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November 2004
Volume 68 |
Number 11 |
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| Resident
Numbers and Graduation Rates From Residencies and Nurse
Anesthetist Schools in 2004
Alan
W. Grogono, M.D. |
his article marks 10 years of annual reports about trends
in recruitment into anesthesiology. Although enthusiasm
for anesthesiology reappeared among U.S. medical students
some years ago, and the numbers of residents graduating
does finally reflect this, anesthesiologists remain
in short supply.
Change in Data Collection
The data about residencies is derived from data compiled
annually at the end of August by the American Board
of Anesthesiology (ABA). This year ABA has slightly
altered the criteria it employs to determine a resident’s
postgraduate year (PGY) status. In the past, the PGY
status was based solely on the number of months of training
completed. This year, and going forward, PGY status
is based on the number of months that ABA has credited
for the training that has been received. A resident
who has not obtained credit will remain listed in the
same PGY year. The effect of this change is that, relative
to previous years, the size of a given cohort may appear
to be slightly larger. In this article, the more familiar
terminology is employed where, for example, clinical
anesthesiology year 1 (CA-1) is used instead of PGY-2.
Anesthesiology Residents in Training [Table 1 and Figure
1]
This year the number of residents in the critical CA-1
year has decreased by 3.8 percent from 1,496 last year
to 1,439 this year. This fall makes it the smallest
CA-1 group since 1999. This year the number of residents
in the PGY-1 year fell by 15.5 percent from 510 to 431.
This is the smallest PGY1 group since 1995. The change
in data collection, however, means that the residents
who are not promoted will enlarge the group that follows.
When this is taken into consideration, the decline in
recruitment may be slightly greater than the numbers
indicate.
Table 1 (click
to enlarge) |
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The numbers graduating
and in each year of anesthesiology residencies
1985-04. |
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 and CA-3) of anesthesiology residencies,
1985-04. |
Anesthesiology Residents Graduating [Table 1 and Figure
1]
The numbers recorded as having graduated in the previous
three years were 1,133 (in 2003), 1,286 (in 2002) and
1,333 (in 2001). The number graduating this year is
1,393, a 4.5-percent increase but still 23 percent below
the maximum of 1,814 graduating in 1995. It is 2 percent
above the average graduating (1,368) since the introduction
of the three-year clinical residency 17 years ago, and
it is 4 percent above the average (1,345) for the 20
years for which we have complete data. The numbers of
residents available to graduate in the next three years,
without attrition, are 1,511, 1,608 and 1,439.
Residency Composition [Tables 1 and 2 and Figures 1
and 2]
The number of international medical graduates (IMGs)
in anesthesiology residencies has declined to 19 percent
with even fewer (14 percent) in the CA-1 year and 16
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 (58 percent) in 1999.
Table 2 |
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| The number of American medical graduates
(AMG) and international medical graduates (IMG)
in anesthesiology residency programs, 1960-04. |
Figure 2 |
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| Graph showing the total number
of American medical graduates (AMG) and international
medical graduates (IMG) in anesthesiology residencies,
1960-04. |
Table 3 |
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| Attrition from residencies.
For each group, the number in the CA-1 group in
the start year is compared to the number graduating
three years later |
Attrition From Residencies [Table 3 and Figure 3 and
4]
Until this year, information about attrition during
the residency was based on the time spent in the residency:
Each cohort advanced year by year with minor perturbations
caused by ill health, childbirth, relocation, etc. As
a result, a decline in the size of a cohort between
CA-1 and CA-3 could be regarded as representing the
number of people departing the specialty either voluntarily
or involuntarily. Because the data now represent the
amount of time credited, the data is now presented in
a different format. The CA-1 group in a given year,
e.g., 2001, is now compared to the size of the graduating
group, e.g., in 2004.
Figure 3 |
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| Attrition from residencies.
Each year plots the number in the CA-1 year for
that group (CA-1) and the number graduating three
years later (Grad). |
Figure 4 |
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| Attrition from residencies.
Each year plots the decrease in the size of the
CA-1 cohort at the time of graduation for CA-1
groups starting in 1986 to 2001. |
Figure 3 shows a pair of graphs for each group. For
a given year, e.g., 1995, one point shows the size of
the CA-1 group for that year, and another, just below
it, shows the size of that cohort graduating in 1998.
In the early years, the number graduating three years
later closely parallels the number in the CA-1 group.
In the mid 1990s, the graph shows the separation of
the lines due to attrition that occurred then. It is
more vividly illustrated in Figure 4, which graphs the
actual fall in numbers for each cohort, e.g., the data
point for “All” in 1994 is minus 386. That
indicates 386 fewer residents graduated in 1997 than
started in the corresponding 1994 CA-1 cohort.
The graph also illustrates the problems that arise when
judging attrition this way for any single year. The
1998 and 1999 cohorts apparently swelled to graduate
more residents than had been recruited three years before.
