Original contributions

Unemployment and Underemployment in 1996 Graduates ofNew York City Gastroenterology Training Programs

Jonathan David, M.D., F.A.C.P., F.A.C.G., Avigayil Mogilner, B.A., and Lisa A. Ozick, M.D., F.A.C.G.Division of Gastroenterology, Department of Medicine, Harlem Hospital Center—Columbia University College of Physicians and

Surgeons, New York, New York

Objective:Based on anecdotal reports of young gas-troenterologists facing extreme difficulty in finding ajob, we sought to gain information about the success ofnewly trained gastroenterologists in finding employmentin their subspecialty, and to find any possible predictorsof unemployment.Methods:We surveyed all fellows fin-ishing basic or advanced gastroenterology fellowshiptraining in New York City in June 1996. Data werecollected on unemployment, underemployment (practic-ing less than half-time gastroenterology), and also typeof job, employment terms, training program, medicalschool, gender, and satisfaction with job plans.Results:Of the 59 study subjects who sought gastroenterologyemployment in the United States, data were collected onall of them (100%). Fifteen subjects (25%) were unem-ployed. An additional 10 subjects (17%) were underem-ployed. Of the 24 subjects expecting to be associates in agroup practice, eight (33%) had either no signed con-tract, were underemployed, or both. Programs that didnot participate in the National Residency Matching Pro-gram were more likely to have both unemployed andunderemployed graduates.Conclusion: Unemploymentamong newly trained gastroenterologists in New YorkCity is very high. Also, there is substantial underemploy-ment, and this phenomenon needs to be taken into ac-count when studying the workforce. (Am J Gastroen-terol 1998;93:1211–1216. © 1998 by Am. Coll. ofGastroenterology)

INTRODUCTION

There is increasing evidence that the United States has asurplus of subspecialist physicians, and that this surplus will

worsen in the coming few years (1–4). We chose to studythis surplus by examining the difficulty among newlytrained gastroenterologists in finding jobs in their subspe-cialty.

Recent studies by Milleret al. reported that in 1994 (1)and 1995 (2), the national unemployment rate among newlytrained gastroenterologists were 3.7% and 0.8%, respec-tively. These figures were obtained by surveying programdirectors nationally; the authors did not interview the grad-uating fellows themselves.

It was our impression that local unemployment amongnewly trained gastroenterologists was, and is, significantlygreater than national figures quoted by Milleret al. This wasbased on anecdotal data from fellows at our affiliated pro-grams and from colleagues at other institutions in New YorkCity, many of whom are recently trained and have hadpersonal experiences with the local job market.

Our aim, then, was to study the job market for gastroen-terology fellows finishing training in New York City in June1996. In addition to raw unemployment figures, we alsostudied “underemployment,” in which case a physicianmight be practicing only a small amount of gastroenterol-ogy, as well as other characteristics of the physicians andprograms from which they were graduating, to identify anypredictors of unemployment.

MATERIALS AND METHODS

We consulted the List of Available Training Programs (5)for a comprehensive catalog of gastroenterology trainingprograms in New York City. Twenty-four programs wereidentified. We reviewed the National Residency Match Pro-gram (NRMP) book (6) for confirmation, and found oneadditional program that was not listed in our original source,making a total of 25 programs in the five boroughs of NewYork City that we included in our survey (Table 1).

Program directors and/or administrators were contactedby phone in early May of 1996 and asked for the names of

Ms. Mogilner is currently at Albert Einstein College of Medicine,Bronx, New York.

Received Nov. 21, 1997; accepted Mar. 6, 1998.

THE AMERICAN JOURNAL OF GASTROENTEROLOGY Vol. 93, No. 8, 1998Copyright © 1998 by Am. Coll. of Gastroenterology ISSN 0002-9270/98/$19.00Published by Elsevier Science Inc. PII S0002-9270(98)00278-0

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fellows completing gastroenterology training that June orwithin the preceding 6 months. In each case, at least oneother person (usually a fellow) was independently asked toidentify all the graduates as corroboration. To be included inthe study, a fellow had to be finishing the training periodspecified by his or her program, either basic fellowship oradvanced gastroenterology fellowship beyond that requiredfor board eligibility. Full time hepatology fellows (all ofwhom had already completed gastroenterology fellowships)were excluded, based on the assumption that they may beseeking full-time hepatology employment.

