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L 5400- 7/995-93 Health Diagnosing Occupations and Assistants Reprinted from the Occupational Outlook Handbook, 1992-93 Edition U.S. Department of Labor Bureau of Labor Statistics Bulletin 2400-7 https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis . ns ' v -/ • • Sp5 atm : Chiropractors (D.O.T. 079.101-010) Nature of the Work Chiropractors, also known as chiropractic doctors, treat patients whose health problems are associated with the body’s muscular, ner vous, and skeletal systems, especially the spine. Interference with these systems is believed to impair normal functions and lower resis tance to disease. Chiropractors hold that misalignment of spinal ver tebrae or irritation of the spinal nerves can alter many important body functions by affecting the nervous system. The chiropractic approach to health care is holistic, stressing the patient’s overall well-being. It recognizes that many factors affect health, including exercise, diet, rest, environment, and heredity. Chi ropractors use natural, nondrug, nonsurgical health treatments, and rely on the body’s inherent recuperative abilities. They also recom mend lifestyle changes—in eating and sleeping habits, for example— to their patients. When appropriate, chiropractors consult with and refer patients to other health practitioners. Like other health practitioners, chiropractors follow a standard rou tine to secure the information needed for diagnosis and treatment: They take the patient’s medical history, conduct physical, neurologi cal, and orthopedic examinations, and may order laboratory tests. Xrays are an important diagnostic tool because of the emphasis on the spine and its proper function. Chiropractors also employ a postural and spinal analysis unique to chiropractic diagnosis. In cases where difficulties can be traced to involvement of muscu loskeletal structures, chiropractors manually manipulate or adjust the spinal column. Many chiropractors also use other forms of treatment such as water, light, massage, ultrasound, electric, and heat therapy. In addition, straps, tapes, braces, and other support mechanisms may be used. Counseling about nutrition, exercise, stress management, and other matters is provided as necessary. Chiropractors do not pre scribe drugs or perform surgery. State laws and regulations specify the types of services chiropractors may provide. Some chiropractors specialize in areas related to athletic injuries, neurology, orthopedics, nutrition and internal disorders. Others spe cialize in taking and interpreting X-rays and other diagnostic images. Almost all chiropractors are solo or group practitioners, who also have the administrative responsibilities of running a practice. In larg er offices, chiropractors delegate these tasks to office managers and chiropractor assistants. Chiropractors in private practice are ultimate ly responsible for developing a clientele, hiring employees, and keep ing records. Training, Other Qualifications, and Advancement All 50 States and the District of Columbia regulate the practice of chiropractic and grant licenses to chiropractors who meet educational requirements and pass a State board examination. Many States have reciprocity agreements that permit chiropractors licensed in another State to obtain a license without further examination. The scope of the practice permitted and the educational require ments for a license vary considerably from one State to another, but in general, State licensing boards require completion of a 4-year chi ropractic college course following at least 2 years of undergraduate education, although some States require a 4-year bachelors’ degree. All State boards recognize academic training in chiropractic colleges accredited by the Council on Chiropractic Education. For licensure, all State boards recognize either all or part of the three-part test administered by the National Board of Chiropractic Examiners. State examinations may supplement the National Board tests, depending on State requirements. To maintain licensure, almost all States require completion of a spec ified number of hours of continuing education each year. Continuing education programs are offered by chiropractic colleges, the American Chiropractic Association (ACA), International Chiropractors Associa tion (ICA), and State chiropractic associations. Special councils within the ACA and ICA also offer programs leading to clinical specialty cer tification, called “diplomate” certification, in areas such as orthopedics, neurology, sports injuries, occupational and industrial health, nutrition, radiology, thermography, and internal disorders. In 1990, 14 of the 17 chiropractic colleges in the United States were fully accredited by the Council on Chiropractic Education. All chiropractic colleges require applicants to have at least 2 years of undergraduate study, including courses in English, the social sciences or humanities, organic and inorganic chemistry, biology, physics, and psychology. Many applicants have a bachelors’ degree, which may eventually become the minimum entry requirement. Chiropractic colleges emphasize courses in skeletal manipulation and spinal adjustments. All, however, offer a broader curriculum con sisting of basic and clinical sciences in addition to the chiropractic courses. During the first 2 years, most chiropractic colleges empha size classroom and laboratory work in basic science subjects such as anatomy, physiology, public health, microbiology, pathology, and biochemistry. The last 2 years stress physical and laboratory diagno- Working Conditions Chiropractors work in offices that are clean and comfortable. The average workweek is about 43 hours. Chiropractors who work for themselves are free to set their own hours. Since they must accommo date their patients, however, they may work evenings or weekends. Chiropractors who take X-rays must take appropriate precautions against the dangers of repeated exposure to radiation. Employment In 1990, an estimated 42,000 persons practiced chiropractic. About 70 percent of active chiropractors are in solo practice. The remainder are in group practice or work for other chiropractors. A small number teach, conduct research at chiropractic colleges, or work in hospitals and HMO’s. Many chiropractors are located in small communities, but the pro portion in larger communities is increasing. There are geographic imbalances in the distribution of chiropractors, in part because many establish practices close to colleges of chiropractic. The Western and Southwestern States have a higher concentration of chiropractors rel ative to the population than the Middle Atlantic States. 2 https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis Chiropractors evaluate posture and spinaI structure. For sale by Superintendant of Documents, U.S. Government Printing Office Washington, D.C. 20402 sis, neurology, orthopedics, geriatrics, physiotherapy, and nutrition, in addition to adjustment techniques and clinical experience. Students completing chiropractic education earn the degree of Doctor of Chi ropractic (D.C.). Chiropractic requires keen observation to detect physical abnor malities and considerable hand dexterity but not unusual strength or endurance. Chiropractors should be able to work independently and handle responsibility. As in other health-related occupations, sympa thy, understanding, and the desire to help others are desirable quali ties for dealing effectively with patients. Newly licensed chiropractors have a number of options: They can apply for a residency program, set up a new practice, purchase an established one, enter into partnership with an established practitioner, or take a salaried position with an established chiropractor to acquire the experience and the funds needed to equip and open an office. Job Outlook Demand for chiropractic is related to the ability of patients to pay, either directly or through health insurance, and to public awareness of the profession, which is growing. The rapidly expanding older popu lation, with their increased likelihood of mechanical and structural problems, will also increase demand. Many job openings will result from the need to replace chiropractors who retire or die. According to a 1990 survey by the American Chiropractic Association, most chiro practors felt supply and demand were in rough balance in their geo graphic area. Earnings In 1990, the median income for chiropractors was about $74,000, after expenses, according to the ACA. In chiropractic, as in other types of independent practice, earnings are relatively low in the beginning, and increase as the practice grows. In 1990, the lowest 10 percent of chiropractors had net incomes of $24,000 or less, and the highest 10 percent earned $180,000 or more. Earnings are also influ enced by the characteristics and qualifications of the practitioner, and geographic location. Self-employed chiropractors must provide for their own health insurance and retirement. obtain dental records. Assistants hand the dentist the proper instru ments and materials and keep patients’ mouths dry and clear by using suction or other devices. Assistants also sterilize and disinfect instru ments and equipment; prepare tray setups for dental procedures; pro vide postoperative instruction; and instruct patients in oral health care. Some dental assistants prepare materials for making impres sions and restorations, expose radiographs, and process dental X-ray film as directed by the dentist. State law determines which clinical tasks a dental assistant may perform, but in most States they may remove sutures, apply anesthetic and caries-preventive agents to the teeth and oral tissue, remove excess cement used in the filling pro cess, and place rubber dams on the teeth to isolate them for individual treatment. Those with laboratory duties make casts of the teeth and mouth from impressions taken by dentists, clean and polish removable appli ances, and make temporary crowns. Dental assistants with office duties arrange and confinn appointments, receive patients, keep treat ment records, send bills, receive payments, and order dental supplies and materials. Dental assistants should not be confused with dental hygienists, who are licensed to perform a wider variety of clinical tasks. (See the statement on dental hygienists elsewhere in the Handbook.) Working Conditions Dental assistants work in a well-lighted, clean environment. Handling radiographic equipment poses dangers, but the hazards can be mini mized by proper use of lead shielding and safety procedures. Like wise, dental assistants wear gloves and masks to protect themselves from infectious diseases like hepatitis. Dental assistants, like dentists, work either standing or sitting. Their work area is usually near the dental chair, so that they can Related Occupations Chiropractors diagnose, treat, and work to prevent disorders and injuries. So do physicians, dentists, optometrists, podiatrists, veteri narians, occupational therapists, and physical therapists. Sources of Additional Information General information on chiropractic as a career is available from: •• American Chiropractic Association, 1701 Clarendon Blvd., Arlington, VA 22209. International Chiropractors Association, 1110 North Glebe Rd., Suite 1000, Arlington, VA 22201. For a list of chiropractic colleges, as well as general information on chiropractic as a career, contact: *• Council on Chiropractic Education, 4401 Westown Pky., Suite 120, West Des Moines, IA 50265. For information on State education and licensure requirements, contact: *■ Federation of Chiropractic Licensing Boards, 901 54th Ave., Suite 101, Greeley. CO 80634. For information on requirements for admission to a specific chiro practic college, as well as scholarship and loan information, contact the admissions office of the individual college. Dental Assistants (D.O.T. 079.371-010) Nature of the Work Dental assistants perform a variety of clinical, office, and laboratory duties. In their clinical duties, dental assistants work at chairside as dentists examine and treat patients. They make patients as comfort able as possible in the dental chair, prepare them for treatment, and https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis Almost 1 out