National policymakers wrestling with physician workforce issues for three decades have unsuccessfully tried to achieve the right number of physicians. Fixed ratios and goals that were intended to prevent a surplus of neurosurgeons by limiting the number of training positions, among other measures, resulted in many small specialties, such as neurosurgery, suffering considerably.
Understanding neurosurgical workforce trends requires analysis of the number of current neurosurgeons, as discussed in this issue’s cover story, as well as the number of those who have recently entered or who are contemplating entrance into neurosurgical residency-neurosurgery’s “pipeline.” With less than 150 neurosurgical residency positions available per year and a lengthy training period of five to seven years, long-range planning is essential for maintaining an adequate neurosurgical workforce. Neurosurgery traditionally has been an extremely competitive specialty, attracting many of the best and the brightest applicants to neurosurgical residency programs. Each year program directors sift through dozens of worthy applications to identify the 10-20 candidates most suitable for interviews for just one or two available positions. The advent of the Central Application System, which is mandatory for neurosurgery applicants, made submission of a vastly increased number of applications possible with no additional effort. For program directors, however, this made the task of determining which of the many applicants to invite to campus even more challenging.
Trends in Residency Applications
Until the last decade, trends in medical education, economics and technology had little effect on the popularity of the neurosurgical specialty. Applications for neurosurgical residencies remained stable at a time when many other specialties were experiencing significant fluctuations in residency applications due to policy changes, supply and demand issues and technological advances.
By the beginning of the 1990s, the proliferation of health maintenance organizations and their “gatekeepers” propelled many medical students into family practice residencies. However, by the end of the 1990s the number of physicians seeking family practice entered a rapid decline. The number of family practice residency positions filled fell from 85.5 percent in 1998 to 79.1 percent in 2002. During the same period, the number of U.S. medical school graduates ripe for residency fell from 66.2 percent to just 47.2 percent.
General surgery was once a highly sought residency; in 1981, more than 12 percent of medical students chose general surgery after graduation. However, by 2001 the number of available general surgery residencies exceeded the number of medical students applying. The expectation now is that the percentage of medical students who will apply for a general surgery residency will drop below 5 percent by 2005.
For neurosurgical residencies, the number of applicants remained stable for many years. Since 1995, however, there has been a slow, but steady decline in medical students’ choice of neurosurgical residencies. This decline parallels the considerable drop both in the overall number of residency applications, as measured by registrants for the National Resident Matching Program, and in the number of rank lists-those committing to the match (see graph, Registrants and Rank List: Neurosurgical Match Program 1993-2003).
Neurosurgery’s January 2003 match marked the first reversal of this trend along with a decline in the specialty’s residency vacancy rate. While it is too early to know whether interest in neurosurgery truly is resurging or if this increase will remain a one-year phenomenon, it is worth noting that even the January 2003 match amounted to just over 300 registrants, compared with a high of 425 registrants in 1995.
The quality of applicants for neurosurgical residencies is more difficult to assess than simply their sheer numbers. The percentage of U.S. medical school seniors matching peaked at 92 percent in 2000, but has remained near 90 percent since then (see graph, U.S. Medical School Seniors and International Medical School Graduates in Neurosurgical Residencies 1991-2003). During this same time, positions filled by international medical school graduates also peaked between 6 percent and 10 percent, suggesting that they are filling the slots made available by the declining number of U.S. graduates. Average scores of U.S. Medical Licensing Exam Step 1, only recorded from 1998 to 2003, rose only slightly during that from 226 to 234, about 20 points above the national average. Scores for those who did not match were at or below the national average and ranged from 207 to 215.
Pool of Medical School Graduates
The pool of candidates for neurosurgical residency is dependent to some extent on the pool of medical school graduates. Taking a look at this group, it is noteworthy that between 1980 and 2000 the U.S. population grew by 24 percent while U.S. medical school graduates increased only 12 percent, suggesting that eventually there may be too few physicians to serve the U.S. population in the future.
Looking a bit further down the pipeline, applications to medical schools were down 6 percent for 2001-2002, continuing a six-year decline, but there was a slight increase in applications of 3.5 percent for 2002-2003.
A variety of factors may be influencing the shrinking pool of medical school graduates, among them the openly expressed message of physician discontent with the practice of medicine, a discouraging message that increasingly has made its way to college campuses. This dissatisfaction is illustrated by a 2004 Merritt, Hawkins & Associates survey in which more than half of physicians ages 50 to 65 said they would choose another career if they were starting out today.
Another factor may be resident burnout, which often is cited as an increasing problem. Association of American Medical Colleges President Jordan J. Cohen, MD, wrote in Annals of Internal Medicine that “the stresses, both professional and personal, that residents now experience do seem much more intense than in the past. Patients are sicker, hospital stays are shorter and attendings are more hassled….” Whether last summer’s Accreditation Council for Graduate Medical Education-mandated resident work hour restrictions will reduce residents’ stress levels over time-and improve patient care-has yet to be seen [link to “Restricted Workweek” and Training Programs Need Enriched Environment,” in this issue).
