|
Original Scientific Article
The Longitudinal Study of Surgical Residents, 1994 to 1996
Francis Kwakwa, MA, Olga Jonasson, MD, FACS
Background: The American College of Surgeons (ACS)
has conducted a detailed annual survey of residents enrolled
in surgical graduate medical education (GME) programs since 1982
and has regularly published the resulting data as the Longitudinal
Study of Surgical Residents. This report documents surgical resident
enrollment and graduation for the academic years 1994-95 and
1995-96.
Study Design: The Medical Education Research and Information
Database of the American Medical Association was supplemented
by the existing ACS Resident Masterfile and by personal
contact with program directors and their staffs to verify accuracy
and completeness of reporting. Each resident was tracked individually
through surgical GME.
Results: The total number of surgical residents graduating
from surgical GME in 1995 and 1996 has not changed since 1982.
Most graduates of surgical residency programs are in obstetrics
and gynecology, followed by general surgery; demographic analysis
of the graduating cohort shows that most are Caucasian male graduates
of US or Canadian medical schools, and that their age at graduation
is 33 to 35 years. International medical graduates (IMG) make
up 8.9% of entering surgical residents and 6% of graduates. Osteopathic
medical school graduates account for 1.2% to 1.3% of entering
and graduating surgical residents.
Women represent 27% of entering and 23% to 24% of graduates
of surgical GME. The largest number and proportion of women in
surgical GME are enrolled in obstetrics and gynecology residency
programs, where they make up the majority of entering and graduating
classes. When all other surgical residency program enrollments
are considered together, women make up 17% and 16% of entering
residents in 1994 and 1995, respectively, and 13% and 14% of
graduates in those years.
Conclusions: Surgical GME enrollment and graduation
is stable. Few women and ethnic minorities are enrolled in surgical
residency programs. IMG enrollment and graduation in surgical
GME is low. (J Am Coll Surg 1999;188:575-585. © 1999 by
the American College of Surgeons)
References
The American College of Surgeons (ACS)
has conducted a detailed annual survey of surgical residents
in all specialties, beginning with the 1982-1983 academic year.1 Data have been reported
in independent publications and, most recently, in a scientific
report published in the Journal of the American College
of Surgeons in 1996.2 The data have been
used to show trends in the total enrollment and graduates of
the 12 surgical specialties during this 15-year time frame, and
have been important information for health care planners addressing
workforce issues.
Since 1994 the ACS has cooperated with the Medical Education
Research and Information Database of the American Medical Association
to obtain information on each surgical resident enrolled in graduate
medical education (GME). Before this collaboration, the ACS conducted
its independent survey of program directors, specialty societies,
and certifying boards, achieving between 97.8% and 100% reporting
frequency. The reporting frequency since 1994 has been 100%.
This report presents the data of surgical residents from the
years 1994-95 and 1995-96, and documents trends in total numbers
and demographics of surgical residents in the 8 core surgical
specialties (specialties offering primary certification by an
American Board of Medical Specialty member board: general surgery,
neurological surgery, obstetrics and gynecology, ophthalmology,
orthopaedic surgery, otolaryngology, plastic surgery, urology),
and in the advanced general surgery-based specialties of colon
and rectal surgery, pediatric surgery, surgical critical care,
thoracic surgery, and vascular surgery.
METHODS
Data sources
The American Medical Association (AMA)
Medical Education Research and Information Database was the main
source of data for this study.3 This database
is fed and updated by the AMA's annual Graduate Medical Education
survey sent to all Accreditation Council for Graduate Medical
Education (ACGME) accredited residency programs for information
on each program and each resident. Since 1994, the ACS has collaborated
with the AMA on the resident-specific portion of the GME survey.
The AMA agreed to provide the ACS with resident data in return
for ACS efforts to increase the response rate of all surgical
programs. By telephone, mail-in, or fax-in surveys, AMA resident
files for the 1994-95 and 1995-96 academic years were updated
by the ACS to include data from all programs that did not respond
to the original AMA surveys.