of 3 dental assistants work part-time. 3 arrange instruments, materials, and medication, and hand them to the dentist when needed. Most dental assistants have a 32- to 40-hour workweek which may include work on Saturday or evenings. Employment Dental assistants held about 176,000 jobs in 1990. Almost 1 out of 3 worked part time, sometimes in more than one dentist’s office. Almost all dental assistants work in private dental offices. Some work in dental schools, private and government hospitals, State and local public health departments, or in clinics. Training, Other Qualifications, and Advancement Most assistants learn their skills on the job, though some are trained in dental assisting programs offered by community and junior col leges, trade schools, and technical institutes. Some assistants are trained in Armed Forces schools. Assistants must be a dentist’s “third hand;” therefore, dentists look for people who are reliable, can work well with others, and have manual dexterity. High school students interested in careers as dental assistants should take courses in biolo gy, chemistry, health, typing, and office practices. The American Dental Association’s Commission on Dental Accreditation approved 246 formal training programs in 1990. Accredited dental assisting programs include classroom, laboratory, and preclinical instruction in dental assisting skills and related theory. In addition, students gain practical experience in dental schools, clin ics, or dental offices. Most programs take 1 year or less to complete and lead to a certificate or diploma. Two-year programs offered in community and junior colleges lead to an associate degree. All pro grams require a high school diploma or its equivalent, and some require typing or a science course for admission. Some private voca tional schools offer 4- to 6-month courses in dental assisting, but these are not accredited by the Commission on Dental Accreditation. Certification is available through the Dental Assisting National Board. Certification is an acknowledgment of an assistant’s qualifica tions and professional competence, but usually is not required for employment. In several States that have adopted standards for dental assistants who perform radiologic procedures, completion of the cer tification examination meets those standards. Candidates may qualify to take the certification examination by graduating from an accredited training program or by having 2 years of full-time experience as a dental assistant. In addition, applicants must have taken a course in cardiopulmonary resuscitation. Without further education, advancement opportunities are limited. Some dental assistants working the front office become office man agers. Others, working chairside, go back to school to become dental hygienists. Job Outlook Employment of dental assistants is expected to grow faster than the average for all occupations through the year 2005. Population growth, higher incomes, more dental insurance, and greater retention of natural teeth by middle-aged and older people will fuel demand for dental ser vices. Also, in the future, dentists are likely to employ more assistants, for several reasons. Older dentists, who are less likely to employ assis tants, will leave and be replaced by recent graduates, who are more likely to use one, or even two. In addition, as the current surplus of dentists abates, dentists’ workloads will increase. As this happens, they are expected to hire more assistants to perform routine tasks, so they may use their own time for more profitable procedures. Opportunities should be good for people entering the occupation. The slow growth in the youth labor force—traditionally the principal source of supply for dental assisting—means that relatively fewer young adults will be available for entry level jobs such as this. Quali fied applicants should have little trouble locating a job, while employers may find it necessary to raise wages, offer better benefits, or try to attract older workers. Most job openings for dental assistants will arise from the need to replace assistants who leave the occupation. Each year many assis tants leave the job to take on family responsibilities, return to school, or transfer to another occupation. 4 https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis Earnings In 1990, median weekly earnings for dental assistants working full time were about $300. According to the American Dental Associa tion, the average hourly wage in 1989 for all dental assistants was $8.90. For chairside dental assistants without experience, the average was $6.90 an hour. Related Occupations Dental assistants perform a variety of duties that do not require the dentist’s professional knowledge and skill. Workers in other occupa tions supporting health practitioners include medical assistants, chiro practor assistants, ophthalmic medical assistants, optometric assistants, podiatric assistants, and veterinary technicians. Sources of Additional Information Information about career opportunities, scholarships, accredited den tal assistant programs, and requirements for certification is available from: »• American Dental Assistants Association, 919 N. Michigan Ave., Suite 3400, Chicago, IL 60611. Commission on Dental Accreditation, American Dental Association, 211 E. Chicago Ave., Suite 1814, Chicago, IL 60611. Dental Assisting National Board, Inc., 216 E. Ontario St., Chicago, IL 60611. Dental Hygienists (D.O.T. 078.361-010) Nature of the Work Who works on your teeth? It may be a dental hygienist. Dental hygienists provide preventive dental care and teach patients how to practice good oral hygiene. Depending on State legal restrictions, dental hygienists provide a wide range of services. They examine the patient’s teeth and mouth, recording the presence of diseases or abnormalities. They remove cal culus, stain, and plaque from above and below the gumline; apply caries-preventive agents such as fluorides and pit and fissure sealants; expose and develop dental X-rays; place temporary fillings and peri odontal dressings; remove sutures; and polish and recontour amalgam restorations. In some States, hygienists administer local anesthetics and nitrous oxide/oxygen analgesia, and place and carve filling materials. Dental hygienists also help patients develop and maintain good oral health. For example, they may explain the relationship between diet and oral health, teach patients how to select toothbrushes, and show patients how to floss their teeth. Some hygienists develop and promote community dental health programs. This may include teach ing groups of people how to practice good oral hygiene. Dental hygienists use a variety of instruments in the course of their work. They use hand and rotary instruments to clean teeth, X-ray machines to take dental pictures, syringes with needles to administer local anesthetics, and models of teeth to explain oral hygiene. Working Conditions Flexible scheduling is a distinctive feature of this job. Full-time, part time, evening, and weekend work is widely available. Dentists fre quently hire hygienists to work only 2 or 3 days a week, so hygienists may hold jobs in more than one dental office. Dental hygienists work in clean, well-lighted offices. Important health safeguards include strict adherence to proper radiological pro cedures, compliance with recommended aseptic technique, and uti lization of appropriate protective devices when administering nitrous oxide/oxygen analgesia. Dental hygienists also wear safety glasses, surgical masks and gloves to protect themselves from infectious dis eases such as hepatitis. The occupation is one of several covered by the Consumer-Patient Radiation Health and Safety Act of 1981, which encourages the States to adopt uniform standards for the train ing and certification of individuals who perform medical and dental radiological procedures. for error within a patient’s mouth. Recommended high school courses for aspiring dental hygienists are biology, health, chemistry, psychol ogy, speech, and mathematics. Job Outlook Employment of dental hygienists is expected to grow much faster than the average for all occupations through the year 2005 in response to increasing demand for dental care. Demand will be stim ulated by population growth, greater retention of natural teeth by middle-aged and elderly people, rising real incomes, and greater availability of dental insurance. Additional job openings will result from the need to replace workers who leave the occupation. Also, in the future, dentists are likely to employ more hygienists, for several reasons. Older dentists, who are less likely to employ den tal hygienists, will leave and be replaced by recent graduates, who are more likely to employ a hygienist part time, or even full time. In addition, as the surplus of dentists abates, dentists’ workloads will increase. As this happens, they are expected to hire more hygienists to perform preventive dental care such as cleaning, so they may use their own time for more profitable procedures like surgery. Enrollments in dental hygiene programs declined during the 1980’s, reducing the number of new graduates entering the field. Unless the number increases sharply, opportunities are expected to remain very good. Dental hygienists often work flexible hours. Employment Dental hygienists held about 97,000 jobs in 1990. Because multiple jobholding is common in this field, the number of jobs greatly exceeds the number of hygienists. About half of all dental hygienists usually worked part time—less than 35 hours a week. Almost all dental hygienists work in private dental offices. Others work in public health agencies, school systems, hospitals, and clinics. Training, Other Qualifications, and Advancement Dental hygienists must be licensed by the State in which they prac tice. To qualify for licensure, a candidate must graduate from an accredited dental hygiene school and pass both a written and a clini cal examination. The American Dental Association Joint Commission on National Dental Examinations administers the written examination that is accepted by all States and the District of Columbia. The indi vidual State or regional testing agency administers the clinical exami nation. In addition, examinations on legal aspects of dental hygiene practice are required by most States. Alabama also allows candidates to take its examination if they have been trained through a State-regu lated on-the-job program in a dentist’s office. In 1991, 205 programs in dental hygiene were accredited by the Commission on Dental Accreditation. Although some programs lead to a bachelor’s degree, most grant an associate degree. A few institu tions offer both types of programs. Six universities offer master’s degree programs in dental hygiene. Completion of an associate degree program is sufficient for prac tice in a private dental office. A bachelor’s or master’s degree is usu ally required for positions that involve research, teaching, or clinical practice in public or school health programs. About half of the dental hygiene programs prefer applicants who have completed at least 1 year of college. Some of the bachelor’s degree programs require applicants to have completed 2 years. How ever, requirements vary from school to school. These schools offer laboratory, clinical, and classroom instruction in subjects such as anatomy, physiology, chemistry, microbiology, pharmacology, nutri tion, radiography, histology (the study of tissue structure), periodontology (the study of gum diseases), pathology, dental materials, clinical dental hygiene, and social and behavioral sciences. Dental hygienists should work well with others, particularly patients who may be under stress. Personal neatness, cleanliness, and good health are important qualities. Dental hygienists must have manual dexterity because they use dental instruments with little room https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis Earnings Earnings of dental hygienists are affected by geographic location, employment setting, and education and experience. Dental hygienists who work in private dental offices may be paid on an hourly, daily, salary, or commission basis. According to the American Dental Association, the average hourly salary for dental hygienists was $17.50 in 