What can internal medicine do to attract more medical students to careers in primary care?
From the December ACP-ASIM Observer, copyright © 2002 by the American College of Physicians-American Society of Internal Medicine.
By Phyllis Maguire
- Students graduating with $150,000 or more in total educational debt
- Primary care losing in the Match
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For five years in a row, the Match has brought bad news for internal medicine. The specialty has watched its appeal slip among U.S. medical graduates, as 12% fewer seniors matched to internal medicine residencies from 1998 to 2002.
Exit surveys of U.S. medical school graduates tell a similar tale. While more than 12% of U.S. graduates in 1999 said they intended to specialize in general internal medicine, that figure had dropped to less than 6% in 2002. Those surveys, which were conducted by the Association of American Medical Colleges (AAMC), also found that the percentage of U.S. medical graduates planning to enter internal medicine subspecialties rose from less than 9% to more than 12% during the same time period.
Primary care's waning appeal has leaders in internal medicine and other primary care specialties asking themselves why so many medical students seem uninterested in office-based general practices. To address the issue, the College formed a working group to assess general internal medicine as a career choice.
This year, the group presented its findings. Not surprisingly, it found that many of the issues affecting career choice have been poorly studied. It did, however, identify several factors it said are hurting internal medicine's prospects.
For one, the next generation of physicians has different priorities than older practitioners. Put simply, the report found that many medical students want to spend more time with family and achieve a better balance between their personal and professional lives than they think older physicians are able to do.
Second, the fact that practicing internists seem overwhelmed—by liability problems, reimbursement cuts and the loss of clinical autonomy—is turning medical students off from the specialty. College leaders are now considering ways not only to attract more students, but to revitalize internists' own enthusiasm for their profession.
We talked to College leaders and other experts to identify exactly what is turning off medical students to internal medicine. Here is a look at some of the challenges they say the specialty faces—and some possible remedies.
Dollars and cents
According to Regent Joel S. Levine, FACP, senior associate dean for clinical affairs at the University of Colorado School of Medicine and Chair of the Regents' working group, financial concerns are high on the list of reasons why more medical students are turning away from generalist careers.
At a presentation to the Board of Governors this fall, Dr. Levine explained that students are well aware that general internists now earn between $100,000 and $150,000 a year. Surgeons and subspecialists, on the other hand, can expect to make between 50% and 300% more.
"General internists may now earn one-third of what subspecialists make in the same communities," Dr. Levine said. "Those figures make a compelling case to subspecialize."
That earning disparity plays an even bigger role as student debt grows. According to AAMC statistics, indebted medical students graduated in 2002 with an average debt of almost $104,000. (That number represents an almost 5% increase over 2001.) Nearly 18% of this year's graduates reported educational debt of $150,000 or more. (See this chart for more information.)
To be sure, getting an earlier start on paying back debt may steer some residents away from subspecialties. But there are signs that more residents are opting for fellowship training—and incurring even greater debt—to get a better return on their educational investment.
According to an article in the April 2002 issue of Academic Medicine, the hours-adjusted net return on educational investment for primary care physicians is just under $6, while the same figure for procedure-based physicians is more than $10. (Both are trumped by attorneys, whose net return is close to $11.)
Another reason students and residents want more money now: They don't expect their incomes to climb in the coming years.
"The mindset we older physicians had when we started out was that we'd build our incomes as well as our careers," Dr. Levine told the Governors. "Younger physicians don't see that happening."
Medical students know that general internists can boost their incomes by working longer hours or shoehorning more patients into their schedules. But that option collides head-on with young physicians' desire to strike a healthy balance between their personal and professional lives.
"We were the first generation of 'latch-key' kids, who never saw our fathers and then never saw our mothers," said Karen Hsu, ACP-ASIM Medical Student Member, Vice-Chair of the College's Council of Student Members, who also addressed the Board of Governors. "Being able to spend time with our families is really important."
For some medical students, residency hours are a problem. "Internal medicine is known for having a difficult residency," said Ms. Hsu, who is a third-year medical student at the University of Iowa College of Medicine in Iowa City. She added that because medical training takes place at a time when many women want to start families, students may think twice about entering specialties known for having a rigorous residency.
Residents who responded to an informal College work hour survey in 2001 suggested that many internal medicine residency programs still don't comply with the 80-hour workweek rule. And even when internal residency programs do stick to work hour rules, they have to compete with residencies that require up to 20 fewer hours a week. They include specialties like physical medicine and rehabilitation (which posted a 33% gain in this year's Match) and diagnostic radiology (which was up 8%).
Making matters worse, burned out internal medicine residents scare medical students off. "The amount of influence residents have on us is often overlooked," Ms. Hsu said. "Their attitude really rubs off very fast." She pointed to what she said was a telling sign: Last year, not one internal medicine resident in her program received an end-of-the-year teaching award from third-year students.
Looking beyond training, primary care office hours—which are typically demanding and can involve extensive call—are not a draw. Students seem to be "shying away" from clinical careers that don't give them a predictable schedule, said internist Richard A. Cooper, FACP, professor of medicine and health policy and director of the Health Policy Institute at the Medical College of Wisconsin in Milwaukee. That would explain the growing appeal of specialties like radiology, anesthesiology and pathology, he said, as well as some surgical disciplines like plastic surgery.
"Even gastroenterologists and nephrologists can control how their days are scheduled," Dr. Cooper continued. "But in general internal medicine, it's tough."
Having a set schedule is also a boon for hospitalist-based medicine. According to some program directors, the new specialty is attracting more than half of the residents now training in general internal medicine.
