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Workforce projections for subspecialists in obstetrics and gynecology
Graduate Education Workforce projections for subspecialists in obstetrics and gynecology Warren H. Pearse, MD, Norman F. Gant, MD, and Allison P. Hagner Objective: To project the future supply of practicing subspecialists in obstetrics and gynecology based on the most recent numbers of physicians entering fellowships. Methods: A discrete actuarial model was developed, and supply projections were examined using 1999 subspecialty fellowship numbers from the American Board of Obstetrics and Gynecology. Results: The numbers of obstetrician-gynecologists entering subspecialty fellowships in maternal-fetal medicine (MFM) and reproductive endocrinology–infertility (REI) declined sharply between 1994 and 1999. There was a slow increase in gynecologic oncology (GO) fellows. Projections show that the numbers of practicing MFM and GO subspecialists will double by 2020, but they will be serving a 20% larger female population in the United States. Numbers of practicing REI subspecialists will increase slowly. Conclusion: The number of fellows in GO continues to enlarge progressively though slightly, whereas those in MFM and REI have fallen sharply in recent years. Among four possible factors affecting growth or decline, the ones that seem most important are existing career opportunities for both generalist and subspecialist obstetrician-gynecologists and the length of subspecialty education. (Obstet Gynecol 2000;95:312– 4. © 2000 by The American College of Obstetricians and Gynecologists.)
In 1998, the overall future physician workforce was described as a part of the provider workforce studies initiated by the Liaison Committee for Obstetrics and Gynecology and supported by ACOG.1 That study showed a plateau in the ratio of obstetrician-gynecologists per US females beginning in about 2005, with a slowly falling ratio thereafter until at least 2020. From the Jacobs Institute of Women’s Health, Washington, DC; the American Board of Obstetrics and Gynecology, Dallas, Texas; and the Department of Preventive Medicine and Biometrics, Uniformed Services University of the Health Sciences, Bethesda, Maryland. Financial support was provided by The American College of Obstetricians and Gynecologists.
312 0029-7844/00/$20.00 PII S0029-7844(99)00545-1
In 1994, a total of 158 (13%) of approximately 1200 fourth-year residents entered subspecialty fellowships. It appeared that the number of practicing subspecialists could be increasing rapidly in proportion to general obstetrician-gynecologists. The Liaison Committee advised that subspecialty data be examined for total numbers and future trends. The following four factors have been suggested that might affect the numbers of physicians choosing (or not choosing) subspecialty fellowships in obstetrics and gynecology: 1) adequate and attractive practice opportunities for residents completing the core 4 years of graduate medical education in obstetrics and gynecology; 2) the increase in the length of fellowship education from 2 to 3 years, including a minimum of 12–18 months of basic research; 3) an inability of program directors to obtain funding for support of graduate medical education beyond 4 years of basic residency; and 4) career opportunities for subspecialists after certification. There are many opinions but few facts to support or deny these four assertions. A recent survey of graduate medical education in New York state provided evidence that practice opportunities for new specialists in obstetrics and gynecology are adequate.2 Residents who completed training in obstetrics and gynecology assessed the regional job market in their specialty at ⫹0.69 on a Likert scale ranging from ⫹2 (many jobs) to ⫺2 (no jobs). Obstetrics and gynecology ranked ninth among 28 reporting specialties, exceeded by emergency medicine, family practice, and psychiatry, but well ahead of internal medicine, pediatrics, and surgery. Residents’ assessment of the national job market was more positive across the board, with obstetrics and gynecology scoring ⫹1.39, ranking tenth. Other issues, particularly physician gender, are affecting practice opportunities for graduating residents.3 However, most reports are more anecdotal than substantive. Residents themselves describe the length of subspecialty education as a negative factor given the need to support a family and begin a practice career. These concerns seem real, but cannot be quantified or assigned solely to this factor. Funding of all graduate medical education, and in particular programs that extend beyond the requirements for basic certification, is a concern. However, in the obstetrics and gynecology fellowship matches of the National Resident Matching Program, the number of first-year gynecologic oncology (GO) fellows has increased from 31 to 39 in the past 5 years.4 In maternalfetal medicine (MFM), entering fellows have declined from 80 to 51, but 21 approved positions went unfilled through the 1999 match. (Most of these were ultimately filled outside the match.) In reproductive endocrinology–infertility (REI), entering fellows have declined from 47 to 24, but five approved positions were still unfilled Obstetrics & Gynecology
through the match. There does not seem to be a surfeit of applicants, and so far program directors appear able to obtain funding for the fellowship positions offered. For example, the required 12–18-month period of research might derive salary support from a research or training grant. The numbers of subspecialists practicing in obstetrics and gynecology are considerably fewer than in fields such as internal medicine, pediatrics, or surgery. Unfortunately, the data collected by the American Medical Association are based on physician self-reporting and cannot be relied upon for exact numbers with subspecialty certifications. With smaller numbers, attractive career options seem more likely to be available. For physicians interested in a career including research, the subspecialty track is an excellent base.
