National Graduate Medical Education Census Research Articles

Current Efforts in Diversity for Pediatric Subspecialty Fellows: Playing a Zero-sum Game

* Abbreviation: URiM — : underrepresented in medicine Medicine in the United States has been hampered by a lack of diversity for centuries. Over the past few decades, greater attention and efforts have been focused on tackling this problem. A diverse workforce is important for many reasons, including a commitment toward a representative workforce in the name of social justice, improved patient care in the form of increased access and patient satisfaction,1 and service to communities for whom we provide care.2 Programs aimed at increasing diversity exist at every level of medical training, from premedical programs to the subspecialty match. Programs throughout are important because structural and individual racism impede minority success at every level, but the earliest interventions are the most likely to succeed. Efforts aimed at increasing diversity will not succeed by simply targeting subspecialty trainees alone. In essence, at the subspecialty level, this is a zero-sum game. The gains made by any one program are exactly balanced by the losses borne by others. A significant impact on increasing the pool of underrepresented in medicine (URiM) candidates for fellowship positions requires that efforts begin early and continue throughout the entire educational journey. The Association of American Medical Colleges defines URiM as “racial and ethnic populations that are underrepresented in the medical profession relative to their numbers in the general population.” This … Address correspondence to Angela C. Weyand, MD, Division of Pediatric Hematology and Oncology, Department of Pediatrics, Medical School, University of Michigan, 1150 W Medical Center Dr, Medical Sciences Research Building III, Room 8220E, Ann Arbor, MI 48109. E-mail: acweyand{at}med.umich.edu

Rate of Programs Affected by Resident Attrition and Program Factors Associated With Attrition in Emergency Medicine.

Resident attrition negatively affects residents and programs. The incidence of attrition in emergency medicine (EM) and program-specific factors associated with attrition remain unclear. We quantified the percentage of EM residencies affected by attrition between 2007 and 2016 and identified program-specific factors associated with attrition. We performed a retrospective analysis of data derived from the American Medical Association National Graduate Medical Education Census. We defined attrition as any postgraduate who left their residency training program prior to completion. We calculated the percentage of residency programs that experienced attrition and the overall incidence of attrition. We used Fisher's exact tests, Wilcoxon rank sum tests, and t tests, as well as multivariable logistic regression, to identify program-specific factors associated with attrition. Between 2007 and 2016, 139 EM residency programs (82%) experienced attrition of at least 1 resident. An average of 23% of EM training programs experienced attrition annually. The incidence of EM resident attrition averaged 0.85% per year. Program-specific factors associated with attrition include 4-year residencies (P = .031), programs with medium class size (P = .0003), more female residents (P = .002), and more female faculty (P = .003). After analysis, only medium class size (compared to small) was associated with attrition (odds ratio = 4.96, 95% confidence interval 1.65-14.91). Between 2007 and 2016, while the incidence of resident attrition in EM was low (< 1%), the majority of programs experienced resident attrition. Medium class size (7 to 12 residents) was the only program-specific factor associated with increased attrition.

Why Residents Quit: National Rates of and Reasons for Attrition Among Emergency Medicine Physicians in Training.

IntroductionRecruiting and retaining residents who will complete their emergency medicine (EM) training is vital, not only because residency positions are a limited and costly resource, but also to prevent the significant disruptions, increased workload, and low morale that may arise when a resident prematurely leaves a program. We investigated national rates of EM resident attrition and examined the reasons and factors associated with their attrition.MethodsIn this retrospective, observational study we used national data from the American Medical Association National Graduate Medical Education Census for all residents who entered Accreditation Council for Graduate Medical Education-accredited EM programs between academic years 2006–2007 and 2015–2016. Our main outcome was the annual national rate of EM resident attrition. Secondary outcomes included the main reason for attrition as well as resident factors associated with attrition.ResultsCompared to the other 10 largest specialties, EM had the lowest rate of attrition (0.8%, 95% confidence interval [CI] [0.7–0.9]), or approximately 51.6 (95% CI [44.7–58.5]) residents per year. In the attrition population, 44.2% of the residents were women, a significantly higher proportion when compared to the proportion of female EM residents overall (38.8%, p=0.011). A greater proportion of Hispanic/Latino (1.8%) residents also left their programs when compared to their White (0.9%) counterparts (p<0.001). In examining reasons for attrition as reported by the program director, female residents were significantly more likely than male residents to leave due to “health/family reasons” (21.5% vs 9.6%, p=0.019).ConclusionWhile the overall rate of attrition among EM residents is low, women and some under-represented minorities in medicine had a higher than expected rate of attrition. Future studies that qualitatively investigate the factors contributing to greater attrition among female and some ethnic minority residents are necessary to inform efforts promoting inclusion and diversity within the specialty.