"The pay is better, and hospitalists have a set time when they hand patients over to someone else and leave," said Barbara L. Schuster, MACP, a member of the Regents' working group and chair of the department of internal medicine at Wright State University School of Medicine in Dayton, Ohio. "It fits the lifestyle of 2002."
Patient mix problems
Experts say that another problem attracting students to generalist careers is one of role models, pointing out that most chairs of medicine and program directors are not general internists.
And Patrick Alguire, FACP, the College's Director of Education and Career Development, underscored another factor: Some medical students say they are "put off" by internal medicine's patient population. "These days, students are saying they don't want to take care of patients with chronic diseases or psychosomatic disorders," he said. "Well, that's internal medicine."
Ms. Hsu from the University of Iowa confirmed that perception among some of her colleagues. "It seems really frustrating to deal with a whole group of patients who never does what you recommend as far as helping their diabetes or diseases related to obesity, smoking or alcohol use," she said.
That perception is compounded when your experience is limited to academic medical centers where you see "the worst of the worst" of the chronically ill, she continued. "You're not seeing the community-based internist who gets a good mix of patients."
To help combat that perception—and help students get to know the patients behind chronic illnesses—many medical schools over the past decade have launched community-based teaching programs, placing medical students with practicing internists for preceptorships or even ambulatory rotations.
One of the best-known programs, the General Internal Medicine Statewide Preceptorship Program in Texas, sponsors one- to four-week preceptorships for medical students in their first and second years. Officials say that 95% of participating students claim the program increased or strongly reinforced their interest in an internal medicine career.
While Dr. Levine applauds such programs, he said it is difficult to track their success in steering medical students toward generalist careers. Students who elect ambulatory rotations or preceptorships may already be self-selected for primary care careers, he said.
He also questioned how long the boost that internal medicine gets from community-based teaching lasts. "The interest in internal medicine that is generated in year two doesn't seem to be sustained in years three and four," he told the Governors. "The rewards of community-teaching programs begin to collide with pay and lifestyle concerns."
Another pervasive problem can be finding community-based physicians who are enthusiastic enough about the specialty to promote it to medical students and residents. Program administrators in Texas say that only one of their roster of 340 internists has dropped out of the program because of falling morale, but C. Scott Smith, FACP, Governor for the College's Idaho Chapter and staff physician for the Veterans Affairs Medical Center in Boise, sees the problem as more widespread. He helps find and set up ambulatory rotation sites with practicing internists for students in a program that spans five states.
"My requirements are that practicing physicians have to be both good and happy," he said. "It's really hard anymore to find that combination."
It's no secret that practicing internists are finding that the specialty's most highly touted reward—the ability to get to know and care for patients over time—seems to be evaporating in many markets. "Students see internists 'pushing paper,' struggling to find liability insurance and not getting paid for a good deal of what they do," Dr. Levine told the Governors. "That has a real impact."
The big picture
Several organizations are trying to ameliorate conditions that affect internal medicine. The Accreditation Council for Graduate Medical Education, for instance, plans to start policing resident work hour rules more strictly.
The College has mobilized staff for its Future of Internal Medicine Project. The program will examine the problems sapping the vitality of internal medicine education and practice, and propose solutions over the next year. College committees will look at issues ranging from innovative debt repayment programs to ways to improve payment for generalists' services that fall outside direct patient encounters.
Advocates have spent a great deal of energy trying to change the formula used to calculate physician fees under Medicare. But analysts do not see any major movement on the part of medicine's leaders or legislators to substantially improve reimbursements for generalists. As a result, some internists are taking a broader view of problems besetting the profession.
"To me, what's happening reflects broader cultural issues about how health care is perceived and expected," said Idaho's Dr. Smith. "Our reliance on more algorithmic, scientific and technological approaches to medicine has an upside in terms of benefits we've gained in treating diseases. But the downside is that the art of medicine keeps getting short shrift."
The problems being encountered in general internal medicine are also fueling a debate over whether the discipline should be reconfigured in order to gain the strength of numbers. At the Board of Governors meeting, Lawrence L. Faltz, FACP, Governor for the New York Hudson Valley Chapter and senior vice president for medical affairs and medical director of Phelps Memorial Hospital Center in Sleepy Hollow, N.Y., proposed merging general internal medicine and family practice into one primary care discipline.
"Take the best of both and add the right amount of pediatrics and ob" for medical and graduate education, Dr. Faltz said in a subsequent interview. While he conceded that doing so would be a daunting task, he added that the two specialties are now competing with each other, "which weakens both groups and costs all of us in terms of dollars and energy."
As the United States population ages, he continued, the need for primary care is only going to grow. The changes in reimbursement, autonomy and expectations needed to attract students, he said, require "primary care to speak with one voice."
Others agree that generalist careers may need to be redefined—but they argue that general internists need to move further away from primary care.
"Internal medicine got itself off track when it hooked into the primary care mania of the early 1990s," said Dr. Cooper of the Health Policy Institute, which analyzes health policy trends, at the Medical College of Wisconsin. "Just like dot-com mania, the primary care bubble has burst."
Dr. Cooper envisions a health care system in which nurse practitioners—particularly those graduating from doctoral programs, which nursing schools are now trying to launch—take over the disease management, wellness screenings, vaccinations and counseling functions of primary care, leaving general internists to treat complex diseases, much as they do in Canada. (Dr. Cooper sees family physicians evolving into rural physicians or, in urban areas, general internists.)
"A lot of people can educate you about obesity and smoking cessation without having to spend eight years incurring $100,000 of debt," Dr. Cooper said. "But there aren't a lot of people who can treat your congestive heart failure. I can do that. That's why I went to medical school, and that's why students are still going."
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