1989. The average starting salary was $15.20 an hour. Fringe benefits vary substantially by practice setting, and may be contingent upon full-time employment. Dental hygienists who work for school systems, public health agencies, the Federal Government, or State agencies usually have substantial benefits. Related Occupations Workers in other occupations supporting health practitioners in an office setting include dental assistants, ophthalmic medical assistants, podiatric assistants, office nurses, medical assistants, and physician assistants. Sources of Additional Information For information on a career in dental hygiene and the educational requirements to enter this occupation, contact: Division of Professional Development, American Dental Hygienists’ Asso ciation, 444 N. Michigan Ave., Suite 3400, Chicago, IL 60611. •" SELECT, American Dental Association/American Association of Dental Schools, 211 E. Chicago Ave., Suite 1804, Chicago, IL 60611. For information about accredited programs and educational requirements, contact: «■ Commission on Dental Accreditation, American Dental Association, 211 E. Chicago Ave., Suite 1814, Chicago, IL 60611. The State Board of Dental Examiners in each State can supply information on licensing requirements. Dentists (D.O.T. 072, except .117) Nature of the Work “Dentists” conjures images of drilling and filling cavities. Dentists perform those tasks, but they also perform many other procedures to diagnose and treat problems of the teeth and tissues of the mouth. Dentists examine X-rays, place protective plastic sealants on chil dren’s teeth, straighten teeth, and repair fractured teeth. They also perform corrective surgery of the gums and supporting bones to treat 5 w ' I they grow older. A considerable number continue in part-time prac tice well beyond the usual retirement age. Most dentists are “solo practitioners,” that is they own their own businesses and work alone or with a small staff. Some dentists have partners, and a few work for other dentists as associate dentists. Dentists wear masks, gloves, and safety glasses to protect them selves and their patients from infectious diseases like hepatitis. Employment Dentists held about 174,000 jobs in 1990. Because some dentists hold more than one job, the number of jobs exceeds the number of all active dentists—about 149,000 in 1990, according to the U.S. Public Health Service. Almost 9 out of 10 dentists are in private practice. Others work in private and public hospitals and clinics. Training, Other Qualifications, and Advancement All 50 States and the District of Columbia require dentists to be licensed. To qualify for a license in most States, a candidate must graduate from a dental school accredited by the Commission on Den tal Accreditation and pass written and practical examinations. Candi dates may fulfill the written part of the State licensing by passing the National Board Dental Examinations. Individual States or regional testing agencies give the practical examinations. Currently, about 15 States require dentists to obtain a specialty license before practicing as a specialist. Requirements include 2 to 4 years of graduate education and, in some cases, completion of a spe cial State examination. Advanced-level education also is necessary in the other States, but the dental profession, not the State licensing authority, defines the specialist’s practice. Most State licenses permit dentists to engage in both general and specialized practice. Dentists who want to teach or do research usually spend an additional 2 to 4 years in advanced dental training in programs operated by dental schools or hospitals. Dental schools require a minimum of 2 years of college-level pre dental education. However, the majority of dental students have at least a bachelor’s degree. Predental education includes courses in both the sciences and humanities. Dentists provide instruction in flossing, brushing, and other dental care. The decline of dental school enrollments points to opportunities for young practitioners. gum diseases. Dentists remove teeth and make molds and measure ments for dentures to replace missing teeth. Some dentists make den tures and crowns; however, most send the specifications to dental laboratories. Dentists provide instruction in diet, brushing, flossing, the use of fluorides, and other aspects of dental care, as well. Dentists use a variety of equipment. They use X-ray machines, drills, and hand tools like mouth mirrors, brushes, and scalpels. They administer anesthetics. Dentists also write prescriptions for antibi otics. Dentists in private practice oversee a variety of administrative tasks, including bookkeeping and buying equipment. They may employ and supervise dental hygienists, dental assistants, and dental laboratory technicians. (These occupations are described elsewhere in the Handbook.) Most dentists are general practitioners who handle a wide variety of dental needs. Other dentists practice in one of eight specialty areas. Orthodontists, the largest group of specialists, straighten teeth. The next largest group, oral and maxillofacial surgeons, operate on the mouth and jaws. The remainder specialize in pediatric dentistry (den tistry for children); periodontics (treating the gums); prosthodontics (making artificial teeth or dentures); endodontics (root canal therapy); dental public health (community dental health); and oral pathology (diseases of the mouth). Working Conditions Most dental offices are open 4 or 5 days a week. Some dentists work evenings and weekends to meet their patients’ needs. Dentists work, on average, 37 hours a week, according to the American Dental Association. Younger dentists may work fewer hours as they build up their practice, while established dentists often work fewer hours as 6 https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis First-year enrollments r J _ _ _ _rl___ r I rtf rv' w' $ A?> l£> o>' r,' V V or ^ tv <t> Qs V q> nc q>‘or nr J k.J k. J k.J k. J £>' £>' £ §? m Sr orT or k. Source: American Dental Association eJ. A' r*! n! o! rlP A £> & & JB or All dental schools require applicants to take the Dental Admissions Test (DAT). They consider scores earned on the DAT, the applicants’ overall grade point average (GPA), science course GPA, and informa tion gathered through recommendations and interviews when select ing students. Dental school generally lasts 4 academic years, although one insti tution condenses the program into 3 calendar years, and another pro gram lasts 5 years. Studies begin with classroom instruction and laboratory work in basic sciences including anatomy, microbiology, biochemistry, and physiology. Beginning courses in clinical sciences, including laboratory technique courses, also are provided at this time. During the last 2 years, the student gains practical experience by treating patients, usually in dental clinics under the supervision of licensed dentists. Most dental schools award the degree of Doctor of Dental Surgery (D.D.S). An equivalent degree, Doctor of Dental Medicine (D.M.D.), is conferred by the rest. Dentistry requires diagnostic ability and manual skills. Dentists should have good visual memory, excellent judgment of space and shape, and a high degree of manual dexterity, as well as scientific ability. Good business sense, self-discipline, communiciation skills, and the ability to instill confidence are helpful for success in private practice. High school students who want to become dentists should take courses in biology, chemistry, health, and mathematics. Some recent dental school graduates work for established dentists as associates for a year or two in order to gain experience and save money to equip an office of their own. Most dental school graduates, however, purchase an established practice or open a new practice immediately after graduation. Each year about one-fourth to one-third of new graduates enroll in postgraduate training programs to prepare for a dental specialty. During recessions, some patients put off dental work, so dentists may have less work and lower earnings. A relatively large proportion of dentists are self-employed. Like other business owners, these dentists must provide their own health insurance, life insurance, and retirement benefits. Job Outlook Employment of dentists is expected to grow more slowly than the average for all occupations through the year 2005. Nevertheless, job prospects should continue to improve because the number of dental school graduates has dropped sharply since the early 1980’s and is not likely to increase through 2005. Dental school enrollments began dropping in 1979, (see chart) as it became clear that keen competition for patients had developed. This surplus of dentists was attributable to the very large numbers of dental graduates that resulted from a Federal decision during the 1960’s to support expansion of the Nation’s dental schools. Demand for dental care should grow substantially. As members of the baby boom generation advance into middle age, a large number will need maintenance on complicated dental work like bridges. Plus, elderly people are more likely to retain their teeth than their predeces sors, so they will require much more care than in the past. The younger generation will continue to need preventive check-ups despite treatments like fluoridation ofthe water supply which decrease dental caries. Furthermore, many people, who presently can not afford the dental care they need, may seek out dental care since more people will have dental insurance and greater disposable incomes in the future. However, the employment of dentists is not expected to grow as rapidly as the demand for dental services. Because of surpluses, many dentists today are not working as many hours as they would like and could take on more patients. Also, as their practices expand, dentists are likely to hire more dental hygienists and dental assistants to han dle routine services that they now perform themselves. Unlike other occupations, replacement needs create relatively few job openings for dentists since dentists tend to remain in the profes sion. Nature of the Work Medical assistants help physicians examine and treat patients and per form routine tasks to keep offices running smoothly. Medical assis tants should not be confused with physician assistants, who examine, diagnose, and treat patients, under the direct supervision of a physi cian. Physician assistants are discussed elsewhere in the Handbook. The duties of medical assistants vary from office to office, depend ing on the location and size of the practice and the physician’s special ty. In small practices, medical assistants are usually “generalists,” handling both clerical and clinical duties and reporting directly to the office manager or physician. Those in large practices tend to specialize in a particular area under the supervision of department administrators. Medical assistants perform many clerical duties. They answer tele phones, greet patients, update and file patient medical records, fill out insurance forms, handle correspondence, schedule appointments, arrange for hospital admission and laboratory services, and handle billing and bookkeeping. Clinical duties vary according to State law and include taking and recording vital signs and medical histories; explaining treatment pro cedures to patients; preparing patients for examination; and assisting during the examination. Medical assistants collect and prepare labo ratory specimens or perform basic laboratory tests on the premises; dispose of contaminated supplies; and sterilize medical instruments. They instruct patients about medication and special diets, prepare and administer medications as directed by a physician, authorize drug refills as directed, telephone prescriptions to a pharmacy, draw blood, prepare patients for X-rays, take EKG’s, remove sutures, and change dressings. Medical assistants may also arrange examining room instruments and equipment, purchase and maintain supplies and equipment, and keep waiting and examining rooms neat and clean. Assistants who specialize have additional duties. Podiatric medical assistants make castings of feet, expose and develop X-rays, and assist podiatrists at surgery. Ophthalmic medical assistants help oph thalmologists provide medical eye care. They use precision instru ments to administer diagnostic tests, measure and record vision, and test the functioning of eyes and eye muscles. They also show patients how to use eye dressings, protective shields, and safety glasses, and insert, remove, and care for contact lenses. Under the direction of the Earnings The net median income of dentists in private practice was about $80,000 a year in 1989, according to the American Dental Associa tion. Net median income of those in specialty practices was about $110,000 a year, and for those in general practice, $75,000 a year. Dentists in the beginning years of their practice often earn less, while those in mid-careers earn more. