Numbers are Way Up in Some Specialties, Flat or Declining in a Few

By Bonnie Darves, a freelance health care writer

When physician specialties land in the limelight, much of the data reported in both mainstream and healthcare news focuses on physician shortages and how those shortages affect care availability and delivery. Primary care specialties appear to be in a perennial shortage state, which garners headlines for compelling reasons: the US population is aging — and growing — and approximately one third of physicians will reach retirement age in the next four years, according to data from the Association of American Medical Colleges (AAMC). Psychiatry and surgical specialties also tend to top the shortage lists on a regular basis.

This may sound dire, but there’s a countering trend that spells good news ahead: young people are choosing medicine in record numbers. The number of US medical students topped 95,000 in 2021, up from about 69,000 in 2002, a recent AAMC report found. In addition, the number of US physicians in 2020 topped one million, up nearly 20 percent from a decade earlier, according to the Federation of State Medical Boards’ biennial census.

What’s happening in the specialties?

So, in a profession that’s growing rapidly, where are physicians landing after training? The AAMC’s 2022 Physician Specialty Data Report yields some interesting findings regarding where growth and attrition are occurring. Michael Dill, AAMC’s director of workforce studies, said that the report yielded few “huge surprises” but did reveal some puzzling declines. These drops occurred in orthopedic surgery, which declined 2.2 percent, and in anatomical/clinical pathology, which was down 7.7 percent. Radiology experienced a 2.4 percent decline, and there was a 1.5 percent decline in preventive medicine. Anesthesiology was essentially flat at 1.1 percent growth, and thoracic surgery declined 0.2 percent. Neurology, ophthalmology, and otolaryngology were also flat, at about one percent. Some declines might be attributed to subspecialization shifts, Mr. Dill said, or to physician supply and demand factors.

Overall, the specialties combined experienced 7 percent growth. A few specialties had moderate growth, including emergency medicine at 14 percent, geriatric medicine at 13 percent, endocrinology at 12.8 percent, infectious disease at 11.4 percent, rheumatology at 10.5 percent, and nephrology at 10 percent. Vascular surgery grew 15.2 percent, and vascular and interventional radiology saw its ranks increase 25.1 percent. Several specialties saw modest growth, based on AAMC findings, including the following:

Allergy and immunology: 7.0%

Dermatology: 6.8%

Gastroenterology: 7.8%

Neurological surgery: 5.9%

Radiation oncology: 8.2%

In pediatrics, although the overall specialty grew by only 2.5 percent, several specialty subsets saw significant growth. Pediatric critical care medicine grew 25.1 percent, pediatric hematology/oncology 18.8 percent, and perinatal/neonatal medicine 12.0 percent. Pediatric anesthesiology experienced 37.7 percent growth, and the field now has nearly three thousand physicians.

PEDIATRICS ANES

Specialties topping the growth charts

At the other end of the spectrum, the report found major growth in a handful of specialties, such as critical care medicine, sports medicine, interventional cardiology, vascular and interventional radiology, and neuroradiology. Pediatric anesthesiology experienced 37.7 percent growth, and pain medicine and management grew by 25.4 percent. Between 2016 and 2021, the following are some trends in specialties that reported either high growth during the study period or a recent major increase in the numbers of first-year residents and fellows:

Sports medicine. In a field that was little known twenty years ago, growth was up 42 percent over the five-year period, to 3,208 active physicians from 2,252 in 2016. William Roberts, MD, chief medical officer of the American College of Sports Medicine, observed that greater recognition of the importance of physical activity in achieving or maintaining health has been one driver, along with the proliferation of hospital- and health system-based sports medicine clinics. In addition, many primary care practices have begun incorporating sports medicine services, which has likely been a boon in expanding practice opportunities, Dr. Roberts noted.

“Sports medicine physicians appreciate the opportunity to work with professional athletes at various stages of their careers, and that’s a big draw for physicians with an interest or personal background in athletics,” Dr. Roberts said. The number of physicians who practice sports medicine surgery as a subset of orthopedics has grown 26 percent.

For Jessie Fudge, MD, a sports medicine physician at Kaiser Permanente in Everett, Washington, the field’s appeal was twofold. She knew, based on her and an athlete, that physical activity and exercise can be key in promoting and maintaining health, and she has witnessed in practice that physical activity can help manage and prevent chronic disease.

