Psychiatrist and nonphysician mental health provider staffing levels in health maintenance organizations.

OBJECTIVE: This study attempts to determine the ratio of full-time-equivalent psychiatrists to members and that of nonphysician mental health professionals to psychiatrists in staff and group model health maintenance organizations (HMOs), and to compare the psychiatrist-to-member ratio with previous estimates of the required psychiatrist-to-population ratios in fee-for-service and managed care environments. METHODS: The Group Health Association of America (now the American Association of Health Plans) collected data on mental health staffing, enrollments, and other characteristics for 30 staff and group model HMOs. The authors evaluated the number of full-time-equivalent psychiatrists and nonphysician mental health professionals per 100,000 HMO members, and the ratio of full-time-equivalent nonphysician mental health professionals to psychiatrists. RESULTS: The overall mean number of full-time-equivalent psychiatrists and nonphysician mental health professionals per 100,000 members in the responding HMOs was 6.8 and 22.9, respectively. The overall mean ratio of nonphysician professionals to psychiatrists was 4.5. The overall number of psychiatrists per 100,000 members is less than half the requirement estimated by the Graduate Medical Education National Advisory Committee in 1980, which assumed a fee-for-service environment, but it is about 40% to 80% greater than that estimated by other studies under the assumption of a managed care environment. CONCLUSIONS: Although a practice environment dominated by managed care may not require as high a psychiatrist-to-population ratio as a predominantly fee-for-service environment, it may well support a greater number of psychiatrists than previous studies have suggested.

Women's reproductive health services in health maintenance organizations.

PIP: Surveys were mailed to health maintenance organizations (HMOs) in February 1994, and the results of all questionnaires were compiled. Of 353 Group Health Association of America (GHAA) members, 236 (66.9%) responded. About 90% of HMOs covered insertion or removal of IUDs, oral contraceptives, and diaphragm fitting. Of these, 78% provided for levonorgestrel implant (Norplant) insertion or removal, and 70% covered at least some diaphragm charges. About 3/4 of the plans required some copayment for Pap tests, IUD insertion or removal, and diaphragm fitting; 67% for levonorgestrel implant insertion and removal; 58% for vasectomies; and 45% for tubal ligation. All HMOs surveyed covered mammography for women 50 years of age or older. Of group-model HMOs, 20% provided mammograms annually even to women between 35 and 40 years of age. Although all HMOs covered Pap tests, about 78% covered Pap tests annually and 18.5% covered them at the discretion of the provider as needed or less frequently than annually. About 88% of HMOs covered at least some abortions. 57% of HMOs responded that they covered abortions. Abortion coverage also varied by HMO model type. Although 75% of staff-model HMOs covered abortion services with no restrictions, only 48% of independent provider associations (IPA) did so. 81% of HMOs either offered enrollers the choice of an obstetrician-gynecologist as their primary care provider or allowed them to self-refer to one. This was true for 55% of staff-model HMOs. Of group and staff models that allowed self-referral, 87% had no restrictions on the number of self-referred obstetric-gynecologic visits per year, compared to 28% of network and IPA models. Certified nurse midwives more often provided routine services in staff models (43%), although they routinely performed pelvic and breast examinations less often in IPAs (20%). 14% of HMOs reported that they contracted with family planning organizations only for abortions, whereas 6% contracted for abortion and other services.^ieng

The relationship of postdoctoral research training to current research activities of faculty in academic departments of psychiatry.

OBJECTIVE: This report describes the postdoctoral research training of faculty in departments of psychiatry and relates research training characteristics to current involvement in research. METHOD: Data were taken from a survey of 3,107 doctoral-level faculty in departments of psychiatry at 116 U.S. medical schools. The survey instrument gathered information about faculty members' postdoctoral research training and current research activities and elicited recommendations for research training programs. RESULTS: Of the survey respondents, 34.8% had had some form of postdoctoral research training. Most of those had trained in medical schools or intramural programs of the National Institutes of Health and federal institutes on alcoholism, drug abuse, and mental health. Most funding came from the federal government. Postdoctoral research training was significantly related to greater current research involvement across all degree types--M.D., Ph.D., and M.D.-Ph.D. Length of training was related to level of research involvement for M.D.s and Ph.D.s but not M.D.-Ph.D.s. Although most researchers believed their training programs prepared them for independent research, a smaller proportion of M.D.s than M.D.-Ph.D.s or Ph.D.s responded affirmatively to that question. Researchers were more likely than nonresearchers to consider their training adequate. Respondents rated time with mentor, course work in statistics, and length of training as the most important training program features. Both research training and research activities were concentrated in a relatively few institutions. CONCLUSIONS: These data show the critical importance of both federal support of research training and postdoctoral research training for subsequent research involvement of psychiatric faculty.

Clinical staffing in staff- and group-model HMOs.