Methods Revised projections of subspecialists per female population (using US Census Bureau projections) were developed using a computer model, including a one-time adjustment for lengthening training from 2 to 3 years. The discrete actuarial model was based on American Medical Association 1997 Masterfile counts of subspecialists, Bureau of Health Professions separation rates for all US physicians, the American Board of Obstetrics and Gynecology examination statistics, and the ACOG resident statistics. Further details regarding the basic model have been published previously.1 Two changes were made to update the projections for events that took place in 1999. The changes in fellowship applicants seen in 1999 were incorporated into the model and were assumed to have plateaued. The onetime adjustment for increased duration of training was incorporated by delaying the addition of the first cohort to the subspecialty population. The first cohort, and those following, in the 3-year fellowship program stay in the general obstetrician-gynecologist population for an extra year and then are transferred to the appropriate subspecialty population in the model. These two changes brought the basic model up to date with current activity in the subspecialties.
Results Numbers of obstetrician-gynecologists who entered the subspecialties of MFM and REI declined sharply over the last 5 years, whereas the numbers who entered GO increased modestly. With these changes, the projected growth of practicing subspecialists diminished from previous projections. Actual numbers are reported in Table 1.5 The subspecialty of urogynecology–reconstructive pelvic surgery, in which programs rather than fellows are accredited, is still in the developmental phase. VOL. 95, NO. 2, FEBRUARY 2000
Table 1. Entering Fellows by Subspecialty and Year Year
GO
MFM
REI
1994 1997 1999
31 38 39
80 55 51
47 31 24
GO ⫽ gynecologic oncology; MFM ⫽ maternal-fetal medicine; REI ⫽ reproductive endocrinology–infertility.
Thirteen such programs were accredited for one fellow each year as of July 1, 1999. A total of 18 fellows are now in all years of these programs. The added qualification in critical care has involved only five individuals to date. No projections were made for these two areas. In the current three major subspecialty projections (Table 2), the numbers in GO will double by 2020, although total numbers nationwide will still be fewer than 1000. About half will be female by the same year as generalist obstetrician-gynecologists, 2014.1 Subspecialists in MFM will be the largest group, with 1300 by 2020; about half will be female by 2011. In REI, at current fellowship numbers, growth will be very slow to 700 by 2007, with essentially no growth thereafter. The majority of subspecialists in this field will continue to be male. Studies comparing practice productivity of male and female providers are in preparation. This issue will affect the volume of services provided based on gender distribution.
