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US Graduate Medical Education, 2003-2004
Sarah E. Brotherton, PhD;
Paul H. Rockey, MD, MPH;
Sylvia I. Etzel
JAMA. 2004;292:1032-1037.
ABSTRACT
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Context Information about recent graduates of medical schools and the characteristics of physicians training in graduate medical education (GME) portends the size and composition of the US physician workforce of the near future.
Objectives To examine trends in training programs and career choices of graduating male and female residents and to monitor trends in the size of the entire residency population.
Design, Setting, and Participants The American Medical Association and Association of American Medical Colleges jointly surveyed residency programs during the academic year 2003-2004 about active, transferred, and graduated residents, as well as about program characteristics. The 8192 programs confirmed the status of 94.6% of residents. Nearly 86% of program directors (n = 7040) completed the accompanying program survey.
Main Outcome Measures Overall trends during the last 6 years in the number and characteristics of residents and programs, as well as the specialty of male and female graduating residents.
Results There were 99 964 active residents during the 2003-2004 academic year, the highest ever recorded by the National GME Census. The number of residents (n = 22 444) entering US graduate medical education programs for the first time is also the highest on record. In 1999, 28 773 physicians completed training, 10 546 (36.7%) of whom were women. In 2003, there were 29 745 graduates, 11 681 (39.3%) of whom were women, representing a 10.8% increase. The number of obstetrics/gynecology male graduates decreased 31.3%, while female graduates increased 18.2%. Other specialties that lost men and gained women were dermatology, family medicine, internal medicine, ophthalmology, pathology, psychiatry, and general surgery. The proportion of graduates who pursued additional training increased; percentages were 27.2% in 1999, 29.6% in 2001, and 32.1% in 2003. In 2000, 35.7% of programs provided opportunities to develop cultural competence; the percentage in 2003 was 50.7%. The percentage of programs with complementary/alternative medicine curriculum has held steady at 24%.
Conclusions The number of physicians in GME is at its highest, and nearly one third of physicians completing training in one program continue on in another. The choices of female residents parallel those of male residents in many respects, but there are important differences.
INTRODUCTION
Characteristics of physicians training in graduate medical education (GME) have changed over the past decade in the proportions of men and women, the choice of specialty, and the pursuit of additional subspecialty training. For instance, more women have been entering US GME programs than before, and since nearly half (49.8%) of matriculating US medical students are women,1 this trend should continue into the foreseeable future. It is impossible to predict all the ways this balance between sexes will affect the profession of medicine, but the impact will likely vary among the specialties and subspecialties. Some specialties (such as obstetrics/gynecology) have been graduating predominantly female physicians, while others (such as orthopedic surgery) have been overwhelmingly graduating men. Charting the ebb and flow between and within the specialties provides data that may be helpful in understanding how current GME graduates will serve the future medical needs of the nation.
In this article, we report on the graduates of US allopathic residency training programs in 3 of the last 6 years—1999, 2001, and 2003. We compare the specialty choices of women and men and describe their immediate plans as reported by program directors to the National GME Census. Some trends emerge from these data that should interest those involved in health workforce policy. Furthermore, by analyzing physicians who have just completed training in a specialty or subspecialty program, these trends have greater immediacy to those involved in workforce planning than data on physicians entering residencies.
We also document the number of residents training in subspecialty GME programs, the number of subspecialty programs in which they train, the changing characteristics of first-year residents, and the provision of cultural competence training and complementary/alternative medicine (CAM) educational opportunities in GME.
METHODS
The National GME Census is administered jointly by the American Medical Association (AMA) and Association of American Medical Colleges (AAMC) through GME Track, an Internet-based AAMC product. The AMA and the AAMC maintain a database of all resident physicians by program, which is updated annually using the previous year's residents and adding approximately 19 000 new residents via the National Resident Matching Program and the AAMC's follow-up report of medical schools. Starting in July 2003, we surveyed all Accreditation Council for Graduate Medical Education (ACGME)–accredited specialty and subspecialty programs and all combined programs about active, transferred, and graduated residents for academic year 2003-2004.
Lists of residents for each program were generated from our updated database. These lists were presented to program directors, who were asked to reconfirm or modify the training status of residents who were present in their programs the previous year (year in program, number of years in GME training in a different specialty, start date in the program, and expected or actual graduation date); to add new residents to their program not included on the list; and to confirm, edit, or add resident demographic information, such as sex, birth date, country of origin, medical school, medical school graduation date, visa or citizenship status, and race/ethnicity. Program directors also were asked to complete a survey about their programs' educational and work environment. Most of these program survey questions provide information for FREIDA Online,2 which is a Web-based public information source on GME programs used by medical students and residents.
