, Pennsylvania 17120. Dr. Tokuhata is Bureau Director and is also Professor of Epidemiology and Biostatistics (adjunct), University of Pittsburgh Graduate School of Public Health, and Associate Professor of Community Medicine, Temple University College of Medicine. This article was presented at the American Public Health Association Annual Meeting (Statistics Section), November 14, 1972, Atlantic City, New Jersey.
occupations.23 The numbers of allied and auxiliary health personnel have so increased that physicians now constitute only 9 per cent of those employed in health services.22 New functions have emerged for existing kinds of personnel, and new kinds of personnel are being developed to meet the needs of modern health care. In the Commonwealth of Pennsylvania medical and other health professions and related occupations are licensed through the Bureau of Professional and Occupational Affairs, Department of State. During 1970 we undertook a special investigation of licensed health personnel because of the pressing need for accurate documentation of such data to better organize all public health programs including planning and evaluation.
Objectives Major objectives of the present study were 6-fold: (1) to determine the overall distribution of each group of the licensed health personnel in Pennsylvania; (2) to derive some practical, numerical criteria with which "relative adequacy" of personnel supply may be determined; (3) to identify counties and minor civil divisions where the supply of health personnel may be considered "unfavorable"; (4) to analyze the pattern of personnel distribution according to the size of the population served; (5) to determine how various health professions are geographically correlated HEALTH MANPOWER DISTRIBUTION 837
with one another; (6) to evaluate certain characteristics of physicians including specialty, patient care status, age, and their relationship to hospital beds.
1971, approved by the Office of Medical Services and Facilities, Pennsylvania Department of Public Welfare.
Results Methods Composition of Licensed Health Personnel The basic data used for the present study were derived from the licensure records maintained by the Pennsylvania Bureau of Professional and Occupational Affairs. The Bureau maintains current information regarding the name and address of each licensee by professional category, license number, date, and zip code; these items of information are routinely coded for computer listing. From the computer printouts each licensee was identified with regard to the county where address was given as of July 1, 1970. It was not clear whether the given address represented the place of residence or that of office. For medical doctors each licensee was further identified by smaller geographic units, specifically by postal service areas. Since the computer printouts, although complete in total counts of licensees in Pennsylvania, contained no information on physician's specialty, age, or patient care status, we decided to employ 1969 summary data published by the American Medical Association24 in order to make appropriate estimates of such characteristics for Pennsylvania physicians as of 1970. The American Medical Association data were not 100 per cent complete in terms of enumeration of all of the licensed physicians, but did prove to be useful for this purpose. In relating location of hospitals to that of physicians we used the Directory of General and Special Hospitals,
Licensed health personnel in Pennsylvania is composed of 16 categories including medical doctor, osteopath, dentist, dental hygienist, registered nurse, practical nurse, pharmacist, physical therapist, podiatrist, chiropractor, optometrist, veterinarian, assistant pharmacist, midwife, drugless therapist, and medical professor. Federal physicians were not included in the present study. As of July 1, 1970, there were a total of 218,227 persons in the health profession who were licensed to practice in the Commonwealth of Pennsylvania (Table 1). However, 49,259 of this total were not residents of Pennsylvania. This indicates that 168,968 or 77 per cent of the total licensees were potentially available for health care and other related activities within the state. The proportion of licensees who actually resided in Pennsylvania varied considerably from one profession to another. Among major categories, those with relatively more in-state addresses were practical nurses and dentists whereas those with relatively fewer in-state addresses were physicians, registered nurses, dental hygienists, pharmacists, and optometrists. By far the largest proportion of the total number of licensees was represented by registered nurses (55 per cent); the next largest group was practical nurses (22 per cent);
TABLE 1-Pennsylvania Licensed Health Personnel, 1970: In-State and Out-of-State and Percentage In-State*
Licensed Health Personnel
Total Licensed in State
Licensees with In-State Addresses
Licensees with Out-of-State Addresses
Physicians (MD) Osteopaths (DO) Dentists (DMD, DDS) Dental hygienists (DH) Registered nurses (RN) Practical nurses (LPN) Pharmacists (RP) Physical therapists (PT) Podiatrists (DPM, DSC) Chiropractors (DC) Optometrists (OD) Veterinarians (DVM, VMD) Assistant pharmacists (AP) Midwives (MW) Drugless therapists (DT) Medical professors (LL)
23,897 2,576 8,125 2,338 124,140 39,078 11,050 1,357
16,645 1,629 6,525 1,553 92,614 36,471 8,348 964
7,252
928 923
800 878
2,101 1,399
1,314
7
Total
218,227
89 40 179
Percentage In-State
177 7
393 128 45 787 471 7 7 2 0
69.7 63.2 80.3 66.4 74.6 93.3 75.5 71.0 86.2 95.1 62.5 66.3 92.1 82.5 98.9 100.0
168,968
49,259
77.4
928 82 33
947
1,600 785
31,526 2,607 2,702
Data based on July 1, 1970, Bureau of Management Information Systems computer printouts. *
838
AJPH AUGUST, 1975, Vol. 65, No. 8
TABLE 2-Licensed Health Personnel: Number, State Average Population Ratio, and Range of Average County Population Ratios for Counties with Health Personnel: Pennsylvania, 1970
Licensed Health Personnel Registered nurses Licensed practical nurses Physicians, total Medical doctors Doctors of osteopathy Pharmacists Dentists Dental hygienists Optometrists Physical therapists Chiropractors Podiatrists
Total No. in State
92,614 36,471 18,274 16,645 1,629 8,348 6,525 1,553 1,314 964 878 800
State Average Ratio: Population/Health Personnel
Range of Population/Personnel Ratios for Counties with Health Personnel Highest (least favorable)
127 323 645 709 7,240 1,413 1,807 7,594
288 1,419 2,981 3,841 105,438a
8,976 12,234 13,433 14,742
36,090d 127,175e
22,634b 5,961
36,090c
37,770f 79,451g
Lowest (most favorable) 43 84 134 134 2,446 878 1,342 3,301 5,030 5,494 4,771 7,409
Ratio Highest/Lowest 6.7 16.9 22.2 28.7 43.1 25.8 4.4 10.9 7.2 23.1 7.9 10.7
a Eight counties (4,926 to 37,721 inhabitants) have no doctors of osteopathy. b One county (4,926 inhabitants) has no pharmacists. c Five counties (4,926 to 39,108 inhabitants) have no dental hygienists. d Three counties (4,926 to 11,818 inhabitants) have no optometrists. e Fifteen counties (4,926 to 99,190 inhabitants) have no physical therapists. f Four counties (5,961 to 16,712 inhabitants) have no chiropractors. g Eleven counties (4,926 to 36,090 inhabitants) have no podiatrists.