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis Related Occupations Dentists examine, diagnose, and treat diseases and abnormalities. So do clinical psychologists, optometrists, physicians, veterinarians, and podiatrists. Sources of Additional Information For information on dentistry as a career and a list of accredited dental schools, contact: •" SELECT Program, American Dental Association, 211 E. Chicago Ave., Chicago, IL 60611. «• American Association of Dental Schools, 1625 Massachusetts Ave. NW., Washington, DC 20036. The American Dental Association also will furnish a list of State boards of dental examiners. Persons interested in practicing dentistry should obtain the requirements for licensure from the board of dental examiners of the State where they plan to work. Prospective dental students should contact the office of student financial aid at the schools to which they apply for information on scholarships, grants, and loans, including Federal financial aid. Medical Assistants (D.O.T. 079.364-010, and -014, .367-010, and .374-018, 355.667-010) 7 physician, they may administer medications, including eye drops. They also maintain optical and surgical instruments and assist the ophthalmologist in surgery. Working Conditions Medical assistants work in a well-lighted, clean environment. They constantly interact with other people, and may have to handle several responsibilites at once. Most full-time medical assistants work a regular 40-hour week. Some work evenings and weekends. Employment Medical assistants held about 165,000 jobs in 1990. Three out of five were employed in physicians’ offices, and about 1 in 5 worked in offices of other health practitioners such as chiropractors, optometrists, and podiatrists. Others worked in hospitals, nursing homes, and other health care facilities. Training, Other Qualifications, and Advancement Medical assisting is one of the few health occupations open to indi viduals with no formal training. Although education in medical assisting is available at both the secondary and postsecondary levels, such training—while generally preferred—is not always required. It is still sometimes the case that medical assistants are trained on the job. Applicants usually need a high school diploma or the equivalent. High school courses in mathematics, health, biology, typing, book keeping, computers, and office skills are helpful. Volunteer experi ence in the health care field may also be helpful. Formal programs in medical assisting are offered in vocationaltechnical high schools, postsecondary vocational schools, community and junior colleges, and in colleges and universities. College-level programs usually last 1 to 2 years and lead to an associate degree. Vocational programs can take up to 1 year and lead to a diploma or certificate. Courses cover anatomy, physiology, and medical termi nology as well as typing, transcription, recordkeeping, accounting, and insurance processing. Students learn laboratory techniques, clini cal and diagnostic procedures, pharmaceutical principles and medica tion administration, and first aid. They are also instructed in office practices, patient relations, and medical law and ethics. Accredited programs may include an externship that provides practical experi ence in physicians’ offices, hospitals, or other health care facilities. Two agencies recognized by the U.S. Department of Education accredit programs in medical assisting: The American Medical Asso ciation’s Committee on Allied Health Education and Accreditation (CAHEA) and the Accrediting Bureau of Health Education Schools (ABHES). In 1991, there were 186 medical assisting programs accredited by CAHEA and 127 accredited by ABHES. The Joint Review Committee for Opthalmic Medical Personnel has approved 12 programs in opthalmic medical assisting. Although there is no licensing for medical assistants, some States require a test or a short course before performing procedures such as taking x-rays, drawing blood, or giving injections. Employers prefer to hire experienced workers or certified applicants who have passed a national examination, indicating that certain standards of competence have been met. The American Association of Medical Assistants awards the Certified Medical Assistant credential; the American Medical Technologists awards the Registered Medical Assistant cre dential; the American Society of Podiatric Medical Assistants awards the Podiatric Medical Assistant Certified credential; and the Joint Commission on Allied Health Personnel in Ophthalmology awards the Ophthalmic Medical Assistant credential at three levels: Certified Ophthalmic Assistant, Certified Ophthalmic Technician, and Certi fied Ophthalmic Medical Technologist. Because medical assistants deal with the public, a neat, wellgroomed appearance and a courteous, pleasant manner are needed. Medical assistants must be good at putting patients at ease, listening to them, and explaining physicians’ instructions. Conscientiousness and respect for the confidential nature of medical information are required. Clinical duties require a reasonable level of manual dexteri ty and visual acuity. Medical assistants may be able to advance to office manager or become ward clerks, medical record clerks, phlebotomists, or EKG technicians in hospitals. Medical assistants may qualify for a wide variety of administrative support occupations, or may teach medical assisting. Some, with additional schooling, enter other health occupa tions such as nursing and medical technology. Job Outlook Employment of medical assistants is expected to grow much faster than the average for all occupations through the year 2005 as the health services industry expands. Employment growth will be driven by the increased medical needs of an aging population, growth in the number of health practitioners, more diagnostic testing, and the increased volume and complexity of paperwork. Most job openings, however, will result from the need to replace experienced assistants who leave the occupation. In view of the high turnover as well as the preference of many physicians for trained personnel, job prospects should be excellent for medical assistants with formal training or experience, particularly those with formal certification. Earnings The earnings of medical assistants vary widely, depending on experi ence, skill level, and location. According to a survey conducted by the Committee on Allied Health Education and Accreditation, the average starting salary for graduates of the medical assistant pro grams they accredit was about $14,000 a year in 1990. According to limited information, experienced medical assistants averaged several thousand dollars more. Related Occupations Workers in other medical support occupations include medical secre taries, hospital admitting clerks, pharmacy helpers, medical record clerks, dental assistants, occupational therapy aides, and physical therapy aides. ' Medical assistants is one of the fastest growing occupations. 8 https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis ■ Sources of Additional Information Information about career opportunities, CAHEA-accredited educa tional programs in medical assisting, and requirements for the Certi fied Medical Assistant exam is available from: The American Association of Medical Assistants, 20 North Wacker Dr., Suite 1575, Chicago, IL 60606. Information about career opportunities and requirements for taking the Registered Medical Assistant certification exam are available from: •" Registered Medical Assistants of American Medical Technologists, 710 Higgins Rd., Park Ridge, IL 60068. For a list of ABHES-accredited educational programs in medical assisting, write: *■ Accrediting Bureau of Health Education Schools, Oak Manor Office, 29089 U.S. 20 West, Elkhart, IN 46514. Information about career opportunities, training programs, and re quirements to become a Certified Ophthalmic Assistant is available from: Joint Commission on Allied Health Personnel in Ophthalmology, 2025 Woodlane Dr., St. Paul, MN 55125-2995. Information about careers for podiatric assistants is available from: <•" American Society of Podiatric Medical Assistants, 2124 S. Austin Blvd., Cicero, IL 60650. Optometrists (D.O.T. 079.101-018) Nature of the Work Over half the people in the United States wear glasses or contact lens es. Optometrists (doctors of optometry, also known as O.D.’s) pro vide most of the primary vision care these people and others need. Optometrists examine people’s eyes to diagnose vision problems and eye disease. They treat vision problems, and in most States, they treat certain eye diseases as well. Optometrists use instrumentation and observation to examine eye health and to test patients’ visual acuity, depth and color perception, and their ability to focus and coor dinate the eyes. They analyze test results and develop a treatment plan. Optometrists prescribe eyeglasses, contact lenses, vision thera py, and low-vision aids. They use drugs for diagnosis in all States and, as of 1991, they may use drugs to treat some eye diseases in 28 States. Optometrists often provide post-operative care to cataract patients. When optometrists diagnose conditions such as diabetes or high blood pressure, that require treatment beyond the optometric scope of practice, they refer patients to other health practitioners. Optometrists should not be confused with ophthalmologists or dis pensing opticians. Ophthalmologists are physicians who diagnose and treat eye diseases and injuries. Ophthalmologists perform surgery and prescribe drugs, eyeglasses, and contact lenses. Dispensing opticians fit and adjust eyeglasses and in some States may fit contact lenses according to prescriptions written by ophthalmologists or optometrists, but they do not examine eyes or prescribe treatment. (See statements on physicians and dispensing opticians elsewhere in the Handbook.) Most optometrists are in general practice. Some specialize in work with the elderly, with children, or with partially sighted persons who use microscopic or telescopic lenses. Others develop and implement ways to protect workers’ eyes from on-the-job strain or injuiy. Some specialize in contact lenses, sports vision, or vision therapy. Still oth ers teach, do research, or consult. Most optometrists are private practitioners who also handle the business aspects of running an office, such as developing a patient base, hiring employees, keeping records, and ordering equipment and supplies. Optometrists who operate franchise optical stores may also have some of these duties. optometrists hold two or more jobs. For example, an optometrist may have a private practice, but also work in another practice, clinic, or vision care center. Although many optometrists are in solo practice, a growing num ber are in partnership or group practice. Some optometrists work as salaried employees in the offices of established optometrists, health maintenance organizations (HMO’s), retail optical stores, ophthal mologists, and the Veterans Administration. Some optometrists are consultants to industrial safety programs, insurance companies, manufacturers of ophthalmic products, HMO’s, and others. Training, Other Qualifications, and Advancement All States and the District of Columbia require that optometrists be licensed. Applicants for a license must have a Doctor of Optometry degree from an accredited optometry school and pass a written and clinical State board examination. In many States, applicants can sub stitute the examinations of the National Board of Examiners in Optometry, usually taken during the student’s academic