Female doctors and the physician shortage

Someone has gone and rained the facts down on what is generally considered a feel–good story in American medicine, the dramatic increase in female doctors in America.

In response to Dr. Herbert Parde’s “The Coming Doctor Shortage” article in the Wall Street Journal, Dr. Curtis Markel pointed out that there is a difference between the raw, gross number of physicians in America, and the effective number of practicing physicians.  Not only that, but he had the audacity to point out that roughly 50% of newly–minted American trained physicians are women, and that many of them do not practice full-time.

The nerve of that guy. I mean, how dare he bring facts into a discussion of physician manpower? This must be just another incidence of the male–dominated world of medicine cracking down on those female party-crashers. Except for the fact that, no, this really isn’t a case of that at all. Just an illumination of a significant part of a more general trend. When we look at the economics of physician resources the more important statistic is not the number of physicians working, but the number of physician–hours that are worked. Physicians newly minted in the United States in the last 20 years work fewer hours per week and annually than their predecessors, and “mommy–track” docs work even less.

That, my friends, is a fact–based reality of healthcare economics in the United States. The fact remains that Heinlein was right: there ain’t no such thing as a free lunch. The facts do not care what you think. They do not they do not care how you feel about them. They do not go away and they do not change if you try to change the topic or bury them with obfuscation. Torn between self–righteousness (I’m staying home for my children) and righteous indignation (I work HARD), the mommy-track docs have fired back.

Unfortunately, their return fire has been little but emotion-loaded pellets, rather than fact–filled ordinance. An ER physician talks about choosing to work fewer shifts in order to tend to her family, or an ailing parent, or even to avoid “burnout,” and conflates the effects of these personal choices with her feelings about the effects of inequities between the compensation for so–called cognitive versus procedural specialties. Another talks about wanting to work part time with the thought that this will make her a more effective doctor. Still others try to shift the conversation from the “mommy–track” to general lifestyle considerations: I wish to “paint, or cycle, or just read.” All well and good, of course, but all also well beside the point. The fact remains that women physicians tend to work fewer hours than their male colleagues, those who have children take long stretches of time away from practicing medicine to do so, and both men and women recently trained tend to work measurably fewer hours than their predecessors did and do.

Sorry. You can’t have it all. Thinking that you can is a fantasy; it’s just not consistent with a fact–based reality. There ain’t no such thing as a free lunch. In medicine or anywhere else.

Please don’t get me wrong. I personally find absolutely nothing inherently wrong with working fewer hours or taking time out to have children. Back in the day there was often a terrible price to be paid because of the traditional work ethic of the American (mostly male) physician. The landscape is littered with the carcasses of medical marriages that didn’t survive this “profession first” rule. Substance abuse was rampant among these physicians, and the physician suicide rate was (and is) a multiple of the general population’s. Younger physicians, mommy–track and otherwise, are certainly onto something. The life balance that is so important to them is healthier in almost all respects, at least as far as the physicians themselves go. But in terms of our health care system as a whole? Nope. The facts say we either need more doctors, or doctors need to work more hours. To say that you, the physician, are making these choices for anything other than lifestyle reasons, to blame some reimbursement inequity or other external factor is disingenuous at best.  My mother used to call it “the consequences of your decisions”, but I prefer Heinlein.

While there are some medical specialties that are very lucrative (neurosurgery, gastroenterology), the income that physicians take-home is generally reflective of how hard they work. How many hours per week they to spend doing clinical work. How much they actually do in each of those hours. General surgeons tend to make more money then family practitioners,  not so much because they get paid all that very much for any individual thing they do, but because they tend to work lots of hours, and they tend to do lots of work in each one of those hours. Nights, weekends, dinnertime, and long after Conan has called it a night, general surgeons are at work because the work needs to be done. The vast majority of primary care physicians work 40 hour weeks, hours that look more like the proverbial banker’s day than the surgeon’s. Nothing wrong with that, and neither is this always the case. I have a friend who is a very successful, family practitioner who is blessed and cursed with both ADD and insomnia. I think he works more than anyone I know, doctor or otherwise, and his income is consequently more like that of a general surgeon.