and then in decreasing order physicians (11 per cent), pharmacists (5 per cent), dentists (4 per cent), dental hygienists (1 per cent), optometrists (1 per cent), and others. Population to Health Personnel Ratio
Differences in the number of available professional personnel by category will influence the population to personnel ratio, i.e., the average size of population being served by a given professional person. Sometimes such ratios are expressed in reciprocals, i.e., the number of personnel per 100,000 population. These ratios are probably the most widely used yardstick to estimate the extent of health care provided in a population. We computed, for each professional category, state average ratio as well as county average ratios. The results of this analysis are presented in Table 2. During 1970, 11,793,909 Pennsylvanians were served by a total of 168,968 health personnel including 18,274 physicians, 6,525 dentists, 1,553 dental hygienists, 92,614 registered nurses, 36,471 practical nurses, 8,348 pharmacists, 964 physical therapists, 800 podiatrists, 878 chiropractors, 1,314 optometrists, and others. On the average, 645 people were served by a physician (MD and DO combined), 1,807 people by a dentist, 127 people by a registered nurse, 323 people by a practical nurse, and 1,413 people by a pharmacist. The population to personnel ratio was much greater for dental hygienist (7,594 people), optometrist (8,976 people), physical therapist (12,234
people), chiropractor (13,433 people), and podiatrist (14,742 people). The average number of people served by one professional person varied exceedingly from one county to another, indicating uneven distribution of such personnel. For example, population to registered nurse ratios varied from the most favorable, 43, to the most unfavorable, 288, a 7-fold difference. For practical nurses the ratio fluctuated from 84 to 1,419, a 17-fold difference. Population to physician ratios ranged from 134 to 2,981, indicating a differential of as much as 22-fold. Variations were much greater for osteopaths than for medical doctors. Pharmacists were distributed with ratios ranging from the most favorable, 878, to the most unfavorable, 22,634, with a 26-fold difference. The distribution of dentists was not as skewed as other professionals, but there still was a 4-fold difference between the most favorable (1,342) and most unfavorable (5,961) ratios. For dental hygienists the most favorable ratio was 3,301 as compared with the most unfavorable ratio of 36,090, a difference of 11-fold. Optometrists were also unevenly distributed with a maximum ratio differential of 7-fold, 5,030 compared with 36,090. The distribution of physical therapists was markedly skewed with a maximum ratio differential of 23-fold, 5,494 compared with 127,175. Chiropractor ratios fluctuated from the most favorable, 4,771, to the most unfavorable, 37,770, an 8-fold difference. Likewise, podiatrists ratios varied from 7,409 to 79,451, an 11-fold difference between the two extreme counties. In a number of counties certain professional categories were completely nonexistent as of 1970. To be specific, HEALTH MANPOWER DISTRIBUTION
839
there were no osteopaths in eight counties with a population to be served ranging from 4,926 to 37,721 per county. In one county no pharmacists were listed. In five counties with a population ranging from 4,926 to 39,108 there were no dental hygienists. Optometrists were missing in three counties having a population up to 11,818 per county. No physical therapists were listed in as many as 15 counties having a population up to 99,190 per county. In four counties there were no chiropractors, and podiatrists were missing in 11 counties including one having 36,090 inhabitants.
