The shifting sands of graduate medical education.

Each year the American Medical Association (AMA) surveys all programs in graduate medical education (GME) accredited by the Accreditation Council for Graduate Medical Education. Because of the importance of GME in the national workforce policy debate, this year's survey report has been expanded to provide more detailed GME data. The authors describe the historical basis of the current GME workforce dilemma and the multiple forces that now tend to neutralize efforts to adapt to a changing marketplace. For example, as resident physicians find it increasingly difficult to locate suitable employment, one would expect a reduction in hospital-based programs and in the number of their resident physician appointments. Yet, while US medical graduates (USMGs) did not pursue certain programs in this year's National Resident Matching Program, AMA data show that during the past 2 years the reduced number of residents in hospital-based programs was almost exactly offset by the increased number in new and expanded programs. Also, more USMGs are leaving residency training to enter practice after 3 years of basic training in primary care (internal medicine, pediatrics, and family practice). At the same time, an increasing number of international medical graduates are remaining in subspecialty programs. Other examples are cited to show the ebb and flow of GME activities that behave like "shifting sands."