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November 2003
Volume 67 |
Number 11 |
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| Resident
Numbers and Total Graduating From Residencies and Nurse
Anesthesia Schools in 2003: Continuing Shortages Expected
Alan
W. Grogono, M.D. |
This is the ninth fall article employing recruitment
data provided by the American Board of Anesthesiology
(ABA) and the third to include data from the American
Association of Nurse Anesthetists (AANA). Continuing
availability of excellent recruits entering residency
programs has yet to result in an adequate supply of
graduates to fill the available employment opportunities.
Indeed various factors discussed below are predicted
to exacerbate and prolong the shortage of anesthesiologists.
Anesthesiology Residents in Training [Table
1 and Figure 1]
The number of residents in the critical CA-1 year increased
but, once again, only modestly (from 1,471 to 1,496),
a 1.7-percent increase. The number approximates levels
experienced in the late 1980s and is still 21 percent
smaller than the peak of 1,904 in 1992. In the years
2000 to 2002, the total in the PGY-1 group rose from
446 to 638. This year the number fell back to 510.
Anesthesiology Residents Graduating [Table 1
and Figure 1]
The numbers recorded as having graduated in the previous
three years were 934, 1,133 and 1,286. The number graduating
this year is 1,333, another 3.7-percent increase. This
is still 26 percent below the maximum of 1,814 graduating
in 1996. It is still 5 percent below the average graduating
(1,403) since the introduction of the three-year clinical
residency 16 years ago; and it is even slightly below
the average (1,343) for the 19 years for which we have
complete data. The groups available to graduate in the
next three years contain, with no further attrition,
1,294, 1,473 and 1,496.
Table 1 (click
to enlarge) |
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The numbers graduating
and in each year of anesthesiology residencies
1985-2003. |
Figure 1
(click to enlarge) |
|
Graph showing the numbers graduating
(Grad) and the composition of all four years
(PGY-1, CA-1, CA-2, CA-3) of anesthesiology
residencies 1985-2002. |
Number of Nurse Anesthetists Graduating and Being Certified
[Table 2 and Figure 2]
This year shows a further increase. The number of nurse
anesthetists graduating has risen to 1,333 and is projected
to exceed 1,534 in 2003.1
The number being certified is probably the best index
of the number available to enter the workforce, and
it rose to 1,235 this year, which is 14 percent higher
than the previous peak of 1,082 in 1995. Projections
for the next three years indicate more dramatic increases;
even allowing for the percentage typically not working,
the graduation rate should more than offset the retirement
rate.
Table
2 |
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Nurse anesthetists graduating
(Grad) and being certified (Cert) during
the years 1989 to 2002 with conservative
projections for 2003 – 2005 based
on numbers in training. |
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Figure 2
(click to enlarge) |
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Nurse anesthetists graduating (Grad)
and being certified (Cert) during the years
1989-2002 with conservative projections for
2003-2005 based on numbers in training. |
Residency Composition [Tables 1 and 3 and Figures
1 and 3]
The number of international medical graduates (IMGs)
in anesthesiology residencies has declined to 23 percent
with even fewer (16 percent) in the CA-1 (entry-level)
year and 15 percent in the PGY-1 year. The smallest
percentage of IMGs in the CA-1 year (about 9 percent)
occurred in the late 1980s and the highest (60 percent)
in 1999.
Table 3 (click
to enlarge) |
| |
The number of American
medical graduates (AMG) and international medical
graduates (IMG) in anesthesiology residency
programs 1960-2003. |
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
1960-2003. |
Attrition From Residencies [Table 1 and Figure
4]
The principal attrition occurs during the first two
clinical anesthesiology residency years (from start
of CA-1 to start of CA-3), not during the final year
(from start of CA-3 to graduation). Attrition during
the first two years had been declining since the high
levels experienced in the late 1990s. Attrition, however,
has increased this year: the 2001 CA-1 group that comprised
1,466 residents shrunk to 1,294 when they became the
2003 CA-3 group. This represents a loss of 172 (12 percent)
and affected both American medical graduates (11 percent)
and IMGs (14 percent).
