Pay and hours driving losses in this year's Match
By Phyllis Maguire
As primary care training programs continue a five-year slide in the Match, educators are debating the need for fewer hours and better pay for primary care, as well as for retooled medical school curricula.
According to this year's Match figures released in March, internal medicine residency programs took yet another hit among U.S. graduates. Internal medicine as a whole posted a 4% loss, with 3,234 seniors matching to internal medicine residencies in 2002, down from 3,369 in 2001.
According to the Association of Program Directors in Internal Medicine (APDIM), this year's Match results represent the lowest number of U.S. seniors entering internal medicine since the early 1990s. Over the past five years, 12% fewer U.S. graduates have matched to internal medicine residencies.
Hardest hit were the primary internal medicine and med-peds tracks, both of which saw a 13% drop. Internal medicine's categorical track posted a relatively small 2% loss, but analysts say that more than half of those candidates will opt for careers in internal medicine subspecialties.
As further evidence of primary care's waning appeal, pediatric training programs had an 8% loss this year, while family practice slipped 7%. Warren A. Jones, MD, president of the American Academy of Family Physicians, put the best spin possible on his specialty's continuing slide. After a whopping 17% drop for family practice between 2001 and 2000, he explained, he is hoping this year's smaller decline means the specialty has "stemmed the tide."
But with family practice matching 36% fewer U.S. seniors than it did five years ago, Dr. Jones admitted that the discipline is taking a hard look at how to attract more candidates. Two long-term studies due to be released in the next year will examine data from medical students and practicing family physicians about the specialty's appeal. Family practice has already begun more outreach efforts targeting medical school students.
While primary care attracted fewer takers, several specialties posted solid gains in this year's Match. The internal medicine preliminary track, which typically serves as a springboard to specialties like dermatology and ophthalmology, showed a 10% increase.
Even more impressive gains were seen in anesthesiology, which had a 25% increase; physical medicine and rehabilitation, which saw a 33% gain; and diagnostic radiology, which was up by 8%.
Opportunities and pay
Analysts point to several factors behind U.S. seniors' slipping interest in primary care. First, many students believe they will be able to find good subspecialist opportunities. That runs counter to the thinking in the early 1990s, when anecdotal evidence held that physicians coming out of fellowship programs were hard pressed to find jobs.
At about the same time, analysts predicted that managed care's focus on primary care gatekeepers would create a subspecialist glut and a heightened need for primary care physicians. But as Herbert S. Waxman, FACP, the College's Senior Vice President for Education, explained, "The world hasn't become a big southern Californian HMO with strong gatekeeping. In the past five years, there has been a strong movement toward allowing patients to self-refer to subspecialists."
While subspecialty job opportunities may be getting medical students' attention, starting salaries are sealing the deal. Dr. Waxman said that subspecialists in non-procedure-oriented fields such as endocrinology often find salaries starting as high as $200,000. Primary care physicians, on the other hand, may be offered $120,000 or less.
"There is a clear relationship between students' indebtedness and their interest in their future earning potential," Dr. Waxman said. According to the Association of American Medical Colleges, the average debt of seniors graduating from private medical schools in 2001 topped $118,000.
Analysts also say that lifestyle considerations increasingly come into play, particularly with the half of medical school students who are women. Robyn M. Potts, ACP-ASIM Medical Student Member, who will graduate this year from the University of Oklahoma College of Medicine, opted out of not only primary care but also internal medicine. It was a tough decision, she said, because she loved the specialty's intellectual stimulation and direct patient care and was initially drawn to rheumatology.
But because Ms. Potts, who serves on the College's Council of Student Members, has two children under age 3, she was reluctant to sign on for a residency with 80-plus-hour workweeks. In the specialty she chose—pathology—she'll work 60 hours a week or less as a resident and have no clinical internship year or in-house call. As a pathologist, she said she can expect a 50-hour workweek—enough to be a "real" doctor, she said, while still leaving time for her family.
Ms. Potts noted that her decision was strongly influenced by the practicing internists she's met. "The women in internal medicine who told me they had a balanced life always seemed to be working part time at a college health center or in a prison," she said. "I didn't go to medical school to get a part-time job. I felt that as a part-time internist, I might not get as much respect."