Perhaps an illuminating example would be the decision I made approximately five years ago to totally change the way I practice my specialty. Suffering from a severe case of professional and business dissatisfaction, I left an extremely successful practice (a practice that remains extremely successful in my absence) and starteda very different type of eye care practice. (As an aside, when they finally got around to replacing me, it took two 30–something year-old physicians to do so.) Here, I see many fewer patients each day, and consequently have a dramatically lower income. When presented with the Zen–like question “do you wish to be wealthy or happy” I chose happy. The decision has made me quite “unwealthy”, but I really am quite happy.

That is the fact–based reality of physician economics, my  little micro–economic example to explain the macro–economic effects of physician–hours versus physician numbers. There’s no one to blame. No government conspiracy. No specialty vs. primary care inequity. I am the sole bread–winner in a home with a “mommy–track” Mom. There are more eye doctors where I live because some of the eye doctors who are already here, mommy–track or otherwise, are now working less.

Are mommy–track docs the sole problem why we face a pending physician shortage in the United States? Of course not. We have a decades–long history of new physicians working fewer hours than their predecessors, a relatively static number of new physicians being trained, and an ever–expanding population of patients who need the care of these physicians. No matter how they might feel about it, and no matter how they might feel about having it pointed out, the fact remains that, on average, newly–minted doctors work fewer hours than their predecessors, and mommy–track docs, on average, work fewer hours than their peers. Wanna stay home with your kids? Cool. 12 weeks to bond with the new baby? Sure, who wouldn’t want that. Just “man up” and face the facts–you can’t have it all. Nobody can. Be a grown up and accept the consequences of the choices that you have made, and accept this gracefully when someone else points that out in the Wall Street Journal or elsewhere.

There ain’t no such thing as a free lunch. Somebody, somewhere, always pays.

Darrell White is an ophthalmologist who blogs at Random Thoughts from a Restless Mind.

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  • http://twitter.com/gianluigi13 giovanna vitale

    hi

  • http://twitter.com/DoctorPullen Edward Pullen

    The facts above are generally true.  The comments of inequity of income between “cognitive” and “procedural” specialists mentioned are the author’s own use of “emotion-loaded pellets, rather than fact–filled ordinance” of his own than the facts he seems to cherish.  I don’t have his desired facts at my fingertips, but suspect if he looked at facts he would find that opthalmologists make a much higher $/hour worked than do primary care physicians.  He has gotten off track here.  His primary point of younger and especially female physicians working less hours is fact.  He should stick with that instead of getting off into the RVU battle where his bias shows.    

  • http://twitter.com/michaelbmoore Mike Moore

    “He has gotten off track here.” Exactly, Dr. Pullen.

  • http://MindOnMed.com Danielle Jones

    What’s the issue? I fail to see the point you’re making. I don’t think anyone has ever argued the fact that new physicans are working less, I think we’ve all only given our reasons for it. Nobody said it wasn’t true, only that there was more background to it than that. Sure, new physicians work less, but is it necessarily a bad thing? 

    First, we need some definitions in this argument. The general public sees things like “mommy-track” and “working less” and assumes a laziness factor, but we need to make sure we are quantifying precision what “fewer hours than their predecessors” means or this conversation become completely undefined. Is it 60/wk instead of 80/wk? 50/wk instead of 70/wk? Does it mean new-age physicians are not “on-call” 24/7 like docs were in the 1940s? Without a quantification of these statements we cannot have this discussion. It’s brought up on blogs over and over as a gross assumption, but honestly without some background it becomes meaningless. 

    So, what I’m seeing as your point to this article is that there are consequences of your decisions. I’m missing something I guess. Maybe I missed an article that this is a follow-up to or something, but I don’t think anyone ever argued that their decision to work less didn’t come with “consequences.”

    Consequences: Flack from co-workers and old physicians, less pay, longer time to pay off debts.

    I disagree, though, that you can’t “have it all” in medicine. This strongly depends on your definition of having it all. I know plenty of physicians, female and male, who feel they have it all – a career they love, a family they see often and above-average pay. They may not make $250,000/yr because they are in primary care and work a set schedule of 40ish hours each week, but to them that’s not included in having it all. 