In early May 1996, each of the study subjects was faxeda three-page survey and asked to return it via fax. Subjectswho had not responded were then contacted at DigestiveDisease Week (the annual gastroenterology meeting) in SanFrancisco on the electronic message system and left surveyswith the paging center there. Those who had still not re-sponded were contacted in New York after the conferencethrough their hospital pager systems. Some subjects whowere reluctant to complete the written survey were offeredthe alternative of a phone interview. All phone interviews

were conducted by the same investigator (J.D.). Most inter-views were completed by the end of June 1996, but somedata was gathered as late as August 1996.

Fellows were asked to identify their primary fellowshipprograms and the extent and type of any further training.They were then asked to designate what best described theirplans for after graduation: associate in a private grouppractice, employee in a hospital-based or HMO practice,solo private practice, full-time academics, more gastroen-terology training, or “no set plan yet.” Respondents who had“no set plan” were contacted in July or August 1996, ifpossible. About half of them were reached—all of thesesubjects were confirmed “unemployed,” suggesting thatfinding a job early after graduation was unlikely.

We classified study subjects into three categories basedon how much gastroenterology they expected to practice.Subjects were asked how much of their medical practiceactivity would be devoted to gastroenterology: 76–100%,51–75%, 26–50%, or,25%. Those planning.50% gas-troenterology were deemed “fully employed.” Those prac-ticing gastroenterology half-time or less were termed “un-deremployed.” Those not practicing any gastroenterologywere called “unemployed.” Physicians planning advancedgastroenterology training were included in the unemployedcategory only if they had sought a nontraining job and hadnot found one.

We analyzed unemployment by subgroups to see if any ofthe following were predictive of unemployment: interna-tional medical school graduate (IMG), sex, or training pro-gram either not participating in the National ResidencyMatching Program (NRMP) or at an “affiliate” program(i.e., one that is not located at the geographic site of amedical school.)

Subjects were asked where they would be practicing: inNew York City or its immediate suburbs (defined as#25miles from Manhattan), distant New York City suburbs(26–50 miles from Manhattan), or leaving the New YorkCity metropolitan area.

In addition to analyzing employment status, we sought todefine the quality and security of the jobs of those physi-cians planning to work as associates for a private practice.These subjects were asked when they were offered theirjobs, when they signed a contract (if at all), the number ofyears they will need to work before they are made fullpartners, and the number of years that they will have to workand will be subject to dismissal “without cause.” All fellowswere asked if they were satisfied with their professionalplans. Finally, they were asked if they “could go back intime, knowing what the job market is now,” would they stillhave chosen to complete a gastroenterology fellowship.

RESULTS

General

A total of 64 physicians met the inclusion criteria for thesurvey, and all participated in the study (100%.) Two re-

TABLE 1NYC Gastroenterology Training Programs

ProgramFellows

GraduatingJune 1996

Long Island Jewish Medical Center 2Bronx-Lebanon Hospital Center* 3Bronx VA Medical Center 2Our Lady of Mercy Medical Center* 1Albert Einstein College of Medicine (A) 6The Brooklyn Hospital* 2Interfaith Medical Center* 1Long Island College Hospital 2Maimonides Medical Center 2SUNY Health Sciences Center, Brooklyn (A) 7Beth Israel Medical Center 3Harlem Hospital Center 2Columbia-Presbyterian Medical Center (A) 5St. Luke’s-Roosevelt Medical Center 4New York Hospital-Cornell U. Med. Coll. (A) 3Lenox Hill Hospital* 2Memorial Sloan-Kettering Cancer Center 3Mount Sinai Hospital (A) 2New York University-Bellevue (A) 3St. Vincent’s Hospital 2New York Hospital Med. Center of Queens 2Catholic Med. Cent. of Brooklyn & Queens* 2Mount Sinai-Elmhurst Hospital 2Queens Hospital Center† 0Cabrini Hospital‡ 1TOTAL 64

* Program does not participate in National Residency Matching Pro-gram.

† Program recently initiated—no senior fellow yet.‡ Program omitted from 1995 Program List (1) but included in 1995

NRMP list.“A”—Program located at the geographic site of its affiliated medical

school (see text).

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spondents were completing advanced clinical training (de-fined as training beyond that required by their primaryfellowship programs); one of these physicians was actuallycompleting a second year of advanced training after nothaving found a job 1 yr earlier. All the other subjects werecompleting their first-level gastroenterology training, whichwas either 2 or 3 yr, depending on the program.

