Douglas R. Bacon, M.D., Editor

National Resident Matching Program — Are We Asking the Right Questions for the Future of Anesthesiology?

It began innocently enough. A group of anesthesiologists from the department were gathered in the physicians’ lounge having coffee. Those assembled were typical of the staff, diverse in background and nationality; they had learned medicine all over the globe and completed their postgraduate training in the United States. All were excellent physicians and were among the best our specialty has to offer.

Thus their combined ire was hard to fathom. It was exactly one year ago, and the May 2003 issue of the ASA NEWSLETTER was under discussion. Comments varied from someone making the reference “American Society Against Foreigners in Anesthesiology” to one anesthesiologist asking why certain authors hated all those practicing in the United States who were not native-born. The obvious anger in the group was disconcerting. Why had the May issue sparked such heated debate?

The article in question was the excellent piece by Alan W. Grogono, M.D., on anesthesiology recruitment and the resident match. Within the piece, Dr. Grogono reported the breakdown of new residents entering anesthesiology, with an emphasis on training. In commenting on the results of the match, Dr. Grogono repeated the mantra that more U.S. graduates in anesthesiology programs meant that anesthesiology was stronger and in better health than when residency slots were filled with those who did not graduate from a U.S. medical school. For decades this has been the mantra of residency program directors. Concerns were raised, at least at the departmental level, when a residency review board evaluation was due, and there were few U.S. graduates in the program.

As the discussion in the lounge suggested, however, this may be an outmoded and capricious division. What do we mean by the term “international medical graduate” (IMG), and why are we so concerned about their number in the residency training programs in the United States? Is this a remnant of our traditional isolationist and possibly xenophobic American culture? Who are we saying is “bad” from outside the country? Is anesthesiology “weaker” than other medical specialties because of the presence of IMGs? The data is even broken down by U.S. citizens who trained outside the United States (IMG/U.S.). Does this presume that the IMG/U.S. is still somehow an inferior physician because he/she could not or did not attend a medical school in the United States? After all, was not everyone equal to a U.S. graduate after completing residency training?

The history of this workforce assessment goes back at least to the late 1950s and early 1960s. With the World War II cadre of physicians alarmed by the drop-off in medical students applying for anesthesiology residency positions, ASA commissioned a group to study the problem. Led by John E. Steinhaus, M.D., the group examined the reasons for the decline, including the fact that many of the residencies did not offer a sound educational experience in anesthesiology. One outgrowth of this study was the ASA Preceptorship, which paid medical students to study with a preceptor in a hospital during the summer for either six or eight weeks. For many it was a lasting introduction to their life’s work that never would have been considered without the program’s existence!

Yet it was this workforce survey and the resulting discussion that brought forth the idea that the health of the specialty can be judged by the number of U.S. graduates entering anesthesiology. What is really at the heart of the matter, though, is the quality of the people who are being trained in anesthesiology. Does it really matter if the candidate matriculated and graduated from McMaster University School of Medicine in Canada, St. Bartholomew’s in London, the University of Eppendorf in Germany, the University of Sydney in Australia, the University of Manila in the Philippines or the Railway Medical College in China so long as the physician is a knowledgeable, caring individual who can communicate effectively with his/her colleagues and patients and is willing to learn our specialty? Why are we concerned?

There is a growing shortage of physician specialists in the United States. The American College of Cardiology is grappling with a shortage in the number of cardiologists trained each year, and by numbers, the deficit is similar to anesthesiology’s. Other specialties are having similar problems. The number of medical students in the United States is not growing, nor are new schools of medicine opening. The number of residency slots is fairly securely fixed by the federal government, and new positions require funding outside of the traditional residency funding mechanisms. The proposed switch of anesthesiology from a three-year to a four-year curriculum to include the postgraduate year one (PGY-1) has some programs concerned that the overall number of residents in training in anesthesiology will drop as lines assigned to PGY-2, PGY-3 and PGY-4 years are reassigned to accommodate this new mandate.

Reading this year’s iteration of Dr. Grogono’s breakdown and interpretation of the data (page 18) might cause some to be alarmed. There has been a drop-off, however slight, in the number of American medical students seeking residency in anesthesiology. If the number of graduating medical students is fixed, and somehow the number of residency slots remains the same or increases in response to the demand for anesthesiologists, from where will the physicians come to fill the gap?

The obvious answer is from outside the United States! What we need to ensure is that the physicians selected to train within the United States are qualified, caring doctors. We need to be able to reassure our patients and the general public that the anesthesiologist taking care of you today is better qualified than the one who cared for you yesterday, with the hope that the anesthesiologist of tomorrow will be even better.

Are the concerns expressed in the lounge a year ago valid? I would hope not. Perhaps it is time to stop thinking about the location of training and look for assessment tools that tell us about the person entering our specialty. Only then will we be able to reassure the public that, indeed, the very best physicians are anesthesiologists regardless of where in the world they received their initial training.

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