American College of Physicians: Internal Medicine — Doctors for Adults ®

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Third consecutive loss in the Match has primary care asking questions

Internal medicine appears stable, but it posts a small decline

From the May 2000 ACP-ASIM Observer, copyright © 2000 by the American College of Physicians-American Society of Internal Medicine.

By Deborah Gesensway

Another year of disappointing Match results has some health care work force experts worried about the number of primary care physicians in the pipeline.

According to the March results of the National Resident Matching Program, the percentage of U.S. medical school seniors interested in primary care medicine showed a drop this year. Just over half (51%) of the nation's allopathic medical school seniors selected residencies in internal medicine, family practice and pediatrics, down from nearly 60% in the mid-1990s.

While internal medicine's downturn was modest—137 fewer U.S. medical school seniors matched into career-bound internal medicine training programs this year, equaling a 4% drop—family practice drew 198 fewer students, a slump of almost 10%.

General pediatrics, which had been relatively immune from dips in popularity during the '90s, saw a decrease of 6% this year. Ob-gyn also took a significant hit in the Match, with a 7.2% decline.

This year's Match numbers reflect a three-year trend in which U.S. medical students appear to be losing interest in primary care. Family practice has taken the biggest hit, suffering an overall drop of nearly 22% in the Match since 1997.

Internal medicine's popularity, in contrast, has experienced more modest changes. This year's 4% decline follows last year's 3% decrease.

While primary care leaders are heartened by internal medicine's relative stability, they are apprehensive about another signal from this year's Match—the fact that 8% of the U.S. medical school seniors matched into one-year internal medicine preliminary residency positions. Most of these residents do not continue their training in primary care specialties but instead go on to second-year residency positions in specialties like dermatology, ophthalmology and radiology.

This year's Match numbers show a one-year increase of 7.5% in U.S. medical school seniors selecting these preliminary internal medicine residencies. That jump, coupled with increases in other non-primary care specialties like emergency medicine and anesthesiology, is prompting medicine's leaders to closely watch the number of internal medicine residents who apply for subspecialty fellowships in two years.

"In recent years, we have seen a drift downwards from about two-thirds of categorical internal medicine residents going into subspecialty fellowships to well under 50%," explained Herbert S. Waxman, FACP, the College's Senior Vice President for Education. "Is that going to reverse itself as part of this trend away from primary care? That will be a critical question as we determine whether there really is a drift away from primary care."

Bruce Bagley, MD, president of the American Academy of Family Physicians, said that if the trend is not reversed and the number of medical school graduates choosing primary care careers continues to decline, "there won't be enough primary care physicians to treat our growing population. Obviously, public health will be hurt."

Most work force analysts, however, say that the situation has not reached a crisis—yet. "This is not a Mayday situation," explained Fitzhugh Mullan, MD, one of the nation's foremost experts on the primary care work force, a contributing editor of the health policy journal Health Affairs and a clinical professor of pediatrics and public health at George Washington University Medical School. "But it certainly should be a warning and an alarm for those who are concerned about balance in our system and about the important role that generalism has played and ought to play. This is a sentinel event, and I think it would be unfortunate not to pay attention to it."

No easy answers

While analysts caution that the Match should not be viewed as a definitive predictor of the physician work force, they say that the results are an initial indicator of the career interests of U.S. medical school graduates seeking training in U.S. residency positions.

Therefore, in the third consecutive year of lackluster Match results with regard to primary care, medicine's leaders are taking a hard look at why U.S. medical student interest in generalist careers is eroding.

Some think the drop-off can be attributed to medical student perceptions about a tight job market for primary care physicians, one that faces increasing competition from nurse practitioners and physician assistants. Others cite concerns that primary care careers will not pay enough over the long term to allow students to pay off their burdensome debt. Some wonder about the attractiveness of primary care physicians' lifestyle, with its potentially long hours and its sometimes low levels of prestige in the medical community. It is worth taking another look at the residency curriculum, some work force experts also say, because some student reluctance may relate to the content of primary care medicine or how it is taught.

