Anesth Analg 2004;99:844-856
© 2004 International Anesthesia Research Society
doi: 10.1213/01.ANE.0000130258.38402.2E
ECONOMICS, EDUCATION, AND HEALTH SYSTEMS RESEARCH
The Effect of Lengthening Anesthesiology Residency on Subspecialty Education
Jeana E. Havidich, MD,
Gary R. Haynes, MD PhD, and
J. G. Reves, MD
The Medical University of South Carolina, Charleston, South Carolina
Address correspondence and reprint requests to Jeana Havidich, MD, Department of Anesthesiology and Perioperative Medicine, The Medical University of South Carolina, 171 Ashley Ave., Charleston, SC 29425. Address e-mail to havidicj{at}musc.edu
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Abstract
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In this study, we sought to determine the long-term effect of the additional year of anesthesia residency (postgraduate year [PGY]-4) instituted in 1989 by the American Board of Anesthesiology on the number of individuals who pursued 12-mo subspecialty anesthesia training. We tested the hypothesis that extending education by a year would decrease the number of anesthesia subspecialty trainees. Surveys were collected from approved anesthesia residency training programs in the United States from 1989 to 2001. The questionnaires determined the number of individuals pursuing subspecialty training during PGY-4 and PGY-5. The subspecialties included cardiac anesthesia, pediatric anesthesia, pain management, obstetrical anesthesia, neuroanesthesia, outpatient anesthesia, intensive care medicine, and research. The number of anesthesiology residents (PGY-5) pursuing 12-mo subspecialty training increased over this period. The specific subspecialty distribution of fellows changed, with the largest increase in number and percentage occurring in pain management. The largest declines occurred in critical care medicine and research. Our data do not indicate a decrease in the number of anesthesiology subspecialists. Factors other than the duration of training appear responsible for the selection of subspecialty education.
IMPLICATIONS: The purpose of this study was to determine the long-term effect of the additional year of anesthesia training instituted in 1989 by the American Board of Anesthesiology on the number of individuals enrolled in subspecialty training. Our data indicate that the number of fellows increased over 10 yr. We conclude that factors other than the duration of training influence the selection of subspecialty education.
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Introduction
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In 1985, the American Board of Anesthesiology (ABA) required an additional clinical anesthesia postgraduate year (PGY)-4 (CA-3) year for entry into the board-certification process. The addition occurred in the 1988–1989 academic year. The third year of anesthesia training was devoted to specialized training or an alternative pathway. This additional year provided resident trainees time for research or advanced clinical training in anesthesiology subspecialties. The ABA created three programs: the Advanced Clinical Track, the Clinical Scientists Track, and the Subspecialty Clinical Track. The ABA stated that this change was necessary for residents to obtain adequate knowledge, judgment, and skills to become competent anesthesiologists (1). The increase in anesthesia knowledge and complexity of clinical cases were the basis for the change.
Residency programs were faced with a sudden increase in the number of trainees, and program directors were forced to deal with a larger number of residents who would compete for a fixed number of subspecialty positions. New subspecialty curricula were needed to accommodate those individuals enrolled in 12-mo subspecialty training. There was speculation that residents would not pursue subspecialty fellowships because of the increase in program duration (2). This could result in an increase in the number of anesthesiology generalists rather than subspecialists or academicians. An initial analysis of the curriculum extension revealed that prolonging this resident training period decreased the number of individuals pursuing 12-mo subspecialty training (3). The purpose of this study was to determine the long-term effects of the additional year on advanced specialty training.
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Methods
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Annual surveys were sent to all approved anesthesiology residency programs during the academic years 1989–1990 to 2000–2001. These data were collected over the first 10 yr of the extended curriculum, and 1989–1990 was used as the index year. To maximize the response, follow-up surveys were sent to the academic centers that did not respond. The questionnaires were constructed to determine the number of individuals pursuing specialized anesthesiology training during the PGY-4 (CA-3) and PGY-5 (CA-4) years, the length of subspecialty training, and the specific subspecialty pursued. The individual’s reason for choosing a particular subspecialty was not included in this survey.
The duration of the subspecialty training was arbitrarily divided into 4 categories: 6 mo, >6 mo but <12 mo, 6 mo in 2 subspecialties, and 12 mo. Subjects who completed training in 2 6-mo subspecialties were counted twice and included in the 6-mo group.