Unfavorable Population to Personnel Ratio For the purpose of our discussion a set of arbitrary criteria was developed defining, only in relative terms, what may be considered "unfavorable" supply of health care personnel in relation to the size of the population to be served. These numerical criteria, therefore, should not be regarded as a definite set of standards or empirically proven indicators of real needs for more health personnel. Currently, there are no such standards in any category of the health profession. However, we did employ some practical orientation in formulating these criteria. Having observed the actual pattern of population to health personnel ratios by county in Pennsylvania, and giving recognition to the fact that training of most of these health professionals is not only time-consuming but also influenced by numerous constraints, we felt that any criteria which could be used as a general guide for estimating the need for more health personnel must somehow be realistic. As summarized in Table 3, we considered 1,500 or more people to be served by one physician as being unfavorable as far as physician supply is concerned. The federal government also uses this same criterion in some of its health programs. For dentists we used 3,000 or more people to be served as a criterion for a county to be labeled as having an unfavorable supply. Likewise, the following numerical criteria were developed: 20,000 or more people per dental hygienist, 200 or more per registered nurse, 500 or more per practical nurse, 3,000 or more per pharmacist, 30,000 or more per physical therapist, 40,000 or more per podiatrist, 20,000 or more per chiropractor, and 15,000 or more per optometrist. Using these arbitrary criteria we developed, some interesting patterns emerged in the distribution of health personnel in Pennsylvania. The result of this analysis is summarized in Table 4. Of 67 counties within the state, 15 may be considered unfavorable in the supply of physicians, 11 may be so labeled for dentists, 13 for dental hygienists, and seven and nine counties for registered nurses and practical nurses, respectively. According to our criteria, 16 of the Pennsylvania counties were unfavorably supplied with pharmacists, 20 counties with physical therapists, and 18 counties with podiatrists. Chiropractors and optometrists were in short supply in 13 and 12 counties, respectively. The data in Table 4 also indicate two interesting characteristics: (1) In general, the relative number of 840 AJPH AUGUST, 1975, Vol. 65, No. 8
TABLE 3-Criteria Used for Defining Unfavorable* Population to Health Personnel Ratios: Pennsylvania, 1970
"Unfavorable" Population/ Health Personnel Ratio
Health Personnel
Physicians Dentists Dental hygienists Registered nurses Practical nurses Pharmacists Physical therapists Podiatrists Chiropractors
1,500 3,000 20,000 200 500 3,000 30,000 40,000 20,000
or more persons/physician or more persons/dentist or more persons/hygienist or more persons/nurse or more persons/nurse or more persons/pharmacist or more persons/therapist or more persons/podiatrist or more persons/chiropractor
Optometrists
15,000
or more
persons/optometrist
The definition of "unfavorable" ratio was arbitrary. These criteria were established to aid in identifying the relative supply of various health personnel in Pennsylvania's counties. *
counties with an unfavorable supply of health personnel decreased as the size of the county population increased, suggesting that health personnel shortage exists more in counties with a smaller population. (2) In counties with a population of less than 25,000, short supply of health personnel was indicated in all categories of the profession; in fact, in more than 50 per cent of such small counties the supply of physicians, dentists, physical therapists, podiatrists, and optometrists was unfavorable. In contrast, in a small proportion of large counties with a population of 250,000 or more, shortage was indicated only in four categories, i.e., registered nurses, practical nurses, chiropractors, and optometrists.
Geographic Clustering of All Health Categories In order to assess the degree to which any two of the 11 selected health personnel categories and hospital beds may be related geographically, we developed a 12 by 12 correlation matrix. As can be seen from Table 5, all of these 12 items, without exception, were highly correlated with one another. This observation clearly indicates (1) that all of the 11 categories of health profession-medical doctors, osteopaths, dentists, dental hygienists, registered nurses, practical nurses, pharmacists, physical therapists, podiatrists, chiropractors, and optometrists-tend to aggregate in the same geographic locations for practice of their professions, and (2) that they also tend to be located where hospital beds are also available.
Distribution of Physicians
COUNTY DISTRIBUTION Of all categories of health professionals, none has attracted more attention than the physician. Therefore, we have analyzed physician data in further detail. First, we computed a population to physician (MD and DO combined) ratio for each of the 67 counties and ranked them according to such ratios.
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As shown in Table 6, the geographic distribution of physicians in Pennsylvania was extremely skewed. Five counties-Sullivan, Cameron, Fulton, Clarion, and Perryhad such a short supply of physicians that as many as 2,000 to 3,000 people had to be served by one physician. In contrast, in another five counties, Montour, Montgomery, Philadelphia, Delaware, and Dauphin, the supply of physicians was very favorable where only 134 to 561 people were to be served by one physician. It should also be noted that as many as 43 per cent of all physicians in Pennsylvania were actually located in only three adjacent counties centered around Philadelphia. Furthermore, a total of 38 per cent of all physicians and 36 per cent of all hospital beds in Pennsylvania were located in the two largest cities, Philadelphia and Pittsburgh, where 21 per cent of the state population actually lived.
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Pennsylvania is divided into six administratively delineated regions. As data in Table 7 indicate, Region I had the most favorable ratio, 440 persons per physician; the most unfavorable ratio, 1,030 persons per physician, was found in Region VI. The data also indicate that the number of persons to be served by one hospital bed fluctuated considerably; the ratio ranged from the most favorable, 194 persons per bed in Region I, to the most unfavorable, 237 persons per bed in Region III. On the other hand, the average number of hospital beds available per physician likewise differed from the lowest, 2.3 beds in Region I, to the highest ratio, 5.4 beds in Region VI. A careful review of these data further revealed that, while the geographic pattern of population to physician ratios generally agreed with that of hospital beds to physician ratios, population to hospital beds ratios were distributed differently. In Region VI the supply of hospital beds was most favorable, but the supply of physicians was most unfavorable. In Region III the supply of hospital beds was most unfavorable, but the supply of physicians was better than three other regions. Region I had the most favorable supply of both physicians and hospital beds, but the availability of hospital beds per physician was least favorable among the six regions being compared. These observations suggest that each region has different needs for the supply of health resources.