Influences on Specialty Choice
Among the benefits of the resident work hour restrictions purportedly is an increase in residents’ quality of life. A recent study by E. Ray Dorsey, MD, and colleagues concluded that the “perception of controllable lifestyle accounts for most of the variability in recent changing patterns in the specialty choices of graduating U.S. medical students.”
Although Dorsey and colleagues found that lifestyle now trumps determinants such as pay in choosing a specialty, the average debt load has reached more than $125,000 for today’s graduating medical student, perhaps tarnishing the appeal of longer training programs like neurosurgery’s five-to-seven year program. The high debt load likely will encourage medical students to gravitate toward lucrative specialties, as well. For example, the advent of coronary artery stents advanced interventional cardiology to the highest median income of all subspecialties, resulting in the increased popularity of this specialty among medical students.
Attracting the Best and Brightest
Attracting the best and brightest physicians over the next decade may start with an understanding of who will be in the pool, as well as how they will make their specialty choice.
Women now comprise more than half of all first-year medical classes, and over the next two decades it is expected that women will comprise more than half of all practicing doctors. This expectation is well founded, given that the number of female physicians grew 300 percent between 1980 and 2000, while the number of male physicians increased just 44 percent. While few women traditionally have chosen to enter neurosurgical residency-only about 5 percent of practicing neurosurgeons are women-nearly 10 percent of all current neurosurgical residents are female, a significant rise over the last decade that bodes well for neurosurgery’s future.
An increased number of minority candidates are expected to enter medical school in the coming years. In 2003 the number of medical school applicants who identified themselves as other than white was approximately 42 percent; slightly fewer U.S. neurosurgeons identify themselves the same way, approximately 31 percent.
Suitable experience with neurosurgery seems to improve the odds that students will choose this specialty. During medical school, exposure to neurosurgery is usually very limited and typically only is available as an elective. Also, role models and mentors often are cited as important influences on specialty choice. Increasing students’ exposure to the specialty during medical school as well as increasing neurosurgery’s access to and active involvement with the “best and brightest” medical students likely would aid in their successful recruitment.
Taking a Proactive Approach
Several medical entities recently have addressed the possibility of an overall physician shortage. In September the Council on Graduate Medical Education (COGME) recognized a shortage of physicians and recommended a 15 percent increase in medical school enrollment over the next 10 years. In December, the Association of American Medical Colleges announced the establishment of the Center for Workforce Studies to assess physician supply. The new center will be headed by Edward Salsberg, who authored the report on which the COGME’s recommendation was based. Also in December, the American Medical Association withdrew its 15-year physician surplus position and declared a shortage of physicians in some geographic areas and in some specialties.
Clearly the lesson to be learned about the physician workforce, and specifically the neurosurgical workforce, is that there must be continual assessment and evaluation. The changing demographics of medicine require a fluid approach to attracting the most qualified students to neurosurgery.
Proactive policies such as increasing neurosurgery’s involvement in medical education and in undergraduate neurosurgical curriculum development, as well as active mentoring, may be necessary to assure that the neurosurgical workforce of the future can meet the demands of the U.S. population.
Deborah L. Benzil, MD, is associate director of the Department of Neurosurgery, New York Medical College in Valhalla, N.Y.
For Further Information
2004 Survey of Physicians 50 to 65 Years Old www.merritthawkins.com/merritthawkins/pdf/2004_physician50_survey.pdf
Bland KI and Isaacs G. “Contemporary Trends in Student Selection of Medical Specialties: Potential Impact on General Surgery.” Archives of Surgery 2002; 137:1078-9. (PubMed ID: 11888445)
Cohen, JJ, “Heeding the Plea to Deal With Resident Stress.” Annals of Internal Medicine 2002; 136(5): 394-5. (PubMed ID: 11874313)
Dorsey ER, et al. “Influence of Controllable Lifestyle on Recent Trends in Specialty Choice by U.S. Medical Students.” Journal of the American Medical Association 2003; 290:2666. (PubMed ID: 12952999)
Gelfand DV, et al. “Choosing General Surgery: Insights Into Career Choices of Current Medical Students.” Archives of Surgery 2002; 137:941-5. (PubMed ID: 12146995)
Guglielmo WJ. “Physician’s Earnings. Our Exclusive Survey.” Medical Economics 2003; 80:71-2, 76-9. (PubMed ID: 14571859)Information on Medical School Applicants, Matriculants and Graduates www.aamc.org/data/facts/start.htm
Newton DA and Grayson MS. “Trends in Career Choice by U.S. Medical School Graduates.” Journal of the American Medical Association 2003; 290:1179-82. (PubMed ID: 12953000)
Rose J. “Practice Beat.” Medical Economics 2002 79:18. www.memag.com
Salsberg ES and Forte GJ. “Trends in the Physician Workforce, 1980-2000.” Health Affairs 2002; 21:165-173. (PubMed ID: 12224879)
Weiss B. “Primary Care? Not Me.” Medical Economics 2002; 79:48-49. (PubMed ID: 12195656)