Of these 64 physicians, five indicated that they had notsought gastroenterology jobs in the United States—two be-cause they were moving abroad, another two because theywere seeking further training beyond basic fellowship, andone who noted that he could not commit himself to afull-time gastroenterology job for personal reasons andwould be working in an emergency room. These five phy-sicians were excluded from further analysis.

Of the 59 subjects then remaining, 24 fellows indicatedthat they had accepted associate positions in private prac-tices, whereas 11 said they were starting their own solopractices. Six fellows found salaried hospital positions andthree chose full-time academics. Fifteen fellows were clas-sified as unemployed gastroenterologists (Table 2).

Unemployment and underemployment

Of the 59 graduating fellows who had sought employ-ment, 34 (58%) were fully employed gastroenterologists.Ten (17%) were underemployed and 15 (24%) were unem-ployed.

The “unemployed” group included physicians who haddecided to obtain more gastroenterology or hepatologytraining because they could not find employment, as well asthose working in full-time internal medicine positions (hav-ing abandoned the search for a gastroenterology position),and emergency rooms (still searching for a gastroenterologyjob). This is summarized in Table 3.

Predictors of unemployment and underemployment

Training program and employment.Fifty-five percent offellows who had completed a training program not partici-pating in the National Residency Matching Program(NRMP) were unemployed, as opposed to only 19% ofthose who had completed an NRMP program. Conversely,only 18% of nonmatch fellows were fully employed gas-troenterologists,vs 67% of match program graduates (p 50.003.Note: statistical analysis is for comparison purposesonly. All data are statistically significant, as study samplewas 100% of study population.) (Table 4).

We defined “A” programs as those located at the site oftheir medical schools. All other programs were called “af-filiates.” Although affiliates had only slightly more unem-ployment (27%vs 23%), they had substantially more un-deremployment, so that they had less full employment (49%vs 73%).

Personal factors and employment.There were onlyslight differences in unemployment between those subjectswho had attended medical schools outside the United States(IMGs) and graduates of United States medical schools(USGs) (28%vs 23%, respectively). However, women hadsubstantially more unemployment than men (50%vs 20%;Table 4).

Location and employment

Of the 11 study subjects leaving the New York Citymetropolitan area, nine were fully employed (82%), one wasto be underemployed (9%), and one unemployed (9%). Theunemployed physician, who was to be practicing full-timeinternal medicine as an associate in a group, alleged that hedid not look for a GI job because he “did not like gastro-enterology.”

Quality of associate positions

On the assumption that a glutted job market might forceunfavorable working terms on new associates, employmentterms of these 24 physicians were further analyzed to de-termine job security and quality.

Future associates reported how many years they expectedto work before becoming a full partner in their practices. Atotal of 75% reported three years or fewer; only 4% antic-ipated a period of.5 yr.

Subjects were also asked how many years they expectedto have to work and to be liable to firing “without cause.”

TABLE 2Job Plans of Graduating Fellows as of June 1996

Type of Job Number of Subjects (%)

Associate in Private Practice 24 (41%)Solo practice 11 (19%)Salaried hospital or HMO 6 (10%)Academics 3 (5%)Unemployed 15 (25%)

TABLE 3Type of Unemployment

Type of Unemployment No. (%)

Advanced gastroenterology training after failed job search 4 26.7Unemployed, supported by spouse (all women) 3 20.0Emergency department (still looking for gastroenterology job) 2 13.3100% Internal medicine (accepted internal medicine job) 1 6.7Unemployed because of visa difficulty 1 6.7Other 4 26.7

TABLE 4Predictors of Unemployment and Underemployment

Program Fully Employed Unemployed Underemployed

Match 32 (67%) 9 (19%) 7 (15%)Non-match 2 (18%) 6 (55%) 2 (27%)A 16 (49%) 5 (27%) 1 (24%)Affiliate 18 (73%) 10 (23%) 9 (5%)IMG 15 (52%) 8 (28%) 6 (21%)USG 19 (63%) 7 (23%) 4 (13%)Male 30 (61%) 10 (20%) 9 (18%)Female 4 (40%) 5 (50%) 1 (10%)

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Only 17% of study subjects expected to have to work.2 yrunder these conditions.

On the theory that the tight job market was causing adelay in the time of year that graduating fellows establishsecure job plans, the subjects were asked when they hadsigned an employment contract. Only 4% of the 24 futureassociates had a signed contract before March 1996. As lateas 1 month before finishing training, 38% of the subjects didnot have a signed contract.

