Health Care Practitioners

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Health Care Practitioners

The art of medicine consists of amusing the patient while nature cures the disease.
—Voltaire
One of the first duties of the physician is to educate the masses not to take medicine.
—William Osler, Sir William Osler: Aphorisms, from His Bedside Teachings and Writings (1950)

PHYSICIANS

Physicians routinely perform medical examinations, provide preventive medicine services, diagnose illness, treat patients suffering from injury or disease, and offer counsel about how to achieve and maintain good health. There are two types of physicians trained in traditional Western medicine: the Doctor of Medicine (MD) is schooled in allopathic medicine and the Doctor of Osteopathy (DO) learns osteopathy. Allopathy is the philosophy and system of curing disease by producing conditions that are incompatible with disease, such as prescribing antibiotics to combat bacterial infection. The philosophy of osteopathy is different; it is based on recognition of the body's capacity for self-healing, and it emphasizes structural and manipulative therapies such as postural education, manual treatment of the musculoskeletal system (osteopathic physicians are trained in hands-on diagnosis and treatment), and preventive medicine. Osteopathy is also considered a holistic practice because it considers the whole person, rather than simply the diseased organ or system.

In modern medical practice, the philosophical differences may not be obvious to most health care consumers because MDs and DOs use many comparable methods of treatment, including prescribing medication and performing surgery. In fact, the American Osteopathic Association (2008, http://www.osteopathic.org/index.cfm?PageID=aoa_main), the national medical professional society that represents more than sixty-one thousand DOs, admits that many people who seek care from osteopathic physicians may be entirely unaware of their physician's training, which emphasizes holistic interventions or special skills such as manipulative techniques. Like MDs, DOs complete four years of medical school and postgraduate residency training; may specialize in areas such as surgery, psychiatry, or obstetrics; and must pass state licensing examinations to practice.

Medical School, Postgraduate Training, and Qualifications

Modern medicine requires considerable skill and extensive training. The road to gaining admission to medical school and becoming a physician is long, difficult, and intensely competitive. Medical school applicants must earn excellent college grades, achieve high scores on entrance exams, and demonstrate emotional maturity and motivation to be admitted to medical school. Once admitted, medical students spend the first two years primarily in laboratories and classrooms learning basic medical sciences such as anatomy (detailed understanding of body structure), physiology (biological processes and vital functions), and biochemistry. They also learn how to take medical histories, perform complete physical examinations, and recognize symptoms of diseases. During their third and fourth years, the medical students work under supervision at teaching hospitals and clinics. By completing clerkships—spending time in different specialties such as internal medicine, obstetrics and gynecology, pediatrics, psychiatry, and surgery— they acquire the necessary skills and gain experience to diagnose and treat a wide variety of illnesses.

Following medical school, new physicians must complete a year of internship, also referred to as postgraduate year one, that emphasizes either general medical practice or one specific specialty and provides clinical experience in various hospital services (e.g., inpatient care, outpatient clinics, emergency rooms, and operating rooms). In the past, many physicians entered practice after this first year of postgraduate training. In the present era of specialization, most physicians choose to continue in residency training, which lasts an additional three to six years, depending on the specialty. Those who choose a subspecialty such as cardiology, infectious diseases, oncology, or plastic surgery must spend additional years in residency and may then choose to complete fellowship training. Immediately after residency, they are eligible to take an examination to earn board certification in their chosen specialty. Fellowship training involves a year or two of laboratory and clinical research work as well as opportunities to gain additional clinical and patient care expertise.

Medical School Applicants

According to the Association of American Medical Colleges (AAMC; September 25, 2007, http://www.aamc.org/newsroom/pressrel/2007/071016.htm), the number of students entering medical school for the 2006–07 academic year was the largest ever—a 2.3% increase from the previous year—with 17,759 first-year students matriculated. The students were selected from a pool of 42,315 applicants. Applications from African-Americans and Hispanics rose by 9.2%.

Conventional and Newer Medical Specialties

Rapid advances in science and medicine and changing needs have resulted in a variety of new medical and surgical specialties, subspecialties, and concentrations. For example, geriatrics, the medical subspecialty concerned with the prevention and treatment of diseases in older adults, has developed in response to growth in this population. In 1909 Ignatz L. Nascher (1863–1944) coined the term geriatrics from the Greek geras (old age) and iatrikos (physician). Geriatricians are physicians trained in internal medicine or family practice who obtain additional training and certification in the diagnosis and treatment of older adults. According to the American Geriatrics Society (AGS; 2008, http://www.americangeriatrics.org/news/geria_faqs.shtml), the United States needs more geriatricians to care for its growing population of older adults. In 2008 there were only 7,590 board-certified geriatricians (one for every 2,500 Americans seventy-five and older) and 1,657 geropsychiatrists (one for every 11,451 Americans seventy-five and older). The AGS forecasts that this ratio will decrease by 2030 to one geriatrician for every 4,254 Americans seventy-five and older and one geropsychiatrist for every 20,195 Americans seventy-five or older.

Another relatively new medical specialty has resulted in physician intensivists. Intensivists, as the name indicates, are trained to staff hospital intensive care units (ICUs, which are sometimes known as critical care units), where the most critically ill patients are cared for using a comprehensive array of state-of-the-art technology and equipment. This specialty arose in response to both the increasing complexity of care provided in ICUs and the demonstrated benefits of immediate availability of highly trained physicians to care for critically ill patients. The Health Resources and Service Administration (HRSA) notes in The Critical Care Workforce: A Study of the Supply and Demand for Critical Care Physicians (May 6, 2006, ftp://ftp.hrsa.gov/bhpr/nationalcenter/criticalcare.pdf) that the demand for intensivists will likely fail to meet the demands of the aging population in the United States by 2020. The HRSA predicts a shortfall of forty-three hundred intensivists in 2020. According to the article “U.S. Predicts Shortage of Intensivists” (California Healthline, May 23, 2006), the Critical Care Workforce Partnership (an alliance of medical societies) advocates increasing medical school capacity to train intensivists and asserts that increasing the supply of intensivists could help save as many as fifty-four thousand lives per year.

The fastest-growing new specialty is hospitalists, physicians who are hospital based as opposed to office based and who provide a variety of services from caring for hospitalized patients who do not have personal physicians to explaining complex medical procedures to patients and families and coordinating many aspects of inpatient care. Robert M. Wachter reports in “The State of Hospital Medicine in 2008” (Medical Clinics of North America, vol. 92, no. 2, March 2008) that there were twenty thousand hospitalists in the United States in 2006 and their ranks are expected to grow in coming years. Wachter opines “that hospitalists have quickly become indispensable to their patients, their hospitals, and to the health care system as a whole. There are no indications that the situation is likely to change in the future.”

More traditional medical specialties include:

Anesthesiologist—administers anesthesia (partial or complete loss of sensation) and monitors patients in surgery
Cardiologist—diagnoses and treats diseases of the heart and blood vessels
Dermatologist—trained to diagnose and treat diseases of the skin, hair, and nails
Family practitioner—delivers primary care to people of all ages and, when necessary, refers patients to other physician specialists
Gastroenterologist—specializes in digestive system disorders
Internist—provides diagnosis and nonsurgical treatment of a broad array of illnesses affecting adults
Neurologist—specializes in the nervous system and provides diagnosis and treatment of brain, spinal cord, and nerve disorders
Obstetrician-gynecologist—provides health care for women and their reproductive systems, as well as care for mothers and babies before, during, and immediately following delivery
Oncologist—dedicated to the diagnosis and treatment of cancer
Otolaryngologist—skilled in the medical and surgical treatment of ear, nose, and throat disorders and related structures of the face, head, and neck
Pathologist—uses skills in microscopic chemical analysis and diagnostics to detect disease in body tissues and fluids
Psychiatrist—specializes in the prevention, diagnosis, and treatment of mental health and emotional disorders
Pulmonologist—specializes in diseases of the lungs and respiratory system
Urologist—provides diagnosis as well as medical and surgical treatment of the urinary tract in both men and women as well as male reproductive health services

HIGH COSTS, LONG HOURS, AND LOW WAGES. According to the AAMC (2008, http://services.aamc.org/tsfreports/report_median.cfm?year_of_study=2008), the medical school tuition and fees during the 2007–08 academic year were $22,199 for in-state residents at public schools and $39,964 for students at private schools. The AAMC indicates in “With Debt on the Rise, Students and Schools Face an Uphill Battle” (AAMC Reporter, January 2008) that medical school students graduating in 2006 had incurred a median debt comparable to a home mortgage—an average of $130,000. Even though a physician's earning power is considerable, and many students are able to repay their debts during their first years of practice, some observers believe the extent of medical students' indebtedness may unduly influence their career choices. They may train for higher-paying specialties and subspecialties rather than follow their natural interests or opt to practice in underrepresented specialties or underserved geographic areas. The high cost of medical education is also believed to limit the number of minority applicants to medical school.

Historically, medical training has been difficult and involved long hours. Fiona McDonald notes in “Working to Death: The Regulation of Working Hours in Health Care” (Law and Policy, vol. 1, no. 1, January 2008) that residents typically work twenty-four- to thirty-six-hour shifts and more than eighty hours per week. Lack of sleep and low wages are a way of life for most medical students and residents, although the thirty-six-hour shift has come under criticism as an unnecessary, and possibly dangerous, practice. In 1995 New York State limited most residents to twenty-four-hour shifts and eighty-hour weeks. The regulations were the first of their kind in the country.

In 2003 the Accreditation Council for Graduate Medical Education, which oversees thousands of residency programs every year, adopted guidelines that limited duty hours to eighty hours per week (surgical programs were permitted to have residents work eighty-eight hours per week) for the nation's one hundred thousand physicians-in-training. In “Adapting to Duty-Hour Limits—Four Years On” (New England Journal of Medicine, vol. 356, no. 26, June 28, 2007), Harry H. Yoon reports that many medical residency programs have had to refashion or overhaul their programs to comply with the new standards.

The Number of Physicians in Practice Is Increasing

In 2005, of the 902,053 physicians in the United States, 300,022 were primary care physicians. (See Table 2.1.) Primary care physicians are the front line of the health care system—the first health professionals most people see for medical problems or routine care. Family practitioners, internists, pediatricians, obstetrician/gynecologists, and general practitioners are considered to be primary care physicians. Primary care physicians tend to see the same patients regularly and develop relationships with patients over time as they offer preventive services, scheduled visits, follow-up, and urgent medical care. When necessary, they refer patients for consultation with, and care from, physician specialists.

In 2005, 563,225 physicians maintained office-based practices; 155,248 were in hospital-based practices; and 95,391 physicians were residents and interns. (See Table 2.2.) Besides the growing number of graduates of U.S. medical schools, the ranks of international medical graduates grew by 46,334, from 144,306 in 1995 to 190,640 in 2005.

The number of active physicians devoted to patient care, as opposed to research, administration, or other roles, varies by geographic region and by state, from a high of 38.4 physicians per 10,000 civilian population in Massachusetts in 2005 to a low of 15.7 physicians per 10,000 people in Oklahoma. (See Table 2.3.) New England has the most physicians devoted to patient care per 10,000 population (33.4), whereas the West South Central and Mountain divisions have the fewest, 19.5 and 20, respectively.

Working Conditions

Many physicians work long, irregular hours. The Bureau of Labor Statistics (BLS; December 18, 2007, http://www.bls.gov/oco/ocos074.htm) reports that in 2006 more than one-third of full-time physicians worked sixty hours or more per week performing patient care and administrative duties such as office management. Physicians and surgeons held about 633,000 jobs in 2006, and 15% were self-employed. About 50% of physicians held salaried positions, and 18% were employed by private hospitals. Physicians in salaried positions, such as those employed by health maintenance organizations, usually have shorter and more regular hours and enjoy more flexible work schedules than those in private practice. Instead of working as solo practitioners, growing numbers of physicians work in clinics or are partners in group practices or other integrated health care systems. Medical group practices allow physicians to have more flexible schedules, to realize purchasing economies of scale, to pool their money to finance expensive medical equipment, and to be better able to adapt to changes in health care delivery, financing, and reimbursement.