Discussion Numbers of subspecialists are increasing and so are the numbers of women in the population. The 1997 US population included approximately 137 million women; the US Census Bureau projects 165 million by 2020, or a 20% increase. In the first report from these provider workforce studies, we projected that with a 10% decrease in first-year residents (approximately what has been experienced over the past 3 years), the number of obstetrician-gynecologists per 10,000 women would reach a peak of 2.7 in 2005 and then begin a slow decline to 2.63 by 2020. We also projected that half of all obstetriciangynecologists would be female by the year 2014.1 It is clear that relatively minor changes in the numbers of subspecialty fellows in any field, if sustained, could materially affect these projections. Nonetheless, the present projections can help guide potential applicants,
Table 2. Projected Numbers of Subspecialists (Percentage Female) Subspecialty GO MFM REI
1999
2005
2010
2020
460 (22) 648 (33) 605 (29)
621 (37) 877 (43) 681 (33)
746 (45) 1051 (49) 729 (38)
955 (57) 1317 (58) 760 (48)
Abbreviations as in Table 1.
Pearse et al
Subspecialist Workforce
313
program directors, and national subspecialty organizations. The Liaison Committee for Obstetrics and Gynecology and its component national organizations can also assess future programmatic needs and specialty developments. Should input data change, the algorithms to update any of these projections are available.
References 1. Jacoby I, Meyer G, Haffner W, Cheng E, Potter A, Pearse W. Modeling the future workforce of obstetrics and gynecology. Obstet Gynecol 1998;92:450 – 6. 2. Center for Health Workforce Studies. Residency training and outcomes by specialty in 1998. Volume 2. Albany, New York: State University of New York at Albany, 1999:28 –33. 3. Weiss B. Women will soon dominate OB-GYN. Medical Economics (Obstetrics-Gynecology Edition). 1999;18:58 –76. 4. Obstetrics and gynecology fellowship—1999 appointment booklet. Washington, DC: National Resident Matching Program, 1998.
Professionalism in obstetricsgynecology residency education: The view of program directors Melissa H. Fries Objective: To define the qualities of professionalism emphasized in obstetrics-gynecology residencies and identify existing means of evaluating them. Methods: A survey, designed to assess the importance of professionalism in residency programs and what means are utilized for its development, was sent to all 270 obstetricsgynecology residency program directors in the United States. Results: Two hundred thirteen surveys were returned (79%). Ninety-seven percent of all respondents indicated that they thought the development of professionalism was necessary for training obstetrics-gynecology residents, and 84.3% thought that formal educational training time should be devoted to this development. Over 85% endorsed faculty examples and mentoring as their methods of teaching professionalism. Respondents ranked honesty; accountability to patients, colleagues, and society; respect for patients; integrity; and excellence as the most important qualities of professionalism. Almost 79% believed those qualities were as important and as necessary as qualities of skill and knowledge in residency training. Almost 80% of respondents thought that the establishment of formal professionFrom the Keesler Medical Center, Keesler Air Force Base, Mississippi. The opinions and assertions contained herein are the private views of the author(s) and are not to be construed as the official policy or position of the US Government, the Department of Defense, or the Department of the Air Force.
314 0029-7844/00/$20.00 PII S0029-7844(99)00499-8
5. The American Board of Obstetrics and Gynecology, Inc. Approved fellowships. Am J Obstet Gynecol 1998;179:31A–5A.
Address reprint requests to:
Warren H. Pearse, MD Jacobs Institute of Women’s Health 409 12th Street, SW Washington, DC 20024 E-mail: [email protected]
Received March 10, 1999. Received in revised form August 12, 1999. Accepted August 19, 1999. Copyright © 2000 by The American College of Obstetricians and Gynecologists. Published by Elsevier Science Inc.
alism guidelines would be valuable in their training programs. Conclusion: A critical quality in resident education is professionalism, which receives emphasis in training programs largely through faculty example and mentoring. The variability inherent in such methods might be reduced by residencywide guidelines for uniform application of standards and to avoid arbitrariness in enforcement. (Obstet Gynecol 2000;95:314 – 6.)
