Where would you hang your shingle?

A unique survey of graduates from New York State residency programs sought to determine variables affecting the flow of new residency graduates into the physician workforce. 55 percent of respondents were excluded because they were pursuing additional training (fellowship) or were not planning on clinical practice. The specialities of interest included obstetrics and gynecology (7% of the survey), general surgeons (10%), and primary care physicians (35%; defined as pediatricians, family practice, and internal medicine). The final sample includes 3,758 physicians.

The variables of interest are three: (1) malpractice premium amount, (2) caps on economic damages, and (3) the impact of health professions shortage areas (HPSAs). Over seven thousand residents and their job choices were available for analysis. Malpractice premium data was derived from the Medical Liability Monitor which reports mean premiums per locations (ranging from state-wide to community-sized units of measurement).

Rising malpractice premiums have a significant negative effect on surgeons, For every 20 percent increase in premiums from one location compared to another, surgeons are 15 percent less likely to practice there (RR=0.852). No significant effect was observed for OB/GYNs or PCPs. Similarly, in areas with damage award caps, surgeons are over three times as likely to begin practice compared to areas without damage caps (RR=3.361).

Primary care providers are far more likely to locate in areas designated health professions shortage areas (RR=3.373). Surgeons show a nonsignificant trend to avoid practice in HPSAs (RR=0.431). Of interest, once a physician has any educational debt, he or she is far less likely to locate in an HPSA. Providers with up to $100,000 debt are 90 percent less likely to practices in a shortage area; providers with over $100,000 debt are 98 percent less likely.

Commentary:

This physician survey had a response rate in the mid 60 percent range; fairly good for such surveys. Despite methodological flaws, this study does give an excellent picture of how certain physicians choose their initial practice location. Surgeons go where the malpractice climate is favorable, OB/GYNs go where people have lots of babies, and primary care providers go where they are needed…unless, of course, they have educational debt. The current incentives designed to get physicians to go where they are needed appear to be small and ineffective. Based on these data and anecdotes from residents about to get their first “real job” young physicians will go where they can earn a suitable living.

Health Services Research (2009) Advanced copy online.

by

Cedric K. Dark, MD, MPH