Evaluation of Sex, Ethnic, and Racial Diversity Across US ACGME-Accredited Orthopedic Subspecialty Fellowship Programs.

In recent years, there has been an increasing trend toward subspecialization in orthopedic surgery via fellowships. This study sought to characterize sex, ethnic, and racial representation within each fellowship program and to examine their changes over time to identify trends and/or gaps. Demographic data were obtained from the National Graduate Medical Education Census. Diversity was assessed using proportions of minority and female trainees. The trends in racial, ethnic, and sex diversity from 2006 to 2015 for orthopedics as a whole and within each subspecialty were analyzed. Of 3722 orthopedic fellows, 2551 identified as white (68.5%), 648 as Asian (17.4%), 175 as Hispanic (4.7%), 161 as black (4.3%), 8 as Native Hawaiian/Pacific Islander (0.21%), and 3 as American Indian/Alaskan Native (0.08%). Further, 479 identified as female (12.9%). Racial and ethnic minority representation among orthopedic fellows did not increase over time. Female representation did increase proportionally with female residents. Asian fellows preferred reconstructive adult and spine, whereas white fellows preferred sports medicine, hand surgery, and trauma. Female fellows preferred pediatrics, hand surgery, and musculoskeletal oncology. Although sex diversity among orthopedic fellows has increased in the past 10 years, racial and ethnic minority representation lacked similar growth. Asian and female fellows preferred specific subspecialties over others. These data are presented as an initial step in determining factors that attract minority groups to different orthopedic subspecialties. Further research should define specific factors and identify ways to increase minority distribution among fellowship programs. [Orthopedics. 2018; 41(5):282-288.].

U.S. Graduate Medical Education and Physician Specialty Choice

The United States is facing a critical physician shortage. It will only get worse as many more Americans gain insurance coverage under the Affordable Care Act and as additional millions enter the Medicare system. There is a serious concern that the pipeline for the production of the physician workforce is inadequate to meet future needs. It is imperative to continue to monitor the structure and size of this pipeline-the purpose of the research reported here. This descriptive analysis uses data derived from the National Graduate Medical Education Census, which includes reports on the entire population of residents in programs accredited by the Accreditation Council for Graduate Medical Education. Data for the years 2001 to 2010 are reported both on specialties which can be entered directly from medical school or with one preliminary year and on subspecialty residencies and fellowships, which require completion of an earlier residency program. Estimates of the number of new trainees who will practice primary care are provided. In 2010, there were 4,754 residents reported in preliminary programs, 89,142 residents in core specialty and combined specialty programs, and 20,007 in subspecialty and sub-subspecialty programs. Between 2001 and 2010, there was a 13.6% (13,655) increase in all residents. Since 2001, there has been a 6.3% (540) decrease in the number expected to enter primary care. Without a substantially accelerated growth in graduate medical education, the physician workforce will fall short of the nation's needs, and competition for available residency positions will radically increase.

National Survey of Geriatric Psychiatry Fellowship Programs: Comparing Findings in 2006/07 and 2001/02 From the American Geriatrics Society and Association of Directors of Geriatric Academic Programs' Geriatrics Workforce Policy Studies Center