Frequently, residency program directors are required to address concerns about residents that are unrelated to diagnostic skills or surgical abilities. Issues such as dishonesty in recording clinical findings, lack of respect to patients and staff, or frank negligence of patient care cause great anxiety about the nature of resident professionalism and occupy hours of discussion in faculty meetings about their management and need for improvement. Much of this discussion stems from a frustration that professionalism is not inherent in residents—“isn’t that supposed to be taught in medical schools?”—and a sense of hopelessness about teaching it—“if a resident isn’t honest by this time of his life, we certainly can’t make him honest.” Program directors face a dilemma when problem residents do not believe they can be held accountable for deficiency in professional qualities when “they were never explained” to them and “faculty members behave like that all the time.” Because professional qualities are often considered intrinsic in students seeking to become doctors, little attention in residency programs might be placed on determining if they are present, although those behaviors are vital for future interactions with patients, peers, committees, and hospitals. This research effort was Obstetrics & Gynecology
In 1998, the overall future physician workforce was described as a part of the provider workforce studies initiated by the Liaison Committee for Obstetrics and Gynecology and supported by ACOG.1 That study showed a plateau in the ratio of obstetrician-gynecologists per US females beginning in about 2005, with a slowly falling ratio thereafter until at least 2020. From the Jacobs Institute of Women’s Health, Washington, DC; the American Board of Obstetrics and Gynecology, Dallas, Texas; and the Department of Preventive Medicine and Biometrics, Uniformed Services University of the Health Sciences, Bethesda, Maryland. Financial support was provided by The American College of Obstetricians and Gynecologists.
312 0029-7844/00/$20.00 PII S0029-7844(99)00545-1
In 1994, a total of 158 (13%) of approximately 1200 fourth-year residents entered subspecialty fellowships. It appeared that the number of practicing subspecialists could be increasing rapidly in proportion to general obstetrician-gynecologists. The Liaison Committee advised that subspecialty data be examined for total numbers and future trends. The following four factors have been suggested that might affect the numbers of physicians choosing (or not choosing) subspecialty fellowships in obstetrics and gynecology: 1) adequate and attractive practice opportunities for residents completing the core 4 years of graduate medical education in obstetrics and gynecology; 2) the increase in the length of fellowship education from 2 to 3 years, including a minimum of 12–18 months of basic research; 3) an inability of program directors to obtain funding for support of graduate medical education beyond 4 years of basic residency; and 4) career opportunities for subspecialists after certification. There are many opinions but few facts to support or deny these four assertions. A recent survey of graduate medical education in New York state provided evidence that practice opportunities for new specialists in obstetrics and gynecology are adequate.2 Residents who completed training in obstetrics and gynecology assessed the regional job market in their specialty at ⫹0.69 on a Likert scale ranging from ⫹2 (many jobs) to ⫺2 (no jobs). Obstetrics and gynecology ranked ninth among 28 reporting specialties, exceeded by emergency medicine, family practice, and psychiatry, but well ahead of internal medicine, pediatrics, and surgery. Residents’ assessment of the national job market was more positive across the board, with obstetrics and gynecology scoring ⫹1.39, ranking tenth. Other issues, particularly physician gender, are affecting practice opportunities for graduating residents.3 However, most reports are more anecdotal than substantive. Residents themselves describe the length of subspecialty education as a negative factor given the need to support a family and begin a practice career. These concerns seem real, but cannot be quantified or assigned solely to this factor. Funding of all graduate medical education, and in particular programs that extend beyond the requirements for basic certification, is a concern. However, in the obstetrics and gynecology fellowship matches of the National Resident Matching Program, the number of first-year gynecologic oncology (GO) fellows has increased from 31 to 39 in the past 5 years.4 In maternalfetal medicine (MFM), entering fellows have declined from 80 to 51, but 21 approved positions went unfilled through the 1999 match. (Most of these were ultimately filled outside the match.) In reproductive endocrinology–infertility (REI), entering fellows have declined from 47 to 24, but five approved positions were still unfilled Obstetrics & Gynecology
through the match. There does not seem to be a surfeit of applicants, and so far program directors appear able to obtain funding for the fellowship positions offered. For example, the required 12–18-month period of research might derive salary support from a research or training grant. The numbers of subspecialists practicing in obstetrics and gynecology are considerably fewer than in fields such as internal medicine, pediatrics, or surgery. Unfortunately, the data collected by the American Medical Association are based on physician self-reporting and cannot be relied upon for exact numbers with subspecialty certifications. With smaller numbers, attractive career options seem more likely to be available. For physicians interested in a career including research, the subspecialty track is an excellent base.