Based on data from this survey and those of prior years, we examined specialty choices of men and women as well their plans after graduation, comparing these choices across 3 years (1999, 2001, and 2003).  2 Tests were used to analyze changes in distribution using SPSS software, version 11.0 (SPSS Inc, Chicago, Ill). P<.05 was considered statistically significant for all analyses.
RESULTS
Survey Respondents
We surveyed 8192 programs, of which 6623 (80.8%) confirmed the status of all their active residents, accounting for 92.9% of active residents in our database. An additional 149 programs (1.8%) confirmed some but not all of their residents (accounting for 4.3% of active residents); 1160 (14.2%) apparently had no residents and 260 (3.2%) programs did not confirm the status of any resident. A total of 94.6% of all residents in our GME database had their status confirmed (eg, active, graduated, or withdrawn) by their program director. Residents in our database whose status was not confirmed by their program were "advanced" into the next year of training (n = 2807 [2.8% of active residents]) or "graduated" based on expected graduation date (n = 1877 [5.5% of graduated residents]).
Nearly 86% of program directors (n = 7040) completed the accompanying program survey. A total of 6337 (77.4%) completed the program survey and confirmed the status of all active residents. Of the remaining 703 programs (8.6%) that completed the program survey, 477 (5.8%) had no residents to report, 100 (1.2%) did not confirm any residents, and 126 (1.5%) confirmed some but not all of their residents. A total of 992 program directors (12.1%) confirmed all or some of their residents but did not complete the program survey, and only 160 (2.0%) completed neither survey. Specialty programs were more likely to complete the program survey than subspecialty programs (92.6% vs 79.0%; 21 = 315.2; P<.001).
Numbers of Programs and Residents
As of December 31, 2003, there were 99 964 resident physicians enrolled in ACGME-accredited and combined specialty GME programs, the highest ever recorded by the National GME Census. Table 1 presents 6 years of trend data on the number of programs, number of total residents, number of residents in graduate year 1 (GY1) positions (entry-level positions that do not require or preclude prior GME), the number of GY1 residents in GY1 positions who have not had any prior GME, and the number of total residents by medical school origin. In 1993-1994, the number of GY1 residents was at its peak at 26 033.3 The number of GY1 residents (currently, n = 23 922) has held steady at less than 24 000 for the last 3 years. The number and proportion of GY1 residents who are making their first appearance in US residency programs (no prior GME in other ACGME-accredited programs) (n = 22 444 [93.8%]) has continued to rise and is at its highest ever. This year, only 1478 GY1 residents (6.2%) had prior training; during the mid 1990s this number was routinely higher than 3000.3 (See Appendix II in this issue for additional data on all residents.)
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Table 1. ACGME-Accredited and Combined Specialty GME Programs and Resident Physicians According to Medical School of Graduation and Specialty and Subspecialty, 1998-2003
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The number of specialty and subspecialty programs and the number of residents training in them for the past 6 years are also presented in Table 1. Specialty programs are transitional-year programs plus those that lead to a general board certificate, as defined by the American Board of Medical Specialties, and subspecialty programs are those that lead to a subspecialty certificate. During the past 2 years, there has been a reverse of the trend that began in 1998-1999 of declining numbers of residents in specialty training, now at 86 357. The last time there were more than 86 000 residents in specialty programs was 1997-1998, with 86 421.3 During that same year, there were 4368 specialty training programs for those residents, a number that declined to 4169 in 2003-2004.
The number of subspecialty programs increased 13% during the past 6 years, from 3561 to 4023. The number of residents in these programs increased even more (15.8%). If the current rate of growth of subspecialty programs and decline in specialty programs persists, there will be as many subspecialty programs as there are specialty programs in a few years.
Women in GME
In 2003, for the first time, the number of female applicants to US medical schools surpassed the number of male applicants.1 Nearly 41% of all physicians training in ACGME-accredited programs in 2003-2004 were women, and in several specialties women have been in the majority for years. Given the length of training, it may be some time before the number of women equals the number of men exiting the GME pipeline; however, we examined the characteristics of residents graduating in 1999, 2001, and 2003 to document recent trends and changes. Table 2 presents the number and percentage of graduates in the major specialties by sex for each of the 3 years.
