Correspondence
Availability of Neonatal Intensive Care and Neonatal Mortality
N Engl J Med 2002; 347:1893-1895December 5, 2002
- Article
To the Editor:
The article by Goodman et al. (May 16 issue)1 and the accompanying editorial by Grumbach2 criticize what these authors interpret as excessive concentrations of neonatologists in response to profit-maximizing behavior by hospitals — proof that there are too many specialists. However, a casual inspection of the maps in Figure 1 of the article reveals that most areas with high ratios of neonatologists to neonates are not hotbeds of health care competition but, rather, sparsely populated regions of the country, such as Alaska, Appalachia, northern Maine, western Texas, and the Dakotas. These higher ratios do not represent an “irrational and inequitable deployment” of specialists, as Grumbach states. Instead, this is what happens when 2275 neonatologists distribute themselves among 285 million people who are spread throughout 3000 counties — more counties than neonatologists — and they do so in units of 1. But what if, by Goodman's estimates, a community needs 0.4 or 2.2 neonatologists? It cannot be done. Even worse, some areas get none. And therein lies the difficulty of conducting geographic analyses like this one for specialties that are so small. The truth is that we are on the cusp of progressively worsening shortages of specialists.3,4 Responding to these shortages will be difficult and costly. What is needed now is rigorous and objective workforce planning.
4 ReferencesRichard A. Cooper, M.D.
Medical College of Wisconsin, Milwaukee, WI 53226
rcooper@mcw.edu 1
Goodman DC ,Fisher ES ,Little GA ,Stukel TA ,Chang C ,Schoendorf KS . The relation between the availability of neonatal intensive care and neonatal mortality. N Engl J Med 2002;346:1538-1544
Full Text | Web of Science | Medline2
Grumbach K . Specialists, technology, and newborns -- too much of a good thing. N Engl J Med 2002;346:1574-1575
Full Text | Web of Science | Medline3
Cooper RA ,Getzen TE ,McKee HJ ,Laud P . Economic and demographic trends signal an impending physician shortage. Health Aff (Millwood) 2002;21:140-154
CrossRef | Web of Science | Medline4
Cooper RA . There's a shortage of specialists: is anyone listening? Acad Med 2002;77:761-766
CrossRef | Web of Science | Medline
To the Editor:
I take exception to the contention that a ratio of 4.3 neonatologists per 10,000 births is adequate to prevent increased mortality. Within the past several years, the American Academy of Pediatrics has reduced the service requirement for pediatric residents in the neonatal unit. Many who complete residency training are unable to take care of critically ill neonates. The authors neglect to consider the real-world implications of fewer neonatologists. Our unit has a catchment area with 5000 births per year. We have a census of 40 babies per day. With a 100-hour workweek, four of us must make rounds daily to finish in a timely manner. With 10,000 births, the census would double. How is it proposed that we double our workload?
Mitchell R. Goldstein, M.D.
Citrus Valley Medical Center, West Covina, CA 91790
mrgoldst@pol.net To the Editor:
To evaluate the adequacy or abundance of neonatology services, we believe additional issues should be considered. Although Goodman et al. excluded 429 neonatologists who spent the majority of their time outside of direct clinical care, they did not take into account the distribution of work time by clinically active neonatologists. Stoddard et al.1 reported that 36 percent of the time spent by neonatologists was in areas other than direct care, such as administration, teaching, and research. Pollack et al.2 reported that 60 percent of neonatology practices were providing newborn care, much of which is primary care for babies discharged from the neonatal intensive care unit.
The role of the neonatologist is a complex one in today's health care environment. The fact that the mortality rate in the first 27 days of life is low regardless of neonatal-care staffing is more a testament to the hard work and technological advances that we have seen in neonatology in the past few years than proof that we are overgrown as a specialty.
2 ReferencesIvan Hand, M.D.
Lawrence Noble, M.D.
Jacobi Medical Center, Bronx, NY 10461
hand@aecom.yu. edu 1
Stoddard JJ ,Cull WL ,Jewett EA ,Brotherton SE ,Mulvey HJ ,Alden ER . Providing pediatric subspecialty care: a workforce analysis. Pediatrics 2000;106:1325-1333
CrossRef | Web of Science | Medline2
Pollack LD ,Ratner IM ,Lund GC . United States neonatology practice survey: personnel, practice, hospital, and neonatal intensive care unit characteristics. Pediatrics 1998;101:398-405
CrossRef | Web of Science | Medline
To the Editor:
The findings reported by Goodman et al. may have an explanation not discussed in their article or in the editorial. Many neonatologists now care for infants who do not have low birth weight and are not extremely ill. In doing so, neonatologists have expanded their clinical activities to provide care for infants traditionally cared for by pediatricians. There are two explanations for this change in practice. First, many office-based pediatricians practice in managed-care settings that discourage them from leaving patients with scheduled office visits to care for unscheduled births, even though the infants may not prove to be particularly ill. Second, over the past decade, the Residency Review Committee for Pediatrics has substantially decreased the portion of pediatric training devoted to neonatal intensive care. As a result, recently graduated pediatricians are less experienced — hence, less comfortable — in the resuscitation and subsequent care of moderately or transiently sick neonates. These factors have expanded the role of neonatologists to include the care of relatively low-risk neonates, an area of practice unlikely to affect neonatal mortality, which was the primary outcome measure in the study by Goodman et al.