Methods Revised projections of subspecialists per female population (using US Census Bureau projections) were developed using a computer model, including a one-time adjustment for lengthening training from 2 to 3 years. The discrete actuarial model was based on American Medical Association 1997 Masterfile counts of subspecialists, Bureau of Health Professions separation rates for all US physicians, the American Board of Obstetrics and Gynecology examination statistics, and the ACOG resident statistics. Further details regarding the basic model have been published previously.1 Two changes were made to update the projections for events that took place in 1999. The changes in fellowship applicants seen in 1999 were incorporated into the model and were assumed to have plateaued. The onetime adjustment for increased duration of training was incorporated by delaying the addition of the first cohort to the subspecialty population. The first cohort, and those following, in the 3-year fellowship program stay in the general obstetrician-gynecologist population for an extra year and then are transferred to the appropriate subspecialty population in the model. These two changes brought the basic model up to date with current activity in the subspecialties.
Results Numbers of obstetrician-gynecologists who entered the subspecialties of MFM and REI declined sharply over the last 5 years, whereas the numbers who entered GO increased modestly. With these changes, the projected growth of practicing subspecialists diminished from previous projections. Actual numbers are reported in Table 1.5 The subspecialty of urogynecology–reconstructive pelvic surgery, in which programs rather than fellows are accredited, is still in the developmental phase. VOL. 95, NO. 2, FEBRUARY 2000
Table 1. Entering Fellows by Subspecialty and Year Year
GO
MFM
REI
1994 1997 1999
31 38 39
80 55 51
47 31 24
GO ⫽ gynecologic oncology; MFM ⫽ maternal-fetal medicine; REI ⫽ reproductive endocrinology–infertility.
Thirteen such programs were accredited for one fellow each year as of July 1, 1999. A total of 18 fellows are now in all years of these programs. The added qualification in critical care has involved only five individuals to date. No projections were made for these two areas. In the current three major subspecialty projections (Table 2), the numbers in GO will double by 2020, although total numbers nationwide will still be fewer than 1000. About half will be female by the same year as generalist obstetrician-gynecologists, 2014.1 Subspecialists in MFM will be the largest group, with 1300 by 2020; about half will be female by 2011. In REI, at current fellowship numbers, growth will be very slow to 700 by 2007, with essentially no growth thereafter. The majority of subspecialists in this field will continue to be male. Studies comparing practice productivity of male and female providers are in preparation. This issue will affect the volume of services provided based on gender distribution.
Discussion Numbers of subspecialists are increasing and so are the numbers of women in the population. The 1997 US population included approximately 137 million women; the US Census Bureau projects 165 million by 2020, or a 20% increase. In the first report from these provider workforce studies, we projected that with a 10% decrease in first-year residents (approximately what has been experienced over the past 3 years), the number of obstetrician-gynecologists per 10,000 women would reach a peak of 2.7 in 2005 and then begin a slow decline to 2.63 by 2020. We also projected that half of all obstetriciangynecologists would be female by the year 2014.1 It is clear that relatively minor changes in the numbers of subspecialty fellows in any field, if sustained, could materially affect these projections. Nonetheless, the present projections can help guide potential applicants,
Table 2. Projected Numbers of Subspecialists (Percentage Female) Subspecialty GO MFM REI
1999
2005
2010
2020
460 (22) 648 (33) 605 (29)
621 (37) 877 (43) 681 (33)
746 (45) 1051 (49) 729 (38)
955 (57) 1317 (58) 760 (48)
Abbreviations as in Table 1.
