The Obstetrician-Gynecologist Workforce in the United States Facts, Figures, and Implications 2011 The Obstetrician- Gynecologist Workforce in the United States Facts, Figures, and Implications 2011 William F. Rayburn, MD, MBA, FACOG The Obstetrician-Gynecologist Workforce in the United States: Facts, Figures, and Implications, 2011 was developed by the American Congress of Obstetricians and Gynecologists (ACOG). This publication was made possible by a grant from the American College of Obstetricians and Gynecologists (the College) Development Fund.Library of Congress Cataloging-in-Publication Data Rayburn, William F. The obstetrician/gynecologist workforce in the United States : facts, figures, and implications 2011 / William F. Rayburn. p. ; cm. Includes bibliographical references and index. ISBN 978-1-935718-03-1 (alk. paper) 1. Obstetricians--Supply and demand--United States. 2. Gynecologists--Supply and demand--United States. I. American Congress of Obstetricians and Gynecologists. II. Title. [DNLM: 1. Gynecology--manpower--United States. 2. Obstetrics--manpower--United States. 3. Gynecology--education--United States. 4. Gynecology--trends--United States. 5. Obstetrics--education- -United States. 6. Obstetrics--trends--United States. WQ 21] RG960.R39 2011 331.11'916181--dc22 2010041169The information, references, and Internet links contained in this publication were current as of April 12, 2011, and may be subject to change without notice. Reference to Internet sites and other sources of information does not indicate endorsement by ACOG. Readers are responsible for confirming the status of information contained in this publication before making decisions based on that information. Copies of The Obstetrician-Gynecologist Workforce in the United States: Facts, Figures, and Implications, 2011 can be purchased through the College Distribution Center by calling 800-762-2264. Orders also can be made from the College web site at sales.acog.org. Copyright 2011 by the American Congress of Obstetricians and Gynecologists. All rights reserved. Printed in the United States of America. No part of this publication may be reproduced, stored in a retrieval system, posted on the Internet, or transmitted in any form by any means, electronic, mechanical, photocopying, recording, or otherwise, without the prior written permission of the publisher. Requests for photocopies should be directed to the Copyright Clearance Center, 222 Rosewood Drive, Danvers, MA 01923.The American Congress of Obstetricians and Gynecologists 409 12th Street, SW PO Box 70620 Washington, DC 20024-9998 www.acog.org 12345/54321 Contents Preface v acknowledgments ix 1 U.S. Medical School Enrollment and 2 Residency Matching in Obstetrics and Gynecology 1 U.S. Graduate Medical Education in Obstetrics and Gynecology 13 3 U.S. Medical School Faculty in Obstetrics and Gynecology 33 4 Characteristics and Distribution of Obstetrician-Gynecologists in the United States 43 5 Obstetrician-Gynecologists as Coordinators of Women's Health Care and as Surgical Specialists 67 6 Financial Considerations and Physician Compensation 85 7 Career Satisfaction of Obstetrician-Gynecologists and Its Impact on the Workforce 99 8 Transforming the Women's Health Care Workforce 109 9 Workforce Projections of Obstetrician-Gynecologists in the United States 119 10 Summary and Moving Forward 137 aPPendix a. definitions 141 aPPendix B. commonly Used acronyms 143 aPPendix c. key soUrces of data on Physician workforce Projections 145 aPPendix d. the american congress of oBstetricians and gynecologists workforce fact sheet for 2011 147 aPPendix e. references for figUres and taBles By section 151 aPPendix f. color figUres 181PrefaCe The Obstetrician-Gynecologist Workforce in the United States: Facts, Figures, and Implications, 2011 is intended to provide Fellows of the American Congress of Obstetricians and Gynecologists (ACOG), health service researchers, academicians, health care policy makers, and the public with data to better understand obstetrician-gynecologist (ob-gyn) workforce trends and dynamics. This data-driven publication provides up-to-date, detailed, and descriptive statistics about active ob-gyns and ob-gyns in training. Trends in obstetrics and gynecology often are compared in this text with those in primary care and surgical specialties, which have the largest number of active physicians (ie, specialties with more than 10,000 active physicians). ? Why Examine Physician Workforce Issues? Undertaking a physician workforce study is not new. The Liaison Committee for Obstetrics and Gynecology decided at its meeting in 1996 to conduct a workforce study in obstetrics and gynecology in response to a national need to reduce the number of nonprimary care residency positions. The purpose of that report led by Jacoby et al* was twofold: 1) to determine what was the current provider supply and 2) what were the projections for 20, 30, and 40 years if the number of residency positions either remained stable or was reduced. Since 2003, a dozen states and more than 20 specialties reported a physician shortage or anticipate one in the next few years. Obstetrics and gynecology is one of those vulnerable specialties for several reasons: 1) the workforce is aging, 2) obstetrics and gynecology is among the most stressful medical specialties, and 3) the interest of U.S. medical students in specializing in obstetrics and gynecology has decreased. Concerns regarding litigation and cost of liability insurance are thought to be a major factor in the early retirement of ob-gyns and in the shift to gynecology-only practices. This anticipated shortage of ob-gyns and a worsening of their distribution are compounded by a projected increase in the demand for women's health care services. In response to this challenge, the Association of American Medical Colleges (AAMC) called for an expansion of medical schools and graduate medical education enrollments in 2006. In addition, ACOG is investigating and documenting workforce issues related to physician supply, demand, utilization, and distribution across geographic regions. The current workforce is undergoing fundamental changes that will have important long-term implications on the professional lives of ob-gyns and on the delivery of women's health care services. Several recent trends affecting the workforce and practice patterns include the following: 1. A new generation of physicians, including an increasing representation of women, with a greater emphasis on life balance 2. Changing practice patterns, including more flexible or part-time schedules *Jacoby I, Mayer G, Haffner W, Cheng E, Potter A, Pearse W. Modeling the future workforce of obstetrics and gynecology. Obstet Gynecol 1998;92:450-6. 3. Relatively less professional satisfaction among ob-gyns 4. Slow or no growth in adjusted income of active health care providers 5. Continued maldistribution of ob-gyn workforce It should be emphasized that these trends are not unique to ob-gyns. The American Congress of Obstetricians and Gynecologists is committed to providing reliable and useful data to support policy making for women's health care services in the United States. This report flows from that commitment and is intended to provide past and present pictures of the ob-gyn workforce in the United States. Data in this text will assist the U.S. Congress in making critical decisions on how women's health care should be provided now and in the future as stated in a later discussion. Effective decision making about health care, workforce planning, and policy development requires accurate information at national, regional, local, and individual levels. As the population grows and as the need for women's health care expands, the supply of ob-gyns is predicted to be insufficient. Therefore, robust projections are needed periodically to prepare for both the short- and long-term health needs of our nation's women. ? Methodology and Limitations of Workforce Studies Effort in developing this book represents a stepwise series of tasks to systematically collect and analyze survey data to determine the present and future needs of ob-gyns. Methods entail examining such factors as changes in office and hospital practices, gender, geographic location, time commitments (part-time or full-time), and scope of practice. This effort enlisted the cooperation of all ACOG offices. The American College of Obstetricians and Gynecologists Resource Center and the AAMC Center for Workforce Studies served as excellent resources among others. Information in each section was carefully scrutinized by individuals in leadership positions for their perspectives and insights. The data to prepare this text were drawn from the best available national inventories and sources. Primary sources of data included the following organizations: o American Board of Obstetrics and Gynecology o American Congress of Obstetricians and Gynecologists o American College of Surgeons Health Policy Research Institute o American Medical Association o American Osteopathic Association o Association of American Medical Colleges o Centers for Disease Control and Prevention o Council for Resident Education in Obstetrics and Gynecology o Health Resources and Services Administration, National Center for Health Workforce Analysis o Medical Liability Monitor o National Residency Matching Program o U.S. Census Bureau o U.S. Bureau of Labor Statistics An important element of the report is visual presentation of the data in tables and figures. These tables and figures are provided to enhance an understanding of the complexities of the composition of the obstetrician-gynecologist workforce and the factors that affect it. They are grouped by topic and presented in each section after the discussion. Provided in the appendixes are definitions of terms used throughout this publication, explanations of commonly used acronyms, key sources of data on physician workforce projections, the ACOG workforce fact sheet, references for the figures and tables organized by section, and supplemental color illustrations. In preparing this presentation, only national data were chosen that included the most current information. Every effort was undertaken initially to use data generated from ACOG or the American Board of Obstetrics and Gynecology. When possible, more than one source was used to validate the information. Close attention was paid to the definitions, restrictions, and categorizations before making direct comparisons of data. Certain limitations in data reporting must be understood. Membership data from ACOG, the American Medical Association (AMA), and AAMC were not intended for research purposes. Therefore, data presented here cannot be guaranteed as being absolutely accurate. For example, the AMA masterfile is based on self-reported categories and designations of physicians surveyed at their preferred mailing addresses once every 3-4 years. Numbers in figures or tables presented here may vary from other summaries because those reports may use different definitions or selection criteria. Recognizing these limitations, ob-gyns now need to be informed about the most current information on which to search for trends as the current national health care reform continues. Projections usually are based on practice patterns of the current workforce. Potential changes in practice patterns, such as reduced work hours, reduced birth rates, aging population, interdisciplinary models, and alternative service models, will affect predictions about the workforce. Because previous efforts to analyze and correct workforce misalignments have not taken into account such changes and limitations in data reporting, they were flawed in logic and had the potential to minimize or exacerbate the problems. ? Future The premise of this text is that effective health care reform must begin by looking at the delivery side of health care; ie, the ob-gyns. An efficient, high-quality women's health care system depends on having the right number of physicians and other health care providers in the right locations. Physicians are the engine of health care, but their responsibilities are increasingly being shared with other skilled workers, in particular certified nurse-midwives, nurse practitioners, and physician assistants. Appreciating these methods and limitations of the current and future workforce calculations will allow ob-gyns to better cope with the impending reform of women's health care and address it more constructively.-william f. rayBUrn, md, mBa, facog Consultant, Workforce Studies and Planning American Congress of Obstetricians and Gynecologists Randolph V. Seligman Professor and Chair Department of Obstetrics and Gynecology University of New Mexico School of MedicineaCknowledgments The Obstetrician-Gynecologist Workforce in the United States: Facts, Figures, and Implications, 2011 is the result of the combined efforts and participation of a number of leaders and staff members within the American Congress of Obstetricians and Gynecologists (ACOG). Special thanks go to my two administrative assistants, Gail Mathis and Erika Elwell, for their tireless attention to detail in helping me prepare each section. Mary Hyde, at the American College of Obstetricians and Gynecologists Resource Center, was invaluable for her prompt and courteous searches of the literature and her confirmation of many of my reported findings. The following ACOG leaders offered their expertise in reviewing this book: Ralph W. Hale, MD Executive Vice President Luella Klein, MD Vice President for Women's Health Issues Hal C. Lawrence III, MD Vice President for Practice Activities Albert Strunk, JD, MD Vice President for Fellowship Activities Sterling B. Williams, MD, MS Vice President for Education John Queenan, MD Deputy Editor of Obstetrics and Gynecology Staff persons and their departments at the ACOG headquarters engaged with this effort are listed as follows: Deirdre Allen, Publications Britta Anderson, Research Elsa Brown, Administration Janet Chapin, Women's Health Issues Anne Diamond, Health Economics Nikoleta Dineen, Publications Thomas Dineen, Publications Lucia DiVenere, Government Relations Lana Dowell, Information Systems Debra Hawks, Practice Activities Anna Hyde, Government Relations Mary Hyde, Resource Center Jeffrey Klagholz, Professional Liability Penny Murphy, Communications Heidi Logothetti, Obstetrics and Gynecology James Lumalcuri, Professional Liability Megan McReynolds, Office of the Executive Vice President Mary Mitchell, Practice Activities DeAnne Nehra, Council on Resident Education in Obstetrics and Gynecology Jean Riedlinger, Resource Center Bernice Rose, Membership Services Penny Rutledge, Legal Issues Jay Schulkin, Research James Scroggs, Health EconomicsThis publication was made possible by a grant from the American College of Obstetricians and Gynecologists Development Fund. U.s. mediCal sChool enrollment and residenCy matChing in obstetriCs and gyneCology Last year marked the 100th anniversary of the Flexner report, Medical Education in the United States and Canada. This landmark report found that medical schools did not base their training on sufficiently high standards of science. The report resulted in the closure of many medical schools and caused the number of medical graduates per year to decrease precipitously. From 1900s to the 1960s, there was almost universal agreement that the nation did not have enough physicians, although the per-capita supply remained relatively stable. This perceived shortage was not reported by any research with acceptable analytic rigor. Support from federal and state governments resulted in the building of some 45 new medical schools and in the expansion of established schools between 1962 and 1986. ? Past Medical School Enrollment and Population Growth In the early 1980s, the number of entry-level medical students plateaued and the construction of new schools ceased because of a projected oversupply of physicians. There remain more than 42,000 applicants each year, or nearly two and one quarter applicants for every available seat in medical school classes. The total enrollment of first-year U.S. medical students (now approximately 18,000 annually) has increased minimally over the past 30 years. Although medical school enrollment remained steady (approximately 130 students per medical school class), the population of the United States increased by 34% from 227 million in 1980 to 304 million in 2010, an increase of nearly 80 million in 30 years. Furthermore, demand on physicians' time has increased and will continue to do so, especially with an aging population and the epidemic of lifestyle-associated illnesses, such as obesity, heart disease, diabetes, and cancer. ? Medical School Expansion How can the "correct" number of doctors be determined? A standard method for determining this "correct" number of medical school graduates is by calculating the physician-to-population ratio. Currently, there are 286 actively practicing physicians per 100,000 people (1 for every 350 persons) in the United States. Based on the increasing population, by 2050 1.2 million doctors may be needed in the United States to maintain this ratio. Assuming that the average physician practices for 35-40 years from medical school graduation until retirement and that American medical schools will not increase enrollment, these schools will be able to supply slightly more than one half of the physicians needed in 2050. Recognizing this projected shortage of physicians, the Association of American Medical Colleges announced in 2006 the need for a 30% increase in medical school enrollment by 2015 using the 2002 first-year class size (16,365 students) as a baseline. Establishing approximately 5,000 new student positions per year will be necessary to graduate 21,000 students each year to keep up with the nation's growing population by 2013. The recommended expansion in enrollments at the 125 medical schools accredited by the Liaison Committee on Medical Education was to account for 76% of the anticipated growth. New schools (five accredited as of 2008 and five applicant schools) would account for the remaining 24% anticipated growth in first-year student enrollment. Total medical school enrollment increased in 2010 to 18,665 students with increases among all underrepresented racial and ethnic minority groups. ? Residency Matching in Obstetrics and Gynecology Students in their senior year of medical school usually enter into the National Residency Matching Program and eventually match with training institutions. In recent years, approximately 5.9% of all U.S. medical students were accepted into obstetric-gynecologic programs. The approximate 1,200 first-year resident positions in obstetrics and gynecology are expected to be filled by graduates who trained at U.S. medical allopathic schools (73%), international medical schools (18%), or at osteopathic schools (9%). Those specialties that are procedure-driven with the highest incomes tend to be filled with the highest percentage of U.S. medical school graduates. Hospitals and other health care institutions will fill more than one quarter of the nation's 100,000 available residency positions with international medical graduates. First-year enrollment at U.S. osteopathic schools in 2002 (3,079 students) increased in 2008 by 53.7% (to 4,732 students) and is projected to increase in 2013 by 79.2% (to 5,519 students).Implications Despite the increase of the U.S. population by 80 million since 1980, the number of U.S. medical graduates remained fairly unchanged over the years. Hiring international medical graduates and nonphysician clinicians are two ways to accommodate the health care needs of this expanding population. The anticipated 30% increase in U.S. medical school enrollment is particularly appropriate in states where the population either has grown rapidly or is projected to do so and where there is a relatively low physician-to-population ratio. In addition, this expansion will provide an opportunity to recruit from a larger and more diverse group of medical students into obstetric-gynecologic residency programs.Bibliography Association of American Medical Colleges. AAMC data book: medical schools and teaching hospitals by the numbers. Washington, DC: AAMC; 2010. Association of American Medical Colleges. AAMC statement on the physician workforce. Washington, DC: AAMC; 2006. p. 1-9. Available at: https://www.aamc.org/download/55458/data/workforceposition. pdf. Retrieved February 25, 2011. Association of American Medical Colleges. Recent studies and reports on physician shortages in the U.S. Washington, DC: AAMC; 2010. Available at: https://www.aamc.org/download/100598/data/ recentworkforcestudiesnov09.pdf. Retrieved April 12, 2011. Ebell MH. Future salary and US residency fill rate revisited [letter]. JAMA 2008;300(10):1131-2. Flexner A. Medical education in the United States and Canada: a report to the Carnegie foundation for the advancement of teaching. New York (NY): Daniel Berkeley Updike printer; 1910. National Resident Matching Program. Results and data 2010 main residency match. Washington, DC: NRMP; 2010. Salsberg E, Grover A. Physician workforce shortages: implications and issues for academic health centers and policymakers. Acad Med 2006;81:782-7. Schulman S, Salsberg E. Projections of future medical school enrollment. AAMC Anal Brief 2009;9(3):1-2. Available at: https://www.aamc.org/download/102372/data/aibvol9no3.pdf. Retrieved April 12, 2011. U.S. Census Bureau. Preliminary annual estimates of the resident population for the United States, regions, states, and Puerto Rico: April 1, 2000 to July 1, 2010. Washington, DC: Census Bureau; 2010. Available at: http://www.census.gov/popest/eval-estimates/eval-est2010.html. Retrieved on February 25, 2011.The following tables and figures provide data related to U.S. medical school enrollment and residency matching. Table 1-1. Projected U.S. Population According to Migration Series Lowest Migration Series Middle Migration Series Highest Migration Series Dependency Ratios Dependency Ratios Dependency Ratios Year Population (N) Age 65 Years and Older and Younger Than 15 Years (%) Age 65 Years and Older (%) Population (N) Age 65 Years and Older and Younger Than 15 Years (%) Age 65 Years and Older (%) Population (N) Age 65 Years and Older and Younger Than 15 Years (%) Age 65 Years and Older (%) 2000 274,910 51.4 19.2 275,306 51.3 19.1 275,756 51.3 19.1 2010 293,438 49.6 20.1 299,862 49.4 19.8 308,668 49.1 19.4 2015 302,069 52.9 23.0 312268 52.6 22.5 327,011 52.2 21.7 2020 310,584 57.7 26.8 324,927 57.6 26.0 346,661 56.4 24.8 2025 318,817 63.3 31.3 337,815 62.3 30.1 337,912 60.7 28.2 2030 326,641 67.6 35.0 351,070 65.9 33.2 391,446 63.4 30.5 2035 333,854 69.0 36.3 364,319 67.0 34.3 416,564 63.9 31.0 2040 340,510 68.8 36.3 377,350 66.8 34.1 442,528 63.5 30.6 2045 346,910 68.5 35.9 390,398 66.5 33.8 469,462 63.2 30.3 2050 353,314 68.8 36.1 403,687 66.9 33.9 497,509 63.5 30.3 Figure 1.1. U.S. first-year medical school enrollment per 100,000 population with the effect of a 30% expansion. 7.5 7.0 6.5 6.0 5.5 5.0 4.5 7.36.8 6.46.2 5.8 5.65.4 5.2 5.0 4.01980 1985 1990 1995 2000 2005 2010 2015 2020 Year of survey Table 1-2. U.S. Medical Schools Accredited by the Liaison Committee on Medical Education Number of Fully Accredited Medical Schools Academic Year Public Private New Fully Accredited Medical Schools 1960-61 39 42 1961-62 41 41 West Virginia University 1962-63 42 41 University of California at Irvine 1963-64 42 41 1964-65 43 41 University of Kentucky College of Medicine 1965-66 43 41 1966-67 43 41 1967-68 43 41 1968-69 44 41 University of New Mexico 1969-70 44 41 1970-71 45 42 University of Texas Health Science Center at San Antonio Mt. Sinai School of Medicine 1971-72 46 43 University of Arizona Penn State* 1972-73 51 44 Medical College of Ohio (currently University of Toledo) Michigan State University University of California at Davis University of California at San Diego University of Connecticut Dartmouth 1973-74 54 45 Louisiana State University Health Sciences Center at Shreveport University of Missouri at Kansas City Rush Medical College University of Texas Health Science Center at Houston 1974-75 59 45 University of Massachusetts Stony Brook University University of South Florida Texas Tech University Rutgers, The State University of New Jersey 1975-76 62 47 Mayo Southern Illinois University University of Hawaii Brown University University of North Dakota 1976-77 64 48 Eastern Virginia Medical School* University of South Alabama University of South Dakota 1977-78 64 48 1978-79 64 48 1979-80 65 47 Penn State* 1980-81 68 47 Wright State University Uniformed Services University of the Health Sciences University of Nevada(continued) Table 1-2. U.S. Medical Schools Accredited by the Liaison Committee on Medical Education (continued) Number of Fully Accredited Medical Schools Academic Year Public Private New Fully Accredited Medical Schools 1981-82 73 48 University of South Carolina Texas A&M University Northeastern Ohio Universities Colleges of Medicine and Pharmacy Marshall University East Carolina University Pontificia Universidad Católica de Puerto Rico 1982-83 74 49 Oral Roberts University East Tennessee State University 1983-84 74 50 Universidad Central del Caribe 1984-85 74 51 Morehouse School of Medicine 1985-86 74 52 Mercer University 1986-87 74 52 1987-88 73 53 Penn State* reclassified as a private school 1988-89 73 53 1989-90 73 53 1990-91 73 52 Closure of Oral Roberts University 1991-92 73 52 1992-93 73 52 1993-94 73 52 1994-95 73 51 Merger of Medical College of Pennsylvania and Hahnemann University in January 1995 (currently Drexel University) 1995-96 73 51 1996-97 73 51 1997-98 73 51 1998-99 73 51 1999-00 73 51 2000-01 73 51 2001-02 73 51 2002-03 74 50 Penn State* reclassified as a public school 2003-04 74 50 2004-05 75 50 Florida State University 2005-06 75 50 2006-07 75 51 The San Juan Bautista School of Medicine 2007-08 76 50 Florida International University Texas Tech University Paul L. Foster School of Medicine University of Central Florida 2008-09 76 50 Preliminarily accredited: The Commonwealth Medical College Virginia Tech Carilion School of Medicine *Penn State and Eastern Virginia Medical School reclassified as public schools. Figure 1-2. New U.S. medical schools accredited by the Liaison Committee on Medical Education in 1962-1986. Table 1-3. U.S. Medical School Applicants and First-Year Enrollment Applicants First-Year Enrollment Academic Year Total (N) Women (%) Total (N) Women (%) 1965-66 18,703 9.0 8,554 9.3 1970-71 24,987 10.9 11,169 11.0 1975-76 42,282 22.7 14,897 23.6 1980-81 36,083 29.5 16,587 28.7 1985-86 32,885 35.1 16,268 33.9 1990-91 29,241 40.3 15,998 38.5 1991-92 33,297 41.1 16,211 39.7 1992-93 37,402 41.8 16,289 41.6 1993-94 42,806 41.9 16,307 42.0 1994-95 45,360 41.8 16,287 41.9 1995-96 46,586 42.5 16,252 42.7 1996-97 46,965 42.6 16,201 42.7 1997-98 43,016 42.5 16,164 43.3 1998-99 40,996 43.4 16,170 44.3 1999-00 38,443 45.2 16,221 45.7 2000-01 37,088 46.6 16,301 45.8 2001-02 34,860 48.0 16,365 47.6 2002-03 33,625 49.2 16,488 49.2 2003-04 34,791 50.8 16,541 49.6 2004-05 35,735 50.4 16,648 49.5 2005-06 37,373 49.8 17,003 48.5 2006-07 39,108 49.3 17,361 48.6 2007-08 42,315 49.0 17,759 48.3 2008-09 42,231 48.2 18,036 47.8 2009-10 42,269 47.9 18,390 47.9 Figure 1-3. U.S. medical school applicants and first-year enrollees. 50,00040,00030,00020,00010,0000 Applicants First-year enrollees 1960 1970 1980 1990 2000 2010 Year of survey Figure 1-4. Number of applicants to residency programs categorized by surgical specialty as of 2010.General surgery 2,241Obstetrics and gynecology Orthopedics Ophthalmology Otolaryngology Urology Neurosurgery Plastic surgery 395337309200 630 996 1,777 0 500 1,000 1,500 2,000 2,500 Number of first-year resident applicants Table 1-4. First-Year Residency Positions Filled in Obstetrics and Gynecology Filled by U.S. Medical Graduates Academic Year Total (N) n % 1978-79 1,163 931 80.1 1986-87 1,135 1,081 95.2 1992-93 1,289 1,218 94.5 1997-98 1,195 1,121 93.8 2003-04 1,066 743 69.7 2004-05 1,083 772 71.3 2005-06 1,130 835 73.9 2006-07 1,149 837 72.8 2007-08 1,151 838 72.8 2008-09 1,179 879 74.6 2009-10 1,187 915 77.1 Table 1-5. First-Year Residency Positions Offered and Filled in Obstetrics and Gynecology Filled Year Offered (N) n % 2004 1,142 1,066 93.3 2005 1,144 1,083 94.7 2006 1,154 1,130 98.0 2007 1,155 1,149 99.5 2008 1,163 1,151 99.0 2009 1,185 1,179 99.5 2010 1,187 1,182 99.6 Table 1-6. First-Year Residency Positions Filled by U.S. Medical School Seniors Positions Filled (%)Year Obstetrics and Gynecology Total Clinical Departments 2006 72.4 64.9 2007 72.5 65.0 2008 72.1 64.6 2009 74.2 64.9 2010 77.1 65.7 Figure 1-5. Percentage of first-year residency positions filled with U.S. medical graduates vs mean overall incomes by medical specialty.1009080 OtolaryngologyEmergency medicineOrthopedic surgery Radiology Anesthesiology Pediatrics 70 60 Psychiatry Internal medicine 50 General surgery Obstetrics and gynecologyPathology Neurology 40 Family medicine 3020100 100,000 200,000 300,000 400,000 500,000 Mean salary for specialty ($) 2U.s. gradUate mediCal edUCation in obstetriCs and gyneCology A substantial change in resident training requirements in obstetrics and gynecology appeared in 1976 when a first-year resident had to satisfactorily complete not less than 4 years of approved clinical training with not less than 36 months in obstetrics and gynecology. Over the subsequent 35 years, the number of residency programs in obstetrics and gynecology decreased gradually from 306 in 1979 to 246 in 2010. Training programs are now equally divided between academic health centers and community-based hospitals. In the academic year 2009-2010, the total number of residents in obstetrics and gynecology (4,842) included 1,168 who were about to graduate and 1,259 who entered their first year of training. The number of residents in obstetrics and gynecology represents 4.5% of the total number of resident physicians on duty in programs accredited by the Accreditation Council of Graduate Medical Education (ACGME). Appendix F provides a color map illustrating the locations of allopathic and osteopathic residency programs in obstetrics and gynecology. ? Trends in Residency Positions Despite the increasing population in the United States, the number of U.S. medical school graduates entering residency programs in obstetrics and gynecology has not increased substantially. There have been approximately 1,200 first-year residency positions for each of the past 30 years. In 2010, the number of first-year residents remained less than the previous peak of 1,311 (6.6% of all U.S. medical school graduates in 1999-2000). The total number per year of residents in obstetrics and gynecology in allopathic residency programs has fluctuated mostly between 4,600 and 5,000 with the peak enrollment occurring between 1994 and 1998 (between 4,912 and 5,033 of total residents per year). The number of residents in obstetrics and gynecology has not increased since the academic year 1992-1993. The number of residents in obstetrics and gynecology in osteopathic residency programs was 282 in 2010. ? Resident Demographics Obstetrics and gynecology was second only to general surgery in the total number of residents in ACGME-approved surgical training programs. Compared with ACGME training programs in other specialties, residents in obstetrics and gynecology comprise a higher percentage of U.S. medical school graduates (73% versus 65% in 2010), a lower percentage of international medical school graduates (18% versus 27%), and approximately the same percentage of osteopathic school graduates (9% versus 7%). A significant percentage (37%) of international medical graduates are either U.S. citizens or U.S. permanent residents. Obstetrics and gynecology has the highest percentage of residents who are women compared with the other medical specialties combined (80% versus 46%), which has remained fairly constant for the past 5 years. It also has the highest combined percentage of residents who are African American, American Indian or Alaskan Native, or Native Hawaiian or Pacific Islander (11% versus 6%). The percentage of residents of Hispanic origin is similar to the other residency specialties (9% versus 8%). ? Role of Government in Graduate Education Important to understanding tomorrow's needs for more physicians is an overview of the major role of the government and also an awareness of signal events that occurred during the past 50 years. Anecdotal evidence antedating the 1960s led to a general consensus that the United States had a shortage of physicians, prompting federal and state governments to allocate funds to increase the supply of physicians. This support began in the early 1960s, and by 1976 resulted in the building of 40 new medical schools and the expansion of established schools. A signal event in 1965 was the passage of Medicare and Medicaid, when the federal government began to assume the responsibility of providing health care for the elderly and disabled individuals. By supporting hospitals to care for the patients enrolled in Medicare, funding was appropriated for the education of resident physicians at those hospitals, triggering a gradual but significant increase in the supply of physicians. Direct graduate medical education payment took two forms: 1) direct, for training of residents, and 2) indirect, for differences in patient care costs between teaching and nonteaching hospitals. Various commissions and studies in the 1980s pointed to an oversupply of physicians, with even larger surpluses projected by 2000 and 2020. Reforms enacted by the Balanced Budget Act (BBA) of 1997 were intended to curb Medicare expenditures rather than to base its graduate medical education policy on workforce requirements. The Balanced Budget Act included changes that altered graduate medical education funding, which reduced the growth and number of intern and resident training positions while attempting to maintain primary care positions. Obstetrics and gynecology was not recognized as a primary care field. The hospitals were then encouraged to reduce their resident training programs by 20-25% in general, except for primary care residents. To encourage primary care programs, the BBA also expanded funding for facilities (especially off site) to include rural health clinics and community health centers and for Medicare managed care plans. ? Resident Duty Hours Probably the single greatest impact on training residents was the limitation on work hours, particularly for those in the surgical fields. A typical intern's weekly schedule in the 1960s was more than 100 hours. The event that started legislative action in New York State was the death of a patient named Libby Zion in 1985, when resident physician fatigue was suspected to be a contributing factor. The resultant 80-hour work week, averaged over 4 consecutive weeks, applied to all time spent by every resident in a hospital, including the clinic, operating room, labor and delivery unit, and teaching conferences. A resident could be on call no more than every third day, on average, and must have at least 24 hours continually off each week. Resident work hours remained high through 2002 and decreased after the ACGME instituted guidelines for any accredited residency program. These 80-hour work week restrictions are considered expensive and difficult to enforce, violations are not always reported, and concern exists in procedure-based fields, such as obstetrics and gynecology, that time in surgical training is insufficient. A systematic review of 54 studies examined the effects of duty hour regulations on residents. Of those studies, only obstetrics and gynecology and surgery assessed procedure volume. Results showed no material negative effect on resident technical experience and on the number of obstetric-gynecologic procedures. The impact of this new 80-hour work week on reducing patient mortality and morbidity remains unclear. If the reduced work hours prove to be highly effective, their implementation could lead to reduced medical errors, but net costs to teaching hospitals would be high. In terms of the impact on the workforce, the fewer man-hours roughly translated into a 20% reduction in work hours of the nation's approximately 112,000 medical residents and fellows, which is equivalent to losing the workload of approximately 15,000-22,000 full-time positions. Well-designed studies are needed before any further work restrictions are imposed. ? Need for Expanded Residency Slots In the judgment of some national groups studying physician workforce issues, the greatest shortage of physicians could occur in obstetrics and gynecology. The Balanced Budget Act should be revised if their analyses are correct. As with the increase in medical school enrollment, the number of residency positions in obstetrics and gynecology should be increased to serve a population of women that is predicted to grow by another 36% by 2050. Otherwise, the only expansion would be in the proportion of residency positions filled by U.S. medical graduates rather than by international or osteopathic graduates. This population-based increase in demand for ob-gyns will be accompanied by a growing database of knowledge, more cutting-edge technology (such as laparoscopic, robotic, and minimally invasive procedures), and a desire of many graduates to attain specialized training that would enable them to stand out in their own consumer-oriented niches. Increasing funding of graduate medical education by eliminating the 14-year freeze in Medicare's support for training positions is essential to address the projected shortfall. The current annual cost of training additional clinicians and surgeons needed in all specialties is slightly less than $500 million. Individually, the greatest costs are thought to be related to training in obstetrics and gynecology, orthopedics, and general surgery. Although this annual cost to train new physicians is significant, it is a very small fraction of current Medicare expenditures. It is relevant to consider alternative scenarios related to the cost of funding different numbers of residency positions depending on the severity of the impending shortage. Residency programs in states with the greatest population growth or highest numbers of physician shortage areas would receive preference. Implications The number of residents in obstetrics and gynecology has remained fairly constant over the years. Expansion of medical school class sizes may create more impediments for senior students finding residency positions. An increase, rather than a decrease, in the number of residency slots in obstetrics and gynecology funded by Medicare would accommodate the additional medical school graduates and the anticipated increased number of women seeking care. However, recent economic events have caused the U.S. Congress to question why the federal government should pay for more physician training. Without sufficient funding, some residency programs may decrease the numbers of residency positions or be overwhelmed with patient service responsibilities. Escalating costs to train additional obstetrics and gynecology residents must be balanced with an essential investment in sufficient numbers of adequately trained health care providers. Achieving this balance is especially important in underserved areas where women currently have the most difficulty in obtaining timely access to health care. Because educating and training of physicians takes several years, graduate medical education must be selectively expanded now.Bibliography The A.B.O.G. Diplomate. 1. Oklahoma City (OK): American Board of Obstetrics and Gynecology; 1975; p. 1-3. The A.B.O.G. Diplomate. 34. Dallas (TX): American Board of Obstetrics and Gynecology; 2008; p. 1-7. American College of Obstetricians and Gynecologists. Future directions in resident education: summary of conclusion: August 2008 and July 2009, Westfields Conference Center, Chantilly, VA. Washington, DC: American College of Obstetricians and Gynecologists; 2010. Association of American Medical Colleges. 