: To document the development of geriatric psychiatry (GP) fellowship training in the United States through 2008. : A cross-sectional survey of the 56 U.S. GP fellowship programs was conducted in summer 2007. Longitudinal data from the American Medical Association and the Association of American Medical Colleges' National Graduate Medical Education Census and data from the Accreditation Council for Graduate Medical Education were also analyzed. : Thirty-seven (66%) of 56 program directors responded. The number of fellowship programs has decreased over the past 7 years. During 2006/07, 72 fellows were in training, as compared with 94 fellows in 2001/02. Application rates declined significantly with a mean of 4.3 applications per program in 2006/07 as compared with the mean of 10 applications per program in 2001/02. The fill rate for first-year GP fellowship positions dropped from 61% in 2001/02 to 48% in 2006/07. During 2006/07, 67% of programs reported having two or fewer first-year fellows and 16% had no first-year fellows. Seventeen programs reported having no United States medical school graduates as first-year fellows. : The number of GP fellows in training has declined by 23% from 2001/02 to 2006/07. This decline has occurred at the same time when the number of older adults continues to expand rapidly. It is critical that an adequate number of geriatric psychiatrists be trained to support and educate general psychiatrists in the care of the elderly. Specific strategies need to be developed urgently to stimulate interest in careers in clinical and academic GP.

Participation in U.S. Graduate Medical Education by Graduates of International Medical Schools

International medical graduates (IMGs) are an important part of U.S. graduate medical education (GME) and medical practice. They make up a significant number of the participants in both the Electronic Residency Application Service (ERAS) and the National Resident Matching Program (NRMP). The authors analyze and report statistics describing the multiple pathways used by IMGs in pursuit of a U.S. residency position. This is a descriptive study of 10,328 IMGs certified by the Educational Commission for Foreign Medical Graduates (ECFMG) between July 1, 2005 and June 30, 2006. Linked data on this cohort were obtained from the ECFMG, ERAS, and the NRMP, combined with residency data from the National GME Census. The study determined the numbers of members of the study cohort who participated in ERAS and/or the NRMP in 2003 through 2009, and who found a residency appointment in the United States between 2003 and the first half of 2010. The IMGs in the study cohort began applying for residencies in significant numbers in the year immediately following ECFMG certification, but almost half were unsuccessful in their first attempts. Three-quarters of the members of the cohort had begun a residency by 2010. IMGs make up a very substantial fraction of ERAS and NRMP participants. Although they face significant hurdles in achieving their goal, the majority of those who persist are ultimately successful. If enrollments and graduations of U.S. MD- and DO-granting medical schools continue to rise, IMGs' difficulty in finding residencies is sure to increase.

Attrition in residents entering US obstetrics and gynecology residencies: analysis of National GME Census data

We sought to identify risk factors for attrition among obstetrics and gynecology residents. We analyzed 2001-2006 American Medical Association Graduate Medical Education (GME) Census data for all residents who entered obstetrics and gynecology in 2001 to characterize residents who did not complete a 4-year training period in their initial programs ("attrition"). Multivariable logistic regression models identified predictors of attrition from among age, gender, race, Hispanic ethnicity, medical school type, and medical school graduation year. Of 1055 residents entering obstetrics and gynecology in 2001, 228 (21.6%) were in the "attrition" group (133 changed obstetrics and gynecology programs and/or completed training on atypical cycles; 75 changed specialty; 20 discontinued GME). Residents who were older, underrepresented minority race, Asian race, osteopathic- or international medical school graduates were more likely to be in the "attrition" group (each P < .05). Analysis of a national cohort of obstetrics and gynecology residents identified substantial attrition and demographic risk factors.

Are entering obstetrics/gynecology residents more similar to the entering primary care or surgery resident workforce?

We compared demographic characteristics of first-year residents entering obstetrics/gynecology with those entering primary care and surgery. We analyzed first-year residents from the 1997-2004 National Graduate Medical Education Census. Multivariable logistic regression models identified independent associations between obstetrics/gynecology residency (compared with primary care and surgery) and demographic predictor variables. More than 90% of studied programs completed the National Graduate Medical Education Census for 146,174 first-year residents. Graduates of US allopathic medical schools, women, African Americans, and entering residents in 2003 and 2004 were more likely to enter obstetrics/gynecology than primary care; Asians were less likely to enter obstetrics/gynecology than primary care. Women, African Americans, and Hispanics were more likely to enter obstetrics/gynecology than surgery; trainees who were Asian, "other" race/ethnicity, and entered residency from 1999-2004 were less likely to enter obstetrics/gynecology than surgery. Demographic characteristics of incoming obstetrics/gynecology-residents differed significantly from both primary care and surgery residents. Obstetrics/gynecology should be a unique category in physician workforce studies.