Specialty	1949^a	1960^a	1970	1980	1990	1995	2000	2002	2004	2005
— Data not available.
^aEstimated by the Bureau of Health Professions, Health Resources Administration. Active doctors of medicine (M.D.s) include those with address unknown and primary specialty not classified.
^bIncludes M.D.s engaged in federal and nonfederal patient care (office-based or hospital-based) and other professional activities.
^cStarting with 1970 data, M.D.s who are inactive, have unknown address, or primary specialty not classified are excluded.
	Number
Total doctors of medicine^b	201,277	260,484	334,028	467,679	615,421	720,325	813,770	853,187	884,974	902,053
Active doctors of medicine^c	191,577	247,257	310,929	435,545	559,988	646,022	737,504	768,498	792,154	801,742
General primary care specialists	113,222	125,359	134,354	170,705	213,514	241,329	274,653	286,294	296,495	300,022
General practice/family medicine	95,980	88,023	57,948	60,049	70,480	75,976	86,312	89,357	91,164	91,858
Internal medicine	12,453	26,209	39,924	58,462	76,295	88,240	101,353	106,499	111,800	112,934
Obstetrics/gynecology	—	—	18,532	24,612	30,220	33,519	35,922	36,810	37,779	38,285
Pediatrics	4,789	11,127	17,950	27,582	36,519	43,594	51,066	53,628	55,752	56,945
Primary care subspecialists	—	—	3,161	16,642	30,911	39,659	52,294	57,929	62,322	65,420
Family medicine	—	—	—	—	—	236	483	627	768	835
Internal medicine	—	—	1,948	13,069	22,054	26,928	34,831	38,821	41,471	43,552
Obstetrics/gynecology	—	—	344	1,693	3,477	4,133	4,319	4,228	4,280	4,315
Pediatrics	—	—	869	1,880	5,380	8,362	12,661	14,253	15,803	16,718
	Percent of active doctors of medicine
General primary care specialist	59.1	50.7	43.2	39.2	38.1	37.4	37.2	37.3	37.4	37.4
General practice/family medicine	50.1	35.6	18.6	13.8	12.6	11.8	11.7	11.6	11.5	11.5
Internal medicine	6.5	10.6	12.8	13.4	13.6	13.7	13.7	13.9	14.1	14.1
Obstetrics/gynecology	—	—	6.0	5.7	5.4	5.2	4.9	4.8	4.8	4.8
Pediatrics	2.5	4.5	5.8	6.3	6.5	6.7	6.9	7.0	7.0	7.1
Primary care subspecialists	—	—	1.0	3.8	5.5	6.1	7.1	7.5	7.9	8.2
Family medicine	—	—	—	—	—	0.0	0.1	0.1	0.1	0.1
Internal medicine	—	—	0.6	3.0	3.9	4.2	4.7	5.1	5.2	5.4
Obstetrics/gynecology	—	—	0.1	0.4	0.6	0.6	0.6	0.6	0.5	0.5
Pediatrics	—	—	0.3	0.4	1.0	1.3	1.7	1.9	2.0	2.1
0.0 Percent greater than zero but less than 0.05.
Notes: Data are as of December 31 except for 1990–1994 data, which are as of January 1, and 1949 data, which are as of midyear. Outlying areas include Puerto Rico, the U.S. Virgin Islands, and the Pacific islands of Canton, Caroline, Guam, Mariana, Marshall, American Samoa, and Wake. Data are based on reporting by physicians.

Physicians' Earnings and Opportunities

Physicians' earnings are among the highest of any profession. According to the Medical Group Management Association (MGMA), in Physician Compensation and Production Survey: 2007 Report Based on 2006 Data (2007, http://www.mgma.com/WorkArea/showcontent.aspx?id=14288), the median annual total compensation for primary care physicians in 2006 was $171,519, and for specialists it was $322,259. The range of salaries varies widely and is often based on a physician's specialty, the number of years in practice, the hours worked, and the geographic location. The MGMA reports that in 2006 orthopedic surgeons and invasive cardiologists were among the top earners, with median annual earnings of $446,517 and $457,563, respectively, whereas pediatricians and family practitioners earned the least: $174,209 and $164,021 per year, respectively.

Physician Visits

In 2005 Americans made 963.6 million office visits to physicians. (See Table 2.4.) Women aged eighteen to forty-four visited physicians nearly twice as often as men, and, as expected, people over seventy-five years of age of both genders saw doctors more than twice as often as most younger people.

Physician Satisfaction

Changes in the health care delivery system—particularly the shift from traditional fee-for-service practice to managed care, with its efforts to standardize medical practice, which reduces physicians' ability to manage their time, schedules, and professional relationships—have been named as factors contributing to physicians' dissatisfaction with their choice of career. Other changes, including decreasing reimbursement andanever-increasingemphasisondocumentationtosatisfy government and private payers, as well as administrative requirements that infringe on time physicians would rather spend caring for patients, have also increased physician dissatisfaction.

Activity and place of medical education	1975	1985	1995	2000	2002	2003	2004	2005
— Data not available.
. . . Category not applicable.
^aExcludes inactive, not classified, and address unknown.
^bInternational medical graduates received their medical education in schools outside the United States and Canada.
^cStarting with 2003 data, separate estimates for federal and nonfederal doctors of medicine are not available.
^dSpecialty information based on the physician's self-designated primary area of practice. Categories include generalists and specialists.
^eStarting with 1990 data, clinical fellows are included in this category. In prior years, clinical fellows were included in the other professional activity category.
^fIncludes medical teaching, administration, research, and other. Prior to 1990, this category also included clinical fellows.
	Number of doctors of medicine
Doctors of medicine	393,742	552,716	720,325	813,770	853,187	871,535	884,974	902,053
Professionally active^a	340,280	497,140	625,443	692,368	719,431	736,211	744,143	762,438
Place of medical education:
U.S. medical graduates	—	392,007	481,137	525,691	544,779	558,167	563,118	571,798
International medical graduates^b	—	105,133	144,306	164,437	172,770	178,044	181,025	190,640
Activity:
Nonfederal^c	312,089	475,573	604,364	672,987	699,249	—	—	—
Patient care^d	287,837	431,527	564,074	631,431	658,123	691,873	700,287	718,473
Office-based practice	213,334	329,041	427,275	490,398	516,246	529,836	538,538	563,225
General and family practice	46,347	53,862	59,932	67,534	71,696	73,508	73,234	74,999
Cardiovascular diseases	5,046	9,054	13,739	16,300	16,989	17,301	17,252	17,519
Dermatology	3,442	5,325	6,959	7,969	8,282	8,477	8,651	8,795
Gastroenterology	1,696	4,135	7,300	8,515	9,044	9,326	9,430	9,742
Internal medicine	28,188	52,712	72,612	88,699	96,496	99,670	101,776	107,028
Pediatrics	12,687	22,392	33,890	42,215	46,097	47,996	49,356	51,854
Pulmonary diseases	1,166	3,035	4,964	6,095	6,672	6,919	7,072	7,321
General surgery	19,710	24,708	24,086	24,475	24,902	25,284	25,229	26,079
Obstetrics and gynecology	15,613	23,525	29,111	31,726	32,738	33,636	33,811	34,659
Ophthalmology	8,795	12,212	14,596	15,598	16,052	16,240	16,304	16,580
Orthopedic surgery	8,148	13,033	17,136	17,367	18,118	18,423	18,632	19,115
Otolaryngology	4,297	5,751	7,139	7,581	8,001	8,103	8,160	8,206
Plastic surgery	1,706	3,299	4,612	5,308	5,593	5,725	5,845	6,011
Urological surgery	5,025	7,081	7,991	8,460	8,615	8,804	8,793	8,955
Anesthesiology	8,970	15,285	23,770	27,624	28,661	29,254	29,984	31,887
Diagnostic radiology	1,978	7,735	12,751	14,622	15,896	16,403	16,828	17,618
Emergency medicine	—	—	11,700	14,541	16,907	17,727	18,961	20,173
Neurology	1,862	4,691	7,623	8,559	9,034	9,304	9,632	10,400
Pathology, anatomical/clinical	4,195	6,877	9,031	10,267	10,103	10,209	10,653	11,747
Psychiatry	12,173	18,521	23,334	24,955	25,350	25,656	25,998	27,638
Radiology	6,970	7,355	5,994	6,674	6,916	7,010	6,900	7,049
Other specialty	15,320	28,453	29,005	35,314	34,084	34,861	36,037	39,850
Hospital-based practice	74,503	102,486	136,799	141,033	141,877	162,037	161,749	155,248
Residents and interns^e	53,527	72,159	93,650	95,125	96,547	100,033	102,563	95,391
Full-time hospital staff	20,976	30,327	43,149	45,908	45,330	62,004	59,186	59,857
Other professional activity^f	24,252	44,046	40,290	41,556	41,126	44,338	43,856	43,965
Federal^c	28,191	21,567	21,079	19,381	20,182	—	—	—
Patient care	24,100	17,293	18,057	15,999	16,701	—	—	—
Office-based practice	2,095	1,156	. . .	. . .	. . .	—	—	—
Hospital-based practice	22,005	16,137	18,057	15,999	16,701	—	—	—
Residents and interns	4,275	3,252	2,702	600	390	—	—	—
Full-time hospital staff	17,730	12,885	15,355	15,399	16,311	—	—	—
Other professional activity^f	4,091	4,274	3,022	3,382	3,481	—	—	—
Inactive	21,449	38,646	72,326	75,168	84,166	84,360	92,323	99,823
Not classified	26,145	13,950	20,579	45,136	49,067	50,447	48,011	39,304
Unknown address	5,868	2,980	1,977	1,098	523	517	497	488
Notes: Data for doctors of medicine are as of December 31, except for 1990–1994 data, which are as of January 1. Outlying areas include Puerto Rico, the U.S. Virgin Islands, and the Pacific islands of Canton, Caroline, Guam, Mariana, Marshall, American Samoa, and Wake. Data are based on reporting by physicians.

Bruce E. Landon, James Reschovsky, and David Blumenthal report in “Changes in Career Satisfaction among Primary Care and Specialist Physicians, 1997– 2001” (Journal of the American Medical Association, vol. 289, no. 4, January 22, 2003) that even though most physicians were satisfied with their careers, there was significant geographic variation in physician satisfaction.