Analysts frequently have used health maintenance organization (HMO) staffing patterns as a yardstick for estimating national clinical workforce requirements. Based on a nationwide survey of fifty-four staff- and group-model HMOs, the largest sample yet used in an analysis of this type, this DataWatch examines physician-to-member ratios, the use of nonphysician providers, and HMOs' methods of estimating clinical staffing needs. Overall physician staffing ratios and primary care physician staffing ratios closely resemble those reported in previous studies, but they exhibit wide variability and are strongly correlated with HMO size. Although caution should be exercised when using HMO staffing ratios in projections of physician workforce requirements, the ratios described here support projections of a specialty physician surplus.

Professional practice patterns of U.S. psychiatrists.

OBJECTIVE: The authors develop a classification of psychiatric practice based on primary and secondary work settings. METHOD: Data from the 1988-1989 APA Professional Activities Survey were used to characterize seven practice groups: public psychiatrists, public psychiatrists with private secondary work settings, private psychiatric/general hospital psychiatrists, private office practice psychiatrists, private office practice psychiatrists with secondary private psychiatric/general hospital work settings, private office practice psychiatrists with secondary settings other than private hospitals, and psychiatrists in private organized outpatient settings. Psychiatrists primarily in government administrative agencies, medical schools, or nursing homes were among those excluded. Usable data were available from 16,135 psychiatrists (82.8% of the target respondents). RESULTS: The largest groups were private psychiatric/general hospital psychiatrists (19.6%), private office practice psychiatrists with secondary settings other than private hospitals (18.9%), and private office practice psychiatrists with secondary private psychiatric/general hospital work settings (17.4%), followed by public psychiatrists with private secondary work settings (14.5%), private office practice psychiatrists (11.7%), public psychiatrists (11.4%), and psychiatrists in private organized outpatient settings (6.6%). During a typical week, the practice groups varied in the average proportion of their outpatients who received assessments, therapy and medication, therapy and no medication, and medication management. The groups also varied in the mean number of patients they treated each month with affective disorders, schizophrenia, anxiety disorders, and other disorders. CONCLUSIONS: Only about one in 10 clinical psychiatrists is engaged exclusively in office-based private practice, and approximately half of the outpatients treated by the average psychiatrist receive medication. Work setting appears to exert a powerful influence over whom psychiatrists treat and what services they provide. Because a majority of psychiatrists work in more than one setting, most psychiatrists serve a broad range of patients and provide a variety of treatments.

Sex differences in psychiatrists' practice patterns and incomes.

OBJECTIVE AND METHOD: Using data from the APA's 1988-1989 Professional Activities Survey, the authors compared male and female psychiatrists on demographic characteristics, training, practice patterns, and income. RESULTS: In keeping with previous studies' findings, female respondents on the average were younger than male respondents and more likely to have taken a residency or fellowship in child or adolescent psychiatry, worked fewer hours per week, allocated their working hours differently among types of activities, saw fewer patients per week, and worked in somewhat different settings. Multiple regression analysis showed that women had significantly lower mean net annual income than men after the effects of those predictors were statistically controlled. CONCLUSIONS: Differences in age, training, hours worked in specific settings, and numbers of patients do not completely account for the gender gap in psychiatrists' annual incomes.

Sex differences in rank attainment and research activities among academic psychiatrists.

Data from a survey distributed to all full-time faculty in academic departments of psychiatry were used to examine possible sex differences in research activities and rank attainment among psychiatrists. A total of 1923 psychiatrists responded, 1564 men (81.3%) and 359 women (18.7%). Continuous dependent variables were analyzed by using analyses of covariance with the year graduated from medical school as a covariate. For categorical dependent variables, the sample was divided into four 10-year cohorts based on the year graduated from medical school, and differences between men and women were analyzed with chi 2 tests. Over the entire sample, men were more likely than women to have had research training, to have ever been principal investigators on peer-reviewed grants, to mentor research trainees, to be currently involved in research activities, and to meet defined criteria as a "researcher." Many gender differences remained significant after controlling for seniority and research training. In every cohort, the men had attained higher academic rank than the women. In general, differences in research activity and productivity were most marked in the youngest cohort. To ensure a rich talent pool for psychiatric research, efforts must be made to recruit and support researchers from among the increased number of women in psychiatry.

Research activities of full-time faculty in academic departments of psychiatry.

Using data collected by a 1989 American Psychiatric Association survey of full-time, salaried faculty in departments of psychiatry at US medical schools, we examined the number of faculty engaged in research, their levels of involvement in research, distribution, sources of funding, fields and topics studied, and training. Using a three-level measure of research involvement, we categorized 39.1% of the respondents as "researchers," 36% as "limited commitment researchers," and 25.1% as not involved in research. In a pattern similar to that observed for research funding in other studies, half of the researchers were concentrated in the top 15 of the 116 responding departments. Level of research involvement varied by degree type (joint-program MD/PhDs were most involved), sources of funding, fields, and topics. Among faculty with MDs, having had research experiences in medical school or postdoctoral research training was associated with a higher level of research involvement. The findings underscore the need to expand and improve postdoctoral research training--especially for MDs--and programs to recruit college and medical students into psychiatric research.

Gender differences in faculty retention and rank attainment in academic departments of psychiatry.