The subspecialties identified were those recognized by the ABA: cardiac anesthesia, intensive care medicine, neuroanesthesia, obstetric anesthesia, outpatient anesthesia, pain management, pediatric anesthesia, and research. Individuals not categorized in the recognized subspecialties were designated as "other."
Analysis of the data was performed with standard statistical methods. The absolute numbers were obtained and the percentages of residents enrolled in subspecialty training were calculated.
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Results
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The percentage of programs responding ranged from 70% to 98% (Table 1). The total number of PGY-5 (CA-4) residents enrolled in 12-mo subspecialty training increased from 62 in 1989–1990 to 383 in 2000–2001 (Table 2). The largest number of PGY-5 (CA-4) residents occurred in 1997–1998, with 547 residents engaged in 12-mo subspecialty education. The number of PGY-5 (CA-4) residents enrolled in 12-mo subspecialty education decreased over the next 3 yr to 383 in the 2000–2001 academic year. The number of PGY-4 (CA-3) residents enrolled in 12-mo subspecialty training decreased from 115 in 1989–1990 to 37 in 2000–2001 (Table 3). The combined number of individuals (PGY-4 and PGY-5) enrolled in 12-mo subspecialty training increased from 177 to 420 over the decade. The greatest enrollment occurred during the 1997–1998 academic year, with 564 trainees (Fig. 1).
The percentage of PGY-5 (CA-4) physicians pursuing a 12-mo subspecialty fellowship increased from 59% in 1989–1990 to 73% in 2000–2001 (Table 4). The peak occurred during the 1997–1998 academic year, in which 90% of PGY-5 (CA-4) residents enrolled in 12-mo subspecialty education. This was followed by a decline in the percentage of individuals enrolled in subspecialty training, with a decrease in the percentage of PGY-5 (CA-4) residents pursuing 6-mo subspecialty education. In the 1989–1990 academic year, 13% of individuals were enrolled in 6-month subspecialty education, compared with 2% in 2000–2001.
The choice in subspecialty fluctuated over the decade (Fig. 2). In 1989–1990, the most popular subspecialty was research (n = 19), followed by intensive care medicine (n = 15) and cardiac anesthesia (n = 12). In 2000–2001, the subspecialty with the most fellows was pain management (n = 171), followed by cardiac anesthesia (n = 69) and pediatric anesthesia (n = 64). The percentage of PGY-5 (CA-4) fellows enrolled in pain management programs increased from 7% in the 1989–1990 academic year to 45% in 2000–2001. The percentage of PGY-5 (CA-4) trainees in cardiac, obstetric, and outpatient anesthesia and those categorized as "other" remained relatively constant during this period. The number of trainees enrolled in pediatric fellowships fluctuated during the decade but demonstrated a slight overall increase. Subspecialties that exhibited a decline in the percentage of fellows included intensive care medicine, neuroanesthesia, and research.
We compared the number of fellows entering subspecialty education with the number of individuals completing their PGY-4 (CA-3) (Fig. 3). The number of individuals enrolled in subspecialty education continued to increase despite the fluctuation in the number of graduating residents.
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Figure 3. The percentage of eligible individuals enrolled in subspecialty fellowship programs. The number of postgraduate year (PGY)-4 residents was obtained from http://www.grogono.com (number of PGY-5 fellows divided by the total number of PGY-4 residents of the previous year).
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The number and percentage of PGY-4 (CA-3) individuals pursuing 12-month subspecialty education decreased during the decade (Table 3). The number of residents enlisted in 12-mo subspecialty training decreased from 115 in 1989–1990 to 36 in 2000–2001. In 1989–1990, cardiac anesthesia demonstrated the largest percentage (37%), followed by pediatric (24%) and other (15%). In 2000–2001, 49% of the PGY-4 (CA-3) residents were in enrolled in pain management, followed by cardiac anesthesia (22%). Residents categorized as "no subspecialty" increased from 44% in 1989–1990 to 94% in 2000–2001 (Tables 4 and 5 ).
