General Pediatrics, Neonatology, and the Law of Diminishing Returns

The growing consensus is that the US physician workforce is too big, growing too fast, and is too highly specialized. These concerns merit attention by pediatric clinicians, researchers, and policymakers. Although differing in their suggested remedies, those proposing to slow the growth of new physicians include diverse organizations and interests—the Association of American Medical Colleges, the Institute of Medicine, the Council of Graduate Medical Education, the American Medical Association, and the Pew Health Professions Commission.1-4 A number of specialty organizations have also called for barriers to international medical graduates and fewer residency positions.56 The federal government recently responded with a pivotal change in federal policy. Teaching hospitals will receive transitional funds from Medicare to replace Medicare graduate medical education support if they cut back residency slots by 20% to 25% over a 5-year period.78Although the legislation doesn't target pediatric residency programs, it doesn't shield them from cutback decisions made by hospitals.The high costs of health care in the United States has long been the driving force behind the efforts to constrain the physician supply.9 Physicians are unarguably expensive to train and, as the primary decision makers in patient care, expensive in practice. This is especially true for highly-paid specialists using costly technologies. Primary care physicians are usually excluded from the call for downsizing because they are often viewed as the less expensive alternative to specialty care.10Pediatrics is now assessing its own future role in serving the health care needs of children through the Future of Pediatric Education II Project. This 3-year project, funded by the American Academy of Pediatrics, is particularly interested in pediatric workforce requirements in addition to the content and funding of pediatric education.11 Similarly the American Academy of Family Physicians is reevaluating its position on workforce reform.12Pediatrics and family practice have been viewed as a special case in the workforce debate. The medical care of children is largely a primary care activity emphasizing preventative services that may favorably influence many decades of life. Most children's illnesses are treated in ambulatory settings with inexpensive measures. When hospitalization and surgery occur, they are usually less complex and expensive than in adults. Furthermore, a significant proportion of children are poor and continue to lack adequate primary care. The combination of the modest cost of pediatric care and the persistence of underserved pediatric populations would seem to argue for increasing, rather than decreasing, the growth of pediatric providers.13The strategy of improving children's health through training more and more pediatric clinicians can only be successful if two conditions are met. The first is that the new clinicians must selectively serve the populations in greater need. Unfortunately, the 24% growth in child health physicians per capita14 (pediatricians and 0.25 family practitioners per 100 000 age 0–17 years) in the past 10 years has not remedied the geographic disparities in distribution. There is a fivefold variation in the per capita supply of child health physicians (unpublished data from the Dartmouth Atlas Working Group that is available from authors). Regions with a notably high number of child health physicians per capita include San Francisco (162 per 100 000 age 0–17 years), Hackensack, New Jersey (144 per 100 000), and eastern Long Island (133 per 100 000). These rates are almost twice as high as Minneapolis (76 per 100 000) and Wichita (67 per 100 000), regions suggested as physician supply benchmarks.15-17 Pediatricians are similar to other specialties in tending to settle in areas with a high per capita income and residency training programs.18 Although detailed nurse practitioner data is not yet available specifically for pediatrics, the location of nurse practitioners overall follows that of primary care physicians.19 Given these settlement patterns, more pediatric clinicians may increase the availability of care, but not preferentially to those with poor access in the first instance.The second necessary condition is that more pediatric clinicians lead to better health in the total cohort of children. Expressed differently, a greater clinician supply must be effective at the population level. Effectiveness could include such improvements as decreased mortality (neonatal and infant), better functional status (school absences, exercise tolerance), fewer hospitalizations, and lower health risks (underimmunized, high lead levels, substance abuse, nonuse of car restraints). Greater family satisfaction with pediatric care is important to measure but harder to interpret. If satisfaction is the reason for increasing the supply of physicians, then more will always seem better up to the point of one physician for each family.The effectiveness of a physician supply is usually asserted as an a priori in workforce planning, but one that is increasingly challenged by data. Studies of adult health services suggest that in many instances more physicians, as well as more medical care, have little effect on health.20-22 In other instances, the potential for harm exists.2324 Researchers interested in pediatric health services, with an occasional exception,25 have been largely silent on workforce effectiveness.An alternative view is the law of diminishing returns.26 This hypothetical curve relates the pediatric clinician supply to net population benefits. In populations with relatively low supply, the net benefits to the population should rise steeply as the supply increases. The pediatric populations on this ascending part of the curve are likely to be medically underserved and disenfranchised receiving inadequate basic preventative and acute care services. As the physician supply increases, the curve will flatten as incremental patient benefits are smaller for each increase in the workforce. Many affluent populations might already be on this part of the curve. Adding more child health physicians to an already ample number is likely to have relatively little effect in the context of highly accessible care and the many other influences on children's health. Finally, we should recognize that the law of diminishing returns includes a region beyond the flat of the curve.26In this hypothetical domain, net patient benefits begin todecline as children receive excessive diagnostic and therapeutic interventions by a rising number of well-intended providers.The idea that a growing supply of pediatric