2008 physician specialty data. Center for Workforce Studies. Washington, DC: AAMC; 2008. Available at: https://www.aamc.org/download/47352/data/specialtydata. pdf. Retrieved April 12, 2011. Brotherton SE, Etzel SI. Graduate medical education, 2009-2010. JAMA 2010;304:1255-70. Graduate Medical Education National Advisory Committee. Summary report of the Graduate Medical Education National Advisory Committee: to the Secretary, Department of Health and Human Services. DHHS publication; No. (HRA) 81-651 - 81-657. Washington, DC: U.S. DHHS Health Resources Administration; 1981. Medicare Payment Advisory Commission. Report to the Congress: aligning incentives in Medicare. Washington, DC: Med PAC; 2010. Available at: http://www.ncrponline.org/PDFs/2010/MEDPAC_ Congress_June2010.pdf. Retrieved February 25, 2011. Salsberg E, Rockey PH, Rivers KL, Brotherton SE, Jackson GR. US residency training before and after the 1997 Balanced Budget Act. JAMA 2008;300:1174-80. Smith RP. Resident technical experience in obstetrics and gynecology before and after implementation of work-hour rules. Obstet Gynecol 2010;115:1166-71. Ulmer C, Wolman DM, Johns MM, editors. Resident duty hours: enhancing sleep, supervision, and safety. Committee on Optimizing Graduate Medical Trainee (Resident) Hours and Work Schedules to Improve Patient Safety. Washington D.C.: National Academies Press; 2008. Volpp KG, Landrigan CP. Building physician work hour regulations from first principles and best evidence. JAMA 2008;300(10):1197-9. Williams TE, Satiani B, Ellison EC. The last hurdle: the Balanced Budget Act of 1997 and graduate medical education funding. The coming shortage of surgeons: why they are disappearing and what that means for our health. Santa Barbara (CA): ABC-CLIO, LLC; 2009. p. 114-26.The following tables and figures provide data related to the U.S. graduate medical education in obstetrics and gynecology. Table 2-1. First-Year Residents and Total Residents in Obstetrics and Gynecology Academic Year Total (N) First Year (n) U.S. Medical Graduates Entering Obstetrics and Gynecology (%) 1991-92 4,563 1,199 7.2 1992-93 4,767 1,215 7.3 1993-94 5,033 1,281 7.5 1994-95 4,912 1,270 7.3 1995-96 4,968 1,278 7.2 1996-97 4,968 1,228 7.2 1997-98 4,929 1,262 7.4 1998-99 4,810 1,262 6.8 1999-00 4,701 1,311 6.6 2000-01 4,679 1,234 6.2 2001-02 4,701 1,208 6.2 2002-03 4,656 1,191 6.3 2003-04 4,681 1,226 5.9 2004-05 4,703 1,215 5.5 2005-06 4,720 1,234 5.6 2006-07 4,739 1,225 5.9 2007-08 4,770 1,214 5.9 2008-09 4,815 1,249 5.8 2009-10 4,842 1,259 5.0 Figure 2-1. Locations of allopathic and osteopathic residency programs in obstetrics and gynecology. (See Appendix F.) Figure 2-2. Change in the total number of U.S. graduate medical education residency programs and residents in obstetrics and gynecology. 360 340 320 300 280 260 240 220 200 Ob-gyn residency programs Ob-gyn residents 1980 1985 1990 1995 2000 2005 20105,2005,0004,8004,6004,4004,2004,000 Figure 2-3. Percentage of residents with U.S. medical degrees in programs accredited by the Accreditation Council of Graduate Medical Education categorized by medical specialty as of 2009. Dermatology Orthopedic surgery Neurosurgery Radiology Emergency medicine General surgery Anesthesiology Obstetrics and gynecology Pediatrics Pathology Psychiatry Neurology Internal medicine 94.8% 91.5% 88.4% 87.4% 81.9% 79.3% 79.1% 73.3% 67.0% 61.8% 57.6% 57.2% 48.7%Family medicine 44.1% Average (65.4%)0 10 20 30 40 50 60 70 80 90 100 Residents with U.S. medical degrees (%) Figure 2-4. Percentage of residents with international medical degrees in programs accredited by the Accreditation Council of Graduate Medical Education categorized by medical specialty as of 2009. Internal medicine Family medicine Neurology Psychiatry Pathology Pediatrics General surgery Obstetrics and gynecology Anesthesiology Neurosurgery Radiology Emergency medicine Dermatology 45.6% 39.9% 35.5% 33.5% 32.1% 24.2% 17.8% 17.7%12.5% 11.1% 8.3%6.5% 3.7%Orthopedic surgery 2.9% Average (27.4%)0 10 20 30 40 50 60 70 80 Residents with international medical degrees (%) Figure 2-5. Percentage of residents with osteopathic degrees in programs accredited by the Accreditation Council of Graduate Medical Education categorized by medical specialty as of 2009. Family medicine Emergency medicine Psychiatry Obstetrics and gynecology Pediatrics Anesthesiology Neurology Pathology Internal medicine Radiology General surgery Dermatology Orthopedic surgeryOphthalmologyNeurosurgery 4.0%2.8%1.4%1.1%0.9%0.4% 7.1%6.1%6.0% 8.7%8.6%8.5%8.2% 11.5% 15.8% Average (6.9%)0 5 10 15 20 Residents with osteopathic degrees (%) Figure 2-6. Percentage of female residents in programs accredited by the Accreditation Council of Graduate Medical Education categorized by medical specialty as of 2009.Obstetrics and gynecology Pediatrics Dermatology Family medicine Psychiatry Pathology Neurology Internal medicine Ophthalmology Emergency medicine Anesthesiology General surgery Otolaryngology Radiology Urology Plastic surgery46.3%44.8%42.5%40.3%37.5%35.0%30.9%28.0%23.1%22.8% 55.6%54.9%54.3% 63.6% 79.7%73.2% NeurosurgeryOrthopedic surgery 13.1%9.1% Average (46.0%)0 10 20 30 40 50 60 70 80 Residents who are female (%) Figure 2-7. Percentage of first-year residents in obstetrics and gynecology who are female.100 80604020 15% 0 80% 1975 1980 1985 1990 1995 2000 2005 2010 Year of survey Figure 2-8. Percentage of African American, American Indian or Alaska Native, or Native Hawaiian or Pacific Islander residents in programs accredited by the Accreditation Council of Graduate Medical Education categorized by medical specialty as of 2009.Obstetrics and gynecologyPsychiatry Family medicine General surgery Anesthesiology Pediatrics Internal medicine Neurosurgery Dermatology Orthopedic surgery Emergency medicine Urology Neurology Pathology Otolaryngology Radiology Ophthalmology 8.9%8.0%7.2%6.8%6.6%6.0%5.9%5.6%5.4%5.4%4.7%4.5%3.9%3.6%3.4%3.2% 11.2% Average (6.3%) 0 2 4 6 8 10 12 14 16 Residents who are African American, American Indian or Alaska Native, or Native Hawaiian or Pacific Islander (%) Figure 2-9. Percentage of Hispanic residents in programs accredited by the Accreditation Council of Graduate Medical Education categorized by medical specialty as of 2009. Family medicinePsychiatry Internal medicine Obstetrics and gynecology Pediatrics Neurology General surgery Ophthalmology Emergency medicine Anesthesiology Dermatology Neurosurgery Otolaryngology Radiology Orthopedic surgery Urology6.7%6.4%6.0%5.7%5.5%5.1%4.9%4.7%4.6% 9.7%9.6%9.1%9.0%8.9%8.5%8.3% Average (8.0%)0 2 4 6 8 10 12 14 16 18 Residents who are Hispanic (%) Figure 2-10. Total numbers of residents in programs accredited by the Accreditation Council of Graduate Medical Education categorized by surgical specialty as of 2009.General surgery Obstetrics and gynecology Orthopedics Otolaryngology Ophthalmology Neurosurgery Urology Plastic surgery1,406 1,266 1,096 1,039 7043,371 4,842 7,661 0 1,500 3,000 4,500 6,000 7,500 9,000 Number of total residents Figure 2-11. Percentage of residents with U.S. medical degrees in programs accredited by the Accreditation Council of Graduate Medical Education categorized by surgical specialty as of 2009. Otolaryngology Orthopedics Urology Ophthalmology Neurosurgery Plastic surgery 96.7%96.1%94.9%91.5%88.4%86.6%General surgeryObstetrics and gynecology 79.3%73.6% Within all surgical residents (82.9%) Within all residents (65.4%)0 10 20 30 40 50 60 70 80 90 100 Residents with U.S. medical degrees (%) Figure 2-12. Percentage of residents with international medical degrees in residency programs accredited by the Accreditation Council of Graduate Medical Education categorized by surgical specialty as of 2009. General surgeryObstetrics and gynecologyNeurosurgery Ophthalmology Plastic surgery Urology Otolaryngology Orthopedics 4.2%2.9%2.5%7.4%7.4%11.1% 17.8%17.7% Within all surgical residents (13.6%) Within all residents (27.6%)0 5 10 15 20 25 30 Residents with international medical degrees (%) Figure 2-13. Percentage of residents with osteopathic degrees in programs accredited by the Accreditation Council of Graduate Medical Education categorized by surgical specialty as of 2009.Obstetrics and gynecology General surgery Orthopedics Ophthalmology Urology Otolaryngology 1.1% 0.9% 0.8% 0.2% 2.8% 8.6% Within all surgical residents (3.2%) Within all residents (6.7%)0 1 2 3 4 5 6 7 8 9 10 Residents with osteopathic degrees (%) Table 2-2. Obstetric Procedures Performed by Residents Graduating in 2008-2009* (Benchmarks Table) Percentiles (%) Obstetric Procedures 10 15 20 30 50 70 90 95 Spontaneous delivery (n) 181 199 213 231 273 313 402 471 Cesarean delivery (n) 150 163 174 195 232 276 356 409 Operative vaginal delivery (n) 13 15 17 21 27 36 52 62 Forceps-assisted delivery (n) 1 1 2 3 6 11 23 30 Vacuum-assisted delivery (n) 8 9 11 13 19 24 37 45 *Total number of residency programs in the United States, 243; total number of graduating residents in the United States, 1,171. Table 2-3. Gynecologic Procedures Performed by Residents Graduating in 2008-2009* (Benchmarks Table) Percentiles (%) Gynecologic Procedures 10 15 20 30 50 70 90 95 Abdominal hysterectomy (n) 44 49 52 59 69 83 113 129 Vaginal hysterectomy (n) 9 11 12 14 19 24 33 38 Laparoscopic hysterectomy (n) 6 8 10 13 20 28 47 56 Treatment of incontinence and pelvic floor repair (n) 33 40 46 54 73 101 152 185 Laparoscopy (n) 51 57 63 73 90 109 145 170 Operative hysteroscopy (n) 31 36 40 47 62 80 116 135 Abortion (n) 13 16 19 22 32 45 82 113 Transvaginal ultrasonography (n) 32 43 53 72 103 149 264 334 Treatment of invasive cancer (n) 23 28 34 43 59 84 129 156 Total number of hysterectomies (n) 77 83 89 97 113 132 169 189 Total number of laparoscopic procedures (n) 64 73 79 92 112 137 182 205 *Total number of residency programs in the United States, 243; total number of graduating residents, 1,171. Table 2-4. Trends in Graduates from Residency Programs in Obstetrics and Gynecology per 100,000 General Population in the United States Graduates per Graduates U.S. Population 100,000 Year (N) (100,000) Population (n) 1995 1,248 2,670 4.7 2000 1,234 2,820 4.4 2005 1,107 2,960 3.7 2010 1,168 3,100 3.83 U.s. mediCal sChool faCUlty in obstetriCs and gyneCology Current data and projections about department sizes are important for faculty, those either considering or beginning an academic career in obstetrics and gynecology, and the specialty as a whole. Periodic national reviews of department sizes are essential to determine whether a sufficient faculty workforce is available to fulfill missions in teaching, patient care, and scholarly activity. An initial survey of departments of obstetrics and gynecology in 1975 served as a benchmark for future comparisons. Seven subsequent workforce studies between 1977 and 2008 were conducted in cooperation with the Association of Professors of Gynecology and Obstetrics and the Council of University Chairs of Obstetrics and Gynecology. ? Department Sizes and Faculty Demographics The number of full-time faculty members of departments of obstetrics and gynecology at U.S. medical schools has more than doubled in the past 31 years. Differences exist between the types of schools. Modest growth in the sizes of departments of obstetrics and gynecology between 1994 and 2008 was mostly among physician rather than nonphysician faculty. In general, private medical schools have more faculty members than public institutions, and this difference is accounted for by an increasing number of physicians. According to funding from National Institutes of Health in 2009, the top 40 research-intensive schools had more faculty members in departments of obstetrics and gynecology than the less research-intensive schools and community-based schools. At all medical schools, obstetrics and gynecology is a critical medical specialty for the training of medical students and residents. Faculty members in departments of obstetrics and gynecology have consistently comprised 3.7% of all medical school faculty members and 4.5% of all clinical department faculty members. Approximately one half of all obstetrics and gynecology faculty are generalists. The combined proportion of African American and Native American, Alaskan, or Pacific Islander faculty members is higher in obstetrics and gynecology (7.9%) than in other clinical departments (3.4%), whereas the proportion of faculty members of Hispanic origin (4.8%) is similar to that of other clinical departments. The most substantial change in faculty demographics is the increase in number and propor- tion of faculty members who are women. The proportion of women in departments of obstetrics and gynecology increased from 14.3% in 1983 to 34.1% in 1994 and to 52.3% in 2008-higher than in any other medical or surgical specialty, including pediatrics. With this steady but gradual increase, women are more likely than men to be instructors or assistant professors than to be associate professors or professors. The percentage of female academic chairs also increased remarkably in recent years, with departments of obstetrics and gynecology now having the most female chairs (20%) compared with other basic science and clinical departments. ? Faculty Retention The development of faculty requires financial, personnel, and facility resources to meet department missions. Teaching and delivering health care pose greater demands on faculty members in small, core clinical departments, such as obstetrics and gynecology, than in large departments. Protected time to support grant writing and scholarly activity is constantly challenged. Long-term retention rates of entry-level faculty at their original departments have been slightly lower for faculty in departments of obstetrics and gynecology than in other clinical departments combined. Recent trends suggest stable or improved retention rates for all entry-level faculty members, especially generalists and gynecologic oncologists. Of those who left their departments, generalists in obstetrics and gynecology, especially women, were more inclined to leave academia than to switch schools compared with specialists. The average percentage of positions filled annually by first-time chairs between 1979 and 2007 was the same in departments of obstetrics and gynecology as the average in all departments (8.2%). Regardless of the department, clinical chairs find themselves faced with more financial pressures, information overload, and time and effort invested in managing and implementing organizational change than before. Compared with other core clinical departments, retention of first-time chairs in departments of obstetrics and gynecology decreased consistently over the past 30 years. The median tenure of first-time chairs of departments of obstetrics and gynecology (7.3 years) is now comparable with that of chairs in departments of surgery, slightly longer than that of chairs of departments of internal medicine, and shorter than that of chairs of departments of psychiatry, family and community medicine, and pediatrics. ? Trends in Salary Support A report by the Association of American Medical Colleges (AAMC) found that between 1988 and 1998 faculty members in departments of obstetrics and gynecology lost the most ground in financial compensation. Data from the annual AAMC Faculty Salary Survey for academic years 2000-2001 through 2008-2009 revealed that unadjusted compensation increased by 24.8% (or 3.3% annually) for faculty members in departments of obstetrics and gynecology. Compensation was consistently highest among faculty members specializing in gynecologic oncology and was similar between those practicing general obstetrics and gynecology and reproductive endocrinology and infertility. Inflation-adjusted growth of faculty salaries for those practicing general obstetrics and gynecology was similar to that of faculty members practicing general internal medicine, family and community medicine, general pediatrics, and general surgery. ? Part-Time Positions A limitation of the AAMC data is that only full-time faculty members were accounted for. Similar to other specialties, most departments of obstetrics and gynecology now have an increasing number of part-time faculty members. A national survey of chairs disclosed that this pattern is anticipated to increase for current and future faculty members. The change in workforce to accommodate more part-time faculty members is critical for chairs and deans to track so that the needs of the faculty members can be more accurately projected. Medical schools are now developing policies to optimize recruitment and promotion of part-time faculty members as the changing landscape of academic medicine becomes more dependent on maintaining satisfied faculty members. ? Attrition and Noncompetition Agreements By 10 years from their initial appointment, approximately one half (48%) of all entry-level faculty members leave their original departments to either switch to another school (21%) or leave academia (79%). In the event that the employment relationship is terminated between the medical school and a faculty member, the employee agrees that for a certain period (typically for 2 years from the date of termination, but this period may vary among schools), the employee will not perform patient care services or practice medicine within the same greater metropolitan area as the medical school boundaries. This written noncompetition agreement usually does not apply to faculty members in the following situations: 1. Retirement 2. Involuntary termination due to a negative review, a negative tenure decision, or other circumstances under which the employee is involuntarily removed from employment with approval of the dean 3. Fellowship training 4. Completion of temporary employment In the event that the employee elects to terminate his or her employment, it is customary to expect that person to "buy out" the obligation by payment to the medical school in an amount often equal to 1 year's current total income plus costs associated with recruitment, moving, and hiring and support of that employee. A waiver or modification of this policy may be granted before hiring or once termination is selected if justified by exceptional circumstances. Upon receipt of a request from the employee, a department chair must submit a written justification to the dean detailing the rationale to support such a waiver.Implications Remarkable growth in academic department sizes during the past 30 years is expected to continue and result in a diverse faculty. Salary support and retention of faculty have remained stable. Because one half of faculty members are subspecialists, rotations on subspecialty services tend to dominate resident education, creating a concern that subspecialty care decreases time available for the expanding continuum of ambulatory care. Although much attention is given to implications of any workforce shortage and patient access to care, less attention has perhaps been given to the downstream effects of shortages of talent overall. Academic departments compete not only with peer institutions but also with private practice and options that doctors have. Bibliography Association of American Medical Colleges. Report on medical school faculty salaries, 2009-2010. Washington, DC: AAMC; 2011. Autry A, Irby D, Hodgson C. Faculty attrition in obstetrics and gynecology. Am J Obstet Gynecol 2007; 196:603.e1-603e.4; discussion 603.e5. Gabbe SG, Mueller-Heubach E, Blechner JN, Pearse WH, Depp R, Creasy RK. A blueprint for academic obstetrics and gynecology. Obstet Gynecol 1998;92:1033-7. Magrane D, Jolly P. The changing representation of men and women in academic medicine. AAMC Anal Brief 2005;5(2):1-2. Available at: https://www.aamc.org/download/75776/data/aibvol5no2.pdf. Retrieved October 5, 2010. Rayburn WF, Anderson BL, Johnson JV, McReynolds MA, Schulkin J. Trends in the academic workforce of obstetrics and gynecology. Obstet Gynecol 2010;115:141-6. Rayburn WF, Fullilove AM, Scroggs JA, Schrader RM. Trends in salaries of obstetrics-gynecology faculty, 2000-01 to 2008-09. Am J Obstet Gynecol 2011;204:82.e1-82.e6. Rayburn WF, Lang J, Fullilove AM, Phelan ST, Rayburn DT, Schrader RM. Retention of entry-level faculty members in obstetrics and gynecology. Obstet Gynecol 2011; In Press, Corrected Proof. Available at: http://www.sciencedirect.com/science/article/B6W9P-52DB33T-2/2/2c30b890e3c9436a568238ba 6c924144. Retrieved March 29, 2011. Rayburn WF, Waldman JD, Schrader R, Fullilove A, Lang J. Retention of chairs in obstetrics and gynecology: a comparison with other clinical departments. Obstet Gynecol 2009;114:130-5. Studer-Ellis E, Gold JS, Jones RF. Trends in US medical school faculty salaries, 1988-89 to 1998-99. JAMA 2000;284:1130-5.The following tables and figures provide data related to the U.S. medical school faculty in obstetrics and gynecology. Table 3-1. Trends in U.S. Medical School Full-Time FacultyYear Faculty in Obstetrics and Gynecology (n) All Clinical Faculty (n) Total Faculty (N) 2001 4,131 90,088 107,383 2002 4,273 94,161 112,037 2003 4,365 98,260 116,720 2004 4,459 102,369 121,426 2005 4,566 103,929 123,101 2006 4,684 106,680 125,932 2007 4,697 108,582 127,774 2008 4,651 109,896 128,683 2009 4,639 109,965 128,650 Figure 3-1. Full-time faculty with Doctor of Medicine (or equivalent) or Doctor of Philosophy degrees per departments of obstetrics and gynecology. 30 25 20 15 10 5 0 1977 1980 1983 1986 1990 1994 2008 Year of surveyPhD MD Total Table 3.2. Average Number of Faculty Members per Departments of Obstetrics and Gynecology Faculty Members per Department Specialty Male (n) Female (n) Total (N) General obstetrics and gynecology 6.4 8.9 15.3 Maternal-fetal medicine 3.3 2.8 6.1 Gynecologic oncology 1.9 1.0 2.9 Reproductive endocrinology and infertility 2.0 1.1 3.1 Female pelvic medicine 0.9 0.9 1.8 Research 1.6 1.0 2.6 Table 3-3. Full-Time Faculty in Departments of Obstetrics and Gynecology by Academic Degree Full-Time Faculty (n) Faculty Category Gender 1994 2008 Doctor of Medicine* Female 803 1,458 Male 1,838 1,452 Total 2,641 2,910 Doctor of Philosophy Female 159 169 Male 309 269 Total 468 438 Other Female 180 283 Male 64 19 Total 244 302 *Includes faculty with a doctorate in medicine, doctorate in osteopathy, and doctorates in medicine and philosophy. Figure 3.2. Percentage of full-time faculty in departments of obstetrics and gynecology by gender. 100806040200 1977 1980 1983 1986 1990 1994 2008 Year of surveyMales Females Figure 3-3. Retention rates of entry-level faculty in departments of obstetrics and gynecology at their original department (A) and in academia (B) categorized by specialty.(A) General obstetrics and gynecology Gynecologic oncology Maternal-fetal medicine Reproductive endocrinology and infertility100 80 60 40 Original department Original department Original department Original department (B) 100 80 60 40 Academia Academia Academia Academia 1 3 5 7 9 1 3 5 7 9 1 3 5 7 9 1 3 5 7 9 Years in position 1981-89 1990-99 2000-08 Figure 3-4. Percentage of department chair positions filled annually between 1979 and 2007. Internal medicine Orthopedic surgery Family medicine Anesthesiology Pediatrics Radiology Physical medicine and rehabilitation Surgery Psychiatry Obstetrics and gynecology Biochemistry Microbiology Neurology Dermatology Ophthalmology Pathology Public health and preventive medicine Anatomy Physiology Otolaryngology Pharmacology 0 2 4 6 8 10 Chair positions filled annually (%)Clinical departments Basic science departments Average (8.2%) Figure 3-5. Percentage of academic chairs of departments of obstetrics and gynecology who are female.20 15 10 5 0 1980 1985 1990 1995 2000 2005 2010 Year of survey Table 3-4. Five-Year Retention Rates of First-Time Academic Chairs in Core Clinical Departments According to Year When Appointment Began Retention Rates in Year When Appointment BeganClinical Department 1979-1982 (%) 1983-1987 (%) 1988-1992 (%) 1993-1997 (%) 1998-2002 (%) Family medicine 62 83 64 70 65 Internal medicine 65 64 72 56 64 Obstetrics and gynecology 80 84 68 67 53 Pediatrics 59 66 76 66 63 Psychiatry 66 69 66 65 64 Surgery 67 79 74 62 71 Table 3-5. Ten-Year Retention Rates of First-Time Academic Chairs in Core Clinical Departments According to Year When Appointment Began Retention Rates in Year When Appointment BeganClinical Department 1979-1982 (%) 1983-1987 (%) 1988-1992 (%) 1993-1997 (%) Family medicine 35 45 38 48 Internal medicine 39 34 30 33 Obstetrics and gynecology 54 51 50 26 Pediatrics 41 40 48 46 Psychiatry 31 37 46 40 Surgery 47 50 45 41 4 CharaCteristiCs and distribUtion of obstetriCian- gyneCologists in the United states Since the late 19th century, practitioners interested in obstetrics, gynecology, and related women's health care fields belonged to nearly 70 independent professional societies. Many of these groups limited themselves to specific geographic localities. The more prestigious organizations placed rigid limits on membership size. In 1930, incorporation of the American Board of Obstetrics and Gynecology unified the two fields. As members of a single specialty, obstetrician-gynecologists (ob-gyns) began to see rapid growth in the numbers of physicians taking examinations and becoming board certified. During the past 20 years, rates of passing grades were on average 73% for the general written examination and 85% for the oral examination. ? Numbers of Obstetrician-Gynecologists Sixty years ago, the American Academy of Obstetricians and Gynecologists (now the American Congress of Obstetricians and Gynecologists [ACOG]) was created to form the specialty's first enduring, national professional organization that was open to all qualified applicants. Physicians were required to be board certified in obstetrics and gynecology to become Fellows, beginning with the 539 Founding Fellows in 1951. The number of Fellows increased gradually by approxi- mately 500 new members per year, whether they were generalists (or specialists) or subspecial- ists. Today, 93-95% of all American ob-gyns are affiliated with ACOG. In 2010, the number of active physician members was 43,298, including 28,808 Fellows and 9,707 Junior Fellows. The total number of active physicians who describe their primary interest in obstetrics and gynecology has nearly doubled since 1975. This rate of growth is less than for physicians in pediatrics, family medicine or general practice, and internal medicine, yet similar to those practicing psychiatry. The number of ob-gyns per 10,000 women in the general U.S. population increased minimally from 8.7 in 1980 to 10.3 in 1990, 10.8 in 2000, and 11.3 in 2008. Obstetrician-gynecologists are viewed by some groups as being primary care physicians for women. However, most ob-gyns are specialists, and they are the chosen personal physicians for most reproductive-aged women and coordinators of their care. Obstetrician-gynecologists represent only a small percentage of all active primary care physicians (5.3% in 1975 and 4.5% in 2008). Those ob-gyns who are board-certified subspecialists (ie, practicing reproductive endocrinology and infertility, maternal-fetal medicine, or gynecologic oncology) constitute 11.1% of all ob-gyns. This percentage increased gradually between 1975 and 1990 (from 4.3% to 10.3%) and has remained constant at approximately 11% since 1995. By 2007, a total of 3,589 diplo- mates had been issued certificates in one of those three subspecialties. The number of sub- specialists currently in active practice (2,900) represents 7.6% of the total 38,071 actively practicing diplomates. Approximately 78% of all active ob-gyns are U.S. medical school graduates compared with 69% of all active physicians. International medical graduates constitute 17% of all active ob-gyns compared with 24% of all physicians. Graduates of osteopathic schools constitute 5% of active ob-gyns and 7% of all active physicians. As the numbers of allopathic and osteopathic school graduates increase, it will be interesting to determine any shifts in these proportions in grad- uates of residency programs in obstetrics and gynecology. ? Demographics of Obstetrician-Gynecologists Over the past 40 years, the relative representation of women as medical students, residents, faculty members, and practitioners in the United States increased steadily. Women now constitute 48% of all medical school applicants and first-year medical students. The percent- age of female medical students selecting residencies in obstetrics and gynecology remained unchanged over the past 30 years, whereas the percentage of women in each medical school class increased steadily. The number of men in each medical school class remained relatively stable, whereas the percentage selecting the specialty of obstetrics and gynecology decreased from 10% to 2%. Today, women represent nearly 80% of all residents in obstetrics and gynecology, approximately 50% of all active ob-gyns, which is second only to pediatricians (53%), and a higher proportion of any group of active surgeons (19%) and all active physicians (28%). The racial mix of ob-gyns is similar to other medical fields. Underrepresented minorities are less represented in obstetrics and gynecology than in the general U.S. population. It is noteworthy that the highest proportion of active African American physicians are ob-gyns, rather than any other major medical specialty (7% versus 3.6% overall), regardless of gender. Is the ob-gyn workforce aging? Currently, the mean age of general ob-gyns (50.1 years) is similar to all physicians in office-based practice (50.8 years) and younger than subspecialists in reproductive endocrinology and infertility (53.9 years), gynecologic oncology (53.7 years), and maternal-fetal medicine (53.5 years). One half of all physicians are aged between 35 years and 54 years. Female ob-gyns are younger than male ob-gyns, which reflects the increasing percentage of women who recently graduated from a residency. The year 2010 marks the first year in which the "baby boomer" generation (individuals born between 1946 and 1964) reaches the traditional retirement age of 65 years. As more ob-gyns of the "baby boomer" generation retire, the percentage of women in the specialty will increase further. ? Distribution of Obstetrician-Gynecologists A clue as to where a resident physician will practice relates to the location of his or her medical school or residency training. Approximately one half of all resident graduates in obstetrics and gynecology will practice in the same state in which they trained. Approximately two thirds are retained in the same state where they attended medical school and undertook residency training. Although this proportion nears the median for graduates in all medical specialties, graduating residents in obstetrics and gynecology practice in the same state as their training at the highest rate of all surgical specialties. In 2010, the national ratio of ob-gyns per 10,000 women was 2.1, the lowest ratio in more than 30 years (2.3 in 1978, 2.5 in 1988, and 2.7 in 1993). As observed with all other medical specialties, practice sites of ob-gyns in the United States are not evenly distributed geographically. The concentration of ob-gyns is highest in Hawaii, District of Columbia, and Connecticut and lowest in Arkansas, Oklahoma, and North Dakota. The mean number of ob- gyns per 10,000 women decreases significantly in the United States from metropolitan counties (2.9), to micropolitan counties (1.7), to rural counties (0.7). Approximately one half (49%) of the 3,107 U.S. counties lack ob-gyns, and nearly 9.5 million Americans live in those, predominantly rural, counties. These counties are in all states but are especially prevalent in the Midwest and the Mountain West. Most counties without ob-gyns are recognized by the Bureau of Primary Health Care of the U.S. Department of Health and Human Services as being underserved. The change in the density of ob-gyns (or net migration) for these underserved counties has not changed remarkably in the past 10 years. Appendix F provides color maps illustrating the numbers of College Fellows and Junior Fellows in Practice per unit patient population (10,000 women and 10,000 reproductive-aged women) for each county and state in the United States. Implications Nearly all active ob-gyns in the U.S. are members of ACOG, which is a rich resource of demographic information. Most ob-gyns practice general obstetrics and gynecology, and the specialty is diverse. Women now represent nearly one half of all active ob-gyns and as more ob-gyns of the baby boomer generation retire, the percentage of women will increase further. Practice sites of ob-gyns are not evenly distributed geographically, and shortages in many areas may worsen if the number of graduates from residency programs in obstetrics and gynecology remains constant with an expanding U.S. female population. Bibliography American Medical Association. Physician characteristics and distribution in the US. 2010. Chicago (IL): AMA 2010. Association of American Medical Colleges. 2008 physician specialty data. Center for Workforce Studies. Washington, DC: AAMC; 2008. Available at: https://www.aamc.org/download/47352/data/specialtydata. pdf. Retrieved April 12, 2011. American College of Obstetricians and Gynecologists. History of the American College of Obstetricians and Gynecologists. Washington, DC: ACOG; 2001.The following tables, boxes, and figures provide data related to the characteristics and distribution of obstetrician- gynecologists in the United States. Box 4-1. Requirements for Becoming a Fellow of the American Congress of Obstetricians and Gynecologists o Board certification in obstetrics and gynecology. The current acceptable examinations are following: - American Board of Obstetrics and Gynecology: Parts I and II - Royal College of Obstetricians and Gynaecologists - Royal College of Physicians and Surgeons of Canada or College des Medecins du Quebec - Consejo Mexicano de Ginecología y Obstetricia - The University of West Indies Postgraduate Doctorate of Medicine - Royal Australian and New Zealand College of Obstetricians and Gynaecologists - Federación Centroamericana de Sociedades de Obstetricia y Ginecología - Japanese Board of Obstericians and Gynecologists - Sociedad Chilena de Obstetricia y Ginecología o Completion of a residency program in obstetrics and gynecology within the geographic confines of the American Congress of Obstetricians and Gynecologists. o Active license to practice medicine. o Continuous limitation of training or professional activities to obstetrics, gynecology, or both for the 5 years immediately before the date of application. o In order to provide adequate peer evaluation, a candidate for Fellowship must have practiced in the same community from which an application is made for a minimum of 12 months before the submission of an application. o Attainment of high ethical and professional standing. o Two endorsements from active Fellows of the American Congress of Obstetricians and Gynecologists. Applicants for Fellowship shall be proposed by a Fellow and shall be endorsed by a Fellow within the same district as the applicant (except applicants from the Armed Forces District). The sponsors must not be district, section, or national officers. Fellow requirements. Washington, DC: American Congress of Obstetricians and Gynecologists; 2011. Available at: http://www.acog.org/from_home/ fellowreq.cfm. Retrieved March 16, 2011. Table 4-1. Rates of Passing Grades for Resident and Fellow Graduates Taking Written and Oral Board Examinations of the American Board of Obstetrics and Gynecology Area of Examination*Reproductive General Obstetrics Endocrinology and Gynecology Gynecologic Oncology Maternal-Fetal Medicine and Infertility Year Written (%) Oral (%) Written (%) Oral (%) Written (%) Oral (%) Written (%) Oral (%) 1974 75 78 N/A 65 N/A 62 N/A 50 1975 N/A 75 N/A N/A N/A N/A N/A N/A 1976 71 79 89 79 65 78 40 65 1977 66 74 80 72 80 64 58 52 1978 67 63 68 N/A 56 N/A 56 N/A 1979 61 61 63 70 58 60 65 63 1980 66 68 63 70 64 59 58 54 1981 62 69 68 50 61 56 62 54 1982 84 74 N/A N/A N/A N/A N/A N/A 1983 86 76 N/A N/A N/A N/A N/A N/A 1984 71 78 N/A N/A N/A N/A N/A N/A 1985 70 77 N/A N/A N/A N/A N/A N/A 1986 75 79 N/A N/A N/A N/A N/A N/A 1987 68 84 81 84 74 79 89 68 1988 68 85 87 70 88 81 91 77 1989 79 84 - 65 - 77 - 67 1990 65 85 - 70 - 77 - 65 1991 75 83 87 61 86 79 92 63 1992 66 86 70 78 - 83 - 55 1993 77 87 - N/A 93 N/A 87 N/A 1994 68 87 77 85 - 80 - 69 1995 75 84 - 77 95 80 89 75 1996 65 83 78 85 - 79 - 73 1997 76 84 - 79 86 82 85 64 1998 70 83 80 86 - 81 - 64 1999 78 85 - 89 86 78 86 76 2000 74 87 79 80 - 89 - 69 2001 76 85 - 85 87 86 85 73 2002 76 87 82 90 - 79 - 77 2003 72 85 - 96 85 88 85 67 2004 76 84 85 96 - 88 - 76 2005 73 85 - 87 83 91 71 75 2006 72 85 86 87 - 87 - 79 2007 69 85 - 82 85 82 81 81 *"N/A" indicates that the data for this examination are not available; "-" indicates that the examination was not administered that year. Figure 4-1. Membership statistics for the American College of Obstetricians and Gynecologists.60,00050,00040,00030,000 20,00010,0000 1955 1960 1965 1970 1975 1980 1985 1990 1995 2000 2005 2010 Year of survey Total members Fellows Junior Fellows Figure 4-2. Fellows and Junior Fellows of the American College of Obstetricians and Gynecologists per 10,000 women. 