The Journal of Pediatrics
Volume 151, Issue 4 , Pages 431-434, October 2007

Inactive Physicians: The State of Our Understanding

Child Health Evaluation and Research (CHEAR) Unit, Division of General Pediatrics, University of Michigan, Ann Arbor, MI.

Received 21 December 2006; received in revised form 16 February 2007; accepted 27 April 2007.

Article Outline

AMA, American Medical Association

 

Some physicians may elect to have an extended period of time during which they do not see patients. The reasons physicians may elect to have periods of “clinical inactivity” range from the desire to provide care to children or other family members to the desire to seek professional opportunities in medical administration, industry, or research. However, the duration of time away from clinical care required before being designated as “inactive” has not been established.

This issue is of growing importance to state licensing authorities and specialty accreditation boards, which must determine (1) whether inactive individuals should have the same licensure or certification as those who are active in clinical practice and (2) whether there should be an educational or testing process for inactive physicians wishing to return to active status.

We reviewed the medical literature to describe the current state of knowledge regarding pediatricians whose clinical status is inactive. Search terms used in an Ovid Medline search included “certification,” “recertification,” “maintenance of certification,” “continuing medical education,” “physician inactivity,” “pediatrics,” and “retirement.” However, no results were found. The search was expanded to include inactive physicians of all specialties; 6 articles were found. A parallel search of the certification/recertification literature found additional articles related to clinical inactivity. In particular, these articles report factors that may contribute to a physician’s decision to leave clinical practice and describe the challenges faced during the reentry process. A Google search for “inactive physicians” yielded 5 additional articles. A total of 38 articles were identified and subsequently classified as review (3), research (13), commentary (13), raw data (4), or other (5). A comprehensive review matrix for details on each of the individual articles is available at http://www.abp.org/jpeds/inactivep/inactivep2007.pdf

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Findings 

Number of Inactive Physicians 

The American Medical Association’s (AMA) publication Physician Characteristics and Distribution in the US,1 is a frequently cited source for national data on inactive physicians. The inactive category includes physicians who are retired, semiretired, working part-time, temporarily not practicing, or not active for other reasons. Between 1990 and 2003, the number of physicians categorized as inactive increased from 52,635 to 84,360—a 60% change. This represents 9.7% of all physicians listed in 2003. A closer estimate of clinically inactive physicians (ie, those who are not practicing medicine but are still professionally active) can be obtained by including physicians who the AMA categorizes as conducting “other professional activities.” This category, totaling 44,338 in 2003, includes physicians engaged in administration, medical teaching, research, and other related activities. For the period 1990 to 2003, the number of those engaged in these nonclinical professional activities remained relatively constant, increasing by only 2.1%.1 This information is also available by specialty; in 2003, 2665 of the 55,114 pediatricians in the US were engaged in nonclinical professional activities (4.8%).

The only other national data on the number of inactive physicians, a 1997 review of the Women’s Physician Health Study, was limited to female physicians. Of the 4,501 participants, 3.8% were inactive.2, 3 The nonclinical professional activities of these physicians were not explored.

Limited information on physician supply and inactivity was found at the state level. A University of North Carolina study of physician supply trends found that between 2002 and 2003, of the 17,090 physicians in North Carolina, 658 dropped off of the state physician licensure file (presumably moved), 303 moved out of state but maintained an active license, 243 retired from practice, and another 138 became clinically inactive.4 Further information about the 138 clinically inactive physicians revealed that 51% were women; the average age of inactive females was 42, compared with 59 for inactive males.