	Total physicians^a				Doctors of medicine in patient care^b
Geographic division and state	1975	1985	1995^c	2005^{d, e}	1975	1985	1995	2005^e
	Number per 10,000 civilian population
United States	15.3	20.7	24.2	26.9	13.5	18.0	21.3	23.8
New England	19.1	26.7	32.5	37.5	16.9	22.9	28.8	33.4
Connecticut	19.8	27.6	32.8	35.4	17.7	24.3	29.5	31.8
Maine	12.8	18.7	22.3	30.1	10.7	15.6	18.2	24.3
Massachusetts	20.8	30.2	37.5	42.8	18.3	25.4	33.2	38.4
New Hampshire	14.3	18.1	21.5	26.7	13.1	16.7	19.8	24.1
Rhode Island	17.8	23.3	30.4	35.8	16.1	20.2	26.7	32.0
Vermont	18.2	23.8	26.9	35.4	15.5	20.3	24.2	32.1
Middle Atlantic	19.5	26.1	32.4	35.0	17.0	22.2	28.0	30.0
New Jersey	16.2	23.4	29.3	32.6	14.0	19.8	24.9	27.6
New York	22.7	29.0	35.3	38.0	20.2	25.2	31.6	33.9
Pennsylvania	16.6	23.6	30.1	32.0	13.9	19.2	24.6	25.8
East North Central	13.9	19.3	23.3	26.6	12.0	16.4	19.8	22.8
Illinois	14.5	20.5	24.8	27.5	13.1	18.2	22.1	24.4
Indiana	10.6	14.7	18.4	21.9	9.6	13.2	16.6	19.8
Michigan	15.4	20.8	24.8	27.4	12.0	16.0	19.0	21.5
Ohio	14.1	19.9	23.8	27.7	12.2	16.8	20.0	23.4
Wisconsin	12.5	17.7	21.5	25.7	11.4	15.9	19.6	23.4
West North Central	13.3	18.3	21.8	25.0	11.4	15.6	18.9	21.7
Iowa	11.4	15.6	19.2	21.1	9.4	12.4	15.1	16.6
Kansas	12.8	17.3	20.8	23.6	11.2	15.1	18.0	20.4
Minnesota	14.9	20.5	23.4	27.9	13.7	18.5	21.5	25.7
Missouri	15.0	20.5	23.9	25.9	11.6	16.3	19.7	21.5
Nebraska	12.1	15.7	19.8	23.8	10.9	14.4	18.3	21.8
North Dakota	9.7	15.8	20.5	24.2	9.2	14.9	18.9	22.3
South Dakota	8.2	13.4	16.7	22.3	7.7	12.3	15.7	20.6
South Atlantic	14.0	19.7	23.4	26.7	12.6	17.6	21.0	23.8
Delaware	14.3	19.7	23.4	26.1	12.7	17.1	19.7	22.4
District of Columbia	39.6	55.3	63.6	75.6	34.6	45.6	53.6	65.8
Florida	15.2	20.2	22.9	25.3	13.4	17.8	20.3	22.4
Georgia	11.5	16.2	19.7	22.0	10.6	14.7	18.0	20.1
Maryland	18.6	30.4	34.1	39.9	16.5	24.9	29.9	34.4
North Carolina	11.7	16.9	21.1	24.8	10.6	15.0	19.4	22.8
South Carolina	10.0	14.7	18.9	23.0	9.3	13.6	17.6	21.3
Virginia	12.9	19.5	22.5	26.8	11.9	17.8	20.8	24.4
West Virginia	11.0	16.3	21.0	25.2	10.0	14.6	17.9	20.9
East South Central	10.5	15.0	19.2	22.8	9.7	14.0	17.8	21.0
Alabama	9.2	14.2	18.4	21.4	8.6	13.1	17.0	19.8
Kentucky	10.9	15.1	19.2	22.9	10.1	13.9	18.0	21.1
Mississippi	8.4	11.8	13.9	18.1	8.0	11.1	13.0	16.5
Tennessee	12.4	17.7	22.5	26.1	11.3	16.2	20.8	24.1
West South Central	11.9	16.4	19.5	21.8	10.5	14.5	17.3	19.5
Arkansas	9.1	13.8	17.3	20.4	8.5	12.8	16.0	18.9
Louisiana	11.4	17.3	21.7	24.5	10.5	16.1	20.3	23.2
Oklahoma	11.6	16.1	18.8	20.5	9.4	12.9	14.7	15.7
Texas	12.5	16.8	19.4	21.7	11.0	14.7	17.3	19.4
Mountain	14.3	17.8	20.2	22.8	12.6	15.7	17.8	20.0
Arizona	16.7	20.2	21.4	22.5	14.1	17.1	18.2	19.2
Colorado	17.3	20.7	23.7	26.8	15.0	17.7	20.6	23.6
Idaho	9.5	12.1	13.9	17.9	8.9	11.4	13.1	16.2
Montana	10.6	14.0	18.4	23.0	10.1	13.2	17.1	21.2
Nevada	11.9	16.0	16.7	19.6	10.9	14.5	14.6	17.5
New Mexico	12.2	17.0	20.2	23.9	10.1	14.7	18.0	21.5
Utah	14.1	17.2	19.2	21.2	13.0	15.5	17.6	19.1
Wyoming	9.5	12.9	15.3	19.4	8.9	12.0	13.9	17.7

In three separate rounds (1997–97, 1998–99, and 2000–01), Landon, Reschovsky, and Blumenthal surveyed more than twelve thousand primary care and specialist physicians who spent at least twenty hours per week in patient care. Each round found that approximately 80% of primary care and specialist physicians were somewhat or very satisfied with their careers, and about 18% were somewhat or very dissatisfied with their careers. The study also examined physician career satisfaction in twelve market regions in an effort to identify some of the underlying reasons for satisfaction and dissatisfaction.

Even though state regulations and health plan mergers, as well as changes in hospital competition and practice ownership, may have contributed to the geographic variation in physician dissatisfaction, Landon, Reschovsky, and Blumenthal find that physician independence—the freedom to make clinical decisions in the best interest of patients, being able to spend adequate time with patients, and maintaining ongoing relationships with patients—was more important than income in predicting changes in physician satisfaction. Physicians who felt they had the greatest degree of autonomy appeared to be the most satisfied with their career choices.

	Total physicians^a				Doctors of medicine in patient care^b
Geographic division and state	1975	1985	1995^c	2005^{d, e}	1975	1985	1995	2005^e
^aIncludes active doctors of medicine and active doctors of osteopathy.
^bExcludes doctors of osteopathy (DOs); states with more than 3,000 active DOs are California, Florida, Michigan, New York, Ohio, Pennsylvania, and Texas. States with fewer than 100 active DOs are North Dakota, South Dakota, Vermont, Wyoming, and the District of Columbia. Excludes doctors of medicine in medical teaching, administration, research, and other non-patient care activities.
^cData for doctors of osteopathy are as of July 1996.
^dData for doctors of osteopathy are as of June 2005.
^eStarting with 2003 data, federal and nonfederal physicians are included. Data prior to 2004 include nonfederal physicians only.
	Number per 10,000 civilian population
Pacific	17.9	22.5	23.3	26.0	16.3	20.5	21.2	23.6
Alaska	8.4	13.0	15.7	24.1	7.8	12.1	14.2	21.3
California	18.8	23.7	23.7	25.7	17.3	21.5	21.7	23.3
Hawaii	16.2	21.5	24.8	31.2	14.7	19.8	22.8	28.2
Oregon	15.6	19.7	21.6	26.9	13.8	17.6	19.5	24.2
Washington	15.3	20.2	22.5	26.6	13.6	17.9	20.2	23.9
Notes: Data for doctors of medicine are as of December 31. Data for additional years are available. Data are based on reporting by physicians.

REGISTERED NURSES

Registerednurses(RNs)arelicensedbythestatetocare for the sick and to promote health. RNs supervise hospital care, administer medication and treatment as prescribed by physicians, monitor the progress of patients, and provide health education. Nurses work in a variety of settings, including hospitals, nursing homes, physicians' offices, clinics, and schools.

Education for Nurses

There are three types of education for RNs. These include associate degrees (two-year community college programs), baccalaureate programs (four years of college), and postgraduate (master's degree and doctorate) programs. The baccalaureate degree provides more knowledge of community health services, as well as the psychological and social aspects of caring for patients, than does the associate degree. Those who complete the four-year baccalaureate degree and the other advanced degrees are generally better prepared to eventually attain administrative or management positions and may have greater opportunities for upward mobility in related disciplines such as research, teaching, and public health.

Between 1999 and 2005 the number of RNs grew from 2.2 million to 2.4 million. (See Table 2.5.) In The Registered Nurse Population: Findings from the March 2004 National Sample Survey of Registered Nurses (June 2006, ftp://ftp.hrsa.gov/bhpr/workforce/0306rnss.pdf), the HRSA reports that as of 2004 there were more than 2.9 million RNs working in the United States; however, just 83.2%, or 2.4 million, were working in the field of nursing. The largest percentage increases occurred among those holding baccalaureate, master's, and doctorate degrees. Figure 2.1 shows the trend from 2000 to 2004 of increasing numbers of RNs receiving master's and doctorate degrees.

NEED FOR NURSES EXCEEDS SUPPLY. Even though the number of RNs holding baccalaureate degrees increased sharply during the 1990s, there is still a shortage of nurses that is predicted to persist until 2020. Some health care experts believe the shortage is intensifying because more lucrative fields are now open to women, the traditional nursing population. In health occupations alone, the percentage of female students entering traditionally male professions continues to increase. For example, in 1980–81 women accounted for just 17% of first-year dentistry students, compared to 43.8% of the class entering in 2004–05. (See Table 2.6.) Similarly, increasing percentages of women are attending medical school and training to become optometrists, pharmacists, podiatrists, and public health care workers. Meanwhile, nursing school enrollment has declined. In “Iowa Faces Severe Nursing Shortage” (Associated Press, February 22, 2008), James Beltran reports that about 41% of registered nurses in the United States are at least fifty years old and nearing retirement. Along with relatively low wages, industry observers also attribute the shortfall to a lack of faculty in nursing programs, which has acted to limit enrollment. According to the American Association of Colleges of Nursing, in the press release “Enrollment Growth Slows at U.S. Nursing Colleges and Universities in 2007” (December 3, 2007, http://www.aacn.nche.edu/media/NewsReleases/2007/enrl.htm), about thirty thousand applicants were denied admission to nursing schools in 2007 because of faculty shortages.

	All places^a				Physician offices
Age, sex, and race	1995	2000	2003	2005	1995	2000	2003	2005
^aAll places includes visits to physician offices and hospital outpatient and emergency departments.
^bEstimates are age-adjusted to the year 2000 standard population using six age groups: under 18 years, 18–44 years, 45–54 years, 55–64 years, 65–74 years, and 75 years and over.
^cStarting with 1999 data, the instruction for the race item on the patient record form was changed so that more than one race could be recorded. In previous years only one race could be checked. Estimates for race in this table are for visits where only one race was recorded. Because of the small number of responses with more than one racial group checked, estimates for visits with multiple races checked are unreliable and are not presented.
	Number of visits in thousands
Total	860,859	1,014,848	1,114,504	1,169,333	697,082	823,542	906,023	963,617
Under 18 years	194,644	212,165	223,724	238,389	150,351	163,459	169,392	185,186
18–44 years	285,184	315,774	331,015	324,108	219,065	243,011	251,853	247,568
45–64 years	188,320	255,894	301,558	328,564	159,531	216,783	257,258	283,180
45–54 years	104,891	142,233	164,431	170,674	88,266	119,474	138,634	145,034
55–64 years	83,429	113,661	137,126	157,890	71,264	97,309	118,624	138,146
65 years and over	192,712	231,014	258,206	278,272	168,135	200,289	227,520	247,683
65–74 years	102,605	116,505	120,655	133,334	90,544	102,447	106,424	119,061
75 years and over	90,106	114,510	137,552	144,938	77,591	97,842	121,096	128,623
	Number of visits per 100 persons
Total, age-adjusted^b	334	374	391	400	271	304	317	329
Total, crude	329	370	390	402	266	300	317	331
Under 18 years	275	293	307	325	213	226	232	253
18–44 years	264	291	301	294	203	224	229	224
45–64 years	364	422	442	454	309	358	377	391
45–54 years	339	385	406	405	286	323	343	344
55–64 years	401	481	494	523	343	412	428	458
65 years and over	612	706	753	792	534	612	664	705
65–74 years	560	656	667	725	494	577	588	647
75 years and over	683	766	850	865	588	654	748	768
Sex and age
Male, age-adjusted^b	290	325	338	352	232	261	273	289
Male, crude	277	314	329	345	220	251	264	283
Under 18 years	273	302	317	338	209	231	241	265
18–44 years	190	203	203	212	139	148	147	158
45–54 years	275	316	335	331	229	260	280	278
55–64 years	351	428	422	468	300	367	365	411
65–74 years	508	614	632	691	445	539	558	619
75 years and over	711	771	881	833	616	670	777	741
Female, age-adjusted^b	377	420	442	445	309	345	360	367
Female, crude	378	424	449	456	310	348	368	377
Under 18 years	277	285	297	311	217	221	223	240
18–44 years	336	377	397	375	265	298	309	290
45–54 years	400	451	475	476	339	384	403	408
55–64 years	446	529	561	574	382	453	486	501
65–74 years	603	692	696	754	534	609	613	671
75 years and over	666	763	830	886	571	645	730	785
Race and age^c
White, age-adjusted^b	339	380	399	413	282	315	332	347
White, crude	338	381	404	420	281	316	337	355
Under 18 years	295	306	330	348	237	243	260	280
18–44 years	267	301	308	306	211	239	242	242
45–54 years	334	386	409	416	286	330	352	362
55–64 years	397	480	500	534	345	416	439	476
65–74 years	557	641	653	727	496	568	582	656
75 years and over	689	764	844	854	598	658	747	763
Black or African American, age-adjusted	309	353	393	398	204	239	261	270
Black or African American, crude	281	324	365	369	178	214	236	243
Under 18 years	193	264	248	278	100	167	131	162
18–44 years	260	257	329	295	158	149	199	172
45–54 years	387	383	445	422	281	269	315	297
55–64 years	414	495	487	515	294	373	349	374
65–74 years	553	656	761	745	429	512	602	589
75 years and over	534	745	774	982	395	568	608	806
Notes: Rates for 1995–2000 were computed using 1990-based postcensal estimates of the civilian noninstitutionalized population as of July 1 adjusted for net underenumeration using the 1990 National Population Adjustment Matrix from the U.S. Census Bureau. Starting with 2001 data, rates were computed using 2000-based postcensal estimates of the civilian noninstitutionalized population as of July 1. The difference between rates for 2000 computed using 1990-based postcensal estimates and 2000 census counts is minimal. Rates will be overestimated to the extent that visits by institutionalized persons are counted in the numerator (for example, hospital emergency department visits by nursing home residents) and institutionalized persons are omitted from the denominator (the civilian noninstitutionalized population). Starting with Health, United States, 2005, data for physician offices for 2001 and beyond use a revised weighting scheme. Data are based on reporting by a sample of office-based physicians, hospital outpatient departments, and hospital emergency departments.

