Sarah E. Brotherton

US Residency Training Before and After the 1997 Balanced Budget Act

CONTEXT Graduate medical education (GME) determines the size and characteristics of the future workforce. The 1997 Balanced Budget Act (BBA) limited Medicare funding for additional trainees in GME. There has been concern that because Medicare is the primary source of GME funding, the BBA would discourage growth in GME. OBJECTIVE To examine the number of residents in training before and after the BBA, as well as more recent changes in GME by specialty, sex, and type and location of education. DESIGN Descriptive study using the American Medical Association/Association of American Medical Colleges National GME Census on physicians in Accreditation Council for Graduate Medical Education (ACGME)-accredited programs to examine changes in the number and characteristics of residents before and after the BBA. MAIN OUTCOME MEASURES Differences in the number of physicians in ACGME-accredited training programs overall, by specialty, and by location and type of education. RESULTS The number of residents and fellows changed little between academic year (AY) 1997 (n = 98,143) and AY 2002 (n = 98,258) but increased to 106,012 in AY 2007, a net increase of 7869 (8.0%) over the decade. The annual number of new entrants into GME increased by 7.6%, primarily because of increasing international medical graduates (IMGs). United States medical school graduates (MDs) comprised 44.0% of the overall growth from 2002 to 2007, followed by IMGs (39.2%) and osteopathic school graduates (18.8%). United States MD growth largely resulted from selection of specialties with longer training periods. From 2002 to 2007, US MDs training in primary care specialties decreased by 2641, while IMGs increased by 3286. However, increasing subspecialization rates led to fewer physicians entering generalist careers. CONCLUSION After the 1997 BBA, there appears to have been a temporary halt in the growth of physicians training in ACGME programs; however, the number increased from 2002 to 2007.

Graduate Medical Education, 2010-2011

THEAMERICANMEDICALASSOCIAtion(AMA)andtheAssociation of American Medical Colleges (AAMC) jointly maintain a databaseof informationongraduatemedical education (GME) training programs accredited by the Accreditation Council for Graduate Medical Education (ACGME) and of the residents and fellows in them. In the spring this database of residents has added to it the approximately21 000newresidentswhomatch intoprogramsthroughtheNationalResident Matching Program and new residents who did not match, the latter informationcollectedthroughtheAAMC’s follow-up report of US medical schools. TheAMAandtheAAMCalso jointlyadminister theannualNationalGMECensus through GME Track, an Internetbased AAMC product. From May until December2010alldirectorsofprograms accredited by the ACGME were asked to complete the census on GME Track. Informationaboutthetrainingprograms supplied by the program directors is added to FREIDA Online, an InternetbasedpublicinformationsourceonGME programs available to medical students andresidentphysicians.InJuly2010programdirectorsweresurveyedabouttheir active, transferred, and graduated residents and fellows for academic year 2010-2011.Programdirectorswereprovided with lists of residents and fellows fromthecurrentdatabaseandwereasked to(1)confirmormodify the trainingstatus of trainees who were present in their programs the prior year; (2) add new physicians to their program who were notalready inourdatabase; and(3)confirm, edit, or add demographic information on all trainees. This demographic information includes sex, birthdate, country of birth, citizenship status, and race/ethnicity. Wesurveyed8967activeprograms,of which8277(92.3%)completed theprogramsurveyand7601(84.8%)confirmed thestatusofallof theiractivephysiciansin-training, accounting for 104 791 (93.9%)activetrainees.Anadditional138 programs(1.5%)confirmedsomebutnot allof their trainees(3488trainees,3.1%), 200 confirmed that they did not have any trainees (2.2%), 316 programs (3.5%)confirmedthestatusofnon-active trainees(graduatesandtransfers)butdid nothaveanycurrentlyactivetrainees,and 712programs(7.9%)didnotconfirmthe statusofanyphysiciantrainingintheprogram (including 480 programs that apparentlydidnothaveanyactivetrainees). A total of 95.3% of all physicians in our database had their status confirmed (eg, active,graduated,transferred,withdrawn). Physicians whose status was not confirmedwere“advanced”intothenextyear of training(n=3347[3.0%ofactive residents])or“graduated”basedonexpected graduationdate(n=1882[4.9%ofgraduated residents and fellows]). In total, we estimate that there were 111 586 active residentsinACGME-accreditedprograms during the 2010-2011 academic year.

Graduate medical education, 2008-2009.