PHYSICIAN CHARACTERISTICS For doctors of medicine we further analyzed their professional activities. The numbers of doctors in various activity statuses were estimated by applying various proportions derived from the 1969 AMA data to the actual numbers of doctors enumerated in Pennsylvania as of July, 1970. These analyses are presented in Tables 8 and 9. Of 16,645 nonfederal MDs licensed and residing in Pennsylvania, 14,076 (85 per cent) are assumed to have been providing patient care, 1,499 (9 per cent) engaged in such activities as teaching, administration, or research, and the remaining 1,070 (6 per cent) retired. This indicates HEALTH MANPOWER DISTRIBUTION
841
TABLE 5-Correlation Matrix: County Distribution of Licensed Health Personnel in Pennsylvania, 1970
Category of Health Personnel
MD
DO
1
0.87 1
MD DO Dentist Dental hygienist RN LPN Pharmacist Physical therapist Podiatrist Ch iropractor Optometrist Hospital beds
Dental Dentist hygienist 0.89 0.73 0.89 1
0.98 0.80 1
RN
LPN
0.88 0.59 0.94 0.90 1
0.96 0.85 0.97 0.80 0.87 1
Phar- Physical macist therapist 0.99 0.85 0.99 0.84 0.87 0.98 1
0.96 0.74 0.99 0.91 0.95 0.94 0.96 1
Podia- Chiro- Optom- Hospital beds trist practor etrist
0.96 0.94 0.92 0.77 0.75 0.96 0.97 0.87 1
0.77 0.52 0.85 0.80 0.93 0.81 0.79 0.85 0.67 1
0.97 0.91 0.95 0.79 0.81 0.98 0.98 0.91 0.99 0.74 1
0.97 0.83 0.98 0.80 0.87 0.98 0.99 0.95 0.96 0.80 0.98 1
TABLE 6-Population, Total Physicians, and Number of Persons per Physician by County: Pennsylvania, 1970
11 Total Physicians
(MD, DO)
County Total Adams Allegheny *Armstrong Beaver
*Bedford Berks Blair Bradford Bucks Butler Cambria *Cameron Carbon Centre Chester *Clarion *Clearf ield Clinton Columbia Crawford Cumberland
Dauphin Delaware Elk Erie
56,937 1,605,016 75,590 208,418 42,353 296,382 135,356 57,962 415,056 127,941 186,785 7,096 50,573 99,267 278,311 38,414 74,619 37,721 55,114 81,342 158,177 223,834 600,035 37,770 263,654 154,667 4,926 100,833 10,776 36,090 39,108 79,451 43,695 16,712
1,294.0 595.1 1,718.0 1,248.0 1,512.0 767.8 846.0 644.0 960.8 1,453.9 893.7 2,365.3 1,032.1 1,141.0 728.6 1,920.7 1,658.2 1,450.8 1,172.6 1,178.9 728.9
90 4 28 27 49 36
Huntingdon
842
44 2,697 44 167 28 386 160 90 432 88 209
4
*Indiana Jefferson *Juniata Persons
645.4
30
Forest Franklin *Fulton Greene
*
11,793,909
316 113
Fayette
11
per
Persons/ (Final Count) Physician Rank
18,274
3 49 87 382 20 45 26 47 69 217 399 1,335
Total Physicians
1970 Population
561.0 449.5
1,259.0 834.3
1,368.7 1,231.5 1,120.4 2.694.0 1,288.9 1,448.4 1,621.4 1,213.8 1,519.3
physician ratio of 1,500 or greater.
AJPH AUGUST, 1975, Vol. 65, No. 8
County
Lackawanna Lancaster Lawrence Lebanon Lehigh Luzerne Lycoming McKean Mercer Mifflin Monroe Montgomery Montour Northampton
45 6 61 40 53 12 21 8 27 51 25 65 29 33 10 64 59 50 34 35
Northumberland
*Perry Philadelphia *Pike Potter Schuylkill *Snyder *Somerset *Sullivan
11 5 4 41 20 47 39 32 66 44
*Susquehanna *Tioga Union Venango Warren
Washington Wayne Westmoreland Wyoming York
49 56 37 54
III
(MD, DO)
283 371 85 113 418 411
136 36 162 47 63 1,930 123 267 74 15 4,713 7 11 154
19 43 2 21 24 31 60 59 177 34 307 15 331
1970 Population Persons/ (Final Count) Physician Rank
234,107 319,693 107,374 99,665
255,304 342,301 113,296 51,915 127,175 45,268 45,422 623,799 16,508 214,368 99,190 28,615 1,948,609 11,818 16,395 160,089 29,269 76,037 5,961 34,344 39,691 28,603 62,353 47,682 210,876 29,581 376,935 19,082 272,603
827.2 861.7 1,263.2 882.0 610.8 832.8 833.1 1,442.1 785.0 963.1 721.0 323.2 134.2 802.9 1,340.4 1,907.7 413.5 1,688.3 1,490.5 1,039.5 1,540.5 1,768.3 2,980.5 1,635.4 1,653.8 922.7 1,039.2 808.2 1,191.4 870.0 1,227.8 1,272.1 823.6
17 22 42 24 7 18 19 48 13 28 9 2 1 14 46 63 3 60 52 31 55 62 67 57 58
26 30 15 36 23 38 43 16 -
TABLE 7-Interregional Distribution of Hospitals, Hospital Beds, and Total Physicians: Pennsylvania, 1970* Ratios Physicians
Population/ physician
Beds/
Hospitals
Hospital beds
Population/
Population
bed
physician
1 11 III IV V VI
3,865,810 1,796,985 1,260,357 1,031,363 2,874,984 964,410
91 53 26 31 62 35
19,931 8,727 5,317 5,223 13,980 5,021
8,792 2,224 1,580 1,072 3,670 936
439.7 808.0 797.7 962.1 783.4 1,030.4
194.0 205.9 237.0 197.5 205.6 192.1
2.3 3.9 3.4 4.9 3.8 5.4
Total
11,793,909
298
58,199
18,274
645.4
202.6
3.2
Region
* The 21 state-operated mental hospitals, totaling 24,799 beds, and the nine state schools and hospitals for the mentally retarded, totaling 10,621 beds, have been excluded from this table.