career, for part or all of the written examination. Some States allow applicants to be licensed without lengthy examination if they have a license in another State. In 47 States and the District of Columbia, optometrists must earn continuing education credits to renew their licenses. Licenses are renewed every 1 to 2 years. The Doctor of Optometry degree requires completion of a 4-year program at an accredited optometry school preceded by at least 2 or 3 years of preoptometric study at an accredited college or university (most optometry students hold a bachelor’s degree). In 1991, 16 U.S. schools and colleges of optometry were accredited by the Council on Optometric Education of the American Optometric Association. Requirements for admission to schools of optometry include cours es in English, mathematics, physics, chemistry, and biology. A few schools require or recommend courses in psychology, history, sociol ogy, speech, or business. All applicants must take the Optometry Admissions Test (OAT), which measures academic ability and scien tific comprehension. Most applicants take the test after their sopho more or junior year. Competition for admission is keen. Optometry programs include classroom and laboratory study of health and visual sciences, and clinical training in the diagnosis and treatment of eye disorders. Included are courses in pharmacology, optics, biochemistry, and systemic disease. Business ability, self-discipline, and the ability to deal tactfully with patients are important for success. Optometrists wishing to teach or perform research may study for a master’s or Ph.D. degree in visual science, physiological optics, neu rophysiology, public health, health administration, health information and communication, or health education. One-year postgraduate clin ical residency programs are available for optometrists who wish to specialize in family practice optometry, pediatric optometry, geriatric optometry, low-vision rehabilitation, vision therapy, contact lenses, hospital based optometry, and primary care optometry. Working Conditions Optometrists work in places—usually their own offices—that are clean, well lighted, and comfortable. The work requires attention to detail and manual dexterity. Self-employed optometrists have some flexibility in their hours of work, and many choose to work over 40 hours a week. Many work Saturdays and evenings to suit the needs of patients, but emergency calls are few. Employment Optometrists held about 37,000 jobs in 1990. The number of jobs is greater than the number of practicing optometrists because some https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis Many optometrists are self-employed. 9 Job Outlook Employment of optometrists is expected to grow about as fast as the average for all occupations through the year 2005 in response to the vision care needs of a growing and aging population. The maturing of the baby-boom generation, together with rapid growth in the elderly population and the coverage of optometric services by Medicare, will drive this growth. Persons over the age of 45 visit optometrists and ophthalmologists more frequently because of the onset of vision problems in middle age and the increased likelihood of cataracts, glaucoma, diabetes, and hypertension in old age. Employment of optometrists will also grow due to greater recognition of the impor tance of vision care, rising personal incomes, and growth in employee vision care plans. Employment of optometrists would grow more rapidly were it not for anticipated productivity gains which will allow each optometrist to see more patients. These will result from greater use of optometric assistants and other support personnel, and the introduction of new equipment. Replacement needs are low. In this occupation, replacement needs arise almost entirely from retirements and deaths. Optometrists general ly remain in practice until they retire; few transfer to other occupations. Earnings According to the American Optometric Association, net earnings of new optometry graduates in their first year of practice averaged about $45,000 in 1990. Overall, optometrists averaged about $75,000 annually. Incomes vary depending upon location, specialization, and other factors. Salaried optometrists tend to earn more initially than optometrists who set up their own independent practice. However, in the long run, those in private practice generally earn more. Related Occupations Workers in other occupations who apply scientific knowledge to pre vent, diagnose, and treat disorders and injuries in humans or animals are chiropractors, dentists, physicians, podiatrists, veterinarians, speech-language pathologists, and audiologists. Sources of Additional Information For information on optometry as a career, and a listing of accredited optometric educational institutions, as well as required pre-optometry courses write to: American Optometric Association, Educational Services, 243 North Lind bergh Blvd., St. Louis, MO 63141. The Board of Optometry in each State can supply information on licensing requirements. For information on specific admission requirements and sources of financial aid, contact the admissions officer of individual optometry schools. Physician Assistants (D.O.T. 079.364-018) Nature of the Work As their title suggests, physician assistants (PA’s) support physicians. However, they should not be confused with medical assistants (see elsewhere in the Handbook). PA’s are formally trained to perform many of the routine but time-consuming tasks physicians usually do. They take medical histories, perform physical examinations, order laboratory tests and X-rays, make preliminary diagnoses, and give inoculations. They also treat minor injuries by suturing, splinting, and casting. In 30 States and the District of Columbia, physician assis tants may prescribe medications. PA’s may have managerial duties too. Some order medical and laboratory supplies and equipment; oth ers oversee technicians and assistants. Physician assistants always work under the supervision of a physi cian. The proximity of supervision, however, depends upon the local 10 https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis ity. For example, some PA’s, working in rural or inner city clinics where a physician may be available just 1 or 2 days each week, may provide most of the health care needs for patients, consulting with the supervising physician by telephone. Other PA’s may make “house calls” or go on “hospital rounds” to check on patients and report back to the physician. PA’s assist physicians in specialty areas, such as family practice, internal medicine, general and thoracic surgery, emergency medicine, and pediatrics. PA’s specializing in surgery, also called surgeon’s assistants, provide pre- and post-operative care and may work as first or second assistants during major surgery. Working Conditions Although PA’s generally work in a climate-controlled, well-lighted environment, those in surgery often stand for long periods, and others do considerable walking. The workweek and schedule vary according to practice setting and are often comparable to that of their supervising physician. A few emergency room PA’s work 24-hour shifts twice weekly, and others work three 12-hour shifts each week. The workweek of PA’s in physi cians’ offices may include weekends, night hours, or early morning hospital rounds to visit patients. PA’s in clinics usually work a 5-day, 40-hour week. Employment Physician assistants held about 53,000 jobs in 1990. Most PA’s work in physicians’ offices and clinics. Others work in hospitals. The rest work for public health clinics, nursing homes, prisons, and rehabilita tion centers. About 30 percent of all PA’s provide health care to communities having fewer than 50,000 residents and where physicians may be in limited supply, according to the American Academy of Physician Assistants. Training, Other Qualifications, and Advancement Almost all States require that new PA’s complete an accredited, formal education program. In 1991, there were 55 such educational programs for physician assistants, including three programs for sur geon assistants. Thirty-seven of these programs offered a baccalaure ate degree or a degree option. The rest offered either a certificate, an associate degree, or a master’s degree. Admission requirements vary, but many programs require 2 years of college and some work experience in the health care field. About half of all applicants hold a bachelor’s or master’s degree. PA programs generally last 2 years. Most are located in medical schools, schools of allied health, or 4-year colleges; a few are in com munity colleges and in hospitals. Many accredited PA programs have clinical teaching affiliations with medical schools. PA education includes classroom instruction in biochemistry, nutri tion, human anatomy, physiology, microbiology, clinical pharmacolo gy, clinical medicine, geriatric and home health care, disease prevention, and medical ethics. Students obtain supervised clinical training in several areas, including family medicine, inpatient and ambulatory medicine, general surgery, obstetrics and gynecology, geriatrics, emergency medicine, internal medicine, ambulatory psy chiatry, and pediatrics. Sometimes, one or more of these “rotations” are served under the supervision of a physician who is seeking to hire a PA. Sometimes these rotations lead to a permanent employment. PA postgraduate residency training programs, as yet unaccredited, are available in emergency medicine, gynecology, critical care medicine, surgery, pediatrics, neonatology, and occupational medicine. Candidates must be graduates of an accredited program and be certified by the National Commission on Certification of Physician Assistants. As of 1990, 49 States, the District of Columbia, and Guam had leg islation governing the qualifications or practice of physician assis tants. Mississippi did not. Forty-five States required physician assistants to pass a certifying exam that is only open to graduates of an accredited educational program. In some States, the duties of a physician assistant are determined by the supervising physician; in others, they are determined by the Sources of Additional Information A free brochure, Physician Assistants, PArtners in Health Care, is available from: American Academy of Physician Assistants, 950 North Washington St., Alexandria, VA 22314. For a list of accredited programs and for a catalog of individual PA training programs, contact: Association of Physician Assistant Programs, 950 North Washington St., Alexandria, VA 22313. For eligibility requirements and a description of the Physician Assistant National Certifying Examination, write to: *■ National Commission on Certification of Physician Assistants, Inc., 2845 Henderson Mill Rd. NE., Atlanta, GA 30341. Physicians Employment opportunities are expected to be excellent for physician assistants. State’s regulatory agency. There is variation in State practice laws and regulations; therefore, aspiring PA’s should investigate the laws and regulations in the States where they wish to practice. Physician assistants need to exhibit leadership, self-confidence, and emotional stability, and be willing to continue studying through out their career to keep up with medical advances. Some PA’s pursue additional education in order to practice in a specialty area such as surgery, neonatology, or emergency medicine. Others—as they attain greater clinical knowledge and experience— advance to added responsibilities and higher earnings. However, by the very nature of the profession, individual PA’s are always super vised by physicians. Job Outlook Employment opportunities are expected to be excellent for physician assistants, particulary in areas or settings, like rural and inner city clinics, that have difficulty attracting enough physicians. Employment of PA’s is expected to grow faster than the average for all occupations through the year 2005 due to anticipated expansion of the health services industry and an emphasis on cost containment. Physicians and institutions are expected to employ more PA’s to pro vide primary care and assist with medical and surgical procedures, thus freeing physicians to perform more complicated and revenue generating tasks. The public and third party payers also seem to approve of PA’s use. For example, Medicare now allows physicians to bill the government for services provided by their PA’s to hospital and nursing home patients. Besides the traditional office-based setting, PA’s should find a growing number of jobs in institutional settings such as hospitals, academic medical centers, public clinics, and prisons. The growth of HMO’s and group medical practices should also lead to more jobs since they use PA’s for basic medical tasks because their salaries are lower than those of physicians. Earnings In 1990, the median salary for physician assistants working in hospi tals and medical schools was about $33,971, according to a national survey conducted by the University of Texas Medical Branch. According to the American Academy of Physician Assistants, the average salary for all physician assistants in 1991 was between $40,000 and $44,999. The average salary for PA’s working in the Federal government was $39,625 in 1991. Related Occupations Other health workers who provide direct patient care that requires a similar level of skill and training include nurse practitioners, physical therapists, occupational therapists, clinical psychologists, and speech and hearing clinicians. https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis (D.O.T. 070 and 071) Nature of the Work Physicians perform medical examinations, diagnose illnesses, and treat people suffering from injury or disease. They advise patients on diet, hygiene, and preventive health care. Those in private prac tices handle or oversee the business aspects of running an office. There are two types of physicians: The M.D.