Resident education in obstetrics and gynecology encompasses essential content areas such as primary and preventive ambulatory care, obstetrics, gynecology, reproductive endocrinology, and oncology.1 In a period of rapid growth of medical knowledge and technologic advancement, increasingly more is expected to be learned and subspecialization appears to be more desirable in many medical and surgical specialties.2,3 Most obstetrician–gynecologists (ob-gyns) choose not to provide or practice the entire breadth of core components required for certification by the American Board of Obstetrics and Gynecology (ABOG).
Progressive subspecialization occurs in response to personal professional desires and patient demands. Although subspecialization may occur over the course of a career as a result of personal choice, it is increasingly a result of fellowship training after residency. This additional subspecialty training narrows a physician's scope of practice and could limit patient access to routine, preventive health care from general ob-gyns.
What effect does subspecialization have on the available physician workforce in obstetrics and gynecology? The most common time when an ob-gyn trainee decides to choose between general and subspecialist training is midway during their 4-year residency. To address this issue requires a review of the number of resident graduates seeking additional postgraduate training. Pursuit of board-certified subspecialized training has not been reported for more than a decade.4 The objectives of the present investigation were to examine whether there has been a recent upward trend in the number of resident graduates who pursued fellowship training in our current accredited subspecialties and to compare if any subspecialty trend in ob-gyns was similar to trends in other specialties.
MATERIALS AND METHODS
This observational study was conducted after review and approval from the University of New Mexico Human Research Review Committee (HRRC 11-328). To conduct a comprehensive review of subspecialization required an evaluation of the entire course from entry into an Accreditation Council for Graduate Medical Education (ACGME)–approved residency program to completion of training in an ABOG–approved fellowship program. Unfortunately, no single longitudinal database provided data that tracked such information. Consequently, we examined databases reported annually from the National Residency Match Program and from the ABOG. The National Residency Match Program was established in 1952 to provide both applicants and residency and fellowship program directors a fair opportunity to consider their options for filling positions, make reasoned decisions, and have their decisions announced annually at a uniform time.5 We gathered data for the current four accredited subspecialties with 3- to 4-year fellowship programs (female pelvic medicine and reconstructive surgery; gynecologic oncology; maternal-fetal medicine; and reproductive endocrinology and infertility).
Our study period began in academic year 2000 after the last published report by Pearse et al4 about subspecialty training between 1994 and 1999. We report here all data for each year until the most recent report in 2012.5 The numbers of all fellowship programs and positions and the corresponding number of applicants per position filled were obtained each year from the National Residency Match Program database. We consider the number taking the ABOG written board examination for the first time to be an accurate reflection of the number of graduates from the residency and fellowship programs.6 Lastly, we examined the numbers of graduates who became board-certified on passing either the general or subspecialty oral examination.6
Data reported here are complete for the total numbers of fellowship programs and positions entering the national match process. An exception was for female pelvic medicine and reconstructive surgery in which there were no National Residency Match Program data about acceptance into fellowship programs until 2002 and no results about written or oral examinations for board certification (to begin in 2013). The National Residency Match Program and ABOG data were reported as a complete set, so no inferences were necessary using confidence intervals. Instead, we calculated group means and, where appropriate, group standard deviations. The rates of annual growth were the slope from simple linear regression models where year was the independent variable and either total approved positions or programs were the dependent variable.
The numbers of ACGME-approved ob-gyn residency programs did not change substantially between 2000 and 2012 (mean 245, range 237–251). The number of the ob-gyn graduates from residency programs who took their written general examinations averaged to be 1,185±56 per year during this period. In contrast, the total number of accredited fellowship programs and approved positions for each subspecialty rose steadily, as shown in Figure 1. Linear increases in all fellowships between 2000 and 2012 were 174.5% for programs and 223.7% for positions. The average number of total fellowship programs increased by 6.8 per year, whereas the average increase in total positions was 10.2 per year.