4.543.532.521.510.5 Fellows Junior Fellows Total0 1950 1955 1960 1965 1970 1975 1980 1985 1990 1995 2000 2005 Year of survey Figure 4-3. Fellows and junior Fellows in Practice of the American College of Obstetricians and Gynecologists per 10,000 women by state and in the United States as of 2009. Hawaii I District of Columbia I Connecticut Rhode Island Maryland Vermont New jersey Massachusetts New Hampshire New York Virginia Colorado North Carolina Delaware Oregon Georgia Tennessee South Carolina Illinois United States Louisiana Maine Pennsylvania Alaska Minnesota Texas Washington Michigan Wyoming California Alabama Nebraska Missouri Wisconsin Ohio South Dakota Montana Florida Utah Kansas New Mexico Indiana Nevada West Virginia Mississippi Kentucky Arizona Idaho North Dakota Oklahoma Io Arkansas II I I::::J I I I III I I I 0 2 3 4 5 10 Numbers of College Fellows and junior Fellows in Practice per 10,000 women Figure 4-4. Fellows and Junior Fellows of the American College of Obstetricians and Gynecologists per 10,000 women of reproductive age.9876543 Fellows Junior Fellows 2 Total10 1950 1955 1960 1965 1970 1975 1980 1985 1990 1995 2000 2005 Year of survey Figure 4-5. Fellows and Junior Fellows in Practice of the American College of Obstetricians and Gynecologists per 10,000 women of reproductive age in the United States as of 2009. Hawaii District of Columbia Connecticut Rhode Island Maryland Vermont New Jersey Massachusetts New Hampshire New York Delaware Virginia North Carolina Oregon Colorado Tennessee South Carolina Maine Pennsylvania Georgia Illinois United States Louisiana Minnesota Wyoming Florida Michigan Alabama Nebraska South Dakota Montana Washington Missouri Ohio Texas Wisconsin Alaska California West Virginia Kansas New Mexico Indiana Arizona Mississippi Nevada Kentucky Utah Idaho North Dakota Oklahoma Iowa Arkansas State median (4.2) 0 1 2 3 4 5 6 7 8 21 22 23 Number of College Fellows and Junior Fellows in Practice 52 per 10,000 women of reproductive age Table 4-2. Number of Physicians in the Largest Specialties by Major Professional Activity as of 2007Specialty Total Active Physicians (N) Patient Care (n) Teaching (n) Research (n) Other (n)* Anatomic and clinical pathology 15,568 11,898 346 672 2,652 Anesthesiology 38,724 35,461 514 235 2,514 Cardiovascular disease 21,511 19,476 322 698 1,015 Child and adolescent psychiatry 7,312 6,318 141 128 725 Dermatology 10,390 9,799 82 108 401 Emergency medicine 30,742 27,981 312 96 2,353 Endocrinology, diabetes, and metabolism 5,448 4,112 150 630 556 Family medicine and general practice 103,315 95,627 1,618 259 5,811 Gastroenterology 12,086 10,998 167 328 593 General surgery 26,769 22,852 278 174 3,465 Geriatric medicine 3,769 2,995 94 116 564 Hematology and oncology 11,802 9,584 172 997 1,049 Infectious disease 6,424 4,567 231 753 873 Internal medicine 104,904 91,457 1,296 1,613 10,538 Internal medicine and pediatrics 3,183 2,714 38 19 412 Neonatal-perinatal medicine 4,054 3,299 109 206 440 Nephrology 7,550 6,359 128 387 676 Neurological surgery 4,921 4,480 46 39 356 Neurology 12,620 10,597 217 713 1,093 Obstetrics and gynecology 39,689 36,827 466 197 2,199 Ophthalmology 17,846 16,616 129 142 959 Orthopedic surgery 20,032 18,912 135 78 907 Otolaryngology 9,220 8,711 86 31 392 Pediatrics 54,061 48,111 850 761 4,339 Physical medicine and rehabilitation 8,084 7,168 48 51 817 Plastic surgery 6,671 6,307 49 23 292 Preventive medicine 7,084 4,224 166 559 2,135 Psychiatry 39,371 33,935 577 865 3,994 Pulmonary disease and critical care medicine 11,567 9,829 258 464 1,016 Radiation oncology 4,209 3,896 30 38 245 Radiology and diagnostic radiology 27,562 24,899 368 186 2,109 Rheumatology 4,568 3,786 104 284 394 Thoracic surgery 4,820 4,388 53 66 313 Urology 9,916 9,308 81 52 475 Vascular surgery 2,610 2,392 38 18 162 *Physicians employed by insurance carriers, pharmaceutical companies, corporations, voluntary organizations, medical associations; those working through grants; or those from foreign countries. Table 4-3. Fellows and Junior Fellows in Practice of the American College of Obstetricians and Gynecologists by State, 2010State Fellows and Junior Fellows in Practice Total Female Population* Women of Reproductive Age† Obstetrician- Gynecologists per 10,000 Women Obstetrician- Gynecologists per 10,000 Women of Reproductive Age Alabama 470 2,403,813 1,117,546 1.96 4.21 Alaska 67 328,686 168,568 2.04 3.97 Arizona 562 3,243,489 1,505,915 1.73 3.73 Arkansas 212 1,456,755 666,252 1.46 3.18 California 3,604 18,368,653 9,114,994 1.96 3.95 Colorado 590 2,448,415 1,210,179 2.41 4.88 Connecticut 595 1,793,842 840,453 3.32 7.08 Delaware 105 449,756 210,794 2.33 4.98 District of Columbia 129 311,953 168,905 4.14 7.64 Florida 1,749 9,323,058 4,153,197 1.88 4.21 Georgia 1,110 4,920,769 2,438,040 2.26 4.55 Hawaii 191 173,811 83,657 10.99 22.83 Idaho 128 757,236 354,463 1.69 3.61 Illinois 1,420 6,541,657 3,167,656 2.17 4.48 Indiana 584 3,234,287 1,521,410 1.81 3.84 Iowa 227 1,519,683 691,190 1.49 3.28 Kansas 258 1,410,243 657,694 1.83 3.92 Kentucky 379 2,181,103 1,025,214 1.74 3.70 Louisiana 476 2,269,998 1,088,550 2.10 4.37 Maine 141 674,087 306,422 2.09 4.60 Maryland 855 2,905,274 1,413,184 2.94 6.05 Massachusetts 912 3,344,791 1,623,191 2.73 5.62 Michigan 1,008 5,079,493 2,395,708 1.98 4.21 Minnesota 533 2,620,494 1,257,969 2.03 4.24 Mississippi 265 1,514,777 711,023 1.75 3.73 Missouri 585 3,023,698 1,414,854 1.93 4.13 Montana 91 482,955 218,887 1.88 4.16 Nebraska 174 899,152 416,490 1.94 4.18 Nevada 227 1,275,577 610,545 1.78 3.72 New Hampshire 172 666,722 317,348 2.58 5.42 New Jersey 1,216 4,430,989 2,093,473 2.74 5.81 New Mexico 183 1,006,030 470,593 1.82 3.89 New York 2,566 10,028,234 4,844,289 2.56 5.30 North Carolina 1,109 4,705,427 2,242,302 2.36 4.95 North Dakota 50 319,548 148,733 1.56 3.36 Ohio 1,127 5,882,142 2,735,569 1.92 4.12 Oklahoma 282 1,843,520 853,884 1.53 3.30 Oregon 437 1,907,328 888,405 2.29 4.92 Pennsylvania 1,331 6,388,109 2,909,902 2.08 4.57 Rhode Island 174 542,083 260,349 3.21 6.68 (continued) Table 4-3. Fellows and Junior Fellows in Practice of the American College of Obstetricians and Gynecologists by State, 2010 (continued)State Fellows and Junior Fellows in Practice Total Female Population* Women of Reproductive Age† Obstetrician- Gynecologists per 10,000 Women Obstetrician- Gynecologists per 10,000 Women of Reproductive Age South Carolina 500 2,298,522 1,073,451 2.18 4.66 South Dakota 76 403,333 181,969 1.88 4.18 Tennessee 711 3,185,773 1,497,491 2.23 4.75 Texas 2,450 12,183,418 5,991,237 2.01 4.09 Utah 249 1,355,163 678,071 1.84 3.67 Vermont 89 315,547 147,231 2.82 6.04 Virginia 954 3,952,047 1,925,822 2.41 4.95 Washington 655 3,279,299 1,580,570 2.00 4.14 West Virginia 163 925,772 413,256 1.76 3.94 Wisconsin 544 2,830,342 1,337,644 1.92 4.07 Wyoming 52 262,478 122,932 1.98 4.23 Total 32,737 153,669,331 73,267,471 2.13 4.47 *Based on the U.S. Census estimates for July 1, 2008 †As per source, women aged 15-50 years Figure 4-6. Districts of the American Congress of Obstetricians and Gynecologists. (See Appendix F.) Figure 4-7. Percent change in the number of active physicians categorized by medical specialty, 1996-2006. Emergency medicinePediatrics Family medicine Internal medicine Neurology Anesthesiology Dermatology Otolaryngology Obstetrics and gynecology Neurosurgery Radiology Orthopedic surgery Psychiatry Pathology UrologyOphthalmologyGeneral surgery 10.5%10.2%10.2%8.6%7.9%7.7%6.8%5.0%1.6%-1.0% 27.5%25.6%23.6%21.3% 37.2%33.0% 49.7%-10 0 10 20 30 40 50 Change in the number of active physicians (%) Figure 4-8. Percentage of active physicians practicing in same state as their resident training categorized by medical specialty as of 2007.Psychiatry Family medicine Internal medicine Pediatrics Anesthesiology Obstetrics and gynecology Pathology Emergency medicine General surgery Radiology Dermatology Neurology Ophthalmology Urology 56.0%55.6%52.8%50.9%47.7%47.4%46.9%45.1%44.4%43.6%43.4%41.3%38.6%38.4%Orthopedic surgeryOtolaryngology 38.2%38.0% Average (47.4%)0 10 20 30 40 50 60 Active physicians practicing in the same state as their resident training (%) Figure 4-9. Percentage of active physicians with U.S. medical degrees categorized by medical specialty as of 2007. Dermatology Ophthalmology Orthopedic surgery Otolaryngology Neurosurgery Urology Radiology Emergency medicine Obstetrics and gynecology General surgery Pediatrics Anesthesiology Psychiatry Neurology Family medicine 90.0%89.7%88.4%86.8%84.1%82.6%82.3%81.8%78.7%74.4%69.2%66.6%66.3%65.9%65.3%PathologyInternal medicine 64.8%59.8% Within all physicians (69.5%)0 10 20 30 40 50 60 70 80 90 100 Active physicians with U.S. medical degrees (%) Figure 4-10. Percentage of active physicians with international medical degrees categorized by medical specialty as of 2007.Internal medicine Pathology Psychiatry Neurology Anesthesiology Pediatrics General surgery Family medicine Obstetrics and gynecology Urology Neurosurgery Radiology Otolaryngology Ophthalmology Emergency medicine Orthopedic surgery Dermatology 9.5%8.1%7.7%7.2%6.1% 18.0%16.5%15.5%14.5%14.3% 22.4% 35.5%33.2%30.5%30.1%27.9%27.5% Within all physicians (24%)0 10 20 30 40 Active physicians with international medical degrees (%) Figure 4-11. Percentage of active physicians with osteopathic degrees categorized by medical specialty as of 2007.Family medicine Emergency medicine Anesthesiology Obstetrics and gynecology Internal medicine Orthopedic surgery Neurology Dermatology Otolaryngology Radiology Pediatrics Psychiatry General surgery Ophthalmology Pathology Urology Neurosurgery 5.5%4.8%4.6%4.4%4.0%4.0%3.7%3.3%3.3%3.2%3.2%2.2%2.0%1.9%1.4% 10.5% 16.4% Within all physicians (6.5%)0 5 10 15 20 Active physicians with osteopathic degrees (%) Table 4-4. Fellows and Junior Fellows in Practice per 10,000 Women and per 10,000 Women of Reproductive Age According to Districts of the American College of Obstetricians and Gynecologists (Excluding the Armed Forces District)District Fellows and Junior Fellows in Practice Total Female Population Obstetrician- Gynecologists per 10,000 Women Women of Reproductive Age Obstetrician- Gynecologists per 10,000 Women of Reproductive Age District I 2,083 7,337,072 2.84 3,494,994 5.96 District II 2,566 10,028,234 2.56 4,844,289 5.30 District III 2,652 11,268,854 2.36 5,214,169 4.95 District IV 6,440 29,030,869 1.56 13,659,252 3.36 District V 3,098 16,377,025 1.92 7,677,901 4.12 District VI 3,024 15,134,209 1.53 7,201,651 3.30 District VII 3,259 17,108,577 2.29 8,007,294 4.92 District VIII 3,174 16,017,970 2.08 7,640,560 4.57 District IX 3,604 18,368,653 1.96 9,114,994 3.95 District XI 2,450 12,183,418 2.01 5,991,237 4.09 Total 32,350 152,854,881 2.12 72,846,341 4.44 Table 4-5. Practice Setting of Fellows and Junior Fellows in Practice of the American College of Obstetricians and Gynecologists Proportion of Fellows and Junior Fellows in Practice by Years of Survey (%)* Practice Setting 1991 1994 1998 2003 2008 Solo practice 32.7 27.2 24.1 22.6 23.6 Single specialty group 40.3 40.8 41.6 45.2 27.1 Multispecialty group 11.5 9.0 15.7 14.6 9.3 Salaried employee in private practice 1.0 2.8 2.4 1.3 11.2 Health maintenance organization 6.4 6.0 6.0 3.9 2.4 Hospital 5.3 9.7 13.6 11.3 11.9 University or medical school 8.9 11.4 11.1 10.0 8.8 State or local government 1.0 2.1 1.0 0.8 0.6 Federal government 0.8 1.1 0.8 0.6 0.9 Active duty military service No data 2.8 1.0 1.5 1.8 Other 1.2 4.9 2.2 4.3 2.3 *Totals in each column may exceed 100% because of a change in practice setting. Table 4-6. Trends in Numbers of Obstetrician-Gynecologists by Subspecialty Obstetricians-Gynecologists in Subspecialty (n)Year of Survey Reproductive Endocrinology and Infertility Maternal-Fetal Medicine Gynecologic Oncology 1994 532 833 486 1995 584 915 516 1996 678 1,058 559 1997 667 1,087 568 1998 710 1,174 605 1999 758 1,267 630 2000 805 1,354 662 2001 852 1,419 690 2002 886 1,457 725 2003 914 1,501 771 2004 949 1,542 792 2005 967 1,585 819 2006 989 1,624 858 2007 1,019 1,685 885 Table 4-7. Self-Designated General Obstetrician-Gynecologists Versus Self-Designated Subspecialists by Year of Survey 1975 1980 1985 1990 1995 2000 2008 Specialty Number General obstetrician- gynecologists 20,797 24,612 28,754 30,220 33,519 35,922 38,272 Obstetrician-gynecologist subspecialists 934 1,693 2,113 3,477 4,133 4,319 4,363 Distribution of All Active Physicians (%) General obstetrician- gynecologists 5.3 5.3 5.2 4.9 4.7 4.4 4.0 Obstetrician-gynecologist subspecialists 0.2 0.4 0.4 0.6 0.6 0.5 0.5 Figure 4-12. Mean ages of the male and female Fellows of the American College of Obstetricians and Gynecologists.565452504846444240 2001 2005 2010 Year of surveyTotal Male Female Figure 4-13. Age intervals of the Fellows of the American College of Obstetricians and Gynecologists by gender as of 2010.3,500 3,000 2,500 2,000 1,500 1,000 500 0 Male Female 30-34 35-39 40- 44 45-49 50-54 55-59 60-64 65-69 70-75 76 and older Age interval (years)Figure 4-14. Numbers of Fellows and Junior Fellows in Practice of the American College of Obstetricians and Gynecologists per 10,000 women by county in 2010. (See Appendix F.) Figure 4-15. Numbers of Fellows and Junior Fellows in Practice of the American College of Obstetricians and Gynecologists per 10,000 women by state in 2010. (See Appendix F.) Figure 4-16. Numbers of Fellows and Junior Fellows in Practice of the American College of Obstetricians and Gynecologists per 10,000 reproductive-aged women by county in 2010. (See Appendix F.) Figure 4-17. Numbers of Fellows and Junior Fellows in Practice of the American College of Obstetricians and Gynecologists per 10,000 reproductive-aged women by state in 2010. (See Appendix F.) Figure 4-18. Sites of allopathic and osteopathic residency programs in relation to the number of Fellows and Junior Fellows in Practice of the American College of Obstetricians and Gynecologists per 10,000 women by state in 2010. (See Appendix F.)Table 4-8. Self-Designated General Obstetrician-Gynecologists Versus Self-Designated Subspecialists by Age and Gender Age Interval (Years) Younger 65 and Specialty Total Than 35 35-44 45-54 55-64 Older All (N) General obstetrician- 38,272 6,025 10,374 9,894 7,867 4,112 gynecologists Obstetrician-gynecologist 4,363 24 310 1,267 1,608 1,154 subspecialists Male (n) General obstetrician- 19,879 1,181 3,667 5,454 5,994 3,583 gynecologists Obstetrician-gynecologist 3,058 11 146 726 1,162 1,016 subspecialists Female (n) General obstetrician- gynecologists 18,393 4,844 6,707 4,440 1,873 52 Obstetrician-gynecologist subspecialists 1,305 13 164 544 446 138 Table 4.9. Racial Distribution of Physicians in Relation to U.S. Population in 2008 Racial Distribution (%)Population Total (n) White Black Hispanic Asian American Indian or Alaskan Native Other or Unknown Obstetrician- gynecologists 42,635 57.1 7.1 5.3 8.6 0.2 21.7 Total physicians 954,224 54.5 3.5 4.9 12.2 0.2 24.7 U.S. population 281,421 906 75.1 12.3 12.5 3.7 0.9 Data not available5 obstetriCian-gyneCologists as Coordinators of women's health Care and as sUrgiCal sPeCialists An obstetrician-gynecologist (ob-gyn) is a physician with particular expertise in the manage- ment of pregnancy, childbirth, and disorders of the reproductive system and one who provides certain medical and surgical care to women. A minimum of 4 years of formal training after medical school is required for a physician to be eligible to take the written and oral board certification examinations. With an additional fellowship training of 3 or 4 years, an ob-gyn may become a candidate for board certification in gynecologic oncology, maternal-fetal medicine, reproductive endocrinology and infertility, or female pelvic medicine and reconstructive surgery. Obstetrics and gynecology is a unique specialty in which there is a coordination of women's health care that ranges from overall preventive care to a wide variety of reproductive tract procedures and surgery. The American College of Obstetricians and Gynecologists (the College) describes ob-gyns as personal physicians to women, acknowledging their broader role in coordinating women's health maintenance, including health screening and disease prevention, evaluation and counseling, and immunization services as appropriate during a woman's life span. ? Coordinators of Women's Health Care Obstetrician-gynecologists constitute the fourth largest group of physicians and represent the largest specialty outside of the three traditional primary care fields-1) internal medicine, 2) family medicine, and 3) pediatrics. Obstetrics and gynecology is ranked highest among the five major medical fields (1] obstetrics and gynecology, 2] internal medicine, 3] family medicine, 4] pediatrics, and 5] psychiatry) in the proportion of time dedicated to direct patient care. Currently, the debate continues as to who is a primary care physician for women and what constitutes the provision of primary care. Consumer demand for health care is greatest in the primary health care fields, as evidenced by the low number of the general population (7,600) and the lowest number of reproductive- aged women (1,656) served by an active ob-gyn. Currently, 32% of physicians in the United States are primary health care providers, of which 13% are family physicians, 11% are general intern-ists, and 8% are general practitioners. With the decreasing numbers of general internists and family physicians relative to the general population offering office-based practice, the role of ob-gyns will take on even greater importance for adult women. Primary health care training was integrated into residency training in obstetrics and gynecology in the 1990s, partly because of the large percentage of women who considered their ob-gyns to be their first-line, personal physicians, especially between ages 15 years and 50 years. At least 85% of all residents in obstetrics and gynecology pursue general practices and, therefore, are more likely to express a need for training in primary health care-related topics. In January 1996, the Residency Review Committee for Obstetrics and Gynecology instituted special requirements to address general medical training most needed by practicing ob-gyns. Primary health care management from adolescence to reproductive age to midlife and beyond is an integral part of practicing obstetrics and gynecology. A wide range of topics, such as immunization; fitness and nutrition; alcohol, tobacco, and drug use; psychologic well-being; and cardiovascular risk factors are to be discussed at well-woman examinations in addition to breast health, sexuality concerns, and contraception. Cervical cytology screening and pelvic examination also are performed at well-woman visits. Periodic assessments, as charted by the College's Committee on Gynecologic Practice, offer an excellent guideline for ob-gyns to provide age-specific preventive screening, evaluation, and counseling on a yearly basis or as appropriate. Personal behavioral characteristics, whether positive (exercise) or negative (smoking), are important for discussion, along with age-related causes of morbidity and mortality. Although it is possible to routinely assess many primary and preventive health care issues, time constraints on ob-gyns may not permit the management of some conditions. Results of a survey of recent residency graduates in obstetrics and gynecology disclosed that they had adequate training in general obstetrics; general gynecology; genetics; pathology; maternal-fetal medicine; reproductive endocrinology and infertility; family planning; ambulatory care; major gynecologic surgery; minor gynecologic surgery; assisted reproductive technology; gynecologic oncology surgery; urogynecologic evaluation; ultrasonography; emergency medicine and critical care; management of menopause; immediate newborn care; and pulmonary, endocrine (thyroid disease and diabetes), psychosocial, infectious, cardiovascular, and psychosexual conditions. However, a significant percentage of young generalists felt that they needed more training in metabolism, nutrition, and dermatologic, infectious, cardiovascular, and rheumatoid or collagen vascular disorders; otherwise, they were inclined to refer patients to specialists. Furthermore, it would seem that for several chronic disorders, for example, diabetes mellitus and hypertension, ob-gyns often assume primary management during pregnancy, but postpartum refer patients to other specialists for ongoing management of these chronic conditions. Many experts continue to emphasize the centrality of a primary health care provider's role as an entry point for any woman to the health care system. The concept of a "patient-centered medical home" for women is gaining attention and hinges on the central role of office-based health care coordination. Reimbursement is related to the time requirements of physicians and their staff and for electronic information-communication systems necessary for the coordination of health care. ? Surgical Specialists Obstetrics and gynecology also is a surgical discipline encompassing a wide variety of procedures involved with pregnancy (eg, spontaneous vaginal delivery, operative vaginal delivery, episiotomy or laceration repair, and cesarean delivery) and the female reproductive tract (eg, abdominal hysterectomy, vaginal hysterectomy, laparoscopic hysterectomy, surgical management of incontinence and pelvic floor repair, laparoscopy, and hysteroscopy). Residency education includes the core principles of all surgical training, and practitioners are prepared to manage common surgical problems. Advances in minimally invasive gynecologic surgery and robotic gynecologic surgery have benefitted all surgical specialties. The evolution of noninvasive procedures has been extraordinary. The widespread availability of intrauterine devices, endometrial ablation techniques, outpatient tubal occlusion, and umbilical artery embolization has decreased the need for hysterectomy. The number of residents completing a surgical program approved by the Accreditation Council of Graduate Medical Education is highest in obstetrics and gynecology, followed by those in general surgery, orthopedics, and ophthalmology programs. The percentage of ob-gyns practicing in the same state where they completed either medical school (40.4%) or residency (47.9%) is the highest among the surgical specialties, followed by physicians practicing ophthalmology, general surgery, and otolaryngology. Acquiring sufficient surgical skills during residency and maintaining those skills, sometimes with the assistance of a senior associate, remains essential. Obstetrician-gynecologists constitute the largest number of active physicians of all surgical specialties and the largest number of active patient care physicians per 100,000 individuals by surgical specialty, followed by general surgeons and orthopedists. It is second to general surgery in the number of applicants for surgical residency or fellowship programs. Of all surgical fields, obstetrics and gynecology has the highest number of female physicians in training and in practice. Data from the National Hospital Discharge Survey, a federal discharge database of U.S. inpatient hospitals, from 1970 to 2006 indicate that inpatient obstetric and gynecologic procedure rates are decreasing over time, but still comprise a large percentage (26.5%) of inpatient surgical procedures for U.S. women. Both operative vaginal delivery rates and episiotomy rates decreased, whereas spontaneous vaginal delivery rates and cesarean delivery rates increased. Rates for all gynecologic procedures decreased during this period, with the exception of procedures for the management of incontinence, which increased.Implications Obstetrician-gynecologists represent the largest group of active physicians outside the traditional primary care fields-internal medicine, family medicine, and pediatrics. It has evolved into an elite specialty in preventive health care for women of all ages. Most ob-gyns consider themselves to be specialists who can also provide either preventive or primary health care for women, as necessary. The role of the ob-gyn as a coordinator of health care makes this specialty unique among surgical disciplines and may take on even greater importance as relatively fewer internists and family physicians offer office-based practices. The specialty is adaptable as evident from the evolution of noninvasive or minimally invasive procedures. The importance of the specialty will continue to expand, with health care system reform being another step in its evolutionary process. Bibliography Coleman VH, Laube DW, Hale RW, Williams SB, Power ML, Schulkin J. Obstetrician-gynecologists and primary care: training during obstetrics-gynecology residency and current practice patterns. Acad Med 2007;82:602-7. Landon BE, Reschovsky J, Blumenthal D. Changes in career satisfaction among primary care and specialist physicians, 1997-2001. JAMA 2003;289:442-9. McAlister RP, Andriole DA, Brotherton SE, Jeffe DB. Are entering obstetrics/gynecology residents more similar to the entering primary care or surgery resident workforce? Am J Obstet Gynecol 2007;197:536. e1-536.e6. Morgan MA, Lawrence H 3rd, Schulkin J. Obstetrician-gynecologists' approach to well-woman care. Obstet Gynecol 2010;116:715-22. Oliphant SS, Jones KA, Wang L, Bunker CH, Lowder JL. Trends over time with commonly performed obstetrics and gynecologic inpatient procedures. Obstet Gynecol 2010;116:926-31. Williams TE, Satiani B, Ellison EC. The coming shortage of surgeons: why they are disappearing and what that means for our health. Santa Barbara (CA): ABC-CLIO, LLC; 2009.The following tables, boxes, and figures provide data related to obstetrician-gynecologists as coordinators of women's health care and as surgical specialists. Box 5-1. Working Definitions of a Primary Care Physician American College of Obstetricians and Gynecologists* A primary physician is a physician directly accessible to patients for their initial contacts. This physician will see patients who have a specific or an undifferentiated complaint or patients who desire health maintenance through periodic health checkups. The primary care physician also provides continuity of care and is readily available to the patient when he or she has either a specific or nonspecific complaint. Such physician performs initial evaluation and management within his or her expertise. A primary care physician advises when referral to another physician is indicated, coordinating subsequent and continuing care to assure the patient of appropriate comprehensive care. The Institute of Medicine† Primary care is the provision of integrated, accessible health care services by clinicians who are accountable for addressing most personal health care needs, developing a sustained partnership with patients and practicing in the context of family and community. Association of American Medical Colleges‡ Physicians are counted as primary care physicians if their self-designated primary specialty is one of the following: adolescent medicine, family medicine, general practice, geriatric medicine, internal medicine, internal medicine/ pediatrics, or pediatrics. Residents and fellows are counted as primary care residents and fellows if they are in one of the following programs: adolescent medicine (pediatrics), family medicine, geriatric medicine (family medicine), geriatric medicine (internal medicine), geriatric medicine/ family practice, geriatric medicine/internal medicine, internal medicine, internal medicine/family practice, internal medicine/ pediatrics, internal medicine/preventive medicine, or pediatrics. *Hale RW. The obstetrician and gynecologist: primary care physician or specialist? Am J Obstet Gynecol 1995;172:1181-3. †Donaldson MS, editor. Primary care: America's health in new era. Institute of Medicine (U.S.). Division of Health Care Services. Committee on the Future of Primary Care. Washington, D.C.: National Academy Press; 1996. p. 395. ‡Association of American Medical Colleges. 2009 state physician workforce data book. Center for Workforce Studies. Washington, DC: AAMC; 2009. Available at: https://www.aamc.org/download/47340/data/statedata2009. pdf. Retrieved February 2, 2011. Table 5-1. Topics Assessed at a Typical Women's Annual Visit by a Generalist and a Subspecialist Obstetrician-Gynecologist Generalist (%) (n=515) Subspecialist (%) (n=276) Cervical cytology* 97.8 73.8 Breast health (examination by physician)* 97.6 73.1 Breast health (self examination)* 93.4 8.3 Pelvic examination* 91.8 71.6 Alcohol, tobacco, or drug use* 90.8 73.4 Sexuality concerns* 83.6 57.6 Fitness and nutrition* 79.4 55.4 Psychologic well-being* 67.4 51.7 Cardiovascular risk factors* 60.8 44.6 Immunizations 27.6 28.4 *Significant difference between generalist and subspecialist obstetric-gynecologic groups (P <.001) Figure 5-1. Top 20 specialties with the largest numbers of active physicians as of 2007.Internal medicine 104,904 Family medicine Pediatrics Obstetrics and gynecology Psychiatry Anesthesiology Emergency medicine Radiology General surgery Cardiology Orthopedic surgery Ophthalmology Anatomy and clinical pathology Neurology Gastroenterology Hematology and oncology Pulmonary disease and critical care medicine Dermatology Urology Otolaryngology 30,742 27,562 26,769 21,511 20,032 17,846 15,568 12,620 12,086 11,802 11,567 10,390 9,916 9,22039,689 39,371 38,724 54,061 103,3150 10,000 20,000 30,000 40,000 50,000 60,000 100,000 110,000 Number of active physicians Figure 5-2. Number of patients in the general population per active physician categorized by medical specialty as of 2007.Internal medicine Family medicine Pediatrics Obstetrics and gynecology Psychiatry Anesthesiology Emergency medicine Radiology General surgery Cardiology Orthopedic surgery Ophthalmology Pathology Neurology Gastroenterology Hematology and oncology Pulmonary disease and critical care medicine Dermatology Urology Otolaryngology Neurosurgery 2,875 2,919 5,579 7,600 7,661 7,789 9,811 10,943 11,268 14,022 15,057 16,901 19,374 23,900 24,956 25,557 26,076 29,030 30,418 32,714 61,293 0 10,000 20,000 30,000 40,000 50,000 60,000 70,000 Number of patients in general population Figure 5-3. Number of active physicians per 100,000 population categorized by surgical specialty as of 2008.Obstetrics and gynecology General surgery Orthopedics Ophthalmology Urology Otolaryngology Neurosurgery 1.63.3 3.1 5.9 7.3 8.6 13.1 Within all physicians (214.7) Within all surgical specialties (45.2)0 5 10 15 Active physicians per 100,000 population Figure 5-4. Numbers of intern applicants to residency programs categorized by surgical specialty as of 2007.General surgery Obstetrics and gynecology Orthopedics Ophthalmology Otolaryngology375 648 913 2,082 1,869 Urology 348 0 500 1,000 1,500 2,000 2,500 Number of intern applicants Figure 5-5. Number of residents completing a program accredited by the Accreditation Council of Graduate Medical Education categorized by surgical specialty as of 2006.Obstetrics and gynecology General surgery Orthopedics Ophthalmology Otolaryngology Urology249 242 392 825 1,064 1,015 0 200 400 600 800 1,000 1,200 Number of residency graduates Figure 5-6. Percentage of active physicians practicing in the same state as their medical school training categorized by surgical specialty as of 2008.Obstetrics and gynecology Ophthalmology General surgery Otolaryngology Orthopedics Urology Neurosurgery 27.0% 40.4% 37.8% 36.9% 36.8% 36.3% 35.2% 0 10 20 30 40 50 Active physicians practicing in the same state as their medical school training (%) Figure 5-7. Percentage of active physicians practicing in the same state as their residency categorized by surgical specialty as of 2008. Obstetrics and gynecology General surgery Urology Ophthalmology Otolaryngology Orthopedics Neurosurgery 38.8% 38.2% 38.2% 36.9% 33.3% 47.8% 44.8% 0 10 20 30 40 50 Active physicians practicing in the same state as their residency (%) Figure 5-8. Percentage of female residents in programs accredited by the Accreditation Council of Graduate Medical Education categorized by surgical specialty as of 2010.Obstetrics and gynecology Ophthalmology General surgery Otolaryngology Urology Neurosurgery Orthopedics 13.1% 9.1%23.1% 35.0% 30.9%42.5% 79.7% Within all surgical specialties (38.1%) Within all physicians (46.0%)0 10 20 30 40 50 60 70 80 Female residents (%) Figure 5-9. Percentage of active physicians who are female categorized by surgical specialty as of 2008. Obstetrics and gynecology Ophthalmology Colorectal surgery General surgery Plastic surgery Otolaryngology Neurosurgery Urology 5.5% 14.1% 13.6% 11.8% 11.1% 4.7%18.4% 43.0% Orthopedics Thoracic surgery 3.9% 3.8% Within all surgical specialties (19%) Within all physicians (28.3%)0 5 10 15 20 25 30 35 40 45 50 Active female physicians (%) Table 5-2. Procedures Performed Annually by the American College of Obstetricians and Gynecologists Fellows and Junior Fellows in Practice Procedures Percentage of Physicians Performing the Procedure (%) Procedures per Year per Physician (n) Hospital-Based Practice Vaginal delivery 76.8 152 Cesarean delivery 76.9 40 Hysterectomy 84.6 28 Endometrial ablation 72.1 20 Assistance at surgery 71.5 35 Office-Based Practice Colposcopy 88.1 72 Endometrial ablation 18.0 15 Cystoscopy 6.7 24 Hysteroscopy 23.3 21 Urodynamics 23.7 26 Sterilization 17.8 15 Figure 5-10. Percentage of active physicians aged 55 years or older categorized by surgical specialty as of 2008. Thoracic surgery Urology Plastic surgery Orthopedics General surgery Otolaryngology Neurosurgery Ophthalmology 48.4% 47.4% 43.2% 42.5% 42.4% 41.9% 41.5% 41.5% Obstetrics and gynecology Colorectal surgery38.8% 35.1% Within all surgical specialties (41.4%) Within all physicians (37.5%)0 10 20 30 40 50 60 Active physicians aged 55 years or older (%)6 finanCial Considerations and PhysiCian ComPensation Understanding physician compensation involves consideration of diverse factors, such as patient composition, sources of reimbursement, impact of managed health care, and geography. Trends in annual physician compensation have been reported by several resources, most notably the American Medical Association, medical specialty organizations, and recruitment firms. Annual compensation for general obstetrician-gynecologists (ob-gyns) is among the lowest of the surgical specialties. The change in median compensation between 1995 and 2004 was low, even when compared with the primary care fields. Furthermore, salaries of ob-gyns remained flat in recent years compared with other surgical specialties. Incomes tended to be highest for physicians practicing in metropolitan areas with population sizes of less than 1 million, rather than in metropolitan areas with larger populations or in rural areas. However, differences in reported incomes do not control for cost of living and other determinants of income (eg, surgeries, deliveries, and patient care hours worked). The American Medical Association no longer publishes information on physician earnings, and compensation infor- mation from individual consulting or research firms may not necessarily be representative because sample sizes are not large. Of note, information on a median rather than a mean salary is preferred because it is a measure of central tendency. Reimbursement for physician services is determined from the monetary value that society places on physician services. Rates and work relative value units reflect the value of a physician's time and expertise; therefore, physicians practicing in specialties that require more years of training and for which there are fewer provider alternatives (eg, surgical specialties) have higher earnings than primary care physicians. Annual earnings are positively related to the number of working hours, graduating from a U.S. medical school, being in the middle of one's career (aged 42-51 years), working in a moderately large practice rather than in a solo practice, and being board certified. Highest earnings are expected to be in practices where patient volume is sufficient to invest in nonphysician clinicians and revenue-generating ancillary services but small enough to avoid costly layers of administration. Although the number of female physicians is increasing, they are represented disproportionately at the lower end of the income spectrum. This difference is largely due to fewer desired work hours. ? Education-Related Indebtedness Tuition and fees for first-year medical students enrolled at both private and public medical schools continue to increase each year. In the public sector, the mean annual tuition and fees for a medical student who is a resident of the state is $18,748. For a nonresident of that state, the tuition and fees at a public medical school are approximately the same as the average tuition at private medical schools ($38,337). For the class of 2007, the average educational debt of nonresident medical students was $139,517 (more for private schools and less for public schools). Projected payments for a 30-year student loan are expected to increase from 10% of a physician's projected after-tax income at the beginning of the repayment period to more than 20% later in the career. Physicians bear approximately $500,000 of their training expenses. This includes the costs of undergraduate medical education and wages lost during this time. Being burdened by educational debt, students realize that they can earn substantially more as specialists than as primary care physicians. It is important to realize that despite their eventual earnings, physicians have a significantly lower return on their educational investments than do other professionals. ? The Impact of Managed Health Care on Physician Compensation Much can be learned from experiences with managed health care. The era of managed health care can be divided into two periods: 1) beginning and growth (1983-1993) and 2) maturity and decline (1993-2000). During the beginning period, there was little overall change in most physician work parameters except for compensation. For example, the number of weeks physicians worked each year, number of patients seen, length of office visits, and number of hours devoted to nonpatient care remained essentially the same. Although ob-gyns and general surgeons were more inclined than other physician groups to work more hours per week in patient care, that number of hours remained relatively constant during the first decade of the managed health care period. At that time, ob-gyns had the largest increase of all specialists in inflation-adjusted earnings before 1993 (6.6% annually), followed by surgeons (6.3%) and radiologists (6%). In the period of maturity and decline of managed health care, additional forces and factors began to be felt. In the 1990s, the principles of managed health care (eg, use of gatekeepers, exclusive networks, utilization review, and capitation) held the health care system to be more efficient as physicians shared a greater burden in the costs of their decisions, either through financial incentives or constraints on recommending certain services, tests, or procedures. Actions taken by clinicians to counter lagging incomes included reducing practice expenses, expanding services, renegotiating contracts with health care plans, hiring nonphysician clinicians, increasing work hours, and relocating. Nonphysician clinicians (eg, certified nurse- midwives, nurse practitioners, and physician assistants) were hired to deliver some services offered by ob-gyns at a lower cost. In addition, payers found other ways to control expenses- by shifting a greater portion of the cost of care onto patients through increasing deductibles and copayments, limiting the scope of services provided, and informing patients about the true cost of their health care. As managed health care matured, the highest paid physicians were hit the hardest. Inflation-adjusted incomes of ob-gyns, surgeons, and anesthesiologists decreased by an average of 3-4% per year compared with a 2% decrease for physicians overall. ? Costs of Professional Liability Insurance Apart from levels of reimbursement, the cost of professional liability insurance is the factor with the greatest financial impact on an obstetric-gynecologic practice. Surveys of Fellows and Junior Fellows in Practice of the American College of Obstetricians and Gynecologists reported that nearly all (96.3% in 2006 and 95.7% in 2009) were covered by a professional liability insurance policy. Two thirds of liability insurance contracts carried policies with a per claim limit of $1 million and an aggregate of $3 million. The cost of premiums in 2009 averaged to be $67,336 per ob-gyn nationwide, which constitutes 17.8% of gross income or approximately $1 for every $6 that the physician receives. Costs of annual insurance coverage and changes in rates vary widely from state to state, often depending on any tort reform. The current annual premiums range from $18,154 in Wisconsin to $201,808 in Florida. The highest average base rate premiums are in the District of Columbia, Florida, Connecticut, and New York, whereas the lowest rates are in Minnesota, Wisconsin, North Dakota, and South Dakota. States with the greatest increase in premiums between 2003 and 2009 included Oklahoma, Maryland, Rhode Island, and Indiana, whereas a decrease in premiums was observed in eight states, most notably Texas, North Carolina, Florida, and West Virginia. It is encouraging to note that there has not been a cumulative change in overall liability insurance in recent years. In some states, for maternal-fetal medicine specialists, the cost of liability insurance has become prohibitive. Quoted premiums in some states, such as New Jersey, exceeded $300,000 for a mature policy with a per claim limit of $1 million and an aggregate of $3 million. Specialists in those states no longer attend deliveries and instead confine their practices to consultative services. ? Opportunities for Enhanced Reimbursement Traditional methods of reimbursement are salary, fee-for-service payments, capitation, and combinations of these as covered by private or government insurance. Whereas several initiatives hold out the promise of increased reimbursement for services, two should be briefly mentioned, pay-for-performance and the patient-centered medical home. There has been an interest in bonus payments resulting from patient safety and quality of health care, desired outcomes, or cost savings. This concept, known as pay-for-performance, is generally understood as aligning reimbursement with a provider's performance. Findings from limited research to date suggest that the amount of such incentive payments is too low to have a significant impact on physician behavior. Many experts continue to emphasize the centrality of a primary health care provider's role as an entry point for patients into the health care system and as a coordinator of care. As a result, a concept known as a patient-centered medical home has been introduced