|
DISCUSSION
Strict adherence to finite resource
and quality based criteria4
for allocation of positions in surgical residency programs has
resulted in essentially no increase in the number of programs
or output of surgical specialists into the physician workforce
of the US during the past 15 years. Several
studies by individual surgical specialties5-7
have documented that the number of new graduates from residency
programs in the specialty approximates the number of surgeons
leaving practice through death and retirement. The
number of surgical specialists needed is more difficult
to determine, but is usually calculated based on the minimum
utilization of surgeons in the specialty by managed care organizations.8-12
These calculations have concluded that surgeons are in oversupply;
other, more comprehensive measures of
the specialist physician workforce have come to different conclusions.13-15
It is clear, however, from data presented
in the annual reports of the Longitudinal Study of Surgical Residents
that surgeons are not being produced at an increasing rate as
has occurred in a number of nonsurgical specialties and subspecialties.16-18
The trend toward further specialization after completion of
a general surgery residency continues. The number of general
surgery graduates who chose to enter plastic surgery dropped
from 130 for the 1995 graduates to 87 for the 1996 graduates.
While needing a longer period of observation to include those
who resume GME after a delay of 1 to 2 years, this may be a trend
that will require close observation. As plastic surgery programs
evolve to an integrated mode, wherein graduating medical students
match directly to plastic surgery as a PGY 1 or enter plastic
surgery after 3 or 4 years of general surgery residency rather
than the full 5 years, the long-established
pattern of becoming fully trained in general surgery before entering
plastic surgery may become a thing of the past.19
This would have important implications for general surgery programs,
which now expect that at least 10% of their graduates will never
practice general surgery but will enter plastic surgery. If the
same number of categorical general surgery residents are appointed,
100 to 130 new general surgeons will be added to the general
surgery workforce each year. Residency programs that are associated
with integrated plastic surgery programs or programs taking residents
into plastic surgery after 3 or 4 years should be aware of this
issue.
Graduates of core surgical specialties are, on average, 33
years old. Women are significantly younger than men at graduation,
averaging 32.7 to 32.8 years of age compared to 33.1 to 33.2
years for men. IMG graduates of core programs are substantially
older, averaging 36.5 to 36.7 years of age. Graduates of advanced
surgical programs are 2 to 3 years older and first enter the
workforce at 35 to 38 years of age. Compared
with the average age of 28 for new lawyers, for example, surgeons
have trained far longer than other professionals.20
This also has implications for the total years each surgeon is
expected to practice; with the average retirement age of surgeons
near 63 years, a surgeon will practice for approximately 25 to
30 years.
Having accounted for the "designated" preliminary
residents entering general surgery as a PGY 1 before beginning
specialty residency education, we found an excess of about 1,000
general surgery PGY 1 residents in 1994-95 and 1995-96. These
are "undesignated" preliminary residents who have no
guarantee of an advanced residency position in a surgical specialty.
In a separate study21
we have found that 19% of these individuals fail to continue
in any type of GME program. Their fate and their practice patterns
are not known but may be of concern if, in fact, they are practicing
medicine or surgery in the US with little graduate education.
Only half of the IMGs who begin a surgical residency program
will graduate. In 1994 and 1995, the entering cohort of IMGs
was approximately 500; only 250 to 300 IMGs graduated during
those years. We suspect that many IMGs who fail to complete surgical
GME may be in the undesignated preliminary general surgery resident
category (Fig. 3).
Figure 3. International medical graduates (IMG) entering
and graduating from surgical residency programs in 1996. PGY1,
postgraduate year 1. (From the American College of Surgeons Surgical
Resident Masterfile and the Medical Education Research and Information
Database, 1995-1996, American Medical Association, Chicago, IL,
with permission.)
These data demonstrate a lack of diversity,
gender or ethnic, in the entering or graduating surgical resident
complement.22
This should be of concern to the profession of surgery for 2
reasons. First, there is evidence that
the African-American, Native American, and Hispanic populations
in the US are better served by physicians who are aware of and
sensitive to cultural and language differences.23
Second, the profession of surgery has taken great pride in recruitment
of "the best and the brightest" graduates of US and
Canadian medical schools. As the proportion of women in medical
school graduating classes increases (from 38% in 1994 to more
than 40% in 1998), it will be
important to actively recruit from this large group of qualified
medical school graduates. There are further threats to the applicant
pool; aggressive recruitment of US medical school graduates into
primary care residency programs has been successful, and nearly
half of current US graduates now enter primary care residency
programs. In 1994, 5,826 US graduates entered primary care and
in 1998, 6,780 matched to internal medicine, pediatrics, and
family practice, a loss of nearly 1,000 US graduates from the
potential pool of surgical applicants during this 5-year period
(Fig. 4). If surgery fails to actively recruit from all US graduates,
the applicant pool will be diminished in both quantity and quality.
Figure 4. Trend in graduates of US medical schools
who match to a postgraduate year 1 (PGY 1) position in internal
medicine, pediatrics, and family practice through the National
Resident Matching Program from 1994-1996. (From the 1998 NRMP
Data Book, National Resident Matching Program, Washington, DC,
with permission.)
Although recruitment of the most highly qualified US and Canadian
medical school graduates into surgery has been a source of pride
to the profession for many years, steps should be taken now to
ensure that the entire qualified pool of applicants for surgery
is used and that successful recruitment continues in parallel
with the changing demographics of medical school enrollment and
the nation's population.
Introduction
| Methods
| Results
| Discussion | References
JACS
menu |