Pearse et al
Subspecialist Workforce
313
program directors, and national subspecialty organizations. The Liaison Committee for Obstetrics and Gynecology and its component national organizations can also assess future programmatic needs and specialty developments. Should input data change, the algorithms to update any of these projections are available.
References 1. Jacoby I, Meyer G, Haffner W, Cheng E, Potter A, Pearse W. Modeling the future workforce of obstetrics and gynecology. Obstet Gynecol 1998;92:450 – 6. 2. Center for Health Workforce Studies. Residency training and outcomes by specialty in 1998. Volume 2. Albany, New York: State University of New York at Albany, 1999:28 –33. 3. Weiss B. Women will soon dominate OB-GYN. Medical Economics (Obstetrics-Gynecology Edition). 1999;18:58 –76. 4. Obstetrics and gynecology fellowship—1999 appointment booklet. Washington, DC: National Resident Matching Program, 1998.
Professionalism in obstetricsgynecology residency education: The view of program directors Melissa H. Fries Objective: To define the qualities of professionalism emphasized in obstetrics-gynecology residencies and identify existing means of evaluating them. Methods: A survey, designed to assess the importance of professionalism in residency programs and what means are utilized for its development, was sent to all 270 obstetricsgynecology residency program directors in the United States. Results: Two hundred thirteen surveys were returned (79%). Ninety-seven percent of all respondents indicated that they thought the development of professionalism was necessary for training obstetrics-gynecology residents, and 84.3% thought that formal educational training time should be devoted to this development. Over 85% endorsed faculty examples and mentoring as their methods of teaching professionalism. Respondents ranked honesty; accountability to patients, colleagues, and society; respect for patients; integrity; and excellence as the most important qualities of professionalism. Almost 79% believed those qualities were as important and as necessary as qualities of skill and knowledge in residency training. Almost 80% of respondents thought that the establishment of formal professionFrom the Keesler Medical Center, Keesler Air Force Base, Mississippi. The opinions and assertions contained herein are the private views of the author(s) and are not to be construed as the official policy or position of the US Government, the Department of Defense, or the Department of the Air Force.
314 0029-7844/00/$20.00 PII S0029-7844(99)00499-8
5. The American Board of Obstetrics and Gynecology, Inc. Approved fellowships. Am J Obstet Gynecol 1998;179:31A–5A.
Address reprint requests to:
Warren H. Pearse, MD Jacobs Institute of Women’s Health 409 12th Street, SW Washington, DC 20024 E-mail: [email protected]
Received March 10, 1999. Received in revised form August 12, 1999. Accepted August 19, 1999. Copyright © 2000 by The American College of Obstetricians and Gynecologists. Published by Elsevier Science Inc.
alism guidelines would be valuable in their training programs. Conclusion: A critical quality in resident education is professionalism, which receives emphasis in training programs largely through faculty example and mentoring. The variability inherent in such methods might be reduced by residencywide guidelines for uniform application of standards and to avoid arbitrariness in enforcement. (Obstet Gynecol 2000;95:314 – 6.)
Frequently, residency program directors are required to address concerns about residents that are unrelated to diagnostic skills or surgical abilities. Issues such as dishonesty in recording clinical findings, lack of respect to patients and staff, or frank negligence of patient care cause great anxiety about the nature of resident professionalism and occupy hours of discussion in faculty meetings about their management and need for improvement. Much of this discussion stems from a frustration that professionalism is not inherent in residents—“isn’t that supposed to be taught in medical schools?”—and a sense of hopelessness about teaching it—“if a resident isn’t honest by this time of his life, we certainly can’t make him honest.” Program directors face a dilemma when problem residents do not believe they can be held accountable for deficiency in professional qualities when “they were never explained” to them and “faculty members behave like that all the time.” Because professional qualities are often considered intrinsic in students seeking to become doctors, little attention in residency programs might be placed on determining if they are present, although those behaviors are vital for future interactions with patients, peers, committees, and hospitals. This research effort was Obstetrics & Gynecology