Industry observers feel this shortage results from a combination of factors including an aging population, a sicker population of hospitalized patients requiring more labor-intensive care, and public perception that nursing is a thankless, unglamorous job involving grueling physical labor, long hours, and low pay. In “Good Careers for 2006” (U.S. News and World Report, January 5, 2006), Marty Nemko deems nursing a “good career,” with salaries ranging from $57,000 to well over $100,000 per year and with excellent job security. Observers also note that the public, particularly high school students considering careers in health care, are unaware of the many new opportunities in nursing, such as advanced practice nursing, which offers additional independence and increased earning potential, and the technology-driven field of applied informatics (computer management of information).

ADVANCED PRACTICE NURSES AND PHYSICIAN ASSISTANTS

Much of the preventive medical care and treatment usually delivered by physicians may also be provided by midlevel practitioners—health professionals with less formal education and training than physicians. Advanced practice nurses make up a group that includes certified nurse midwives, nurse practitioners (NPs; RNs with advanced academic and clinical experience), and clinical nurse specialists (RNs with advanced nursing degrees who specialize in areas such as mental health, gerontology, cardiac or cancer care, and community or neonatal health). Physician assistants (PAs) are midlevel practitioners who work under the auspices, supervision, or direction of physicians. They conduct physical examinations, order and interpret laboratory and radiological studies, and prescribe medication. They even perform procedures (e.g., flexible sigmoidoscopy, biopsy, suturing, casting, and administering anesthesia) that were once performed exclusively by physicians.

The origins of each profession are key to understanding the differences between them. Nursing has the longer history, and nurses are recognized members of the health care team. For this reason, NPs were easily integrated into many practice settings.

PA is the newer of the two disciplines. PAs have been practicing in the United States since the early 1970s. The career originated as civilian employment for returning Vietnam War veterans who had worked as medics. The veterans needed immediate employment and few had the educational prerequisites, time, or resources to pursue the training necessary to become physicians. At the same time, the United States was projecting a dire shortage of primary care physicians, especially in rural and inner-city practices. The use of PAs and NPs was seen as an ideal rapid response to the demand for additional medical services. They could be deployed quickly to serve remote communities or under-served populations for a fraction of the costs associated with physicians.

The numbers of PAs and NPs have increased dramatically since the beginning of the 1990s. The HRSA reports in Registered Nurse Population that in 2004 there were 240,460 advanced practice nurses—141,209 NPs (59%), 72,521 clinical nurse specialists (30%), 32,523 certified RN anesthetists (14%), and 13,684 certified nurse midwives (6%). Advanced practice nurses accounted for 8.3% of the total RN population. According to the American Academy of Physician Assistants (http://www.aapa.org/research/07census-intro.html), there were 75,260 PAs eligible to practice in 2007. When combined, midlevel practitioners outnumber primary care physicians.

Training, Certification, and Practice

Advanced practice nurses usually have considerable clinical nursing experience before completing certificate or master's degree NP programs. Key components of NP programs are instruction in nursing theory and practice as well as a period of direct supervision by a physician or NP. The American College of Nurse Practitioners (April 20, 2007, http://www.ejfhc.org/American%20College%20of%20Nurse%20Practitioners.htm) states that NPs are prepared to practice “either independently or as part of a health care team,” but the NP scope of practice varies by state.

The Commission on Accreditation of Allied Health Education Programs accredits PA training programs. According to the American Academy of Physician Assistants (AAPA), in “Physician Assistants and Anesthesiologist Assistants—the Distinctions” (February 2005, http://www.aapa.org/gandp/issuebrief/aas.pdf), most students have an undergraduate degree and about forty-five months of health care experience before they enter a two-year PA training program. Graduates sit for a national certifying examination and, once certified, must earn one hundred hours of continuing medical education every two years and pass a recertification exam every six years.

Occupation title	1999	2000	2004	2005	1999–2005	1999	2000	2004	2005	1999–2005
^aEstimates do not include self-employed workers and were rounded to the nearest 10.
^bAverage annual percent change. AACP is the American Association of Colleges of Pharmacy.
^cThe mean hourly wage rate for an occupation is the total wages that all workers in the occupation earn in an hour divided by the total employment of the occupation.
Healthcare practitioner and technical occupations		Number of employees^a			AAPC^b		Mean hourly wage^c			AACP^b
Audiologists	12,950	11,530	9,810	10,030	−4.2	$21.96	$22.92	$26.47	$27.72	4.0
Cardiovascular technologists and technicians	41,490	40,080	43,540	43,560	0.8	$16.00	$16.81	$19.09	$19.99	3.8
Dental hygienists	90,050	148,460	155,810	161,140	10.2	$23.15	$24.99	$28.58	$29.15	3.9
Diagnostic medical sonographers	29,280	31,760	41,280	43,590	6.9	$21.04	$22.03	$25.78	$26.65	4.0
Dietetic technicians	29,190	28,010	24,630	23,780	−3.4	$10.09	$10.98	$11.89	$12.20	3.2
Dietitians and nutritionists	41,320	43,030	46,530	48,850	2.8	$17.96	$18.76	$21.46	$22.09	3.5
Emergency medical technicians and paramedics	172,360	165,530	187,900	196,880	2.2	$11.19	$11.89	$13.30	$13.68	3.4
Licensed practical and licensed vocational nurse	688,510	679,470	702,740	710,020	0.5	$13.95	$14.65	$16.75	$17.41	3.8
Nuclear medicine technologists	17,880	18,030	17,520	18,280	0.4	$20.40	$21.56	$29.43	$29.10	6.1
Occupational therapists	78,950	75,150	83,560	87,430	1.7	$24.96	$24.10	$27.19	$28.41	2.2
Opticians, dispensing	58,860	66,580	62,350	70,090	3.0	$12.11	$12.67	$14.37	$14.80	3.4
Pharmacists	226,300	212,660	222,960	229,740	0.3	$30.31	$33.39	$40.56	$42.62	5.8
Pharmacy technicians	196,430	190,940	255,290	266,790	5.2	$ 9.64	$10.38	$11.87	$12.19	4.0
Physical therapists	131,050	120,410	142,940	151,280	2.4	$28.05	$27.62	$30.00	$31.42	1.9
Physician assistants	56,750	55,490	59,470	63,350	1.9	$24.35	$29.17	$33.07	$34.17	5.8
Psychiatric technicians	54,560	53,350	59,010	62,040	2.2	$11.30	$12.53	$13.43	$14.04	3.7
Radiation therapists	12,340	13,100	14,470	14,120	2.3	$20.84	$25.59	$29.05	$30.59	6.6
Radiologic technologists and technicians	177,850	172,080	177,220	184,580	0.6	$17.07	$17.93	$21.41	$22.60	4.8
Recreational therapists	30,190	26,940	23,050	23,260	−4.3	$14.08	$14.23	$16.48	$16.90	3.1
Registered nurses	2,205,430	2,189,670	2,311,970	2,368,070	1.2	$21.38	$22.31	$26.06	$27.35	4.2
Respiratory therapists	80,230	82,670	91,350	95,320	2.9	$17.72	$18.37	$21.24	$22.24	3.9
Respiratory therapy technicians	33,990	28,230	24,190	22,060	−7.0	$16.07	$16.46	$18.00	$18.57	2.4
Speech-language pathologists	85,920	82,850	89,260	94,660	1.6	$22.99	$23.31	$26.71	$27.89	3.3
Healthcare support occupations
Dental assistants	175,160	250,870	264,820	270,720	7.5	$11.60	$12.86	$13.97	$14.41	3.7
Home health aides	577,530	561,120	596,330	663,280	2.3	$ 9.04	$ 8.71	$ 9.13	$ 9.34	0.5
Massage therapists	21,910	24,620	32,200	37,670	9.5	$13.82	$15.51	$17.63	$19.33	5.8
Medical assistants	281,480	330,830	380,340	382,720	5.3	$10.89	$11.46	$12.21	$12.58	2.4
Medical equipment preparers	29,070	32,760	40,380	41,790	6.2	$10.20	$10.68	$12.14	$12.42	3.3
Medical transcriptionists	97,260	97,330	92,740	90,380	−1.2	$11.86	$12.37	$14.01	$14.36	3.2
Nursing aides, orderlies, and attendants	1,308,740	1,273,460	1,384,120	1,391,430	1.0	$ 8.59	$ 9.18	$10.39	$10.67	3.7
Occupational therapist aides	9,250	8,890	5,240	6,220	−6.4	$10.92	$11.21	$12.51	$13.20	3.2
Occupational therapist assistants	17,290	15,910	20,880	22,160	4.2	$15.97	$16.76	$18.49	$19.13	3.1
Pharmacy aides	48,270	59,890	47,720	46,610	−0.6	$ 9.14	$ 9.10	$ 9.52	$ 9.76	1.1
Physical therapist aides	44,340	34,620	41,910	41,930	−0.9	$ 9.69	$10.06	$11.14	$11.01	2.2
Physical therapist assistants	48,600	44,120	57,420	58,670	3.2	$16.20	$16.52	$18.14	$18.98	2.7
Psychiatric aides	51,100	57,680	54,520	56,150	1.6	$10.76	$10.79	$11.70	$11.47	1.1
Notes: This table excludes occupations such as dentists, physicians, and chiropractors, with a large percentage of workers who are self-employed and/or not employed by establishments. Data are based on a semi-annual mail survey of nonfarm establishments.

PA practice is always delegated by the physician and conducted with physician supervision. The extent and nature of physician supervision varies from state to state. For example, Connecticut permits a physician to supervise up to six PAs, whereas California limits a supervising physician to two. Even though PAs work interdependently with physicians, supervision is not necessarily direct and onsite; some PAs working in remote communities are supervised primarily by telephone.