    The whole problem with this argument, not just your article but all of the articles being written on this recently, is that we’re lacking any definition. Everything is arbitrary – women are responsible for “some” of the shortage, you can’t have “it all,” people are “working less.” There is not any concreteness in these arguments which makes it impossible to get anywhere with the discussion.
    As a side note, why do we have to blame any physicians for lack of access to healthcare? There are thousands of extremely qualified people every year rejected from medical school, why can’t we blame lack of access to training and let people make their own decisions about how much/little to work? If we trained every qualified applicant to become a doctor and all those people worked “part-time” (whatever that means) we wouldn’t have a shortage of a physicians. So, why is our focus on individual decisions to limit work hours and balance life and not on the fact that a ridiculously large number of well-qualified people are told “no” and refused entry into this field due to lack of funding for training. Seems like there’s a lot more at play than part-time work to me. 

  • http://twitter.com/Skepticscalpel Skeptical Scalpel

    Echos what Kay S. Hymowitz said in an article in City Magazine http://is.gd/3L8Col

  • http://twitter.com/Skepticscalpel Skeptical Scalpel

    Women work fewer hours in most occupations. Echos what Kay S. Hymowitz said in an article in City Magazine http://is.gd/3L8Col

  • Anonymous

    As a female physician/ ophthalmologist whose father is a neurosurgeon and first of 4 daughters is a second year med student, I can’t help but chime in on this. This is not solely a male/ female MD issue, this is an American cultural/societal issue. The American male has been subjected to discrimination, unless they are a minority. Because Most males in the US are not minorities, this gender discrimination affects Most males. The progressive movement has undermined the family unit and the role of the male in particular. Accordingly, look what has happened to the American male compared to the American female-boys are doing less well than us girls on standardized tests and GPA’s, less are going to college, less are going to med school…they are living at home longer, getting marrried later (marriage is another discussion related to a virtuous and morally strong society.) They are failing to step up to the plate. We have set them up for failure. They have, in effect, given up and given into that reality. Those who choose to stand up for the male are called names such as Hater or Racist. The father is absent from the family. More and more males are not striving for sexual purity but rather “hooking up” with whoever they please for immediate gratification, ignoring consequences, doing alcohol, drugs…These are not character traits required in med school candidates, and this perpetuates the inequity in the med school admission process, which is heavy on service, character, and good scores-tests,GPA… Besides,who would actually want to go into medicine with the negative, demonic, poor picture the lefties/progressives have perpetuated …especially when the future now is ruled by Obamacare… In reality, the “best” surgeons and clinicians I have known, trained, and been cared for by, are “Best” not because of their gender, but because of the traits required of a physician, regardless of gender. Fortunately, my husband is not a physician, so I can afford to continue to practice medicine in this oppressive climate. I am humbled and privileged to be a doctor and consider medicine the most noble profession. I have sacrificed  much but been rewarded so much more…and for you libs, I am not talking about financial reward. I am talking about that sacred doctor-patient relationship which you cannot understand and seek to destroy.   And, by the way,those of you that continue to degrade us ophthalmologists, beware. As humans, we cannot replace our eyes like we can our Ipods and iphones.I have trained many an eye surgeon. There is a distinct difference in surgical skill and surgical judgment, which correlates directly with surgical outcome. Remember that old addage-you get what you pay for. Further, time spent is irrelevant to quality in surgery, as in many things in life. In reality, the best surgeons most often have the shortest operating times. Please, people apply some common sense here. The problem is not that there are more females in medicine…the problem is that there is too much socialized/progressive/communist government in medicine and in the American family/ culture for that matter…by the way, many female( and male) physicians have been forced to go part time or leave the practice of medicine altogether, because of the low reimbursement, high risk, high stress, high overhead, long hours…and it is unfeasible to do this and live any sort of life at all regardless of gender. There just happens to be more of us xx’s now. Was this by design/or are we why they have been able to swoop down and confiscate the entire practice of medicine… maybe we truly are just damsels in distress… 

  • http://twitter.com/scutmonkey Michelle Au

    1.) Even if every single doctor in the country worked “full-time” (which can be construed as anywhere between 50-100 hours a week, depending on the field) the shortage of doctors in this country would still exist, owing to a number of factors, including the static number of medical residency spots in this country coupled with a growing aging population, as well as leaps in medical technology that are helping much sicker people live longer.  

    2.) Despite the many, many rewards of a career in medicine, getting people to become doctors is becoming an increasingly hard sell.  Just off the top of my head, I can count medicolegal factors, increasing risk with decreasing compensation, an arduous training track that can span more ten years or more, the cost of medical school, and of course the challenges in balancing work and career, to name a few.  Many otherwise very good MD candidates might look at some or all of these reasons and decide that a career in medicine might just not be worth it.

