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Match results show continued move to primary care

Students respond to market forces, more ambulatory training in internal medicine

From the May 1995 ACP Observer, copyright © 1995 by the American College of Physicians.

By Christine Wiebe

Anna Likos joined a growing movement when she decided to pursue a residency in internal medicine this fall. "I wanted to be in a field that really trains me well in general medicine," says Dr. Likos, who graduated from the University of Oklahoma College of Medicine this month. This fall, she begins her residency in Yale's Primary Care Program.

Dr. Likos, and other students apparently responding to the call for more generalists, also may have been spurred by positive experiences in ambulatory training and the knowledge that jobs for subspecialists are dwindling, experts say. In fact, for the first time in seven years, a slight majority of candidates in the annual residency Match selected programs in internal medicine, family practice or pediatrics over specialties, according to the National Resident Matching Program.

Dr. Likos considered variations of those three disciplines before making her choice. "I felt that internal medicine would give me the strongest background possible," she says.

Those words are just what specialty leaders want to hear. And the statistics from the recent Match reinforce other anecdotal evidence that the popularity of internal medicine, along with other primary care specialties, is on the rise. This year, the number of U.S. graduating seniors matching in internal medicine rose 7.7%, on the heels of a 6.4% increase last year. After a number of disappointing showings in previous years, specialty leaders are cautiously optimistic.

"It was good news for primary care and good news for internal medicine," says Jack Ende, FACP, president of the Association of Program Directors in Internal Medicine and associate professor of medicine at the University of Pennsylvania.

"It's pretty gratifying," agrees Harold C. Sox Jr., FACP, Chair of ACP's Educational Policy Committee and chair of the department of medicine at Dartmouth-Hitchcock Medical Center.

This year, 2,697 graduates matched in internal medicine, representing nearly 20% of the Match pool. An additional 5% of students chose categorical and primary care programs, as well as medicine-pediatrics programs.

Family practice is the second-largest specialty, with just over 15% of the Match candidates. Pediatrics attracted another 11%.

The number of international medical graduates matching in internal medicine declined slightly this year, from 1,809 to 1,765. However, the number of categorical positions offered through the Match also declined-from 4,733 to 4,656-and leaders speculate that a growing number of international graduates are finding positions outside the Match.

Supply and demand

Experts say the move toward general medicine can be partly explained by market forces. Burgeoning managed care systems rely extensively on primary care physicians as gatekeepers who only refer patients when necessary. Subspecialists, in contrast, are having more and more trouble finding jobs.

"There is such a shortage of primary care physicians," says Christopher Rhodes, director of marketing for Cejka and Co., a health care consulting firm based in St. Louis. "There just aren't enough of them to go around." Furthermore, he predicts, "the need is going to continue to grow." New physicians looking for primary care jobs generally get 15 to 20 offers, he says, and the median income for primary care practitioners has risen 14% in two years to $129,000.

Mr. Rhodes attributes the recent Match results to market developments such as the growth of managed care.

Some educators agree. "It's no longer any secret that trainees graduating from subspecialty fellowships are having increasing trouble finding jobs," says Dr. Ende. "I think students are responding to market forces." In addition, he believes students also are influenced by the zeitgeist that medical care of the future will be led by generalists.

But ask students like Anna Likos and you get a different perspective. While Dr. Likos welcomes the benefits she may reap from choosing general medicine, she says she never considered the job market when choosing her career path, "and I don't know many students who did." She focused more on her personal goals, such as her desire to work in a less-developed country eventually. "Medicine is the right place to be for that," she says.

She acknowledges that broad exposure to internal medicine during medical school influenced her decision to choose internal medicine. During her third year she spent two months on hospital medicine wards. During her fourth year, she spent one month in an ambulatory medicine rotation, which included hospice visits to patients' homes and work at the public health department. She says she found her experience interesting and rewarding.

Such anecdotal evidence, combined with the recent Match numbers, suggest that organized efforts to improve the specialty's image are working. Students apparently are receiving a more positive, less distorted view of internal medicine during clerkships, says Jordan Cohen, MACP, president of the Association of American Medical Colleges. Thus, the move toward more ambulatory training and more community-based experiences must be paying off, he concludes. He also believes that the call for more generalists has motivated more educators to counsel students in that direction.

On the other hand, Dr. Cohen adds, many internal medicine residents eventually subspecialize, so the effect on primary care is still somewhat unclear. Thus, the specialty needs to continue its efforts to promote the practice of general medicine, he says. In addition, internal medicine programs will likely continue competing for students because positions still greatly outnumber U.S. medical graduates, he says.

Other leaders agree that more challenges lie ahead for the specialty. "Our residency programs are still, for the most part, inpatient-based," says Dr. Ende. The curricula need to be changed, such as adding even more ambulatory care, not just to attract more students but to provide a more appropriate education, he says.

In fact, some leaders are worried the good Match news could lead to complacency. The increase this year was "still relatively small in terms of what needs to be done," says James P. Nolan, MACP, immediate past Chair of the ACP Board of Regents. He points to the number of graduates entering internal medicine in 1985 compared with this year. "We're not nearly back to where we were," he says.

Although he feels good about changes in many residency programs, "what needs to be done is concentrate more on the student level," he says. "They need to see that internal medicine practice is a very satisfying career."

Just the beginning

Although specialty leaders are cautious about the recent Match gains, they also believe they must be doing something right. For instance, the College has developed the Community-based Teaching Network, which links willing community physicians with medical schools and residency programs, to give trainees the opportunities to experience the practice of internal medicine firsthand.

At the recent Annual Session, a new task force was formed to study the College's programs and other groups' efforts, and to develop new ways to improve internal medicine training, says Dr. Sox. The College is also working with other groups to develop a model residency curriculum that would incorporate broad-based educational experiences.

"Internal medicine is just getting its momentum going," Dr. Sox says. Thus far, "we have a good product that is kind of selling itself." The specialty still has much untapped potential, he insists, and efforts to improve training programs and boost the specialty's image should lead to continued growth.

Already, the message is reaching some students. "Internal medicine is a good, strong field for generalist training," says Anne Olinger, MD, who plans to start her residency at the University of Rochester primary care program in the fall.

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