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In the Match, internal medicine leads primary care

From the May 1998 ACP Observer, copyright © 1998 by the American College of Physicians.

By Howard Wolinsky

Winifred Gresens, a senior at Loyola University Stritch School of Medicine in suburban Chicago, says that strong mentoring and a holistic approach to patient care made a residency in internal medicine a clear choice for her. Ms. Gresens, who participated in the 1998 Match, will be doing her residency next fall across town at the University of Chicago Hospitals.

A look at this year's Match results shows that Ms. Gresens isn't alone in her enthusiasm for internal medicine. The National Resident Matching Program reported that 56% of graduating U.S. seniors—7,612 students—matched to residencies in internal medicine, family medicine or pediatrics. About 27%—3,680 U.S. seniors—are entering an internal medicine residency, an increase of 87 students over last year. This year's figures mark the fifth consecutive year that internal medicine has posted gains in the Match.

Not all primary care specialties did so well. While pediatrics saw 13% of graduating seniors—1,753 students—match to its programs (up 103 students over last year), family practice attracted 16%—2,179—a decrease of 161 students over last year's figures. Obstetrics/gynecology, surgery and psychiatry also experienced slight declines.

Long-time observers downplayed the significance of family practice's weakened showing. Herbert Waxman, FACP, the College's Senior Vice President for Education, said that family medicine may simply be undergoing a leveling off after years of significant growth. And while he characterized the recent Match figures as "good news for our specialty," he emphasized that the full picture won't be known until a head count is completed for positions filled outside the Match. He also noted that it is too early to know whether there will be long-term gains in the ranks of generalists, because a proportion of residents who match in general internal medicine will always opt to subspecialize.

Banner year

Nonetheless, 1998 is shaping up to be a banner year for many internal medicine program directors. Edward Lynch, FACP, director of the internal medicine residency program at Houston's Baylor College of Medicine, received 500 more applications this year than ever before. Equally encouraging, he said, has been the growth of applications from U.S. graduates. This year, he received 845 applications from U.S. graduates, up from 350 in 1993, when internal medicine was in something of a slump.

In fact, internal medicine leaders were quick to point out that this year's news is a stark contrast to the predictions of doom the specialty faced just five years ago. Harold C. Sox, FACP, ACP's President, for example, said that internal medicine should be proud of its showing not only this year, but its achievements over the past five years. "Internists should take heart at the news that the number of graduates choosing internal medicine is steadily increasing," he said, "with 601 more graduates choosing internal medicine this year than just five years ago."

Thomas Cooney, FACP, president of the Association of Program Directors in Internal Medicine and vice president of education and internal medicine program director at Oregon Health Sciences University, characterized internal medicine's recent performance in the Match as a "turnaround."

"When viewed from the nadir of 1993," he said, "internal medicine has increased career matches by all applicants by 17% and U.S. graduates by 28%."

Educators point to a number of factors in internal medicine's recent success. Jordan Cohen, MACP, president of the American Association of Medical Colleges, said that efforts within the specialty have helped. "In addition to market forces, which undoubtedly play a big role," he said, "medical schools across the country are doing a lot of things to alert students to the opportunities and gratification in the generalist disciplines."

Baylor's Dr. Lynch, for example, pointed to state-funded efforts in Texas to place students in general internists' offices for preceptorships in the summer between their second and third years. He also said that internal medicine is getting a boost from the popularity of internal medicine special interest groups or clubs. One such club at Baylor that was started two years ago now has 150 members.

Appeal of flexibility

The reason for internal medicine's steady growth may be more basic. Senior medical students interviewed for this article said they recognized that the field offers flexibility in preparing for careers in a number of paths and a variety of settings.

Dr. Cooney from Oregon Health Sciences University, for example, said that medical students seem to appreciate the number of career paths available within internal medicine, such as opportunities in both urban and rural settings; in primary care and subspecialties; and in caring for diverse population groups such as adolescents, the elderly and women. "I suspect that students are finding the rapidly changing health care system a bit intimidating and are worried about their long-term career options," he said. "Internal medicine offers great flexibility."

Amit Khera, a senior medical student at Baylor who will be doing an internal medicine residency at Brigham and Women's Hospital in Boston, shares that sentiment. While he had originally leaned toward a career in surgery—his father's specialty—he opted instead for internal medicine. Mr. Khera said he looks forward not only to developing relationships with patients as an internist, but also to a diverse career. "One of the bonuses of a career in internal medicine is the wide array of job opportunities and career options that are available," he said.

Still others are attracted to internal medicine for more philosophical reasons. Ms. Gresens, the senior medical student at Loyola who just matched in internal medicine, said she chose internal medicine because it allows her to take charge of a patient's "entire well-being" and offers challenges, especially in complicated cases.

She said she learned those lessons from a good source: other internists. "These individuals have conveyed to me their love of internal medicine, their enthusiasm for caring for patients and for passing on their knowledge and experience," she said.

Howard Wolinsky is a Chicago-based freelance medicine and technology writer.

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