—Doctor of Medicine—and the D.O.—Doctor of Osteopathic Medicine. M.D.’s are also known as allopathic physicians. While M.D.’s and D.O.’s may use all accepted methods of treatment, including drugs and surgery, D.O.’s place special emphasis on the body's musculoskele tal system. They believe that good health requires proper alignment of bones, muscles, ligaments, and nerves. Most M.D.’s specialize. (See table 1.) Pediatricians, general and family practitioners, and general internists are often called primary care physicians since they are the first health professionals patients usually consult. They tend to see the same patients on a regular basis for a variety of ailments and preventive treatment. When appropriate, they refer patients to other specialists. D.O.’s tend to be primary care providers although they can be found in all specialties. Working Conditions Physicians often work long, irregular hours. Almost half work more than 60 hours a week, but one-fourth generally work a 40-hour week. Most specialists work fewer hours than general practitioners and family practitioners. In general, as doctors approach retirement age, they may accept fewer new patients and tend to work shorter hours. Salaried physicians who are employees of Health Maintenance Organizations (HMO’s) or group practices work about the same number of hours a week as self-employed physicians. However, salaried physicians spend fewer hours in direct patient care. Employment Physicians (M.D.’s and D.O.’s) held about 580,000 jobs in 1990. About 2 out of 3 were in office-based practice, including clinics and HMO’s; about one-fifth were employed in hospitals; and most oth ers practiced in the Federal Government. While physicians have traditionally been solo practitioners, a growing number are partners or salaried employees of group prac tices. Organized as clinics, HMO’s, or as groups of physicians, med ical groups can afford expensive medical equipment and realize other business advantages. The Northeast has the highest ratio of physicians to population; the South, the lowest. D.O.’s tend to practice in small cities and towns and in rural areas. M.D.’s, on the other hand, tend to locate in urban areas, close to hospital and educational centers. Some rural areas remain underserved, although the situation is changing some what. Currently, more medical students are being exposed to prac tice in rural communities with the direct support of educational centers and hospitals in more populous areas. 11 Table 1. Distribution of M.D.’s by specialty, 1989 Percent Total........................................................................................... 100.0 General and family practice........................................................ 11.7 Medical specialties: Allergy....................................................................................... Cardiovascular diseases........................................................... Dermatology............................................................................. Gastroentrology........................................................................ Internal medicine...................................................................... Pediatrics................................................................................... Pediatric allergy........................................................................ Pediatric cardiology.................................................................. Pulmonary diseases.................................................................. 0.2 2.6 1.2 1.2 16.2 6.6 0.1 0.1 1.0 Surgical specialties: Colon and rectal surgery.......................................................... General surgery........................................................................ Neurological surgery................................................................ Obstetrics and gynecology...................................................... Ophthalmology......................................................................... Orthopedic surgery................................................................... Otolaryngology......................................................................... Plastic surgery.......................................................................... Thoracic surgery....................................................................... 0.1 6.4 0.7 5.5 2.7 3.1 1-3 0.7 0.4 Other specialties: Aerospace medicine................................................................. Anesthesiology......................................................................... Child psychiatry....................................................................... Diagnostic radiology................................................................ Emergency medicine................................................................ Forensic pathology................................................................... General preventive medicine................................................... Neurology.................................................................................. Nuclear medicine...................................................................... Occupational medicine............................................................ Psychiatry.................................................................................. Public health............................................................................. Physical medicine and rehabilitation...................................... Pathology................................................................................... Radiology.................................................................................. Radiation oncology.................................................................. Urology...................................................................................... Other specialty.......................................................................... Unspecified/unknown.............................................................. 0.1 4.2 0.7 2.5 2.3 0.1 0.2 1.5 0.2 0.5 5.8 0.3 0.7 2.7 1.9 0.5 1.5 1.5 12.3 SOURCE: American Medical Association have at least a bachelor’s degree, and many have advanced degrees. A few medical schools offer a combined college and medical school program that lasts 6 years instead of the customary 8 years. Required premedical study includes undergraduate work in physics, biology, and inorganic and organic chemistry. Students should also take courses in English, other humanities, mathematics, and the social sciences. There are 141 medical schools in the United States—126 teach allopathic medicine and award a Doctor of Medicine (M.D.); 15 teach osteopathic medicine and award the Doctor of Osteopathic Medicine (D.O.). Acceptance to medical school is very competitive. Applicants must submit transcripts, scores from the Medical College Admission Test (MCAT), and letters of recommendation. An interview with an admissions officer may also be necessary. Character, personality, leadership qualities, and participation in extracurricular activities also are considered. Students spend the first 2 years of medical school primarily in labo ratories and classrooms taking courses such as anatomy, biochemistry, physiology, pharmacology, microbiology, pathology, medical ethics, and laws governing medicine. They also learn to take case histories, perform examinations, and recognize symptoms. During the last 2 years, students work with patients under the supervision of experi enced physicians in hospitals and clinics to learn acute, chronic, pre ventive, and rehabilitative care. Through rotations in internal medicine, obstetrics and gynecology, pediatrics, psychiatry, and surgery, they gain experience in the diagnosis and treatment of illness. Following medical school, almost all M.D.’s go directly on to gradu ate medical education, called a residency. The National Board of Medi cal Examiners (NBME) gives a standard examination for all students, including foreign medical school graduates, applying for an M.D. resi dency. All D.O.’s serve a 12-month rotating internship after gradua tion. The National Board of Osteopathic Medical Examiners gives an examination for internship application. Following their internship, many D.O.’s take a residency program in a specialty area, too. M.D.’s and D.O.’s seeking board certification in a specialty may spend up to 6 years—depending on the specialty—in residency train ing. A final examination immediately after residency, or after 1 or 2 years of practice, is also necessary for board certification by the American Board of Medical Specialists (ABMS) or the American Osteopathic Association (AOA). Physicians can be board-certified in 24 different areas: Allergy and immunology; anesthesiology; colon and rectal surgery; dermatology; emergency medicine; family prac tice; internal medicine; neurological surgery; neurology; nuclear medicine; obstetrics and gynecology; ophthalmology; orthopaedic surgery; otolaryngology; pathology; pediatrics; physical medicine and rehabilitation; plastic surgery; preventative medicine; psychiatry; radiology; surgery; thoracic surgery; and urology. For those training in a subspecialty, another 1 to 2 years of residency is usual. To teach or do research, physicians may acquire a master’s or Ph.D. in such fields as biochemistry or microbiology. They may oth erwise spend 1 year or more in research or in an advanced clinical training fellowship. Osteopathic physicians are located chiefly in States that have osteopathic hospitals. In 1991, 4 out of 5 D.O.’s were practicing in 16 States. Michigan had the most D.O.’s, followed by Pennsylvania, Ohio, Florida, Texas, and New Jersey. Training and Other Qualifications All States, the District of Columbia, and U.S. territories require physicians to be licensed. Licensure requirements for both D.O.’s and M.D.’s include graduation from an accredited medical school (usually 4 years), completion of a licensing examination, and between 1 and 6 years of graduate medical education, that is, a residency for M.D.’s and an internship for D.O.’s. Although physicians licensed in one State can usually get a license to practice in another without further examination, some States limit reciprocity. Graduates of foreign med ical schools can generally begin practice in the United States after completing a U.S. hospital residency training program. The minimum educational requirement for entry to a medical or osteopathic school is 3 years of college; most applicants, however, 12 https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis Physicians often work long, irregular hours. A physician’s training is costly. In 1987-88, the annual tuition for public medical schools averaged approximately $13,100; for private medical schools it was approximately $25,600. Room, board, and other expenses are extra. While education costs have increased, student finan cial assistance has not. Scholarships have become harder to find. Loans are available, but subsidies to reduce interest rates are limited. People who wish to become physicians must have a desire to serve the ill, be self-motivated, and be able to survive the pressures and long hours of premedical and medical education. For example, medi cal residents often work 24-hour shifts and 80 hours a week or more. Efforts, however, are being made to limit the hours residents work. Prospective physicians must also be willing to study throughout their career to keep up with medical advances. Physicians should have a good bedside manner, be emotionally stable, and be able to make decisions in emergencies. Job Outlook Employment of physicians is expected to grow faster than the average for all occupations through the year 2005 due to continued expansion of the health industry. The population is growing and aging, and health care needs increase sharply with age. In addition, new technologies per mit physicians to do more tests, perform more procedures, and treat conditions previously regarded as untreatable. Despite efforts to control costs, the payment of most services through private insurance, Medi care, and Medicaid will continue to encourage growth. The need to replace physicians is lower than for most occupations because almost all physicians remain in the profession until they retire. Job prospects are better for primary care physicians such as family practitioners and internists, and for geriatric and preventive care spe cialists, than for those in some nonprimary care specialties such as surgery and radiology. However, changes in Federal Medicare and Medicaid reimbursement, which are designed to encourage more physicians to provide primary care services, may equalize prospects. There are shortages of physicians in some rural and low income areas. This is because physicians find these areas unattractive due to low earnings potential, isolation from medical colleagues, or other reasons, not because of any overall shortage. Some health care analysts believe that there is, or that there will soon be a general oversupply of physicians; others disagree. In ana lyzing job prospects, it should be kept in mind that an oversupply may not necessarily limit the ability of physicians to find employ ment or to set up and maintain a practice. It could result in physicians performing more procedures than otherwise so as to keep up their incomes, or it could result in their providing more time to each patient, giving more attention to preventive care, and providing more services in rural and poor areas. It is also possible that where surplus es are due to specialty imbalances, physicians in surplus specialities would provide more services in shortage ones. Unlike their predecessors, newly trained physicians face radically different choices of where and how to practice. Many new physicians are likely to avoid solo practice and take salaried jobs in group medi cal practices, clinics, and HMO’s in order to have regular work hours and the opportunity for peer consultation. Others will take salaried positions simply because they cannot afford the high costs of estab lishing a private practice while paying off student loans. Graduates of foreign medical schools have long been a source of physicians in the United States. It seems unlikely, however, that they will continue to augment the supply of U.S.-trained physicians to the extent they have had in the past. This is due to such factors as more difficult qualifying entrance exams for foreign-trained students seek ing U.S. residencies and keener competition for a residency once hav ing passed the exams. Earnings Physicians have among the highest earnings of any occupation. According to the American Medical Association, average income, after expenses, for all physicians was about $155,800 in 1989; those under 36 years of age averaged $113,300. Earnings vary according to specialty; the number of years in practice; geographic region; hours worked; and skill, personality, and professional reputation. Selfemployed physicians—those who own or are part owners of their https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis medical practice—had an average income of $175,300, while those who were employed by others earned an average of $119,200 a year. As shown in table 2, average income of physicians, after expenses, varies by specialty. Table 2. Average income of M.D.’s after expenses, 1989 All physicians.......................................................................... $155,800 Surgery..................................................................................... Radiology................................................................................. Obstetrics/gynecology............................................................ Anesthesiology........................................................................ Pathology................................................................................. Internal medicine.................................................................... Psychiatry................................................................................. Pediatrics.................................................................................. General practice/family practice........................................... 220,500 210,500 194,300 185,800 154,500 146,500 117,700 104,700 95,900 SOURCE: American Medical Association Salaries of medical residents averaged $25,858 in 1990-91 for those in their first year of residency to $33,277 for those in their sixth year, according to the Association of American Medical Colleges. Physicians who establish their own practice make a sizable finan cial investment to equip a modem office. Related Occupations Physicians work to prevent, diagnose, and treat diseases, disorders, and injuries. Professionals in other occupations that require similar kinds of skill and critical judgment include audiologists, chiroprac tors, dentists, optometrists, podiatrists, speech pathologists, and vet erinarians. Sources of Additional Information For a list of allopathic medical schools, as well as general informa tion on premedical education, financial aid, and medicine as a career, contact; American Medical Association, 515 N. State St., Chicago, IL 60610. Association of American Medical Colleges, Publications Department, 2450 N St. NW„ Washington, DC 20037. For general information on osteopathic medicine as a career, contact: •- American Osteopathic Association, Department of Public Relations, 142 East Ontario St., Chicago, IL 60611. American Association of Colleges of Osteopathic Medicine, 6110 Execu tive Blvd., Suite 405, Rockville, MD 20852. Information on Federal scholarships and loans is available from the directors of student financial aid at schools of allopathic and osteo pathic medicine. Information on licensing is available from State boards of examiners. Podiatrists (D.O.T. 079.101-022) Nature of the Work The human foot is a complex structure, containing twenty-six bones, plus muscles, nerves, ligaments, and blood vessels, designed for bal ance and mobility. Podiatrists, also known as doctors of podiatric medicine (DPM’s), diagnose and treat disorders and diseases of the foot and lower leg to keep this part of the body working properly. Podiatrists treat the major foot conditions; Corns calluses, ingrown toenails, and bunions; as well as, hammertoes, ankle and foot injuries, and foot complaints associated with diseases such as diabetes. In treating these problems, podiatrists prescribe drugs, order physical therapy, and perform surgery. They also fit corrective inserts called orthotics and design custom-made shoes. Podiatrists may use a force 13 plate to help design the orthotics and shoes. They have patients walk across the plate that is connected to a computer, which “reads” the patients’ feet. From the computer readout, podiatrsts may order the correct design. In diagnosing a foot problem, podiatrists may order X-rays and laboratory tests. Podiatrists refer patients to other health practitioners when they spot systemic diseases, such as arthritis, diabetes, and heart disease, of which first symtoms may appear in the foot. For example, diabetics are prone to foot ulcers and infections due to their poor circulation. Most podiatrists are in private practice, which means that they run a small business. They handle administrative duties like hiring employees, ordering supplies, and overseeing recordkeeping. Most podiatrists have a general practice. Some podiatrists special ize in surgery. Others specialize in orthopedics and public health. Besides these certified specialties, podiatrists may practice a subspe cialty such as sports medicine, pediatrics, dermatology, radiology, and diabetic foot care. Working Conditions Podiatrists usually work independently in their own offices. They work about 38 hours a week, on the average. Podiatrists with solo practices set their own hours, but to meet the needs of their patients, they may have some evening and weekend hours. Podiatrists who are employed in hospitals or clinics may work nights and weekends and be on call. Employment Podiatrists held about 16,000 jobs in 1990. Traditionally, podiatrists have been solo practitioners and most still are; however, some are entering into partnerships and group practices. Some podiatrists are employed in hospitals, nursing homes, and offices and clinics of physicians clinics. The Veterans Administration and public health departments employ podiatrists, too. Geographic imbalances are pronounced in podiatric medicine. This reflects the fact that most podiatry graduates establish their practices in or near one of the seven States that have colleges of podatric medicine. This has left large areas of the country—particularly the South, the Southwest, and nonmetropolitan areas—with few podia trists. In these areas, foot care is typically provided by primary care physicians and orthopedists. Training, Other Qualifications, and Advancement All States and the District of Columbia require a license for the prac tice of podiatric medicine. Each defines its own licensing require ments. Generally, however, the applicant must be a graduate of an accredited college of podiatric medicine and pass written and oral examinations. Twenty-two States also require completion of an accredited residency program. Some States permit applicants to sub stitute the examination of the National Board of Podiatric Examiners, A podiatrist operates to correct a hammertoe. 