The postgraduate year (PGY) status of a resident in the AMA
files was frequently verified with information from the ACS Resident
Masterfile, which contains tracking data about individual residents
from 1982 to the present. Created from a combination of annual
surveys of ACGME-accredited surgical programs and data obtained
from specialty boards, the Surgical Resident Masterfile represents
the most comprehensive and complete source of surgical resident
data in the United States.
Selecting surgical residents beginning a residency program
For 1994-95 and 1995-96, surgical residents were considered
beginners in a residency program in general surgery, orthopaedic
surgery, otolaryngology, urology, and neurological surgery if
they were not identified in any surgical program in preceding
years. Residents who were identified in a specialty program after
one or more years in general surgery were arbitrarily assigned
to the specialty. For example, a resident was considered to have
begun a residency program in neurological surgery in the 1994-95
academic year if he or she was a resident in general surgery
in 1994-95 and continued in neurological surgery in 1995-96.
Because of this redistribution of designated preliminary residents
into their respective postpreliminary specialties, the remaining
residents in general surgery are either categorical general surgery
residents or undesignated preliminary residents.
Residents in plastic surgery and ophthalmology have a variety
of prerequisite GME options, and there is no GME prerequisite
for residents entering obstetrics and gynecology. Hence, residents
entering programs in these specialties were considered beginners
in a particular academic year if they were not identified in
any program in those specialties in the preceding years.
Selecting the 1995 and 1996 graduates
We included all residents graduating within a calendar year
in the cohort of graduates of that year.
Analysis
Corrected data in the AMA 1994-95 and 1995-96 resident files
were analyzed to derive counts of 1995 and 1996 graduates in
the 8 core and 5 advanced surgical residencies. Counts of beginning
and graduating residents in the core and advanced surgical residencies
were also obtained. Data were analyzed by gender, ethnic background,
citizenship status, age, and the type of medical school attended.
Chi-square tests of independence were used for comparing proportions;
t-tests were used for continuous measures. The Statistical
Package for the Social Sciences (SPSS) software (SPSS Inc, Chicago,
IL) was used for all computations.
RESULTS
Graduates of 1994-1995 and 1995-1996 residency programs
in surgery
In 1995, 4,228 residents graduated from the core surgical
specialties; in 1996 this number was 4,154. An additional 359
and 369 residents completed residency programs in the advanced
general surgery-based specialties in 1995 and 1996, respectively,
for a total of 4,587 graduates in 1995 and 4,523 in 1996 (Table
1). These numbers are essentially unchanged from those reported
in prior years, varying from the 15 -year average by less than
1% each year (Fig. 1). In 1995 and 1996 the largest number of
graduates of core surgical programs, 1,188 (28%) and 1,194 (29%),
respectively, were in the specialty of obstetrics and gynecology;
1,011 (24%) and 998 (24%) of the graduates were in general surgery.
Although it appears that there has been an increase in graduates
in thoracic surgery (138 in 1995 and 148 in 1996), this represents
residents in programs admitting 2 residents in one year and 1
the next. With the exception of neurological surgery, which had
131 graduates in 1995 and 143 in 1996, core and advanced programs
graduates remained the same or decreased slightly (Table 2).
Table 1. Graduates of Surgical Residencies, 1995 and 1996
|
|
|
1995 Graduates |
1996 Graduates |
|
|
|
|
|
Residencies |
n |
% |
n |
% |
|
|
Core Surgical* |
|
|
|
|
|
General surgery |
1,011 |
23.9 |
998 |
24.0 |
Obstetrics and
gynecology |
1,188 |
28.1 |
1,194 |
28.7 |
|
Orthopaedic surgery† |
635 |
15.0 |
607 |
14.6 |
|
Ophthalmology† |
506 |
12.0 |
484 |
11.6 |
|
Otolaryngology† |
282 |
6.7 |
273 |
6.6 |
|
Urology‡ |
256 |
6.1 |
249 |
6.0 |
|
Plastic surgery§ |
219 |
5.2 |
206 |
5.0 |
|
Neurological surgery† |
131 |
3.1 |
143 |
3.4 |
|
Subtotal |
4,228 |
100 |
4,154 |
100 |
|
Advanced Surgical|| |
|
|
|
|
|
Thoracic surgery |
138 |
38.3 |
148 |
40.1 |
|
Vascular surgery |
79 |
21.9 |
76 |
20.6 |
|
Colon and rectal surgery |
54 |
15.0 |
54 |
14.6 |
|
Surgical critical care¶ |
62 |
17.2 |
65 |
17.6 |
|
Pediatric surgery |
26 |
7.2 |
26 |
7.0 |
|
Subtotal |
359 |
100 |
369 |
100 |
|
Total |
4,587 |
|
4,523 |
|
|
* Core Surgical Specialties offer primary
certification by an American Board of Medical Specialties board.