US Graduate Medical Education, 2004-2005

Over the last decade, the primary care specialties have experienced an ebb and flow in popularity. A description of the future primary care workforce may inform planning for the health care needs of our population. To describe characteristics of physicians training in primary care specialties over the past 9 years and to monitor trends in the characteristics of the entire residency population. Descriptive survey study of the National GME Census, conducted by the American Medical Association and Association of American Medical Colleges, which jointly surveyed 8246 allopathic graduate medical education (GME) programs during the academic year 2004-2005 about active, transferred, and graduated residents, as well as about program characteristics. Program directors confirmed the status of 97.3% of active residents. The accompanying program survey was completed by 7163 (87%) of the program directors. General trends in the numbers and characteristics of all residents, fellows, and training programs, with specific trends for residents and fellows training in the primary care specialties and subspecialties over the past 9 years. The census counted 101 291 physicians-in-training during the 2004-2005 academic year, the largest number ever recorded by this survey. The number of osteopathic medical school graduates (DOs) in allopathic GME decreased from 5838 in 2003-2004 to 5675, following many years of annual increases. The number of residents in primary care specialties reached a peak in the mid 1990s. The number of family medicine residents who are graduates of US allopathic medical schools (USMDs) has fallen from 8232 (77.6%) in 1998-1999 to 4848 (51.7%) in 2004-2005. The number of primary care residents who are graduates of foreign medical schools and US citizens (USIMGs) nearly doubled between 1995-1996 (n = 1768) and 2004-2005 (n = 3304). The number of USIMGs training in internal medicine or pediatrics subspecialties increased by 45.7% between 1995-1996 (n = 622) and 2004-2005 (n = 906). The number of pediatric subspecialty fellows grew 55.7%, mostly because of the near doubling of USMDs, from 813 to 1617. More than half of primary care residents are women (52.5%). All primary care specialties and subspecialties experienced gains in the proportion of female residents, with the greatest in obstetrics/gynecology, which increased by 28.7% (57.9% in 1995-1996 vs 74.5% in 2004-2005). An increasing proportion of physicians are pursuing subspecialty training, while the number in primary care specialties has leveled off. Trends in GME suggest that the primary care medical workforce of the future will include more women, more IMGs, and more DOs.

Physician Recruitment into Geriatrics—Further Insight into the Black Box

Physician Recruitment into Geriatrics—Further Insight into the Black Box

US graduate medical education, 2003-2004.

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. 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. 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. 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. 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%. 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.

Trends in career choice by US medical school graduates.

Trends in career choice among specialties have varied greatly. Most notable is the recent decrease in the percentage of US medical student graduates choosing a primary care career, which has important implications for the US physician workforce. To review temporal trends in career choice by graduates of allopathic US medical schools, focusing on US medical doctors entering residencies since 1987. Three databases, the Association of American Medical Colleges Graduation Questionnaire (AAMC GQ), the National Resident Matching Program, and the national Graduate Medical Education census, were used to review temporal trends in the number of US medical doctors entering residencies in primary care, general or subspecialty surgical, and non-primary care and nonsurgical specialties from 1987 to 2002. In 1987, 49.2% of all medical school graduates matched to one of the generalist residencies (internal medicine, pediatrics, or family medicine). The percentage of students matching to primary care specialties declined in the early 1990s, peaked at 53.2% in 1998, and declined to 44.2% in 2002. Concurrent with the latter decline, AAMC GQ data showed a decrease in medical student interest in primary care careers (35.6% in 1999 to 21.5% in 2002). The total percentage of US medical doctors matching to general or subspecialty surgical residencies remained stable at 11% to 12% from 1987 to 2002. During this same period, emergency medicine and plastic surgery increased as a match choice, while anesthesiology, pathology, and psychiatry were more variable over time. Distribution of medical students' career choices among specialties varied considerably from 1987 to 2002. The debate will continue regarding the appropriate specialty mix within the physician workforce.