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Table 2. Male and Female Residents Graduating From ACGME-Accredited and Combined Specialty Programs in 1999, 2001, and 2003
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There has been a substantial increase in the number of graduates in this 4-year period, and women constituted the entire increase. In 1999, 28 773 physicians completed training in a specialty or subspecialty program, 10 546 (36.7%) of whom were women. In 2003, there were 29 745 graduates, 11 681 (39.3%) of whom were women, an increase of 10.8%. The number of men graduating decreased from 18 226 to 18 047.
Notable changes between 1999 and 2003 include dramatic growth in the numbers of anesthesiology and emergency medicine graduates, with an overall increase of 43.9% and 12.5%, respectively. Specialties that lost men and gained women were dermatology, family medicine, internal medicine, obstetrics/gynecology, ophthalmology, pathology, psychiatry, and general surgery. Obstetrics/gynecology experienced the most dramatic change, with an overall 31.3% decrease in male graduates and 18.2% increase in female graduates.
Plans of Graduating Residents
Program directors provided specific career plans for 24 762 graduates in 1999 (86.0%), 18 369 graduates in 2001 (62.8%), and 20 498 graduates in 2003 (68.9%) (Table 3).
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Table 3. Graduating Plans of Male and Female Residents Graduating From ACGME-Accredited and Combined Specialty Programs in 1999, 2001, and 2003*
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Overall, there has been an increase in the proportion of graduates continuing their training: 27.2% in 1999, 29.6% in 2001, and 32.1% in 2003. The increase was especially evident among female graduates, although there are still fewer women than men who continue training. The proportion of graduates entering the military was stable over time, with men twice as likely as women to join. Female graduates were as likely as male graduates to take academic positions in each of the 3 years, although this option fluctuated for all graduates (17.2% in 1999, 15.7% in 2001, and 16.1% in 2003).
Women were more likely than men to enter nonacademic practice on graduating, a consistent difference in all 3 years. Overall, the percentage of total graduates entering nonacademic practice declined: 48.2% in 1999, 48.0% in 2001, and 45.6% in 2003. Women decreased their rate of entering practice more than men during this period (6.9% vs 5%). The rate of unemployment among graduates has been stable, with women more than twice as likely to be reported as unemployed at the time of the census. The unemployment response category is nonspecific (ie, the resident could be unemployed by choice or for lack of finding a suitable job). The percentage of graduates leaving the country declined by half (from 2.3% in 1999 to 1.2% in 2003). This decline may be the result of an increasing number of graduates who are citizens or permanent residents (82.0% in 1999, 84.6% in 2001, and 85.6% in 2003).
Educational Program Characteristics
Other changes within GME that reflect society's overall greater diversity include expanding educational opportunities for residents to enhance their ability to effectively communicate with and provide care for those who may not share the same cultural or medical background. Table 4 presents the number and percentage of programs that had opportunities in cultural competence awareness, CAM curriculum, and instruction in medical Spanish or other non-English languages available to their residents for the last 4 years. The growth in opportunities in cultural competence awareness has increased from 35.7% of programs in 2000-2001 providing cultural competence awareness to 50.7% in 2003-2004. The percentage of programs with CAM curriculum has held steady at 24%. The proportion of programs providing instructional opportunities in a non-English language decreased by 12% (from 21.6% to 19.0%).