    So the point is this.  Yes, fewer manpower hour are fewer manpower hours–math is math.  But does a calculation based purely on hours lose the forest for the trees, and would an emphasis on “getting our money’s worth” out of physicians do more harm than good, driving people away from an understaffed field just because the traditional ethos of what it is to be a medical professional simply does not mesh with modern reality?  Or would it instead be worth it to explore the notion that a more equal (and less pejoratively-viewed) culture of work-life balance will not be the downfall of our field, and instead might rather be the very thing that keeps it alive?

    Also, Dr. White (and I say this with all collegiality and respect–my husband is also an ophthalmologist, and I have read and enjoyed your blog) I wonder why it is that your own decision to scale back your work hours with the attendent drop in income is framed as a choice for “happy vs. wealthy,” whereas doctors on the so-called “Mommy Track” (and you’ll have to excuse me for loathing that term in all its diminutive oversimplification) making what the exact same decision are being told to “man up.”

  • http://onhealthtech.blogspot.com Margalit Gur-Arie

    OK, so if the newly minted docs are working less hours because of the mommy-track or the daddy-track or the happy-track or whatever, why are we not just minting more docs?

    • Anonymous

      Why aren’t we “minting” more docs? Uh, because unlike coins and money which can be pressed and printed cheaply and at will, making more doctors requires attracting people both able and willing to go through the long educational and training process, a lot of money, paid for more now than ever before by heavy borrowing, and a long delay to being able to be gainfully employed (and residency doesn’t count as gainful.) Even the prospects we try to attract from other countries aren’t coming fast enough. 

      I hope you aren’t suggesting we lower the bar on qualifications (that is already being done here and there, clandestinely.) Trust me that is a place where you should not want to go. As someone intimately familiar with the rigors of medical training, I do not want less competitive and less qualified people as my doctor.

      If we have a shortage of internists, perhaps we ought to pay them better to make their work more attractive. That does not mean we have to buy into a rob Peter to pay Paul solution either. Lift the upper limiting charge on all 99xxx CPT codes. See what happens.

      • http://onhealthtech.blogspot.com Margalit Gur-Arie

        Are you suggesting that we have reached the limit on the availability of “best and brightest” in the US?
        I don’t think the real reason for not “minting” more docs is a shortage of willing talent. And if the talent now chooses to be less productive, i.e. work less hours, then it is only logical to turn out two part-time docs for every  previously full time one (at the very least). What this means to the tax payer who is paying for residencies full price regardless of future life-style choices is something that should be considered as well.

        I do agree with you that we should pay PCPs more, and that this should not be a zero sum game.

  • http://twitter.com/murmur55 murmur55

    Umm… Multiple women doctors at UMass Medical Center had their lives and careers destroyed or seriously compromised by violent Jew power-monger doctors from Harvard. Where are these women doctors in your calculations? Two female employees had family members suicide or become psychotic due to the extreme abuse they were subjected to at their workplace by violent Jew power-monger doctors.  I had to care for a family member who was left psychotic and suicidal on the streets of Boston for years while being cared for by Harvard hospitals and BCBS “insurance”.

    The most malevolent abuser of women now has a temple dedicated to himself on state and federal property. Another violent, incompetent Jew from Harvard was allowed to become president of the APA, even though he has obvious Asperger’s disorder and interfered with patient care, even killing a disabled female psych patient during an unethical research study.  What about all the female patients who were abused, even raped, by these malevolent Harvard Jew doctors? I’m on my third rape by a Harvard-associated doctor. Where are these women patients in your calculations? Where is that information? Who has access to “the facts”?

    This article is a disgraceful piece of political power-mongering trash.

  • Anonymous

    Huh? The idea that some specialties earn more than others based mainly on hours worked is just not correct.  In fact, right here at Kevinmd was posted an Archives of Internal Medicine study:  Per hour salaries:  Primary care $60, IM and peds $85, derm over $100, etc, etc.  A little more reading is the prescription for you, Dr. White.
    In the rant on women in medicine and young docs working less it was difficult to find the point.  Do you think that is good or bad, or what?  Or are you just trying to point out to us ignoramuses that if docs work fewer hours then–wait for it–fewer hours will in fact be worked! Not breaking any new ground with that insight.

