Changes in approved internal medicine subspecialty fellowship programs and positions 2001-2008

Robert P. Ferguson, MD, FACP¹ and Fernanda Porto Carreiro² (¹Union Memorial Hospital, ²University of Maryland School of Medicine)

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Internal medicine subspecialty fellowships, in both size and number, respond to various educational forces.  In the mid-90’s, a general decline took place in the number of subspecialists being trained.  This was during the time of influence in growth of primary care medicine.  In the decade of the 2000’s, opposing forces have been at work, including market studies that have predicted an increasing need for future subspecialists.  In 2005, in this context, the ACGME deleted the requirement for a critical mass of at least three subspecialties for sponsoring institutions. 

To our knowledge, the impact of these forces have not been examined, particularly in reference to community hospital sponsorship.

Objectives:

• To review approved fellowship programs and positions between 2001 and 2008, in order to examine the status of internal medicine subspecialty training, particularly, trends in community program sponsorship in response to the changing environment and regulations. 
• To our knowledge, separating community from non-community fellowship sponsorship has not previously been studied, in part because of difficulties in determining community vs non-community criteria.

Methods:

• Using archived ACGME data, we were able to examine programs and positions and their status between 2001 and 2008.
• We divided programs into "university" (which included traditional primary medical school fellowships as well as other federally sponsored fellowships - V.A. and military).  All others, including multispecialty clinics, traditional community programs and municipal hospitals were included under "community".  This is a modification of the current classification used by the Association of Program Directors in Internal Medicine.

Results:

• From 2001 – 2008, there were 86 newly approved internal medicine subspecialty fellowships.  Fifty-two (60%) were community hospital sponsored; thirty-four– university.  As of 3/01/08, all 86 are in good standing. 
• The highest numbers were in pulmonary/critical care or either of the two (18), cardiovascular disease (11) and geriatrics (11).  Eleven of these newly sponsored programs were started as a first fellowship since 2005. 
• The number of new programs approved between 2005 and 2008 was roughly three times that approved between 2001 and 2004.  During the same period, there were 102 programs withdrawn, twenty due to accreditation withdrawal and 82 voluntary withdrawals. 
• The total number of fellowship positions has continued to increase.  The greatest has been in hematology/oncology.  There had been sharp declines in positions in hematology.

Conclusions:

There has been an overall increase in subspecialty fellowships approved positions in the last eight years, and many of the new programs have been at community hospitals.  A significant increase in newly approved solo programs was found primarily at community hospitals since the RRC regulations changed in 2005.  Fellowship positions are growing most impressively in the subspecialty of hematology/oncology.