† One prerequisite year of graduate medical education is
required before entering specialty.
‡ Two years of prerequisite general surgery residency is
required before entering urology.
§ A minimum of three prerequisite years of general surgery
or completion of an otolaryngology residency is required before
entering plastic surgery.
|| Successful completion of a general surgery residency is required
before entering these surgical specialties.
¶ Three or more years of
general surgery residency are required before entering a residency
program in surgical critical care; completion of a general surgery
residency is required to be eligible for certification in surgical
critical care.
From the American College of Surgeons Surgical
Resident Masterfile and the Medical Education Research and Information
Database, 1996, American Medical Association, Chicago, IL, with
permission.
Figure 1. Graduates from core surgical residency programs,
1987 to 1996. The total number of graduates each year varies
from the 15-year average by less than 1%. Core surgical residency
programs offering primary certification by an American Board
of Medical Specialties member board include general surgery,
neurological surgery, obstetrics and gynecology, ophthalmology,
orthopaedic surgery, otolaryngology, plastic surgery, and urology.
(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.)
Table 2. Graduates of Surgical Residencies, 1983 to 1996
|
|
Specialty |
1983 |
1985 |
1987 |
1989 |
1991 |
1993 |
1994 |
1995 |
1996 |
|
|
General surgery |
996 |
1,024 |
1,023 |
994 |
995 |
979 |
1,001 |
1,011 |
998 |
|
Obstetrics and gynecology |
NA |
NA |
1,175 |
1,104 |
1,133 |
1,175 |
1,177 |
1,188 |
1,194 |
|
Orthopaedic surgery |
613 |
639 |
620 |
598 |
653 |
630 |
655 |
635 |
607 |
|
Ophthalmology |
NA |
NA |
512 |
504 |
461 |
465 |
507 |
507 |
484 |
|
Otolaryngology |
252 |
223 |
257 |
259 |
268 |
271 |
273 |
282 |
273 |
|
Urology |
264 |
260 |
254 |
237 |
254 |
247 |
252 |
256 |
249 |
|
Neurological surgery |
90 |
127 |
118 |
129 |
110 |
127 |
126 |
131 |
143 |
|
Plastic surgery |
186 |
205 |
187 |
191 |
204 |
212 |
209 |
219 |
206 |
|
Thoracic surgery |
139 |
141 |
135 |
132 |
133 |
144 |
147 |
138 |
148 |
|
Colon and rectal surgery |
50 |
46 |
48 |
49 |
58 |
53 |
54 |
54 |
54 |
|
Vascular surgery |
0* |
10 |
61 |
69 |
74 |
72 |
78 |
79 |
76 |
|
Pediatric surgery |
17 |
17 |
17 |
17 |
22 |
21 |
21 |
26 |
26 |
|
Total |
2,607 |
2,692 |
4,407 |
4,283 |
4,365 |
4,396 |
4,500 |
4,587 |
4,521 |
|
* Vascular surgery first accredited in
1984.
NA, not available until 1987.
From the American College of Surgeons Surgical
Resident Masterfile and the Medical Education Research and Information
Database, 1996, American Medical Association, Chicago, IL, with
permission.
By the beginning of the 1997-98 academic year, 446 (44%) of
the 1995 general surgery graduates have continued in advanced
general surgery-based accredited GME (Table 3). In addition,
graduates entered formal specialty fellowship programs in transplantation
and surgical oncology that are not accredited through the ACGME
system, leaving fewer than half of the graduates of general surgery
residency programs who enter broad-based general surgery practice.