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Table 4. Programs Providing Opportunities in Cultural Competence Awareness, Complementary/Alternative Medicine, and Non–English Language Instruction, 2001-2004
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COMMENT
In the last few years, a decreasing number of GY1 residents have started residency training with prior GME training. This trend may be due to an increase in the proportion of GY1 residents who are native or naturalized US citizen international medical graduates, as well as the growing number of osteopathic physicians who pursue allopathic residencies.4
As more residents pursue additional training, there are growing numbers of residents in subspecialty training. While the debate continues about the most appropriate mix of physicians in primary and specialty care,5-7 residents are pursuing greater specialization. The causes are likely myriad; however, lower compensation in primary care relative to work effort,8 perceived differences in "controllable lifestyles,"9 and reported declining professional satisfaction of primary care physicians10 may all be factors. There has been a declining interest in family medicine and internal medicine, and their leadership have articulated strategic plans for the future.11-12 Conversely, there have been predictions that pediatrics, a primary care specialty not experiencing a decline in entrants, may experience a surplus by 2020.13
Although the numbers and proportions of women in GME training are increasing at a pace that suggests parity with men in the not-too-distant future, the career paths of women on graduating from GME programs continue to diverge from men's in several areas, with convergence in a few. Like men, an increasing percentage of women continue on with their GME training (with more rapidly increasing proportions than men), albeit typically 7 percentage points fewer than men (currently, 27.9% vs 34.8%). Both women and men are less likely than before to enter nonacademic practice, but women are more likely to choose this option compared with men (currently, 48.5% vs 43.7%). Men are consistently more likely than women to enter the military, while women are now nearly 3 times as likely to be unemployed at the time of the survey. Men and women are equally likely to enter academic positions on graduating from a GME program, in proportions that have remained stable in the midst of fluctuations in other career options. Career progress for women in academics has been well described and, in general, has been found to be lagging behind that of men,14 especially in disproportionately male specialties such as general surgery,15 but also reported in obstetrics and gynecology,16 despite the fact that nearly 75% of residents in obstetrics and gynecology are women (see Appendix II).
Examining specialty at graduation and initial practice plans of women and men provides a few pieces to a complex puzzle. Further data are needed to understand how practice patterns may be shifting and how much sex is influencing these changes. For example, recent US Census data documented that female physicians earned on average less than two thirds the income of their male colleagues. In addition to clinical productivity, this finding may stem from differences in income by specialty and changing work habits of younger physicians, since women in practice are younger.
The number and proportion of programs offering cultural competence training has increased markedly over the past few years. This is probably because of a recognition of the increasing diversity of the patient population and in response to pressure from entities such as the ACGME and the Institute of Medicine, which recommended that cross-cultural curricula be part of the training of clinicians from undergraduate education through continuing education programs.17
The apparent contradictory decline in the number of programs offering instructional opportunities in medical Spanish or another non-English language may not indicate a waning interest in this area but that such instruction may have been subsumed under the broader rubric of cultural competency. There are now national standards for "culturally and linguistically appropriate services in health care" that were developed and promulgated by the US Department of Health and Human Services' Office of Minority Health,18 which encourage comprehensive programs to incorporate both enhanced communication skills and cultural competency. Residents possibly are acquiring language skills while in medical school as part of a cultural competency curriculum. Furthermore, institutions may now be providing interpreter services to comply with federal law,19 thus reducing the need for language educational programs for residents.
The lack of growth, however, in the number of programs offering educational opportunities in CAM runs counter to the American public's increased use of CAM.20 Many physicians are unaware of patients' use of CAM21; educating physicians on the prevalence and composition of CAM by patients will likely increase the safety and possibly efficacy of CAM use. Although a program may report educational opportunities in cultural competency, non-English language acquisition, and CAM, we do not know the format of the curricula, length or intensity of the educational experience, or what proportion of residents, if any, partake in training.22
Great efforts are made to ensure that the National GME Census collects complete and accurate information on GME and residents; however, it is a prodigious enterprise, both for the data collectors and the data providers, taking several months each year, with numerous follow-up requests of program directors to finish the survey. Overall, our response rate is good, yet there are components of the survey that have lower response rates than others. In addition, we noted a declining response rate to the survey portion asking programs to report graduating residents' plans. Nevertheless, we have no reason to suspect that this introduced any reporting bias based on the sex, specialty, or plan of the resident.
Nearly 100 000 resident physicians are currently training in GME programs in the United States. Mirroring an increasingly complex health delivery system, they appear to be pursuing longer educational pathways and differentiating into a more specialized medical workforce.
AUTHOR INFORMATION
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Corresponding Author: Sarah E. Brotherton, PhD, Division of Graduate Medical Education, American Medical Association, 515 N State St, Chicago, IL 60610 (sarah_brotherton{at}ama-assn.org).
Author Contributions: Dr Brotherton had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.
Study concept and design: Brotherton, Rockey.
Acquisition of data: Brotherton, Etzel.
Analysis and interpretation of data: Brotherton, Rockey.
Drafting of the manuscript: Brotherton, Rockey.
Critical revision of the manuscript for important intellectual content: Brotherton, Rockey, Etzel.
Statistical analysis: Brotherton.
Administrative, technical, or material support: Brotherton, Etzel.
Study supervision: Brotherton, Rockey.
Acknowledgment: We thank the Department of Census and Self-reported Data at the AMA and the Division of Health Care Affairs at the AAMC for administering the National GME Census.
