Application Trends in Pulmonary and Critical Care Medicine Fellowships

Background

This study, using publicly available data from the NRMP (National Resident Matching Program), was designed to describe changes in the last decade in internal medicine (IM) subspecialty fellowship match patterns, with a focus on pulmonary and critical care medicine (PCCM).

In 1995, representatives of the American College of Chest Physicians, American Thoracic Society, Society of Critical Care Medicine, and the Association of Pulmonary and Critical Care Medicine Program Directors formed COMPACCS (Committee on Manpower for Pulmonary and Critical Care Societies) to evaluate the workforce and training needs in PCCM (1). In 2000, this committee published a report forecasting a shortage of PCCM physicians because of rising demand from an aging population (1). This projected shortage prompted COMPACCS to recommend critical care societies take steps to improve the efficiency of and increase the number of critical care providers (2). This has resulted in the implementation of tele-intensive care unit care, using advanced practice providers, and providing intensive care training to hospitalists (3).

Increasing the number of trainees who pursue PCCM would have the most direct impact on the shortage. However, shortly after this report, IM residents reported reservations about the specialty (4). In a 2005 survey, whereas 41% of residents seriously considered PCCM as a specialty, only 3.4% ultimately applied to a PCCM fellowship program (4). Residents cited time demands and stress as major dissuading features. There was concern that growth in the specialty would lag because of interest. However, a recent study showed considerably higher growth in PCCM applications and fellowship positions since that time when compared with the pulmonary medicine fellowship (5).

Methods

We used publicly available data from the NRMP to examine the application and match data for all IM subspecialties using Microsoft Excel. Subspecialties with more than 200 applications in the 2021 matriculation cycle were included. Annual match data for each specialty (number of applications and positions offered) from 2010 to the present were collected from the publicly available NRMP archive (6).

We used this data to calculate the “specialty competitiveness ratio” (SCR) to define the number of applicants per match position offered within the specialty. The SCR is calculated as shown below.

SCR=Number of unique applicants to the specialty/Number of available training positions in that specialty

An SCR greater than one indicates more applicants than match positions, meaning this specialty is more competitive. An SCR of less than one indicates more match positions than applicants.

The average annual growth rate of fellowship positions and applications was calculated for each specialty. One-sample t test was performed on mean annual growth for all specialties using an α of 0.05 and a null hypothesis of zero growth.

Results

In 2021, the largest fellowships were cardiology (1,045 match positions), PCCM (657), hematology/oncology (638), gastroenterology (590), and nephrology (474). The specialties with the greatest number of applicants were cardiology (1,575 applicants), PCCM (1,023), hematology/oncology (909), gastroenterology (895), and palliative care (415).

In 2021, PCCM had the highest SCR (1.56) of the IM subspecialties for the first time since 2014 (Figure 1). Gastroenterology and cardiology fellowships ranked second and third, respectively, with SCRs of 1.52 and 1.51. Infectious diseases, nephrology, and geriatrics are the only specialties with an SCR below 1.

Figure 1.

Specialty competitiveness ratio for internal medicine subspecialties since 2010.

Figure 2 outlines the annual growth in applications and fellowship positions for each specialty since 2010. Two specialties with less than 10 years of data, geriatric medicine and palliative care, were excluded from this figure. PCCM applications increased by 5.37% annually, the most of any specialty. The second greatest annual increase in applications was in gastroenterology with 3.35%. PCCM has been the third-fastest growing specialty in match positions since 2010, with average annual growth of 4.40%, behind gastroenterology (4.63%) and endocrinology (4.59%) (Figure 2). Since 2010, PCCM has been the only specialty with greater percent growth in applications than match positions. Cardiology, endocrinology, gastroenterology, hematology/oncology, PCCM, and rheumatology all had statistically significant annual growth in fellowship positions, whereas PCCM and gastroenterology were the only two specialties with statistically significant annual growth of applications.

Figure 2.

Average annual percent growth of fellowship positions and applications since 2010.

Discussion

This evaluation of NRMP match data indicates that in the 2020 match cycle, PCCM was the most popular specialty, as measured by the SCR. The 60.2% growth in PCCM fellowship positions over the last decade ranked third among IM subspecialties, and PCCM is the only IM subspecialty that has had more growth in applicants than in match positions.

This rising popularity correlates with workforce analysis from the Department of Health and Human Services, which estimated the 2013 supply of pulmonologists in the United States to be 12,380, notably greater than the predicted supply of pulmonologists by Angus and colleagues of approximately 7,000 (1, 7). Despite this finding, they still estimated a shortage of 1,400 pulmonary physicians by 2025.

There is little published to explain the rise in popularity of PCCM. A recent survey of PCCM fellows reported high rates of depression (41%) and burnout (32%) that appear to be at odds with the rising SCR (8). The increased popularity is likely multifactorial, including the following. First, PCCM provides a diverse spectrum of disease and intellectual stimulation; both are features that residents rank as important when choosing career paths (9). PCCM has the third highest salary among IM subspecialties (10). Other specialties with high SCR scores also have high salaries, which would suggest some financial motivation to explain the rise in popularity (10). The pandemic has shone a spotlight on critical care physicians, and there is some thought that this may drive more applicants to PCCM. Given the discordance between published literature on PCCM interest and fellowship application data, a more thorough analysis of factors influencing IM resident decisions about fellowship choice is warranted.

Over the last decade, PCCM has grown in both fellowship positions and applications, and it was the only specialty with a greater percent increase in applications than fellowship positions. This resulted in PCCM ranking number one in popularity by the SCR for the first time since 2014. This rise in popularity has helped alleviate the PCCM physician shortage predicted in 1995.