14FRASER Digitized for https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis given in the second and fourth years of podiatric medical college, for part or all of the written State examination. Certain States grant reciprocity to podiatrists who are licensed in another State. The seven colleges of podiatric medicine are located in California, Florida, Illinois, Iowa, New York, Pennsylvania, and Ohio. Prerequi sites for admission include the completion of at least 90 semester hours of undergraduate study, an acceptable grade point average, and suitable scores on the Medical College Admission Test (MCAT). All of the colleges require 8 semester hours each of biology, inorganic chemistry, organic chemistry, and physics and 6 hours of English. Most entrants surpass the minimum qualifications. Although not mandated, over 95 percent of podiatric students possessed a bache lor’s degree. Colleges of podiatric medicine offer a 4-year program whose core curriculum is similar to that in other schools of medicine. Classroom instruction in basic sciences, including anatomy, chemistry, patholo gy, and pharmacology, is given during the first 2 years. Third- and fourth-year students have clinical rotations in private practices, hospi tals, and clinics. During these rotations, they acquire clinical skills— learning how to take general and podiatric histories, to perform routine physical examinations, to interpret tests and findings, to make diagnoses, and to perform therapeutic procedures. Graduates are awarded the degree of doctor of podiatric medicine, DPM. Most graduates complete a 1- to 3-year residency program after receiving the DPM degree. Residency programs are hospital based. The first-year resident receives advanced training in podiatric medicine and surgery and serves clinical rotations in anesthesiolo gy, internal medicine, pathology, radiology, emergency medicine, and orthopedic and general surgery. Second- and third-year residen cies provide more extensive training in one of the three specialty areas. There are three recognized certifying boards for the specialty areas; The American Board of Podiatric Surgery, the American Board of Podiatric Orthopedics, and the American Board of Podiatric Public Health. A fourth board in general practice is being developed. Certifi cation means that the DPM meets higher standards than those required for licensure. Each board requires advanced training, com pletion of written and oral examinations, and experience as a practic ing podiatrist. People planning a career in podiatry should have scientific apti tude, manual dexterity, interpersonal skills, and a good business sense. Job Outlook Employment of podiatrists is expected to grow much faster than the average for all occupations through the year 2005 as more people turn to podiatrists for foot care. The growing population of the elderly and increased enthusiam for sports will spur demand. The elderly have accumulated more wear and tear on their feet and lower legs than most younger people, so they are prone to foot ailments. In addi tion, the growing popularity of jogging, racquetball, and other sports is expected to result in more podiatric injuries that require medical attention. Even less strenuous activities, like step aerobics, are likely to add to the demand for podiatric care. Like dental services, podiatric care is more dependent on dispos able income than other medical services. Medicare and most private health insurance programs cover acute medical and surgical foot ser vices as well as diagnostic X-rays, fracture casts, and leg braces. However, routine foot care—including the removal of corns and cal luses—is not ordinarily paid for by health insurance. Since disposable income is expected to rise, more people are expected to pay for podi atric care out-of-pocket. Establishing a new podiatric practice will be the most difficult in the areas surrounding the seven colleges of podiatric medicine and in the Northeast since podiatrists are concentrated in these locations. Earnings According to a survey conducted by Podiatry Management, the medi an net income of podiatrists was about $73,746 in 1990. Newly licensed podiatrists generally earn less than the median; well estab lished ones earn more. Related Occupations Podiatrists work to prevent, diagnose, and treat diseases, disorders, and injuries. Workers in other occupations that require similar skills include chiropractors, dentists, optometrists, physicians, and veteri narians. Sources of Additional Information For information on podiatric medicine as a career, contact: American Podiatric Medical Association, 9312 Old Georgetown Rd., Bethesda, MD 20814-1621. Information on colleges of podiatric medicine, entrance require ments, curriculums, and student financial aid is available from: American Association of Colleges of Podiatric Medicine, 1350 Piccard Dr., Suite 322, Rockville, MD 20850-4307. Veterinarians (D.O.T. 073. except .361-010) Nature of the Work Veterinarians care for pets, livestock, sporting and laboratory animals, and protect humans against diseases carried by animals. Veterinarians diagnose medical problems, dress wounds, set broken bones, perform surgery, prescribe and administer medicines, and vaccinate animals against diseases. They also advise owners on care and breeding. Most veterinarians are in private practice. Some have a general practice, treating all kinds of animals. The majority, however, just treat small companion animals such as dogs, cats, and birds. Others treat both small and larger animals, and some treat only large ani mals, such as cattle and horses. Veterinarians in companion animal medicine provide services in 20,000 animal hospitals or clinics; 80 of these only treat cats and some only treat birds. Veterinarians for large animals treat and care for cattle, horses, sheep, and swine. They also advise ranchers and farmers on the care, breeding, and management of livestock. Others specialize in fish and poultry. Veterinarians contribute to human as well as animal health. A num ber of veterinarians engage in research, food safety inspection, or education. Some work with physicians and scientists on research to prevent and treat diseases in humans. Veterinarians are also in regula tory medicine or public health. Those who are livestock inspectors check animals for disease, advise owners on treatment, and may quar antine animals. Veterinarians who are meat inspectors examine slaughtering and processing plants, check live animals and carcasses for disease, and enforce government food purity as well as sanitation regulations. Some veterinarians care for zoo or aquarium animals or for laboratory animals. Veterinarians help prevent the outbreak and spread of animal dis eases, some of which—like rabies—can be transmitted to humans, and perform autopsies on diseased animals. Some specialize in epi demiology or animal pathology, to control diseases transmitted through food animals, and problems of residues from herbicides, pes ticides, and antibiotics in animals used for food. Working Conditions Veterinarians usually treat pets in hospitals and clinics. Often these facilities are noisy. Those in large animal practice usually work out of well-equipped mobile clinics and drive considerable distances to farms and ranches. Veterinarians can be exposed to disease and infec tion and may be kicked, bitten, or scratched. Those in private practice often work long hours. They may set their own schedules and may work nights and weekends. Large animal vet erinarians may work outdoors in all kinds of weather. Employment Veterinarians held about 47,000 jobs in 1990. Almost half were self employed, in solo or group practices. Most others were employees of https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis Almost half of all veterinarians were self-employed, in solo or group practices. a practice. The Federal Government employed about 2,000 civilian veterinarians, chiefly in the U.S. Departments of Agriculture, Defense, and Health and Human Services. Other employers of veteri narians are State and local governments, colleges of veterinary medicine, medical schools, research laboratories, animal food compa nies, and pharmaceutical companies. A few veterinarians work for zoos. Most veterinarians caring for zoo animals are private practition ers who contract with zoos to provide services, usually on a part-time basis. Training, Other Qualifications, and Advancement All States and the District of Columbia require that veterinarians be licensed. To obtain a license, applicants must have a Doctor of Veteri nary Medicine (D.V.M. or V.M.D.) degree from an accredited college of veterinary medicine and pass a State board examination. Some States issue licenses without further examination to veterinarians already licensed by another State. For research and teaching jobs, a master’s or Ph.D. degree usually is required. Veterinarians who seek specialty certification in a field such as opthalmology, pathology, surgery, radiology, or laboratory animal medicine must complete 3-year residency program, and pass an examination. The D.V.M. degree requires a minimum of 6 years of college con sisting of at least 2 years of preveterinary study that emphasizes the physical and biological sciences and a 4-year veterinary program. Most successful applicants have completed 4 years of college. In addition to academic instruction, training includes clinical experience in diagnosing and treating animal diseases, performing surgery, and performing laboratory work in anatomy, biochemistry, and other sci entific and medical subjects. In 1991, all 27 colleges of veterinary medicine were accredited by the Council on Education of the American Veterinary Medical Asso ciation (AVMA). Admission is highly competitive. Applicants usual ly have grades of “B” or better, especially in sciences. Applicants must take the Veterinary Aptitude Test, Medical College Admission Test, or the Graduate Record Examination and submit evidence they have experience working with animals. Colleges usually give prefer ence to in-State applicants, because most are State supported. There are regional educational agreements in which States without veteri nary schools send students to designated regional schools. In other areas, schools give priority to applicants from nearby States that do not have veterinary schools. 15 To meet State licensure requirements, foreign-trained veterinarians must fulfill the English language and clinical evaluation requirements of the Educational Commission for Foreign Veterinary Graduates. Most veterinarians begin as employees or partners in established practices. With experience, they may set up their own practice or pur chase an established one. Newly trained veterinarians may become U.S. Government meat and poultry inspectors, disease-control workers, epidemiologists, research assistants, or commissioned officers in the U.S. Public Health Service. A State license may be required. Veterinarians need good manual dexterity. They should be able to calm animals that are upset, and get along with animal owners, and be able to make decisions in emergencies. Job Outlook Employment of veterinarians is expected to grow faster than the aver age for all occupations through the year 2005. Rising incomes and the movement of baby boomers into the 34-59 year age group, where pet ownership is highest, should cause the number of pets to increase rapidly. Pet owners may also be more willing to pay for more inten sive care than in the past. In addition, emphasis on scientific methods of breeding and raising livestock and poultry, and continued support for public health and disease control programs will contribute to the demand for veterinarians. Jobs will also occur as veterinarians retire. The outlook is good for veterinarians with specialty training. Demand for specialists in toxicology, laboratory animal medicine, and pathology is expected to remain strong, as is the demand for fac ulty at colleges of veterinary medicine. Most jobs for specialists will be in metropolitan areas. Prospects for veterinarians who specialize in SMSU libraries 3 2356 00377410 4 16 https://fraser.stlouisfed.org Federal Reserve Bank of St. Louis farm animals is also good, because most veterinarians prefer working in metropolitan areas. Earnings Newly graduated veterinarians working in the private practices of established veterinarians had an average salary of $27,000 in 1990, according to the American Veterinary Medical Association. Veteri narians in private practices generally earned between $50,000 and $100,000 a year. Newly graduated veterinarians employed by the Federal Govern ment started at $31,116 a year in 1991. The average annual salary of all veterinarians in the Federal Government was $45,893 in 1991. Related Occupations Veterinarians prevent, diagnose, and treat diseases, disorders, and injuries in animals. Workers who do this for humans include audiolo gists, chiropractors, dentists, optometrists, physicians, podiatrists, and speech pathologists. Other occupations that involve working with animals include animal trainers, zoologists, marine biologists, natu ralists, and veterinary technicians. Sources of Additional Information For more information on careers in veterinary medicine, write to: American Veterinary Medical Association, 1931 N. Meacham Rd., Suite 100, Schaumburg, IL 60173-4360. For information on scholarships, grants, and loans, contact the finan cial aid officer at the veterinary schools to which you wish to apply. For information on veterinary education, write to: m- Association of American Veterinary Medical Colleges, 1023 15th St. NW., Third Floor, Washington, DC 20005.
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