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Discussion
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In 1985, the ABA announced the requirement of the additional year of anesthesia training for entry into the board-certification process. This change was based on the expanding knowledge base, complexity, and growth of the specialty. We were concerned that the increased length of residency training would deter individuals from pursuing subspecialty education. The information presented in this study illustrates that the additional year did not negatively affect the total number of individuals in subspecialty training, as was feared. However, the composition of subspecialists significantly changed during the decade. In the 2000–2001 academic year, 63% of fellows were enrolled in either pain management or cardiac anesthesia. This was accompanied by a declining interest in critical care medicine and research. In addition, the length of subspecialty training increased for virtually all subspecialties. We believe that these trends will have a major effect on the development of the field of anesthesiology.
Critical care medicine experienced a decline in percentage of PGY-5 (CA-4) fellows over the 10-year period. Historically, anesthesiologists have comprised most physicians in critical care medicine. Today, most critical care specialists are trained as internists, pediatricians, or surgeons, and anesthesiologists comprise only 10% of physicians with critical care qualifications (4). The cause for the decline in the number of residents in critical care fellowships is most likely multifactorial (5). The exodus of academic anesthesiologists to the private sector decreased the number of individuals available to mentor residents. The reduction in the number of residents in anesthesia training, combined with the manpower shortage in the latter half of the decade, may have forced academic and private practices to revise their services provided. Decreasing reimbursement in critical care medicine may have contributed to physicians shifting their professional practice from intensive care units to the operating room. Furthermore, hospitals rely on production of the operating rooms as a significant source of revenue. Pressure from hospital administration to provide traditional operating room services may have deterred academic and nonacademic anesthesiologists from practicing in intensive care units.
In 1996, the Committee of Manpower for Pulmonary and Critical Care Societies was formed to determine future manpower requirements through the year 2030 (6). Physicians from three specialty societies—the Society of Critical Care Medicine, the American College of Chest Physicians, and the American Thoracic Society—were represented on the committee. Surveys were distributed to intensive care unit directors and randomly selected physician members of these societies. This study demonstrated a significant need for additional critical care specialists and estimated that only 22% of the demand will be filled by the year 2020 and 35% by 2030. It is interesting to note that in 1997, intensivists provided only 37% of all care to critical care unit patients. Nearly half of the patients were provided care under a multispecialist physician model. Numerous studies have shown that dedicated critical care specialists reduce mortality, hospital costs, and length of stay and improve outcomes (7–9). Organizations such as the Leap Frog Group have increased public awareness regarding the importance of having a dedicated critical care specialist (10). As a result, academic leaders and hospital administrators may be forced to recognize the value of dedicated intensivists. Furthermore, the data provided by the Committee of Manpower for Pulmonary and Critical Care Societies study suggest that there will be a substantial demand for critical care specialists and services for the next 30 years. On the basis of the anticipated increase in the number of patients older than 65 years, this projection assumes that health care policies and patient expectations will not waver. Inevitably, inadequate physician manpower may dictate decreased medical care available to patients requiring intensive care or a model that does not provide trained intensivists.
The decline of anesthesiologists involved in critical care medicine has not gone unnoticed. Numerous organizations, including the American Society of Critical Care Anesthesiologists, have called on anesthesiology chairpersons and residency directors to increase resident exposure to critical care medicine (11–13). Those who believe that the future of anesthesiology lies in the practice of perioperative medicine have encouraged further involvement in pain and critical care medicine. Our data suggest that a renewed interest in critical care medicine is urgently warranted.
The other subspecialty that had a decline in both absolute number and percentage was in the training of investigators. It is well known, and has been recently publicized, that anesthesiologists compete poorly for National Institutes of Health investigator-initiated research awards (14) (pp. 84–92). This clearly places anesthesiology in academic medicine at a disadvantage, because institutional support requires that investigators and departments earn space and institutional dollars by successfully completing for National Institutes of Health grants. The recent increased demand for clinical anesthesiologists has deterred individuals from pursuing academic careers and has hampered anesthesiology departments from fostering research. Anesthesiologists in academic institutions have been pressured to increase their clinical productivity, and this has led to a decrease in basic and clinical science research. As a result, the number of individuals available to mentor and foster fellows has declined. Ultimately, this trend will have a negative effect on the development of anesthesiology. Elsewhere, we have proposed that research be introduced during PGY-3 (CA-2) to attract residents to academic careers (14) (pp.133–66). Our data show a need for immediate attention to the education of investigators and to the PGY-5 (CA-4) level and beyond.
