OBJECTIVES: To examine trends in pediatric residents’ training and job search experiences from 2003 through 2009.
METHODS: Annual national random samples of 500 graduating pediatric residents from 2003 through 2005 and 1000 from 2006 through 2009 were surveyed. Responses were compared across years to identify trends. We examined resident demographics, training, satisfaction, career intentions, and job search experiences. Overall response rate was 61%.
RESULTS: Between 2003 and 2009, there was an increase in the proportion of female graduating pediatric residents (69%–75%), residents from international medical schools (15%–23%), and levels of educational debt among the subgroup of residents with debt ($139 945 in 2003 to $166 972 in 2009). Residents consistently reported (>90% of residents) that they would choose pediatrics again if they had the choice. By 2009, the majority was very satisfied with the quality of their training in most areas, with ratings improving across years in caring for children with special health care needs, evidence-based medicine, and using information technology in practice. Although primary care remained the most common clinical practice goal, there was a modest decline in interest in primary care practice across survey years, whereas interest in subspecialty practice increased. Residents accepting both general pediatric practice and hospitalist positions reported less difficulty in their job search over time.
CONCLUSIONS: Despite continually changing demographics of pediatric training programs, residents overall remain very satisfied with their decision to become pediatricians. Pediatricians continue to face difficult financial challenges associated with rising debt, but they also report increasing job search success.
- AAP —
- American Academy of Pediatrics
- FT —
- PT —
What’s Known on This Subject:
In the previous decade, graduating pediatric residents generally experienced success in finding desired jobs, but they also experienced increased debt and flat starting salaries.
What This Study Adds:
This study highlights trends over the past several years (2003–2009) including high levels of satisfaction among graduating pediatric residents, increasing ease in obtaining postresidency positions, and a modest decline in interest in primary care practice.
Graduating pediatric residents can provide valuable information about their residency experiences, future goals, and interests. The American Academy of Pediatrics (AAP) developed the Third-Year Graduating Resident Survey to systematically collect information annually from a national sample of graduating pediatric residents. Data have been collected since 1997, and findings have provided insight into resident characteristics, various training areas, and career intentions.1–10
In 2003, the first national trend report from the AAP survey was published using data from 1997 through 2002.6 Several changes in pediatric training, resident career goals, and the pediatric job market were reported, including more residents with debt and higher debt, decreasing starting salaries, increasing presence of women and underrepresented minorities, and decreasing presence of international medical graduates. Future clinical goals of graduating residents also changed, with resident interest in general pediatric practice declining across years and subspecialty practice interest increasing.
In this article, we present national trend data from the AAP Third-Year Graduating Resident Survey on resident characteristics, training and satisfaction with training, career intentions, and job search experience, including salary of posttraining position. This article focuses on 7 years of data, from 2003 through 2009.
We analyzed data from 7 years of the AAP Third Year Graduating Resident Survey, 2003 through 2009. The survey was fielded annually to a random sample of 500 graduating pediatric residents from 2003 through 2005 and 1000 from 2006 through 2009 during and following their last months of training (May to November). The residents were randomly selected from an AAP database that includes residents from all US programs. Residents from combined training programs, such as Med/Peds programs were not included in each sample.
In years 2003 through 2005, residents were sent up to 4 mailings of the survey, and in years 2006 through 2009, residents were contacted up to 4 times through the US Postal Service and up to 4 times by e-mail, for up to 8 contacts. Response rates to the survey varied from a low of 57% in 2005 to a high of 64% in 2007; the combined response rate was 61% (n = 3260). We examined response rates for possible patterns of change and found no decline in rates over time, P = .64. Residents from >175 residency programs responded to the survey across the 7-year period, which represents 88% of the programs currently listed on the American Medical Association’s online database, FREIDA.11
To assess potential response bias, respondents were compared with nonrespondents for gender and age. For all survey years combined, significant differences were found between respondents and nonrespondents for gender (percentage female: 73% vs 65%, P < .001) but not age (percentage > 34 years old: 13% vs 14%, P = .07).
The surveys included core questions that were repeated each year and thematic questions that varied from year to year. This study focuses on questions that were common across all 7 years including 1) resident characteristics, 2) training and satisfaction with training, 3) career plans, and 4) job search experience, including salary of posttraining position.
Residents were asked questions on demographic characteristics and about educational debt. They were asked to include college, medical school, and, if married, spouse educational debt. For all variables expressed in dollars, adjustments for inflation were performed by using the yearly Consumer Price Index to convert all values to 2009 dollars.