that, on the average, 838 persons in Pennsylvania were provided medical care by one medical doctor in 1970 with the population to MD ratio ranging from 142 (most favorable) to 4,802 (most unfavorable) by county. If we define ratios of 1,500 persons or more per MD as "disadvantaged," 25 of the 67 counties of Pennsylvania may be considered in need of more medical doctors. Of 14,076 MDs in patient care, 10,272 probably had officebased practice and 3,804 worked in hospitals either as an intern, resident, or a member of full-time house staff. Of 10,272 MDs in office-based practice, 3,229 were general practitioners, 2,172 medical specialists, 3,068 surgical specialists, and the remaining 1,803 were other specialists. Within the group of medical specialties, the largest number, 1,737 (1,536 in patient care), was represented by internal medicine and then in decreasing order pediatrics, cardiovascular disease, dermatology, allergy, pulmonary disease, gastroenterology, pediatric allergy, and pediatric cardiology. Nearly twice as many medical specialists were engaged in research as in administration. The largest subspecialty in surgery was general surgery which included 1,360 physicians, of whom 1,312 were estimated to be in direct patient care. In decreasing order there followed obstetrics and gynecology, ophthalmology, orthopedic surgery, urology, neurological surgery, thoracic surgery, plastic surgery, and colon-rectal surgery. The number of surgeons engaged in research was nearly 3 times as great as that of surgeons who were teaching or holding an administrative position. Other specialties with relatively large memberships include psychiatry, radiology, pathology, anesthesiology, occupational medicine, child psychiatry, and neurology. Of these groups, a relatively large proportion of psychiatrists were found in health administration whereas relatively more pathologists were pursuing research activities. Of the four counties with more than 1,000 MDs in each, relatively more physicians in Delaware and Allegheny were providing patient care than in Montgomery or Philadelphia. In contrast, both Philadelphia and Montgomery counties had relatively more physicians who were
engaged in activities other than direct patient care. The proportion of physicians already retired, however, was higher in Montgomery and Delaware counties than in Philadelphia or Allegheny (includes Pittsburgh) counties suggesting that physicians may choose to retire in suburban counties. Age distribution of Pennsylvania physicians (MD) active in office-based practice during 1970 is illustrated in Table 10. Of 10,272 physicians in this category, 2,044 or 20 per cent were estimated to be under 40 years of age, 2.983 or 29 per cent between 40 and 49 years of age, 2,589 or 25 per cent between 50 and 59 years of age, and the remaining 2,656 or 26 per cent in the oldest age group, 60 years or over. It should be noted that more than one-half (51 per cent) of all active physicians with office practice in Pennsylvania are now already 50 years of age. DISTRIBUTION BY POSTAL SERVICE AREA Since physicians were identifiable only through their mailing addresses, it was not possible to determine the exact number of physicians practicing in any given city, township, or borough. For this reason we analyzed detailed geographic distribution of physicians (MD and DO combined) according to the "postal service area." This was the only practical way in which 1970 census population could be related directly to the number of physicians in a smaller geographic area. For each postal service area representing one municipality or a group of municipalities we listed the size of population served and the number of physicians and then computed a population to physician ratio. The number of postal service areas with at least 1,500 population without any physician or with an "inadequate" (more than 1,500 people per physician) supply of physicians by county is summarized in Table 11. Of 1,353 postal service areas in Pennsylvania with at least 1,500 inhabitants, 195 had no physicians at all whereas in an additional 266 such areas the supply of physicians was considered inadequate. The population to physician ratios where there was at least one physician HEALTH MANPOWER DISTRIBUTION 843
TABLE 8-Estimated Number of Active Medical Doctors by Specialty Groups and Major Professional Activity: Pennsylvania, 1970*
Major Professional Activity
Patient care
Total
Officebased
Hospitalbased
Other professional activity
15,575
14,076
10,272
3,804
1 ,499
General practice
3,454
3,413
3,229
184
41
Medical specialties Allergy Cardiovascular diseases Dermatology Gastroenterology Internal medicine Pediatrics Pediatric allergy Pediatric cardiology Pulmonary diseases
3,385 104 357 184 98 1 ,737 765 19 18 103
2,964 94 301 171 82 1 ,536 676 16 13 75
2,172 89 256 135 69 1,088 471 13 5 46
792 5 45 36 13 448 205 3 8 29
421 10 56 13 16 201 89 3 5 28
Surgical specialties General surgery Neurological surgery Obstetrics and gynecology Ophthalmology Orthopedic surgery Otolaryngology Plastic surgery Colon and rectal surgery Thoracic surgery Urology
4,171 1 ,360 105 964
4,007 1,312 101 911
3,068 907 67 745
939 405 34 166
164 48 4 53
553 411 292 66 50 84 286
535 395 283 66 49 81 274
446 285 241 54 42 58 223
89
18 16 9
Other specialties Aerospace medicine Anesthesiology Child psychiatry Diagnostic roentgenology Forensic pathology Neurology Occupational medicine Psychiatry Pathology Physical medicine and rehabilitation General preventive medicine Public health Radiology Therapeutic radiology Other specialty Unspecif ied
4,565 7 453 154 76
3,692 5 409 132 68 5 107 122 815 389
1,889 2 172 41
72
1,803 3 237 91 43 4 64 116 504 134 32
1 43 6 311 255 40
873 2 44 22 8 3 29 40 165 134 8
28
13
10
3
15
96 614 44 470 734
25 567 38 239 686
18 286 20 168 73
7
281 18 71 613
71 47 6 231 48
Total Active Medical Doctors
Total active MDs
Specialty
8 136 162 980 523 80
110
42 12 7 23 51
25
1 3 12
* Estimates based on the distribution of nonfederal physicians (Pennsylvania) by specialty and other professional activity presented in the American Medical Association publication, Distribution of Physicians, Hospitals, and Hospital Beds in the U.S., 1969, Vol. 1, p. 1 1 1 .2 4
844
AJPH AUGUST, 1975, Vol. 65, No. 8
TABLE 9-Estimated Number of Medical Doctors in Selected Specialty and Other Professional Activity Groups: Pennsylvania, 1970*
No.