Although numbers of 1996 general surgery graduates continuing
in advanced programs appear lower, we have found that some residents
enter advanced programs one to two years after graduation from
the core general surgery program; we anticipate that the number
of 1996 general surgery graduates who eventually enter accredited
advanced surgical residency programs will be the same as in prior
years. One hundred thirty of the 1995 general surgery graduates
entered plastic surgery in 1995, 1996, or 1997; the number of
1996 general surgery graduates entering plastic surgery in 1996
and 1997 was 87, although followup of this group has been insufficient
to detect some of the graduates who begin plastic surgery programs
after a hiatus of one to two years.
Table 3. General Surgery Graduates Continuing in Accredited
General Surgery Based Residency Programs
|
|
Specialty |
1995 general surgery graduates* |
1996 general surgery graduates† |
|
|
Colon and rectal surgery |
50 |
38 |
|
Plastic surgery |
130 |
87 |
|
Surgical critical care |
39 |
47 |
|
Pediatric surgery |
24 |
21 |
|
Vascular surgery |
74 |
74 |
|
Thoracic surgery |
129 |
116 |
|
Total |
446 |
383 |
|
* 1995 general surgery graduates identified in
1995/96, 1996/97, or 1997/98 advanced residency programs.
† 1996 general surgery graduates identified in 1996/97 or
1997/98 advanced residency programs.
From the American College of Surgeons Surgical
Resident Masterfile and the Medical Education Research and Information
Database, 1996, American Medical Association, Chicago, IL, with
permission.
Graduates of core surgical residency programs were 33 years
old on average; graduates of the advanced general surgery-based
programs were, as expected, at least 2 years older (35 to 36
years old) (Table 4). Women were slightly, though significantly,
younger than men. IMG graduates were older than US and Canadian
graduates when graduating either from core programs (36.5 years
versus 33 years) or from advanced programs (38 years versus 35
years). Osteopathic graduates of core programs were, on average,
1.8 years older than allopathic graduates from US and Canadian
medical schools.
Table 4. Average Age of 1995 and 1996 Graduates of Surgical
Residencies*
|
|
|
1995 graduates† |
1996 graduates† |
|
|
|
|
|
Specialties |
Age (y) |
n |
Age (y) |
n |
|
|
Core Surgical‡ |
|
|
|
|
|
All core specialties |
33.0 + 3.1 |
4,062 |
33.1 + 3.7 |
4,127 |
|
Men |
33.1 + 3.0 |
3,087 |
33.2 + 3.4 |
3,056 |
|
Women |
32.7 + 3.5 || |
975 |
32.8 + 4.3 || |
1.071 |
|
Graduates of US/Canadian allopathic
medical schools |
32.8 + 2.9 |
3,806 |
32.9 + 3.4 |
3,808 |
Graduates of international
medical schools |
36.5 + 4.4 |
205 |
36.7 + 4.7 |
261 |
Graduates of osteopathic
medical schools |
34.1 + 3.2 |
51 |
34.8 + 4.3 |
58 |
|
Advanced surgical§ |
|
|
|
|
|
All advanced specialties |
35.4 + 3.2 |
306 |
36.0 + 5.8 |
358 |
|
Men |
35.4 + 3.2 |
277 |
36.0 + 5.9 |
329 |
|
Women |
34.8 + 3.1 |
29 |
35.3 + 4.5 |
29 |
Graduates of US/Canadian
allopathic medical schools |
35.1 + 2.8 |
272 |
35.7 + 5.9 |
325 |
Graduates of international
medical schools |
37.7 + 4.7 |
34 |
38.2 + 3.7 |
32 |
Graduates of osteopathic
medical schools |
0 |
0 |
33.0 + 4.3 |
1 |
|
*Ages are reported as mean plus or minus one
standard deviation.
† Data were missing for 4.8% of the 1995 graduates and 0.8%
of the 1996 graduates.
‡ Core surgical specialties offer primary certification
by an American Board of Medical Specialties board.
§ Successful completion of a general surgery residency is
required before entering these surgical specialties.
|| Women are significantly younger than men at graduation from
a surgical residency (p <.005).