Table
4 |
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Percentage of nurse anesthetists
by age groups in 2003. |
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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. |
Gender
The percentage of women entering medical schools is
approaching, or may have exceeded, 50 percent. Overall
40 percent of residencies and fellowships are filled
by women.2 For the last
four years, data have been collected by ABA about the
number of females in anesthesiology residencies. Schubert
et al. projected a 1-percent increase in the percentage
of female anesthesiologists working and pointed out
that this may impact the availability of physicians
because females tend to work proportionately less during
child-rearing years. The percentage in the CA-1 year,
however, has remained close to 27 percent for four years.
It does not appear to be changing, and it is important
to remember that any impact associated with child-rearing
might be offset later due to men’s shorter life
expectancy. There is some evidence to support this.
Statistics from various countries suggest that between
the age of 35 and 65, male mortality exceeds female
mortality by about 8 in 1,000. In addition the overall
percentage in the United States who are not limited
in their ability to work3
shows little difference between men (91.2 percent) and
women (90.9 percent). These numbers may or may not represent
U.S. anesthesiologists.
In practice the effects of gender are paradoxical. Although
there may be little overall impact nationally, there
may well be a marked difference for an anesthesiology
group. When a female takes time off for childbirth,
her colleagues usually cover her work while she is away.
When a colleague dies, he or she can be replaced first
with a locum and then with a permanent replacement.
Extra work may not be needed, and the recruit might
cost less! Additional data about the impact of gender
are needed.
Future Physician Workforce
This year the average age at which anesthesiologists
graduated from residency programs was 35.2 years. This
age should be taken into consideration when predicting
workforce availability in the future. Schubert et al.4
assumed that currently about 600 anesthesiologists would
be retiring each year. This estimate appears rather
low. Thirty years ago, we were training close to 1,000
and in addition were recruiting trained anesthesiologists
from other countries. Such recruitment levels imply
retirement rates around 1,000, which would tend to increase
any predicted physician shortfall.
For 19 years, we have graduated an average of 1,343
residents per year, an average that will be changed
little by the next two years’ cohorts. Indeed
despite recent increases, we have yet even to attain
this low average. In other words, the average is still
falling. By contrast the population we serve is increasing.5
During the period for which Schubert et al. had data,
the population grew annually by an average of 0.93 percent,
and the number of anesthesiologists grew by 1.4 percent,
which approaches the lower end of their projected annual
growth in workload of 1.5 percent and 2 percent. The
data is plotted on the same graph [Figure 6]. The swings
in recruitment have had surprisingly little effect on
the total workforce. Utilizing the total number of anesthesiologists
in conjunction with recruitment data also allows the
attrition rate to be calculated [Table 5]. This attrition
inevitably includes deaths and career changes as well
as retirement, but for most years, this calculated number
can be used as a surrogate for retirement rates. On
this basis, the brief downturn in the rate of retirement
(1999-2000) appears likely to be a response to the shortage
of graduates and certainly occurred well before the
plunge in the stock market.
Table
5 |
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The
attrition rate for anesthesiologists 1995-2002
calculated from total number of anesthesiologists
and graduation data. |
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Figure 5
(click to enlarge) |
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Percentage of nurse anesthetists by age groups in 2003. |
Figure 6
(click to enlarge) |
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U.S. population in millions
compared to the number of
anesthesiologists 1994-2002. |
Future Nurse Anesthetist Workforce
This year’s data for nurse anesthetists [Table
4 and Figure 5] is based on a survey in which age data
was provided by 58 percent of the 26,456 active nurse
anesthetists. If this data is representative, very nearly
half (49.3 percent) of the nurse anesthetists are now
50 or older, and 5,529 nurse anesthetists would be in
the age group 50-54 years. Because 20 percent or more
of nurse anesthetists in each age group are not active
and the percentage of nurse anesthetists working declines
rapidly after age 54, increased rates of retirement
seem inevitable. The rapid rise in the rates of graduation
and certification, however, may compensate for this
so that overall the number of nurse anesthetists working
may change little or eventually even rise.
Discussion
The 2001 paper by Schubert et al. selected 1994 to represent
a base year when there was “…neither a shortage
nor an oversupply…” and “…the
overwhelming majority of graduating residents found
positions.” It was undeniably a year when the
combination of anxiety and deliberate delayed recruitment
by practice groups and academia exacerbated any real
shortage of employment opportunities. Not just in that
year, however, but also in the succeeding few years,
the majority continued to find jobs without delay. Indeed
jobs actually became plentiful before a significant
decline in graduation rate reached the marketplace.