Specialty and Activity
%
Total, medical doctors
16,645
100.0
Patient care
Office-based practice General practice Medical specialties Surgical specialties Other specialties Hospital-based practice
14,076 10,272 3,229 2,172 3,068 1,803 3,804
84.6 61.7 19.4 13.1 18.4 10.8 22.9
Other professional activity
1,499
9.0
Inactive
1,070
6.4
* Estimated number of physicians by specialty and activity based on Pennsylvania Medical Practice data shown in the American Medical Association publication, Distribution of Physicians, Hospitals, and Hospital Beds in the U.S., 1969, Vol. 1, p. 252.24
TABLE 10-Estimated Age Distribution of Medical Doctors Active in Office-Based Patient Care: Pennsylvania, 1970* Age Group All ages Under 30 30-39 40-49 50-59 60 and over
No.
%
10,272
100.0
82
0.8 19.1 29.0 25.2
1,962 2,983 2,589 2,656
tion and out-migration will determine the final count of physicians available for patient care and other related activities.
25.9
Estimated from the age distribution of medical doctors active in patient care, December, 1968 (AMA Tape File). *
varied from an extreme low of 76 persons per physician to an extreme high of 13,441 persons per physician. Medical Training in Pennsylvania
One of the major factors determining the supply and distribution of physicians in Pennsylvania is formal training of physicians within the state. As of 1970 there were seven medical colleges and one college of osteopathy in the Commonwealth of Pennsylvania (Table 12). At present approximately 4,000 students are enrolled in these professional institutions. During 1971, a total of 843 students graduated, but only 369 or 44 per cent actually interned in Pennsylvania. Relatively speaking, Pennsylvania contributes more than its share in the supply of physicians in the United States. While some physicians graduating from colleges in other states or interning in other states do move into Pennsylvania for practice, it is not known what proportion of those physicians trained in Pennsylvania will remain in Pennsylvania. The difference between in-migra-
Conclusions A careful analysis of the available data clearly indicates that the fundamental problem in the supply of health personnel is more that of maldistribution than that of available number. All of the categories of licensed health personnel in Pennsylvania are unevenly distributed in relation to the size of the local population. There is a clear trend of high concentration of vital health personnel in and near large metropolitan communities, particularly where large and more hospitals or economic resources are located. Furthermore, there is a substantial proportion of professional personnel who are licensed but do not reside in Pennsylvania. These nonresident professionals and inactive personnel, either retired or engaged in other activities, do not actually contribute to the direct medical and other health care services needed in the population. Considering nonfederal medical doctors, active or inactive, Pennsylvania had 16,645 or approximately 5 per cent of the total number of medical doctors (290,942) estimated in the United States around 1970. In terms of the average number of persons to be served, the supply of MDs in Pennsylvania was slightly better than the national average. In evaluating adequacy of the supply of physicians in a population, it is important to recognize that not all those who are licensed are available for patient care. For example, only 14,076 MDs in Pennsylvania were providing direct medical care in 1970 with a ratio of 838 persons per MD when, in fact, as many as 16,645 MDs were licensed in the state with a ratio of 709 persons per MD. The total number of active MDs in Pennsylvania in the same year was estimated to be 15,575 or 757 persons per MD. Ideally, the supply of physicians should be viewed in relation to the real need of the population rather than just the size of it. If Schonfeld's criteria26 for determining the real need for primary medical care are acceptable, the supply of medical doctors in Pennsylvania is far short, 838 per MD available as compared with 752 per MD needed. Even if all of the active physicians in Pennsylvania were providing direct patient care, the ratio still would not reach such a standard. The concept of "need" or "adequacy" is relative. In the absence of empirical documentation relating the supply of health personnel to the actual health status of a population, we discussed the pattern of geographic distribution of health personnel mostly in terms of "favorable" or "unfavorable" population ratios. An analysis of the crude mortality (all causes) data in relation to the population to health personnel ratios by counties in Pennsylvania indicated that only physicians as a whole were positively and significantly correlated. Obviously, such mortality data represent only one aspect of the health status of a population, and better morbidity indicators are needed to HEALTH MANPOWER DISTRIBUTION
845
TABLE 11-Number of Postal Service Areas with at Least 1,500 Population with No or Insufficient Supply of Physicians by County: Pennsylvania, 1970
Service Areas Used
No. of Areas with No Physicians
No.of Areas with Inadequate Supply of Physicians*
1,353
195
266
13 52 22 21 20 35 10 27 34
2 8 4 5 3 6
4 1 2 1 1 3 7
4 17 6 4 4 7 4 2 8 10 9 1 3 3 7 5 3 4 2 7 4 2 6 3 5 8
-
-
2
6
-
-
4 2 14 -
1 1 2 1
-
-
Total No. of
