Pediatric Work Force: Data From the American Board of Pediatrics

For a number of years, the American Board of Pediatrics (ABP) has gathered work force data using questionnaires administered in association with its various examinations. These data provide important information regarding trainees and practitioners in pediatrics; such information is particularly useful during this era of health care change and debate. The data presented in this report are based on questionnaire results from three sets of examinations: the in-training examination (ITE) administered to residents during their training, the certifying examination for general pediatrics, and the pediatric subspecialty certifying examinations.The ITE is offered to all accredited programs in the United States (US) and Canada. It is a half-day examination administered during the same week in early July at all program sites. Only residents in pediatric levels 1 through 3 (PL-1 through PL-3) years of training in categorical pediatric programs may take the examination. Residents in internal medicine/pediatrics (med/peds) 4-year dual training programs, as well as three other smaller, 5-year dual training programs (with the American Board of Psychiatry and Neurology, the American Board of Emergency Medicine, and the American Board of Physical and Rehabilitative Medicine), are permitted to take the ITE during each year of training. Demographic and work force data are obtained by appending several relevant questions to the examination registration form.Candidates who apply to take the General Pediatrics Certifying Examination for the first time are asked to complete a short questionnaire about their career intentions. Similarly, candidates who apply for the first time to take 1 of 12 subspecialty certifying examinations in pediatrics are asked to complete a separate set of demographic and work force questions.There are currently 213 accredited categorical pediatric training programs in the US and 16 accredited programs in Canada. In 1995, all but one of these 229 programs participated in the ITE. Because of illness, vacation, duty assignments, or similar reasons, not all residents are able to take the examination; however, after receipt of examination results the program directors are asked to verify registration data and to provide information regarding those residents who did not take the examination, including names, gender, level of training, and medical school from which they graduated. Programs that do not participate in the ITE are asked to complete verification forms for their residents. Table 1 contains the information gathered on categorical pediatric residents for 1991 through 1995. Table 2 contains information for med/peds residents. The tables do not include the 117 residents enrolled in the three combined programs.During the 5-year period (1991 through 1995) the total number of categorical pediatric residents (PL-1, 2, and 3) increased by 18%, from 6731 in 1991 to 7914 in 1995. The number of first-year categorical pediatric residents who are American medical school graduates [AMGs] (AMGs are defined as graduates of any medical school accredited in the US by the Liaison Committee for Medical Education [LCME] or the American Osteopathic Association [AOA] or, in Canada, by the Royal College of Physicians and Surgeons of Canada [RCPSC]) increased by 14% from 1991 to 1995. The number of PL-1 international medical school graduates [IMGs] (IMGs are defined as graduates of any medical school not accredited by the LCME, AOA, or RCPSC) dropped slightly in 1995, but it has risen consistently at the PL-3 level for the past 5 years. This increase at the PL-3 level reflects ABP policy that permits IMGs with at least 3 years of categorical pediatric training abroad to become eligible for the certifying examination via a two-step process that includes satisfactory completion of a PL-3 year in an accredited program in the US or Canada and acceptable performance on a screening examination.Over the past two decades, there has been a striking increase in the number of women choosing careers in pediatrics. In 1975, approximately 30% of pediatric residents were women. This proportion had risen to 57% by 1991, and it was 61% in 1995. As can be seen in Table 1, 64% of PL-1 residents beginning training in 1995 were women.Med/peds training programs have considerably fewer trainees than the categorical programs (403 first-year trainees in 1995 versus 2682 in categorical pediatrics). However, there has been a 60% increase in the total number of residents enrolled in this dual program over the past 5 years, from 724 in 1991 to 1155 in 1995. In 1995, 84% of the residents in this program were AMGs, versus 68% in categorical pediatric programs. The percentage of women enrolled in med/peds programs is less than in categorical pediatrics, but it is increasing yearly.There is a modest attrition of categorical pediatric residents, especially noticeable between the PL-1 and PL-2 years. Some of these residents have chosen other fields of training after a transitional year in pediatrics. The loss of residents after the PL-2 year reflects those who, after two categorical years, enter subspecialty training in disciplines such as pediatric neurology or those exceptional candidates who “fast-track” into a pediatric subspecialty after passing a screening examination that allows a waiver of the PL-3 year of categorical training.There were 50 fewer residency year (R-4) residents (20%) in the combined med/peds programs in 1995 than R-1 residents in 1992, the year they began training. This appears to represent a decision to choose a career in either categorical pediatrics or categorical internal medicine.Data regarding career choice collected from first-time candidates for the certifying examination show that over the last decade approximately 60% of residents have chosen a career in general pediatrics, 30% have indicated plans to enter a pediatric