THEAMERICANMEDICALASSOCIAtion(AMA)andtheAssociation of American Medical Colleges (AAMC) maintain a database of informationongraduatemedical education(GME)trainingprogramsaccredited by the Accreditation Council for Graduate Medical Education (ACGME) and of the residents and fellows in them. Every springthisdatabaseofresidentsisupdated byadding to it theapproximately19 000 newresidentswhomatch intoprograms throughtheNationalResidentMatching Program (NRMP) as well as from information collected through the AAMC’s follow-upreportofmedical schools.The AMA and the AAMC also jointly administer the annual National GME Census through GME Track, an Internet-based AAMCproduct.FromMay2008untilDecember2008alldirectorsofprogramsaccredited by the ACGME were asked to complete theCensusonGMETrack. Information about the training programs supplied by the program directors is uploaded to FREIDA Online, an Internetbasedpublic informationsourceonGME programsthat isavailable tomedical studentsandresidents. In July2008wesurveyed program directors about their active, transferred,andgraduatedresidents andfellowsforacademicyear2008-2009. Programdirectorswereprovidedwithlists of residentsand fellows fromthecurrent database and were asked to confirm or modifythetrainingstatusof traineeswho were present in their programs the prior year;addnewphysicianstotheirprogram whomwedidnotalreadyhave inourdatabase; and confirm, edit, or add demographic information. This demographic informationincludessex,dateandcountry of birth, citizenship status, and race/ ethnicity. We surveyed 8694 active programs, of which 7921 (91.1%) completed the program survey and 7337 (84.4%) confirmed the status of all of their active physicians-in-training, accounting for 100 751 (93.1%) active trainees. An additional 127 programs (1.5%) confirmed some but not all of their trainees (4925 trainees, 4.6%), 179 confirmed that they did not have any trainees (2.1%), 284 programs (3.3%) confirmed the status of non-active trainees (graduates and transfers) but did not have any currently active trainees, and 767 programs (8.8%) did not confirm the status of any physician training in the program (including 586 programs that apparently did not have any active trainees). A total of 96.9% of all physicians in our database had their status confirmed (eg, active, graduated, transferred, withdrawn). Physicians whose status was not confirmed were “advanced” into the next year of training (n=2500 [2.3% of active residents]) or “graduated” based on expected graduation date (n=1479 [4.0% of graduated residents and fellows]). In total, we estimate that therewere108 176active residents in ACGME-accredited programs during the 2008-2009 academic year.

Graduate medical education, 2009-2010.

THEAMERICANMEDICALASSOCIAtion(AMA)andtheAssociation of American Medical Colleges (AAMC) together maintain a database of information on graduate medical education (GME) training programs accredited by the Accreditation Council forGraduateMedicalEducation (ACGME)andoftheresidentsandfellows in them. Every spring approximately 19 000newresidentswhomatchintoprograms through the National Resident MatchingProgram(NRMP)areaddedto thisdatabaseaswellasnewresidentswho did not match, information collected throughtheAAMC’s follow-upreportof medicalschools.TheAMAandtheAAMC alsojointlyadministertheannualNational GME Census through GME Track, an Internet-basedAAMCproduct.FromMay 2009 until December 2009 all directors of programs accredited by the ACGME were asked to complete the Census on GMETrack. Informationaboutthetrainingprogramssuppliedbytheprogramdirectors is added to FREIDA Online, an Internet-basedpublic informationsource on GME programs that is available to medical students and residents. In July 2009wesurveyedprogramdirectorsabout their active, transferred, and graduated residents and fellows for academic year 2009-2010. Program directors are provided with lists of residents and fellows from the current database and are asked to(1)confirmormodify the trainingstatus of trainees who were present in their programstheprioryear;(2)addnewphysicianstotheirprogramnotalreadyinour database; and (3) confirm, edit, or add demographicinformation(includingsex, birth date, country of birth, citizenship status, and race/ethnicity). Wesurveyed8875activeprograms,of which7978(89.9%)completed theprogramsurveyand7468(84.1%)confirmed the status of all of their active physicians-in-training,accountingfor101 596 (92.5%)activetrainees.Anadditional146 programs(1.6%)confirmedsomebutnot allof their trainees(5522trainees,5.0%), 176confirmedthat theydidnothaveany trainees(2.0%),341programs(3.8%)confirmed the status of nonactive trainees (graduatesandtransfers)butdidnothave anycurrentlyactivetrainees,and744programs (8.4%) did not confirm the status of any physician training in the program (including541programsthatapparently did not have any active trainees). A total of96.0%ofallphysicians inourdatabase had their status confirmed (eg, active, graduated, transferred,withdrawn).Physicians whose status was not confirmed were “advanced” into the next year of training (n=2722 [2.5% of active residents])or“graduated”basedonexpected graduationdate(n=1608[4.3%ofgraduated residents and fellows]). In total, we estimate that there were 109 840 active residentsinACGME-accreditedprograms during the 2009-2010 academic year.