To assess training satisfaction, residents were asked (1) if they did their residency over, would they choose a categorical pediatrics residency again, and (2) how well their residency prepared them for various professional activities by using a 5-level scale. Responses were dichotomized: very good/excellent and good/fair/poor. Residents assessed their preparation for general categories of training (eg, primary care practice or pediatric fellowship training).
Career Plans and Job Search
All residents were asked questions about their career plans and clinical practice goals. Residents were also asked about their post-residency job or position, if their new position was in the same state as their residency, and if the new position was in a rural area (population <2500) or small town (population 2500–49 999). The question on practice goal included the following response options: primary care, primary and subspecialty practice, subspecialty practice, hospitalist, and not entering clinical practice. The question on postresidency job or position included the following response options: general pediatric practice, pediatric subspecialty fellowship, hospitalist, chief resident, other, and no position or job. Residents who had accepted a general pediatrics practice position when surveyed were also asked how many hours they expected to work in the practice, excluding hospital rounding and on-call hours. Job search experiences were assessed in various ways including asking residents if they had no, some, moderate or considerable difficulty in their job search. Because differences in job search experiences and income have been reported for different careers,6 we present trend data separately for general pediatric practice and hospitalist positions. For income, we present mean income, excluding bonuses and benefits, separately for residents with full-time (FT) and residents with part-time (PT) or reduced-hours positions.
Trend analyses comparing survey years were conducted for each variable by using linear regression analyses for continuous outcome variables and linear association χ2 tests for categorical variables. In summarizing trend analyses in the text, we provide 2003 results and 2009 results, as well as the P value, which refers to the overall trend across years.
The number of cases in each statistical analysis varied slightly because of missing values for specific questions. An α level of .05 was used to determine statistical significance. Surveys for this study were approved by the AAP Institutional Review Board.
The percentage of female respondents significantly increased across survey years from 69% in 2003 to 75% in 2009, P < .05. The percentage of residents graduating from international medical schools also increased (15% in 2003 to 23% in 2009, P < .01). Of those who graduated from US medical schools, the percentage of unrepresented minorities (black, Hispanic, or Native American) did not significantly change across years (9% in 2003 to 15% in 2009, P = .09), white US medical graduates decreased from 73% in 2003 to 64% in 2009, P < .05, and Asian US graduates (15% in 2003 and 16% in 2009, P = .37) and other US graduates (3% in 2003 and 5% in 2009, P = .42) remained stable. Marital status among residents remained steady with 66% in 2003 and 70% in 2009 married or living with a partner (P = .63). Residents with children was also unchanged (30% in 2003 and 31% in 2009, P = .55).
The percentage of residents reporting that they had any education debt remained high with no change over time (75% in 2003 and 74% in 2009, P = .40). From 2003 through 2009, residents reported increasing total debt (see Fig 1). The average resident debt (in 2009 dollars) for all respondents increased 17% from $104 358 (SD = $93 000) in 2003 to $121 935 (SD = $103 000) in 2009, P < .01. Among a subgroup of respondents, those who reported having educational debt, the average debt in 2009 dollars increased 19% from $139 945 (SD = $81 000) in 2003 to $166 972 (SD = $84 000) in 2009, P < .001. Overall, among residents reporting debt, married respondents reported higher debt ($156 994; SD = $89 000) than unmarried respondents ($140 093, SD = $68 000), P < .001.
Resident Training and Satisfaction With Training
The percentage of residents with a mentor who provided career advice during residency increased from 87% in 2003 to 93% in 2009, P < .001. Resident-reported program class size increased from a mean of 17 (SD = 8) in 2003 to 19 (SD = 12) in 2009, P < .001. More than 9 of 10 residents across the years reported that they would repeat a pediatric residency (94% in both 2003 and 2009, P = .58).
The percentage of residents rating their program as very good or excellent in preparing them for caring for children with special health care needs, evidence-based medicine, and using information technology increased across years (see Table 1). Ratings for preparation for research remained low with no change (18% in 2003 and 22% in 2009, P = .58).
Residents were asked if they planned to practice primary care at the start of their residency. The majority of residents had such plans in 2003 (51%) decreasing to 40% in 2009, P < .001 (see Table 2).