In retrospect the “oversupply” must be attributed
to anxiety and delayed recruitment rather than to any
genuine surplus of graduates.
When considering the influences on the availability
of practitioners and employment opportunities, recruitment
into anesthesiology is merely one of many factors, e.g.,
population aging and growth, changes in the incidence
of surgery, gender distribution, child care, sick leave,
mortality and age at retirement. Schubert et al. provided
a comprehensive review. In 2001 they projected that
about 642 IMGs would graduate in 2003, declining to
500 annually by 2006. Their 2003 update reduced the
projected number of IMGs slightly. Data presented here
indicate projecting fewer than 250. Because they assumed
that a quarter of the IMGS will not be available to
work in the United States, this revision increases the
number expected to enter the workforce by at least 62
per year.
They also projected that the total number graduating
per year from 2002 onward would be: 1,082, 1,234, 1,320,
1,409, 1,556, 1,616, 1,679 and 1,745. Actual graduation
rates for the first two years (1,286, 1,333) exceeded
their estimates. Even without further attrition, however,
the size of two current groups (CA-1 at 1,496 and CA-3
at 1,294) are already smaller than the graduation rates
they projected for these cohorts. Their estimates of
future graduation rates can only be achieved by a rapid
expansion of the size of the CA-1 group. There is, as
yet, no evidence of any such rapid expansion.
In addition, because this year’s attrition rate
(start of CA-1 to start of CA-3) has increased to 12
percent, it might be necessary to revise their estimate
that the attrition rates “…will decline
to their historical 3-percent rate over the next five
years.” Overall when the effects of high attrition,
limited recruitment and corrected retirement rates are
all considered, it seems likely that the number available
in the workforce in the next five to seven years will
fall short of their estimates by several hundred.
Conclusion
Recent data allow some of projections by Schubert et
al. to be updated. These updates do nothing to weaken
their overall recommendations. If anything they provide
grounds for reiterating and strengthening them. Residency
size is increasing more slowly than they estimated,
attrition rates from residency programs remain higher
than normal and retirement rates probably exceed their
estimates. The current shortage of anesthesiologists,
therefore, appears likely to exceed their estimates,
and their projected balance between supply and demand
within five to 10 years may be unattainable.
By contrast the numbers of nurse anesthetists projected
to graduate in the next few years represent more than
a three-fold increase from 1989. Concerns of a nurse
anesthetist shortage may eventually become concerns
of a surplus.
The profession should marshal its forces to increase
the number of residency positions and then promote recruitment
into these extra positions. We must also stop worrying
about oversupply. If ever again we are lucky enough
to be threatened by an oversupply, we should hope that
we have learned our lesson: be grateful, keep the information
shielded from deans and newspapers and discuss the “oversupply”
quietly, hoping that our medical students do not over-react.
Acknowledgments
As usual it is a pleasure to thank Francis P. Hughes,
Ph.D., of the American Board of Anesthesiology, 4101
Lake Boone Trail, Suite 510, Raleigh, NC 27607-7506;
and Steven Horton of the Bookstore and Resource Center
of the American Association of Nurse Anesthetists, 222
S. Prospect Ave., Park Ridge, IL 60068-4001. Their efficient
help makes it possible to produce this report promptly.
Web Site
To see previous articles, additional data about anesthesiology
workforce and the results of the residency matching
program, readers are invited to visit <www.grogono.com/nrmp>.
 |
| References: |
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| 1. Schubert A, Eckhout G, Tremper K. An updated
view of the national anesthesia personnel shortage.
Anesth Analg. 2003. 96:207-214. |
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| 2. Physician Characteristics and Distribution
in the United States, 2003-2004 edition. Table
1.11 and 1.12. American Medical Association. |
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| 3. Summary Health Statistics for the U.S. Population:
National Health Interview Survey, 1999. Series
10, Number 211. Table 7. <www.cdc.gov/nchs/data/series/sr_10/sr10_211.pdf>. |
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| 4. Schubert A, Eckhout G, Cooperider T, Kuhel
A. Evidence of a current and lasting national
anesthesia personnel shortfall: Scope and implications.
Mayo Clin Proc. 2001. 76:995-1010. |
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| 5. <www.census.gov/population/projections/nation/summary/np-t1.txt>. |
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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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