Graduate Medical Education, 2007-2008

THE AMERICAN MEDICAL ASSOciation and the Association of American Medical Colleges (AAMC) jointly maintain a databaseof informationongraduatemedical education (GME) training programs accredited by the Accreditation Council for Graduate Medical Education (ACGME) and of the residents and fellows in them. This database of residents is updated annually by adding to it the approximately19000newresidentswho match into programs through the National Resident Matching Program (NRMP)aswellas frominformationcollected through the AAMC’s follow-up reportofmedical schools.TheAMAand theAAMCalsojointlyadminister theannual National GME Census through GME Track, an Internet-based AAMC product. From May 2007 until December2007alldirectorsofprogramsaccredited by the ACGME were asked to complete the Census on GME Track. Informationfromtheprogramdirectorsabout their programs is uploaded to FREIDA Online, an Internet-based public information source on GME programs that is available tomedical students andresidents. InJuly2007wesurveyedprogram directors about their active, transferred, and graduated residents and fellows for academicyear2007-2008.Weprovided program directors with lists of residents and fellows from the current database and asked the directors to confirm or modifythetrainingstatusoftraineeswho were present in their programs the prior year; to add new physicians to their program whom we did not already have in ourdatabase;andtoconfirm,edit,oradd demographic information. This demographic information includes sex,birthdate, country of birth, citizenship status, and race/ethnicity. We surveyed 8589 active programs, of which 7746 (90.2%) completed the program survey and 7211 (84.0%) confirmed the status of all of their active physicians-in-training, accounting for 102 226 (96.4%) active trainees. An additional 61 programs (0.7%) confirmed some but not all of their trainees (2028 trainees, 1.9%), 202 confirmed that they did not have any trainees (2.4%), 322 programs (3.7%) confirmed the status of nonactive trainees (graduates and transfers), but did not have any currently active trainees, and 793 programs (9.2%) did not confirm the status of any physician training in the program (including 644 programs that apparently did not have any active trainees). A total of 97.0% of all physicians in our database had their status confirmed (eg, active, graduated, withdrawn). Physicians whose status was not confirmed were “advanced” into the next year of training (n=1721 [1.6% of active residents]) or “graduated” based on expected graduation date (n=1348 [3.7% of graduated residents or fellows]). In total, we estimate that there were 106 012 active residents in ACGME-accredited programs during the 2007-2008 academic year.

Graduate medical education, 2011-2012.

THEAMERICANMEDICALASSOCIAtion(AMA)andtheAssociation of American Medical Colleges (AAMC)maintainadatabaseof informationongraduatemedical education(GME)trainingprogramsaccredited by the Accreditation Council for Graduate Medical Education (ACGME) and of the residents and fellows in them. In the spring,thisdatabaseofresidentshasadded to it the approximately 21 000 new residentswhomatch intoprogramsthrough theNationalResidentMatchingProgram, as well as new residents who did not match, the latter information collected throughtheAAMC’s follow-upreportof US medical schools. The AMA and the AAMCtogetheradministertheannualNationalGMECensusthroughGMETrack, anInternet-basedAAMCproduct.From MayuntilDecember2011alldirectorsof programsaccreditedbytheACGMEwere asked to complete the Census on GME Track.Informationaboutthetrainingprogramssuppliedby theprogramdirectors is added to FREIDA Online, an Internetbasedpublic informationsourceonGME programsthat isavailable tomedical studentsandresidentphysicians.InJuly2011 program directors were surveyed about their active, transferred, and graduated residents and fellows for academic year 2011-2012.Programdirectorswereprovided with lists of residents and fellows fromthecurrentdatabaseandwereasked to(1)confirmormodify the trainingstatus of trainees who were present in their programstheprioryear;(2)addnewphysicians to theirprogramwhowerenotalready in our database; and (3) confirm, edit,oradddemographic informationon all trainees. This demographic information includes sex, birthdate, country of birth,citizenshipstatus,andrace/ethnicity. Wesurveyed9111activeprograms,of which8712(95.6%)completed theprogramsurveyand7890(86.6%)confirmed thestatusofallof theiractivephysiciansin-training, accounting for 107 503 (94.8%)of active trainees.Anadditional 97programs(1.1%)confirmedsomebut not all of their trainees (3468 trainees, 3.1%), 118 confirmed that they did not have any trainees (1.3%), 338 programs (3.7%)confirmedthestatusofnonactive trainees(graduatesandtransfers)butdid nothaveanycurrentlyactivetrainees,and 668programs(7.3%)didnotconfirmthe statusofanyphysiciantrainingintheprogram (including 496 programs that apparentlydidnothaveanyactivetrainees). A total of 95.3% of all physicians in our database had their status confirmed (eg, active,graduated,transferred,withdrawn). Physicians whose status was not confirmedwere“advanced”intothenextyear of training(n=2456[2.2%ofactive residents])or“graduated”basedonexpected graduationdate(n=1307[3.8%ofgraduated residents and fellows]). In total, we estimate that there were 113 427 active residentsinACGME-accreditedprograms during the 2011-2012 academic year.

