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November 2002
Volume 66 |
Number 11 |
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| Residency
Composition and Numbers Graduating From Residencies
and Nurse Anesthesia Schools Alan
W. Grogono, M.D. |
This is the eighth in a series of fall articles based
on recruitment data provided by the American Board of
Anesthesiology (ABA) and the second to include data
from the American Association of Nurse Anesthetists
(AANA). Recruitment and workforce issues in anesthesiology
continue to be of interest. However, the transition
from apparent surplus to evident shortage has refocused
our attention; the question now is: how much longer
must we wait before recruitment will meet critical shortages?
Recent experience raises questions about the causes
and responses to the apparent surplus of recruits in
the early 1990s and invites consideration of the effects
and wisdom of introducing controls on the size of residencies.
This article reports the current data and discusses
these questions.
Some caution is required when analyzing numerical data
retrospectively. ABA obtains the data from more than
100 programs, and experience reported last year indicates
that the data can contain anomalies. However, the data
are collected in the same way each year, and the striking
recent changes deserve critical review.
Number of Anesthesiologists Graduating [Table 1, Figure
1]
The results this year contain no surprises. The trend
of the last few years continues, and the number reported
as having completed training from September 2001 to
August 2002 (1,263) is essentially the same as the number
of CA-3 residents one year before at the start of the
year 2001-02 (1,253). The total is greater by 344 (37
percent) than the low of 919 that occurred in 2000 but
smaller by 533 (30 percent) than the high of 1,796 that
occurred in 1995.
Table 1 (click
to enlarge) |
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The
numbers graduating and in each year of
anesthesiology residencies 1985-02. |
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Figure 1 (click
to enlarge) |
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Graph showing the numbers graduating
(Grad) and the composition of all four
years (PG-1, CA-1, CA-2, CA-3) of anesthesiology
residencies 1985-02 |
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Number of Nurse Anesthetists Graduating and Being Certified
[Table 2, Figure 2]
During the last 13 years, there has been a wider fluctuation
in the number of nurse anesthetists graduating and being
certified than has occurred in the number of residents
graduating. The numbers of nurse anesthetists graduating
has risen from a low of 592 in 1989 to a high of 1,159
in 2001 (96 percent increase). The number being certified
has risen from a low of 574 in 1989 to a high of 1,129
(97 percent increase).
Table
2 (click to enlarge) |
Figure 2 (click
to enlarge) |
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Number of nurse anesthetists graduating
(Grad) and being certified (Cert) during
the years 1989-01. |
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Graph showing number of nurse
anesthetists graduating (Grad) and being
certified (Cert) during the years 1989-01. |
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Residents in Training [Table 1, Figure 1]
This year there are anticipated increases in the CA-2
group (from 1,374 to 1,420) and CA-3 group (from 1,253
to 1,357). However, the number of residents in the critical
CA-1 group (1,471) has scarcely changed from last year
(1,466). With these CA-1 intakes, the number expected
to graduate appears likely to plateau, at least for
a while, somewhere around 1,400, which is about 20 percent
below the high of 1,796 in 1995. The number of residents
in the PG-1 year has risen significantly over the last
three years from 446 in 2000 to 543 in 2001, to 638
this year. This is the largest PG-1 group recruited
in the last 20 years.
Residency Composition [Table 3, Figure 3]
The number of international medical graduates (IMGs)
in anesthesiology residencies has declined to 1,531
(31 percent) from a peak of 2,285 (58 percent) in 1999
[Table 3]. The trend is more marked in the critical
CA-1 year [Table 1] where the number of IMGs declined
this year to 352 out of 1,471 (24 percent) from a peak
of 770 out of 1,387 (56 percent) in 1999. The PG-1 year
also shows a decline in the number of IMGs to 138 out
of 638 (22 percent) from a peak of 397 out of 507 (78
percent) in 1997. This is the first year since 1994
that there are more American medical graduates (AMGs)
than IMGs in every year.
Table 3 (click
to enlarge) |
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The number of American medical
graduates (AMG) and international medical
graduates (IMG) in anesthesiology residency
programs 1960-02. |
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Figure 3 (click
to enlarge) |
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Graph showing the number of American
medical graduates (AMG) and international
medical graduates (IMG) in anesthesiology
residencies 1960-02.. |
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Attrition
Fewer residents are leaving their residency programs.
This year the total attrition during the three years
between the 1999 CA-1 year and the 2002 number graduating
fell to 9 percent compared to 12 percent last year and
the peak of 21 percent for the 1994 CA-1 cohort. The
rate of attrition between the 2001 CA-1 and 2002 CA-2
years shows a similar trend: 3 percent this year compared
to 5 percent last year and the peak of 14 percent for
the 1994 CA-1 group.
Comparison of the Rate of Attrition for AMGs and IMGs
[Figures 4, 5]
The number of AMGs and IMGs leaving residencies during
the two years between the CA-1 and CA-3 years is compared
in Figure 4. This graph of absolute numbers suggests
a relatively large loss of AMGs around 1994, followed
a few years later by recovery. The size of the two groups,
however, is very different. A more meaningful comparison
of the relative attrition rates is provided in Figure
5 where the data are normalized to a starting size of
100 percent for both AMGs and IMGs. Initially attrition
was negligible and similar for both groups. Then during
1994 and 1995, the attrition rate for both groups exceeded
20 percent but remained similar. Recently, however,
there has been a difference. For the last three years,
the attrition rate for AMGs has averaged 4 percent while
that for IMGs has averaged 13 percent.