Geriatric medicine fellowship programs: a national study from the Association of Directors of Geriatric Academic Programs' Longitudinal Study of Training and Practice in Geriatric Medicine.

This report documents the development and growth of geriatric medicine fellowship training in the United States through 2002. A cross-sectional survey of geriatric medicine fellowship programs was conducted in the fall 2001. All allopathic (119) and osteopathic (7) accredited geriatric medicine fellowship-training programs in the United States were involved. Data were collected using self-administered mailed and Web-based survey instruments. Longitudinal data from the American Medical Association (AMA) and the Association of American Medical Colleges' (AAMC) National Graduate Medical Education (GME) Census, the Accreditation Council for Graduate Medical Education (ACGME), and the American Osteopathic Association (AOA) were also analyzed. The survey instrument was designed to gather data about faculty, fellows, program curricula, and program directors (PDs). In addition, annual AMA/AAMC data from 1991 to the present was compiled to examine trends in the number of fellowship programs and the number of fellows. The overall survey response rate was 76% (96 of 126 PDs). Most (54%) of the PDs had been in their current position 4 or more years (range: <1-20 years), and 59% of PDs reported that they had completed formal geriatric medicine fellowship training. The number of fellowship programs and the number of fellows entering programs has slowly increased over the past decade. During 2001-02, 338 fellows were training in allopathic programs and seven in osteopathic programs (all years of training). Forty-six percent (n = 44) of responding programs offered only 1-year fellowship-training experiences. PDs reported that application rates for fellowship positions were stable during the academic years (AYs) 1999-2002, with the median number of applications per first year position available in AY 2000-01 being 10 (range: 1-77). In 2001-02, data from the AMA/AAMC National GME Census indicated a fill rate for first-year geriatric medicine fellowship positions of 69% (259 first-year fellows for 373 positions). During 2001-02, more than half of programs (53%) reported having two or fewer first-year fellows, whereas 31% had three or four first-year fellows. Thirty-three programs (36%) reported having no U.S. medical school graduate first-year fellows, and another 25 (28%) reported having only one. Of the 51 programs offering second-year fellowship training, PDs reported 61 post-first-year fellows (median 1, range: 0-7). During the past 10 years, 27 new allopathic geriatric medicine fellowship programs opened; there are now 119 programs. There are also seven osteopathic programs. The recruitment of high-quality U.S. medical school graduates into these programs remains a challenge for the discipline. Furthermore, the retention of first-year fellows for additional years of academic training has been difficult. Incentives will be needed to attract the best graduates of U.S. family practice and internal medicine training programs into academic careers in geriatric medicine.

US graduate medical education, 2000-2001.

For the last three quarters of a century, the American Medical Association's national collection of graduate medical education (GME) data has evolved in its scope and methods. This year's GME survey involved new technology. The National GME Census for 2000-2001, jointly administered by the American Medical Association and the Association of American Medical Colleges, was part of an Internet-based product called GME Track. Because of technical problems, data collection was less complete than in previous years. Similar to the 1999-2000 survey, we observed an increase in the number of subspecialty programs, with 79 more than last year (2.1% increase), and a decrease in the number of specialty programs, with 40 (0.9%) fewer. Parallel to this continuing trend was a decrease in the number of graduates of US medical schools who were matched into primary care residencies, particularly family practice programs (20% decrease compared with 1996-1997). The number of graduates of osteopathic medical schools training in allopathic programs continued to rise, increasing 7.9% from last year. Numbers of Hispanic and Asian graduates from US allopathic medical schools (USMDs) in graduate year 1 (GY1) positions increased numerically to 887 and 2356, respectively, and proportionally by 7.2% and 17.3%, respectively. Although the number of white USMDs in GY1 positions increased, their proportion decreased slightly among those with known race or ethnicity from 72.2% to 71.7%, and the number of black USMD GY1 residents, numbering 859, declined from the previous year. Although we observed an overall decline in the average number of on-duty hours expected of residents in their first year in a program (from 55 in 1996-1997 to 54 in 2000-2001; P<.001), the average number of hours reported by the majority of programs that typically report the most on-duty hours did not decrease. The issues of resident work hours and the diversity and specialty distribution of the physician workforce continue to foster debate.