We arbitrarily defined a “good” job as one where anassociate had both a signed contract and was to practice.50% gastroenterology. Using these criteria, only 16 (67%)of associates had “good” jobs. Excluding the two subjectswith good jobs who were to work with their fathers, thisnumber dropped to 14 (58%).

Future associates leaving the New York City metropoli-tan area were more likely to have a “good” job (64%vs54%), but this difference was not marked.

Satisfaction with job

As expected, all subjects who were unemployed wereunsatisfied. However, there was no correlation beyond thisbetween underemployment and satisfaction. When asked“would you have done a gastroenterology fellowship if youknew then what you know now,” only three respondentsanswered no, whereas 46 answered in the affirmative (10subjects did not answer).

DISCUSSION

Our data demonstrate that, at least for the local New YorkCity market, the glut of newly trained gastroenterologists ismuch more serious than anyone has yet suggested. Manydifferent measures confirm this. Most striking is the 25%raw unemployment figure. Of course, unemployment in ourstudy group does not correlate exactly with the New YorkCity gastroenterology job market because many of thesephysicians also sought employment outside of New York.

An additional 15% of physicians were underemployed.This more subtle statistic confirms that even those physi-cians who could have been termed “gastroenterology-em-ployed” in previous surveys are feeling the effects of thephysician surplus.

Of those gastroenterologists working as associates in pri-vate practice, only 58% were practicing more than half-timegastroenterology, had a signed contract, and were not work-ing in their father’s practice. We suppose that without asigned contract there is an increased risk for denial ofpartnership, and subsequent unemployment or underem-ployment. Although the large amount of underemploymentamong gastroenterology associates and the large number ofstudy subjects without contracts suggest an insecure em-ployment environment, we found little evidence that themarketplace has enabled employers to force unfavorableworking terms on associates: only 25% of associates antic-ipated working.3 yr until full partnership and only 17%

were told they would be subject to dismissal without causefor .2 yr.

As expected, job satisfaction was related to employment:almost all fully employed physicians were very or some-what satisfied, and all unemployed physicians were unsat-isfied. What surprised us is how few of the unemployedstudy subjects expressed regret over having taken time totrain in gastroenterology. This could be because these phy-sicians are still hopeful of obtaining good jobs. This maydemonstrate just how well entrenched the notion of thesuccessful gastroenterologist is—that, despite much real andpersonal evidence to the contrary, young gastroenterologistsstill expect that their gastroenterology training will prove tohave been a worthwhile investment.

We are not the first to document the difficulty facinggraduating gastroenterologists in obtaining employment intheir specialty. Milleret al. (1) reported that, of gastroen-terologists starting full time clinical practice in 1994, 21.1%had “difficulty finding their full-time practice position.” Ayear later, gastroenterology was found to be the specialtywith the most job placement difficulty of the 31 differentspecialties and subspecialties studied (2).

Despite this, however, Milleret al. estimated outrightunemployment among newly trained gastroenterologists tobe 3.7% in 1994 (1), and only 0.8% in 1995 (2). (Note:Miller defined unemployment as those physicians who “didnot find a full time job in their specialty or subspecialty.)There are a number of possible explanations for the hugediscrepancy between these unemployment figures and ours(25%). First, our study was done after managed care ob-tained a stronger foothold in the market while subspecialtytraining programs had continued to produce large number ofgraduates. We also examined New York City only, whichhas an unusually large number of training programs andfellows (7) and, therefore, is more likely to be a place whereyoung physicians cannot find jobs in their chosen field.

In addition to this, however, we believe that the studies ofMiller et al. underestimated the severity of the physicianglut for a number of reasons. First, that survey did notaccount for underemployment. Second, it was an indirectsurvey, and program directors might have overestimated thesuccesses of their graduates to protect their training pro-grams or because graduates may not have been frank withtheir program directors about the difficulties they werefacing. Last, there was significant room for response bias inthe results—program directors with the poorest placementrates might have been more likely to be among the 16.4%(1995) to 29.3% (1994) who did not complete the survey.