In 2007 AAPA Physician Assistant Census Report (October 12, 2007, http://www.aapa.org/research/07census-intro.html), the AAPA states that in 2007 the mean (average) annual income of physician assistants who were not self-employed was $86,214. New graduates (in 2006) could anticipate a mean annual income of $73,013.

Distinctions between Midlevel Practitioners Blurring

Pohla Smith reports in “Doing Doctors' Work” (Pittsburgh Post-Gazette, March 12, 2008) that even though their training may be different, in terms of their day-to-day job responsibilities, NPs and PAs are becoming essentially interchangeable. Both types of practitioners diagnose and treat illness, take medical histories, and perform physical examinations. They can order diagnostic tests, prescribe medication, and assist in operating rooms and emergency departments.

DENTISTS

Dentists diagnose and treat problems of the teeth, gums, and mouth, take x-rays, apply protective plastic sealant to children's teeth, fill cavities, straighten teeth, and treat gum disease. The BLS (December 18, 2007, http://www.bls.gov/oco/ocos072.htm) reports that in 2006 there were 161,000 professionally active (as opposed to retired or employed in other fields) dentists in the United States.

Fluoridation of community water supplies and improved dental hygiene have dramatically improved the dental health of Americans. Dental caries (cavities) among all age groups have declined significantly. As a result, many dental services are shifting focus from young people to adults. In the twenty-first century, many adults are choosing to have orthodontic services, such as straightening their teeth. In addition, the growing older adult population generally requires more complex dental procedures, such as endodontic (root canal) services, bridges, and dentures.

The overwhelming majority of dentists own solo dental practices, where only one dentist operates in each office. The BLS reports that in 2006 about one-third of dentists were self-employed, nearly all were in private practice, and that one out of seven dentists belonged to a partnership. On average, dentists work between thirty-five and forty hours per week and supervise staffers, such as dental assistants and hygienists. In May 2007 National Occupational Employment and Wage Estimates (May 12, 2008, http://www.bls.gov/oes/current/oes_nat.htm), the BLS notes that self-employed dentists in general practice had mean annual wages of $147,010 in 2007, whereas dental specialists' mean annual wages ranged from $120,360 to $185,340.

	Both sexes			Women
Enrollment and occupation	1980–1981	1990–1991	2004–2005^a	1980–1981	1990–1991^b	2004–2005^a
—Data not available.
^aStarting with 2003–2004 data, osteopathic medicine data include the students of the Edward Via Virginia College of Osteopathic Medicine.
^bPercentage of women podiatry students is for 1991–1992.
^cInclude data from schools in Puerto Rico.
^d2004–2005 optometry data are for 2005–2006.
^eFirst-year enrollment data for pharmacy schools are for students in the first year of the final three years of pharmacy education. Prior to 1992–1993, pharmacy total enrollment data were for students in the final three years of pharmacy education. Starting in 1992–1993, pharmacy total enrollment data are for all students.
^fFor 2003–2004 data, first-year enrollment data for public health schools include Spring, Summer, and Fall enrollment. All other years of data including 2004–2005 are for Fall enrollment only and are not directly comparable to 2003–2004 data.
First-year enrollment		Number of students			Percent of students
Dentistry	6,030	4,001	4,612	19.8	38.0	—
Medicine (allopathic)^c	17,186	16,876	17,059	28.9	38.8	49.4
Medicine (osteopathic)	1,496	1,950	3,646	22.0	34.2	50.1
Nurses, registered	110,201	113,526	—	92.7	89.3	—
Optometry^{c, d}	1,258	1,239	1,429	25.3	50.6	64.9
Pharmacy^{c, e}	7,377	8,267	10,437	48.4	—	65.4
Podiatry	695	561	519	—	28.0	49.0
Public health^{c, f}	3,348	4,289	7,206	—	62.1	70.9
Total enrollment
Dentistry	22,842	15,951	18,315	17.0	34.4	43.8
Medicine (allopathic)^c	65,189	65,163	67,466	26.5	37.3	48.7
Medicine (osteopathic)	4,940	6,792	12,525	19.7	32.7	48.8
Nurses, registered	230,966	221,170	—	94.3	—	—
Optometry^{c, d}	4,641	4,760	5,377	—	47.3	63.1
Pharmacy^{c, e}	26,617	29,797	43,908	47.4	62.4	66.5
Podiatry	2,577	2,154	1,584	11.9	28.9	46.9
Public health^{c, f}	8,486	11,386	19,434	55.2	62.5	69.6
Notes: Total enrollment data are collected at the beginning of the academic year while first-year enrollment data are collected during the academic year. Data for chiropractic students and occupational, physical, and speech therapy students were not available for this table. Some numbers in this table have been revised and differ from previous editions of Health, United States. Data are based on reporting by health professions associations.

Dental Specialists

The ADA explains in What Can a Career in Dentistry Offer You? (2008, http://www.ada.org/public/careers/team/dentistry_fact.pdf) that 20% of all dentists practice in one of the nine specialty areas that the ADA recognizes. Orthodontists, who straighten teeth, make up the largest group of specialists. The next largest group, oral and maxillofacial surgeons, operates on the mouth and jaws. The balance of the specialists concentrates in pediatric dentistry (dentistry for children), periodontics (treating the gums), prosthodontics (making dentures and artificial teeth), endodontics (root canals), public health dentistry (community dental health), and oral pathology (diseases of the mouth).

According to the BLS (December 18, 2007, http://www.bls.gov/oco/ocos072.htm), as of 2006, seventeen states licensed or certified dentists who practice in specialty areas. Requirements vary by state and specialty and may include two to four years of postgraduate education and a passing score on a state-administered examination. Dentists who teach or conduct research generally spend an additional two to five years in advanced dental training in programs operated by dental schools or university-affiliated hospitals.

Training to Become a Dentist

Entry into dental schools requires two to four years of college-level predental education—most dental students have earned excellent grades and have at least a bachelor's degree when they enter dental school. Dentists should have good visual memory, excellent judgment about space and shape, a high degree of manual dexterity, and scientific ability. Development and maintenance of a successful private practice requires business acumen, the ability to manage and organize people and materials, and strong interpersonal skills.

Dental schools require applicants to take the Dental Admissions Test (DAT). During the admission process, schools consider scores earned on the DAT, applicants' grade-point averages, and information gleaned from recommendations and interviews. Dental school usually lasts four academic years. A student begins by studying the basic sciences, including anatomy, microbiology, biochemistry, and physiology. During the last two years, students receive practical experience by treating patients, usually in dental clinics supervised by licensed dentists.

Visiting the Dentist

In 2005 more than half (57.7%) of Americans over two years of age had visited their dentists at least once in the past year. (See Table 2.7.) Children aged two to seventeen (76.2%) were more likely to have visited the dentist than any other age group, and women aged sixty-five and older were somewhat more likely to see the dentist than men. Among adults aged eighteen to sixty-four, the proportion of non-Hispanic whites (67.9%) visiting dentists was considerably higher than the proportions of non-Hispanic African-Americans (57%) and Hispanics (48.5%). People who were poor or near poor were much less likely to visit the dentist annually than those who were not poor.

SEVERE SHORTAGES OF DENTISTS IN SOME AREAS. The United States boasts the highest concentration of dentists of any country in the world. Nonetheless, health care planners caution that dentists' ranks will begin to decline during the coming decade as the number of dental school graduates—about four thousand or so annually, according to Eric S. Solomon, in “The Future of Dentistry” (Dental Economics, November 2004)—falls below the number of dentists retiring from the workforce. Even before this decline, residents of many states do not have adequate access to dental care, especially people in rural communities and poor urban neighborhoods, where, arguably, the need is greatest.

Even though the American Dental Hygienists' Association (ADHA) believes access to quality, affordable dental care is a right, according to the fact sheet “ADHA Access to Care Facts and Stats” (2008, http://www.adha.org/media/facts/access.htm), 40% of Americans do not receive needed care. Access to care is limited by both a shortage of practicing dentists in many communities and many Americans' inability to pay for care. In “Access to Care Position Paper, 2001” (June 9, 2008, http://www.adha.org/profissues/access_to_care.htm), the ADHS asserts that the shortage of dentists will persist and that by 2020 the number of dentists per 100,000 U.S. population will fall to 52.7. In areas where there are few practicing dentists, uninsured and low-income families have even more difficulty gaining access to already overbooked dentists.

In February 2008 the death of a twelve-year-old boy from complications resulting from an untreated dental problem underscored how lack of access to dental care has created a situation the Oral Health in America: A Report of the Surgeon General (September 2000, http://silk.nih.gov/public/[email protected]) calls a “silent epidemic.” The report asserts that dental disease afflicts the nation's most vulnerable populations: poor children, older adults, and many members of racial and ethnic minority groups.

ALLIED HEALTH CARE PROVIDERS

Many health care services are provided by an interdisciplinary team of health professionals. The complete health care team may include physicians, nurses, midlevel practitioners, and dentists; physical and occupational therapists; audiologists and speech-language pathologists; licensed practical nurses, nurses' aides, and home health aides; and pharmacists, optometrists, podiatrists, dental hygienists, social workers, registered dieticians, and others. Table 2.8 describes some of these allied heath professions. Specific health care teams are assembled to meet the varying needs of patients. For example, the team involved in stroke rehabilitation might include a physician, a nurse, a speech-language pathologist, a social worker, and physical and occupational therapists.

Besides these allied health professionals, the HRSA asserts in Fifth Annual Report to the Secretary of the U.S. Department of Health and Human Services and to the Congress, 2005 (November 2005, ftp://ftp.hrsa.gov/bhpr/interdisciplinary/cblreports/rpt5.pdf) that there is a growing need for other allied health personnel to fill a variety of health care professions, including epidemiologists, biostatisticians, environmental health professionals, toxicologists, public health nutritionists, preventive medicine specialists, and behavioral and mental health professionals. Other allied health care workers such as pharmacy technicians, athletic trainers, cardiovascular technologists, dispensing opticians, genetic counselors, massage therapists, and phlebotomists work in a variety of settings including hospitals, clinics, nursing homes, mental health facilities, managed care organizations, federal, state, and local government agencies, colleges and universities, public and private research organizations, and medical supply, equipment, and pharmaceutical industries.

Physical and Occupational Therapists

Physical therapists (PTs) are licensed practitioners who work with patients to preserve and restore function, improve capabilities and mobility, and regain independence following illness or injury. They also aim to prevent or limit disability and slow the progress of debilitating diseases. Treatment involves exercise to improve range of motion, balance, coordination, flexibility, strength, and endurance. PTs may also use electrical stimulation to promote healing, hot and cold packs to relieve pain and inflammation (swelling), and therapeutic massage.

