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10 THE EXTENT OF THE PHYSICIAN SHORTAGE in 1972 the National Institute for Occupational Safety and Health (NtOSH) identified a shortage of 3,000 physicians in occupational medicine and a projected national need for 5,400 such specialists.72 In 1980 the Graduate Medical Education National Advisory Committee (GMENAC) estimated the need by 1990 for 2,300 board-certified occupational medicine specialists,~3 a smaller number from that initially estimated by a technical pane' convened by GMENAC. The lowered projection reflected both limitations in availability of medical training and a perception by some that physicians in preventive medicine made lithe contribution to clinical services.73~4 A 1988 report by the Bureau of Health Professions (BHPr) of the Health Resources and Services Administration estimated the need in 1992 for 4,830 board-certified specialists, the first estimate to include the need for environmental as well as occupational medicine specia~ists.75

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11 The lOM Subcommittee on the Physician Shortage commissioned a needs estimate that included fully trained OEM specialists as well as OEM clinicians, the lager defined as primary care physicians with added competence in the field, who would serve as consultants and educators when specialists were not needed or accessible. The resulting estimate of 1989 need by Castorina was 3,100 to 4,700 full-fledged specialists and 1,500 to 2,000 GEM clinicians. The estimate of specialists was based on a need for (1) 127 to 378 academic faculty (1 to 3 faculty per 127 medical schools); (2) 2,400 to 3,600 community specialists (1.0 to 1.5 specialists per 100,000 population); and (3) 550 to 700 physicians in public health agencies (1 physician per 505 local programs serving 100,000 inhabitants and 1-3 per 57 state and territorial health agencies). The need for 1,500 to 2,000 OEM clinicians was taken as 0.75 percent to 1 percent of all primary care physicians (195,538 internists, family practitioners, general practitioners and pediatricians) se~f-identified in the American Medical Association postal survey in 1987. ]7 Estimates of physician supply in this field have been largely derived from some form of self-report or se~f-designation on the part of the physician. None has deliberately included the relatively new and less defined field of environmental medicine. GMENAC projections overall for the 1990 supply of preventive medicine specialists, adjusted to the proportion of AMA survey respondents who practice occupational medicine (40 percent), yield an estimate of 2,200 trained specialists. Other estimates of supply include (1) AMA self-report, 2,700; (2) American College of Occupational Medicine membership, 4,800; and (3) Bureau of Health Professions (using board-certification figures for 1987 extrapolated to

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12 1992), 1,550. Based on available data about the number of individuals board-certified to date (1,378) and preliminary data that about 15 percent are no longer active, Castorina estimated for 1989 a supply of between 1,200 and 1,500 active, board-certified or board-eligible occupational medicine specialists. Table ~ reviews the range of estimates of the physician shortage in occupational medicine. Although the final GMENAC estimates identify only a small deficit (10 percent), the GMENAC preventive medicine specialty (Delphi) pane! estimatecl a deficit of more than 2,000, closer to the BHPr estimate of a shortage of more than 3,000. Because of the limitations of these estimates, including the lack of specific consideration of environmental medicine as part of the field, Castorina estimated a current shortage of 3,100 to 5,500 physicians, numbers that include primary care physicians with special competence in occupational and environmental medicine (OEM clinicians). For OEM specialists only, the deficit would range between 1,600 and 3,500.

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13 Table 1. The Physician Shortage in Occupational and Environmental Medicine Source Estimate Need Supply for Year (estimated number) Deficit GMENAC1 1990 2,000a 2,200a 1 OOa BHPr2 1992 4,830a 1,550a 3,280a Castorina and Rosenstock3 1989 4,600-6,700b 1,200-1,500a 3,100-5,500b a Estimate for occupational medicine specialists only. b Estimates for specialists and IOM clinicians (physicians with special competence in occupational and environmental medicine). 1 Graduate Medical Education National Advisory Committee; see reference 15. 2 Bureau of Health Professions; see reference 17 3 See reference 1.