Figure 4 (click to enlarge) |
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The change in size of each group
of residents between CA-1 and CA-3 years
by year of starting training. The gray
dots indicate the change in size of the
total group AMG plus IMG. |
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Figure 5 (click to enlarge) |
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The size of each group of residents
between CA-1 and CA-3 years as a percentage
of its starting size by year of starting
training. The gray dots indicate the percentage
size of the total group AMG plus IMG. |
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Discussion
In 2001 the number of nurse anesthetists graduating
(1,159) and being certified (1,129) was at the highest
levels recorded in the last 14 years. Both figures have
risen since last year from 1,075 and 997, respectively.
The number certified was only 30 fewer than the number
graduating. In the previous two years, the difference
was greater (67 in 1999 and 78 in 2000). At present,
there is no sign that these increases are leveling off.
This year, the number of anesthesiology residents in
the PG-1 year has risen again. In the last two years,
the total number has increased by 43 percent to 638
and the number of AMGs has more than doubled to 500
(78 percent of the total). The total in the PG-1 year
is approaching half of the total recruitment into the
CA-1 year. The growth is probably explained by an increased
availability of primary care internship positions due
to declining enthusiasm for primary care. By contrast,
the number entering the anesthesiology CA-1 year is
almost constant, although there has been a 14-percent
increase in the proportion of AMGs to 1,119 out of 1,471
(76 percent). The number graduating from anesthesiology
residencies increased moderately this year, but for
the next three years, the total completing training
is anticipated to be almost steady around 1,400.
The average output for the last 14 years is 1,402. The
numbers graduating fell below this level in 1998. The
average output for the years 1989-97 was 1,582, and
the average for the years 1998-02 was 1,079; that is,
there was a relative excess production of 1,620 during
the years 1989-97 and a relative deficiency of 1,605
during the years 1998-02. A steady output of 1,402 for
the last 14 years would have resulted in the numbers
we now have. One conclusion must be that if this level
of output has resulted in a shortage, then a continuation
of the average output of 1,402 per year cannot correct
the current deficit.
If there was a temporary excess output from the residencies,
it would have been approximately 1,620 by 1997. This
calculated “surplus” is hard to reconcile
with estimates today of a deficit of the same order
of magnitude. Moreover employment opportunities were
already reappearing before the numbers graduating had
significantly declined, that is, even when the average
number graduating was still well above the average of
1,402 per year.
The “surplus” was exacerbated and might
actually have been caused by changes in recruiting behavior.
In the early 1990s, anesthesiology departments were
concerned about the effects of managed care and also
expected a more-than- adequate supply of anesthesiologists.
Instead of recruiting early to ensure adequate staffing
for the future, groups delayed recruitment until the
need was pressing. A change in behavior by employers
combined with anxiety by graduating residents almost
certainly explains the extraordinary transition from
“surplus” to deficit.
High rates of attrition disrupt the lives of the affected
residents and inconvenience the residency programs.
The very high rates of attrition experienced by both
AMGs and IMGs for the 1994 and 1995 CA-1 groups occurred
well before the greatest shortage of applicants. AMGs
and IMGs appear to have been similarly affected, and
the residents made the decision to leave in comparable
proportions. The likely motive was the growing anxiety
in residency programs about the availability of employment
opportunities.
In the late 1990s, however, when the shortage of applicants
was greatest, the attrition rate for IMGs was greater
than for AMGs. This implies a difference between the
groups due either to a change in selection made by the
candidates, the programs or both. There was certainly
a striking increase in the number of IMGs seeking anesthesiology
residency positions, and at the same time, residency
programs were faced with a relative shortage of AMGs.
Presumably, either the choices made by IMGs or the selection
of IMGs by the programs caused the higher incidence
of attrition. The data alone do not indicate which is
the explanation.
Entry into anesthesiology happens primarily via training
in U.S. residency programs with, as of now, negligible
recruitment of trained graduates from other countries.
In the early 1990s, concern about over-recruitment resulted
in the requirement that anesthesiology programs obtain
approval before increasing their size. Prior to that
time, increasing availability of applicants was usually
followed by an even greater increase in the capacity
of residencies. In addition, recruitment was supplemented
with fully trained IMGs. Current growth in residency
size appears to have stalled well short of the previous
maximum due, presumably, to the controls. There is still
a shortage. The anticipated output is unlikely to overcome
it.
One possible strategy is a prompt increase in the size
of the CA-1 group. However, any such increase now involves
requests, committee activity and approvals before recruitment.
The effect of such delays will worsen the problem and
necessitate a larger correction with the risk of an
oversupply some years later. If this occurs, the marketplace
will, once again, intervene and control recruitment.
A second strategy would be to examine the training programs
in other countries and accept graduates from countries
whose training programs have been approved. This strategy
might result in a more rapid solution to the current
deficit. Radiology is an example of a specialty that
has implemented this policy. It warrants consideration.
Hindsight invites us to examine the role played by our
current controls on residency size and overseas recruitment.
Reducing or eliminating such controls would increase
the rapidity of response. A happy side effect would
be eliminating the dilemma of whether our duty is to
provide sufficient anesthesiologists for communities
throughout the country or to ensure employment opportunities
for anesthesiologists. Speed, convenience, simplicity
and elimination of this awkward ethical question are
powerful arguments in favor of facilitating the role
played by the marketplace.
Acknowledgments
As usual, it is a pleasure to thank Francis P. Hughes,
Ph.D., of the American Board of Anesthesiology and Steven
Horton of the Bookstore and Resource Center of the American
Association of Nurse Anesthetists. Their efficient help
makes it possible to produce this report promptly.
Web Site
To see previous articles, additional data about the
workforce and the results of the residency matching
program, readers are invited to visit: <www.grogono.com/nrmp>. 
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Alan
W. Grogono, M.D., now retired, is former Chair
and Meryl and Sam Israel Professor, Department
of Anesthesiology, Tulane University School of
Medicine, New Orleans, Louisiana. |
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