Significant changes also occurred in the future clinical practice goals of residents at the time of graduation (see Table 2). Although primary care practice remained the most common goal, the percentage of residents interested declined across survey years, P < .05, and the percentage interested in subspecialty practice increased, P < .01. The percentage of residents with a hospitalist goal did not increase significantly over time.
Job Search Experience for Residents With a General Pediatric or Hospitalist Position
Almost all residents had a job when surveyed, increasing from 89% in 2003 to 97% in 2009, P < .001. Overall, 35% of all respondents accepted a general pediatric practice position, and nearly all (96%) of these residents reported having a primary care or a combined primary care and subspecialty care practice goal.
For residents who accepted a general pediatric position or a hospitalist position (overall, 35% and 9%, respectively), fewer reported moderate or considerable job search difficulty by 2009, P < .001 (see Table 3). Across survey years, the mean number of job applications submitted decreased for general pediatric positions. Among married/partnered residents, the percentage with a general pediatric practice or hospitalist position who reported that their spouse/partner’s career plans or their family situation limited their selection of positions decreased over time, P < .05. The tendency for most accepted positions to be in the same state of residency training was consistent over time for general pediatric positions (P = .43) and decreased for hospitalist positions (P = .05). Less than one-third of the general pediatrics positions that residents accepted were in a rural area or small town (population <50 000), and this remained stable over the years, P = .73. Although a consistent number of residents with a general pediatric position accepted a PT or reduced-hours position, fewer with a hospitalist position accepted such a position across years.
Among both residents who accepted a FT or PT general pediatric position, the expected number of work hours in the practice, excluding hospital rounding and on-call hours, was consistent (FT mean = 40 hours in both 2003 [SD = 9] and 2009 [SD = 11], P = .94; and PT mean = 25 hours in 2003 [SD = 9] and 22 hours in 2009 [SD = 7], P = .33).
Starting mean salaries, excluding bonuses (in 2009 dollars) remained stable across survey years for those accepting FT general pediatric practice ($128 000 in 2003 [SD = $21 000] and $126 000 in 2009 [SD = $25 000], P = .42), pediatric fellowship training ($54 000 in both 2003 [SD = $12 000] and 2009 [SD = $13 000], P = .99), and chief residency ($62 000 in 2003 [SD = $13 000] and $65 000 in 2009 [SD = $14 000], P = .24) positions. Salaries increased for those accepting FT hospitalist positions ($114 000 in 2003 [SD = $23 000] and $126 000 in 2009 [SD = $17 000], P = .05). Starting salaries for PT general pediatric practice and hospitalist jobs remained unchanged across years ($79 000 in 2003 [SD = $25 000] and $80 000 in 2009 [SD = $25 000], P = .79).
The AAP Third-Year Graduating Resident Survey (2003–2009) highlights high levels of satisfaction among pediatric residents, increasing ease in obtaining positions, and a modest change in career goals away from primary care and toward subspecialty care. These findings have importance for pediatric training and for the pediatrician workforce.
Despite changing demographics and career goals of residents, our data indicate that training programs seem to be doing considerably well. More than 9 out of 10 residents would choose a pediatrics residency again if they had a choice, and by 2009, nearly all graduating residents reported having a mentor who provided career advice during residency. Others have reported that mentored residents describe positive impacts on professional and personal development and receipt of helpful career advice.12
The majority of residents left residency feeling well prepared for both primary care pediatric practice and pediatric fellowship training. Graduating residents were progressively more satisfied with their residency program preparation for caring for children with special health care needs, evidence-based medicine, and using information technology in practice. These skills are all important components in the ability to practice medical home principles.13,14 These gains were made without concomitant losses in other training areas. Approximately half of residents felt well prepared for child advocacy, and this was consistent across years. More research is needed to understand the scope of opportunities available to residents to develop skills in advocacy and become community partners in advocating for children. Although required by the Accreditation Council for Graduate Medical Education15 and recommended by the AAP Committee on Pediatric Research,16 few residents in our study reported feeling prepared for research. Some work has been done on development of research skills during residency training,17–19 but more is needed to understand the best approaches to advancing knowledge of basic research principles given the limited time available during residency.
Residents continue to experience increasing debt burdens with 3 in 4 residents carrying debt. Although there was considerable variation in resident debt, the average amount of debt continued to rise across survey years. At the same time, starting FT salaries for residents going into general pediatric practice remained stable. Starting salary for hospitalist positions did increase over the years and is now similar to those going into general pediatric practice, ∼$126 000 in 2009. Our figure might underestimate pediatrician starting salaries overall because bonuses are excluded.20 Rising educational debt coupled with a considerably lower salary than other specialties21 puts young pediatricians at a disadvantage as they start their postresidency careers.