“We’ve seen an increased focus on exercise as medicine, even if some people don’t understand or follow the guidelines,” said Dr. Fudge, who has been involved in Special Olympics for several years. The other appeal of the field is its broad reach across patient types and its extensive specialization options. “The practice opportunities are so broad that physicians can basically identify their passion and then find a way to pursue it,” she said.

Critical care medicine. This field grew 30 percent over five years, from 10,883 to 14,159 active physicians, due in part to expanding treatments and also to growing awareness of its range of pathways to fellowship specialization: internal medicine, pulmonary medicine, and anesthesia. Shaun Thompson, MD, chair of the Society of Critical Care Medicine’s Graduate and Resident Education Committee, said that interest in the field spiked during the pandemic, when residents were, by necessity, exposed to the specialty.

“It’s the last stop between life and death for some patients, and many young physicians found themselves attracted to both the intense care environment and the teamwork aspect of critical care medicine,” said Dr. Thompson, who is director of the critical care anesthesiology fellowship at the University of Nebraska. “It’s a great feeling to take a patient who is at death’s door and turn the situation around.” He observed that the robust critical care job market, in light of the predicted 30 percent shortfall by 2030, the opportunities for telehealth consulting, and the recognition that compensation is increasing are also spurring more interest in the field.

“Most of my trainees have signed contracts by the end of their first year of fellowship. So, the need is clearly there.”

—Shaun Thompson, MD, chair, Society of Critical Care Medicine Graduate and Resident Education Committee

Interventional cardiology. The 32.6 percent growth in this field — from 3,572 to 4,736 physicians — is hardly surprising, given the ongoing treatment advances in the sector and the aging population. In addition, approximately 60 percent of all cardiologists are nearing retirement age, which is creating a vibrant job market for subspecialists. And although the field remains predominantly male, at approximately 91 percent, the number of women entering interventional cardiology is rising.

Pain medicine and pain management. Continuing a trend seen in earlier years, pain medicine remains a popular practice option. The field grew by 25.4 percent between 2015 and 2019, to approximately 3,000 physicians. In the previous AAMC report covering the years 2014–2019, the specialty’s physician numbers increased by 34.3 percent.

Two trends likely spurring the growth are increasing awareness of the field’s advances, including the broad range of new and evolving treatments and therapies available beyond traditional pain medications and opioids, and the demographics: approximately 25 million Americans suffer from chronic pain, and both patients and health care organizations want expert-guided options. Charles Argoff, MD, president-elect of the American Academy of Pain Medicine and professor of neurology at Albany Medical College in New York, cites a third reason physicians choose the field: a personal experience involving patients or family members challenged by unrelieved pain.

“Today, people realize that pain medicine is a very active specialty that offers many different treatments. We’re seeing a lot of interest in the advanced non-opioid treatments and techniques — there’s been a virtual explosion of those in the last 10 to 15 years”

—Charles Argoff, MD, president-elect, American Academy of Pain Medicine

Dr. Argoff also noted that Albany Med’s fellowship program draws scores of applicants and that practicing physicians in other specialties are also interested in becoming better educated on pain management. “It’s a very exciting time for the specialty, and there are a lot of practice opportunities.”

Pediatric anesthesiology. The major growth spurt in the field — 37.7 percent between 2015 and 2019 — is likely due to a couple of factors, according to James Fehr, MD, president of the Society for Pediatric Anesthesia (PSA) and anesthesiologist-in-chief at Lucile Packard Children’s Hospital at Stanford University. The specialty was founded in 1986, but board certification wasn’t available until 2013. That sparked more interest in the specialty, as existing specialists were “grandmothered in,” Dr. Fehr said, and the number of fellowships increased, from about 100 in 2005 to 215 by 2020.

“We’ve had significant growth in replacement levels, but we’re also seeing a lot of people retiring. This is creating a lot of opportunities for jobs, so it’s a wonderful time to get into the field,” Dr. Fehr said. “And people who choose our specialty are generally happy, so that’s another plus.” Practice opportunities have become more plentiful as health care organizations realize that they want — and need — the specialized expertise to care and advocate for these vulnerable patients.” Pediatric anesthesia has also progressed impressively in recent years, Dr. Fehr added, with advances in neuromonitoring and patient safety, including the development of the SPA’s Pedi-Crisis app now being used globally to improve intraoperative care.