and currently is gaining more attention. In this model, reimbursement is related to the time required of physicians and their staff to coordinate their tasks and mandates an electronic information- communication system. As with the pay-for-performance concept, it is unclear at present whether reimbursement incentives will exceed the additional expense to one's practice of creating an accredited patient-centered medical home for women. ? Factors of Indeterminate Impact Several factors have an indeterminate impact on physician income. Personal income taxes, the aging population, and the nation's economic status can affect where physicians practice, level of reimbursement, and the demand for physician services. Personal Income Taxes A way to reduce the growing national debt often includes increasing personal income taxes. Most physicians are in high income tax brackets (income greater than $200,000 per year), and an increase in tax rates could affect physician supply. Increased tax rates would reduce the return on working additional hours, which could have a negative effect on physician access and supply. Alternatively, some physicians might choose to work longer hours to make up for higher federal and state income taxes. Any increase in state income tax rates could result in a cross-state migration by some physicians. Aging of the Population The continued increase in numbers of the U.S. elderly population will likely result in a larger proportion of physician reimbursement from Medicare. Compared with other adult care specialists, general ob-gyns receive the lowest proportion of revenue from Medicare because their patients are least likely to be aged 65 years or older. Like pediatricians, ob-gyns receive the highest proportion of their revenue from Medicaid and private insurance carriers. However, Medicaid and private-payer sources often are linked to Medicare policies and reimbursement formulas, so practice patterns in obstetrics and gynecology will be adversely affected by any diminution in Medicare reimbursement. Reduced reimbursements from either the government or private insurers may decrease and consequently affect physicians' income and hasten their early retirement. National Economic Prosperity A positive correlation exists between economic well-being and demand for physician services. An estimated 2% annual growth in the per-capita gross domestic product leads one to conclude that by 2020, demand for physician services (particularly for specialty services) will result in a projected shortfall of 200,000 physicians. Although economic growth may lead to a greater demand for physician services, this relationship is complicated by a third- party payer system in which patients and providers do not bear the full cost of health care decisions. Greater economic well-being does allow employers and governments to expand in several ways, including improved access to health care through expanded medical insurance coverage, more generous coverage, and increased ability and willingness of individual patients to purchase physician services. Accordingly, the net impact of these countervailing influences cannot be determined. Implications The current financial environment with flat or decreasing reimbursement and increasing practice expenses continues to challenge ob-gyns. Compensation for obstetric-gynecologic services has increased more slowly than in other major medical specialties and is highly variable depending on the type of practice, but is perceived to be less economically viable than in other medical specialties. As health care costs escalate, cost containment is essential for sustaining health care reforms and the economic viability of the United States. By standardizing and streamlining the administrative functions, especially in office-based practices, providers and health care plans may reduce expenses and improve physician satisfaction. Use of nonphysician clinicians will gain greater importance yet requires thoughtful consideration about its financial value. Bibliography 2008 Socioeconomic Survey of ACOG Fellows. Washington, DC: American College of Obstetricians and Gynecologists; 2010. Available at: http://www.acog.org/departments/dept_notice. cfm?recno=19&bulletin=5099. Retrieved October 5, 2010. Inwald JM. The picture of a market not yet firming: annual rate survey issue. Med Liabil Monit 2009; 34(10):1-39. Medical Group Management Association. Physician compensation and production survey: 2009 report based on 2008 data. Englewood (CO): MGMA; 2009. Reyes JW. Gender gaps in income and productivity of obstetricians and gynecologists. Obstet Gynecol 2007;109:1031-9. Robeznieks A. Feeling the pain. Mod Healthc 2009;39(28):20, 26. Scheffler RM. Physician incomes: following the money. Is there a coctor in the house? Market signals and tomorrow's supply of doctors. Stanford (CA): Stanford University Press; 2008. p 28-42. Sweeney JF. Exclusive survey: how do you measure up? Contemp Pediatr 2010;27(10):48-56. Weiss GG. Keeping up in down times. As recession gripped America, physician incomes remained stable. Med Econ 2009;86(18):18-9, 23-5.The following tables and figures provide data related to financial considerations and physician compensation. Figure 6-1. Median medical education debt after attending a private or a public medical school.180,000150,000120,00090,00060,00030,000 Private Public 0 1984 1986 1988 1990 1992 1994 1996 1998 2000 2002 2004 2006 Year of survey Table 6-1. Average Percentage of Physician Revenue by Payment SourceMedical Specialty Medicare (%) Medicaid (%) Insurance (%) Self-pay (%) Other (%) All physicians 29 12 43 12 4 Family practice 23 12 44 17 4 General internal medicine 44 8 36 9 3 Surgery 35 8 43 12 2 Pediatrics 1 26 56 13 5 Obstetrics and gynecology 11 20 54 13 2 Radiology 34 10 42 11 3 Psychiatry 16 17 37 22 9 Anesthesiology 28 13 48 9 3 Pathology 28 11 41 10 10 Other specialties 28 10 43 12 8 Table 6-2. Estimated Percentage of Time Physicians Spend Providing Health Care to Patients Aged 65 Years and Older 2000 2020 Medical Specialty (%) (%) All specialties 32 39 General internal medicine 43 50 Pathology 43 49 Surgery 39 46 Psychiatry 34 41 Family practice 30 38 Anesthesiology 19 25 Radiology 15 20 Obstetrics and gynecology 5 7 Pediatrics 0 0Table 6-3. Distribution of Type of Health Insurance CoverageInsurance Coverage* Percentage of Population Private 67.5 Employment-based Direct purchase 59.3 8.9 Government 27.8 Medicare Medicaid Military health care plan 13.8 13.2 3.7 None 15.3 *Patients can be covered by more than one type of health insurance plan during any year. Figure 6-2. Ten-year change in median physician compensation from 1995 to 2004. Hematology and oncology Gastroenterology Dermatology Radiology Urology Cardiology Psychiatry Anesthesiology Pulmonary medicine Otolaryngology General surgery Neurology Emergency medicine Inflation Pediatrics Internal medicine Family medicine Obstetrics and gynecology38%35%35%35%30%28%26%24%24%21%20%15%47%57% 64% 76%74% 86% 0 20 40 60 80 100 Change in compensation (%) Table 6-4. Physician Compensation Survey by the American Medical Group Association* Medical Specialty Starting Income Median Income Anesthesiology $325,000 $366,640 Emergency medicine $199,782 $267,293 Family medicine $144,990 $197,655 Family medicine with obstetrics $145,513 $202,047 General surgery $260,000 $340,000 General obstetrics and gynecology $225,000 $294,190 Gynecologic oncology No data $406,000 Gynecology No data $218,607 Hospital medicine $165,000 $211,835 Internal medicine $146,251 $205,441 Neonatology $174,158 $265,000 Orthopedic surgery $370,000 $476,083 Maternal-fetal medicine No data $394,121 Psychiatry $163,840 $208,462 Reproductive endocrinology No data $317,943 *The American Medical Group Association represents medical groups nationwide, including some of the nation's largest, most integrated health care delivery systems.Table 6-5. Median Annual Compensation of Physicians by Surgical Specialty Surgical Specialty 2007 2009 Obstetrics and gynecology $297,887 $294,190 General surgery $327,902 $340,000 Otolaryngology $327,399 $365,171 Urology $365,999 $389,198 Orthopedics $436,481 $476,083 Thoracic and cardiovascular surgery $460,000 $507,143 Neurosurgery $530,000 $548,186 Table 6-6. Median Annual Compensation of Physicians by Obstetric-Gynecologic Specialty Specialty 2000 2002 2005 2008 General obstetrics and gynecology $238,186 $257,997 $274,367 $302,362 Gynecologic oncology $270,222 $292,901 $322,188 $356,262 Maternal-fetal medicine $268,369 $303,451 $337,182 $411,679 Reproductive endocrinology and infertility $218,406 $295,496 $358,470 $408,679Table 6-7. Median Annual Compensation for General Obstetrician-Gynecologists by Research Firm Source 2004 2005 2009 American Medical Group Association $266,245 $321,746 $321,746 Medical Group Management Association $261,073 $285,812 $285,812 Hay Group $252,300 $240,700 $240,700 Merritt, Hawkins, and Associates $242,000 $266,000 $266,000 Hospital and Healthcare Compensation Services $233,343 $312,990 $312,990 Sullivan, Cotter, and Associates $222,625 $252,778 $252,778 Figure 6-3. Professional liability insurance premiums for general obstetrician-gynecologists by state for a $1 million/ $3 million claims-made policy as of 2009.District of Columbia Florida Connecticut New York Maryland Rhode Island New Jersey Illinois Nevada Pennsylvania Massachusetts Missouri West Virginia Wyoming Ohio Montana Louisiana Mississippi Arizona United States Utah Michigan Delaware Texas New Mexico Georgia New Hampshire Kentucky Washington Indiana Hawaii Oklahoma North Carolina California Alaska Virginia Tennessee Colorado Oregon Vermont Kansas Maine South Carolina Alabama Arkansas Idaho Iowa South Dakota North Dakota Wisconsin Nebraska Minnesota States with nonpatient compensation fund States with patient compensation fund Median premium ($67,336) 0 20,000 40,000 60,000 80,000 100,000 120,000 140,000 160,000 Premiums ($) Figure 6-4. Percent change in average base rate premiums for general obstetrician-gynecologists, 2003-2009. Oklahoma Maryland Rhode Island Indiana South Dakota Wyoming Mississippi Idaho Delaware Arizona New York Connecticut Washington Nebraska District of Columbia Georgia Montana Maine New Hampshire South Carolina New Jersey Nevada Oregon Missouri Vermont Kentucky Arkansas Kansas Utah United States Tennessee Louisiana New Mexico Iowa Hawaii North Dakota California Minnesota Alaska Ohio Virginia Alabama Colorado Illinois Pennsylvania Wisconsin Massachusetts Michigan West Virginia Florida North Carolina Texas States with nonpatient compensation fund States with patient compensation fund -40 -20 0 20 40 60 80 100 120 140 160 180 Change in base rate premiums (%) Figure 6-5. Cumulative change in rates of professional liability insurance by medical specialty. 120 100 80 60 40 Internal medicine General surgery 20 Obstetrics and gynecology 0 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 Year of survey 7Career satisfaCtion of obstetriCian-gyneCologists and its imPaCt on the workforCe Career satisfaction is a key factor when examining workforce issues, and being an obstetrician- gynecologist (ob-gyn) can be associated with a high sense of personal accomplishment. However, career dissatisfaction among ob-gyns contributes to decreases in the physician workforce. Improv- ing career satisfaction may retain more physicians who are currently in practice, even those at or near retirement age. Regardless of age and experience, most physicians desire personal appreciation, a comfortable work environment, and some form of professional stimulation. ? Practice Patterns Obstetrician-gynecologists spend much time (50 hours per week on average) per- forming patient care-related activities that are particularly office-based. Over the past decade, several nontraditional formats of obstetric-gynecologic practice have developed. Lifestyle changes and practice preferences were factors in this evolution. The traditional generalist practice will be one of many offered to the ob-gyn in the future. As workforce issues become more critical, collaborative practices will expand as the number of solo practices or two-physician offices decreases. Evolving work patterns will incorporate job sharing, part-time positions, flexible work hours, and closer working relations with large medical centers. Obstetrician- gynecologists will need to acquire improved time and financial management skills. Current survey data of practice patterns indicate that more generalists are referring patients with either high-risk pregnancies or a need for complex gynecologic surgery to other specialists. These changes, driven mostly by lifestyle and medical professional liability concerns, have modified practice patterns. Some physicians will provide gynecologic care only or an office practice with or without ambulatory surgery. Others will focus mostly on obstetrics, including ambulatory, high-risk, and laborist care. Unique or nontraditional models of providing outpatient care that address common needs of patients will continue to evolve. For example, many larger practices are offering more collaborative services, such as skin renewal treatment, treatment of sexual dysfunction, counseling services, and imaging studies (eg, mammography). ? Hours Worked and Flexible Schedules Most spouses or partners of ob-gyns are well-educated professionals with work schedules. The dual-career families of younger physicians contrast with the stay-at-home spouse that more senior male physicians historically relied on. With an increasing number of females practicing obstetrics and gynecology, there will be a greater interest in part-time employment, shortening of long work days, and more extended leave. Concurrent with the desire by some physicians to work part-time is the need for a more flexible lifestyle, regardless of gender. Most ob-gyns are more satisfied when they work closer to their desired number of hours per week in order to better balance their work with their personal lives and any family responsibilities. For example, the introduction of the hospitalist and laborist models to obstetrics demonstrates an ability to create jobs with schedules and incentives that may improve the satisfaction of certain physicians. The strongest correlation with work-life balance is the ability to control scheduling and hours worked, not just total number of hours worked weekly. Data on hours worked by physicians have not been reported by the American Medical Association since 2001 because findings before that time did not suggest any significant shift in hours worked. Subsequently, other than adjusting for changes in the composition of the workforce (eg, accounting for the growing proportion of female physicians and the increase in physician retirements), most workforce projections assume that hours worked by physicians would remain constant. This is now likely to be incorrect. A review of self-reported hours among U.S. physicians using data from the U.S. Census Bureau Current Population Survey between 1976 and 2008 disclosed that physicians decreased their work hours after their residencies by 5.7%. This decrease was greatest among physicians younger than 45 years and those who worked outside the hospital. After adjusting for inflation, physician fees across all specialties decreased nationwide by 25% between 1995 and 2006, coincident with the decrease in work hours. Any desire to work fewer hours may present certain barriers. Coverage from professional liability premiums, medical school debt, income, benefits packages, practice stability, maintaining technical skills, and future professional opportunities must be considered. These potential barriers must be recognized when examining work hours and flexible schedules. Another reason for valuing flexible schedules is the growing volume of reports that document the potential detrimental effects of sleep deprivation. The historical model of care in which most infants are delivered by an obstetrician who provided the mother's prenatal care is much less tenable in a culture focused more on patient safety and on working shifts. A clearer division between inpatient obstetric responsibilities and other professional activities appears to be one of the few plausible solutions. If professional self-regulation of sleep-work hours is not undertaken, government-imposed regulation is likely inevitable. ? Professional Liability Concerns Both professional liability concerns and the practice of defensive medicine are detractors to most ob-gyns. The American College of Obstetricians and Gynecologists (College) has conducted 10 surveys of its membership since 1983 about professional liability. Approximately 90% of all ob-gyns reported in 2006 and 2009 that at least one claim had been filed against them during their careers. Of those groups that experienced claims, 37.3% of physicians in 2006 and 42.8% of physicians in 2009 reported that at least one claim arose out of care rendered during their residency training. Tremendous time and effort are diverted from patient care due to the inefficient, costly, and often unfair liability climate. An individual's reputation can be damaged or destroyed. In particular, ob-gyns are being driven from the specialty when approaching retirement age. According to survey results over the past two decades, the average age at which ob-gyns stopped providing obstetric care was 48 years, which used to be considered a prime time of productivity and income in an obstetrician's career. Furthermore, female ob-gyns are inclined to stop performing deliveries at an earlier age (43 years compared with 51 years in male ob- gyns), which is a major concern for the future. Not surprisingly, ob-gyns report changes in their clinical practice over the years. Cesarean delivery rates continue to increase whereas the number of gynecologic procedures, especially major surgery, has decreased. Sixty percent of respondents to the College's 2009 Survey on Professional Liability made one or more changes in their practice because of the affordability of professional liability insurance, availability of professional liability insurance, or both. It is difficult to be a part-time ob-gyn in most states because malpractice premiums usually are not adjusted to a physician's level of practice volume. Liability insurance policies should be written to facilitate job sharing in obstetrics and gynecology, so that one full-time job equivalent can be subdivided among several physicians. Despite numerous attempts, no meaningful liability reform has been achieved at the national level. Rather than continued political posturing and rhetoric, reform legislation can and will result in a more favorable practice environment. Reasonable compensation for those patients injured by negligence or those with avoidable injury or morbidity is fair, with all funds going to the patient and not to profiteering attorneys. As observed in Texas where tort reform was enacted, premium costs decreased as the number of companies providing liability insurance increased. ? Physician Gender and Practice Satisfaction Both female and male ob-gyns appear to be satisfied with their jobs. Women are more inclined to consider their gender to be an asset in deciding on a career in obstetrics and gynecology, in obtaining employment, and in maintaining their practices. Conversely, men in general are more apt to see limitations in their practice options and less likely to report that they would choose a career in obstetrics and gynecology again. Another difference between male and female ob-gyns in obtaining and maintaining a practice is that men are more likely to practice in small urban or rural settings. Because the percentage of men entering residency programs in obstetrics ad gynecology remains much lower than previously reported, the number of men entering the general obstetric-gynecologic workforce may decrease further or remain low. ? Retirement Currently, the average age of an actively practicing ob-gyn is 51 years. This age is similar to physicians in other medical and surgical specialties. However, nearly two thirds of ob-gyns aged 50 years or older wish to retire early. Increasing professional liability insurance costs, insufficient net compensation, and stresses of practice are factors that especially influence ob-gyns when considering retirement. Currently, slightly more than one in three physicians is older than 55 years (more than 15,000 active ob-gyns) and will likely retire in 10 years. The percentage of College Fellows aged 55-65 years has increased from 19% in 2002, to 26% in 2005, and 27% in 2010. The number of ob-gyns reaching retirement age is approaching the number of those com- pleting residency training each year. The anticipated and actual ages of retirement are often not the same. Obstetrician-gynecologists approaching retirement age are more likely to work less, which, although counterintuitive, will help the physician workforce rather than harming it. This is not only because part-time ob-gyns older than 50 years are more satisfied than their full-time counterparts, but those who have the option to work part-time are more inclined to remain active in medicine longer. Implications The anticipated reduced accessibility to physicians in women's health care is not merely from the increasing demand for medical services and the aging physician population, but also because less satisfied ob-gyns are more likely to restrict services or retire early and new ob-gyns wish to work fewer hours. Many factors that younger physicians consider to be important, such as work-life balance with flexible schedules, also keep more senior ob-gyns in the workforce longer. Offering part-time work opportunities with job sharing and reducing liability concerns should improve career satisfaction. Research activities and policies aimed to increase physician satisfaction are necessary to prevent early retirement or otherwise diminish patient access to the obstetrician- gynecologist workforce. Bibliography Anderson BL, Hale RW, Salsberg E, Schulkin J. Outlook for the future of the obstetrician-gynecologist workforce. Am J Obstet Gynecol 2008;199:88.e1-88.e8. Association of American Medical Colleges. Recent studies and reports on physician shortages in the U.S. Washington, DC: AAMC; 2009. Available at: https://www.aamc.org/download/100598/data/ recentworkforcestudiesnov09.pdf. Retrieved April 12, 2011. Bettes BA, Chalas E, Coleman VH, Schulkin J. Heavier workload, less personal control: impact of delivery on obstetrician-gynecologists' career satisfaction. Am J Obstet Gynecol 2004;190:851-7. Bettes BA, Strunk AL, Coleman VH, Schulkin J. Professional liability and other career pressures: impact on obstetrician/gynecologists' career satisfaction. Obstet Gynecol 2004;103:967-73. Clark SL. Sleep deprivation: implication for obstetric practice in the United States. Am J Obstet Gynecol 2009;201:136.e1-136.e4. Funk C, Anderson BL, Schulkin J, Weinstein L. Survey of obstetric and gynecologic hospitalists and laborists. Am J Obstet Gynecol 2010;203:177e1-177.e4. Keeton K, Fenner DE, Johnson TR, Hayward RA. Predictors of physician career satisfaction, work-life balance, and burnout. Obstet Gynecol 2007;109:949-55. Klagholz J, Strunk AL. Overview of the 2009 ACOG survey on professional liability (electronic). Washington, DC: Amerian College of Obstetricians and Gynecologists; 2009. p. 1-6. Available at: http:// www.acog.org/departments/professionalliability/2009PLSurveyNational.pdf. Retrieved October 5, 2010. Klagholz J, Strunk AL. Overview of the 2009 ACOG survey on professional liability. ACOG Clin Review 2009;14(6):1, 13-6. Phelan S. Generational issues in the ob-gyn workplace: "Marcus Welby, Md," versus "Scrubs". Obstet Gynecol 2010;116:568-9. Robinson P, Xu X, Keeton K, Fenner D, Johnson TR, Ransom S. The impact of medical legal risk on obstetrician-gynecologist supply. Obstet Gynecol 2005;105:1296-302. Staiger DO, Auerbach DI, Buerhaus PI. Trends in the work hours of physicians in the United States. JAMA 2010;303:747-53. Weinstein L, Wolfe HM. The downward spiral of physician satisfaction: an attempt to avert a crisis within the medical profession. Obstet Gynecol 2007;109:1181-3.The following tables and figures provide data related to the career satisfaction of obstetrician-gynecologists and its impact on the workforce. Table 7-1. Hours Worked per Week by Obstetrician-Gynecologists in Professional Activities Survey Year 1991 1994 1998 2003 2008 Office hours (seeing patients) 24.0 24.8 26.5 26.6 26.6 Operating room for labor and delivery 14.2 15.7 15.2 14.3 13.1 Hospital rounds 4.7 4.0 3.7 3.5 3.4 Outpatient clinic or emergency room 1.8 2.6 2.2 2.0 2.0 House calls or seeing patients in nursing home 0.1 0.1 0.2 0.1 0.3 Telephone calls, interpreting test results, correspondence, etc. 4.3 4.2 4.0 3.6 3.5 All patient care activities 49.2 51.3 51.8 50.1 48.5 Administrative activities No data 15.5 13.8 13.1 No data Total professional activities No data 66.1 65.5 62.0 No dataTable 7-2. Distribution of Major Professional Activities by SpecialtySpecialty Patient Care Activities (%)* Office-Based Activities (%)† Obstetrics and gynecology 96.9 79.7 Family medicine 96.2 78.9 Pediatrics 94.3 68.8 Internal medicine 93.3 67.4 Psychiatry 92.5 64.8 *Includes office-based practitioners, residents, fellows, and hospital staff †Includes only physicians outside of training who are engaged in seeing patientsTable 7-3. Average Age at Which Fellows of the American College of Obstetricians and Gynecologists Stop Practicing ObstetricsYear All Fellows (Years) Males (Years) Females (Years) 1985 49.4 No data No data 1987 49.3 No data No data 1990 49.8 No data No data 1992 48.9 50.2 39.5 1996 46.6 48.4 39.2 1999 48.2 51.2 40.8 2003 48.0 51.0 42.0 2006 48.0 51.7 43.1 2009 48.0 51.9 43.8 Figure 7-1. Percentage of active female physicians categorized by medical specialty as of 2007. Pediatrics Obstetrics and gynecology Dermatology Psychiatry Internal medicine Pathology Family medicine Neurology Anesthesiology Emergency medicine Radiology Ophthalmology General surgery Otolaryngology Neurosurgery 5.6% 23.2%22.0%21.5%20.8%18.2%13.6%11.2% 32.8%32.2%32.1%31.3% 38.2% 43.2% 55.4%UrologyOrthopedic surgery 4.7%3.6% Average (28.3%) 0 10 20 30 40 50 60 Physicians who are female (%) Table 7-4. Obstetric and Gynecologic Practice Changes as a Result of the Affordability or Availability of Professional Liability Insurance National Rate Practice Changes (%) Obstetrics Decreased number of high-risk obstetric patients 21.4 Increased number of cesarean deliveries 19.5 Stopped offering and performing vaginal births after 19.5 cesarean delivery Gynecology Decreased number of total deliveries 10.4 Stopped practicing obstetrics 6.5 Decreased number of gynecologic surgical procedures 11.0 Stopped performing major gynecologic surgery 4.5 Stopped performing all surgery 1.8 Table 7-5. Distribution of Obstetrician-Gynecologists and All Physicians by Age By Age (%) Total Count Younger Than 35-44 45-54 55-64 65 Years (N) 35 Years Years Years Years and Older Obstetrician-Gynecologists Males 22,937 5.2 16.6 26.9 31.2 20.1 Females 19,698 24.7 29.8 25.3 11.8 3.4 Total 42,631 14.4 25.1 26.2 22.2 12.4 All Physicians Males 677,807 11.2 19.0 22.9 21.2 25.5 Females 276,417 24.6 30.1 24.3 13.4 7.6 Total 954,224 15.1 22.2 23.4 19.0 20.3 Figure 7-2. Percentage of active physicians aged 55 years or older categorized by medical specialty as of 2007. Psychiatry Pathology Urology Orthopedic surgery Radiology General surgery Otolaryngology Neurology Ophthalmology Neurosurgery Dermatology Obstetrics and gynecology Family medicine Pediatrics Anesthesiology 47.7%46.0%44.0%42.4%41.5%41.5%41.3%41.3%40.6%38.5%36.7%33.6%33.4% 54.5%52.8%Internal medicineEmergency medicine 32.3%30.0% Average (37.6%)0 10 20 30 40 50 60 Physicians aged 55 years and older (%) Figure 7-3. Fellows of the American College of Obstetricians and Gynecologists aged 55 years or older.55-65 Years 40 55 Years or older35302520151050 2002 2005 2010 Year of survey 8 transforming the women's health Care workforCe In light of relatively fewer physicians pursuing office-based primary care, it is logical to assume that the future clinical load may increase for obstetrician-gynecologists (ob-gyns). Many experts suggest that the solution to the decreasing interest in primary health care in adults involves increased reimbursement. In the face of looming budget shortages, funding for additional health care expenses seems to be unlikely in the near future. Transforming the women's health care workforce will entail more teamwork and the addition of nonphysician clinicians to the workforce in obstetrics and gynecology. Advanced practice nurses, such as certified nurse-midwives (CNMs) and nurse practitioners (NPs), and physician assistants (PAs) can perform clinical tasks and assist at surgery. Their emergence as a strong presence in the workforce grew out of the market reconfiguration in the 1980's produced by managed health care. These providers can handle a fair portion of independent care, and they must be considered in any reshaping or forecasts of the medical workforce. ? Certified Nurse-Midwives To become a CNM requires 2 years of masters' level training after obtaining a Bachelor of Science degree. The number of education programs for CNMs has decreased from a high of 50 accredited programs in 1997 to the current 39 programs. Tracking the number of active CNMs has been reasonably accurate. The ratio of CNMs to certified ob-gyns is approximately 1:7. There are 11,546 CNMs in the United States and 97% attend deliveries in hospital settings. Approximately 7.4% of all deliveries in the United States and 10.8% of all vaginal deliveries are attended by CNMs. This 2006 national rate of attending deliveries represents a double of the 1990 rate (3.6%). Fourteen states recorded 10% or more of all deliveries being attended by CNMs, led by New Mexico (29%), Vermont (18%), Georgia (16%), New Hampshire (16%), and Oregon (15%). States with the greatest increase in deliveries by CNMs from 1990 to 2006 were New Mexico (from 11% to 29%), West Virginia (from 1% to 14%), New Hampshire (from 6% to 16%), Vermont (from 8% to 18%), and Maine (from 5% to 14%). ? Certified Nurse Practitioners and Physician Assistants Certified nurse practitioners (NPs) and physician assistants (PAs) are filling more of the gap in the physician workforce, especially in primary care. The numbers of PAs and NPs have especially exploded since the early 1990s. There were 18 physicians for every NP and 28 physicians for every PA in 1990. Based on the forecasts for the number of primary care physicians by the year 2015, there may be 5.4 physicians for every NP and 9.3 for every PA. The proportion of NPs and PAs who work for ob-gyns is currently unknown but thought to be low. Nurse practitioners or "advanced practice nurses" perform two roles, that of a nurse and that of a primary care provider. Students enrolled in NP programs undergo 2 years of additional masters' level nurse training to acquire fundamental skills as clinical practitioners. Traditional nursing roles focus on establishing diagnoses and drug therapy, along with complementary services that require more time, such as counseling, medical education, self-care training, disease prevention, diet, exercise, and so forth. In contrast, PA students often are trained in similar classes as medical students. Graduates can perform practically any task a physician delegates to them, except as restricted by hospital privileges and state laws. Research results indicate that NPs and PAs are capable of establishing many more diagnoses seen in outpatient primary care settings than they are credited for and that patient acceptance of such practitioners is high. Analyses of data also have found that the cost of employing a nonphysician clinician ranges from 30% to 40% of the cost of employing a physician. Most NPs and PAs are trained in primary care, yet higher salaries are attracting more of these professionals into medical and surgical specialties. Currently, NPs are authorized to prescribe medications in all states, but there is considerable variation as to the extent of their authority. Nonetheless, work responsibilities of NPs in some areas closely parallel those of primary care physicians. Although NPs have lobbied for and slowly gained the right to practice primary care independently, it is likely that most will continue working under physician supervision. The potential exists for nonphysician clinicians to work in underserved areas. In one half of the states, NPs do not have to be supervised by physicians. Although PAs must be supervised by a physician, they do not have to practice at the same site. Various states have different methods of reimbursing NPs and PAs; each has its own licensing board, Medicaid requirements, payment arrangements, and laws governing their practice. ? Re-entry of Obstetrician-Gynecologists Into the Workforce Being away from practicing medicine can leave a physician with knowledge and skill deficits. The American College of Obstetricians and Gynecologists (the College) established a task force to study interruptions of career or restrictions on the scope of practice that affect its membership. Reasons for interruptions include childbearing or child care, medical illness, caring for a sick or aged family member, military service, and acceptance of a nonclinical position or other significant career move. If not actively practicing for 2 years or more, these physicians may find it difficult, if not impossible, to return to practice. The College's Task Force on Re-entry estimates that there could be several hundred inactive but eligible ob-gyns. If a mechanism was developed to facilitate the re-entry of those physicians into the workforce, both the public and the profession may be better served. Challenges in constructing a 3-month re-entry program include determining which candidates are appropriate, assessing the needs of the re-trainee, individualizing the curriculum based on those needs, obtaining a commitment to their training by faculty and residents, and evaluating the trainee's progress and success in completing of the program. A model could be adopted by any teaching center in any state that has experienced educators and a surplus of clinical cases available for re-trainees. ? Advanced Obstetrics Training in Family Medicine Results from the American Medical Association's Socioeconomic Survey in the 1980s and 1990s indicated that 13% of all deliveries in the United States are performed by family practitioners or general practitioners. More recent experience has not been reported. Family physicians often are the only physicians accessible for patients in underserved communities, and these physicians may need to have advanced procedural skills or knowledge about management of certain high-risk pregnancies. Maternal-child health fellowships were initially developed for family physicians to be more competent with skills to deliver pregnancy care to patients in areas where obstetricians are unavailable. The first formal fellowship for advanced obstetrics began in the mid-1980s. Approximately 24 maternal-child health fellowships now offer family physicians additional, usually 2-year, training in performing procedures, such as cesarean delivery, operative vaginal delivery, postpartum tubal ligation, colposcopy, obstetric ultrasonography, and dilation and curettage. Working in a rural setting or performing greater than 50 cesarean deliveries during fellowship training is associated with a greater likelihood for that physician of obtaining privileges to perform cesarean deliveries. ? Other Workforce Considerations Other issues affecting the ob-gyn workforce are nonphysician staffing and specialized training of primary care physicians in areas of obstetrics and gynecology. The role of such providers requires consideration when examining expanded roles of ob-gyns in the future. Additional Office Assistants There appears to be an upward trend in the number of office assistants per physician. Nonphysician workers, such as secretaries, nurses, medical assistants, and technicians, can help relieve ob-gyns of the mounting burden of nonclinical duties so that the ob-gyns can focus on tasks that require their clinical expertise. The cost of this shift in nonclinical responsibilities to others contributes to ob-gyns' net incomes remaining relatively constant in recent years. Women's Health Training Programs in Internal Medicine A small number of internal medicine training programs allow residents to conduct didactic sessions and attend clinics supervised by gynecologists. Such training also may include medical consultation clinics dedicated to evaluating women for preoperative conditions. Blocks of time often are devoted to such women's health issues as breast disease, urogynecology, abnormal cervical cytology, sexually transmitted infections, contraception, and emotional difficulties during pregnancy and the postpartum period. Thus, general internal medicine graduates attending such programs will have more expertise in women's general outpatient and reproductive health care. Although there is no special degree awarded, a certificate acknowledging their participation is given at graduation. Certified Professional Midwife The number of certified professional midwives is much lower than that of CNMs. Certified professional midwives may or may not attend a formal midwifery education program. Often they learn as apprentices and take a national board examination administered by their professional organization. Although the College supports women having a choice in selecting their providers of care and site of delivery, the College does not support the provision of care by licensed midwives or other midwives who are not certified by the American Midwifery Certification Board (AMCB). Furthermore, the College does not support individuals who advocate for or who provide home births. Locum Tenens Many ob-gyns have travelled to work short-term at a variety of practice sites with either temporary or long-term workforce shortages. No data are available to track the extent of this practice in addressing workforce shortages. Implications Leaders representing the ob-gyn workforce need to build a workforce to meet women's expanding health care needs. Merely enlarging the supply of ob-gyns is unlikely to meet this demand. A sustainable practice model of physician-led collaborative care has undergone visible change in recent years with the emergence of qualified nonphysician clinicians whose new roles developed in response to the needs for better distribution of health care and improvements in quality of primary care. Their utility and impact on health care costs probably will require the financial support of federal, state, and private payers and ob-gyns themselves. Examining the numbers of nonphysician clinicians being trained and their sites of practice in women's health care will gain greater interest. Retraining ob-gyns who wish to re-enter the workforce as well as general internists or family physicians with special interests in women's health care deserves closer attention and support when appropriate. Bibliography Adams KE, Allen R, Cain JM. Physician reentry: a concept whose time has come. Obstet Gynecol 2008;111:1195-8. American College of Obstetricians and Gynecologists. Midwifery education and certification. ACOG Statement of Policy 82. Washington, DC: ACOG; 2007. Boulis AK, Jacobs JA. The changing face of medicine: women doctors and the evolution of health care in America. Ithaca (NY): Cornell University Press; 2008. Chang Pecci C, Leeman L, Wilkinson J. Family medicine obstetrics fellowship graduates: training and post-fellowship experience. Fam Med 2008;40:326-32. Declercq E. Births attended by certified nurse-midwives in the United States reach an all-time high: trends from 1989 to 2006. J Midwifery Womens Health 2009;54:263-5. Scheffler RM. Reshaping the workforce: nurse practitioners and physician assistants. Is there a doctor in the house? Market signals and tomorrow's supply of doctors. Stanford (CA): Stanford University Press; 2008. p. 53-63.The following tables and figures provide data related to transforming the women's health care workforce. Table 8-1. Estimated Numbers of Training Programs and Practitioners in Various Nonphysician Clinical Specialties Training Programs Estimated Number of Types of Nonphysician in the Nonphysician Practitioners United States (N) Practitioners (N) Certified nurse-midwives 38 11,546 Nurse practitioners 350 135,000 Physician assistants 140 85,345Figure 8-1. Percentage of live births in the United States attended by certified nurse-midwives. 