According to the BLS (December 18, 2007, http://www.bls.gov/oco/ocos080.htm), PTs worked at 173,000 jobs in 2006, but some were part-time jobs and some PTs held two

	2 years and over			2–17 years			18–64 years			65 years and over^a
Characteristic	1997	2004	2005	1997	2004	2005	1997	2004	2005	1997	2004	2005
—Data not available.
^aBased on the 1997–2005 National Health Interview Surveys, about 25%–30% of persons 65 years and over were edentulous (having lost all their natural teeth). In 1997–2005 about 68%–70% of older dentate persons compared with 16%–20% of older edentate persons had a dental visit in the past year.
^bRespondents were asked “About how long has it been since you last saw or talked to a dentist?”
^cIncludes all other races not shown separately.
^dThe race groups, white, black, American Indian or Alaska Native, Asian, Native Hawaiian or other Pacific Islander, and 2 or more races, include persons of Hispanic and non-Hispanic origin. Persons of Hispanic origin may be of any race. Starting with 1999 data, race-specific estimates are tabulated according to the 1997 Revisions to the Standards for the Classification of Federal Data on Race and Ethnicity and are not strictly comparable with estimates for earlier years. The five single-race categories plus multiple-race categories shown in the table conform to the 1997 standards. Starting with 1999 data, race-specific estimates are for persons who reported only one racial group; the category 2 or more races includes persons who reported more than one racial group. Prior to 1999, data were tabulated according to the 1977 standards with four racial groups, and the Asian only category included Native Hawaiian or other Pacific Islander. Estimates for single-race categories prior to 1999 included persons who reported one race or, if they reported more than one race, identified one race as best representing their race. Starting with 2003 data, race responses of other race and unspecified multiple race were treated as missing, and then race was imputed if these were the only race responses. Almost all persons with a race response of other race were of Hispanic origin.
^ePercent of poverty level is based on family income and family size and composition using U.S. Census Bureau poverty thresholds. Missing family income data were imputed for 25%–29% of persons in 1997–1998 and 32%–35% in 1999–2005.
	Percent of persons with a dental visit in the past year^b
2 years and over^c	65.1	66.0	65.8	72.7	76.4	76.2	64.1	64.0	63.5	54.8	56.3	57.7
Sex
Male	62.9	63.7	63.0	72.3	75.1	75.5	60.4	60.5	59.4	55.4	57.1	56.6
Female	67.1	68.1	68.4	73.0	77.7	77.0	67.7	67.4	67.6	54.4	55.8	58.6
Race^d
White only	66.4	67.0	66.8	74.0	77.3	77.1	65.7	65.2	64.8	56.8	58.6	59.9
Black or African American only	58.9	59.5	59.8	68.8	72.5	72.9	57.0	56.9	57.0	35.4	33.6	36.0
American Indian or Alaska Native only	55.1	63.4	59.3	66.8	70.3	74.8	49.9	63.4	54.1	32.2
Asian only	62.5	66.1	62.5	69.9	73.8	70.1	60.3	64.2	60.2	53.9	58.1	60.0
Native Hawaiian or other Pacific Islander only	—	—	—	—	—	—	—	—	—	—	—	—
2 or more races	—	65.3	67.3	—	78.0	78.1	—	58.4	60.8	—	28.7	39.7
Black or African American; white	—	67.1	66.0	—	72.6	75.3	—	61.0	51.3	—	—	—
American Indian or Alaska Native; white	—	55.1	56.2	—	78.9	70.9	—	49.1	54.4	—	—	—
Hispanic origin and race^d
Hispanic or Latino	54.0	54.2	53.9	61.0	65.3	66.5	50.8	49.6	48.5	47.8	42.5	43.1
Not Hispanic or Latino	66.4	67.9	67.8	74.7	78.9	78.5	65.7	66.3	66.0	55.2	57.2	58.7
White only	68.0	69.5	69.4	76.4	80.9	80.4	67.5	68.1	67.9	57.2	59.8	61.2
Black or African American only	58.8	59.8	59.7	68.8	72.9	72.7	56.9	57.3	57.0	35.3	33.3	35.5
Percent of poverty level^e
Below 100%	50.5	49.6	50.4	62.0	65.5	66.2	46.9	44.5	44.6	31.5	30.7	34.7
100%–less than 200%	50.8	52.6	52.4	62.5	69.0	68.6	48.3	47.6	47.8	40.8	43.2	42.5
200% or more	72.5	73.0	72.6	80.1	82.2	82.0	71.2	71.3	70.5	65.9	66.4	67.8
Hispanic origin and race and percent of poverty level^{d, e}
Hispanic or Latino:
Below 100%	45.7	47.1	47.4	55.9	61.9	64.4	39.2	38.3	36.3	33.6	29.8	37.1
100%–less than 200%	47.2	47.2	47.6	53.8	59.1	60.2	43.5	41.7	42.3	47.9	37.7	36.2
200% or more	65.1	63.7	61.9	73.7	74.2	73.6	62.3	60.4	58.2	58.8	55.4	51.8
Not Hispanic or Latino:
White only:
Below 100%	51.7	51.1	51.5	64.4	68.7	65.0	50.6	48.7	49.6	32.0	33.4	37.9
100%–less than 200%	52.4	54.3	54.5	66.1	73.5	72.5	50.4	50.0	50.9	42.2	45.6	45.7
200% or more	73.8	74.8	74.6	81.3	84.3	84.2	72.7	73.2	72.8	67.0	68.5	69.7
Black or African American only:
Below 100%	52.8	49.8	52.5	66.1	68.2	71.1	46.2	42.3	44.1	27.7	21.5	24.6
100%–less than 200%	48.7	52.1	51.3	61.2	70.5	70.5	46.3	46.4	45.2	26.9	29.4	26.9
200% or more	67.7	68.2	67.6	77.1	77.7	75.9	66.1	67.0	66.7	49.8	45.0	50.7
Notes: In 1997 the National Health Interview Survey questionnaire was redesigned. Data are based on household interviews of a sample of the civilian noninstitutionalized population.

or more jobs at the same time. Two-thirds of practicing PTs worked in hospitals and physicians' offices; the remaining PTs were employed in outpatient rehabilitation clinics, nursing homes, and home health agencies. Even though most work in rehabilitation, PTs may specialize in areas such as sports medicine, pediatrics, or neurology. PTs often work as

TABLE 2.8

Allied health care providers

Dental hygienists provide services for maintaining oral health. Their primary duty is to clean teeth.

Emergency medical technicians (EMTs) provide immediate care to critically ill or injured people in emergency situations.

Home health aides provide nursing, household, and personal care services to patients who are homebound or disabled.

Licensed practical nurse (LPNs) are trained and licensed to provide basic nursing care under the supervision of registered nurses and doctors.

Medical records personnel analyze patient records and keep them up-to-date, complete, accurate, and confidential.

Medical technologists perform laboratory tests to help diagnose diseases and to aid in identifying their causes and extent.

Nurses' aides, orderlies, and attendants help nurses in hospitals, nursing homes, and other facilities.

Occupational therapists help disabled persons adapt to their disabilities. This may include helping a patient relearn basic living skills or modifying the environment.

Optometrists measure vision for corrective lenses and prescribe glasses.

Pharmacists are trained and licensed to make up and dispense drugs in accordance with a physician's prescription.

Physician assistants (PAs) work under a doctor's supervision. Their duties include performing routine physical exams, prescribing certain drugs, and providing medical counseling.

Physical therapists work with disabled patients to help restore function, strength and mobility. PTs use exercise, heat, cold, water, and electricity to relieve pain and restore function.

Podiatrists diagnose and treat diseases, injuries, and abnormalities of the feet. They may use drugs and surgery to treat foot problems.

Psychologists are trained in human behavior and provide counseling and testing services related to mental health.

Radiation technicians take and develop x-ray photographs for medical purposes.

Registered dietitians (RDs) are licensed to use dietary principles to maintain health and treat disease.

Respiratory therapists treat breathing problems under a doctor's supervision and help in respiratory rehabilitation.

Social workers help patients to handle social problems such as finances, housing, and social and family problems that arise out of illness or disability.

Speech pathologists diagnose and treat disorders of speech and communication.

SOURCE: “Allied Health Care Providers,” U.S. Department of Commerce, Washington, DC

members of a health care team and may supervise physical therapy assistants or aides. PTs' median annual earnings were $70,920 in 2006.

Occupational therapists (OTs) focus on helping people relearn and improve their abilities to perform the “activities of daily living,” meaning the tasks they perform during the course of their work and home life. Examples of activities of daily living that OTs help patients regain are dressing, bathing, and meal preparation. For people with long-term or permanent disabilities, OTs may assist them to find new ways to accomplish their responsibilities on the job, sometimes by using adaptive equipment or by asking employers to accommodate workers with special needs such as people in wheelchairs. OTs use computer programs and simulations to help patients restore fine motor skills and practice reasoning, decision making, and problem solving.

The BLS (December 18, 2007, http://www.bls.gov/oco/ocos078.htm) reports that OTs filled ninety-nine thousand jobs in 2006, with one out of ten holding more than one job at a time. The demand for OTs and PTs is expected to exceed the available supply through 2016. Besides hospital and rehabilitation center jobs, it is anticipated that PTs and OTs will increasingly be involved in school program efforts to meet the needs of disabled and special education students.

Historically, a bachelor's degree in occupational therapy has been the minimum educational requirement; beginning in 2007, however, a master's degree or higher is required. According to the BLS, the median annual earnings of occupational therapists were $60,470 in 2006.

Pharmacists Provide Valuable Patient Care Services

Pharmacists are involved in many more aspects of patient care than simply compounding and dispensing medication from behind the drugstore counter. According to the American Pharmacists Association (2008, http://www.pharmacist.com/), which represents the nation's sixty thousand pharmacists (as well as pharmaceutical scientists, students, and technicians), pharmacists provide pharmaceutical care that not only improves patient adherence to prescribed drug treatment but also reduces the frequency of drug therapy mishaps, which can have serious and even life-threatening consequences.

Studies citing the value of pharmacists in patient care describe pharmacists improving rates of immunization against disease (pharmacists can provide immunization in twenty-seven states), assisting patients to better control chronic diseases such as asthma and diabetes, reducing the frequency and severity of drug interactions and adverse reactions, and helping patients effectively manage pain and symptoms of disease, especially at the end of life. Pharmacists also offer public health education programs about prescription medication safety, prevention of poisoning, appropriate use of nonprescription (over-the-counter) drugs, and medical self-care.

The BLS (December 18, 2007, http://www.bls.gov/oco/ocos079.htm) reports that pharmacists held about 243,000 jobs in 2006. About 62% worked in community pharmacies—either independently owned or part of a drugstore chain, grocery store, department store, or mass merchandiser. Most full-time salaried pharmacists worked about forty hours per week, and many self-employed pharmacists worked more than fifty hours per week. About 23% worked in hospitals in 2006. The median annual earnings of pharmacists in 2006 was $94,520.

MENTAL HEALTH PROFESSIONALS

The mental health sector includes a range of professionals—psychiatrists, psychologists, psychiatric nurses, psychiatric social workers, and marriage and family therapists—whose training, orientation, philosophy, and practice styles differ, even within a single discipline. For example, clinical psychologists may endorse and offer dramatically different forms of therapy—ranging from long-term psychoanalytic psychotherapy to short-term cognitive-behavioral therapy.

Psychiatrists

Psychiatrists are physicians who have completed residency training in the prevention, diagnosis, and treatment of mental illness, mental retardation, and substance abuse disorders. Because they are trained physicians, they are especially well equipped to care for people who have coexisting medical diseases and mental health problems and they are able to prescribe medication including psycho-active drugs. Psychiatrists may also obtain additional training that prepares them to treat selected populations such as children and adolescents or older adults (this subspecialty is called geriatric psychiatry or geropsychiatry), or they may specialize in a specific treatment modality.

Psychologists

Research psychologists investigate the physical, cognitive, emotional, or social aspects of human behavior. They work in academic and private research centers and in business, nonprofit, and governmental organizations.

Clinical psychologists help mentally and emotionally disturbed clients better manage their symptoms and behaviors. Some work in rehabilitation, treating patients with spinal cord injuries, chronic pain or illness, stroke, arthritis, and neurologic conditions. Others help people cope during times of personal crisis, such as divorce or the death of a loved one. Psychologists are also called on to help communities recover from the trauma of natural or human-made disasters, working with, for example, people who have lost their homes to earthquakes, fires, or floods, or students who have witnessed school violence.

Clinical psychologists may specialize in health psychology, neuropsychology, or geropsychology. Health psychologists promote healthy lifestyles and behaviors and provide counseling such as smoking cessation, weight reduction, and stress management to assist people to reduce their health risks. Neuropsychologists often work in stroke rehabilitation and head injury programs, and geropsychologists work with older adults in institutional and community settings.