The Office of Data, Research and Vital Statistics of the Maine Department of Human Services used survey data collected in December 2000 by the Cooperative Health Manpower Resource Inventory on the number of licensed inactive allopathic and osteopathic physicians. Of the 179 licensed and inactive allopathic physicians who responded to the survey, 130 (73%) were retired, 9 (5%) were inactive due to household responsibilities, 23 (13%) were inactive for other reasons, 11 (6%) were inactive for unknown reasons, and 6 (3%) were unemployed. Only 16 licensed inactive osteopathic physicians responded to the survey; 10 (63%) were retired, 1 (6%) was inactive due to household reasons, 2 (13%) were inactive for other reasons, and 3 (19%) were inactive for unknown reasons.5, 6

Wisconsin’s 2000 Physician Workforce Survey and 1996 Physician Profile Survey reported physician workforce data for the state. In 2000, 16,691 of the 18,573 licensed physicians participated in the workforce survey. Of the 16,691 participants, 9533 (57.1%) were active in clinical practice in Wisconsin, 3981 (23.9%) were working outside Wisconsin, 1130 (6.8%) were retired or permanently disabled, 158 (0.95%) were working in another field, 290 (1.74%) were seeking work or were temporarily inactive, 995 (6%) were working in an academic setting, 152 (0.91%) were working in a state or local government agency, 116 (0.7%) were working in a health care business/corporation, 92 (0.55%) were working in a nursing home, 76 (0.46%) were working in a federally funded agency, and 46 (0.28%) were working in a certified rural health clinic.7 The activities of the temporarily inactive physicians were not specified.

Reasons for Inactivity 

Published articles have cited family responsibilities, career dissatisfaction, compensation and early retirement, health related issues, and sexual harassment as the primary reasons why physicians become inactive or leave practice.

Family Responsibilities 

Historically, women are more likely to experience clinical inactivity and reentry because of societal expectations to temporarily or permanently cease clinical practice when starting families or when family members become ill.8, 9, 10 The dual demands of balancing a clinical career and family needs often lead to career interruptions in health care professionals. A 1996 survey found that 90% of female physicians had made career changes to care for their children, compared with 50% of male physicians. The most frequent career changes included changes in work and practice type, decreased hours, and discontinuation of clinical careers.11 Female physicians were twice as likely as male physicians to become clinically inactive and interrupt their careers to accommodate their partners’ careers, especially in the case of dual–physician relationships.12

However, other studies found rising inactivity rates with increasing age in both men and women, with the smallest sex difference in inactivity rates in the younger age groups, when most female physicians are likely to leave clinical practice to start families.13, 14 Furthermore, these periods of clinical inactivity are short, typically less than 3 months.13, 15

Career Dissatisfaction 

Career dissatisfaction is usually attributed to high degrees of stress and burnout. Medicine is an extremely demanding field, and high stress and physician discontent in the workplace are likely to lead to burnout and subsequent periods of clinical inactivity.16, 17 A study examining the degree of career satisfaction and the retention of female physicians found that those who worked reduced hours were less likely to leave their practice. However, those female physicians who worked reduced hours but still believed that their work still significantly interfered with their family had a greater tendency to leave their jobs compared with full-time female physicians.2, 3 A similar study found that general practitioners benefited from less administrative responsibilities, more flexible working hours, and ease in moving practice. Women reported higher levels of job satisfaction and lower levels of stress than men; these findings were attributed to women working fewer hours than men.18

Compensation and Early Retirement 

Some studies have suggested that changes in compensation bring about early retirement.19, 20, 21 One report correlated declines in income with the flow of physicians into inactive status.22 The annual percentage change in the number of physicians classified as inactive by the AMA increased by 0.7% between 1989 and 1994.22 This increase in physician inactivity was attributed to the growth of managed care and increasing regulation of health insurance by the federal government, threatening physician retention and causing increased early retirement. Nationwide, the number of pediatricians age 55 to 64 who were inactive has ranged from a low of 3.72% in 1997 to a high of 6.6% in 1986.22 Nearly half of US physicians age 50 years and older have reported an intention to retire or leave medical practice in the next 1 to 3 years as a result of managed care and government mandates.23, 24