Psychiatry. Although the specialty has grown little overall in the past decade (only 0.2 percent between 2016 and 2021) and remains seriously undersupplied in many areas of the country, there has been a notable increase in interest in the field in recent years. The number of first-year residents and fellows in American Council for Graduate Medical Education-accredited programs grew by 26.3 percent between 2016 and 2021, and overall, child and adolescent psychiatry grew nearly 10 percent.

Petros Levounis, MD, president of the American Psychiatric Association, attributes the increased interest to three factors. First, awareness of the importance of mental health in overall health status is growing, and, at long last, there has been a decline in the stigma surrounding mental health conditions. Further, the specialty has seen a significant expansion in the treatments available for conditions such as depression and schizophrenia. In addition, the pandemic highlighted the need for and benefits of mental health services, including among physicians.

“We used to scream from the rooftops about the importance of mental health, and now people finally understand — they want the services and the education,” said Dr. Levounis, who is chair of psychiatry at Rutgers New Jersey Medical School. “The treatment advances are off the chart, especially for depression and substance-use disorders, and this is generating more interest in the specialty.”

Dr. Levounis cited the recent virtual explosion in telepsychiatry services during the pandemic, which has generated increased interest among medical graduates who find the care setting appealing and who view the field, generally, as one that allows for a more integrated professional and personal life. “That potential for integration of their personal and practice lives by virtue of the humanistic work they do daily is attractive to young physicians. Many young physicians believe they’ve become better psychiatrists because of that integration,” Dr. Levounis said.

For Amira Collison, MD, a third-year psychiatry resident at the University of California, Los Angeles, a desire to improve access to mental health care for underserved and marginalized populations, as well as a personal experience with mental illness in her own family, led to her specialty choice. She was also attracted to a benefit that’s increasingly rare in medicine: the opportunity to spend time with patients and truly get to know them.

“Psychiatry is one of the only specialties in which you get to spend an entire hour with your patients. And a lot of people go into medicine because they want to talk to their patients,” she said. Dr. Collison added that perceptions about the field have changed in tandem with both treatment advances and the recognition that mental illness can be effectively treated in many individuals. In short, psychiatry is not a “fallback” specialty, according to Dr. Collison.

“Psychiatry is no longer the field you go into when you don’t ‘have the scores’ for other specialties. It’s become far more competitive”

— Amira Collison, MD, UCLA resident

Data on residents and fellows in the specialties

Not surprisingly, the renewed interest in primary care among medical students continues to be borne out by the data on first-year residents and fellows. In 2021, there were 11,297 first-year internal medicine trainees, 4,856 family medicine/general practice trainees, and 3,143 pediatrics residents and fellows. Overall growth between 2016 and 2021 was 3.8 percent in family medicine, 3.6 percent in internal medicine, and 2.5 percent in pediatrics. The AAMC’s 2020 report on the previous five years found increases of approximately five percent in the three specialties.

The breakdown in the pathways of current trainees is likewise not surprising. US MDs make up 60.1 percent of all trainees, according to report data, and DOs 16.9 percent. International medical graduates account for 22.9 percent of residents and fellows. In the 2020 report, those figures were 66.1 percent, 8.2 percent, and 24.7 percent, respectively. There were 149,200 active residents and fellows in the 2020–2021 academic year, an increase of 2.9 percent from the previous year.

The gender breakdown — in 2021, 47.3 percent of first-year trainees were male — may soon start shifting because approximately 53 percent of matriculating medical students are now female, according to Mr. Dill of the AAMC. He noted that 2022 was the first time that gender data was tallied for the specialties report. In the interim, only a few specialties can claim higher numbers of female physicians than male physicians. These include OB/GYN, at 60.5 percent female, geriatric medicine (55.1 percent), pediatric hematology/oncology (55.7 percent), child and adolescent psychiatry (54.6 percent), pediatrics (53.4 percent), dermatology (52.2 percent), neonatal/perinatal medicine (54.2 percent), and endocrinology (53 percent).

As the trends in psychiatry and sports medicine reported above illustrate, recent data can illuminate growth and decline trends in the making. Preventive medicine’s overall 1.6 percent decline between 2016 and 2021 over five years translated, by 2021, into a 39.4 percent decline in the number of first-year residents and fellows. Pediatric anesthesiology saw a more pronounced trajectory; although total numbers in the field had increased, growth in first-year residents and fellows fell 16 percent.