Postal County Total Adams Allegheny Armstrong Beaver Bedford Berks Blair Bradford Bucks Butler Cambria Cameron Carbon Centre Chester Clarion
Clearfield Clinton Columbia Crawford Cumberland Dauphin Delaware Elk Erie Fayette Forest Franklin Fulton
Greene Huntington Indiana Jefferson Juniata
-
2 -
28 33
5 9
4 13 20 35 21 33 16 10 19 15 21 29 10 19 27 4 14 10 19 29 28 19 9
-
4
8 2 8 1 1
County
Lackawanna Lancaster Lawrence Lebanon Lehigh Luzerne Lycoming McKean Mercer Mifflin Monroe Montgomery Montour No, thampton Northumberland Perry Philadelphia Pike Potter Schuylkill Snyder Somerset Sullivan
Susquehanna Tioga Union Venango Warren Washington Wayne Westmoreland Wyoming York
Total No. of Postal Service Areas Used
18 41 12 11 15 27 20 16 19 10 12 28 515 22 11 1 10 11 44 14 27 7 26 22 8 15 14 42 17 48 10 36
No. of Areas with No Physicians
No. of Areas with Inadequate Supply of Physicians*
11 3 2 5 2 6 4 2 1 4
3 8 1 5 3 7 3 -
4 2 1 9 -
2 1
5 5 4
-
-
-
1 1 5 2
-
-
7 1 4 -
-
2 -
2 1 8 2 10 1 5
6 1 3 3 1 2 5 9 -
8 -
10
* Population to physician ratio of 1 ,500 or greater.
more equitably assess the nature and extent of contributions being made by various health personnel. In the absence of "perfect" or "complete" health or well-being in reality, public health professionals may strive for a "best attainable state of health." Yet, what kinds and how many of health personnel are actually needed to attain even such a level of health in a population have not been determined. It should also be emphasized that, in addition to the supply of needed health care providers, there are many other factors which also influence the health status of a population, e.g., extent of consumer utilization of the available health services, motivation and education of general public as well as health professions, the method of health care delivery, and the cost and payment for services
rendered. The concept of "need" is also subject to many 846 AJPH AUGUST, 1975, Vol. 65, No. 8
misinterpretations; this is particularly true when it is applied to health services. Need is the kind and amount of health care believed necessary by medical authorities, which
is often different from actual "demand" for such care. Medically defined need, while it sounds obvious, has not been adequately documented, particularly when applied to a large population. Also, the definition of need in public health is congruent with the belief that health care is a right of every person and should be distributed as equally as
practical.
The composition of health personnel has changed remarkably during the past many decades. In 1900 there was one supportive person to each physician. Today, the ratio of supportive persons to physicians is estimated to be at least 13 to 1, and is expected to grow even greater in the future.2 7 While both advantages and disadvantages of
TABLE 12-Medical Schools of Pennsylvania
Medical School Pennsylvania State UniversityHershey Medical School Hahnemann Medical College Medical College of Pennsylvania
Interned
Percentage Interned
1971
in Pennsylvania
in Pennsylvania
243
33
14
42.4
475 267
107 51
53 21
49.5 41.8
594
131
48
36.6
810 617 465
185 134 96
85 68 53
45.9 50.7 55.2
575
106
27
25.5
4,046
843
369
43.8
Total No. of Students, 1971-1972
Total Graduating,
(Women's) University of Pennsylvania School of Medicine Jefferson School of Medicine Temple School of Medicine University of Pittsburgh School of Medicine Philadelphia College of Osteopathic Medicine Total
various allied health personnel are being recognized, one important consideration should be given with respect to the idea of "health team" which could help alleviate some of the problems associated with the short supply of essential health personnel, such as physicians. A recent study conducted by Latham and associates2 8 indicates that the distribution of health services and personnel is closely interrelated with the availability of health facilities, family income, and health insurance. The authors concluded that the health care markets (supply) are more sensitive to economic demand factors than to medically determined need. The actual distribution of health manpower in Pennsylvania, as we have presented in this paper, does seem to agree with their conclusions. Pennsylvania licensure data which we used for the present study lacked much of the qualitative information; for example, data on physicians regarding specialty, patient care status, and type and place of practice were not available. This is the most serious defect in the existing licensure data, not only in Pennsylvania but probably in most other states as well. In view of the vital importance of accurate and current health manpower data for public health programs, a new system of ascertaining such information is in order. The use of the state licensure mechanism for such purposes would be more effective in achieving complete cooperation of all of the health professionals licensed by the state.
References 1. Hoff, W. Resolving the Health Manpower Crisis: A Systems Approach to Utilizing Personnel. Am. J. Public Health 61:2491, 1971. 2. Editorial: The Medical Manpower Shortage. J. A. M. A. 217:1857, 1971. 3. Hudson, C. L. Medical Manpower Shortage-Fact or Fiction? Proc. Med. Sect. Am. Life Convention 55:13, 1967. 4. Schaefer, M., and Hilleboe, H. E. The Health Man-
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6.
7. 8. 9. 10. 11. 12. 13.
14. 15.
16. 17. 18.