From the American College Surgeons Surgical
Resident Masterfile and the Medical Education Research and Information
Database, 1996, American Medical Association, Chicago, IL, with
permission.
Residents entering surgical GME in 1994 and 1995
Twice as many residents enter general surgery as graduate,
reflecting the preliminary category of residency appointments
in general surgery (Table 5). "Designated" preliminary
residents (those fulfilling a prerequisite general surgery experience
for 1 or 2 years before beginning specialty GME) have been identified
by longitudinal followup of the 1994 and 1995 entry cohort, and
have been arbitrarily assigned to their specialty at the postgraduate
year (PGY) 1 level for the purposes of this study. The excess
of general surgery residents, therefore, represent the "undesignated"
preliminary cohort. In contrast, the number entering the other
core surgical specialties closely resembles the number of graduates,
as is typical of categorical resident positions. Approximately
5,000 individuals enter a surgical residency program each year.
Table 5. Specialty of Surgical Residents Beginning a Residency
Program, 1994-1995 and 1995-1996
|
|
|
Residents |
|
|
|
|
|
1994-1995 |
1995-1996 |
|
|
|
|
|
Core surgical residencies* |
n |
% |
n |
% |
|
|
General surgery |
2,094 |
40.5 |
1,927 |
38.3 |
|
Obstetrics and gynecology |
1,220 |
23.6 |
1,211 |
24.1 |
|
Orthopaedic surgery† |
553 |
10.7 |
583 |
11.6 |
|
Ophthalmology† |
475 |
9.2 |
467 |
9.3 |
|
Otolaryngology† |
213 |
4.1 |
261 |
5.2 |
|
Urology‡ |
261 |
5.0 |
223 |
4.4 |
|
Plastic surgery§ |
207 |
4.0 |
211 |
4.2 |
|
Neurological surgery† |
152 |
2.9 |
144 |
2.9 |
|
Total |
5,175 |
100 |
5,027 |
100 |
|
* Core Surgical Specialties offer primary
certification by an American Board of Medical Specialties board.
† One prerequisite year of graduate medical education is
required before entering specialty.
‡ Two years of prerequisite general surgery residency is
required before entering urology.
§ A minimum of 3 prerequisite years of general surgery or
completion of an otolaryngology residency is required before
entering plastic surgery. In 1995, the Accreditation Council
for Graduate Medical Education (ACGME) began accrediting programs
to offer a 5- to 6-year program in plastic surgery, called the
Integrated Educational Model.
From the American College of Surgeons Surgical
Resident Masterfile and the Medical Education Research and Information
Database, 1996, American Medical Association, Chicago, IL, with
permission.
Most who enter surgical residency programs are male (73.4%
in 1994 and 73.8% in 1995), Caucasian (67.5% in 1994 and 62.3%
in 1995), and graduates of US or Canadian allopathic medical
schools (89.4% in 1994 and 89.6% in 1995). Twenty-seven
percent are women, 16% are Asian, 5% are African American or
Native American, and approximately 4% are from Hispanic backgrounds
(Tables 6 and
7). Approximately 9% of entering residents are graduates
of international medical schools (IMG), and 1.2 to 1.3% are graduates
of US osteopathic medical schools. Graduates of surgical residency
programs are even more homogenous: 77% of graduates in 1995 and
75.6% in 1996 are male; 77.5% in 1995 and 78.2% in 1996 are Caucasian.
Only 6% of graduates in both 1995 and 1996
are IMGs and 1% are osteopathic graduates (Tables 8 and
9).