Three in 4 residents graduating from pediatric residency programs were women. The increasing presence of women in pediatrics places the profession among the top 2 specialties most attractive to women.22 Almost 1 in 4 pediatric residency graduates attended an international medical school in 2009, which could also have training and workforce implications. International medical school graduates might have different training and cultural expectations and different career goals.7,23,24
In the previous 6-year study, the percentage of underrepresented minorities from US medical schools significantly increased across years (1997–2002).6 We found that the percentage of underrepresented minority graduates has stabilized over the past 7 years and still fails to reflect the growing racial and ethnic diversity of US children25 despite the call by many to promote diversity within the medical profession.26–30
We found a modest decline in future clinical practice goals of primary care and an increase in subspecialty practice interest across years. The data do not reflect that primary care practice is being de-emphasized by residency training programs.6 The quality ratings for primary care pediatric practice have remained stable over time and are comparable to the ratings for pediatric fellowship training. Approximately 7% of graduating pediatric residents reported having a combined primary care–subspecialty practice goal. Others have also reported that some pediatricians split their time between general and subspecialty care.31 Career path decision-making is a complex process, and many factors such as resident characteristics, medical school location, residency program size, debt, potential income, mentors, work-life balance, interest in specific disciplines, job opportunities, job security, and family circumstances might be related to changes seen in career choice.
Overall, 11% of residents in our sample had a future clinical practice goal as a hospitalist, which is consistent with other surveys of hospitalist careers.24 In our study, we found that residents with either a general pediatric or hospitalist position experienced less difficulty in their job search. Hospitalist options may be providing another set of choices, making it easier to find either primary care or hospitalist jobs, especially within desired geographic locations. Hospital medicine is an evolving field, and it will be important to continue to monitor its growth and better understand pediatric hospitalist careers and whether there are limits to the number of new hospitalist positions that can be generated.
As the US moves forward with health care reform, there is growing concern about a shortage of primary care physicians. Although it is crucial to include pediatrics with other primary care specialties in workforce discussions, it is also important to recognize that the pediatrician supply differs from other primary care physicians.32–34 Pediatric subspecialists are different from adult specialists, and the pediatric medical subspecialty workforce may already be experiencing some areas of inadequate or undersupply.35 At the same time, decreasing numbers of primary care pediatricians may become problematic if the pendulum swings too far away from primary care. For both primary care and subspecialty care, geographic maldistribution remains a significant challenge, and policy efforts should continue to explore possible solutions.
There are limitations to the current study. All data were self-reported by residents and are subject to some recall bias. Response rates and sample sizes varied over the years and may have had an impact on the comparability of samples across years. Overall, women were more likely to respond to the surveys. As a result, interest in subspecialty training and expected future work hours could be underestimated. However, increasing interest in subspecialty training is consistent with American Board of Pediatrics data.36 Reported debt for married respondents included spousal debt, so for these individuals, we are unable to separate out the debt load for the respondent versus their spouse. Finally, the timing of survey completion could have affected responses to items pertaining to job search and postresidency position. Previous research found that the amount of time before survey completion was not related to likelihood of having a job.6
Our study provides insight into the training and career goals of graduating pediatric residents from 2003 through 2009. Many changes have occurred, including an increasing presence of women and international medical school graduates, modest increase in resident interest in subspecialty practice and decrease in primary care interest, and increased training satisfaction despite increasing debt and lower starting incomes than other specialties. Job search difficulties have declined, possibly related to more residents going into subspecialties or the availability of hospitalist positions. These trends need to be monitored continuously to assess the impact of policy changes, such as health care reform, on residency training and the career choices of new pediatricians.
- Accepted October 27, 2011.
- Address correspondence to Mary Pat Frintner, MSPH, American Academy of Pediatrics, 141 Northwest Point Blvd, Elk Grove Village, IL 60007. E-mail:
Ms Frintner and Dr Cull have made substantive intellectual contributions to the conception and design of the article; the acquisition, analysis, and interpretation of data; the drafting of the article or revising it critically for important intellectual content; and have approved the article for publication. Ms Frintner and Dr Cull have participated sufficiently in the work to take public responsibility for appropriate portions of the content. The views represented here are those of the authors.
FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.
FUNDING: Supported by the American Academy of Pediatrics.
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