Emily K. Burns, ACP-ASIM Medical Student Member, who is also on the College's Council of Student Members, was also drawn away from internal medicine by the prospect of an easier residency. Ms. Burns, who will graduate this year from the University of Colorado School of Medicine and is expecting her first child, chose physical medicine and rehabilitation instead.
She will have very little call or weekend duty as a resident, she pointed out. And while the specialty demands a firm foundation in internal medicine, something she liked, it also has benefits she didn't think she'd find in primary care.
"I like the focus on regaining function as one of the primary endpoints of treatment," Ms. Burns said. "In primary care medicine, I often felt that nothing was really being done to improve the patient's quality of life." She said she was also swayed by the specialty's team approach and looks forward to working with social workers and other therapy specialists.
A curriculum overhaul?
In response to these kinds of concerns, some advocates are lobbying for more humane resident schedules. (See "Under pressure, medicine revisits resident work hours," in the March 2002 ACP-ASIM Observer.)
No one, however, expects internal medicine residency workweeks to shrink well below 80 hours. And while Medicare's resource-based payment system has helped narrow the gap between generalist and specialist salaries, Medicare physician payments are projected to continue to fall over the next 10 years. That may further discourage medical students from careers in primary care internal medicine—the specialty that treats most Medicare patients.
Some educators are also talking about ways to tailor medical education to meet students' changing needs. "Part of the problem is that we have a 'one-size-fits-all' medical school curriculum, and that's not practical," said David L. Battinelli, ACP-ASIM Member, chair of education at Boston University School of Medicine and immediate past president of APDIM. "We should start developing different tracks to help prepare students for different careers." One option, he said, would be curricula that offer both generalist and specialist tracks, as well as tracks for rural, urban and hospitalist medicine.
That approach might help boost primary care as a career choice, said Fitzhugh Mullan, MD, clinical professor of pediatrics and public health at George Washington University and contributing editor of the journal Health Affairs. It might also encourage greater collaboration among primary care disciplines and more continuity in teaching primary care core competencies like health maintenance, problem-solving and communication skills. And it could lead to more health services and clinical research, he added, as well as a more highly trained group of primary care physicians.
But Dr. Mullan warned that by fracturing medical education early on, specialists would get only minimal exposure to the larger issues of patient care and clinical management. "They might get more technical expertise," he said, "but very limited amounts of anything that's considered 'doctoring.' "
That early split, he said, might also exacerbate a bigger problem: the growing gap between generalists and specialists that is being driven by technological advances.
"Society is starting to believe that technologies will become so rifle-shot precise that all they'll need is the right medley of specialists to take care of them forever," Dr. Mullan explained. "We seem to forget the role that integrated, longitudinal caretaking and decision-making—which is the domain of primary care—will have to play."
It is already getting harder to focus on that need for primary care in the midst of "genome fever," he said.
"Genomic breakthroughs may be spectacular science, but they aren't good health care," Dr. Mullan explained. "A good health care system requires much more social sweat equity in health professionals' training, tax dollars and an effective, fair distribution of health care services."
While the number of U.S. medical graduates matching to primary care and internal medicine residencies is dropping, the number of available positions remains the same. International medical graduates (IMGs)—around 6,000 of whom enter U.S. training programs every year—will be needed to fill those vacancies.
But according to 2002 Match figures, the pool of available IMGs continues to decline. This year, 4,556 IMGs applied to the Match—an 11% drop from last year. Since 1997, when 8,090 IMGs applied, 44% fewer IMGs have applied to the Match.
Some analysts say that the dwindling number of IMGs in the Match masks a growing number who arrange residency slots before the Match. While many educators frown on that practice, IMGs and the smaller internal medicine programs that depend on them say it offers both the IMGs and the institutions more stability.
By offering pre-Match contracts, smaller institutions claim they can secure higher-quality candidates. And IMGs, who appreciate knowing ahead of time that they have a slot, won't have to jockey feverishly (and from a very long distance) during the post-Match "scramble" if they come up empty in the Match.
Experts also say that the shrinking number of IMG applicants reflects the impact of the clinical skills assessment examination required for certification by the Educational Commission for Foreign Medical Graduates. That exam, which is administered only in Philadelphia, poses a financial hardship for many international students who may also face problems getting visas to take the test—difficulties that some analysts say is leading many IMGs to seek training elsewhere.
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