1210864 All births Vaginal births 2 Year of survey Figure 8-2. Births attended by certified nurse-midwives in 2006 categorized by state. Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming 0 5,000 10,000 15,000 20,000 25,000 30,000 35,000 40,000 45,000 50,000 Number of births Table 8-2. Place of Delivery and Number of Live Births by Attendant in the United States in 2007 Physician Doctor Doctor of of Place of delivery All births Medicine Osteopathy Midwife Certified Nurse- Other Midwife Midwife Other* Unspecified In hospital 4,275,762 3,726,278 214,634 305,791 9,079 18,506 1,480 Not in hospital 40,224 2,875 354 Freestanding 10,817 656 151 birthing center Clinic or 424 271 14 doctor's office Residence 26,667 1,409 168 Other 2,316 539 21 10,971 14,862 10,274 888 6,195 3,466 328 21 52 19 65 3 4,548 11,179 8,708 655 176 198 1,173 209 Unspecified 247 46 7 49 8 84 53 Total 4,316,233 3,729,199 214,995 316,811 23,943 28,864 2,421 *"Other" refers to another professional, such as paramedic, police officer, or nurse. Table 8-3. National Trends in the Numbers of Nurse Practitioners and Physician Assistants Numbers by Years 1990 1995 2000 2005 2010 2015 NPs 29,000 58,000 88,186 115,000 142,500 170,000 PAs 19,000 32,156 45,311 62,000 81,000 100,000 NPs and PAs 48,000 90,156 133,497 177,000 223,500 270,000 Physicians 532,638 617,362 717,898 802,300 887,300 926,000 Number of Physicians per NP 18.4 10.6 8.1 7.0 6.2 5.4 Number of Physicians per PA 28.0 19.2 15.8 12.9 11.0 9.3 Number of Physicians per NP or PA 11.1 6.8 5.4 4.5 4.0 3.4 Abbreviations: NP indicates nurse practitioner; PA, physician assistant. Table 8-4. Trends in Average Net Incomes of Nurse Practitioners and Physician Assistants Compared With Physicians' Incomes 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 All Physicians $216,508 $210,366 $214,961 $219,556 $213,094 $206,632 $206,186 $205,740 $206,128 No data PAs No data No data $74,035 $75,219 $74,481 $77,288 $75,425 $75,780 $75,855 $78,064 Percentage of Physician's Income No data No data 34.4% 34.4% 34.3% 35.0% 37.4% 36.6% 36.8% No data NPs $63,205 $63,433 $70,288 $67,361 $70,270 $70,349 $67,451 $68,897 $69,433 $73,034 Percentage of Physician's Income 29.2% 30.2% 32.7% 30.7% 33.0% 34.0% 32.7% 33.5% 33.7% No data Abbreviations: NP indicates nurse practitioner; PA, physician assistant.Table 8-5. Procedures Performed by 165 Graduates From Family Medicine-Obstetrics and Maternal-Child Health Fellowship Programs Types of Procedures Performed During Fellowship Graduates (%) Postpartum tubal ligation 90.9 Basic ultrasound examination 89.7 Dilation and curettage 83.6 Colposcopy 77.0 Complete obstetric ultrasound examination 58.2 Hysterectomy 35.2 Bowel or bladder repair 27.3 Abortion 10.9 Cesarean delivery (N) 0-50 19.4 51-75 18.1 76-100 27.7 101-125 11.6 126-150 12.9 Greater than 150 10.39 workforCe ProjeCtions of obstetriCian- gyneCologists in the United states An adequate supply of obstetrician-gynecologists (ob-gyns) is needed to better ensure access for women to health care. For the past three decades, the number of U.S. medical school graduates has remained relatively constant after rapid growth between the 1960s and the 1980s. The physician workforce is aging, the average number of hours worked is decreasing compared with historical levels, and a large number of physicians is approaching retirement age. As a result, the physician-to-population ratio is expected to decrease. However, growth and aging of the U.S. population, advances in medical technology, and a probable greater public demand will contribute to an expanding need for health care services. Simply educating more students and resident physicians will not address the shortage in the physician workforce. Practice-based changes, such as improving efficiency, reconfiguring the way certain services are delivered, selectively hiring more nonphysician clinicians, and making better use of our current ob-gyns and future graduates will be needed. ? Projected Supply of Obstetrician-Gynecologists Several algorithms or models have been described for assessing physician supply. They include, but are not limited, to the following models: o Cooper's Trend Analysis o The Work-Per-Capita Analysis o Simplified Population Growth Analysis o The Physicians Supply Model and Physicians Requirement Model Population growth projections have a lower margin of error, and physician-to-population ratios with fairly standard terms of practice seem to be a better foundation on which to base calculations. The future supply of any workforce is determined by the current and new ob-gyns and the number of ob-gyns exiting the workforce (by death or retirement). Key measures to project the future supply include the current total active ob-gyns, ob-gyn-to-adult women population ratio, physician gender and age, and geography. The best combined data are available from surveys of the American Congress of Obstetricians and Gynecologists, U.S. Census Bureau, and the U.S. Bureau of Labor Statistics. Other publicly available supply data sources can be obtained from the Center for Workforce Sources at the Association of American Medical Colleges (AAMC). The American Medical Association's masterfile and Physicians Characteristics and Distribution in the United States provide data every 3 years about physicians according to their specialty and location (by zip code). The consistent format of tables allows for trend analyses dating back to the 1980s (except for osteopathic physicians who began to be reported in the 2008 edition of the report). These registries of physicians were not intended for research purposes, so certain limitations must be accepted. For example, the registries do not distinguish generalist obstetricians from subspecialists, nor is it clear from the data whether the ob-gyn is truly active in direct patient care or is working full-time. The American Medical Association's masterfile includes data about physicians who retire between mailings of the survey and may falsely include physicians who are no longer active. Analyzing the data from any registry often requires specialized skills. The counts of ob-gyns will vary according to their background (all, active, active excluding residents or fellows or active in direct patient care, and being board certified). ? Projected Demand for Obstetrician-Gynecologists Demand for physicians often is hard to determine because it is perceived differently by providers and by patients. Unlike calculating physician supply, projecting demands for physicians is much more difficult and more open to error. Demand would be defined as the products of the size of population, general health, and historical use of certain services. The population would be reflected by the number of persons and their age, gender, race, and location distributions. Health factors encompass the prevalence and incidence of conditions and diseases that result from the public health and prevention measures, environment, income level, lifestyle, and epidemics. As an example, the U.S. National Center for Health Statistics reported that the U.S. birth rate decreased for the second year in a row and is the lowest in a century. This situation is a striking turnaround from 2007, when more infants were born in the United States than any other year. Sources of data in calculating demand about populations are available from the U.S. Census Bureau and the National Vital Statistics System. Utilization and health characteristic data may be obtained from the National Center for Health Statistics and Agency for Healthcare Research and Quality, whereas data about physician hours worked and income may be obtained from the U.S. Bureau of Labor Statistics. Each of these sources is publicly available, along with resources of the AAMC Center for Workforce Studies. It should be noted that time lags in available data and information about race or ethnicity are not always available. Data-driven measures about demand would include the number of office visits for a given population, ease of getting an appointment, cost barriers, emergency department visits for a certain condition, and slots for new patients. In addition to these resources, examining experience from recruiting firms may be helpful, especially if it is collective experience from a combination of agencies. An example of measuring trends in demand was a study in which 10-20 obstetric-gynecologic offices were called at random in 15 metropolitan areas to deter- mine the first available time for a nonemergent well-woman gynecologic examination. The average time for the first appointment increased from 23.3 days in 2004 to 27.5 days in 2009. The percentage of offices that accepted Medicaid coverage decreased from 60% in 2004 to 41% in 2009. ? Projected Shortages of Obstetrician-Gynecologists The adult female population is projected to be 157 million in 2010, 170 million in 2020, and 213 million in 2050. The reported ob-gyns-to-women population ratio has remained fairly stable during the past two decades at 27 ob-gyns per 100,000 adult women. It also seems fair to assume that the number of U.S. medical graduates electing to pursue residencies in obstetrics and gynecology will remain at approximately 5.9% of all students and that the number of graduates from these residencies will remain at approximately 1,200 each year. Estimating a shortage of physicians involves deducting the grand total of practicing physicians from the number of physicians needed for any year. To estimate the percentage of shortage, the number for shortage is divided by the number of physicians needed and the result is multiplied by 100. Like all other models, this formula relies on many assumptions, any one of which, if altered significantly, would result in widely divergent findings. According to physician-to-population calculations in one study with no increase in the number of graduates, the anticipated shortage of ob-gyns based on 35 years of anticipated practice after graduation from residency will be 18% (approximately 9,000) by 2030 and 25% (15,723) by 2050. On examining projections based on 30 years of clinical practice, the authors of the study projected a shortage of ob-gyns to be 25% by 2030 and 35% by 2050. This shortage projection, resulting from a briefer overall clinical practice period, may be more realistic because the increasing number and proportions of ob-gyns who are women will represent more physicians who wish to take off more time during their childbearing years or have a greater interest in working shortened weeks than they do currently. ? Trends That Affect Physician Workforce Projections All projection models are simplified versions of a complex health care system that generalize the multitude of decisions made by physicians, patients, insurers, and other entities. Probabil- ities that certain events will occur are based on historical patterns of behavior and on assump- tions for the future. Current issues affecting physician workforce supply and demand were reported by the Bureau of Health Professions of the Health Resources and Services Adminis- tration in December 2008. The following findings from that report especially apply to ob-gyns: o Demographics of the U.S. population are changing. The U.S. population is growing, aging, and becoming more racially and ethnically diverse, which will be important when selecting and training residents. o Women are living longer lives. Their mean age is older than that of men (80.4 years for women versus 75.2 years for men), with a higher percentage being older than 65 years (20% for women versus 17% for men). The elderly population represents the fastest growing age group of women now and in the future. Whether ob-gyns will play more of a role is currently unclear. o Demographics of ob-gyns are changing. The physician workforce is aging, and a growing proportion of physicians have been and will be female. o Costs of government programs for the elderly are increasing. The needs of the aging population will place increasing financial pressure on state and federal government retirement plans and on social programs that serve the elderly (eg, Medicare and Social Security). o Cost consciousness has increased. Increasing health care costs are spurring efforts by insurers to find new ways to contain costs. o Economic growth is not constant. Any increase (or decrease) in prosperity has the potential to increase (or decrease) public expectations and demand for physician services. o Health care specialties, including nonphysician clinicians, have proliferated. This growth provides patients with a broader range of health care services than before and may increase competition between practices. o Scientific and technological advances are ongoing. Technological breakthroughs continue to change both demand for health care services and the way in which these services are delivered.? Complexities Determining Demand for Obstetrician- Gynecologists Difficulties in projecting the "correct" number of ob-gyns often relate to inaccuracies in deter- mining demand. The AAMC's The Complexities of Physician Supply and Demand: Projections Through 2025 reports on the difficulties in projecting the number of physicians being required. Described as follows were their findings that affect workforce projections of ob-gyns: o The nation is likely to experience a shortage of physicians that will increase over time. o Although the supply of physicians is projected to increase modestly between 2011 and 2025, the demand is projected to increase even more sharply. o Aging of the population may drive the demand sharply upward for those obstetric- gynecologic subspecialties that predominantly serve the elderly women (eg, gynecologic oncology, female pelvic medicine, and reconstructive surgery) rather than general obsterics and gynecology. o The U.S. Census Bureau projects that the U.S. population will increase by more than 50 million (to a total of 350 million) between 2006 and 2025. This increase alone will lead to an increase in the demand for women's health care services. o Increase in future demand could double if visit rates by age continue to increase at the same pace that were seen in recent years. o Health care reform will result in 32 million young Americans being newly insured, which will add to overall demand for physicians. o Productivity improvements in health care have been hard to achieve because health care has become more complex. Even a modest increase in physician productivity could alleviate the projected gap between physician supply and demand. o Future demand for physicians could be significantly reduced if nonphysician clinicians play a greater role in patient care. o Even a robust expansion of residency capacity in obstetrics and gynecology (eg, a 15% increase from 1,200 first-year residents per year to 1,380 first-year residents per year) would only reduce the projected baseline shortage. o Shortages are likely to be manifested in a number of subtle ways, such as longer waiting times for appointments, increased travel distances to gain access to health care, shorter visit times with ob-gyns, expanded use of nonphysician clinicians, and higher fees. o The status of planned retirements of physicians is difficult to study because retirement depends on what individuals believe that they will do in the future. o Any future shortages are likely to have an uneven effect; some geographic areas and subpopulations may be affected more than others. Hardships for both poor urban and rural communities, where access to routine outpatient care is problematic, will continue. o In reducing the projected shortage, the increase in the supply of ob-gyns should be accom- panied by other actions, such as improvements in the delivery of physician services. o Concerns with the supply of adult primary health care physicians (eg, family physicians, general internists, or geriatricians) that many already believe to be insufficient are likely to intensify as demand outpaces supply faster for those physician groups than for any other physician group. This effect will undoubtedly have some impact on ob-gyns.? Strategies to Reduce Shortage Projections There is little doubt that health care delivery to women will change. Unclear projected shortages of ob-gyns to meet patient demands will require strategies to reduce this shortfall. Suggested strategies are listed as follows wherein more specific objectives can be formulated: o Encourage more medical students to pursue careers in the dynamic field of obstetrics and gynecology. o Continue to promote selective increases in residency slots, especially at programs in states with underrepresentation of ob-gyns or with anticipated continued population growth. o Promote efforts to improve training and use of nonphysician clinicians. o Anticipate that loan repayment programs and other efforts to attract physicians to areas that have a shortage of health care providers will gain more visibility and relative importance. o Recognize and address physician lifestyle concerns (both for men and women), such as flexible scheduling and part-time work. o Acknowledge the fact that decisions by the increasing number of physicians older than 55 years regarding retirement will have an enormous impact on the physician supply. o Improve data collection regarding the supply of ob-gyns and begin to prepare the workforce regarding collaboration with other health care professional organizations. The federal government, which already plays a great role in the health care system, will exert more influence than before as the principle insurer, subsidizer of physician training, and guardian for access to health care by underserved populations. State and federal governments often have exerted their influence in attempts to create a coherent local and national health care workforce policy and to improve access to affordable, quality health care.Implications The "correct" number of ob-gyns has not been determined. However, there is mounting evidence about projected shortages and the need for workforce planning. Complexity is the theme that most clearly emerges. Projections of the obstetric-gynecologic workforce are not futile, but can lead to errors if there are incorrect assumptions about supply and demand. Physician demographics, the need for work-life balance, training capacity at all stages of the educational pipeline, the role of nonphysician clinicians, and plans for retirement have direct bearing on the future supply and demand for ob-gyns and their collaborative services. Better planning also needs to factor in more health care providers in the workforce, medical and technical advances, and changing reimbursement systems. The growing shortage projections of certain physician groups, if left unchecked, could impede national health care goals by broadening geographic disparities in the supply of ob-gyns.Bibliography 2009 review of physician and CRNA recruiting incentives. Irving (TX): Merritt Hawkins & Associates; 2009. Available at: http://www.merritthawkins.com/pdf/mha2009incentivesurvey.pdf. Retrieved March 25, 2011. 2009 survey of physician appointment wait times. Irving (TX): Merritt Hawkins and Associates; 2009. Available at: http://www.merritthawkins.com/pdf/mha2009waittimesurvey.pdf. Retrieved February 25, 2011. A profile of older Americans: 2010. Administration on Aging. U.S. Department of Health and Human Services. Washington, DC: Administration on Aging; 2010. p. 1-17. Available at: http://www.aoa.gov/ aoaroot/aging_statistics/Profile/2010/docs/2010profile.pdf. Retrieved February 25, 2011. Association of Academic Health Centers. Out of order out of time: the state of the nation's health workforce. Washington, DC: AAHC; 2008. Available at: http://www.acadhlthctrs.org/policy/AAHC_ OutofTime_4WEB.pdf. Retrieved October 5, 2010. Association of American Medical Colleges. Physician shortages to worsen without increasing residency training. Washington, DC: AAMC; 2010. p. 1-2. Available at: https://www.aamc.org/download/150584/ data/physician_shortages_to_worsen_without_increases_in_residency_tr.pdf. Retrieved February 25, 2011. Bureau of Health Professions. Health Resources and Services Administration. U.S. Department of Health and Human Services. The physician workforce: projections and research into current issues affecting supply and demand. Rockville (MD): USDHHS HRSA BHP; 2008. Available at: ftp://ftp.hrsa.gov/bhpr/ workforce/physicianworkforce.pdf. Retrieved October 5, 2010. Dill MJ, Salsberg ES. The complexities of physician supply and demand: projections through 2025. Washington, DC: Association of American Medical Colleges; 2008. Available at: http://www.tht.org/ education/resources/AAMC.pdf. Retrieved October 5, 2010. Hollmann FW, Mulder TJ, Kallan JE. Methodology and assumption for the population projections of the United States: 1999 to 2100. Population Division Working Paper No. 38. Washington, DC: U.S. Census Bureau; 2000. p. 1-33. Available at: http://www.census.gov/population/www/documentation/twps0038. pdf. Retrieved December 17, 2010. Jacoby I, Meyer GS, Haffner W, Cheng EY, Potter AL, Pearse WH. Modeling the future workforce of obstetrics and gynecology. Obstet Gynecol 1998;92:450-6. Merritt J, Hawkins J, Miller PB. Will the last physician in America please turn off the lights? A look at America's looming doctor shortage. 4th edition. Irving (TX): The MHA Group; 2008. Population Division, U.S. Census Bureau. Table 2: projected population of the United States, by age and sex: 2000 to 2050. U.S. interim projections by age, sex, race, and Hispanic origin. Washington, DC: U.S. Census Bureau; 2004. Available at: http://www.census.gov/population/www/projections/ usinterimproj/. Retrieved February 25, 2011. Population Division, U.S. Census Bureau. State interim population projections by age and sex, 2004- 2030. U.S. population projections. Washington, DC: U.S. Census Bureau; 2004. Available at: http://www. census.gov/population/www/projections/projectionsagesex.html. Retrieved February 25, 2011. Scheffler RM. Is there a doctor in the house? Market signals and tomorrow's supply of doctors. Stanford (CA): Stanford University Press; 2008. Williams TE, Satiani B, Ellison EC. Obstetrics and gynecology. The coming shortage of surgeons: why they are disappearing and what that means for our health. Santa Barbara (CA): ABC-CLIO, LLC; 2009. p. 85-92.The following tables and figures provide data related to workforce projections of obstetrician-gynecologists in the United States. Figure 9-1. Supply projection of obstetrician-gynecologists.3.0 2.9 2.8 2.7 2.6 2.5 2.4 2.3 2.2 2.1 ? 2.0Projections of current policy 10 % decrease in incoming practitioners ? Managed care norm 1997 2000 2005 2010 2015 2020 Year of projectionFigure 9-2. Illustration of methodology to calculate physician supply. Future supply = (current workers + new workers - exiting workers) × efficiencyNumber of workers × Work hours Training slots o Age distribution o Economy o Satisfaction o Structure of work and service delivery o Technology o Gender o Age o Education reimbursement and policy o Pipeline enrollment o Regulations o Payment o Policies Figure 9-3. Projections of the growth of female population by selected age groups in the United States. 90,000 80,000 70,000 60,000 50,000 40,000 30,000 20,000 10,000 060.1 41.523.2 65.9 41.740.7 83.2 5048.6 16-44 years 45-64 years 65 years and older 2010 2020 2030 2040 2050 Year of projection Figure 9-4. Number of the female population in the United States for each age group.0-13 14-24 25-44 32,726,800 28,300,14125,128,410 22,968,09545,397,527 41,109,550 45-64 65 and older Total 41,658,196 41,510,23340,110,755 23,232,589 157,120,608 2010 Projected 2030185,021,688 0 20 40 60 80 100 120 140 160 180 200 Number of females in U.S. population (million) Figure 9-5. Projected change of the female population for each state and in the United States from 2010 to 2030.Nevada Arizona Florida Texas Utah Washington Idaho North Carolina Alaska Oregon Georgia Virginia California Maryland Tennessee Colorado South Carolina New Hampshire United States Minnesota Delaware Arkansas Hawaii Montana Vermont Missouri New Jersey Oklahoma Wisconsin New Mexico Massachusetts Indiana Kentucky Alabama Maine Kansas Connecticut Illinois Mississippi Louisiana Rhode Island Nebraska Michigan Pennsylvania South Dakota Wyoming New York Ohio Iowa North Dakota West Virginia District of Columbia -20 -10 0 10 20 30 40 50 60 70 Change in female population (%) Figure 9-6. Projected births in the United States.6.0 5.5 5.0 4.54.35.7 4.02010 2020 2030 2040 2050 Year of projectionTable 9-1. Ten Most Sought After Physicians by Medical Specialty by a Professional Search Firm Number of Searches per Time Range Medical Specialties 2003-2004 2004-2005 2005-2006 2006-2007 2007-2008 2008-2009 1. Family practice* 165 166 257 303 492 595 2. Internal medicine 124 188 274 273 314 391 3. Hospitalist 82 62 112 194 208 169 4. Radiology 202 218 237 187 109 74 5. Orthopedic surgery 210 210 207 172 145 147 6. Obstetrics and gynecology 103 83 111 159 159 137 7. Cardiology 181 231 174 163 69 103 8. General surgery 112 116 165 121 81 152 9. Emergency medicine 42 47 91 91 90 86 10. Psychiatry 54 80 69 81 106 122 *Includes family practice-obstetrics. Table 9-2. Wait times before next new appointment at obstetric-gynecologic offices for a nonemergent well- woman gynecologic examination. City Year Offices Called (n) Shortest Time to Appointment Longest Time to Appointment Average Time to Appointment Offices Accepting Medicaid (%) Boston, MA 2009 10 14 days 200 days 70 days 77 Boston, MA 2004 16 3 days 126 days 45 days 56 Philadelphia, PA 2009 15 1 day 161 days 46 days 27 Philadelphia, PA 2004 17 8 days 72 days 28 days 24 Houston, TX 2009 20 1 day 137 days 41 days 60 Houston, TX 2004 18 5 days 69 days 20 days 72 Seattle, WA 2009 14 1 day 200 days 39 days 50 Seattle, WA 2004 17 1 day 153 days 26 days 70 San Diego, CA 2009 20 1 day 200 days 35 days 15 San Diego, CA 2004 15 2 days 96 days 31 days 80 Washington, DC 2009 8 6 days 69 days 33 days 38 Washington, DC 2004 20 2 days 22 days 11 days 100 Los Angeles, CA 2009 14 1 day 116 days 26 days 57 Los Angeles, CA 2004 16 1 day 52 days 19 days 69 Miami, FL 2009 18 1 day 60 days 22 days 28 Miami, FL 2004 12 3 days 12 days 10 days 50 Portland, OR 2009 14 1 day 58 days 19 days 42 Portland, OR 2004 20 1 day 79 days 30 days 100 Atlanta, GA 2009 16 1 day 41 days 17 days 62 Atlanta, GA 2004 20 3 days 57 days 24 days 25 Dallas, TX 2009 21 1 day 65 days 17 days 14 Dallas, TX 2004 15 1 day 60 days 17 days 100 Denver, CO 2009 15 5 days 56 days 15 days 33 Denver, CO 2004 20 1 day 33 days 23 days 25 Detroit, MI 2009 14 1 day 50 days 15 days 50 Detroit, MI 2004 20 8 days 90 days 39 days 40 New York, NY 2009 14 1 day 53 days 13 days 14 New York, NY 2004 20 1 day 29 days 14 days 5 Minneapolis, MN 2009 15 1 day 14 days 5 days 47 Minneapolis, MN 2004 15 6 days 61 days 20 days 80 Total 2009 228 2.5 days 98.7 days 27.5 days 41 Total 2004 261 3.0 days 65.1 days 23.3 days 60 Table 9-3. Projections of the Female Population in the United States and for states for 2010 and 2030State Projections for July 1, 2010 (N) Projections for July 1, 2030 (N) Change (%) United States 157,120,608 185,021,688 17.76 Alabama 2,375,889 2,518,723 6.01 Alaska 339,875 436,685 28.48 Arizona 3,312,530 5,304,768 60.14 Arkansas 1,467,519 1,651,413 12.53 California 19,203,649 23,546,338 22.61 Colorado 2,390,397 2,854,289 19.41 Connecticut 1,847,001 1,919,294 3.91 Delaware 457,834 529,623 15.68 District of Columbia 278,088 225,171 -19.03 Florida 9,853,331 14,670,757 48.89 Georgia 4,825,482 6,028,495 24.93 Hawaii 670,778 731,265 9.02 Idaho 756,921 984,371 30.05 Illinois 6,560,599 6,802,537 3.69 Indiana 3,242,671 3,449,462 6.38 Iowa 1,526,761 1,501,383 -1.66 Kansas 1,407,885 1,469,107 4.35 Kentucky 2,166,634 2,301,486 6.22 Louisiana 2,368,411 2,451,331 3.50 Maine 696,749 731,678 5.01 Maryland 3,066,708 3,681,804 20.06 Massachusetts 3,452,656 3,681,975 6.64 Michigan 5,285,228 5,407,445 2.31 Minnesota 2,717,926 3,147,054 15.79 Mississippi 1,526,954 1,581,855 3.60 Missouri 3,031,080 3,291,263 8.58 Montana 486,385 529,956 8.96 Nebraska 893,808 920,290 2.96 Nevada 1,340,801 2,206,668 64.58 New Hamshire 702,433 836,981 19.15 New Jersey 4,629,468 5,023,955 8.52 New Mexico 1,017,712 1,095,979 7.69 New York 10,055,121 10,094,612 0.39 North Carolina 4,738,845 6,162,366 30.04 North Dakota 316,601 299,708 -5.34 Ohio 5,922,900 5,881,244 -0.70 Oklahoma 1,818,911 1,969,896 8.30 Oregon 1,907,039 2,443,602 28.14 Pennsylvania 6,499,185 6,628,373 1.99 Rhode Island 579,618 598,912 3.33 South Carolina 2,218,301 2,647,289 19.34 South Dakota 392,705 399,987 1.85 Tennessee 3,197,502 3,823,319 19.57 (continued) Table 9-3. Projections of the Female Population the United States and for states for 2010 and 2030 (continued)State Projections for July 1, 2010 (N) Projections for July 1, 2030 (N) Change (%) Texas 12,425,412 16,811,762 35.30 Utah 1,294,631 1,732,908 33.85 Vermont 330,474 359,407 8.76 Virginia 4,086,724 5,048,486 23.53 Washington 3,290,031 4,352,210 32.28 West Virginia 933,383 874,289 -6.33 Wisconsin 2,890,861 3,116,305 7.80 Wyoming 259,201 263,612 1.70Table 9-4. Projected Need and Shortage of Obstetrician-Gynecologists in Practice (for Anticipated 30 Years and 35 Years of Practice) Year Projections 2010 2020 2030 2040 2050 U.S. population of women (millions) 157 171 185 200 213 Obstetrician-gynecologists needed (n) 42,547 46,341 50,135 54,200 57,723 35 Years of Practice Obstetrician-gynecologists in practice (n) 39,449 40,299 41,149 42,000 42,000 Shortage (n) 3,098 6,042 8,986 12,200 15,723 (7%) (13%) (18%) (23%) (27%) 30 Years of Practice Obstetrician-gynecologists in practice (n) 38,519 37,509 36,499 36,000 36,000 Shortage (n) 4,023 8,832 13,636 18,200 21,723 (9%) (19%) (27%) (34%) (38%) Figure 9-7. Resident graduates in obstetrics and gynecology per 1,000,000 women, assuming the number of graduates remains constant. 20 19.1 18 16 14 12 10 9.6 8 6 3.9 4 2 0 14.56.72.7 Reproductive- aged women All women Total population 2010 2020 2030 2040 2050 Year of projectionFigure 9-8. Illustration of methodology to calculate physician demand.Demand = population × health × utilization rateso Number o Age o Gender o Race or ethnicity o Location Prevalence and incidence of conditions and diseases o Insurance o Access to health care o Available supply o Organization and efficiency of serviceso Environment o Income o Prevention o Public health measures o Behavior or lifestyle Figure 9-9. Projected shortages in the numbers of obstetrician-gynecologists. 60,000 50,000 40,000 30,0002010 2020 2030 2040 2050 Year of projectionObstetrician- gynecologists needed Supply of obstetrician- gynecologists (35 years of practice) Supply of obstetrician- gynecologists (30 years of practice)10 sUmmary and moving forward The U.S. female population is projected to increase by approximately 36% over the next 40 years, which is a benchmark period for physicians from medical school graduation until a traditional age of retirement. This increase in population will affect the demand for women's health care services. A natural choice to handle this greater demand is by increasing the number of obstetrician-gynecologists (ob-gyns). Obstetrician-gynecologists already provide an important share of maintenance care and subspecialty services to the rapidly increasing elderly female population for gynecologic conditions, as well as many generalist services to younger women. However, current services and training orientation by ob-gyns have largely been specialty-specific. Consequently, the curriculum of training programs in obstetrics and gynecology may undergo a redesign to emphasize generalist services, especially if more health care is to be provided to an expanding outpatient base with relatively fewer adult primary care physicians. ? Medical School Enrollment and Residency Slots in Obstetrics and Gynecology Despite the increase in the U.S. population by 80 million since 1980, the number of U.S. medical graduates has not inreased. The anticipated 30% expansion in U.S. medical school enrollment before 2020 is particularly important in states where the population either has increased or is projected to increase rapidly and where there is a low physician-to-population ratio. This expansion will provide an opportunity to recruit more medical students into obstetrics and gynecology. Strategically changing the processes of medical student and resident selection and altering the design of educational environments could create a workforce of ob-gyns who may be more accountable for coordinating health care and meeting societal needs than before. Expansion in the number of medical schools and class sizes will create impediments for senior students seeking residency positions in obstetrics and gynecology. A select increase in the number of residency slots funded by Medicare is essential to accommodate additional medical school graduates. However, recent economic events have caused the U.S. Congress to question whether the federal government should pay for any extended physician training. Without federal funding, nearly all residency programs could not expand and some may become overwhelmed with patient care services. Expanding the number of residency positions to maintain an ob-gyn-to-adult-female- population ratio is not necessarily the right answer. Selectively increasing funding for graduate medical education and revising accreditation policies should support the goal of eventually producing an obstetric-gynecologic workforce that is better qualified and trained for a transformed practice environment than before. This goal should take into consideration the number of full-time equivalent active physicians in clinical practice, rather than the number of physicians in residency training. Desires of the current generation of students and residents, as well as the diverse health care needs of women, must be continually evaluated as we face an ever-changing landscape in academic medicine. The sizes of academic departments of obstetrics and gynecology will continue to increase with a more diverse faculty and with more faculty working on a part- time basis. Subspecialty care education, although important, decreases time dedicated to the expanding continuum of ambulatory care. This dominance needs reevaluation because most resident graduates will continue their careers in the general practice of obstetrics and gynecology while often creating their own areas of special interests. ? Number of Actively Practicing Obstetrician-Gynecologists Approximately 90-95% of active ob-gyns in the U.S. are members of the American Congress of Obstetricians and Gynecologists, which will continue to be a rich resource of demographic information. Women now represent nearly 80% of all residents in obstetrics and gynecology and almost one half of all active ob-gyns. As the members of the baby boomer generation begin to retire, the percentage of female ob-gyns will increase. Practice sites of ob-gyns will remain unevenly distributed and shortages in many geographic areas may worsen if the number of ob-gyns remains constant (or decreases as these physicians reach retirement age) despite an expanding U.S. population. Obstetrician-gynecologists represent the largest group of active physicians outside the traditional primary care fields-internal medicine, family medicine, and pediatrics. Policies should be implemented to increase the number and proportion of ob-gyns (eg, from approximately 5% to 7-8%) of all physicians. Eventual achievement of this goal should be measured by counting physicians in active practice, rather than students at the beginning of medical training. ? Financial Compensation and Reshaping the Practice Compensation for services of ob-gyns has increased more slowly than that of physicians in many other major medical specialties. Although compensation depends on the type of practice, obstetrics and gynecology is perceived to be less economically viable than other surgical specialties. At the same time, escalating health care expenses require cost containment. Standardizing and streamlining administrative functions between office-based practices and health care plans should reduce expenses and improve physician satisfaction. Use of nonphysician clinicians will gain greater importance yet will require continual review about their roles and financial value. To achieve the desired ratio of actively practicing general ob-gyns per 100,000 women, median incomes must be maintained or preferably increased. Investments in office infrastruc- ture will be needed to deal with an increasing ambulatory care workload and with providing more coordinated care. Payment policies should be modified to support both of these goals. Delayed or reduced accessibility of physicians in women's health care is anticipated in many practices. This projection is not based on merely increasing demand for medical services and the fact that the physician population is aging, but also on the fact that ob-gyns who are less satisfied are more likely to restrict services, work fewer hours, or retire early. Many factors that younger physicians consider to be very important, such as work-life balance and flexible schedules, are the same as those of senior colleagues. Offering part-time work opportunities and reducing liability concerns will foster more career satisfaction. Continued research and policy development intended to increase the career satisfaction of ob-gyns of all ages will remain essential. ? Collaborative Care and Geographic Maldistribution The ob-gyn workforce needs to take into account alternatives to accommodate the increasing number of patients seeking services and to improve effectiveness in delivering health care. A practice model of collaborative care has undergone much change in recent years with the emergence of nonphysician clinicians who can absorb the greater health care needs, as well as provide care that may be less costly. Obstetrician-gynecologists must follow trends in the number of active certified nurse-midwives, nurse practitioners, physician assistants, and primary care physicians receiving additional postgraduate training in women's health care. Retraining ob-gyns who wish to re-enter into the workforce deserves closer attention. There is mounting evidence about projected shortages of physicians and the need for workforce planning in obstetrics and gynecology. Physician demographics, the need for work-life balance, trends in retirement, the role of primary or coordinated care in the health care delivery system, training capacity at all stages of education, roles of nonphysician clinicians, and plans for retirement have a direct bearing on the future supply and demand for ob-gyns and the extent of their services. Better planning needs to factor in more part- time work, medical advances, and changing payment systems. Projected shortages of ob-gyns, if left unchecked, will impede national health care goals. Policies should promote creative innovations in programs that have been proved effective in enhancing more uniform geo- graphic distribution of women's health care services. ? Health Care Reform and Workforce Issues Affordable health care that is in the best interest of patients has been a central theme in recent national health care reform legislation. In 2009, U.S. health care expenditures represented more than 17% of the gross domestic product and are predicted to increase to nearly 20% by 2019. What ails the health care system is especially concerning for women's needs. Nearly one half (47%) of all women in their reproductive years consider their