Table 6. Surgical Residents Beginning a Residency Program,
1994-1995 and 1995-1996: Gender, Ethnic Background, and Medical
School Attended
|
|
|
Residents |
|
|
|
|
|
1994-1995 |
1995-1996 |
|
|
|
|
|
Characteristic |
n |
% |
n |
% |
|
|
Gender |
|
|
|
|
|
Male |
4,069 |
73.4 |
3,982 |
73.8 |
|
Female |
1,472 |
26.6 |
1,415 |
26.2 |
|
Ethnic background |
|
|
|
|
|
Caucasian |
3,738 |
67.5 |
3,364 |
62.3 |
|
Asian* |
910 |
16.4 |
865 |
16.0 |
African-Ameican and
Native American |
301 |
5.4 |
305 |
5.7 |
|
Hispanic† |
218 |
3.9 |
226 |
4.2 |
|
Other/unknown |
374 |
6.7 |
637 |
11.8 |
|
Medical school attended |
|
|
|
|
|
US/Canadian allopathic |
4,955 |
89.4 |
4,837 |
89.6 |
|
US osteopathic |
69 |
1.2 |
70 |
1.3 |
|
International medical graduate |
492 |
8.9 |
481 |
8.9 |
|
Unknown medical school |
25 |
0.5 |
9 |
0.2 |
|
Total residents |
5,541 |
100 |
5,397 |
100 |
|
* Asian, Pacific Islander, Indian, Middle
Eastern (1995).
† Mexican American, Puerto Rican, or other Hispanic.
From the American College of Surgeons Surgical
Resident Masterfile and the Medical Education Research and Information
Database, 1996, American Medical Association, Chicago, IL, with
permission.
Table 8. 1995 and 1996 Graduates of Surgical Residencies:
Gender, Ethnic Background, and Medical School Attended
|
|
|
Graduates |
|
|
|
|
|
1995 |
1996 |
|
|
|
|
|
Characteristic |
n |
% |
n |
% |
|
|
Gender |
|
|
|
|
|
Male |
3,530 |
77.0 |
3,418 |
75.6 |
|
Female |
1,057 |
23.0 |
1,105 |
24.4 |
|
Ethnic background |
|
|
|
|
|
Caucasian |
3,553 |
77.5 |
3,537 |
78.2 |
|
Asian* |
497 |
10.4 |
432 |
9.6 |
African-Ameican and
Native American |
218 |
4.8 |
213 |
4.7 |
|
Hispanic† |
193 |
4.2 |
202 |
4.5 |
|
Other/unknown |
144 |
3.1 |
139 |
3.1 |
|
Medical school attended |
|
|
|
|
|
US/Canadian allopathic |
4,276 |
93.2 |
4,165 |
92.1 |
|
US osteopathic |
55 |
1.2 |
60 |
1.3 |
|
International medical graduate |
253 |
5.5 |
298 |
6.6 |
|
Unknown medical school |
3 |
0.1 |
0 |
|
|
Total graduates |
4,587 |
100 |
4,523 |
100 |
|
* Asian, Pacific Islander, Indian, Middle Eastern
(1995).
† Mexican American, Puerto Rican, or other Hispanic.
From the American College of Surgeons Surgical
Resident Masterfile and the Medical Education Research and Information
Database, 1996, American Medical Association, Chicago, IL, with
permission.
The predominant ethnic minority group represented in surgical
GME is Asian (10% of graduates). African-American and Hispanic
individuals make up 5% and 4% of graduates from surgical residency
programs, respectively, in both the 1995 and 1996 graduating
classes (Tables 7 and 9 and Fig. 2).
Figure 2. Ethnic backgrounds of graduates of all surgical
residency programs in 1996. (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.)
Women make up 27% of entering residents and 23% to 24% of
graduates of surgical GME programs (Tables 6 and 8). Most women
are registered in obstetrics and gynecology residency programs
where they represent the majority of the entering class (59%
in 1994 and 60% in 1995) and of graduates (53% in 1995 and 55%
in 1996). In all other surgical specialties combined, women made
up 17% of the entering class in 1994 and 16% in 1995; in 1995,
13% of graduates from surgical specialties other than obstetrics
and gynecology were women and in 1996 this number was 14%. Women
represented 19% of entering general surgical residents in 1994
and 1995, and 15% and 16% of general surgery graduates in 1995
and 1996, respectively.
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.
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No competing interests declared.
Received December 2, 1998; Revised January 26, 1999; Accepted
February 15, 1999.
From the American College of Surgeons, Chicago, IL.
Correspondence address: Francis Kwakwa, American College of Surgeons,
633 N St Clair St, Chicago, IL 60611.
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