School psychologists identify, diagnose, and address students' learning and behavior problems. They work with teachers, parents, and school personnel to improve classroom management strategies or parenting skills and design educational programs to meet the needs of students with disabilities or gifted and talented students.

Industrial-organizational psychologists aim to improve productivity and the quality of life in the workplace. They screen prospective employees and conduct training and development, counseling, and organizational development and analysis. Industrial-organizational psychologists examine aspects of work life, whereas social psychologists consider interpersonal relationships and interactions with the social environment. They work in organizational consultation, market research, systems design, or other applied psychology fields. For example, both industrial-organizational and social psychologists may be involved in efforts to understand and influence consumer-purchasing behaviors.

EDUCATION, TRAINING, LICENSURE, AND EARNINGS. Most psychologists hold a doctoral degree in psychology, which entails between five and seven years of graduate study. Clinical psychologists must usually have earned Doctor of Philosophy or Doctor of Psychology degrees and completed an internship of at least a one-year duration. An educational specialist qualifies an individual to work as a school psychologist; however, most school psychologists complete a master's degree followed by a one-year internship. People with a master's degree in psychology may work as industrial-organizational psychologists or as psychological assistants, under the supervision of doctoral-level psychologists, and conduct research or psychological evaluations. Vocational and guidance counselors usually need two years of graduate education in counseling and one year of counseling experience. A master's degree in psychology requires at least two years of full-time graduate study. People with undergraduate degrees in psychology assist psychologists and other professionals in community mental health centers, vocational rehabilitation offices, and correctional programs as well as research or administrative capacities.

Psychologists in clinical practice must be certified or licensed in all states and the District of Columbia. According to the BLS (December 18, 2007, http://www.bls.gov/oco/ocos056.htm), the median annual salary for clinical, counseling, and school psychologists was $59,449 in 2006.

Psychiatric Nurses

Psychiatric nurses have earned a degree in nursing, are licensed as RNs, and have obtained additional experience in psychiatry. Advanced practice psychiatric nurses (RNs prepared at the master's level) may prescribe psychotropic medications and conduct individual, group, and family psychotherapy as well as perform crisis intervention and case management functions. Along with primary care physicians, they are often the first points of contact for people seeking mental health help.

The American Psychiatric Nurses Association (APNA) is the professional society that represents psychiatric nurses and examines the changing profile of the profession. According to the APNA, in “About Psychiatric-Mental Health Nurses (PMHNs)” (2008, http://www.apna.org/i4a/pages/index.cfm?pageid=3292), basic-level nurses usually start at an annual salary of $35,000 to $40,000, depending on the geographic location. Advanced practice nurses' salaries start at $60,000. Nurse executives can make $100,000 or more per year. Meanwhile, faculty members average about $65,000 per year, depending on the amount of education and experience.

Clinical Social Workers

Clinical social workers are the largest group of professionally trained mental health care providers in the United States. Clinical social workers offer psychotherapy or counseling and a range of diagnostic services in public agencies, clinics, and private practice. They assist people to improve their interpersonal relationships, solve personal and family problems, and advise them about how to function effectively in their communities.

According to the BLS (April 14, 2007, http://www.bls.gov/oco/ocos060.htm), approximately 595,000 social workers were employed in the United States in 2006. Of this total, 282,000 were child, family, and school social workers, 124,000 were medical and public health social workers, and 122,000 were mental health and substance abuse social workers. In 2006 the median annual earnings of child, family, and school social workers were $37,480. Medical and public health social workers earned $43,040, and the median annual earnings of mental health and substance abuse social workers were $35,410.

EDUCATION, CERTIFICATION, AND LICENSURE. A bachelor's degree in social work is usually the minimum requirement for employment as a social worker, and an advanced degree has become the standard for many positions. A master's degree in social work is necessary for positions in health and mental health settings and is typically required for certification for clinical work. Licensed clinical social workers hold a master's degree in social work along with additional clinical training. Supervisory, administrative, and staff training positions usually require an advanced degree, and university teaching positions and research appointments normally require a doctorate in social work.

Even though all the states and the District of Columbia have licensing, certification, or registration requirements that delineate the scope of social work practice and the use of professional titles, standards for licensing vary by state. The National Association of Social Workers (2008, https://www.socialworkers.org/nasw/default.asp) is the largest membership organization of professional social workers in the world, with 150,000 members.

Counselors

Counselors assist people with personal, family, educational, mental health, and job-related challenges and problems. Their roles and responsibilities depend on the clients they serve and on the settings in which they work. According to the BLS (December 18, 2007, http://www.bls.gov/oco/ocos067.htm), more than half of all counselors have earned a master's degree. In 2006 forty-nine states and the District of Columbia had some form of counselor credentialing, licensure, certification, or registry legislation governing counselors who practice outside schools; however, requirements vary from state to state. The American Counseling Association (ACA; 2008, http://www.counseling.org/AboutUs/), which is the world's largest association for professional counselors, represents nearly forty-five thousand professional counselors in various practice settings. The ACA has taken an active role in advocating for certification, licensure, and registry of counselors.

The BLS notes that of the 635,000 counselors employed in the United States during 2006, 260,000 were educational, vocational, and school counselors, 141,000 were rehabilitation counselors, 100,000 were mental health counselors, 83,000 were substance abuse and behavioral disorder counselors, and 25,000 were marriage and family therapists.

Working in elementary, secondary, and postsecondary schools, educational, vocational, and school counselors work with people with disabilities and help them overcome the personal, social, and vocational effects of their disabilities. They advise people with disabilities resulting from birth defects, illness or disease, accidents, or the stress of daily life.

Mental health counselors work in prevention programs to promote optimum mental health and provide a wide range of counseling services. They work closely with other mental health professionals, including psychiatrists, psychologists, clinical social workers, psychiatric nurses, and school counselors.

Substance abuse and behavioral disorder counselors help people overcome addictions to alcohol, drugs, gambling, and eating disorders. They counsel individuals, families, or groups in clinics, hospital-based outpatient treatment programs, community mental health centers, and inpatient chemical dependency treatment programs.

Marriage and family therapists use various techniques to intervene with individuals, families, and couples or to help them resolve emotional conflicts. They aim to modify perceptions and behavior, enhance communication and understanding among family members, and prevent family and individual crises. Individual marriage and family therapists may also offer psychotherapy intended to assist individuals, couples, and families to improve their interpersonal relationships.

Pastoral counselors offer a type of psychotherapy that combines spiritual resources as well as psychological understanding for healing and growth. According to the American Association of Pastoral Counselors (AAPC; 2008, http://www.aapc.org/practice.cfm), this therapeutic modality is more than simply the comfort, support, and encouragement a religious community can offer; instead, it provides “psychologically sound therapy that weaves in the religious and spiritual dimension.” Typically, an AAPC-certified counselor has obtained a bachelor's degree from a college or university, a three-year professional degree from a seminary, and a specialized master's or doctoral degree in the mental health field.

The AAPC asserts that demand for spiritually based counseling is on the rise, in part because interest in spirituality is on the rise in the United States. The organization also believes that despite increased interest in psychotherapy and increasing numbers of therapists, managed mental health care has reduced the availability of, and payment for, counseling services for many people. As a result, more people are turning to clergy for help with personal, marital, and family issues as well as with faith issues. For many working poor Americans without health insurance benefits, free or low-cost counseling from pastoral counselors is the most accessible, available, affordable, and acceptable form of mental health care.

PRACTITIONERS OF COMPLEMENTARY AND ALTERNATIVE MEDICINE

The field of complementary and alternative medicine (CAM) is attracting a growing number of professionals. The National Center for Complementary and Alternative Medicine (NCCAM; June 26, 2008, http://nccam.nih.gov/health/whatiscam/) defines alternative medicine as “a group of diverse medical and health care systems, practices, and products that are not presently considered to be part of conventional medicine.” Though there is some overlap between them, the NCCAM further distinguishes complementary, alternative, and integrative medicine in the following manner:

Alternative medicine is therapy or treatment that is used instead of conventional medical treatment.
Complementary medicine is nonstandard therapy or treatment that is used along with conventional medicine, not in place of it. Complementary medicine appears to offer health benefits, but historically, there has been less scientific evidence to support its utility than is generally available for conventional and integrative therapies.
Integrative medicine is the combination of conventional medical treatment and CAM therapies that have been scientifically researched and have demonstrated evidence that they are both safe and effective.

In general terms, alternative therapies are often entirely untested and unproven, whereas complementary and integrative practices that are used in conjunction with mainstream medicine have substantial scientific basis of demonstrated safety and efficacy.

Susan S. Smith indicates in “Who Uses Complementary Therapies?” (Holistic Nursing Practice, vol. 18, no.3, May– June 2004) that in the United States there is increasing enthusiasm for and use of CAM approaches and practices. Multiple surveys reveal that more than four out of ten Americans use or have used some form of complementary or alternative therapy (including the services of nutritionists, Pilates and tai chi instructors, and chiropractors, among others).

Several government agencies, including the National Institutes of Health (NIH), the NCCAM, and the Centers for Disease Control and Prevention, collaborated on The Use of Complementary and Alternative Medicine in the United States (May 27, 2008, http://nccam.nih.gov/news/camsurvey_fs1.htm), a telephone survey of more than thirty-one thousand adults conducted in 2002. With this comprehensive study, findings of previous surveys were confirmed—that a significant proportion of Americans, as high as 74.6%, had ever used CAM therapies and products and a full 62.1% said they had used CAM therapies in the twelve months preceding the survey. (See Figure 2.2.) The survey found that the ten-most frequently used CAM therapies were:

Prayer for own health (43%)
Prayer by others for the respondent's health (24.4%)
Natural products such as herbs, other botanicals, and enzymes (18.9%)
Deep breathing exercises (11.6%)
Participation in prayer group for own health (9.6%)

Meditation (7.6%)
Chiropractic care (7.5%)
Yoga (5.1%)
Massage (5%)
Diet-based therapies (3.5%)

Homeopathic Medicine

Homeopathic medicine (also called homeopathy) is based on the belief that “like cures like” and uses very diluted amounts of natural substances to encourage the body's own self-healing mechanisms. Homeopathy was developed by the German physician Samuel Hahnemann (1755–1843) in the 1790s. Hahnemann found that he could produce symptoms of particular diseases by injecting small doses of various herbal substances. This discovery inspired him to administer to sick people extremely diluted formulations of substances that would produce the same symptoms they suffered from in an effort to stimulate natural recovery and regeneration.

According to Kenneth R. Pelletier, a clinical professor of medicine at Stanford University School of Medicine and director of the NIH-funded Complementary and Alternative Medicine Program at Stanford, homeopathy has demonstrated effectiveness for a variety of ailments. In his book The Best of Alternative Medicine: What Works? What Does Not? (2000), Pelletier reports that clinical trials of homeopathy find it effective for the treatment of disorders such as seasonal allergies, asthma, childhood diarrhea, fibromyalgia, influenza, and rheumatoid arthritis.

Naturopathic Medicine

As its name suggests, naturopathic medicine (also called naturopathy) uses naturally occurring substances to prevent, diagnose, and treat disease. Even though it is now considered an alternative medicine system, it is one of the oldest medicine systems and has its origins in Native American culture and even draws from Greek, Chinese, and East Indian ideas about health and illness.

The guiding principles of modern naturopathic medicine are “first, do no harm” and “nature has the power to heal.” Naturopathy seeks to treat the whole person, because disease is seen as arising from many causes rather than a single cause. Naturopathic physicians are taught that “prevention is as important as cure” and to view creating and maintaining health as equally important as curing disease. They are instructed to identify and treat the causes of diseases rather than to act only to relieve symptoms.

Naturopathic treatment methods include nutritional counseling; use of dietary supplements, herbs, and vitamins; hydrotherapy (water-based therapies, usually involving whirlpool or other baths); exercise; manipulation; massage; heat therapy; and electrical stimulation. Because naturopathy draws on Chinese and Indian medical techniques, naturopathic physicians often use Chinese herbs, acupuncture, and East Indian medicines to treat disease.