clinicians may do more harm than good is untested, but plausible. Consider the case of neonatology.27-32 It is widely recognized that neonatologists and intensive care nurseries have improved birth weight-specific outcomes.33-35 This success sparked a rapid growth in the supply of neonatologists, fueled more recently by the competitive hospital industry. There are now more than 3000 board-certified neonatologists.36 A recent survey suggests that >80% are younger than 50 years of age37; retirement will have negligible effects on the specialty's growth during the next decade. As a result of the expansion in the workforce, each year there are fewer and fewer newborns per neonatologist (Table1). The number of births per neonatologist decreased from 7201 in 1981 to 1687 in 1996. More striking is the decline in the number of extremely low birth weight infants (<1000 g) per neonatologists from 39 to 11.Once considered the core of regionalized perinatal care, there is concern that neonatology is becoming increasingly deregionalized.3839 The growth in the numbers of neonatologists has been accompanied by the development of many more intensive care nurseries. There are now more than 600 hospitals offering advanced level care, and 60% of neonatologists identify themselves as practicing in nonuniversity private or hospital settings.37 Many hospitals compete against nearby facilities for neonatal patients. In addition, more than 50% of neonatologists provide normal newborn care,37 which provokes a mixed reaction from pediatricians and family practitioners.40-42 Some welcome the opportunity to narrow their clinical practices; others see it as an invasion of expensive care that competes with their own practice model. In either case, subspecialty-trained physicians are delivering care to populations long-served by general pediatricians and family practitioners.At first glance, the growth and diffusion of neonatal intensive care services might be viewed as an obvious benefit. Isn't more sophisticated care always beneficial? Perhaps not, given the absence of a simple relationship between the supply of neonatologists and infant mortality rates in the studies done so far.2931 These tentative findings suggest that we are already at the point of diminishing returns. Could the supply of neonatologists be at the point where harm begins to outweigh benefit? Neonatal care developed for the sickest infants may have unintended consequences when applied to those with milder illness. How do larger and less ill infants fare? Do the benefits outweigh the potential harm from a greater number of diagnostic and therapeutic procedures and separation from parents? Furthermore, there may be hidden dangers for even the sickest newborns. A recent study suggests that neonatal outcomes are better in units with higher volumes.43 The proliferation of intensive care nurseries with each caring for fewer newborns may erode the critical number necessary for optimum clinical care and organization of perinatal services. As the number of neonatologists continues to grow, the effectiveness of the differing supply across regions is important to investigate.General pediatricians and other clinicians caring for children may also be subject to the law of diminishing returns. The traditional wisdom is that children in areas or health plans with very high per capita numbers of pediatric providers benefit from more available medical care. In these locales, physicians may devote more effort to risk reduction and behavioral issues. Perhaps greater access translates to earlier acute illness visits with fewer school absences. These are some plausible benefits from more pediatric clinicians per capita.It is also conceivable that children cared for in settings with higher clinician supply receive excessive care. Greater access, for example, may lead to more visits for viral illness with parental expectation of antibiotic treatment. Toddlers with equivocal ear findings may be treated more frequently with antibiotics.44 What is certain is that overtreatment of upper respiratory infections with antibiotics has contributed to higher rates of antibiotic resistance in bacterial pathogens, a growing public health concern.45Although misguided practice styles may also be blamed, these examples of excessive pediatric care may be an unintended consequence of a high primary care clinician supply.As we expand our knowledge of the ways to improve health, our blind spot to the effectiveness of the size of our workforce is increasingly apparent. The growing, but unevenly distributed, number of physicians should awaken our desire to understand the epidemiology of the child health workforce beyond descriptive statistics. Costs are important, but at this juncture we hardly know what society is paying for in areas with a high supply. The origins of today's “evidence-based medicine” can be found in the desire to understand cause and effect in disease pathogenesis and treatment. The fundamental research questions about the pediatric workforce must also address effectiveness and mechanisms.These questions can be answered with the same methods used to test a new therapy or a public health intervention. In some instances theefficacy of the workforce can be tested (eg, in a controlled research setting). In general pediatrics, for example, randomized clinical trials of physician panel sizes could be undertaken. Families newly enrolled in a health maintenance organization could be randomly assigned either to a panel with intentionally lower number of children (in effect, a high physician supply) or a standard-sized panel. Testing the effectiveness of physician supply, by definition, necessitates studies outside research environments. Furthermore, in neonatology most intervention trials are not feasible or ethical. Answers about the effectiveness of neonatal supply will come from observational studies that exploit the natural experiments in neonatologist distribution. Existing clinical data collection systems are now sophisticated enough to permit population-based studies of neonatal cohorts. Although studies will be challenged by the confounders and possible sources of bias common to observational studies, the methods of outcome research continue to gain in sophistication.The results of this research may provide evidence to bolster current assertions that more pediatric clinicians are always better for children. Or we may learn that pediatric and neonatal clinicians are similar to all other good things in life: food, sunshine, and exercise. Moderation leads to health and happiness. But taken in excess, it really is possible to have too much of a good thing.This work was supported by a grant from the Robert Wood Johnson Foundation.