ob-gyns to be their regular physicians. In 2008, 18% of the 95.3 million women aged 18 years to 64 years were uninsured. Medicaid today covers 41% of all U.S. births and 71% of all family planning services. By law, women in all states whose health insurance coverage began after March 2010 are now guaranteed direct access to their ob-gyns. Many elements of the new Patient Protection and Affordable Care Act will establish delivery systems designed to maximize savings and emphasize improved outcomes. To address access to care, the U.S. Congress wants to provide financial assistance to physicians in rural and underserved areas. The geographic practice cost index that was used to adjust for variations in medical practice costs (higher in urban than in rural areas) may be mitigated by the U.S. Congress. This adjustment will benefit ob-gyns in newly designated Frontier States especially in the upper Midwest and intermountain West, in which at least 50% of the counties have less than six inhabitants per square mile. Another theme in health care reform is the U.S. Congress' interest in experimenting with theoretically more efficient practice models. Under this scenario, the physician workforce and interdisciplinary teams will be organized into larger groups or employed by hospitals to establish accountable care organizations, with more sophisticated health information technology and more visible and advanced management. This effort would lead to the creation of patient-centered medical homes, particularly for those patients enrolled in Medicare and Medicaid programs. A new National Center for Health Workforce Analysis will collect statistical information and provide reports to the U.S. Congress. These analyses will guide the U.S. Congress on how to best align federal health care workforce resources with national needs. By April 1, 2011, a National Health Care Workforce Commission that is separate from the National Center for Health Workforce Analysis, also will advise the U.S. Congress about ways to align Medicare and Medicaid graduate medical education policies with national workforce goals. The U.S. Congress provided $25 million in 2010 and pledged to appropriate $50 million in 2011 and 2012 for new and expanded primary care residency programs at teaching hospitals. Residency programs in obstetrics and gynecology are eligible to receive grant funds for up to $500,000 for over 3 years each.Conclusions The role of the ob-gyn as a data-driven physician providing preventive services for women and as a coordinator of health care makes this specialty unique among surgical disciplines. The role of an ob-gyn has evolved into that of an elite provider of women's health care. The specialty will continue to adapt and grow, with health care system reform being another step in its evolutionary process. Continuous monitoring of workforce needs is essential to providing sufficient numbers of qualified teams, led by ob-gyns, dedicated to delivering sustained and valued health care for all women.Bibliography Rovner J. Health care policy and politics A to Z. 3rd ed. Washington, D.C.: CQ Press; 2009. aPPendix aDefinitions* Active physicians: Physicians who report working in administration, direct patient health care, medical research, or other nonpatient health care activities. Physicians whose major professional activity is unclassified also are considered active. Excluded are physicians in training (residents and fellows) and those who are retired, semi-retired, temporarily not in practice, or not active for other reasons. Active patient care physicians: This group is a subset of active physicians. It comprises only those physicians whose self-reported type of practice is direct patient health care. Doctors of Osteopathy: Physicians who received their Doctor of Osteopathy degrees from U.S. osteopathic schools accredited by the American Osteopathic Association. Fellows†: Physicians whose professional activities are devoted to the practice of obstetrics, gynecology, or both. Practicing board certified ob-gyns in the geographic confines of the American Congress of Obstetricians and Gynecologists may apply for membership under this category. Hospital-based practice: Medical practice arrangement in which physicians, including residents, fellows, and staff physicians, are employed under contract with hospitals to provide direct patient care. International medical graduates: Individuals who graduated from a medical school outside of the United States, Puerto Rico, or Canada. Often they include U.S. citizens. To be eligible for licensure and practice in the United States, all international medical graduates must be certified by the Educational Commission for Foreign Medical Graduates and have completed a residency training program in the United States. Junior Fellows†: Residents in obstetrics and gynecology in an approved program in the United States or Canada, recent graduates of an approved program, or residents in obstetrics and gyne- cology in Mexico, Central America, Argentina, Dominican Republic, Chile, or the West Indies. Medical school: A school that confers the Doctor of Medicine degree and is accredited by the Liaison Committee on Medical Education. Metropolitan: A statistical area containing at least one urban area of 50,000 or more inhabitants. Micropolitan: A statistical area with at least one urban area with a population between 10,000 and 50,000. Office-based patient practice: Medical practice arrangement in which physicians are engaged in seeing patients at an office. Osteopathic school: A school that confers the Doctor of Osteopathy degree and is accredited by the American Osteopathic Association. Primary care physicians: Physicians whose self-designated primary specialty is adolescent medicine, family medicine, general practice, geriatric medicine, internal medicine, internal medicine and pediatrics, or pediatrics. Residents and fellows are counted as primary care residents and primary care fellows if they practice adolescent medicine (pediatrics), family medicine, geriatric medicine (family medicine), geriatric medicine (internal medicine), geriatric medicine and family practice, geriatric medicine and internal medicine, internal medicine, internal medicine and family practice, internal medicine and pediatrics, internal medicine and preventive medicine, or pediatrics. Reproductive age‡: Age of a women between 16 years and 44 years old based on fertility rates. Residents: Physicians who have completed undergraduate medical education and are at any level of training in a program accredited by the Accreditation Council of Graduate Medical Education or the American Osteopathic Association. U. S. medical doctors: Physicians who received their Doctor of Medicine degree from a medical school in the United States or Puerto Rico accredited by the Liaison Committee on Medical Education. Graduates of Canadian medical schools are not considered U. S. medical doctors. Woman§: A female person aged 18 years or older. *Unless otherwise indicated, the definitions are reprinted with permission from Association of American Medical Colleges. 2009 state physician workforce data book. Center for Worforce Studies. Washington, DC: AAMC; 2009. Available at: https://www.aamc.org/download/47340/data/statedata2009.pdf. Retrieved February 2, 2011. © 2009 Association of American Medical Colleges. All rights reserved. Reproduced with permission. †Modified from American Congress of Obstetricians and Gynecologists. Membership information and applications: membership categories. Washington, DC: American College of Obstetricians and Gynecologists; 2011. Available at http://www.acog.org/departments/dept_notice. cfm?recno=22&bulletin=2635. Retrieved March 9, 2011. ‡An arbitrarily chosen age range that corresponds with ages reported by the U.S. Census Bureau. §American Medical Association. Age and sex referents. In: Iverson C, Christiansen S, Flanagin A, Fontanarosa PB, Glass RM, Gregoline B, et al, editors. AMA manual of style: a guide for authors and editors. 10th ed. New York (NY): Oxford University Press; 2007. p. 410. aPPendix bCommonly Used Acronyms AAMC Association of American Medical Colleges ABOG American Board of Obstetrics and Gynecology ACGME Accreditation Council of Graduate Medical Education ACOG American Congress of Obstetricians and Gynecologists ACOOG American College of Osteopathic Obstetricians and Gynecologists ACS American College of Surgeons AGOS American Gynecological and Obstetrical Society AHRQ Agency for Healthcare Research and Quality AMA American Medical Association AOA American Osteopathic Association APGO Association of Professors in Gynecology and Obstetrics ASRM American Society for Reproductive Medicine AUGS American Urogynecologic Society BBA Balanced Budget Act of 1997 CDC Centers for Disease Control and Prevention CMS Centers for Medicare and Medicaid Services CNM Certified Nurse-Midwife COGME Committee on Graduate Medical Education CREOG Council on Resident Education in Obstetrics and Gynecology CUCOG Council of University Chairs in Obstetrics and Gynecology DHHS Department of Health and Human Services DO Doctor of Osteopathy ECFMG Educational Commission for Foreign Medical Graduates GME Graduate Medical Education HIT Health Information Technology HMO Health Maintenance Organization HRSA Health Resources and Services Administration IOM Institute of Medicare LCME Liaison Committee on Medical Education LCOG Liaison Committee for Obstetrics and Gynecology MD Doctor of Medicine MGMA Medical Group Management Association MOC Maintenance of Certification NCHS National Center for Health Statistics NCI National Cancer Institute NICHD National Institute of Child Health and Human Development NP Nurse Practitioner NRMP National Resident Matching Program PA Physician Assistant PSQI Patient Safety Quality Improvement RRC Residency Review Committee for Obstetrics and Gynecology SGI Society for Gynecologic Investigation SGO Society of Gynecologic Oncologists SMFM Society for Maternal-Fetal Medicine SOGC The Society of Obstetricians and Gynaecologists of Canada aPPendix CKey Sources of Data on Physician Workforce Projections Supply o Association of American Medical Colleges www.aamc.org - Association of American Medical Colleges. 2009 state physician workforce data book. Center for Workforce Studies. Washington, DC: AAMC; 2009. Avaialble at: https:// www.aamc. org/download/47340/data/statedata2009.pdf. Retrieved February 2, 2011. - Association of American Medical Colleges. 2008 physician specialty data. Center for Workforce Studies. Washington, DC: AAMC; 2008. Available at: https://www.aamc. org/download/47352/data/specialtydata.pdf. Retrieved April 12, 2011. - AAMC' FACTS: applicants, matriculants, enrollment, graduates, MD or PhD, and residency applicants data. Washington, DC: AAMC; 2011. Available at: https://www. aamc.org/data/facts/. Retrieved February 15, 2011. o Accreditation Council of Graduate Medical Education www.acgme.org - Graduate medical education data resource book. Chicago (IL): ACGME; 2011. Available at: http://www.acgme.org/acWebsite/dataBook/dat_index.asp. Retrieved February 15, 2011. o American Medical Association www.ama-assn.org - American Medical Association. Physician characteristics and distribution in the US. 2010. Chicago (IL): AMA; 2010. - Brotherton SE, Etzel SI. Graduate medical education 2009-2010. JAMA 2010;304:1255-70. o National Resident Matching Program www.nrmp.org - NRMP: data and reports. Washington, DC: NRMP; 2010. Avaialable at: http://www. nrmp.org/data/index.html. Retrieved February 15, 2011. Demand o Agency for Health Care Research and Quality www.ahrq.gov - Contains links to all surveys - Contains National Health Care Disparities Report o Centers for Disease Control and Prevention www.cdc.gov - "Gateway" web site to various types of health data o National Center for Health Statistics www.cdc.gov/nchs/ - Contains links to all National Center for Health Statistics surveys, for example, NAMS, National Health Interview Survey, NHDS, and National Health and Nutrition Examination Survey o U.S. Census Bureau www.census.gov -Includes population estimates categorized by age, sex, race or ethnicity, state, county, and metropolitan statistical areas -Contains Behavioral Risk Factor Surveillance System o Surveillance of Epidemiology and End Results cancer statistics review http://seer.cancer.gov/publications/csr.html Projections o Association of American Medical Colleges' Center for Workforce Studies www.aamc.org/initiatives/workforce/cfws/ o Dill MJ, Salsberg ES. The complexities of physician supply and demand: projections through 2025. Washington, DC: Association of American Medical Colleges; 2008. Available at: http://www.tht.org/education/resources/AAMC.pdf. Retrieved October 5, 2010. o Bureau of Labor Statistics (Employment projections by occupation and industry) www.bls.gov/emp/ o Bureau of Health Professions. Health Resources and Services Administration. U.S. Department of Health and Human Services. The physician workforce: projections and research into current issues affecting supply and demand. Rockville (MD): USDHHS HRSA BHP; 2008. Available at: ftp://ftp.hrsa.gov/bhpr/workforce/physicianworkforce.pdf. Retrieved October 5, 2010. aPPendix dThe American Congress of Obstetricians and Gynecologists Workforce Fact Sheet for 2011 Most young women seek an obstetrician-gynecologist (ob-gyn) for their preventive health and routine care. Continued access to high-quality obstetric and gynecologic care is critical to women of all ages. The obstetric-gynecologic workforce is aging, the average number of work hours is decreasing compared with historical levels, and a large number of physicians are nearing retirement age. With fewer general internists and family physicians projected to be in clinical practice and an increased number of women being eligible for health care benefits as a result of the Patient Protection and Affordable Care Act, the availability of an ob-gyn or a team led by an ob-gyn will be of even greater importance to women than before. Practice Demographics and Services o Obstetrician-gynecologists represent the largest group of active physicians outside the three traditional primary care fields-internal medicine, family medicine, and pediatrics. o Women constitute one half of all ob-gyns. The highest proportion of active African American physicians are ob-gyns. o Well-woman examinations by ob-gyns offer excellent opportunities for women to receive age-specific preventive screening, evaluation, and counseling either annually or when otherwise indicated. o Like pediatricians, ob-gyns represent a group of physicians who provide health care for a high proportion of Medicaid patients. o More than 15,000 actively practicing ob-gyns will likely retire in the next 10 years. The percentage of the Fellows of the American College of Obstetricians and Gynecologists who are aged 55 years or older increased from 19% in 2002 to 26% in 2005 to 27% in 2010. o The number of ob-gyns retiring will soon equal the number of residents graduating each year. Workforce Concerns o There has been essentially no net increase in the number of ob-gyns trained since 1980, whereas the population of women in the United States has increased by 26% and will increase by 36% by 2050. o Approximately one half (49%) of the 3,107 U.S. counties lack an ob-gyn and nearly 9.5 million Americans (3%) live in those predominantly rural counties. o After medical school, the average physician will likely work less than 40 years. Between 2010 and 2030, the number of female patients will increase by nearly 20% and the number of women older than 65 years will double. o The anticipated shortage of ob-gyns based on 35 years of anticipated practice will be 18% (9,000) by 2030 and 25% (15,723) by 2050 to maintain physician-to-population ratios. o Without sufficient Medicare funding for graduate medical education, residency programs in obstetrics and gynecology will not grow and are at risk of being overwhelmed with service obligations. o As workforce issues become more critical and numbers of physicians decrease, practices will have to function more collaboratively. o Despite numerous ongoing attempts, no meaningful medical liability reform has been achieved at the federal level. Health Care Reform o The Patient Protection and Affordable Care Act is projected to add 32 million people to the health care system through Medicaid and state exchanges, which will strain the existing workforce and diminish patients' access to health care providers. o Between 15.9 million and 22.8 million adults younger than 65 years with incomes less than 133% of the federal poverty level are expected to be added to Medicaid by 2019. o Of all U.S. births, 41% are currently financed by Medicaid; as high as 60% in Mississippi and as low as 23% in New Hampshire. o Although the Patient Protection and Affordable Care Act takes some steps to alleviate workforce concerns through education loan repayment, support for training of health professionals and graduate medical education slot re-allocation are geared towards the fields of primary care and could largely leave out ob-gyns. o States with an already low workforce are expected to have more Medicaid enrollees. For example, Oklahoma is expected to have a 51-67% increase in Medicaid enrollment by 2019; Iowa, a 25-36% increase; and Arkansas, a 27-40% increase. Modeling for the Future o Ensure proper implementation of workforce provisions in obstetrics and gynecology in the Patient Protection and Affordable Care Act, including direct access to obstetric- gynecologic services, workforce policy development by the National Health Care Workforce Commission, and loan repayment programs. o Encourage more medical students to pursue careers in obstetrics and gynecology and women's health. o Promote federal funding of selective increases in residency slots, especially at programs in states with a shortage of ob-gyns or anticipated significant population increase. o Publicize loan repayment programs and other efforts to attract ob-gyns to health care provider shortage areas. o Promote sustainable collaborative models with certified nurse-midwives, nurse practitioners, and physician assistants and establish physician-led teams. o Alter practices by improving efficiency, reconfiguring the delivery of services, increasing the use of health information technology, and selectively hiring more nonphysician clinicians. o Recognize and respond to physician lifestyle concerns (ie, more flexible scheduling and part-time work). o Enact medical liability reform to improve access to care and career satisfaction. o Anticipate that retirement decisions by the increasing number of ob-gyns aged older than 55 years will enormously impact the physician supply. o Improve data collection about the supply of ob-gyns and prepare workforce policies through collaboration with other health professional organizations. Bibliography American Congress of Obstetricians and Gynecologists.Membership information. Washington, DC: American Congress of Obstetricians and Gynecologists; 2010. NGA Center for Best Practices. Maternal and child health update: states increase eligibility for children's health in 2007. Washington, DC: National Governor's Association 2008. p. 1-26. Avaialble at: http:// www.nga.org/files/pdf/0811mchupdate.pdf. Retrieved March 9, 2011. Williams TE, Santiani B, Ellison EC. The coming shortage of surgeons: why they are disappearing and what that means for our health. Santa Barbara (CA): ABC-CLIO, LLC; 2009.aPPendix eReferences for Figures and Tables by Section 1 U.S. Medical School Enrollment and Residency Matching in Obstetrics and Gynecology Table 1-1. Projected U.S. Population According to Migration series Hollmann FW, Mulder TJ, Kallan JE. Methodology and assumption for the population projections of the United States: 1999 to 2100. Population Division Working Paper No. 38. Washington, DC: U.S. Census Bureau; 2000. p. 1-33. Available at: http://www.census.gov/population/www/documentation/twps0038.pdf. Retrieved December 17, 2010. Figure 1-1. U.S. first-year medical school enrollment per 100,000 population with the effect of a 30% expansion. Association of American Medical Colleges. Help wanted: more U.S. doctors: projections indicate America will face shortage of M.D.s by 2020. Washington, DC: AAMC; (2007). Available at: https://www.aamc.org/ download/82874/data/helpwanted.pdf. Retrieved March 30, 2011. Table 1-2. U.S. Medical Schools Accredited by the Liaison Committee on Medical Education Association of American Medical Colleges. Fully accredited four-year U.S. medical schools. Table A1. AAMC data book: medical schools and teaching hospitals by the numbers. Washington, DC: AAMC; 2010. p. 3-4. Figure 1-2. New U.S. medical schools accredited by the Liaison Committee on Medical Education in 1962-1986. Figure courtesy of William F. Rayburn. Table 1-3. U.S. Medical School Applicants and First-Year Enrollment Association of American Medical Colleges. U.S. medical school women applicants, accepted applicants and matriculants. Table B9. AAMC data book: medical schools and teaching hospitals by the numbers. Washington, DC: AAMC; 2010. p. 28-9. Association of American Medical Colleges. U.S. medical school women enrollment and graduates. Table B10. AAMC data book: medical schools and teaching hospitals by the numbers. Washington, DC: AAMC; 2010. p. 30-1. Figure 1-3. U.S. medical school applicants and first-year enrollees. Association of American Medical Colleges. Fully accredited four-year U.S. medical schools. Table A2. AAMC data book: medical schools and teaching hospitals by the numbers. Washington, DC: AAMC; 2010. p. 5. Figure 1-4. Number of applicants to residency programs categorized by surgical specialty as of 2010. National Resident Matching Program. Match summary, 2010. Table 1. Results and data 2010 main residency match. Washington, DC: NRMP; 2010. Ophthalmology residency match report - January 2010: comparative statistics. San Francisco (CA): San Francisco Matching Programs; 2010. Available at: http://www.sfmatch.org/residency/ophthalmology/about_ match/match_report.pdf. Retrieved October 5, 2010. Table 1-4. First -Year Residency Positions Filled in Obstetrics and Gynecology National Resident Matching Program. Match summary, 2010. Table 1. Results and data 2010 main residency match. Washington, DC: NRMP; 2010. National Resident Matching Program. Results and data 2009 main residency match. Washington, DC: NRMP; 2009. National Resident Matching Program. Results and data 2008 main residency match. Washington, DC: NRMP; 2008. National Resident Matching Program. Results and data 2007 main residency match. Washington, DC: NRMP; 2007. National Resident Matching Program. Results and data 2006 match. Washington, DC: NRMP; 2006. National Resident Matching Program. Results and data 2005 match. Washington, DC: NRMP; 2005. National Resident Matching Program. Results and data 2004 match. Washington, DC: NRMP; 2004. National Resident Matching Program. Results and data 2003 match. Washington, DC: NRMP; 2003. National Resident Matching Program. Results and data 2002 match. Washington, DC: NRMP; 2002. National Resident Matching Program. Results and data 2001 match. Washington, DC: NRMP; 2001. National Resident Matching Program. Results and data 2000 match. Washington, DC: NRMP; 2000. National Resident Matching Program. 1999 NRMP Match Data. Washington, DC: NRMP; 1999. National Resident Matching Program. NRMP Data. Washington, DC: NRMP; 1998. National Resident Matching Program. NRMP Data. Washington, DC: NRMP; 1997. National Resident Matching Program. NRMP Data. Washington, DC: NRMP; 1996. National Resident Matching Program. NRMP Data. Washington, DC: NRMP; 1995. National Resident Matching Program. NRMP Data. Washington, DC: NRMP; 1994. National Resident Matching Program. NRMP Data. Washington, DC: NRMP; 1993. National Resident Matching Program. NRMP Data. Evanston (IL): NRMP; 1992. National Resident Matching Program. NRMP Data. Evanston (IL): NRMP; 1991. Brotherton SE, Etzel SI. Graduate medical education, 2009-2010. JAMA 2010;304:1255-70. Brotherton SE, Etzel SI. Graduate medical education, 2008-2009. JAMA 2009;302:1357-72. Brotherton SE, Etzel SI. Graduate medical education, 2007-2008. JAMA 2008;300:1228-43. Brotherton SE, Etzel SI. Graduate medical education, 2006-2007. JAMA 2007;298:1081-96. Brotherton SE, Etzel SI. Graduate medical education, 2005-2006. JAMA 2006;296:1154-69. Graduate medical education. JAMA 2005;294:1129-43. Graduate medical education. JAMA 2004;292:1099-113. Graduate medial education. JAMA 2003;290:1234-8. Graduate medical education. JAMA 2002;288:1151-64. Graduate medical education. JAMA 2001;286:1095-107. Appendix: II. Graduate Medical Education. JAMA 2000;284:1159-72. Graduate medical education. JAMA 1999;282:893-906. Graduate medical education. JAMA 1998;280:836-41. Graduate medical education (II). JAMA 1998;280:842-5. Graduate medical education. JAMA 1997;278:775-84. Graduate medical education. JAMA 1996;276:739-48. Graduate medical education. JAMA 1995;274:755-62. Graduate medical education. JAMA 1994;272:725-33. Graduate medical education. JAMA 1993;270:1116-22. Graduate medical education. JAMA 1992;268:1170-6. Table 1-5. First-Year Residency Positions Offered and Filled in Obstetrics and Gynecology National Resident Matching Program. Results and data 2010 main residency match. Washington, DC: NRMP; 2010. National Resident Matching Program. Results and data 2009 main residency match. Washington, DC: NRMP; 2009. National Resident Matching Program. Results and data 2008 main residency match. Washington, DC: NRMP; 2008. National Resident Matching Program. Results and data 2007 main residency match. Washington, DC: NRMP; 2007. National Resident Matching Program. Results and data 2006 match. Washington, DC: NRMP; 2006. National Resident Matching Program. Results and data 2005 match. Washington, DC: NRMP; 2005. National Resident Matching Program. Results and data 2004 match. Washington, DC: NRMP; 2004. Table 1-6. First-Year Residency Positions Filled by U.S. Medical School Seniors National Resident Matching Program. Results and data 2010 main residency match. Washington, DC: NRMP; 2010. National Resident Matching Program. Results and data 2009 main residency match. Washington, DC: NRMP; 2009. National Resident Matching Program. Results and data 2008 main residency match. Washington, DC: NRMP; 2008. National Resident Matching Program. Results and data 2007 main residency match. Washington, DC: NRMP; 2007. National Resident Matching Program. Results and data 2006 match. Washington, DC: NRMP; 2006. Figure 1-5. Percentage of first-year residency positions filled with U.S. medical graduates vs mean overall incomes by medical specialty. Ebell MH. Future salary and US residency fill rate revisited [letter]. JAMA 2008;300(10):1131-2. 2 U.S. Graduate Medical Education in Obstetrics and Gynecology Table 2-1. First-Year Residents and Total Residents in Obstetrics and Gynecology National Resident Matching Program. Results and data 2010 main residency match. Washington, DC: NRMP; 2010. National Resident Matching Program. Results and data 2009 main residency match. Washington, DC: NRMP; 2009. National Resident Matching Program. Results and data 2008 main residency match. Washington, DC: NRMP; 2008. National Resident Matching Program. Results and data 2007 main residency match. Washington, DC: NRMP; 2007. National Resident Matching Program. Results and data 2006 match. Washington, DC: NRMP; 2006. The National Resident Matching Program. Results and data 2005 match. Washington, DC: NRMP; 2005. National Resident Matching Program. Results and data 2004 match. Washington, DC: NRMP; 2004. National Resident Matching Program. Results and data 2003 match. Washington, DC: NRMP; 2003. National Resident Matching Program. Results and data 2002 match. Washington, DC: NRMP; 2002. National Resident Matching Program. Results and data 2001 match. Washington, DC: NRMP; 2001. National Resident Matching Program. Results and data 2000 match. Washington, DC: NRMP; 2000. National Resident Matching Program. 1999 NRMP Match Data. Washington, DC: NRMP; 1999. National Resident Matching Program. NRMP Data. Washington, DC: NRMP; 1998. National Resident Matching Program. NRMP Data. Washington, DC: NRMP; 1997. National Resident Matching Program. NRMP Data. Washington, DC: NRMP; 1996. National Resident Matching Program. NRMP Data. Washington, DC: NRMP; 1995. National Resident Matching Program. NRMP Data. Washington, DC: NRMP; 1994. National Resident Matching Program. NRMP Data. Washington, DC: NRMP; 1993. National Resident Matching Program. NRMP Data. Evanston (IL): NRMP; 1992. National Resident Matching Program. NRMP Data. Evanston (IL): NRMP; 1991. Brotherton SE, Etzel SI. Graduate medical education, 2009-2010. JAMA 2010;304:1255-70. Brotherton SE, Etzel SI. Graduate medical education, 2008-2009. JAMA 2009;302:1357-72. Brotherton SE, Etzel SI. Graduate medical education, 2007-2008. JAMA 2008;300:1228-43. Brotherton SE, Etzel SI. Graduate medical education, 2006-2007. JAMA 2007;298:1081-96. Brotherton SE, Etzel SI. Graduate medical education, 2005-2006. JAMA 2006;296:1154-69. Graduate medical education. JAMA 2005;294:1129-43. Graduate medical education. JAMA 2004;292:1099-113. Graduate medial education. JAMA 2003;290:1234-8. Graduate medical education. JAMA 2002;288:1151-64. Graduate medical education. JAMA 2001;286:1095-107. Appendix: II. Graduate Medical Education. JAMA 2000;284:1159-72. Graduate medical education. JAMA 1999;282:893-906. Graduate medical education. JAMA 1998;280:836-41. Graduate medical education (II). JAMA 1998;280:842-5. Graduate medical education. JAMA 1997;278:775-84. Graduate medical education. JAMA 1996;276:739-48. Graduate medical education. JAMA 1995;274:755-62. Graduate medical education. JAMA 1994;272:725-33. Graduate medical education. JAMA 1993;270:1116-22. Graduate medical education. JAMA 1992;268:1170-6. Figure 2-1. Locations of allopathic and osteopathic residency programs in obstetrics and gynecology. Figure courtesy of William F. Rayburn. Figure 2-2. Change in the total number of U.S graduate medical education residency programs and residents in obstetrics and gynecology. Graduate medical education in the United States. JAMA 1981;246:2938-44. Crowley AE, Etzel SI. Graduate medical education. JAMA 1986;256:1585-94. Rowley BD, Baldwin DC, Jr, McGuire MB. Selected characteristics of graduate medical education in the United States. JAMA 1991;266:933-43. Graduate medical education. JAMA 1996;276:739-48. Graduate medical education. JAMA 2001;286:1095-107. Brotherton SE, Etzel SI. Graduate medical education, 2005-2006. JAMA 2006;296:1154-69. Brotherton SE, Etzel SI. Graduate medical education, 2009-2010. JAMA 2010;304:1255-70. Figure 2-3. Percentage of residents with U.S. medical degrees in programs accredited by the Accreditation Council of Graduate Medical Education categorized by medical specialty as of 2009. Brotherton SE, Etzel SI. Graduate medical education, 2009-2010. JAMA 2010;304:1255-70. Figure 2-4. Percentage of residents with international medical degrees accredited by the Accreditation Council of Graduate Medical Education categorized by medical specialty as of 2009. Brotherton SE, Etzel SI. Graduate medical education, 2009-2010. JAMA 2010;304:1255-70. Figure 2-5. Percentage of residents with osteopathic degrees in programs accredited by the Accreditation Council of Graduate Medical Education categorized by medical specialty as of 2009. Brotherton SE, Etzel SI. Graduate medical education, 2009-2010. JAMA 2010;304:1255-70. Figure 2-6. Percentage of female residents in programs accredited by the Accreditation Council of Graduate Medical Education categorized by medical specialty as of 2009. Brotherton SE, Etzel SI. Graduate medical education, 2009-2010. JAMA 2010;304:1255-70. Figure 2-7. Percentage of first-year residents in obstetrics and gynecology who are female. Graduate medical education. JAMA 2001;286(9):1095-107. Graduate medical education. JAMA 1996;276(9):739-48. Brotherton SE, Etzel SI. Graduate medical education, 2009-2010. JAMA 2010;304(11):1255-70. Brotherton SE, Etzel SI. Graduate medical education, 2005-2006. JAMA 2006;296(9):1154-69. Rowley BD, Baldwin DC,Jr, McGuire MB. Selected characteristics of graduate medical education in the United States. JAMA 1991;266(7):933-43. Figure 2-8. Percentage of African American, American Indian or Alaska Native, or Native Hawaiian or Pacific Islander residents in programs accredited by the Accreditation Council of Graduate Medical Education categorized by medical specialty as of 2009. Brotherton SE, Etzel SI. Graduate medical education, 2009-2010. JAMA 2010;304(11):1255-70. Figure 2-9. Percentage of Hispanic residents in programs accredited by the Accreditation Council of Graduate Medical Education categorized by medical specialty as of 2009. Brotherton SE, Etzel SI. Graduate medical education, 2009-2010. JAMA 2010;304(11):1255-70. Figure 2-10. Total number of residents in programs accredited by the Accreditation Council of Graduate Medical Education categorized by surgical specialty as of 2009. Brotherton SE, Etzel SI. Graduate medical education, 2009-2010. JAMA 2010;304(11):1255-70. Figure 2-11. Percentage of residents with U.S. medical degrees in programs accredited by the Accreditation Council of Graduate medical Education categorized by surgical specialty as of 2009. Brotherton SE, Etzel SI. Graduate medical education, 2009-2010. JAMA 2010;304(11):1255-70. Figure 2-12. Percentage of residents with international medical degrees in residency programs accredited by the Accreditation Council of Graduate Medical Education categorized by surgical specialty as of 2009. Brotherton SE, Etzel SI. Graduate medical education, 2009-2010. JAMA 2010;304(11):1255-70. Figure 2-13. Percentage of residents with osteopathic degrees in programs accredited by the Accreditation Council of Graduate Medical Education categorized by surgical specialty as of 2009. Brotherton SE, Etzel SI. Graduate medical education, 2009-2010. JAMA 2010;304(11):1255-70. Table 2-2. Obstetrics Procedures Performed by Residents Graduating in 2008-2009 (Benchmarks Table) Accreditation Council for Graduate Medical Education. Obstetrics and gynecology case logs: national data report. 2009. p. 1-5. Available at: http://www.acgme.org/acWebsite/RRC_220/ObGynNatData0809.pdf. Retrieved January 6, 2011. Table 2-3. Gynecologic Procedures Performed by Residents Graduating in 2008-2009 (Benchmarks Table) Accreditation Council for Graduate Medical Education. Obstetrics and gynecology case logs: national data report. 2009. p. 1-5. Available at: http://www.acgme.org/acWebsite/RRC_220/ObGynNatData0809.pdf. Retrieved January 6, 2011. Table 2-4. Trends in Graduates from Residency Programs in Obstetrics and Gynecology per 100,000 General Population in the United States Graduate medical education. JAMA 2001;286:1095-107. Graduate medical education. JAMA 1996;276:739-48. Brotherton SE, Etzel SI. Graduate medical education, 2005-2006. JAMA 2006;296:1154-69. U.S. Census Bureau. Statistical abstract of the United States: 2011. 131st ed. Washington, DC: USCB; 2011. Available at: http://www.census.gov/prod/2011pubs/11statab/pop.pdf. Retrieved January 6, 2011. 3 U.S. Medical School Faculty in Obstetrics and Gynecology Table 3-1. Trends in U.S. Medical School Full-Time Faculty Association of American Medical Colleges. Trends in U.S. medical school full-time faculty counts by department. Table C2. AAMC data book: medical schools and teaching hospitals by the numbers. Washington, DC: AAMC; 2010. p. 42. Figure 3-1. Full-time faculty with Doctor of Medicine (or equivalent) or Doctor of Philosophy degrees per departments of obstetrics and gynecology. Rayburn WF, Anderson BL, Johnson JV, McReynolds MA, Schulkin J. Trends in the academic workforce of obstetrics and gynecology. Obstet Gynecol 2010;115:141-6. Table 3-2. Average Number of Faculty Members per Departments of Obstetrics and Gynecology Rayburn WF, Anderson BL, Johnson JV, McReynolds MA, Schulkin J. Trends in the academic workforce of obstetrics and gynecology. Obstet Gynecol 2010;115:141-6. Table 3-3. Full-Time Faculty in Departments of Obstetrics and Gynecology by Academic Degrees Rayburn WF, Anderson BL, Johnson JV, McReynolds MA, Schulkin J. Trends in the academic workforce of obstetrics and gynecology. Obstet Gynecol 2010;115:141-6. Figure 3-2. Percentage of full-time faculty in departments of obstetrics and gynecology by gender. Rayburn WF, Anderson BL, Johnson JV, McReynolds MA, Schulkin J. Trends in the academic workforce of obstetrics and gynecology. Obstet Gynecol 2010;115:141-6. Figure 3-3. Retention rates of entry-level faculty in departments of obstetrics and gynecology at their original department (A) and in academia (B) categorized by specialty. Rayburn WF, Anderson BL, Johnson JV, McReynolds MA, Schulkin J. Trends in the academic workforce of obstetrics and gynecology. Obstet Gynecol 2010;115:141-6. Figure 3-4. Percentage of department chair positions filled annually between 1979 and 2007. Rayburn WF, Alexander H, Lang J, Scott JL. First-time department chairs at U.S. medical schools: a 29-year perspective on recruitment and retention. Acad Med 2009;84:1336-41. Figure 3-5. Percentage of academic chairs of departments of obstetrics and gynecology who are female. Rayburn WF, Schrader RM, Cain JM, Artal R, Anderson GD, Merkatz IR. Tenure of academic chairs in obstetrics and gynecology: a 25-year perspective. Obstet Gynecol 2006;108:1217-21. Table 3-4. Five-Year Retention Rates of First-Time Academic Chairs in Core Clinical Departments According to Year When Appointment Began Rayburn WF, Waldman JD, Schrader R, Fullilove A, Lang J. Retention of chairs in obstetrics and gynecology: a comparison with other clinical departments. Obstet Gynecol 2009;114:130-5. Table 3-5. Ten-Year Retention Rates of First-Time Academic Chairs in Core Clinical Departments According to Year When Appointment Began Rayburn WF, Waldman JD, Schrader R, Fullilove A, Lang J. Retention of chairs in obstetrics and gynecology: a comparison with other clinical departments. Obstet Gynecol 2009;114:130-5. 4 Characteristics and Distribution of Obstetrician-Gynecologists in the United States Table 4-1. Rates of Passing Grades for Resident and Fellow Graduates Taking Written and Oral Board Examinations of the American Board of Obstetrics and Gynecology The A.B.O.G. Diplomate. 36. Dallas (TX): American Board of Obstetrics and Gynecology; 2010. p. 1-7. The A.B.O.G. Diplomate. 35. Dallas (TX): American Board of Obstetrics and Gynecology; 2009. p. 1-8. The A.B.O.G. Diplomate. 34. Dallas (TX): American Board of Obstetrics and Gynecology; 2008. p. 1-7. American Board of Obstetrics and Gynecology. Maintenance of certification in obstetrics and gynecology and its subspecialties. 2007. p. 1-28. The A.B.O.G. Diplomate. 32. Dallas (TX): American Board of Obstetrics and Gynecology; 2006. p. 1-6. The A.B.O.G. Diplomate. 31. Dallas (TX): American Board of Obstetrics and Gynecology; 2005. p. 1-7. The A.B.O.G. Diplomate. 30. Dallas (TX): American Board of Obstetrics and Gynecology; 2004. p. 1-6. The A.B.O.G. Diplomate. 29. Dallas (TX): American Board of Obstetrics and Gynecology; 2002-2003. p. 1-6. The A.B.O.G. Diplomate. 28. Dallas (TX): American Board of Obstetrics and Gynecology; 2001-2002. p. 1-10. The A.B.O.G. Diplomate. 27. Dallas (TX): American Board of Obstetrics and Gynecology; 2000-2001. p. 1-6. The A.B.O.G. Diplomate. 26. Dallas (TX): American Board of Obstetrics and Gynecology; 1999-2000. p. 1-7. The A.B.O.G. Diplomate. 25. Dallas (TX): American Board of Obstetrics and Gynecology; 1998. p. 1-6. The A.B.O.G. Diplomate. 24. Dallas (TX): American Board of Obstetrics and Gynecology; 1997. p. 1-8. The A.B.O.G. Diplomate. 23. Dallas (TX): American Board of Obstetrics and Gynecology; 1996. p. 1-5. The A.B.O.G. Diplomate. 22. Dallas (TX): American Board of Obstetrics and Gynecology; 1995. p. 1-5. The A.B.O.G. Diplomate. 21. Dallas (TX): American Board of Obstetrics and Gynecology; 1994. p. 1-5. The A.B.O.G. Diplomate. 