To our knowledge, no previous physician employmentstudy has examined one local market for one specific spe-cialty. By surveying each graduate individually, and perse-vering until each study subject had participated, we negatedthe effects of response bias. Of course, our data could beinaccurate for a number of reasons. Foremost is the fact thatit relied onprojectionsof anticipated employment, not sur-veys of actual work. However, we feel that surveying the

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physicians,6 wk before their graduation was late enoughto ascertain whether or not they had secure employmentprospects. Another flaw is the potential inaccuracy of theself-reporting by the respondents—some may have beenreluctant to admit to an interviewer that they were not ableto find successful gastroenterology employment or alterna-tively, may have downplayed the quality of their plans in thefear that acknowledging a good job plan would attractunwanted competition from other young gastroenterolo-gists. However, short of auditing the records of a practice,which is not feasible, we believe that our method is a validway of studying the marketplace.

Underemployment is undesirable for a number of reasons,yet has not been examined by any previous study. First,when a gastroenterologist practices much internal medicineand little gastroenterology, his or her gastroenterology skillsmight decline. Also, it is much more expensive for societyto train more people to devote less time each to a field, thanto train fewer physicians who will devote all of their effortsto it. Third, it may not be an efficient use of resources for thegastroenterologists themselves: as managed care forces phy-sicians to cut expenses, it is likely that only gastroenterol-ogists who perform a large volume of procedures will beable to reduce the marginalized costs sufficiently to providecost-effective care.

In the few months since we designed this study, there hasbeen substantial research into the physician workforce, all ofwhich is consistent with our findings. Salsberget al. (7)studied physician supply in New York State. He noted thatNew York has the second highest number of patient carephysiciansper capitaof any state, and more resident phy-siciansper capita than any other state (3). He found thatdespite the recommendations of the New York State Coun-cil on Graduate Medical Education (GME) to reduce thetotal number of trainees, especially of subspecialists such asgastroenterologists, the number of all residents grew bynearly 21% from 1988 to 1994. This, he concluded, isbecause “the market for residents is not connected to themarket for practicing physicians.” Indeed, only recently hasCongress addressed this oversupply issue in New YorkState, by giving financial compensation to training programsthat downsize (8).

The gastroenterology establishment itself has begun toaddress workforce issues specific to the field. The Gastro-enterology Leadership Council (9) (GLC) calculated that,given the numerous gastroenterologists already practicing,and the many already in the training pipeline, an immediate50% reduction in trainee volume would be required just tokeep the gastroenterologist supply at its current level (whichin itself, they estimated, is probably more than double thatwhich is required). They therefore supported “significant,prompt reductions in trainee numbers (9).” They did note,however, that 40% of United States health care service areasare without a gastroenterologist (9), suggesting that theremay also be a serious maldistribution of gastroenterologists,

in addition to a general oversupply. Although we neglectedto ask specifically whether the unemployed physicians inNew York were limited geographically in their job search(e.g., because of a working spouse), the fact that 82% ofthose physicians leaving New York were fully employed, asagainst 52% of those staying in New York or its suburbs,supports the notion that physicians would rather be unem-ployed or underemployed in a geographic area of theirchoice, rather than migrate to another area of the country.

Even before the GLC report, some degree of gastroen-terology workforce planning was already underway. TheAmerican Board of Internal Medicine (ABIM) SubspecialtyCommittee on Gastroenterology 2 yr ago mandated 3 yr ofgastroenterology training for certification (10). This had the(perhaps not unintended) effect of forcing some programs toreduce their class sizes. Indeed, the total number of NewYork City positions posted in the List of Available TrainingPrograms dropped from 73 in 1995 (5) to 60 in 1996 (11),a drop of 18% in 1 yr, and the ABIM memorandum mayhave been partly responsible. However, significant furtherdecreases in overall class size will be needed to achieve thenecessary reductions in gastroenterology workforce that theGLC study suggest.

In summary, we have demonstrated that there is a verylarge oversupply of newly trained gastroenterologists inNew York City. Given the fact that New York has one of themost oversaturated physician markets in general, our datacertainly cannot be applied to the country as a whole. Forthis reason, similar studies are needed in other areas of thecountry. Although the findings may not be as dramatic asours, we expect the next few graduating classes of gastro-enterologists to face increasing difficulty in finding jobs.

ACKNOWLEDGMENT

The authors thank Dr. Don Powell for his review of themanuscript and helpful comments.

Reprint requests and correspondence: Jonathan David, M.D., F.A.C.P.,F.A.C.G., Harlem Hospital Center MLK 13-106, 506 Lenox Ave., NewYork, NY 10037.

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7. Salsberg ES, Wing P, Dionne MG, et al. Graduate medical educationand physician supply in New York State. JAMA 1996;276:683–8.

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