J. Ross Milley, M.D., Ph.D.
University of Utah School of Medicine, Salt Lake City, UT 84132
ross.milley@hsc. utah. edu Author/Editor Response
The authors reply:
To the Editor: Dr. Cooper's suggestion that a large supply of neonatologists is a rural phenomenon is incorrect. Although the large rural areas on the map catch the eye, there is no relation between the rural or urban nature of Neonatal Intensive Care Regions and the number of neonatologists per newborn. The full range of the supply, from very low to very high, is present in both urban and rural areas.1
Drs. Hand and Noble note that we ignored the nonclinical responsibilities of neonatologists, but there is no evidence that this additional work varies significantly in relation to the fourfold regional variation in the supply of neonatologists. We tested several definitions of the clinical work of neonatologists; our findings were robust in these sensitivity analyses.
We agree with Dr. Goldstein and Dr. Milley that the training time in neonatal intensive care units has decreased since we were pediatric house officers, and general pediatricians with less training may add to the responsibilities of neonatologists. Yet many neonatologists have sufficient time to replace general pediatricians in providing care for low-risk newborns — at a time when the number of patients per physician is declining in both specialties.2,3 Although neonatologists are busy, 68 percent report that they face competition for their services, and 65 percent predict that their communities will not need additional neonatologists in the next three to five years.4
We did not suggest that there are too many specialists in the United States. Dr. Cooper's assertion that there is an impending shortage is based on the assumptions that additional physicians will settle where patients' needs are greater and that adding more specialists will result in improved outcomes. Our study suggests that, for neonatology at least, these assumptions are flawed. The fourfold regional variation in the supply of neonatologists is not explained by differences in newborn risk factors, and a larger supply was not related to lower neonatal mortality, beyond the second (low) quintile of supply.1 Until it is known whether greater numbers of physicians in other specialties would further benefit their patients and populations, we need to temper our enthusiasm for a larger supply of physicians. We expect evidence of safety and effectiveness before adopting new medical interventions. Why not hold further expansion of the supply of physicians to the same standard?
Our analyses do not slight the remarkable accomplishment of neonatology in improving birth-weight–specific outcomes. The next great achievement would be attaining levels of overall perinatal health outcomes that are similar to those for women and newborns in other developed countries.5
5 ReferencesDavid C. Goodman, M.D.
Dartmouth Medical School, Hanover, NH 03755
david.goodman@dartmouth. edu Elliott S. Fisher, M.D., M.P.H.
Veterans Affairs Outcomes Group, White River Junction, VT 05009-0001George A. Little, M.D.
Dartmouth Medical School, Hanover, NH 037551
Goodman DC ,Fisher ES ,Little GA ,Stukel TA ,Chang C ,Schoendorf KS . The relation between the availability of neonatal intensive care and neonatal mortality. N Engl J Med 2002;346:1538-1544
Full Text | Web of Science | Medline2
Pasko T, Seidman B. Physician characteristics and distribution in the US: 1999 edition. Chicago: American Medical Association, 1999.
3
Roback G, Randolph L, Seidman B. Physician characteristics and distribution in the U.S.: 1992 edition. Chicago: American Medical Association, 1992.
4
Stoddard JJ ,Cull WL ,Jewett EA ,Brotherton SE ,Mulvey HJ ,Alden ER . Providing pediatric subspecialty care: a workforce analysis. Pediatrics 2000;106:1325-1333
CrossRef | Web of Science | Medline5
Thompson LA ,Goodman DC ,Little GA . Is more neonatal intensive care always better? Insights from a cross-national comparison of reproductive care. Pediatrics 2002;109:1036-1043
CrossRef | Web of Science | Medline
Author/Editor Response
The editorialist replies:
To the Editor: The study by Goodman et al. and the letters in response to their report illustrate the challenges in reconciling the day-to-day experiences of clinicians with evidence about the performance of the health care system viewed at a more “macro” level. The study by Goodman et al. does not discount the notion that neonatologists and newborn intensive care units, when properly deployed, can improve health outcomes for high-risk babies. However, the study does show that many regions of the United States have a relatively large supply of neonatologists, yet have mortality rates among newborns that are no lower than those in regions with fewer neonatologists and intensive care units. National trends in managed care, residents' work hours, and related factors do not account for the failure of this regional variation in supply to produce differences in outcomes. The findings of Goodman et al. illustrate the unsettling paradox of health care in the United States: specialist physicians appear to be working hard and experiencing pressure to do more, whether they work in areas with many or few physicians, yet there is a lack of clear evidence that a greater supply of specialty resources is producing better outcomes for patients. Research is needed to identify meaningful measures of outcomes other than mortality (the measure used in this study) that may be sensitive to differences in the regional supply of specialists, as well as to identify possible reasons why increases in supply may not be producing improvements in health.
This paradox also points out why the declaration of a shortage of physicians, such as that of Dr. Cooper, should be received with skepticism and a request for a clearer definition of “shortage.” If it simply means that the health care system could keep more physicians busy and gainfully employed, then this definition of shortage may apply to the United States (and is likely to apply no matter how many more physicians the United States produces). If “shortage” means that more physicians would produce better health, then the study by Goodman et al. suggests that there is not yet evidence to justify the conclusion that a meaningful shortage of specialists exists.
Kevin Grumbach, M.D.
University of California, San Francisco, San Francisco, CA 94110
keving@itsa.ucsf. edu