  • http://twitter.com/DarrellWhite Darrell White

    The point, BK, is that fewer hours worked by physicians of any and all kinds, specialists, proceduralists, men, women, will be a net negative as we strive to accommodate our aging population. There’s no such thing as a free lunch, and fewer hours worked will have a downstream cost. 

    The additional point, a more visceral one to be sure, is that the choices made by physicians to improve their “lifestyles” are just that, and that those decisions are being made for personal reasons that have nothing to do with the difference between primary care physician and specialty surgeon income. Not admitting this, indeed obfuscation through emphasis on stuff like per hour differentials, is at best disingenuous. That’s bad.

    • Anonymous

      “made for personal reasons that have nothing to do…”  But that’s not what you wrote.  You wrote that surgeons get paid more mainly because they work more.  That is simply not true. Increased income is a function both of hours worked and income per hour, and I called you on your error.  Hello, this blog is not a fact-free zone.   If you want to make a “visceral” point then make it, but  do not adduce evidence that is bogus.   As for obfuscation, incorrect statements in support of a emotional conclusion is quite an example of that.  Indeed, why should we pay attention to you if you write these howlers and then shrug your shoulders as if to say that facts are irrelevant in any case?
      And then you blow it again, writing that these decisions are made without regard to income differentials.  Where the hell are the references for that?  What are the p-values? Or are you just making this up?
      As for docs’ personal decisions having a societal cost, well, indeed it might be true. You should have just said that and stopped.

  • http://twitter.com/DarrellWhite Darrell White

    Michele, I like everything about your post. My own decision was labelled “wealthy vs. happy” because that is the most accurate way to describe my own, personal situation at the time. I actually work MORE hours and take LESS vacation in my present situation, and I have essentially lost my entire life’s savings in the process. Nonetheless, I am much happier, albeit much less rested and no longer wealthy at all. 

    Where I am behaving differently than the subjects of the WSJ article is that I am, indeed, “manning up.” I didn’t make my change because of declining reimbursement (present as you know in ophthalmology!), increased liability exposure, or some other unnamed outside influence. I did so with eyes open to the consequences, with no illusions, and openly stating that it was to increase my professional satisfaction, my happiness. Unlike the “Mommy-Track” docs in the article who are looking for some greater, systemic significance to their equally personal and (for them and me) self-centered decisions. 

    Part-time docs increase the need for more docs, your well-reasoned argument that we might get BETTER docs in that case notwithstanding. Docs who reduce the number of patients they see per unit of time, like me, also increase the need for more docs, though I think I am proof that your thesis is true!

    The article in the WSJ essentially said the same thing as Heinlein: There Ain’t No Such Thing As A Free Lunch.

  • Juliet Mavromatis

    Darrell, good to hear your authentic view on this topic. I hadn’t seen Dr. Parde’s piece in the Wall Street Journal. I did, however, read Dr. Sibert’s Op-Ed in the New York Times about one month ago. She is an anesthesiologist. The viewpoint was very similar. I think that the part of her piece that enraged female physicians the most was the implication that federal funding is not well spent on training female physicians, because they work part-time so often. Here’s what I wrote in my blog: http://www.drdialogue.com/2011/07/part-time-women-in-medicine-are-they.html. One of the key work force issues in medicine is recruiting trainees to careers in primary care. Women tend to choose primary care more often than men. I disagree with your comments about work hours in primary care, which imply this is an easy field of medicine where full time equates to bank hours (9-5) or 40 hours a week. A recent study http://content.healthaffairs.org/content/30/2/193.abstract has shown that women (despite number of hours worked) earn less than their male counterparts. Women are paying the price in medicine and are important and inexpensive contributors to the work force, even when they decide to cut back to part-time.

  • http://twitter.com/AustrianSchool_ Austrian School

    Dr. White good for you for choosing happiness :)

  • http://onhealthtech.blogspot.com Margalit Gur-Arie

    Are you suggesting that we have reached the limit on the availability of “best and brightest” in the US? I don’t think the real reason for not “minting” more docs is a shortage of willing talent. And if the talent now chooses to be less productive, i.e. work less hours, then it is only logical to turn out two part-time docs for every  previously full time one (at the very least). What this means to the tax payer who is paying for residencies full price regardless of future life-style choices is something that should be considered as well.I do agree with you that we should pay PCPs more, and that this should not be a zero sum game.