Author Affiliations: Division of Graduate Medical Education, American Medical Association, Chicago, Ill.
REFERENCES
1. Barzansky B, Etzel SI. Educational programs in US medical schools, 2003-2004. JAMA. 2004;292:1025-1031.
FREE FULL TEXT
2. FREIDA Online: Fellowship and Residency Electronic Interactive Database. Available at: http://www.ama-assn.org/go/freida. Accessed June 4, 2004.
3. Miller RS, Dunn MR, Richter T. Graduate medical education, 1998-1999. JAMA. 1999;282:855-860.
FREE FULL TEXT
4. Brotherton SE, Rockey PH, Etzel SI. US graduate medical education, 2002-2003. JAMA. 2003;290:1197-1202.
FREE FULL TEXT
5. Weiner JP. Prepaid group practice staffing and US physician supply: lessons for workforce policy. Health Aff (Millwood). Feb 4, 2004. Web exclusive. Available at: http://content.healthaffairs.org/cgi/content/full/hlthaff.w4.43v1/DC1. Accessed June 4, 2004.
6. Cooper RA, Getzen TE, McKee HJ, Laud P. Economic and demographic trends signal an impending physician shortage. Health Aff (Millwood). 2002;21:140-154.
FREE FULL TEXT
7. Fisher ES, Wennberg DE, Stukel TA, et al. The implications of regional variations in Medicare spending, I: the content, quality, and accessibility of care. Ann Intern Med. 2003;138:273-287.
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8. Biola H, Green LA, Phillips RL, et al. The US primary care physician workforce: undervalued service. Am Fam Physician. 2003;68:1494, 1496-1498, 1500.
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9. Dorsey ER, Jarjoura D, Rutecki GW. Influence of controllable lifestyle on recent trends in specialty choice by US medical students. JAMA. 2003;290:1173-1178.
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10. Landon BE, Reschovsky J, Blumenthal D. Changes in career satisfaction among primary care and specialist physicians, 1997-2001. JAMA. 2003;289:442-449.
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11. Martin JC, Avant RF, Bowman MA, et al. The future of family medicine: a collaborative project of the family medicine community. Ann Fam Med. 2004;2 (suppl 1):S3-S32.
12. Larson EB, Fihn SD, Kirk LM, et al. The future of general internal medicine: report and recommendations from the Society of General Internal Medicine Task Force on the Domain of General Internal Medicine. J Gen Intern Med. 2004;19:69-77.
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13. Shipman SA, Lurie JD, Goodman DC. The general pediatrician: projecting future workforce supply and requirements. Pediatrics. 2004;113(3 pt 1):435-442.
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14. Buckley LM, Sanders K, Shih M, et al. Obstacles to promotion? values of women faculty and career success and recognition. Acad Med. 2000;75:283-288.
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15. Schroen AT, Brownstein MR, Sheldon GF. Women in academic general surgery. Acad Med. 2004;79:310-318.
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16. Seltzer VL. Changes and challenges for women in academic obstetrics and gynecology. Am J Obstet Gynecol. 1999;180:837-848.
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17. Smedley BD, ed, Stith AY, ed, Nelson AR, ed. Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care. Washington, DC: National Academies Press; 2002.
18. US Department of Health and Human Services Office of Minority Health. National Standards for Culturally and Linguistically Appropriate Services in Health Care: Final Report. Rockville, Md: US Dept of Health and Human Services; 2001.
19. US Department of Health and Human Services. Guidance to federal financial assistance recipients regarding Title VI prohibition against national origin discrimination affecting limited English proficient persons. November 20, 2003. Available at: http://www.hhs.gov/ocr/lep/revisedlep.html. Accessed June 15, 2004.
20. Barnes PM, Powell-Griner E, McFann K, Nahin RL. Complementary and Alternative Medicine Use Among Adults: United States, 2002. Hyattsville, Md: National Center for Health Statistics; 2004. Advance data from Vital and Health Statistics No. 343.
21. Oldenick R, Coker AL, Wieland D, et al. Population-based survey of complementary and alternative medicine usage, patient satisfaction, and physician involvement. South Med J. 2000;93:375-381.
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22. Park E, Betancourt J, Kim M, et al. Qualitative assessment of resident physicians' training and preparedness to deliver cross cultural care. Poster presented at: AcademyHealth Annual Research Meeting; June 6-8, 2004; San Diego, Calif.
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