"This Match sends us a message that we have got to understand much more fully what drives medical students' career decision-making," said Lawrence G. Smith, FACP, vice chairman of the department of medicine at Mt. Sinai Medical Center and Governor for ACP­ASIM's New York Downstate I Chapter. "Is it role-modeling? Is it indebtedness? It's probably all those plus a lot of things that we have never even thought of, like the Internet and all of the talk about the job market."

Some say that because managed care has played such a prominent role in promoting primary care over the last several years, the backlash against HMOs has helped damage medical students' views of the value of primary care. "You might call it collateral damage," Dr. Mullan said. "A bomb was dropped on managed care, but it hit primary care too."

At the same time, he added, more health plans are developing programs where primary care is not as dominant as it was in the past. That trend, he said, will only further tighten the job market for primary care providers.

Still others think the fading interest in primary care relates to more basic supply and demand issues. "I think this Match tells us that students have looked and have said, 'People told us there was going to be a great oversupply of you-pick-it specialist, and it hasn't happened, so I'm going to do what I want to do and take my chances,' " said Michael E. Whitcomb, FACP, senior vice president for medical education at the Association of American Medical Colleges.

IMGs shifting course?

Despite some uneasiness, physician work force experts emphasize that the Match results should not be viewed as a sure sign of overall labor force trends because they do not include most foreign-born international medical graduates (IMGs), U.S. citizens from non-U.S. medical schools and osteopaths. This year, for example, only 66% of the positions offered through the Match were filled. Most of the rest will be filled later this year by foreign-educated doctors and osteopaths.

While foreign-trained physicians have never been a big part of the Match, their presence appears to be shrinking at an alarming rate. This year, the National Resident Matching Program reported dramatic decreases in the number of non-U.S. citizen IMGs applying for residency positions through the Match. Just under 11,000 non-U.S. citizen IMGs participated in this year's Match, a decrease of 22.5% from last year and the smallest number since 1995.

Educators say that the shrinking number of IMGs in the pipeline merits watching. If the number of IMGs were to fall dramatically, internal medicine training programs could have difficulty filling all their positions, which in turn could have drastic consequences on teaching hospitals' financial well-being, the way undergraduate medical education is taught and how much indigent care is provided in this country.

Fewer IMGs may be participating in the Match because of a number of factors. These include the new clinical skills assessment test required for certification by the Educational Commission for Foreign Medical Graduates, a cutback on training visas and a tightening of other immigration policies. When coupled with what many perceive as an increasingly tight labor market, many physician work force experts are predicting that fewer and fewer foreign-born IMGs are going to be looking to come to the United States in the future.

"Physicians from other countries will begin to see it as less enticing or advantageous to come to the United States to train and then to stay here," predicted Thomas J. Nasca, FACP, president of the Association of Program Directors in Internal Medicine (APDIM). "There are signs this is happening already," he said, pointing to the sagging numbers of IMGs sitting for the Step 1 United States Medical Licensing Examination.

For now, though, educators say they are not too worried about a lack of IMGs. While internal medicine training programs are particularly dependent on IMGs—roughly 45% of their residents are non-U.S. graduates—internal medicine leaders say there is no reason to suspect that any programs will end up with unfilled slots by July when the training year begins. "Even if the supply pipeline shrinks substantially, there would still be more than enough applicants to fill all the available slots," explained the College's Dr. Waxman.

That attitude reflects the relatively good position that internal medicine finds itself in. Despite a drop in interest among graduating medical students, internal medicine was able to retain its position as the residency most popular with U.S. medical school seniors. A quarter of all U.S. seniors who participated in the Match chose one of the career internal medicine programs—preliminary, primary care or med/peds.

Educators credit internal medicine's relative stability in this Match to the specialty's capacity of training both generalists and specialists. Much more than family practice, a residency in internal medicine keeps career doors open longer for medical students who are not sure if the marketplace's message to them is to become a primary care provider or to subspecialize.

"I believe students see that internal medicine has the greatest amount of flexibility because of its diverse nature and the potential that it provides to practitioners as the care environment changes," said Dr. Nasca, APDIM president. "Compared to family practice and ob-gyn, I read this year's numbers as stability for internal medicine."

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