  • http://onefamilytable.wordpress.com/ Yolanda (One Family Table)

    I agree wholeheartedly that we make our personal decisions and we reap the consequences.  Although the decision does involve a sort of “wealth vs. happiness” mentality, I feel like I have achieved both.  Not because I make as much as others on an hourly basis working part time as a pediatrician, and at a community health center no less.  But because I recognize that what I make as an MD is still a lot more than many.  The perception and definition of wealth is very dependent on each individual’s expectations.  (Whether or not MD earnings are actually based on number of hours worked is a totally different topic which I won’t even bother touching…)
    Nevertheless, I do also believe that the decision to work part-time has helped me be a better physician.  It has prevented burn-out.  I have noticed that my attitude in general is much more positive and I am more willing to go the extra mile with each family.  Not to say that those working full-time are not incredible physicians.  Just a statement of knowing myself and seeing the difference in my own patient encounters.  This was one consideration when I chose to work part-time, in addition to the desire to be at home with kids part of the week.

  • http://twitter.com/Cascadia Sherry Reynolds

    Actually it is a myth that we suffer from a provider shortage. (see one of the articles linked in Kevin’s blog). If we do it is one that was artificially created by the AMA when they advocated for less students years ago and our payment systems that focus on pay for procedure vs outcomes. It is also based on the assumption that you need to have an MD for the bulk of medical care when a nurse or nurse practitioner could easily handle it. When we know that group visits for people with diabetes are more effective then the rushed 8 minute one problem we currently see.. When people in Boston receive twice or three times as much care as people in Minneapolis.. Where doctors never have open slots on their appontments and drive 1/3 of all care..

     I won’t even both to address the obvious misogyny or perhaps envy in this post. I haven’t heard the term “female doctors” used since grade school.. Or that very little behavior change in health care is the result of “facts.” Most people born in the last 40 years know that emotion is an equally valuable form of intelligence and that providers who live a balanced life are far better healers who can partner with their patients.

  • LBENT

    Dr. White is categorically wrong when he
    says, “When we look at the economics of physician resources, the more important
    statistic is not the number of physicians working, but the number of
    physician-hours that are worked.” 
    Here’s why.

    1) No definition of physician productivity
    exists–and certainly none that cuts across specialties would be
    appropriate.  Is the surgeon who
    works 10 hours in the OR and does 10 hernia repairs in one day, but has a 20%
    recurrence rate, more productive than the surgeon who works 6 hours in the OR
    and has 2% recurrence rate? 
    Outcomes count.  Studies
    have shown that women physicians have better outcomes in treating congestive
    heart failure: http://www.ncbi.nlm.nih.gov/pubmed/19188237?dopt=Citation .

    2) No study has been done that actually
    measures how much time over a career women and men work.  In fact, women appear to be more
    productive towards the ends of their careers as men slow down.  Do men have more medical leaves for injuries
    and cardiac events, etc.? 

    3) In informal polling only 7% of doctors
    cited numbers of hours worked or patients seen as a measure of productivity https://app.sermo.com/posts/posts/92548/results.  RVUs, outcomes,
    patient complexity, patient satisfaction and other measures accounted for 65%
    of responses. 

    4) Most importantly, medicine is not
    practiced the same way it was 20-30 years ago.  Teaming with highly trained medical personnel such as nurse
    practitioners and physician assistants and the use of technology to manage
    medical records and patient care, for example, have physicians working in new
    ways.  Recognizing that the
    structure and function of the healthcare workplace need to better align with
    the emerging healthcare workforce is essential, and should be at the heart of
    the discussion.

    For more than a century, women physicians
    have found ways to be incredibly productive.  Their strategies are only just now being recognized as worthy
    of institutionalization, mainly because women are not the only ones who see the
    benefits of change.  It’s time to
    stop the finger pointing and blame game. 
    It’s time to re-engineer the healthcare workplace so that all doctors
    can contribute to their fullest abilities. 

  • http://twitter.com/katellington Katherine Ellington

    My question is about the numbers you and others are quoting.  What is the source of the data? Is there a national database that holds these numbers?

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