Graduate medical education, 2012-2013.

The American Medical Association (AMA) and the Association of American Medical Colleges (AAMC) jointly sponsor and administer the National GME Census through GME Track, an Internet-based AAMC product, and also maintain a database of information on training programs accredited by the Accreditation Council for Graduate Medical Education (ACGME) and of the residents and fellows in them. From May until December 2012, all directors of programs accredited by the ACGME were asked to complete the program survey component of the census on GME Track. Information on the educational characteristics of the training programs is added to FREIDA Online, an Internet-based public information source on GME programs that is available to medical students and resident physicians. InSeptember2012wesurveyedprogramdirectorsabouttheir active, transferred, and graduated residents and fellows for academic year 2012-2013. We provided program directors with lists of residents and fellows from the current database and asked the directors to confirm or modify the training status of trainees who werepresentintheirprogramstheprioryear;addnewphysicians to their program who were not already in our database; and confirm, edit, or add demographic information on all trainees. This demographic information includes sex, birthdate, country of birth, citizenship status, and race/ethnicity. We surveyed 9384 active programs, of which 8943 (95.3%) completed the program survey and 8200 (87.4%) confirmed the status of all their active physicians-in-training, accounting for 109 755 (95.3%) of active trainees. An additional 89 programs (0.9%) confirmed some but not all of their trainees (2431 trainees, 2.1%), 236 confirmed that they did not have any trainees (2.5%), 271 programs (2.9%) confirmed the status of nonactive trainees (graduates and transfers), but did not have any currently active trainees, and 588 programs (6.3%) did not confirm the status of any physician training in the program (including 389 programs that apparently did not have any active trainees). A total of 95.9% of all physicians in our database had their status confirmed (eg, active, graduated, transferred, withdrawn). Physicians whose status was not confirmed were “advanced” into the next year of training (n = 2924 [2.5% of active residents]) or “graduated” based on expected graduation date (n = 1812 [4.6% of graduated residents and fellows]). In total, we estimate that there were 115 111 active residents in ACGME-accredited programs during the 2012-2013 academic year. The following tables contain data from these surveys.

Graduate medical education, 2013-2014.

The American Medical Association (AMA) and the Association of American Medical Colleges (AAMC) jointly sponsor and administer the National GME Census through GME Track, an Internet-based AAMC product, and also maintain a database of information on training programs accredited by the Accreditation Council for Graduate Medical Education (ACGME) and of the residents and fellows in them. From May until December 2013, all directors of training programs accredited by the ACGME were asked to complete the program survey component of the census on GME Track. Information on the educational characteristics of the training programs is added to FREIDA Online, an Internet-based public information source on GME programs that is available to medical students and resident physicians. In August 2013 we surveyed program directors about their active, transferred, and graduated residents and fellows for academic year 2013-2014. We provided program directors with lists of residents and fellows from the current database and asked directors to confirm or modify the training status of trainees who were present in their programs the prior year; add new physicians to their program who were not already in our database; and confirm, edit, or add demographic information on all trainees. This demographic information includes sex, birthdate, country of birth, citizenship status, and race/ethnicity. We surveyed 9613 active programs, of which 9180 (95.5%) completed the program survey and 8487 (88.3%) confirmed the status of all of their active physicians in training, accounting for 111 992 (95.4%) of active trainees. An additional 161 programs (1.7%) confirmed some but not all of their trainees (3101 trainees, 2.6%), 267 programs confirmed that they did not have any trainees (2.8%), 313 programs (3.2%) confirmed the status of nonactive trainees (graduates and transfers) but did not have any currently active trainees, and 385 programs (4.0%) did not confirm the status of any physician training in the program (including 301 programs that apparently did not have any active trainees). A total of 95.5% of all physicians in our database had their status confirmed (eg, active, graduated, transferred, withdrawn). Physicians whose status was not confirmed were “advanced” into the next year of training (n = 2333 [2.0% of active residents]) or “graduated” based on expected graduation date (n = 1468 [3.7% of graduated residents and fellows]). In total, we estimate that there were 117 427 active residents in ACGME-accredited programs during the 2013-2014 academic year. The following tables contain data from these surveys.

