From Certification to Care

Amy E. Young, MDGabriella Gosman, MDKenneth H. Kim, MD, MHPEGeorge A. Macones, MD, MSCEA competent, appropriately sized, and equitably distributed obstetrician–gynecologist (ob-gyn) workforce is essential to the health of the U.S. population. Rayburn and Xierali1 add significantly to the literature with their analysis using publicly available datasets and the Health Workforce Simulation Model at the Health Resources & Services Administration (HRSA).2 Their article provides a baseline and projected assessment of ob-gyn physician workforce adequacy relative to demand, including geographic density distribution. Their work projects ob-gyn physician deficits for future demand, compounded by a national maldistribution of physician supply. Their findings corroborate predictions from the AAMC assessment for surgical specialties.3 The American Board of Obstetrics & Gynecology (ABOG) plays several roles in the realm of ob-gyn workforce analysis and actions. As a certifying body, ABOG defines practice standards; certifies physicians; and facilitates continuous learning to advance knowledge, practice, and professionalism in women's health4 in both general obstetrics and gynecology (specialists) and obstetrics and gynecology subspecialties. Through these actions, ABOG influences the competence of the ob-gyn workforce that voluntarily pursues and maintains ABOG board certification. In addition to certification activities, ABOG certification programs generate valuable data through diplomate and candidate survey information. Diplomate survey information obtained through the annual continuing certification process is designed to increase relevance in assessments. These data provide self-reported information on clinical effort, practice type, use of advanced practice professional (APPs), and specific areas of care in which diplomates focus their practices. Specialty and subspecialty candidate surveys (voluntary) gathered after qualifying examinations provide information regarding educational programming, compliance with eligibility standards, and other information relevant to patient care and obstetrics and gynecology practice. With appropriate consent and confidentiality safeguards, these data can be aggregated and accessed by specialty and subspecialty societies, researchers, and policymakers to inform workforce analyses and guide policy decisions to optimize the ob-gyn physician workforce in the United States. Rayburn and Xierali's use of the HRSA’s Health Workforce Simulation Model2 provides a valuable baseline for workforce adequacy and distribution. However, several model assumptions warrant scrutiny. The Health Workforce Simulation Model does not differentiate between generalists and subspecialists, despite their distinct roles and practice settings. Among the nearly 40,000 physicians participating in ABOG's Continuing Certification program in 2024, there were approximately 20% practicing subspecialists and 80% specialists. Based on enrollment for the 2024 Qualifying Exam, ABOG predicts this will approach 70% specialists and 30% subspecialists. Further, based on results from the 2024 Continuing Certification Survey, approximately half of subspecialists in maternal–fetal medicine, gynecologic oncology, reproductive endocrinology and infertility, and urogynecology and reproductive pelvic surgery indicated that they spend zero time dedicated to specialist practice. This information highlights the problematic nature of subspecialty inclusion in the model, which may obscure critical nuances in workforce planning. Additionally, the model defines full-time equivalency as more than 20 hours per week, a threshold that may overestimate actual clinical capacity. The model also uses inputs derived from estimates taken during the coronavirus disease 2019 (COVID-19) pandemic, when there were significant aberrations in care delivery. These assumptions may lead to erroneous estimates of the overall physician deficit and maldistribution and must be accounted for in interpretation. The authors note a physician shortage despite declining demand in the U.S. birth rate. The HSWM model assumes staffing ratios based on demand information created by International Classification of Diseases codes for utilization at the county level in 2022. As patient comorbidities and obstetric acuity increase, the intensity of care per patient rises. Moreover, the aging female population will alter demand for gynecologic services such as cancer care, pelvic floor disorders, and menopause management. These evolving clinical needs necessitate strategic workforce planning to inform specialty and subspecialty training and evolution of competencies in the existing workforce. The HRSA’s Health Workforce Simulation Model currently presents independent analyses for APPs distinct from ob-gyn physicians. Midwives, women's health physician assistants, and women's health nurse practitioners are modeled independently. Thus, the interrelated nature of ob-gyn physician and APP practices in team-based care is not captured fully. The 2024 ABOG Continuing Certification Survey data show that APPs are widely engaged across the specialty (82.1%) and subspecialties (87.7%). Seventy percent of specialists and 77.1–89.9% of subspecialists use APPs in their outpatient practices. APPs were highly used in the inpatient setting by specialists and subspecialists (up to 56.9% in the labor and delivery department and 47.3% in the operating room). Of note, in the HRSA’s Health Workforce Simulation Model, APPs are predicted to have an oversupply (135–201% adequacy). Future workforce analysis tools that further the understanding of APP–physician team models could result in insights with the potential to mitigate deficiencies in physician supply. Geographic maldistribution of clinicians remains a persistent challenge.5 Understanding what drives practice location is key to addressing maldistribution. ABOG's 2024 Qualifying Exam survey identified top factors influencing location choice among specialists and subspecialists. Through the creation of a weighted average of categorical survey data (no influence, some influence, strong influence), preferences were ranked and are presented in Table 1. Specialty examinees ranked call characteristics, continued mentorship/support, practice structure, and access to subspecialists as the most influential factors; subspecialists ranked continued mentorship/support, patient population, access to subspecialists, and permissive legal practice environment as most influential. Access to subspecialists was noted as influential for both groups, further highlighting the need to address maldistribution issues specifically as it relates to subspecialty access. In the upcoming 2026 Continuing Certification Survey, a limited set of questions will be deployed to provide additional clarity.Table 1.: Factors Influencing Practice LocationMedical access represents a complex problem for the health of the U.S. population. As aptly stated by Rayburn and Xierali, “Effective decision making about ob-gyn workforce planning and policy development requires accurate information.” ABOG remains committed to contributing to this effort by sharing aggregated data, partnering with stakeholders, and supporting improved modeling to drive solutions to this complex problem. Through collaboration, we can ensure that the ob-gyn workforce is prepared to meet the evolving needs of obstetrics and gynecology patients across the United States.