The aggregate total of accredited fellowship training programs for each subspecialty between 2000 and 2012 is listed in Table 1. The number of programs increased in each subspecialty. The most rapid growth in programs was in female pelvic medicine and reconstructive surgery, which became an accredited subspecialty in 2012. The largest total number of programs was consistently in maternal-fetal medicine.
The total number of applicants per fellowship position in each subspecialty is illustrated in Figure 2. This ratio was lowest in maternal-fetal medicine between 2000 and 2002, when there were fewer applicants than positions. Otherwise, there were more applicants per preapproved fellowship position in the four ob-gyn subspecialties between 2000 and 2011. The number of applicants per fellowship position varied from year to year and did not necessarily keep pace with the growth in the total number of positions.
The number and percent of total resident graduates accepted into fellowship programs are shown for each accredited subspecialty in Table 2. The number of enrollees into fellowship programs increased steadily in each subspecialty. This represented a gradual change in total resident graduates accepted into fellowships from 7.0% in 2001 to 19.5% in 2012. The percentage of resident graduates accepted into maternal-fetal medicine and reproductive endocrinology and infertility fellowships more than doubled during this period. The number of resident graduates enrolling in maternal-fetal medicine fellowships was approximately twice that of the remaining three gynecologic subspecialty programs.
The number of fellows who completed their training was assessed by the number taking the ABOG written examination for the first time either immediately or at 1 year after graduation. Trends in the number of resident and fellow graduates who took the written examination each year are shown in Table 3. Although the number of resident graduates did not change significantly, the numbers of fellowship graduates increased gradually in each of the three subspecialties (gynecologic oncology, maternal-fetal medicine, reproductive endocrinology and infertility) for those years in which the ABOG written examination was administered. Similar findings were observed for fellow graduates who eventually became board-certified (passed oral examination) in the three subspecialties (Table 3). This increase in number of board-certified subspecialists during this period was less apparent as a result of the greater lag in time from the beginning of fellowship training until certification (usually 6–8 years) and as a result of certain graduates not passing their subspecialty oral examination. Furthermore, the proportion of subspecialists who became board-certified each year averaged to be 10.7% (range 6.9% in 2005 to 12.0% in 2000) of all who passed the general and specialty oral examinations.
Without an increase in the annual number of graduates from ACGME-accredited residency programs, any additional graduates pursuing training in accredited subspecialties would lead to a decrease in the number of practicing general ob-gyns. For this reason, this investigation was undertaken to examine the trend in training patterns to more easily quantify the number of accredited fellowship programs and positions. Results from this report clearly demonstrate an increase in the number and proportion of ob-gyn resident graduates applying to accredited fellowship programs between 2000 and 2012. This progressive growth in the numbers of graduates pursuing fellowships might be explained by a combination of reasons: 1) personal choice such as lifestyle, interest in the subject, or financial gain; 2) advances in surgical science and technology making subspecialization a means to better master a subject; 3) the public's demand for subspecialists to satisfy presumed needs for qualified second opinions and improvements in health care quality; and 4) the previously mentioned expanding volume (and complexity) of medical information that health care providers must assimilate.
The number of resident graduates who entered maternal-fetal medicine and reproductive endocrinology and infertility fellowships declined sharply between 1994 and 1999, presumably as a result of an expansion in duration of training from 2 or 3 years.4 This decline has reversed with a clear increase in both subspecialty fellowship programs and positions. The reported modest growth in gynecologic oncology fellowship programs and positions in the 1990s continued during this past decade. The numbers of female pelvic medicine and reconstructive surgery fellowship programs and positions increased significantly and are now similar to numbers in reproductive endocrinology and infertility.
