Work-life integration, lower job satisfaction, increasing subspecialization, and concerns about income and professional liability are among the issues shaping the ob/gyn workforce and how they practice, according to a new report from the American Congress of Obstetricians and Gynecologists (ACOG). Available online, The Obstetrician-Gynecologist Workforce in the United States: Facts, Figures, and Implications, 2017 looks at how the landscape of the specialty has changed over the last 6 years.
ACOG last published a workforce analysis in April 2011, little more than a year after the Patient Protection and Affordable Care Act (PPACA) was signed into law. The trends identified in that report are strikingly similar, in some ways, to the findings in the new report. Representation of women in the specialty continues to increase; the ob/gyn workforce in the United States suffers from geographic maldistribution; and lack of growth in adjusted income remains a problem for clinicians (Table).
Looking at how ob/gyns are distributed in the United States, ACOG found that in 2017, there are 35,586 ACOG Fellows in practice (31,163 Fellows and 4235 Junior Fellows), up slightly from 32,737 in 2011. Nearly half of all ob/gyn residents and 58.7% of practicing ob/gyns are women, a much higher proportion than any other group of active surgeons. In the next 10 years, according to ACOG, 66% of ob/gyns are expected to be female. While women are arguably overrepresented in the specialty, minorities—particularly African Americans (11.1%) and Hispanics (6.7%)—are underrepresented.
Of the 3143 counties in the United States, 49% have not 1 ob/gyn, which ACOG says is largely because they lack a hospital with maternity services. More than 10 million US women live in the counties lacking in ob/gyn care, which are mainly rural and in the Central and Mountain West regions. Ob/gyns practicing in rural areas are more likely to be American Indians, Alaska Natives, or Pacific Islanders. Young, male, African-American or international graduates are the ob/gyns most likely to relocate and 6% of all physicians in the specialty did so from 2006 to 2015.
In the 2017 report, ACOG foresees a 6% increase in demand for women’s healthcare in the United States over the next 10 years because of the ongoing increase in the female population (Figure 1). However, the organization also sounds a warning about geographic imbalances in availability of ob/gyns and the cost of training more clinicians to serve states such as Nevada, where the demand is expected to rise by 27%. Also compounding the supply-and-demand issue is the fact that one-third of ob/gyns are aged 55 years or older and so, potentially approaching retirement. “Without increases in the number of obstetric-gynecologic trainees,” says ACOG, “the nation will rely heavily on services by nonphysician healthcare professionals. Furthermore, other physicians trained to address many of the general healthcare needs of women include obstetric-gynecologic subspecialists and primary care physicians in family medicine or ambulatory general internal medicine.” According to the report, more than half of all ob/gyn offices already employ “physician extenders” such as nurse practitioners, certified nurse-midwives, and physician assistants.
A piece of good news in the report is the finding that median compensation for clinicians in the specialty increased between 2010 and 2015 (from $281,190 to $330,696). However, ob/gyns are among the surgeons with the lowest annual compensation. Physicians who practice only gynecology earn approximately $100,000 less per year than their counterparts who practice both obstetrics and gynecology, whereas annual income goes up approximately $100,000 for those who subspecialize. It’s not surprising, then, that more ob/gyn residency graduates are seeking American Board of Obstetrics and Gynecology-accredited fellowships—up from 7% in 2000 to 19.5% in 2012. As they enter practice, the ACOG report notes, these new clinicians will enter a practice environment with an increasing trend toward “value-based care models with payments dependent on reporting patient safety and quality of healthcare measures, achieving desired outcomes, and especially cost savings.” For all ob/gyns, premiums for professional liability insurance continue to loom large as an issue in 2017, as they did in 2011, although both insurance premiums and the frequency and severity of lawsuits in obstetrics have decreased in recent years.
Work-life balance and practice setting
As was also underscored by the findings from Contemporary OB/GYN’s Second Annual Labor Force Survey (Figure 2), the new ACOG report shows that balancing work and home life and avoiding professional burnout are key challenges for ob/gyns. Some 40% to 70% of physicians in the specialty will experience some form of burnout, according to ACOG, and female surgeons are more likely to reduce their clinical work hours or to leave their current practices because of issues with balancing their work and family responsibilities. Data from the Association’s past professional liability surveys indicate that the proportion of ACOG Fellows in solo practice declined from 32% in 1992 to 19% in 2012 whereas the proportion in hospital physicians (15%) and on academic faculty (12%) increased. The report postulates that in the future, ob/gyn practice “will be increasingly office-based, efficient, and oriented toward standardizing practices and improving the patient experience.”
A look into the future
Among the predictions made by ACOG for the coming years in the 2017 report are that:
· Competition for residency positions will continue to increase;
· By 2020, at least one-third of ob/gyn residency graduates will subspecialize;
· By 2022, two-thirds of ob/gyns will be women;
· Ob/gyns’ role as coordinators of women’s healthcare will increase; and
· Competition for inpatient gynecologic surgery will increase.
The Association also calls for ongoing research about the ob/gyn research to address critical questions such as how payment models such as modifications to the PPACA will affect the specialty; whether new recommendations on the well-woman exam and routine pelvic examination will results in a decrease in office visits; and whether the demand for ob/gyns will be altered by the use of new technology, such as telemedicine.