Health-Related Issues 

Several articles suggested that health-related issues, including substance abuse disorders, mental health issues, and physical illness, may contribute to extended absences and thus clinical inactivity.17, 25, 26 Health care professionals experience substance abuse (including alcohol and other drug misuse) at rates similar to those in society as a whole (8% to 12%). Depression is also prevalent among health care professionals.27, 28

Sexual Harassment 

Evidence shows that female physicians are more likely than male physicians to encounter sexual harassment. A 1996 AMA survey found that 42% of 2300 female physicians experienced sexual harassment in their medical practice,8 and 73% of female residents reported being sexually harassed at least once during medical training, compared with only 22% of men.29

Physician Reentry into the Workforce after Clinical Inactivity 

Trends in physician reentry into the workforce are not well documented. The absence of efforts to track the number of inactive clinicians and the number of reentering clinicians makes determining the actual number of physicians returning to their careers after an extended leave difficult. Several attempts have been made to establish reentry training programs for clinicians;30 however, most of the related research focuses on the nursing workforce. Recommendations for a national clinical practice reentry program, as well as a national clinical practice database, have been proposed.4

A study of participants in a physician retraining program tracked the changes in physician characteristics from 1976 to 1981 and compared them with those of physicians who completed the program between 1968 and 1975.31 The number of physicians returning to clinical activity after completing the program was comparable for the 2 time periods (85% and 83%, respectively). During the first 7 years of the program (1968 to 1975), the participants were predominately women (82%). In contrast, between 1976 and 1981, the program attracted more male participants, resulting in a more balanced sex mixture (49% women and 51% men). This sex shift affected other retrainee characteristics, including the nature of inactivity, years of inactivity, and status of licensure. Women were more often reported to be inactive due to family responsibilities. In general, women with families remained inactive for about 12 years before returning to medicine, whereas physicians involved in nonclinical medical activities and in the nonprimary care clinical specialties remained in those fields for 14 to 17 years.

Limitations 

The current state of the literature on clinically inactive physicians produces more questions than answers. The available literature focuses on potential explanations for inactivity, and little evidence exists regarding the specific professional activities of inactive physicians. Most data on inactive physicians do not categorize the activities of physicians beyond “inactive” or “other.”

The AMA Physician Masterfile and self-reports of physicians’ intentions to leave clinical practice are 2 major sources of information on the inactive status of physicians. Their reliability has been called into question, however. The AMA Physician Masterfile has a sensitivity of 9% for detecting physicians who have left clinical practice within the past 3 years.32 Further lack of information on the activities of the physician workforce can be attributed to reporting lags that limit what is known.7

Future Information Needs 

There is a clear need for further investigation both to replicate findings from earlier, dated surveys and to answer questions about the activities of clinically inactive pediatricians. Potential areas for future research include (1) examination of the variability among member boards of the American Board of Medical Specialties, the AMA, and state licensing authorities in their definitions for clinically inactive physicians; (2) determination of the number of clinically inactive pediatricians; (3) exploration of the reasons why pediatricians leave clinical practice; (4) characterization of the duration of inactivity and reasons why pediatricians return to clinical practice; (5) analysis of the characteristics (eg, sex, age) of pediatricians who leave and return to clinical practice; (6) investigation of the professional activities of clinically inactive pediatricians; and (7) description of the characteristics of participants in clinical retraining programs.

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Summary 

Workforce issues related to physician inactivity are likely to be of greater importance to pediatrics than other specialties, due to the predominance of women entering the pediatric workforce. As greater accountability for both state licensure and board certification are demanded by the public, new challenges will arise regarding processes to ensure that physicians are indeed qualified to provide up-to-date care to their patients.

A comprehensive review matrix for details on each of the individual articles is available at http://www.abp.org/jpeds/inactivep/inactivep2007/pdf.

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References 

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 Supported by a grant from the American Board of Pediatrics Foundation.

PII: S0022-3476(07)00443-X

doi:10.1016/j.jpeds.2007.04.066

The Journal of Pediatrics
Volume 151, Issue 4 , Pages 431-434, October 2007

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