Pelletier's research finds studies demonstrating that naturopathy is effective for conditions such as asthma, atherosclerosis, back pain, some cancers, depression, diabetes, eczema (a skin condition), middle ear infections, migraine headaches, natural childbirth, and osteoarthritis. Furthermore, Pelletier asserts that licensed naturopathic physicians are among the best trained CAM practitioners and predicts that research will continue to confirm the benefits and efficacy of the safe, inexpensive, and low-risk therapies they can provide.

Traditional Chinese Medicine

Traditional Chinese medicine (TCM) uses nutrition, acupuncture, massage, herbal medicine, and Qi Gong (exercises to improve the flow of vital energy through the body) to help people achieve balance and unity of their mind, body, and spirit. Practiced for more than three thousand years by about a quarter of the world's population, TCM has been adopted by naturopathic physicians, chiropractors, and other CAM practitioners in the United States.

TCM views balancing qi (pronounced “chee”), the vital life force that flows over the surface of the body and through internal organs, as central to health, wellness, disease prevention, and treatment. This vital force or energy is thought to flow through the human body in meridians (channels). The Chinese believe that pain and disease develop when there is any sort of disturbance in the natural flow. TCM also seeks to balance the feminine and masculine qualities of yin and yang using other techniques such as moxibustion, which is the stimulation of acupuncture points with heat, and cupping, in which the practitioner increases circulation by putting a heated jar on the skin of a body part. Herbal medicine is the most commonly prescribed treatment.

Acupuncture

Acupuncture is a Chinese practice that dates back more than five thousand years. Chinese medicine describes acupuncture—the insertion of extremely thin, sterile needles to any of 360 specific points on the body—as a way to balance qi. After a diagnosis of an imbalance in the flow of energy, the acupuncturist inserts needles at specific points along the meridians (pathways of energy flow throughout the body). Each point controls a different part of the body. Once the needles are in place, they are rotated gently or are briefly charged with a small electric current.

Traditional Western medicine explains the acknowledged effectiveness of acupuncture as the result of triggering the release of pain-relieving substances called endorphins that occur naturally in the body, as well as neurotransmitters and neuropeptides that influence brain chemistry. Besides providing lasting pain relief, acupuncture has demonstrated success in helping people with substance abuse problems, relieving nausea, heightening immunity by increasing total white blood cells and T-cell production, and assisting patients to recover from stroke and other neurological impairments. Imaging techniques confirm that acupuncture acts to alter brain chemistry and function.

Chiropractic Physicians

Chiropractic physicians treat patients whose health problems are associated mainly with the body's structural and neurological systems, especially the spine. These practitioners believe that interference with these systems can impair normal functions and lower resistance to disease. Chiropractic medicine asserts that misalignment or compression of, for example, the spinal nerves can alter many important body functions. The American Chiropractic Association (2008, http://www.amerchiro.org/level2_css.cfm?T1ID=13&T2ID=61) defines the term chiropractic as “a health care profession that focuses on disorders of the musculoskeletal system and the nervous system, and the effects of these disorders on general health. Chiropractic care is used most often to treat neuromusculoskeletal complaints, including but not limited to back pain, neck pain, pain in the joints of the arms or legs, and headaches.” Doctors of chiropractic medicine do not use or prescribe pharmaceutical drugs or perform surgery. Instead, they rely on adjustment and manipulation of the musculoskeletal system, particularly the spinal column.

Many chiropractors use nutritional therapy and prescribe dietary supplements; some employ a technique known as applied kinesiology to diagnose and treat disease. Applied kinesiology is based on the belief that every organ problem is associated with weakness of a specific muscle. Chiropractors who use this technique claim they can accurately identify organ system dysfunction without any laboratory or other diagnostic tests.

Besides manipulation, chiropractors also use a variety of other therapies to support healing and relax muscles before they make manual adjustments. These treatments include:

Heat and cold therapy to relieve pain, speed healing, and reduce swelling
Hydrotherapy to relax muscles and stimulate blood circulation
Immobilization such as casts, wraps, traction, and splints to protect injured areas
Electrotherapy to deliver deep tissue massage and boost circulation
Ultrasound to relieve muscle spasms and reduce swelling

All states and the District of Columbia license chiropractors that meet the educational and examination requirements established by the state. According to the BLS (December 18, 2007, http://www.bls.gov/oco/ocos071.htm), in 2006 there were about fifty-three thousand chiropractors, and most were self-employed and in solo practice. Median annual earnings of salaried chiropractors were $65,220 in 2006. Visits to chiropractors are most often for treatment of lower back pain, neck pain, and headaches.

INCREASE IN HEALTH CARE EMPLOYMENT

The number of people working in health care services increased from 12.2 million in 2000 to 14.4 million in 2006. (See Table 2.9.) Health care workers are employed in medical offices, outpatient and nursing care centers, and in patients' homes. Even though hospitals still employ a larger proportion of health workers than any other service location, more patients are now able to receive treatment in physicians' offices, clinics, and other outpatient settings.

Why Is Health Care Booming?

Three major factors appear to have influenced the escalation in health care employment: advances in technology, the increasing amounts of money spent on health care, and the aging of the U.S. population. In other sectors of the economy, technology often replaces humans in the labor force. However, health care technology has increased the demand for highly trained specialists to operate the sophisticated equipment. Because of technological advances, patients are likely to undergo more tests and diagnostic procedures, take more drugs, see more specialists, and be subjected to more aggressive treatments than ever before.

The second factor involves the amount of money the nation spends on keeping its citizens in good health. According to Kevin Freking, in “Spending on Health to Rise Dramatically” (Associated Press, February 26, 2008), the Centers for Medicare and Medicaid Services forecasts that national health expenditures will rise from an average of $7,026 per person in 2006 to $13,101 per person in 2017, which will account for 20% of the U.S. gross domestic product (the total market value of final goods and services produced within an economy in a given year). For each year that the amount of money spent on health care continues to grow, employment in the field grows as well. Some health care industry observers believe that government and private financing for the health care industry, unlike most other fields, is virtually unlimited.

The third factor contributing to the rise in the number of health care workers is the aging of the nation's population. There are greater numbers of older adults in the United States than ever before, and they are living longer. The U.S. Census Bureau (2004, http://www.census.gov/ipc/www/usinterimproj/natprojtab02a.pdf) estimates that in 2000 there were 4.3 million Americans aged eighty-five and older; by 2050 there will be 20.9 million people over the age of eighty-five.

Site	2000	2001	2002	2003	2004	2005	2006
^aExcludes workers under the age of 16 years.
^bData for health service sites for men and women may not sum to total for all health service sites for both sexes due to rounding.
^cIncludes health service sites such as psychologists' offices, nutritionists' offices, speech defect clinics, and other offices and clinics.
^dIncludes health service sites such as clinical laboratories, blood banks, CT-SCAN (computer tomography) centers, and other offices and clinics.
Both sexes			Number of persons in thousands
All employed civilians^a	136,891	136,933	136,485	137,736	139,252	141,730	144,427
All health service sites^b	12,211	12,558	13,069	13,615	13,817	14,052	14,352
Offices and clinics of physicians	1,387	1,499	1,533	1,673	1,727	1,801	1,785
Offices and clinics of dentists	672	701	734	771	780	792	852
Offices and clinics of chiropractors	120	111	132	142	156	163	163
Offices and clinics of optometrists	95	102	113	92	93	98	98
Offices and clinics of other health
Practitioners^c	143	140	149	250	274	275	292
Outpatient care centers	772	830	850	873	885	901	919
Home health care services	548	582	636	741	750	795	928
Other health care services^d	1,027	1,101	1,188	943	976	1,045	1,096
Hospitals	5,202	5,256	5,330	5,652	5,700	5,719	5,712
Nursing care facilities	1,593	1,568	1,715	1,877	1,858	1,848	1,807
Residential care facilities, without nursing	652	668	689	601	618	615	700
Men
All health service sites^b	2,756	2,778	2,838	2,986	3,067	3,097	3,187
Offices and clinics of physicians	354	379	370	414	424	418	421
Offices and clinics of dentists	158	150	151	163	158	156	173
Offices and clinics of chiropractors	32	39	47	53	63	68	61
Offices and clinics of optometrists	26	27	29	29	24	27	29
Offices and clinics of other health practitioners^c	38	41	42	63	69	80	80
Outpatient care centers	186	185	172	200	203	201	199
Home health care services	45	51	54	56	65	81	91
Other health care services^d	304	345	362	297	314	311	344
Hospitals	1,241	1,187	1,195	1,263	1,333	1,347	1,337
Nursing care facilities	195	189	223	267	251	246	263
Residential care facilities, without nursing	177	185	193	181	164	162	189
Women
All health service sites^b	9,457	9,782	10,232	10,631	10,750	10,958	11,167
Offices and clinics of physicians	1,034	1,120	1,164	1,259	1,302	1,383	1,364
Offices and clinics of dentists	514	551	584	607	623	637	679
Offices and clinics of chiropractors	88	72	85	90	93	95	102
Offices and clinics of optometrists	69	75	84	64	69	71	69
Offices and clinics of other health practitioners^c	106	99	106	186	204	195	213
Outpatient care centers	586	646	678	673	683	700	720
Home health care services	503	531	582	685	685	713	837
Other health care services^d	723	756	826	646	662	734	752
Hospitals	3,961	4,069	4,135	4,390	4,366	4,372	4,376
Nursing care facilities	1,398	1,380	1,492	1,611	1,607	1,602	1,544
Residential care facilities, without nursing	475	483	496	420	454	453	511
Both sexes			Percent of employed civilians
All health service sites	8.9	9.2	9.6	9.9	9.9	9.9	9.9
	Percent distribution
All health service sites	100.0	100.0	100.0	100.0	100.0	100.0	100.0
Offices and clinics of physicians	11.4	11.9	11.7	12.3	12.5	12.8	12.4
Offices and clinics of dentists	5.5	5.6	5.6	5.7	5.6	5.6	5.9
Offices and clinics of chiropractors	1.0	0.9	1.0	1.0	1.1	1.2	1.1
Offices and clinics of optometrists	0.8	0.8	0.9	0.7	0.7	0.7	0.7
Offices and clinics of other health practitioners^c	1.2	1.1	1.1	1.8	2.0	2.0	2.0
Outpatient care centers	6.3	6.6	6.5	6.4	6.4	6.4	6.4
Home health care services	4.5	4.6	4.9	5.4	5.4	5.7	6.5
Other health care services^d	8.4	8.8	9.1	6.9	7.1	7.4	7.6
Hospitals	42.6	41.9	40.8	41.5	41.3	40.7	39.8
Nursing care facilities	13.0	12.5	13.1	13.8	13.4	13.2	12.6
Residential care facilities, without nursing	5.3	5.3	5.3	4.4	4.5	4.4	4.9
Notes: Annual data are based on data collected each month and averaged over the year. Data are based on household interviews of a sample of the civilian noninstitutionalized population.

The increase in the number of older people is expected to boost the demand for home health care services, assisted living, and nursing home care. Many nursing homes now offer special care for stroke patients, people with Alzheimer's disease (a progressive cognitive impairment), and people who need a respirator to breathe. To care for such patients, nursing homes need more physical therapists, nurses' aides, and respiratory therapists—three of the fastest-growing occupations. The BLS (December 18, 2007, http://www.bls.gov/oco/oco2003.htm) estimates that health care services will grow 25.4% between 2006 and 2016. The fastest-growing health care occupations will be personal and home health aides, medical assistants, substance abuse and behavioral disorder counselors, skin care specialists, physical therapist assistants, pharmacy technicians, dental hygienists, mental health counselors, and mental health and substance abuse social workers. (See Figure 2.3.)

The Health Care System