Our report does not include nonaccredited fellowships, but we do not intend to disregard the importance of such additional training. Resident graduates accepted into non-ABOG or non-ACGME programs were outside the National Residency Match Program matching process (except for pediatric and adolescent gynecology). Examples of fellowship programs not included are minimally invasive gynecologic surgery and family planning. Only recently did the subspecialty pediatric and adolescent gynecology begin to report matching of applicants by the National Residency Match Program. There were also several fellowships in female pelvic medicine and reconstructive surgery before 2002. Data about less formal postgraduate training in infectious disease, hospitalist or laborist care, global health, breast disease, ultrasonography, and women's health research are likewise not available. Those programs usually involve a 2-year training period without a formal ABOG examination process. Our expectation is that these fellowship programs will continue to grow and, when combined, will constitute for another 2–4% of resident graduates.
A limitation of this investigation is that an unknown number of fellowship programs may have accepted resident graduates “outside the Match.” Each specialty is requested by the National Residency Match Program to verify that at least 75% of the programs with available positions in a given year will be registered for the Match.5 We compared results of the National Residency Match Program matches with the number of approved fellowship programs and positions in our subspecialties and found that this possibility of underreporting was very uncommon and did not vary on a year-to-year basis. Furthermore, we were unable to track every resident graduate accepted into fellowship training. Data from the 2009 the American College of Obstetricians and Gynecologists (the College) Professional Liability Survey suggest that a high percent of self-identified subspecialists were not board-certified (gynecologic oncology: 48.4%; reproductive endocrinology and infertility: 53.1%; maternal-fetal medicine: 25.9%).7 Therefore, an indeterminate number of fellowship-trained physicians may be practicing without being subspecialty board-certified, and the number of subspecialty health care practitioners would likely be underestimated.
A trend toward more subspecialization appears to be evolving in the current, complex environments of medical education and health care delivery. According to the Graduate Medical Education Census track of the Association of American Medical Colleges and the American Medical Association, all of the core clinical specialties have witnessed an increase in the proportion of residents who choose to undertake ACGME-approved subspecialty training.8 This increase in the pursuit of subspecialties among disciplines is displayed in Figure 3. Although the proportion of ob-gyn residents accepted into accredited fellowship programs increased from 7.0% in 2000 to 16.5% in 2009, these changes are less than other core clinical specialties except for family medicine. Nonetheless, the number of resident graduates pursuing accredited fellowships training in family medicine remained higher than in obstetrics and gynecology, however, because there were more resident graduates in family medicine.
We encourage that all types of accredited and nonaccredited fellowship training programs report the number of applicants and match rates using the annual National Residency Match Program process. We recommend that a task force be formed in the College's Fellowship Division to regularly monitor the workforce of all ob-gyn subspecialties by using state-of-the-art methodologies and comprehensive workforce databases that longitudinally track College Junior Fellows from the beginning of residency training into practice. The Association of American Medical Colleges maintains an accurate roster of all full-time ob-gyn faculty beginning from entry into their initial institution, and it would also be useful to ascertain whether any other organization has been able to accomplish this tracking task.9
In conclusion, additional training in board-accredited subspecialties is increasing at our time when the workforce pool of general ob-gyns has a shortfall of supply relative to demand in relation to continued population growth.10 With the environment of expanded education and practice, resident graduates in general obstetrics and gynecology are no more likely to offer depth and overall clinical services than those provided previously by general ob-gyns. As the phenomenon of subspecialization continues to evolve in obstetrics and gynecology, the effect on hospital and health care delivery could be substantial, especially between urban and rural locations.10 The effect of the Patient Protection and Affordable Care Act and development of accountable care organizations on trends in subspecialty training in medicine is difficult to predict. If the trend continues toward more subspecialization, the number of general ob-gyns will decrease. Some work will shift to subspecialists, a larger number of ACGME-accredited ob-gyn residency positions would be desired, and an expansion in the workforce of nonphysician clinicians (nurse practitioners, certified nurse midwife, physician assistants) will be needed to provide the many services considered to be primary components of women's health care.
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9. Rayburn WF, Lang J, Fullilove AM, Phelan ST, Rayburn DT, Schrader RM. Retention of entry-level faculty members in obstetrics and gynecology. Am J Obstet Gynecol 2011;204:540.e1–6.
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