Using 1989 data from the Faculty Roster System of the Association of American Medical Colleges, the authors examined gender differences in retention and rank attainment of psychiatry faculty who had received their first full-time medical school appointments in 1978. Retention differences between men and women were not significant in either the M.D. or the Ph.D. subgroup. Women M.D.'s in the sample had advanced through the academic ranks to a significantly lesser extent than had men M.D.'s; the rank attainment differences among Ph.D.'s, however, were not significant. These results underscore the need for more study of gender differences in the career paths of faculty in academic psychiatry departments.

Factors associated with future psychiatrists' selection of academic or clinical careers.

Graduation Questionnaire data collected by the Association of American Medical Colleges (AAMC) were used to identify student and medical school characteristics associated with future psychiatrists' career plans. Subjects were senior medical students in the class of 1986 who definitely planned to specialize in psychiatry or child psychiatry. Medical school variables such as research experience, publication history, and exposure to a research-oriented environment were associated with plans for a career in academic medicine or research (versus clinical practice). Membership in a non-underrepresented minority group, having taken elective course work at a military or government agency, and having attended a private medical school all were associated with plans for a career in salaried clinical practice (versus private clinical practice).

Sex differences in rank attainment among radiology and internal medicine faculty.

Overall, the percentage of women attaining the ranks of associate professor and professor remains well below the percentage of men in those ranks. Few studies of women in academic medicine have been conducted that might guide the leaders of medical schools and specialty societies in addressing the reasons for this disparity. The Association of American Medical Colleges (AAMC) Faculty Roster System allows comparison of a cohort of faculty at any selected time following their first faculty appointments. This study examined men and women faculty who received their first appointments in the departments of radiology and internal medicine in 1976 and who were still active in 1986. Disparities between men and women in rank attained were apparent in both specialties but were greater in radiology than in internal medicine. Other variables examined include ethnic-racial self-description and teaching, research, patient care, and administrative responsibilities. The authors pose additional research questions requiring information that the Faculty Roster System is not designed to provide.

Postdoctoral research training of full-time faculty in academic departments of medicine.

This report shows the results of a survey of 5604 faculty in departments of medicine, 4200 of whom had postdoctoral research training. As a follow-up to a previous study of research activity in the same population, this retrospective survey focused on location of training, source of funding, structure of the training program, impact of the training experience on career development, and respondents' recommendations for changes in training programs. A predominant finding is that most postdoctoral training occurred in medical schools, and the primary source of funding was the National Institutes of Health. For faculty members with the MD degree, being an active researcher and principal investigator for a peer-reviewed research grant were associated with length of training. The average length of time between the end of postdoctoral research training and obtaining the first peer-reviewed research grant was 24 months, regardless of length of training, source of training support, training site, or type of academic degree (MD, MD-PhD, or PhD). The results of this survey suggest a tentative formula to be a successful researcher in academic medicine: 2 or more years of postdoctoral research training, including formal course work in the fundamental sciences pertinent to biomedical research; 2 to 3 years of full research support from the academic institution until the first extramural grant is obtained; and commitment of at least 33% of time to research activities. The results also suggest directions for change and improvement in future research training programs.

Predictive validity of specialty choice data from AAMC graduation questionnaire. Association of Medical Colleges.

Several previous studies have used data from the Association of American Medical Colleges' annual graduation survey to address questions about medical students' specialty preferences. Only recently, however, has it become possible to test the validity of these data as indicators of the specialties in which students will actually receive training. Comparisons of 1983 graduation questionnaire data with data on the third-year residencies for the same cohort reveal that the specialty preferences indicated on the questionnaire were good predictors of the residency programs the respondents were in during the third year following graduation.

Career, research involvement, and research fellowship plans of potential psychiatrists.

For this investigation, we used Association of American Medical Colleges survey data to compare the career, research involvement, and research fellowship plans of 532 senior medical students in 1985 intending to specialize in psychiatry with plans of 10,516 students designating other specialty preferences, and discriminant analyses to identify factors associated with psychiatry students' career, research, and fellowship plans. Although a higher percentage of the psychiatry students planned academic or research careers than did their classmates in the other specialties (34.6% vs 27.8%), a lower percentage expected to take a research fellowship (15.4% vs 20.7%). In the multivariate analysis, medical school experience variables such as research, publication, and exposure to a research-oriented environment all were associated with plans for a career in academic medicine or research, exclusive or significant research involvement, and plans to complete a research fellowship.

Relationship of scholarships and indebtedness to medical students' career plans.

Discriminant functions analyses of data from the 1983 survey of senior medical students by the Association of American Medical Colleges showed that the effects of scholarships must be taken into account when assessing the influence of indebtedness on medical students' career choices. Receipt of a federal scholarship, type of medical school attended (public or private), marital status, sex, and receipt of a nonfederal scholarship were found to be more powerful than indebtedness as predictors of whether the students preferred primary care or nonprimary care specialties. Receipt of a federal scholarship, type of school attended, and sex were found to be more powerful than indebtedness as predictors of whether the students preferred private clinical practice, salaried clinical practice in a hospital or clinic, salaried clinical practice in a public agency, or a nonclinical career. Indebtedness was found not to be a predictor of willingness to locate in a socioeconomically deprived area.