subspecialty, and 10% have either chosen a nonpediatric specialty (eg, pediatric anesthesiology, allergy-immunology, or child neurology) or have decided to interrupt their medical careers for family or other reasons. As shown in Table 3, the percentage of candidates choosing general pediatrics has increased in the last 4 years, from 60% in 1992 to 67% in 1995. A downward trend is noted in nonpediatric specialty choice, from 10% in 1992 to 5% in 1995. A similar downward trend is noted in the percentage of candidates choosing a pediatric subspecialty, from 33% in 1990 to 27% in 1995. Although there has been a decrease in the percentage of those choosing pediatric subspecialties, the actual number of candidates choosing subspecialties increased from 666 in 1992 to 728 in 1995 as a result of the increased number of pediatric trainees.Table 4 illustrates the pediatric subspecialty career choices of first-time certifying examination candidates in 1995. Neonatal-perinatal medicine, selected by 6.3% of candidates, was the leading subspecialty career choice, as it has been every year since such data have been solicited. Pediatric emergency medicine, a relatively new pediatric subspecialty, has become the second most popular subspecialty career choice, accounting for 3.8% of the candidates. Hematology-oncology and cardiology are the third and fourth choices, respectively.The data collected from candidates applying to take the twelve subspecialty examinations offered in 1994 and 1995 are shown in Table5. Except in neonatal-perinatal medicine, the majority (68% to 89%) of subspecialty examinees have chosen careers in academic settings; 45% of neonatal-perinatal candidates have done so. Subspecialists in academic health centers envision full-time activity in their subspecialty rather than part-time in the subspecialty and part-time in general pediatrics. In contrast, almost 50% of endocrinologists and gastroenterologists entering nonacademic medical center practice plan to do part-time work in general pediatrics, as do 73% of those entering nephrology. Fourteen percent of those in neonatal-perinatal medicine plan part-time activity in general pediatrics.In the last few years, there has been an increasing trend among US medical school graduates to enter primary care residencies. Pediatrics has shown a steady increase as a career choice for US medical school graduates. As stated earlier, the increasing popularity of dual training in internal medicine and pediatrics is particularly impressive. Although there is currently no mandate to increase primary care residency positions, students are well aware of the market environment and the trend toward generalist training is expected to continue.There is also a trend among pediatric residency graduates to enter general pediatrics rather than pediatric subspecialty or other nonpediatric specialty training. Reasons for this trend may include a bona fide increased interest in generalist care, an unwillingness to extend training because of debt burden, an inability of subspecialty training programs to secure funding for fellowship positions or future faculty positions, and a concern about the impact of managed care on job availability for pediatric subspecialists. The job market has had a major impact on first-time candidates' choice of a nonpediatric specialty. An example is the choice for training in anesthesiology, where there has been a fivefold reduction between 1992 and 1995.Since its inception in 1933 and through December 31, 1995, the American Board of Pediatrics has certified 57 808 general pediatricians, of whom 4733 (8%) were born before 1925 and 6993 (12%) before 1930. Table 6 shows that 9530 (16%) of these diplomates have achieved subspecialty certification in pediatrics. It is worthwhile to emphasize the striking differences in subspecialty certification between the ABP and the American Board of Internal Medicine (ABIM). For example, during the 10-year period from 1985 through 1994, ABIM issued 50 252 certificates in general internal medicine and 34 157 subspecialty certificates. Corresponding totals for the ABP were 23 714 general certificates and 5572 subspecialty certificates issued. During this time period, therefore, 68% of internists became certified in a subspecialty, whereas only 23% of pediatricians did so. From 1985 to 1994, ABIM issued more than six times as many subspecialty certificates as the ABP while certifying more than twice as many generalists. There are various explanations for these differences, the most fundamental of which is that there are many more adults than children with subspecialty problems. Over the last 5 years, however, the proportion of ABIM certificate holders entering subspecialties has dropped, presumably in recognition of an oversupply of adult subspecialists (Harry Kimball, ABIM president, personal communication, 1996).The 1990s have proven to be a decade of uncertainty and change in medicine. As a greater portion of the US population enter managed care situations, increasing pressure will come to bear on the health care community. These pressures include the realization that there is an excess of physicians, particularly subspecialists; that we need to alter the way we educate physicians for the managed care arena; and that medical schools and graduate training programs will find it difficult to compete in an environment intent on obtaining the least expensive medical care. Pediatrics, a primary care specialty, has weathered the storms of change better than some other specialties, but we still face many odysseys. Careful work force needs assessments are required to more precisely determine requirements for pediatric generalists and specialists. The lack of data on the need for pediatric subspecialists is particularly troublesome at the present time, especially as subspecialty services for children are being increasingly provided by nonpediatric trained specialists in some communities.