20. Dallas (TX): American Board of Obstetrics and Gynecology; 1993. p. 1-5. The A.B.O.G. Diplomate. 19. Seattle (WA): American Board of Obstetrics and Gynecology; 1992. p. 1-4. The A.B.O.G. Diplomate. 18. Seattle (WA): American Board of Obstetrics and Gynecology; 1991. p. 1-4. The A.B.O.G. Diplomate. 17. Seattle (WA): American Board of Obstetrics and Gynecology; 1990. p. 1-4. The A.B.O.G. Diplomate. 16. Seattle (WA): American Board of Obstetrics and Gynecology; 1989. p. 1-4. The A.B.O.G. Diplomate. 15. Seattle (WA): American Board of Obstetrics and Gynecology; 1988. p. 1-4. The A.B.O.G. Diplomate. 14. Seattle (WA): American Board of Obstetrics and Gynecology; 1987. p. 1-4. The A.B.O.G. Diplomate. 13. Seattle (WA): American Board of Obstetrics and Gynecology; 1986. p. 1-4. The A.B.O.G. Diplomate. 12. Seattle (WA): American Board of Obstetrics and Gynecology; 1985. p. 1-3. The A.B.O.G. Diplomate. 11. Seattle (WA): American Board of Obstetrics and Gynecology; 1984. p. 1-3. The A.B.O.G. Diplomate. 10. Oklahoma City (OK): American Board of Obstetrics and Gynecology; 1983. p. 1-4. The A.B.O.G. Diplomate. 9. Oklahoma City (OK): American Board of Obstetrics and Gynecology; 1982. p. 1-4. The A.B.O.G. Diplomate. 8. Oklahoma City (OK): American Board of Obstetrics and Gynecology; 1981. p. 1-4. The A.B.O.G. Diplomate. 7. Oklahoma City (OK): American Board of Obstetrics and Gynecology; 1980. p. 1-4. The A.B.O.G. Diplomate. 6. Oklahoma City (OK): American Board of Obstetrics and Gynecology; 1979. p. 1-4. The A.B.O.G. Diplomate. 5. Oklahoma City (OK): American Board of Obstetrics and Gynecology; 1978. p. 1-4. The A.B.O.G. Diplomate. 4. Oklahoma City (OK): American Board of Obstetrics and Gynecology; 1977. p. 1-4. The A.B.O.G. Diplomate. 3. Oklahoma City (OK): American Board of Obstetrics and Gynecology; 1976. p. 1-4. The A.B.O.G. Diplomate. 1. Oklahoma City (OK): American Board of Obstetrics and Gynecology; 1975. p. 1-3. Figure 4-1. Membership statistics for the American College of Obstetricians and Gynecologists. American Congress of Obstetricians and Gynecologists. Membership information. Washington, DC: American Congress of Obstetricians and Gynecologists; 2010. Figure 4-2. Fellows and Junior Fellows of the American College of Obstetricians and Gynecologists per 10,000 women. American Congress of Obstetricians and Gynecologists. Membership information. Washington, DC: American Congress of Obstetricians and Gynecologists; 2010. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for Alabama: April 1, 2000 to July 1, 2008. SC-EST2008-02-01. Washington, DC: U.S. Census Bureau; 2009. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for Alaska: April 1, 2000 to July 1, 2008. SC-EST2008-02-02. Washington, DC: U.S. Census Bureau; 2009. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for Arizona: April 1, 2000 to July 1, 2008. SC-EST2008-02-04. Washington, DC: U.S. Census Bureau; 2009. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for Arkansas: April 1, 2000 to July 1, 2008. SC-EST2008-02-05. Washington, DC: U.S. Census Bureau; 2009. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for California: April 1, 2000 to July 1, 2008. SC-EST2008-02-06. Washington, DC: U.S. Census Bureau; 2009. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for Colorado: April 1, 2000 to July 1, 2008. SC-EST2008-02-08. Washington, DC: U.S. Census Bureau; 2009. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for Connecticut: April 1, 2000 to July 1, 2008. SC-EST2008-02-09. Washington, DC: U.S. Census Bureau; 2009. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for Delaware: April 1, 2000 to July 1, 2008. SC-EST2008-02-10. Washington, DC: U.S. Census Bureau; 2009. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for District of Columbia: April 1, 2000 to July 1, 2008. SC-EST2008-02-11. Washington, DC: U.S. Census Bureau; 2009. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for Florida: April 1, 2000 to July 1, 2008. SC-EST2008-02-12. Washington, DC: U.S. Census Bureau; 2009. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for Georgia: April 1, 2000 to July 1, 2008. SC-EST2008-02-13. Washington, DC: U.S. Census Bureau; 2009. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for Hawaii: April 1, 2000 to July 1, 2008. SC-EST2008-02-15. Washington, DC: U.S. Census Bureau; 2009. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for Idaho: April 1, 2000 to July 1, 2008. SC-EST2008-02-16. Washington, DC: U.S. Census Bureau; 2009. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for Illinois: April 1, 2000 to July 1, 2008. SC-EST2008-02-17. Washington, DC: U.S. Census Bureau; 2009. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for Indiana: April 1, 2000 to July 1, 2008. SC-EST2008-02-18. Washington, DC: U.S. Census Bureau; 2009. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for Iowa: April 1, 2000 to July 1, 2008. SC-EST2008-02-19. Washington, DC: U.S. Census Bureau; 2009. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for Kansas: April 1, 2000 to July 1, 2008. SC-EST2008-02-20. Washington, DC: U.S. Census Bureau; 2009. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for Kentucky: April 1, 2000 to July 1, 2008. SC-EST2008-02-21. Washington, DC: U.S. Census Bureau; 2009. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for Louisiana: April 1, 2000 to July 1, 2008. SC-EST2008-02-22. Washington, DC: U.S. Census Bureau; 2009. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for Maine: April 1, 2000 to July 1, 2008. SC-EST2008-02-23. Washington, DC: U.S. Census Bureau; 2009. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for Maryland: April 1, 2000 to July 1, 2008. SC-EST2008-02-24. Washington, DC: U.S. Census Bureau; 2009. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for Massachusetts: April 1, 2000 to July 1, 2008. SC-EST2008-02-25. Washington, DC: U.S. Census Bureau; 2009. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for Michigan: April 1, 2000 to July 1, 2008. SC-EST2008-02-26. Washington, DC: U.S. Census Bureau; 2009. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for Minnesota: April 1, 2000 to July 1, 2008. SC-EST2008-02-27. Washington, DC: U.S. Census Bureau; 2009. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for Misississippi: April 1, 2000 to July 1, 2008. SC-EST2008-02-28. Washington, DC: U.S. Census Bureau; 2009. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for Missouri: April 1, 2000 to July 1, 2008. SC-EST2008-02-29. Washington, DC: U.S. Census Bureau; 2009. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for Montana: April 1, 2000 to July 1, 2008. SC-EST2008-02-30. Washington, DC: U.S. Census Bureau; 2009. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for Nebraska: April 1, 2000 to July 1, 2008. SC-EST2008-02-31. Washington, DC: U.S. Census Bureau; 2009. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for Nevada: April 1, 2000 to July 1, 2008. SC-EST2008-02-32. Washington, DC: U.S. Census Bureau; 2009. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for New Hampshire: April 1, 2000 to July 1, 2008. SC-EST2008-02-33. Washington, DC: U.S. Census Bureau; 2009. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for New Jersey: April 1, 2000 to July 1, 2008. SC-EST2008-02-34. Washington, DC: U.S. Census Bureau; 2009. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for New Mexico: April 1, 2000 to July 1, 2008. SC-EST2008-02-35. Washington, DC: U.S. Census Bureau; 2009. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for New York: April 1, 2000 to July 1, 2008. SC-EST2008-02-36. Washington, DC: U.S. Census Bureau; 2009. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for North Carolina: April 1, 2000 to July 1, 2008. SC-EST2008-02-37. Washington, DC: U.S. Census Bureau; 2009. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for North Dakota: April 1, 2000 to July 1, 2008. SC-EST2008-02-38. Washington, DC: U.S. Census Bureau; 2009. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for Ohio: April 1, 2000 to July 1, 2008. SC-EST2008-02-39. Washington, DC: U.S. Census Bureau; 2009. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for Oklahoma: April 1, 2000 to July 1, 2008. SC-EST2008-02-40. Washington, DC: U.S. Census Bureau; 2009. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for Oregon: April 1, 2000 to July 1, 2008. SC-EST2008-02-41. Washington, DC: U.S. Census Bureau; 2009. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for Pennsylvania: April 1, 2000 to July 1, 2008. SC-EST2008-02-42. Washington, DC: U.S. Census Bureau; 2009. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for Rhode Island: April 1, 2000 to July 1, 2008. SC-EST2008-02-44. Washington, DC: U.S. Census Bureau; 2009. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for South Carolina: April 1, 2000 to July 1, 2008. SC-EST2008-02-45. Washington, DC: U.S. Census Bureau; 2009. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for South Dakota: April 1, 2000 to July 1, 2008. SC-EST2008-02-46. Washington, DC: U.S. Census Bureau; 2009. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for Tennessee: April 1, 2000 to July 1, 2008. SC-EST2008-02-47. Washington, DC: U.S. Census Bureau; 2009. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for Texas: April 1, 2000 to July 1, 2008. SC-EST2008-02-48. Washington, DC: U.S. Census Bureau; 2009. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for Utah: April 1, 2000 to July 1, 2008. SC-EST2008-02-49. Washington, DC: U.S. Census Bureau; 2009. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for Vermont: April 1, 2000 to July 1, 2008. SC-EST2008-02-50. Washington, DC: U.S. Census Bureau; 2009. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for Virginia: April 1, 2000 to July 1, 2008. SC-EST2008-02-51. Washington, DC: U.S. Census Bureau; 2009. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for Washington: April 1, 2000 to July 1, 2008. SC-EST2008-02-53. Washington, DC: U.S. Census Bureau; 2009. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for West Virginia: April 1, 2000 to July 1, 2008. SC-EST2008-02-54. Washington, DC: U.S. Census Bureau; 2009. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for Wisconsin: April 1, 2000 to July 1, 2008. SC-EST2008-02-55. Washington, DC: U.S. Census Bureau; 2009. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for Wyoming: April 1, 2000 to July 1, 2008. SC-EST2008-02-56. Washington, DC: U.S. Census Bureau; 2009. Figure 4-3. Fellows and Junior Fellows of the American College of Obstetricians and Gynecologists per 10,000 women by state and in the United States as of 2009. American Congress of Obstetricians and Gynecologists. Membership information. Washington, DC: American Congress of Obstetricians and Gynecologists; 2010. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for Alabama: April 1, 2000 to July 1, 2008. SC-EST2008-02-01. Washington, DC: U.S. Census Bureau; 2009. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for Alaska: April 1, 2000 to July 1, 2008. SC-EST2008-02-02. Washington, DC: U.S. Census Bureau; 2009. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for Arizona: April 1, 2000 to July 1, 2008. SC-EST2008-02-04. Washington, DC: U.S. Census Bureau; 2009. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for Arkansas: April 1, 2000 to July 1, 2008. SC-EST2008-02-05. Washington, DC: U.S. Census Bureau; 2009. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for California: April 1, 2000 to July 1, 2008. SC-EST2008-02-06. Washington, DC: U.S. Census Bureau; 2009. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for Colorado: April 1, 2000 to July 1, 2008. SC-EST2008-02-08. Washington, DC: U.S. Census Bureau; 2009. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for Connecticut: April 1, 2000 to July 1, 2008. SC-EST2008-02-09. Washington, DC: U.S. Census Bureau; 2009. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for Delaware: April 1, 2000 to July 1, 2008. SC-EST2008-02-10. Washington, DC: U.S. Census Bureau; 2009. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for District of Columbia: April 1, 2000 to July 1, 2008. SC-EST2008-02-11. Washington, DC: U.S. Census Bureau; 2009. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for Florida: April 1, 2000 to July 1, 2008. SC-EST2008-02-12. Washington, DC: U.S. Census Bureau; 2009. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for Georgia: April 1, 2000 to July 1, 2008. SC-EST2008-02-13. Washington, DC: U.S. Census Bureau; 2009. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for Hawaii: April 1, 2000 to July 1, 2008. SC-EST2008-02-15. Washington, DC: U.S. Census Bureau; 2009. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for Idaho: April 1, 2000 to July 1, 2008. SC-EST2008-02-16. Washington, DC: U.S. Census Bureau; 2009. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for Illinois: April 1, 2000 to July 1, 2008. SC-EST2008-02-17. Washington, DC: U.S. Census Bureau; 2009. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for Indiana: April 1, 2000 to July 1, 2008. SC-EST2008-02-18. Washington, DC: U.S. Census Bureau; 2009. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for Iowa: April 1, 2000 to July 1, 2008. SC-EST2008-02-19. Washington, DC: U.S. Census Bureau; 2009. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for Kansas: April 1, 2000 to July 1, 2008. SC-EST2008-02-20. Washington, DC: U.S. Census Bureau; 2009. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for Kentucky: April 1, 2000 to July 1, 2008. SC-EST2008-02-21. Washington, DC: U.S. Census Bureau; 2009. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for Louisiana: April 1, 2000 to July 1, 2008. SC-EST2008-02-22. Washington, DC: U.S. Census Bureau; 2009. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for Maine: April 1, 2000 to July 1, 2008. SC-EST2008-02-23. Washington, DC: U.S. Census Bureau; 2009. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for Maryland: April 1, 2000 to July 1, 2008. SC-EST2008-02-24. Washington, DC: U.S. Census Bureau; 2009. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for Massachusetts: April 1, 2000 to July 1, 2008. SC-EST2008-02-25. Washington, DC: U.S. Census Bureau; 2009. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for Michigan: April 1, 2000 to July 1, 2008. SC-EST2008-02-26. Washington, DC: U.S. Census Bureau; 2009. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for Minnesota: April 1, 2000 to July 1, 2008. SC-EST2008-02-27. Washington, DC: U.S. Census Bureau; 2009. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for Misississippi: April 1, 2000 to July 1, 2008. SC-EST2008-02-28. Washington, DC: U.S. Census Bureau; 2009. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for Missouri: April 1, 2000 to July 1, 2008. SC-EST2008-02-29. Washington, DC: U.S. Census Bureau; 2009. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for Montana: April 1, 2000 to July 1, 2008. SC-EST2008-02-30. Washington, DC: U.S. Census Bureau; 2009. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for Nebraska: April 1, 2000 to July 1, 2008. SC-EST2008-02-31. Washington, DC: U.S. Census Bureau; 2009. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for Nevada: April 1, 2000 to July 1, 2008. SC-EST2008-02-32. Washington, DC: U.S. Census Bureau; 2009. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for New Hampshire: April 1, 2000 to July 1, 2008. SC-EST2008-02-33. Washington, DC: U.S. Census Bureau; 2009. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for New Jersey: April 1, 2000 to July 1, 2008. SC-EST2008-02-34. Washington, DC: U.S. Census Bureau; 2009. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for New Mexico: April 1, 2000 to July 1, 2008. SC-EST2008-02-35. Washington, DC: U.S. Census Bureau; 2009. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for New York: April 1, 2000 to July 1, 2008. SC-EST2008-02-36. Washington, DC: U.S. Census Bureau; 2009. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for North Carolina: April 1, 2000 to July 1, 2008. SC-EST2008-02-37. Washington, DC: U.S. Census Bureau; 2009. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for North Dakota: April 1, 2000 to July 1, 2008. SC-EST2008-02-38. Washington, DC: U.S. Census Bureau; 2009. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for Ohio: April 1, 2000 to July 1, 2008. SC-EST2008-02-39. Washington, DC: U.S. Census Bureau; 2009. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for Oklahoma: April 1, 2000 to July 1, 2008. SC-EST2008-02-40. Washington, DC: U.S. Census Bureau; 2009. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for Oregon: April 1, 2000 to July 1, 2008. SC-EST2008-02-41. Washington, DC: U.S. Census Bureau; 2009. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for Pennsylvania: April 1, 2000 to July 1, 2008. SC-EST2008-02-42. Washington, DC: U.S. Census Bureau; 2009. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for Rhode Island: April 1, 2000 to July 1, 2008. SC-EST2008-02-44. Washington, DC: U.S. Census Bureau; 2009. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for South Carolina: April 1, 2000 to July 1, 2008. SC-EST2008-02-45. Washington, DC: U.S. Census Bureau; 2009. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for South Dakota: April 1, 2000 to July 1, 2008. SC-EST2008-02-46. Washington, DC: U.S. Census Bureau; 2009. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for Tennessee: April 1, 2000 to July 1, 2008. SC-EST2008-02-47. Washington, DC: U.S. Census Bureau; 2009. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for Texas: April 1, 2000 to July 1, 2008. SC-EST2008-02-48. Washington, DC: U.S. Census Bureau; 2009. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for Utah: April 1, 2000 to July 1, 2008. SC-EST2008-02-49. Washington, DC: U.S. Census Bureau; 2009. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for Vermont: April 1, 2000 to July 1, 2008. SC-EST2008-02-50. Washington, DC: U.S. Census Bureau; 2009. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for Virginia: April 1, 2000 to July 1, 2008. SC-EST2008-02-51. Washington, DC: U.S. Census Bureau; 2009. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for Washington: April 1, 2000 to July 1, 2008. SC-EST2008-02-53. Washington, DC: U.S. Census Bureau; 2009. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for West Virginia: April 1, 2000 to July 1, 2008. SC-EST2008-02-54. Washington, DC: U.S. Census Bureau; 2009. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for Wisconsin: April 1, 2000 to July 1, 2008. SC-EST2008-02-55. Washington, DC: U.S. Census Bureau; 2009. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for Wyoming: April 1, 2000 to July 1, 2008. SC-EST2008-02-56. Washington, DC: U.S. Census Bureau; 2009. Figure 4-4. Fellows and Junior Fellows of the American College of Obstetricians and Gynecologists per 10,000 women of reproductive age. American Congress of Obstetricians and Gynecologists. Membership information. Washington, DC: American Congress of Obstetricians and Gynecologists; 2010. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for Alabama: April 1, 2000 to July 1, 2008. SC-EST2008-02-01. Washington, DC: U.S. Census Bureau; 2009. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for Alaska: April 1, 2000 to July 1, 2008. SC-EST2008-02-02. Washington, DC: U.S. Census Bureau; 2009. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for Arizona: April 1, 2000 to July 1, 2008. SC-EST2008-02-04. Washington, DC: U.S. Census Bureau; 2009. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for Arkansas: April 1, 2000 to July 1, 2008. SC-EST2008-02-05. Washington, DC: U.S. Census Bureau; 2009. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for California: April 1, 2000 to July 1, 2008. SC-EST2008-02-06. Washington, DC: U.S. Census Bureau; 2009. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for Colorado: April 1, 2000 to July 1, 2008. SC-EST2008-02-08. Washington, DC: U.S. Census Bureau; 2009. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for Connecticut: April 1, 2000 to July 1, 2008. SC-EST2008-02-09. Washington, DC: U.S. Census Bureau; 2009. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for Delaware: April 1, 2000 to July 1, 2008. SC-EST2008-02-10. Washington, DC: U.S. Census Bureau; 2009. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for District of Columbia: April 1, 2000 to July 1, 2008. SC-EST2008-02-11. Washington, DC: U.S. Census Bureau; 2009. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for Florida: April 1, 2000 to July 1, 2008. SC-EST2008-02-12. Washington, DC: U.S. Census Bureau; 2009. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for Georgia: April 1, 2000 to July 1, 2008. SC-EST2008-02-13. Washington, DC: U.S. Census Bureau; 2009. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for Hawaii: April 1, 2000 to July 1, 2008. SC-EST2008-02-15. Washington, DC: U.S. Census Bureau; 2009. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for Idaho: April 1, 2000 to July 1, 2008. SC-EST2008-02-16. Washington, DC: U.S. Census Bureau; 2009. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for Illinois: April 1, 2000 to July 1, 2008. SC-EST2008-02-17. Washington, DC: U.S. Census Bureau; 2009. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for Indiana: April 1, 2000 to July 1, 2008. SC-EST2008-02-18. Washington, DC: U.S. Census Bureau; 2009. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for Iowa: April 1, 2000 to July 1, 2008. SC-EST2008-02-19. Washington, DC: U.S. Census Bureau; 2009. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for Kansas: April 1, 2000 to July 1, 2008. SC-EST2008-02-20. Washington, DC: U.S. Census Bureau; 2009. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for Kentucky: April 1, 2000 to July 1, 2008. SC-EST2008-02-21. Washington, DC: U.S. Census Bureau; 2009. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for Louisiana: April 1, 2000 to July 1, 2008. SC-EST2008-02-22. Washington, DC: U.S. Census Bureau; 2009. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for Maine: April 1, 2000 to July 1, 2008. SC-EST2008-02-23. Washington, DC: U.S. Census Bureau; 2009. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for Maryland: April 1, 2000 to July 1, 2008. SC-EST2008-02-24. Washington, DC: U.S. Census Bureau; 2009. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for Massachusetts: April 1, 2000 to July 1, 2008. SC-EST2008-02-25. Washington, DC: U.S. Census Bureau; 2009. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for Michigan: April 1, 2000 to July 1, 2008. SC-EST2008-02-26. Washington, DC: U.S. Census Bureau; 2009. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for Minnesota: April 1, 2000 to July 1, 2008. SC-EST2008-02-27. Washington, DC: U.S. Census Bureau; 2009. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for Misississippi: April 1, 2000 to July 1, 2008. SC-EST2008-02-28. Washington, DC: U.S. Census Bureau; 2009. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for Missouri: April 1, 2000 to July 1, 2008. SC-EST2008-02-29. Washington, DC: U.S. Census Bureau; 2009. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for Montana: April 1, 2000 to July 1, 2008. SC-EST2008-02-30. Washington, DC: U.S. Census Bureau; 2009. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for Nebraska: April 1, 2000 to July 1, 2008. SC-EST2008-02-31. Washington, DC: U.S. Census Bureau; 2009. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for Nevada: April 1, 2000 to July 1, 2008. SC-EST2008-02-32. Washington, DC: U.S. Census Bureau; 2009. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for New Hampshire: April 1, 2000 to July 1, 2008. SC-EST2008-02-33. Washington, DC: U.S. Census Bureau; 2009. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for New Jersey: April 1, 2000 to July 1, 2008. SC-EST2008-02-34. Washington, DC: U.S. Census Bureau; 2009. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for New Mexico: April 1, 2000 to July 1, 2008. SC-EST2008-02-35. Washington, DC: U.S. Census Bureau; 2009. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for New York: April 1, 2000 to July 1, 2008. SC-EST2008-02-36. Washington, DC: U.S. Census Bureau; 2009. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for North Carolina: April 1, 2000 to July 1, 2008. SC-EST2008-02-37. Washington, DC: U.S. Census Bureau; 2009. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for North Dakota: April 1, 2000 to July 1, 2008. SC-EST2008-02-38. Washington, DC: U.S. Census Bureau; 2009. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for Ohio: April 1, 2000 to July 1, 2008. SC-EST2008-02-39. Washington, DC: U.S. Census Bureau; 2009. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for Oklahoma: April 1, 2000 to July 1, 2008. SC-EST2008-02-40. Washington, DC: U.S. Census Bureau; 2009. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for Oregon: April 1, 2000 to July 1, 2008. SC-EST2008-02-41. Washington, DC: U.S. Census Bureau; 2009. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for Pennsylvania: April 1, 2000 to July 1, 2008. SC-EST2008-02-42. Washington, DC: U.S. Census Bureau; 2009. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for Rhode Island: April 1, 2000 to July 1, 2008. SC-EST2008-02-44. Washington, DC: U.S. Census Bureau; 2009. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for South Carolina: April 1, 2000 to July 1, 2008. SC-EST2008-02-45. Washington, DC: U.S. Census Bureau; 2009. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for South Dakota: April 1, 2000 to July 1, 2008. SC-EST2008-02-46. Washington, DC: U.S. Census Bureau; 2009. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for Tennessee: April 1, 2000 to July 1, 2008. SC-EST2008-02-47. Washington, DC: U.S. Census Bureau; 2009. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for Texas: April 1, 2000 to July 1, 2008. SC-EST2008-02-48. Washington, DC: U.S. Census Bureau; 2009. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for Utah: April 1, 2000 to July 1, 2008. SC-EST2008-02-49. Washington, DC: U.S. Census Bureau; 2009. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for Vermont: April 1, 2000 to July 1, 2008. SC-EST2008-02-50. Washington, DC: U.S. Census Bureau; 2009. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for Virginia: April 1, 2000 to July 1, 2008. SC-EST2008-02-51. Washington, DC: U.S. Census Bureau; 2009. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for Washington: April 1, 2000 to July 1, 2008. SC-EST2008-02-53. Washington, DC: U.S. Census Bureau; 2009. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for West Virginia: April 1, 2000 to July 1, 2008. SC-EST2008-02-54. Washington, DC: U.S. Census Bureau; 2009. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for Wisconsin: April 1, 2000 to July 1, 2008. SC-EST2008-02-55. Washington, DC: U.S. Census Bureau; 2009. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for Wyoming: April 1, 2000 to July 1, 2008. SC-EST2008-02-56. Washington, DC: U.S. Census Bureau; 2009. Figure 4-5. Felows and Junior Fellows in Practice of the American College of Obstetricians and Gynecologists per 10,000 women of reproductive age in the United States as of 2009. American Congress of Obstetricians and Gynecologists. Membership information. Washington, DC: American Congress of Obstetricians and Gynecologists; 2010. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for Alabama: April 1, 2000 to July 1, 2008. SC-EST2008-02-01. Washington, DC: U.S. Census Bureau; 2009. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for Alaska: April 1, 2000 to July 1, 2008. SC-EST2008-02-02. Washington, DC: U.S. Census Bureau; 2009. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for Arizona: April 1, 2000 to July 1, 2008. SC-EST2008-02-04. Washington, DC: U.S. Census Bureau; 2009. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for Arkansas: April 1, 2000 to July 1, 2008. SC-EST2008-02-05. Washington, DC: U.S. Census Bureau; 2009. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for California: April 1, 2000 to July 1, 2008. SC-EST2008-02-06. Washington, DC: U.S. Census Bureau; 2009. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for Colorado: April 1, 2000 to July 1, 2008. SC-EST2008-02-08. Washington, DC: U.S. Census Bureau; 2009. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for Connecticut: April 1, 2000 to July 1, 2008. SC-EST2008-02-09. Washington, DC: U.S. Census Bureau; 2009. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for Delaware: April 1, 2000 to July 1, 2008. SC-EST2008-02-10. Washington, DC: U.S. Census Bureau; 2009. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for District of Columbia: April 1, 2000 to July 1, 2008. SC-EST2008-02-11. Washington, DC: U.S. Census Bureau; 2009. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for Florida: April 1, 2000 to July 1, 2008. SC-EST2008-02-12. Washington, DC: U.S. Census Bureau; 2009. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for Georgia: April 1, 2000 to July 1, 2008. SC-EST2008-02-13. Washington, DC: U.S. Census Bureau; 2009. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for Hawaii: April 1, 2000 to July 1, 2008. SC-EST2008-02-15. Washington, DC: U.S. Census Bureau; 2009. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for Idaho: April 1, 2000 to July 1, 2008. SC-EST2008-02-16. Washington, DC: U.S. Census Bureau; 2009. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for Illinois: April 1, 2000 to July 1, 2008. SC-EST2008-02-17. Washington, DC: U.S. Census Bureau; 2009. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for Indiana: April 1, 2000 to July 1, 2008. SC-EST2008-02-18. Washington, DC: U.S. Census Bureau; 2009. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for Iowa: April 1, 2000 to July 1, 2008. SC-EST2008-02-19. Washington, DC: U.S. Census Bureau; 2009. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for Kansas: April 1, 2000 to July 1, 2008. SC-EST2008-02-20. Washington, DC: U.S. Census Bureau; 2009. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for Kentucky: April 1, 2000 to July 1, 2008. SC-EST2008-02-21. Washington, DC: U.S. Census Bureau; 2009. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for Louisiana: April 1, 2000 to July 1, 2008. SC-EST2008-02-22. Washington, DC: U.S. Census Bureau; 2009. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for Maine: April 1, 2000 to July 1, 2008. SC-EST2008-02-23. Washington, DC: U.S. Census Bureau; 2009. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for Maryland: April 1, 2000 to July 1, 2008. SC-EST2008-02-24. Washington, DC: U.S. Census Bureau; 2009. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for Massachusetts: April 1, 2000 to July 1, 2008. SC-EST2008-02-25. Washington, DC: U.S. Census Bureau; 2009. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for Michigan: April 1, 2000 to July 1, 2008. SC-EST2008-02-26. Washington, DC: U.S. Census Bureau; 2009. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for Minnesota: April 1, 2000 to July 1, 2008. SC-EST2008-02-27. Washington, DC: U.S. Census Bureau; 2009. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for Misississippi: April 1, 2000 to July 1, 2008. SC-EST2008-02-28. Washington, DC: U.S. Census Bureau; 2009. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for Missouri: April 1, 2000 to July 1, 2008. SC-EST2008-02-29. Washington, DC: U.S. Census Bureau; 2009. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for Montana: April 1, 2000 to July 1, 2008. SC-EST2008-02-30. Washington, DC: U.S. Census Bureau; 2009. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for Nebraska: April 1, 2000 to July 1, 2008. SC-EST2008-02-31. Washington, DC: U.S. Census Bureau; 2009. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for Nevada: April 1, 2000 to July 1, 2008. SC-EST2008-02-32. Washington, DC: U.S. Census Bureau; 2009. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for New Hampshire: April 1, 2000 to July 1, 2008. SC-EST2008-02-33. Washington, DC: U.S. Census Bureau; 2009. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for New Jersey: April 1, 2000 to July 1, 2008. SC-EST2008-02-34. Washington, DC: U.S. Census Bureau; 2009. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for New Mexico: April 1, 2000 to July 1, 2008. SC-EST2008-02-35. Washington, DC: U.S. Census Bureau; 2009. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for New York: April 1, 2000 to July 1, 2008. SC-EST2008-02-36. Washington, DC: U.S. Census Bureau; 2009. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for North Carolina: April 1, 2000 to July 1, 2008. SC-EST2008-02-37. Washington, DC: U.S. Census Bureau; 2009. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for North Dakota: April 1, 2000 to July 1, 2008. SC-EST2008-02-38. Washington, DC: U.S. Census Bureau; 2009. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for Ohio: April 1, 2000 to July 1, 2008. SC-EST2008-02-39. Washington, DC: U.S. Census Bureau; 2009. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for Oklahoma: April 1, 2000 to July 1, 2008. SC-EST2008-02-40. Washington, DC: U.S. Census Bureau; 2009. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for Oregon: April 1, 2000 to July 1, 2008. SC-EST2008-02-41. Washington, DC: U.S. Census Bureau; 2009. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for Pennsylvania: April 1, 2000 to July 1, 2008. SC-EST2008-02-42. Washington, DC: U.S. Census Bureau; 2009. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for Rhode Island: April 1, 2000 to July 1, 2008. SC-EST2008-02-44. Washington, DC: U.S. Census Bureau; 2009. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for South Carolina: April 1, 2000 to July 1, 2008. SC-EST2008-02-45. Washington, DC: U.S. Census Bureau; 2009. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for South Dakota: April 1, 2000 to July 1, 2008. SC-EST2008-02-46. Washington, DC: U.S. Census Bureau; 2009. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for Tennessee: April 1, 2000 to July 1, 2008. SC-EST2008-02-47. Washington, DC: U.S. Census Bureau; 2009. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for Texas: April 1, 2000 to July 1, 2008. SC-EST2008-02-48. Washington, DC: U.S. Census Bureau; 2009. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for Utah: April 1, 2000 to July 1, 2008. SC-EST2008-02-49. Washington, DC: U.S. Census Bureau; 2009. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for Vermont: April 1, 2000 to July 1, 2008. SC-EST2008-02-50. Washington, DC: U.S. Census Bureau; 2009. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for Virginia: April 1, 2000 to July 1, 2008. SC-EST2008-02-51. Washington, DC: U.S. Census Bureau; 2009. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for Washington: April 1, 2000 to July 1, 2008. SC-EST2008-02-53. Washington, DC: U.S. Census Bureau; 2009. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for West Virginia: April 1, 2000 to July 1, 2008. SC-EST2008-02-54. Washington, DC: U.S. Census Bureau; 2009. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for Wisconsin: April 1, 2000 to July 1, 2008. SC-EST2008-02-55. Washington, DC: U.S. Census Bureau; 2009. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for Wyoming: April 1, 2000 to July 1, 2008. SC-EST2008-02-56. Washington, DC: U.S. Census Bureau; 2009. Table 4-2. Number of Physicians in the Largest Specialties by Major Professional Activity as of 2007 American College of Surgeons Health Policy Research Institute, Association of American Medical Colleges. The surgical workforce in the United States: profile and recent trends. Chapel Hill (NC); Washington, DC: ACS HPRI; AAMC; 2009. Table 4-3. Fellows and Junior Fellows in Practice of the American College of Obstetricians and Gynecologists by State, 2010. American Congress of Obstetricians and Gynecologists. Membership information. Washington, DC: American Congress of Obstetricians and Gynecologists; 2010. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for Alabama: April 1, 2000 to July 1, 2008. SC-EST2008-02-01. Washington, DC: U.S. Census Bureau; 2009. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for Alaska: April 1, 2000 to July 1, 2008. SC-EST2008-02-02. Washington, DC: U.S. Census Bureau; 2009. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for Arizona: April 1, 2000 to July 1, 2008. SC-EST2008-02-04. Washington, DC: U.S. Census Bureau; 2009. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for Arkansas: April 1, 2000 to July 1, 2008. SC-EST2008-02-05. Washington, DC: U.S. Census Bureau; 2009. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for California: April 1, 2000 to July 1, 2008. SC-EST2008-02-06. Washington, DC: U.S. Census Bureau; 2009. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for Colorado: April 1, 2000 to July 1, 2008. SC-EST2008-02-08. Washington, DC: U.S. Census Bureau; 2009. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for Connecticut: April 1, 2000 to July 1, 2008. SC-EST2008-02-09. Washington, DC: U.S. Census Bureau; 2009. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for Delaware: April 1, 2000 to July 1, 2008. SC-EST2008-02-10. Washington, DC: U.S. Census Bureau; 2009. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for District of Columbia: April 1, 2000 to July 1, 2008. SC-EST2008-02-11. Washington, DC: U.S. Census Bureau; 2009. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for Florida: April 1, 2000 to July 1, 2008. SC-EST2008-02-12. Washington, DC: U.S. Census Bureau; 2009. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for Georgia: April 1, 2000 to July 1, 2008. SC-EST2008-02-13. Washington, DC: U.S. Census Bureau; 2009. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for Hawaii: April 1, 2000 to July 1, 2008. SC-EST2008-02-15. Washington, DC: U.S. Census Bureau; 2009. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for Idaho: April 1, 2000 to July 1, 2008. SC-EST2008-02-16. Washington, DC: U.S. Census Bureau; 2009. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for Illinois: April 1, 2000 to July 1, 2008. SC-EST2008-02-17. Washington, DC: U.S. Census Bureau; 2009. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for Indiana: April 1, 2000 to July 1, 2008. SC-EST2008-02-18. Washington, DC: U.S. Census Bureau; 2009. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for Iowa: April 1, 2000 to July 1, 2008. SC-EST2008-02-19. Washington, DC: U.S. Census Bureau; 2009. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for Kansas: April 1, 2000 to July 1, 2008. SC-EST2008-02-20. Washington, DC: U.S. Census Bureau; 2009. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for Kentucky: April 1, 2000 to July 1, 2008. SC-EST2008-02-21. Washington, DC: U.S. Census Bureau; 2009. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for Louisiana: April 1, 2000 to July 1, 2008. SC-EST2008-02-22. Washington, DC: U.S. Census Bureau; 2009. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for Maine: April 1, 2000 to July 1, 2008. SC-EST2008-02-23. Washington, DC: U.S. Census Bureau; 2009. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for Maryland: April 1, 2000 to July 1, 2008. SC-EST2008-02-24. Washington, DC: U.S. Census Bureau; 2009. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for Massachusetts: April 1, 2000 to July 1, 2008. SC-EST2008-02-25. Washington, DC: U.S. Census Bureau; 2009. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for Michigan: April 1, 2000 to July 1, 2008. SC-EST2008-02-26. Washington, DC: U.S. Census Bureau; 2009. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for Minnesota: April 1, 2000 to July 1, 2008. SC-EST2008-02-27. Washington, DC: U.S. Census Bureau; 2009. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for Misississippi: April 1, 2000 to July 1, 2008. SC-EST2008-02-28. Washington, DC: U.S. Census Bureau; 2009. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for Missouri: April 1, 2000 to July 1, 2008. SC-EST2008-02-29. Washington, DC: U.S. Census Bureau; 2009. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for Montana: April 1, 2000 to July 1, 2008. SC-EST2008-02-30. Washington, DC: U.S. Census Bureau; 2009. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for Nebraska: April 1, 2000 to July 1, 2008. SC-EST2008-02-31. Washington, DC: U.S. Census Bureau; 2009. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for Nevada: April 1, 2000 to July 1, 2008. SC-EST2008-02-32. Washington, DC: U.S. Census Bureau; 2009. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for New Hampshire: April 1, 2000 to July 1, 2008. SC-EST2008-02-33. Washington, DC: U.S. Census Bureau; 2009. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for New Jersey: April 1, 2000 to July 1, 2008. SC-EST2008-02-34. Washington, DC: U.S. Census Bureau; 2009. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for New Mexico: April 1, 2000 to July 1, 2008. SC-EST2008-02-35. Washington, DC: U.S. Census Bureau; 2009. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for New York: April 1, 2000 to July 1, 2008. SC-EST2008-02-36. Washington, DC: U.S. Census Bureau; 2009. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for North Carolina: April 1, 2000 to July 1, 2008. SC-EST2008-02-37. Washington, DC: U.S. Census Bureau; 2009. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for North Dakota: April 1, 2000 to July 1, 2008. SC-EST2008-02-38. Washington, DC: U.S. Census Bureau; 2009. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for Ohio: April 1, 2000 to July 1, 2008. SC-EST2008-02-39. Washington, DC: U.S. Census Bureau; 2009. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for Oklahoma: April 1, 2000 to July 1, 2008. SC-EST2008-02-40. Washington, DC: U.S. Census Bureau; 2009. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for Oregon: April 1, 2000 to July 1, 2008. SC-EST2008-02-41. Washington, DC: U.S. Census Bureau; 2009. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for Pennsylvania: April 1, 2000 to July 1, 2008. SC-EST2008-02-42. Washington, DC: U.S. Census Bureau; 2009. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for Rhode Island: April 1, 2000 to July 1, 2008. SC-EST2008-02-44. Washington, DC: U.S. Census Bureau; 2009. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for South Carolina: April 1, 2000 to July 1, 2008. SC-EST2008-02-45. Washington, DC: U.S. Census Bureau; 2009. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for South Dakota: April 1, 2000 to July 1, 2008. SC-EST2008-02-46. Washington, DC: U.S. Census Bureau; 2009. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for Tennessee: April 1, 2000 to July 1, 2008. SC-EST2008-02-47. Washington, DC: U.S. Census Bureau; 2009. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for Texas: April 1, 2000 to July 1, 2008. SC-EST2008-02-48. Washington, DC: U.S. Census Bureau; 2009. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for Utah: April 1, 2000 to July 1, 2008. SC-EST2008-02-49. Washington, DC: U.S. Census Bureau; 2009. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for Vermont: April 1, 2000 to July 1, 2008. SC-EST2008-02-50. Washington, DC: U.S. Census Bureau; 2009. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for Virginia: April 1, 2000 to July 1, 2008. SC-EST2008-02-51. Washington, DC: U.S. Census Bureau; 2009. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for Washington: April 1, 2000 to July 1, 2008. SC-EST2008-02-53. Washington, DC: U.S. Census Bureau; 2009. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for West Virginia: April 1, 2000 to July 1, 2008. SC-EST2008-02-54. Washington, DC: U.S. Census Bureau; 2009. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for Wisconsin: April 1, 2000 to July 1, 2008. SC-EST2008-02-55. Washington, DC: U.S. Census Bureau; 2009. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for Wyoming: April 1, 2000 to July 1, 2008. SC-EST2008-02-56. Washington, DC: U.S. Census Bureau; 2009. Figure 4-6. Districts of the American Congress of Obstetricians and Gynecologists. ACOG District Map. Washington, DC: American Congress of Obstetricians and Gynecologists; 2011. Available at: http://www.acog.org/departments/juniorFellows/DistrictMap.pdf. Retrieved April 1, 2011. Figure 4-7. Percent change in the number of active physicians categorized by medical specialty, 1996-2006. American Medical Association. Physician characteristics and distribution in the US. 2008. Chicago (IL): AMA; 2008. American Medical Association. Physician characteristics and distribution in the US. 1997-1998. Chicago (IL): AMA; 1997. Figure 4-8. Percentage of active physicians practicing in same state as their resident training categorized by medical specialty as of 2007. Association of American Medical Colleges. 2008 physician specialty data. Center for Workforce Studies. Washington, DC: AAMC; 2008. Available at: https://www.aamc.org/download/47352/data/specialtydata.pdf. Retrieved April 12, 2011. © 2008 Association of American Medical Colleges. All rights reserved. Reproduced with permission. Figure 4-9. Percentage of active physicians with U.S. medical degrees categorized by medical specialty as of 2007. Association of American Medical Colleges. 2008 physician specialty data. Center for Workforce Studies. Washington, DC: AAMC; 2008. Available at: https://www.aamc.org/download/47352/data/specialtydata.pdf. Retrieved April 12, 2011. © 2008 Association of American Medical Colleges. All rights reserved. Reproduced with permission. Figure 4-10. Percentage of active physicians with international medical degrees categorized my medical specialty as of 2007. Association of American Medical Colleges. 2008 physician specialty data. Center for Workforce Studies. Washington, DC: AAMC; 2008. Available at: https://www.aamc.org/download/47352/data/specialtydata.pdf. Retrieved April 12, 2011. © 2008 Association of American Medical Colleges. All rights reserved. Reproduced with permission. Figure 4-11. Percentage of active physicians with osteopathic degrees categorized by medical specialty as of 2007. Association of American Medical Colleges. 2008 physician specialty data. Center for Workforce Studies. Washington, DC: AAMC; 2008. Available at: https://www.aamc.org/download/47352/data/specialtydata.pdf. Retrieved April 12, 2011. © 2008 Association of American Medical Colleges. All rights reserved. Reproduced with permission. Table 4-4. Fellows and Junior Fellows in Practice per 20,000 Women of Reproductive Age According to Districts of the American College of Obstetricians and Gynecologists (Excluding the Armed Forces District) American Congress of Obstetricians and Gynecologists. Membership information. Washington, DC: American Congress of Obstetricians and Gynecologists; 2010. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for Alabama: April 1, 2000 to July 1, 2008. SC-EST2008-02-01. Washington, DC: U.S. Census Bureau; 2009. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for Alaska: April 1, 2000 to July 1, 2008. SC-EST2008-02-02. Washington, DC: U.S. Census Bureau; 2009. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for Arizona: April 1, 2000 to July 1, 2008. SC-EST2008-02-04. Washington, DC: U.S. Census Bureau; 2009. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for Arkansas: April 1, 2000 to July 1, 2008. SC-EST2008-02-05. Washington, DC: U.S. Census Bureau; 2009. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for California: April 1, 2000 to July 1, 2008. SC-EST2008-02-06. Washington, DC: U.S. Census Bureau; 2009. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for Colorado: April 1, 2000 to July 1, 2008. SC-EST2008-02-08. Washington, DC: U.S. Census Bureau; 2009. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for Connecticut: April 1, 2000 to July 1, 2008. SC-EST2008-02-09. Washington, DC: U.S. Census Bureau; 2009. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for Delaware: April 1, 2000 to July 1, 2008. SC-EST2008-02-10. Washington, DC: U.S. Census Bureau; 2009. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for District of Columbia: April 1, 2000 to July 1, 2008. SC-EST2008-02-11. Washington, DC: U.S. Census Bureau; 2009. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for Florida: April 1, 2000 to July 1, 2008. SC-EST2008-02-12. Washington, DC: U.S. Census Bureau; 2009. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for Georgia: April 1, 2000 to July 1, 2008. SC-EST2008-02-13. Washington, DC: U.S. Census Bureau; 2009. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for Hawaii: April 1, 2000 to July 1, 2008. SC-EST2008-02-15. Washington, DC: U.S. Census Bureau; 2009. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for Idaho: April 1, 2000 to July 1, 2008. SC-EST2008-02-16. Washington, DC: U.S. Census Bureau; 2009. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for Illinois: April 1, 2000 to July 1, 2008. SC-EST2008-02-17. Washington, DC: U.S. Census Bureau; 2009. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for Indiana: April 1, 2000 to July 1, 2008. SC-EST2008-02-18. Washington, DC: U.S. Census Bureau; 2009. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for Iowa: April 1, 2000 to July 1, 2008. SC-EST2008-02-19. Washington, DC: U.S. Census Bureau; 2009. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for Kansas: April 1, 2000 to July 1, 2008. SC-EST2008-02-20. Washington, DC: U.S. Census Bureau; 2009. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for Kentucky: April 1, 2000 to July 1, 2008. SC-EST2008-02-21. Washington, DC: U.S. Census Bureau; 2009. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for Louisiana: April 1, 2000 to July 1, 2008. SC-EST2008-02-22. Washington, DC: U.S. Census Bureau; 2009. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for Maine: April 1, 2000 to July 1, 2008. SC-EST2008-02-23. Washington, DC: U.S. Census Bureau; 2009. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for Maryland: April 1, 2000 to July 1, 2008. SC-EST2008-02-24. Washington, DC: U.S. Census Bureau; 2009. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for Massachusetts: April 1, 2000 to July 1, 2008. SC-EST2008-02-25. Washington, DC: U.S. Census Bureau; 2009. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for Michigan: April 1, 2000 to July 1, 2008. SC-EST2008-02-26. Washington, DC: U.S. Census Bureau; 2009. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for Minnesota: April 1, 2000 to July 1, 2008. SC-EST2008-02-27. Washington, DC: U.S. Census Bureau; 2009. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for Mississippi: April 1, 2000 to July 1, 2008. SC-EST2008-02-28. Washington, DC: U.S. Census Bureau; 2009. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for Missouri: April 1, 2000 to July 1, 2008. SC-EST2008-02-29. Washington, DC: U.S. Census Bureau; 2009. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for Montana: April 1, 2000 to July 1, 2008. SC-EST2008-02-30. Washington, DC: U.S. Census Bureau; 2009. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for Nebraska: April 1, 2000 to July 1, 2008. SC-EST2008-02-31. Washington, DC: U.S. Census Bureau; 2009. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for Nevada: April 1, 2000 to July 1, 2008. SC-EST2008-02-32. Washington, DC: U.S. Census Bureau; 2009. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for New Hampshire: April 1, 2000 to July 1, 2008. SC-EST2008-02-33. Washington, DC: U.S. Census Bureau; 2009. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for New Jersey: April 1, 2000 to July 1, 2008. SC-EST2008-02-34. Washington, DC: U.S. Census Bureau; 2009. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for New Mexico: April 1, 2000 to July 1, 2008. SC-EST2008-02-35. Washington, DC: U.S. Census Bureau; 2009. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for New York: April 1, 2000 to July 1, 2008. SC-EST2008-02-36. Washington, DC: U.S. Census Bureau; 2009. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for North Carolina: April 1, 2000 to July 1, 2008. SC-EST2008-02-37. Washington, DC: U.S. Census Bureau; 2009. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for North Dakota: April 1, 2000 to July 1, 2008. SC-EST2008-02-38. Washington, DC: U.S. Census Bureau; 2009. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for Ohio: April 1, 2000 to July 1, 2008. SC-EST2008-02-39. Washington, DC: U.S. Census Bureau; 2009. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for Oklahoma: April 1, 2000 to July 1, 2008. SC-EST2008-02-40. Washington, DC: U.S. Census Bureau; 2009. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for Oregon: April 1, 2000 to July 1, 2008. SC-EST2008-02-41. Washington, DC: U.S. Census Bureau; 2009. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for Pennsylvania: April 1, 2000 to July 1, 2008. SC-EST2008-02-42. Washington, DC: U.S. Census Bureau; 2009. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for Rhode Island: April 1, 2000 to July 1, 2008. SC-EST2008-02-44. Washington, DC: U.S. Census Bureau; 2009. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for South Carolina: April 1, 2000 to July 1, 2008. SC-EST2008-02-45. Washington, DC: U.S. Census Bureau; 2009. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for South Dakota: April 1, 2000 to July 1, 2008. SC-EST2008-02-46. Washington, DC: U.S. Census Bureau; 2009. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for Tennessee: April 1, 2000 to July 1, 2008. SC-EST2008-02-47. Washington, DC: U.S. Census Bureau; 2009. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for Texas: April 1, 2000 to July 1, 2008. SC-EST2008-02-48. Washington, DC: U.S. Census Bureau; 2009. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for Utah: April 1, 2000 to July 1, 2008. SC-EST2008-02-49. Washington, DC: U.S. Census Bureau; 2009. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for Vermont: April 1, 2000 to July 1, 2008. SC-EST2008-02-50. Washington, DC: U.S. Census Bureau; 2009. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for Virginia: April 1, 2000 to July 1, 2008. SC-EST2008-02-51. Washington, DC: U.S. Census Bureau; 2009. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for Washington: April 1, 2000 to July 1, 2008. SC-EST2008-02-53. Washington, DC: U.S. Census Bureau; 2009. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for West Virginia: April 1, 2000 to July 1, 2008. SC-EST2008-02-54. Washington, DC: U.S. Census Bureau; 2009. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for Wisconsin: April 1, 2000 to July 1, 2008. SC-EST2008-02-55. Washington, DC: U.S. Census Bureau; 2009. Population Division, U.S. Census Bureau. Table 2: annual estimates of the resident population by sex and age for Wyoming: April 1, 2000 to July 1, 2008. SC-EST2008-02-56. Washington, DC: U.S. Census Bureau; 2009. Table 4-5. Practice Setting of Fellows and Junior Fellows in Practice of the American College of Obstetricians and Gynecologists Profile of ob-gyn practice. Washington, DC: ACOG; 2004. Available at: http://www.acog.org/from_home/ departments/practice/ProfileofOb-gynPractice1991-2003.pdf. Retrieved February 1, 2011. 2003 Socioeconomic survey of ACOG Fellows. Washington, DC: American College of Obstetricians and Gynecologists; 2004. Available at: http://www.acog.org/from_home/departments/practice/ProfileofOb- gynPractice1991-2003.pdf. Retrieved February 1, 2011. 2008 Socioeconomic Survey of ACOG Fellows. Washington, DC: American Congress of Obstetricians and Gynecologists; 2010. Available at: http://www.acog.org/departments/dept_notice. cfm?recno=19&bulletin=5099. Retrieved October 5, 2010. Table 4-6. Trends in Numbers of Obstetrician-Gynecologists by Subspecialty The A.B.O.G. Diplomate. 34. Dallas (TX): American Board of Obstetrics and Gynecology; 2008. p. 1-7. The A.B.O.G. Diplomate. 32. Dallas (TX): American Board of Obstetrics and Gynecology; 2006. p. 1-6. The A.B.O.G. Diplomate. 31. Dallas (TX): American Board of Obstetrics and Gynecology; 2005. p. 1-7. The A.B.O.G. Diplomate. 30. Dallas (TX): American Board of Obstetrics and Gynecology; 2004. p. 1-6. The A.B.O.G. Diplomate. 29. Dallas (TX): American Board of Obstetrics and Gynecology; 2002-2003. p. 1-6. The A.B.O.G. Diplomate. 28. Dallas (TX): American Board of Obstetrics and Gynecology; 2001-2002. p. 1-10. The A.B.O.G. Diplomate. 27. Dallas (TX): American Board of Obstetrics and Gynecology; 2000-2001. p. 1-6. The A.B.O.G. Diplomate. 26. Dallas (TX): American Board of Obstetrics and Gynecology; 1999-2000. p. 1-7. The A.B.O.G. Diplomate. 25. Dallas (TX): American Board of Obstetrics and Gynecology; 1998. p. 1-6. The A.B.O.G. Diplomate. 24. Dallas (TX): American Board of Obstetrics and Gynecology; 1997. p. 1-8. The A.B.O.G. Diplomate. 23. Dallas (TX): American Board of Obstetrics and Gynecology; 1996. p. 1-5. The A.B.O.G. Diplomate. 22. Dallas (TX): American Board of Obstetrics and Gynecology; 1995. p. 1-5. The A.B.O.G. Diplomate. 21. Dallas (TX): American Board of Obstetrics and Gynecology; 1994. p. 1-5. Table 4-7. Self-Designated General Obstetrician-Gynecologists Versus Self-Designated Subspecialists by Year of Survey American Medical Association. Physician characteristics and distribution in the US. 2010. Chicago (IL): AMA; 2010. Figure 4-12. Mean ages of the male and female Fellows of the American College of Obstetricians and Gynecologists. American Congress of Obstetricians and Gynecologists. Membership information. Washington, DC: American Congress of Obstetricians and Gynecologists; 2010. Figure 4-13. Age intervals of the Fellows of the American College of Obstetricians and Gynecologists by gender as of 2010. American Congress of Obstetricians and Gynecologists. Membership information. Washington, DC: American Congress of Obstetricians and Gynecologists; 2010. Figure 4-14. Numbers of Fellows and Junior Fellows in Practice of the American College of Obstetricians and Gynecologists per 10,000 women by county in 2010. American Congress of Obstetricians and Gynecologists. Membership information. Washington, DC: American Congress of Obstetricians and Gynecologists; 2010. U.S. Census Bureau. Population estimates. Washington, DC: Census; 2010. Available at: http://www.census. gov/popest/estimates.html. Retrieved March 30, 2011. Figure 4-15. Numbers of Fellows and Junior Fellows in Practice of the American College of Obstetricians and Gynecologists per 10,000 women by state in 2010. American Congress of Obstetricians and Gynecologists. Membership information. Washington, DC: American Congress of Obstetricians and Gynecologists; 2010. U.S. Census Bureau. Population estimates. Washington, DC: Census; 2010. Available at: http://www.census. gov/popest/estimates.html. Retrieved March 30, 2011. Figure 4-16. Numbers of Fellows and Junior Fellows in Practice of the American College of Obstetricians and Gynecologists per 10,000 repriductive-aged women by county in 2010. American Congress of Obstetricians and Gynecologists. Membership information. Washington, DC: American Congress of Obstetricians and Gynecologists; 2010. U.S. Census Bureau. Population estimates. Washington, DC: Census; 2010. Available at: http://www.census. gov/popest/estimates.html. Retrieved March 30, 2011. Figure 4-17. Numbers of Fellows and Junior Fellows in Practice of the American College of Obstetricians and Gynecologists per 10,000 reproductive-aged women by state in 2010. American Congress of Obstetricians and Gynecologists. Membership information. Washington, DC: American Congress of Obstetricians and Gynecologists; 2010. U.S. Census Bureau. Population estimates. Washington, DC: Census; 2010. Available at: http://www.census. gov/popest/estimates.html. Retrieved March 30, 2011. Figure 4-18. Sites of allopathic and osteopathic residency programs in relation to the number of Fellows and Junior Fellows in Practice of the American College of Obstetricians and Gynecologists per 10,000 women by state in 2010. American Congress of Obstetricians and Gynecologists. Membership information. Washington, DC: American Congress of Obstetricians and Gynecologists; 2010. U.S. Census Bureau. Population estimates. Washington, DC: Census; 2010. Available at: http://www.census. gov/popest/estimates.html. Retrieved March 30, 2011. Table 4-8. Self-Designated General Obstetrician-Gynecologists Versus Self-Designated Subspecialists by Age and Gender American Medical Association. Physician characteristics and distribution in the US. 2010. Chicago (IL): AMA; 2010. Table 4-9. Racial Distribution of Physicians in Relation to U.S. Population in 2008 American Medical Association. Physician characteristics and distribution in the US. 2010. Chicago (IL): AMA; 2010. U.S. Census Bureau. Statistical abstract of the United States: 2010. 130th ed. Washington, DC: USCB; 2010. Available at: http://www.census.gov/prod/2011pubs/11statab/pop.pdf. Retrieved January 6, 2011. 5 Obstetrician-Gynecologists as Coordinators of Women's Health Care and as Surgical Specialists Table 5-1. Topics Assessed at a Typical Women's Annual Visit by a Generalist and a Subspecialist Obstetrician-Gynecologist Coleman VH, Laube DW, Hale RW, Williams SB, Power ML, Schulkin J. Obstetrician-gynecologists and primary care: training during obstetrics-gynecology residency and current practice patterns. Acad Med 2007;82:602-7. Figure 5-1. Top 20 specialties with the largest numbers of active physicians as of 2007. Association of American Medical Colleges. 2008 physician specialty data. Center for Workforce Studies. Washington, DC: AAMC; 2008. Available at: https://www.aamc.org/download/47352/data/specialtydata.pdf. Retrieved April 12, 2011. © 2008 Association of American Medical Colleges. All rights reserved. Reproduced with permission. Figure 5-2. Number of patients in the general population per active physician categorized by medical specialty as of 2007. Association of American Medical Colleges. 2008 physician specialty data. Center for Workforce Studies. Washington, DC: AAMC; 2008. Available at: https://www.aamc.org/download/47352/data/specialtydata.pdf. Retrieved April 12, 2011. © 2008 Association of American Medical Colleges. All rights reserved. Reproduced with permission. Figure 5-3. Number of active physicians per 100,000 population categorized by surgical specialty as of 2008. American College of Surgeons Health Policy Research Institute, Association of American Medical Colleges. The surgical workforce in the United States: profile and recent trends. Chapel Hill (NC): ACS HPRI; Washington, DC: AAMC; 2009. Figure 5-4. Numbers of intern applicants to residency programs categorized by surgical specialty as of 2007. American College of Surgeons Health Policy Research Institute, Association of American Medical Colleges. The surgical workforce in the United States: profile and recent trends. Chapel Hill (NC): ACS HPRI; Washington, DC: AAMC; 2009. Figure 5-5. Number of residents completing a program accredited by the Accreditation Council of Graduate Medical Education categorized by surgical specialty as of 2006. Brotherton SE, Etzel SI. Graduate medical education, 2006-2007. JAMA 2007;298:1081-96. Figure 5-6. Percentage of active physicians practicing in the same state as their medical school training categorized by surgical specialty as of 2008. American College of Surgeons Health Policy Research Institute, Association of American Medical Colleges. The surgical workforce in the United States: profile and recent trends. Chapel Hill (NC): ACS HPRI; Washington, DC: AAMC; 2009. Figure 5-7. Percentage of active physicians practicing in the same state as their residency categorized by surgical specialty as of 2008. American College of Surgeons Health Policy Research Institute, Association of American Medical Colleges. The surgical workforce in the United States: profile and recent trends. Chapel Hill (NC): ACS HPRI; Washington, DC: AAMC; 2009. Figure 5-8. Percentage of female residents in programs accredited by the Accreditation Council of Graduate Medical Education categorized by surgical specialty as of 2010. Brotherton SE, Etzel SI. Graduate medical education, 2009-2010. JAMA 2010;304:1255-70. Figure 5-9. Percentage of active physicians who are female categorized by surgical specialty as of 2008. American College of Surgeons Health Policy Research Institute, Association of American Medical Colleges. The surgical workforce in the United States: profile and recent trends. Chapel Hill (NC): ACS HPRI; Washington, DC: AAMC; 2009. Table 5-2. Procedures Performed Annually by the American College of Obstetricians and Gynecologists Fellows and Junior Fellows in Practice 2008 Socioeconomic Survey of ACOG Fellows. Washington, DC: American Congress of Obstetricians and Gynecologists; 2010. Available at: http://www.acog.org/departments/dept_notice. cfm?recno=19&bulletin=5099. Retrieved October 5, 2010. Figure 5-10. Percentage of active physicians aged 55 years or older categorized by surgical specialty as of 2008. American College of Surgeons Health Policy Research Institute, Association of American Medical Colleges. The surgical workforce in the United States: profile and recent trends. Chapel Hill (NC): ACS HPRI; Washington, DC: AAMC; 2009. 6 Financial Considerations and Physician Compensation Figure 6-1. Median medical education debt after attending a private or a public medical school. Association of American Medical Colleges. Medical school tuition and young physician indebtedness: an update to the 2004 report. Washington, DC: AAMC; 2007. p. 1-8. Available at: https://www.aamc.org/ download/105368/data/showfile.pdf. Retrieved February 2, 2011. Association of American Medical Colleges. Medical school tuition and young physician indebtedness. Washington, DC: AAMC; 2004. p. 1-26. Table 6-1. Average Percentage of Physician Revenue by Payment Source American Medical Association. Physician socioeconomic statistics 1999-2000. 1999-2000. Chicago (IL): AMA; 1999. Table 6-2. Estimated Percentage of Time Physicians Spend Providing Health Care to Patients Aged 65 Years and Older Bureau of Health Professions. Health Resources and Services Administration. U.S. Department of Health and Human Services. Changing demographics and the implications for physicians, nurses, and other health workers. Rockville (MD): USDHHS HRSA BHP; 2003. Available at: http://bhpr.hrsa.gov/healthworkforce/ reports/changingdemo/summary.htm. Retrieved October 5, 2010. Table 6-3. Distribution of Type of Health Insurance Coverage U.S. Census Bureau. Table HI01. Health insurance coverage status and type of coverage by selected characteristics: 2007. Current Population Survey: Annual Social and Economic (ASEC) Supplement. Washington, DC: U.S. Census Bureau; 2008. Available at: http://pubdb3.census.gov/macro/032008/health/ h01_001.htm. Retrieved February 2, 2011. Figure 6-2. Ten-year change in median physician compensation from 1995 to 2004. Medical Group Management Association. Physician compensation and production survey: 2006 report based on 2005 data. Englewood (CO): MGMA; 2006. Table 6-4. Physician Compensation Survey by the American Medical Group Association American Medical Group Association. Medical group compensation & financial survey. 2009. Alexandria (VA): AMGA; 2009. Table 6-5. Median Annual Compensation of Physicians by Surgical Specialty American Medical Group Association. Medical group compensation & financial survey. 2009. Alexandria (VA): AMGA; 2009. American Medical Group Association. Medical group compensation & financial survey. 2007. Alexandria (VA): AMGA; 2007. Table 6-6. Median Annual Compensation of Physicians by Obstetric-Gynecologic Specialty Medical Group Management Association. Physician compensation and production survey: 2009 report based on 2008 data. Englewood (CO): MGMA; 2009. Table 6-7. Median Annual Compensation for General Obstetrician-Gynecologists by Research Firm By the numbers. Physicians. Physician compensation survey. Mod Healthc 2009;Suppl:58. Romano M. Holding steady. Specialists are still seeing biggest paychecks, but raises are flat, and some generalists are gaining ground, physician compensation survey shows. Mod Healthc 2005;35(29):S1-5. Moon S. Big demand, bigger paydays. Physician Compensation Survey shows how far primary-care docs lag behind their specialist colleagues in pay range, growth. Mod Healthc 2004;34(29):25-9. Figure 6-3. Professional liability insurance premiums for general obstetrician-gynecologists by state for a $1 million/$3 million claims-made policy as of 2009. Inwald JM. The picture of a market not yet firming: annual rate survey issue. Med Liabil Monit 2009;34(10): 1-39. Figure 6-4. Percent change in average base rate premiums for general obstetrician-gynecologists, 2003-2009. Inwald JM. The picture of a market not yet firming: annual rate survey issue. Med Liabil Monit 2009;34(10):1-39. Figure 6-5. Cumulative change in rates of professional liability insurance by medical specialty. Inwald JM. The picture of a market not yet firming: annual rate survey issue. Med Liabil Monit 2009;34(10):1-39. 7 Career Satisfaction of Obstetrician-Gynecologists and Its Impact on the Workforce Table 7-1. Hours Worked per Week by Obstetrician-Gynecologists in Professional Activities 2008 Socioeconomic Survey of ACOG Fellows. Washington, DC: American Congress of Obstetricians and Gynecologists; 2010. Available at: http://www.acog.org/departments/dept_notice. cfm?recno=19&bulletin=5099. Retrieved October 5, 2010. Profile of ob-gyn practice. Washington, DC: ACOG; 2004. Available at: http://www.acog.org/from_home/ departments/practice/ProfileofOb-gynPractice1991-2003.pdf. Retrieved February 1, 2011. Table 7-2. Distribution of Major Professional Activities by Specialty American Medical Association. Physician characteristics and distribution in the US. 2010. Chicago (IL): AMA; 2010. Table 7-3. Average Age at Which Fellows of the American College of Obstetricians and Gynecologists Stop Practicing Obstetrics Klagholz J, Strunk AL. Overview of the 2009 ACOG survey on professional liability. ACOG Clin Rev 2009;14(6):1, 13-16. Figure 7-1. Percentage of active female physicians categorized by medical specialty as of 2007. Association of American Medical Colleges. 2008 physician specialty data. Center for Workforce Studies. Washington, DC: AAMC; 2008. Available at: https://www.aamc.org/download/47352/data/specialtydata.pdf. Retrieved April 12, 2011. © 2008 Association of American Medical Colleges. All rights reserved. Reproduced with permission. Table 7-4. Obstetric and Gynecologic Practice Changes as a Result of the Affordability or Availability of Professional Liability Insurance Klagholz J, Strunk AL. Overview of the 2009 ACOG survey on professional liability (electronic). Washington, DC: American College of Obstetricians and Gynecologists; 2009. p. 1-6. Available at: http://www.acog.org/ departments/professionalLiability/2009PLSurveyNational.pdf. Retrieved October 5, 2010. Table 7-5. Distribution of Obstetrician-Gynecologists and All Physicians by Age American Medical Association. Physician characteristics and distribution in the US. 2010. Chicago (IL): AMA; 2010. Figure 7-2. Percentage of active physicians aged 55 years or older categorized by medical specialty as of 2007. Association of American Medical Colleges. 2008 physician specialty data. Center for Workforce Studies. Washington, DC: AAMC; 2008. Available at: https://www.aamc.org/download/47352/data/specialtydata.pdf. Retrieved April 12, 2011. © 2008 Association of American Medical Colleges. All rights reserved. Reproduced with permission. Figure 7-3. Fellows of the American College of Obstetricians and Gynecologists aged 55 years or older. American Congress of Obstetricians and Gynecologists. Membership information [unpublished]. Washington, DC: American Congress of Obstetricians and Gynecologists; 2010. 8 Transforming the Women's Health Care Workforce Table 8-1. Estimated Numbers of Training Programs and Practitioners in Various Nonphysician Clinical Specialties Position statement on Nurse Practitioner curriculum. Austin (TX): AANP; 2010. Available at: http://www.aanp. org/AANPCMS2/AboutAANP/NPCurriculum.htm. Retrieved March 21, 2011. Nurse Practitioner facts. Austin (TX): AANP; 2010. Available at: http://www.aanp.org/NR/ rdonlyres/54B71B02-D4DB-4A53-9FA6-23DDA0EDD6FC/0/NPFacts2010.pdf. Retrieved March 21, 2011. FAQs about PAs. Alexandria (VA): AAPA; 2011. Available at: http://www.aapa.org/about-pas/faq-about-pas. Retrieved March 21, 2011. Essential facts about midwives. Silver Spring (MD): ACNM; 2009. Available at: http://www.midwife.org/ Essential-Facts-about-Midwives. Retrieved April 12, 2011. Midwifery education programs. Silver Spring (MD): ACNM; 2009. Available at: http://www.midwife.org/ eduprog_all.cfm. Retrieved March 21, 2011. PA programs directory. Alexandria (VA): PAEA; 2011. Available at: http://www.paeaonline.org/index. php?ht=d/sp/i/25515/pid/25515. Retrieved March 21, 2011. Figure 8-1. Percentage of live births in the United States attended by certified nurse-midwives. Vital statistics natality data set. Hyattsville (MD): NCHS; 2006. Available at: http://www.cdc.gov/nchs/ VitalStats.htm. Retrieved February 15, 2011. Figure 8-2. Births attended by certified nurse-midwives in 2006 categorized by state. Vital statistics natality data set. Hyattsville (MD): NCHS; 2006. Available at: http://www.cdc.gov/nchs/ VitalStats.htm. Retrieved February 15, 2011. Table 8-2. Place of Delivery and Number of Live Births by Attendant in the United States in 2007 Martin JA, Hamilton BE, Sutton PD, Ventura SJ, Mathews TJ, Kirmeyer S, et al. Births: final data for 2007. Natl Vital Stat Rep 2010;58(24):1-85. Available at: http://www.cdc.gov/nchs/data/nvsr/nvsr58/nvsr58_24.pdf. Retrieved March 29, 2011. Table 8-3. National Trends in the Numbers of Nurse Practitioners and Physician Assistants Scheffler RM. Reshaping the workforce: nurse practitioners and physician assistants. In: Is there a doctor in the house? Market signals and tomorrow's supply of doctors. Stanford (CA): Stanford University Press; 2008. p. 53-63. Table 8-4. Trends in Average Net Incomes of Nurse Practitioners and Physician Assistants Compared With Physicians' Incomes Scheffler RM. Reshaping the workforce: nurse practitioners and physician assistants. In: Is there a doctor in the house? Market signals and tomorrow's supply of doctors. Stanford (CA): Stanford University Press; 2008. p. 53-63. Table 8-5. Procedures Performed by 165 Graduates From Family Medicine-Obstetrics and Maternal-Child Health Fellowship Programs Chang Pecci C, Leeman L, Wilkinson J. Family medicine obstetrics fellowship graduates: training and post- fellowship experience. Fam Med 2008;40:326-32. 9 Workforce Projections of Obstetrician-Gynecologists in the United States Figure 9-1. Supply projection of obstetrician-gynecologists. Jacoby I, Meyer GS, Haffner W, Cheng EY, Potter AL, Pearse WH. Modeling the future workforce of obstetrics and gynecology. Obstet Gynecol 1998;92:450-6. Figure 9-2. Illustration of methodology to calculate physician supply. Figure courtesy of William F. Rayburn. Figure 9-3. Projections of the growth of female population by selected age groups in the United States. Population Division, U.S. Census Bureau. Table 2: projections of the population by selected age groups and sex for the U.S.: 2010 to 2050. NP2008-T2. Washington, DC: U.S. Census Bureau; 2008. Available at: http://www. census.gov/population/www/projections/summarytables.html. Retrieved February 19, 2010. Figure 9-4. Number of the female population in the United States for each age group. Population Division, U.S. Census Bureau. Interim projections of the female population by selected age groups for the United States: April 1, 2000 to July 1, 2030. Table B-3. Washington, DC: U.S. Census Bureau; 2005. Available at: http://www.census.gov/population/www/projections/files/SummaryTabB3.pdf. Retrieved March 29, 2011. Figure 9-5. Projected change of the female population for each state and in the United States from 2010 to 2030. Population Division, U.S. Census Bureau. Interim projections of the female population by selected age groups for the United States: April 1, 2000 to July 1, 2030. Table B-3. Washington, DC: U.S. Census Bureau; 2005. Available at: http://www.census.gov/population/www/projections/files/SummaryTabB3.pdf. Retrieved March 29, 2011. Figure 9-6. Projected births in the United States. Population Division, U.S. Census Bureau. Table 1: projections of the population and components of change for the U.S.: 2010 to 2050. NP2008-T1. Washington, DC: U.S. Census Bureau; 2008. Table 9-1. Ten Most Sought After Physicians by Medical Specialty by a Professional Search Firm 2009 review of physician and CRNA recruiting incentives. Irving (TX): Merritt Hawkins & Associates; 2009. Available at: http://www.merritthawkins.com/pdf/mha2009incentivesurvey.pdf. Retrieved March 25, 2011. Table 9-2. Wait times before next appointment at obstetric-gynecologic offices for a nonemergent well-woman gynecologic examination. 2009 survey of physician appointment wait times. Irving (TX): Merritt Hawkins and Associates; 2009. Available at: http://www.merritthawkins.com/pdf/mha2009waittimesurvey.pdf. Retrieved February 25, 2011. Table 9-3. Projections of the Female Population in the United States and for states for 2010 and 2030. Population Division, U.S. Census Bureau. State interim population projections by age and sex, 2004-2030. U.S. population projections. Washington, DC: U.S. Census Bureau; 2004. Available at: http://www.census.gov/ population/www/projections/projectionsagesex.html. Retrieved February 25, 2011. Table 9-4. Projected Need and Shortage of Obstetrician-Gynecologists in Practice (for Anticipated 30 Years and 35 Years of Practice) Williams TE, Satiani B, Ellison EC. Obstetrics and gynecology. The coming shortage of surgeons: why they are disappearing and what that means for our health. Santa Barbara (CA): ABC-CLIO, LLC; 2009. p. 85-92. Figure 9-7. Resident graduates in obstetrics and gynecology per 1,000,000 women. Population Division, U.S. Census Bureau. Interim projections of the female population by selected age groups for the United States: April 1, 2000 to July 1, 2030. Table B-3. Washington, DC: U.S. Census Bureau; 2005. Available at: http://www.census.gov/population/www/projections/files/SummaryTabB3.pdf. Retrieved March 29, 2011. Figure 9-8. Illustration of methodology to calculate physician demand. Figure courtesy of William F. Rayburn. Figure 9-9. Projected shortages in the numbers of obstetrician-gynecologists. Williams TE, Satiani B, Ellison EC. Obstetrics and gynecology. The coming shortage of surgeons: why they are disappearing and what that means for our health. Santa Barbara (CA): ABC-CLIO, LLC; 2009. p. 85-92.aPPendix fColor FiguresFigure 2-1. Locations of allopathic and osteopathic residency programs in obstetrics and gynecology. [Back] (13 programs)(16 programs)(40 programs) (9 programs)Allopathic program Osteopathic program Figure 4-6. Districts of the American Congress of Obstetricians and Gynecologists, 2011. [Back] ... HAWAII C> DISTRICT II Also includes BermudaDISTRICT Ill Also includes the Dominican Republic DISTRICT IV o g JAMAICA PUERTO ' R tcO .. liS WEST INDIES I ' II Other nondistricted section: Argentina CARIBBE:N ISLANDS (OISTRK::T VIII) PANAI.'IA Figure 4-14. Numbers of Fellows and Junior Fellows in Practice of the American College of Obstetricians and Gynecologists per 10,000 women by county in 2010. [Back] None 0.1-1 1.1-2 2.1-3 3.1- 4 4.1 or more Figure 4-15. Numbers of Fellows and Junior Fellows in Practice of the American College of Obstetricians and Gynecologists per 10,000 women by state in 2010. [Back] Less than 2 2-2.2 2.3-2.4 2.4-2.6 2.6-2.8 2.8 or more Figure 4-16. Numbers of Fellows and Junior Fellows in Practice of the American College of Obstetricians and Gynecologists per 10,000 reproductive-aged women by county in 2010. [Back] ACOG Fellows and Junior Fellows in Practice per 10,000 Reproductive Age Women 2009None 0. .1-1 . 1. .1-2 . 2. .1-3 . 3. .1-4 . 4. .1 or moreLess than 2 2-2.2 2.3-2.4 2.4-2.6 2.6-2.8 2.8 and more Figure 4-18. Sites of allopathic and osteopathic residency programs in relation to the number of Fellows and Junior Fellows in Practice of the American College of Obstetricians and Gynecologists per 10,000 women by state in 2010. [Back]Less than 2 2 -2.2 2.3-2.4 2.4 -2.6 2.6 -2.8 2.8 and more Allopathic program Osteopathic program

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