Pain management has surpassed cardiac anesthesia as the most popular subspecialty selected by residents. In 2000–2001, nearly 2
times the number of individuals enrolled in pain management compared with the next most popular specialty of cardiac anesthesia. This does not indicate an oversupply of pain management specialists, because the need for this specialty has yet to be determined. The advances in the treatment of chronic pain, in conjunction with the technical aspects of the practice, are features that attract residents to pain management. This popularity may be due to the expansion of knowledge in pain management, increased marketability, the unique technical skills required, and expansion into the perioperative arena. It is evident from this study that the vast majority of individuals pursuing fellowship training are choosing pain management.
It may be misleading that some subspecialties did not display an increase in the percentage of trainees in the PGY-5 (CA-4) year. Although the total percentage of individuals did not increase, the absolute numbers increased over the 10-year period. In 1989–1990, 4 individuals were enrolled in 12-month obstetrical anesthesia fellowships, accounting for 7% of the total number of fellows. In the 2000–2001 academic year, 16 individuals (a 4-fold increase) represented 4% of the PGY-5 (CA-4) residents.
We examined the influence of board certification on the choice of subspecialty (Fig. 4). Pain management and critical care medicine are the only subspecialties that offer formal certification by the ABA. The percentage of PGY-5 (CA-4) individuals enrolled in pain management increased and the percentage of fellows in critical care declined over the decade. These data indicate that certification in a subspecialty does not greatly influence whether residents pursue subspecialization. Furthermore, subspecialties that do not offer formal certification, such as cardiac and pediatric anesthesia, continue to be popular choices among graduates.
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Figure 4. The percentage of residents enrolled in programs offering American Board of Anesthesiology certification (pain and intensive care unit (ICU)) compared with all subspecialties. The slope of the ICU and pain fellowships are significantly different (P < 0.001); this suggests that factors other than subspecialty certification affect fellowship choice.
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The percentage of residents entering fellowship programs increased during a period when the number of residents completing anesthesia training fluctuated. There was no apparent association between the number of residents choosing to enroll in fellowship training and the number of graduating residents. The recent decline in the percentage of individuals entering subspecialty training may be due to the increased demand for clinical anesthesiologists. It appears that market forces for generalists are a powerful attraction for medical students to enter the field of anesthesiology and that they prevent residents from subspecialization. Close monitoring of this downward trend and its potential effect on the development of anesthesiology as a specialty is warranted.
The decrease in funding for fellowship training may also contribute to the decline in the number of subspecialty fellows. The Balanced Budget Act of 1997 reduced Medicare funding to academic centers and limited the number of resident training positions to the 1996 level. Although the Balanced Budget Refinement Act of 1999 restored several hundred million dollars to disproportionate share and direct graduate medical education funds, the overall effect was a decrease of several billion dollars over five years (15). Pressure from government and private sectors to provide inexpensive high-quality health care will continue to have a major effect on academic medical centers. The growth of managed care has forced academic institutions to compete with the private sector for health care dollars. Decreases in reimbursement combined with the increased operating costs of academic institutions have had a negative effect on resident and subspecialty education. The Council of Graduate Medical Education continues to emphasize limiting the number of specialists and promoting the development of primary care by recommending increasing direct and indirect medical educational funding to primary care specialties while reducing funding to other specialties (16). In addition, direct medical education payments for residents who have surpassed the number of years required for board certification are reduced by 50%. These actions place substantial barriers to subspecialty education.
The additional PGY-4 (CA-3) year did not negatively influence the number of individuals pursuing subspecialty education. Analysis of the past decade reveals an increase in both the number and percentage of graduating residents pursuing specialty training. Continued growth of anesthesiology as a discipline depends on advanced training and research in all subspecialties. Because most individuals are pursuing pain and cardiac subspecialties, progress in the other subspecialties will not occur at the same rate. The ABA may need to review current educational requirements, including the duration of training and the composition of the clinical base year, for entry into the board-certification process. Our current residency programs strongly emphasize traditional training in the operating room. Residency directors and academic chairmen need to place greater emphasis on critical care and research. Providing residents with exposure to critical care medicine and research earlier in their training may ultimately influence their career decisions. In addition, residents must obtain adequate training and training in evolving areas of our specialty, including genomics, geriatrics, and information management systems. The challenge for chairpersons of anesthesia departments will be to provide opportunities for resident education in all of these areas while funding for graduate medical education continues to decrease.
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Accepted for publication April 8, 2004.
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[Abstract]
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Abstract
Introduction