Graduate Medical Education, 2014-2015

The American Medical Association (AMA) and the Association of American Medical Colleges (AAMC) sponsor andadministertheNationalGraduateMedicalEducation (GME)CensusthroughGMETrack,anInternet-basedAAMCproduct, and together maintain a database of information on training programs accredited by the Accreditation Council for Graduate Medical Education (ACGME) and of the residents and fellows in them.FromMayuntilDecember2014,alldirectorsoftrainingprograms accredited by the ACGME were asked to complete the program survey component of the census on GME Track. Information on the educational characteristics of the training programs is added to FREIDA Online, an Internet-based public information source on GME programs. Beginning in late July 2014, program directors were surveyed about their active, transferred, and graduated residents and fellows for academic year 2014-2015. Program directors were provided with lists of residents and fellows from the current database and were asked to confirm or modify the training status of trainees who were present in their programs the prior year; add new physicians to their program who were not already in our database; and confirm, edit, or add demographic information on all trainees. This demographic information includes sex, birthdate, country of birth, citizenship status, race, and Hispanic ethnicity. Race and Hispanic ethnicity for residents and fellows who had provided such information through various AAMC applications (eg, the Electronic Residency Application Service) was carried forward from those applications and included in the census. AAMC race data collection allows for more than 1 selection; therefore the following Tables have a new category: multiracial. We surveyed 9768 active programs, of which 9263 (94.8%) completed the program survey and 8514 (87.2%) confirmed the status of all of their active physicians in training, accounting for 112 942 (95.4%) of active trainees. An additional 72 programs (0.7%) confirmed some but not all of their trainees (1772 trainees, 1.5%), 245 confirmed that they did not have any trainees (2.5%), 397 programs (4.1%) confirmed the status of nonactive trainees (graduates and transfers), but did not have any currently active trainees, and 540 programs (5.5%) did not confirm the status of any physician training in the program (including 283 programs that apparently did not have any active trainees). A total of 94.8% of all physicians in our database had their status confirmed (eg, active, graduated, transferred, withdrawn). Physicians whose status was not confirmed were “advanced” into the next year of training (n = 3652 [3.1% of active residents]) or “graduated” based on expected graduation date (n = 1627 [4.0% of graduated residents and fellows]). In total, we estimate that there were 118 366 active residents in ACGME-accredited programs during the 2014-2015 academic year. The following Tables contain data from these surveys.

A national survey of 'inactive' physicians in the United States of America: enticements to reentry

BackgroundPhysicians leaving and reentering clinical practice can have significant medical workforce implications. We surveyed inactive physicians younger than typical retirement age to determine their reasons for clinical inactivity and what barriers, real or perceived, there were to reentry into the medical workforce.MethodsA random sample of 4975 inactive physicians aged under 65 years was drawn from the Physician Masterfile of the American Medical Association in 2008. Physicians were mailed a survey about activity in medicine and perceived barriers to reentry. Chi-square statistics were used for significance tests of the association between categorical variables and t-tests were used to test differences between means.ResultsOur adjusted response rate was 36.1%. Respondents were fully retired (37.5%), not currently active in medicine (43.0%) or now active (reentered, 19.4%). Nearly half (49.5%) were in or had practiced primary care. Personal health was the top reason for leaving for fully retired physicians (37.8%) or those not currently active in medicine (37.8%) and the second highest reason for physicians who had reentered (28.8%). For reentered (47.8%) and inactive (51.5%) physicians, the primary reason for returning or considering returning to practice was the availability of part-time work or flexible scheduling. Retired and currently inactive physicians used similar strategies to explore reentry, and 83% of both groups thought it would be difficult; among those who had reentered practice, 35.9% reported it was difficult to reenter. Retraining was uncommon for this group (37.5%).ConclusionAvailability of part-time work and flexible scheduling have a strong influence on decisions to leave or reenter clinical practice. Lack of retraining before reentry raises questions about patient safety and the clinical competence of reentered physicians.