This is almost certainly explained by delayed graduation
of some residents in the 1996 and 1997 cohorts. These
earlier groups appeared to suffer unexpectedly great
“attrition” because a significant number
of residents did not graduate on time. When these residents
did graduate, their presence swelled the two succeeding
years by more than the rate of attrition.
Number of Nurse Anesthetists Graduating and Being Certified
[Table 4 and Figure 5]
This year shows another increase in the number graduating
(1,474), only slightly smaller than the 1,500 predicted
a year ago. The number certified this year (1,454) is
probably the best index of the number available to enter
the workforce and is 18 percent higher than last year,
which was already the highest number ever. Based on
the numbers now in training, even larger numbers (1,679
are 1,870) are expected to graduate in the next two
years. At the time of this writing, the enrollment data
for 2006 is incomplete and unreported.
Table 4 |
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| Nurse anesthetists graduating
(Grad) and being certified (Cert) during the years
1989-03 with conservative projections for 2003-06
based on numbers in training. |
Figure 5 |
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| Nurse anesthetists graduating
(Grad) and being certified (Cert) during the years
1989-02 with projections for 2004-05 based on
numbers in training. |
Nurse Anesthetist Workforce [Table 5 and Figure 6]
The number of nurse anesthetists by age has been updated
and now covers data for two consecutive years. The percentage
of nurse anesthetists is plotted in five-year groups.
The large percentage in the middle years is aging, and
this year, the size of the older groups has increased
slightly. The effects of the recent increases in recruitment,
however, also are evident; the size of the three youngest
cohorts also has increased this year.
Table 5 |
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| Percentage of nurse anesthetists
in cohorts of five years in 2003-04. |
Figure 6 |
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| Percentage of nurse anesthetists
in cohorts of five years in 2003-04. |
Gender [Table 6]
ABA has now collected data about the gender distribution
in anesthesiology residencies for five consecutive years.
For the first four years, the percentage of women being
trained hovered around 27 percent with no evident trend.
This year, however, the percentage of women in the PGY-1
year has risen to 33 percent and in the CA-1 year to
32 percent.
Table 6 |
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| The percentage of women in anesthesiology
residency programs by year, 2000-04. |
Discussion: The decline in the size
of the CA-1 group follows seven consecutive years of
growth. The number of AMGs fell by 57 and the number
of IMGs fell by 31. There has been no recent drop in
the number of residency programs, nor in the number
of positions being offered via the National Resident
Matching Program (NRMP). In fact, this spring, there
was an additional program in the NRMP, and 25 more positions
were available. There was, though, a decline in the
number matching from 1,211 to 1,200 and a slightly greater
decline in the number of U.S. graduates matching from
927 to 897. Although this decline in recruitment of
U.S. graduates via the NRMP parallels the decline in
the numbers present in this CA-1 year, it cannot explain
it; this is because the group recruited via the NRMP
this year will not be entering the CA-1 group until
2005.
Attrition has been discussed annually in these reports.
This year’s presentation is probably a more useful
reflection of the entire process, even though delayed
graduation for some residents means they are counted
in a later year. As time passes and the dramatic changes
of the mid 1990s recede, the overall attrition rate
has fallen to just under 5 percent, which approaches
the low levels enjoyed 15 years ago.
The striking growth in the number of nurse anesthetists
in training shows no significant change from the trend
reported last year. The number of nurse anesthetists
graduating this year, 1,474, exceeds the number of residents
graduating (1,393), and in the next few years, seems
likely to exceed even the 1995 peak of 1,814.
The number of women entering anesthesiology has finally
shown a small increase, though the number is still far
short of the percentage of women now graduating from
medical schools. The number of women graduating has
been around 50 percent for some years. A disproportionate
increase might reflect some underlying perception of
the specialty. Time will show whether this increase
is transient, and investigation may reveal whether it
merely reflects altering demographics or a modified
perception of anesthesiology as a career choice.
Conclusion
The changes in residency numbers this year are not great.
The apparent decline in recruitment occurs, however,
when we are still experiencing significant shortages.
Moreover, as discussed last year, this is against a
background of a growing U.S. population. Any decline
when we have both shortages and a growing population
must be a cause for concern as well as an impetus for
maintaining recruitment. With this in mind, the increasing
number of women selecting anesthesiology is to be welcomed.
Desirably, this could be attributed to some change in
our image; more practically it is to be welcomed because
we appear to be recruiting fewer men.
The ongoing increase in the numbers of nurse anesthetists
graduating is, by contrast, more dramatic. In the 1990s,
the decline in their numbers entering nurse anesthetist
training occurred at the same time as, and for the same
reasons as, the decline in numbers entering anesthesiology
residencies. The current increase should, therefore,
probably be attributed to optimism about career opportunities
as a nurse anesthetist.
Acknowledgments: As usual it is a pleasure
to thank ABA Executive Vice-President Francis P. Hughes,
Ph.D., 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 NRMP, 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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