19.
power Crisis-Cause or Symptoms? Am. J. Public Health 57:6, 1967. Estes, E. H., Jr. The Critical Shortage-Physicians and Supporting Personnel. Ann. Intern. Med. 69:957, 1968. Fahs, I. J., Choi, T., Barchas, K., and Zakariasen, P. Indicators of Need for Health Care Personnel: The Concept of Need, Alternative Measures Employed to Determine Need, and a Suggested Model. Med. Care 19:144, 1971. Kissick, W. L. Forecasting Health Manpower Needs: The "Numbers Game is Obsolete." Hospitals 41:47, 1967. Mace, D. J. Basic Principles in Manpower Utilization. Pediatr. Clin. North Am. 16:915, 1969. Kissick, W. L. Effective Utilization: The Critical Factor in Health Manpower. Am. J. Public Health 58:23, 1968. Fenninger, L. D. Where Do Allied Personnel Fit in Health Services? Milit. Med. 134:383, 1969. Sanazaro, P. J. Physician Support Personnel in the 1970's: The R. and D. Approach to Health Manpower. J. A. M. A. 214:98, 1970. Hatch, C. D. Allied Health Personnel: An Answer to the Manpower Crisis. Hosp. Prog. 51:69, 1970. Estes, E. H., Jr. Advantages and Limitations of Medical Assistants. J. Am. Geriatr. Soc. 16:1083, 1968. Yankauer, A. Allied Health Workers in Pediatrics. Pediatrics 41:1031, 1968. Stokes, J., 3rd. Physician's Assistants, More Physicians, More Highly Trained Nurses, or a New Health Worker? Am. J. Nurs. 67:1441, 1967. Lenzer, A. New Health Careers for the Poor. Am. J. Public Health 60:45, 1970. Cherkasky, M. Medical Manpower Needs in Deprived Areas. J. Med. Educ. 44:126, 1969. Ginzberg, E. New Dimensions of Public Health: Their Impact on the Evaluation and Selection of Health Personnel. II. A Manpower Strategy for Public Health. Am. J. Public Health 57:588, 1967. Forgotson, E. H., and Forgotson, J. Innovations and Experiments in Uses of Health Manpower: A Study of Selected Programs and Problems in the United Kingdom and the Soviet Union. Med. Care 8:1, 1970. HEALTH MANPOWER DISTRIBUTION
847
20. Hill, F. T. The Revolution in Health Care. J. Maine Med. Assoc. 60:21, 1969. 21. Shryock, R. Medical Licensing in America, 1650-1965. Johns Hopkins Press, Baltimore, 1967. 22. Pennell, M. Y., and Hoover, D. B. Health Manpower Source Book 21. Allied Health Manpower Supply and Requirements, 1950-80. PHS Publication No. 263. U.S. Government Printing Office, Washington, DC, 1970. 23. Roemer, R. Legal Regulation of Health Manpower in the 1970's. HSMHA Health Rep. 86:1053, 1971. 24. Distribution of Physicians, Hospitals, and Hospital Beds in the U.S., 1969. Vol. 1. Region, State, County. American Medical Association, Chicago, 1970.
25. Health Resources Statistics. Reported from National Center for Health Statistics. PHS Publication No. 1509. U.S. Government Printing Office, Washington, DC, 1970. 26. Schonfeld, H. K., Heston, J. F., and Falk, I. S. Numbers of Physicians Required for Primary Medical Care. N. Engl. J. Med. 286:571, 1972. 27. Perry, J. W. Trends in Allied Health. Presented at National Regional Medical Programs Conference for Allied Health Professions, Asilomar, CA, 1969. 28. Latham, R. J., Hu, T.-W., and Werner, J. L. The Distribution of Health Services in Pennsylvania. Pennsylvania State University, Institute for Research on Human Resources.
(Excerpts from letters received by the APHA Smoking and Health Project from former smokers.)
MAN'S BEST FRIEND I grew up in a rural county on the edge of the Missouri River. Like most rural children of those days we had little chance for supervised recreation. We thought it was smart to mimic older people. Most of the farmers smoked either a corn-cob pipe or roll-your-own cigarettes. Occasionally the of my so-called "tailor-mades" were bought by the. carton. We thought it was clever to sneak a pack picked we Sometimes the share and pack. older brother's Fatimas, meet as a group on the river bank, up what we called "snipes" on the railroad track-tossed away cigar butts. We would cut the burned end off the butt and would light up and puff away. In those days we never inhaled. Later, when I was 19 and attending a nearby business college, I thought I just HAD to learn to inhale because my peers were doing it. I kept up the smoking habit for 30 years! In 1960 I moved to Florida and started working for a county health department. My dog got an awful crop of fleas and I was offered a new kind of insect killer called chlordane to dustIton the dog. all It seemed innocuous enough until I lighted a cigarette 2 days later and "took a drag." burned irritated had chlordane The blood. of the way to my stomach, and I began to expectorate bright clots I my respiratory tract so much that even months after the incident whenever I would try to smoke,to said and wised I up a for finally smoke to year, After trying would raise pink-tinged sputum. myself: "Only a fool would persist in smoking and falling heir to lung cancer. I certainly have a head start on getting cancer and it's high time that I stop smoking." Now that I am a "reformed smoker" I sometimes carry a survival mask to meetings where I know in advance that everybody else will be lighting up and polluting my air. Laura Alice Lee Bureau of Drug Abuse Prevention Division of Mental Health Tallahassee, FL 32301
848 AJPH AUGUST, 1975, Vol. 65, No. 8
