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In this year's Match, internal medicine continues to lose U.S. graduates

From the May ACP Observer, copyright © 2003 by the American College of Physicians.

By Phyllis Maguire

Internal medicine continued its six-year slide in this year's match, with fewer U.S. medical seniors applying for internal medicine residency positions.

Results released by the National Resident Matching Program in March showed that 3,040 U.S. graduates matched to categorical, primary and medicine-pediatrics internal medicine programs. That amounts to a loss of 194 U.S. seniors over last year's Match, for a one-year decline of 6%. Since 1998, 17% fewer U.S. graduates have matched to those three tracks.

For many educators, the gloomy figures offer yet more proof that American medical students are losing interest in primary care careers. This year, 5.4% fewer U.S. seniors selected the categorical track, which includes medical students interested in subspecialty fellowships as well as those seeking generalist careers. Primary internal medicine residencies posted a 6% decrease from 2002, while the medicine-pediatrics track took the hardest hit, with an 11% one-year decline.

While internal medicine is experiencing a downward slide, family practice is in a freefall. The specialty saw its Match numbers drop 12% this year, for a six-year loss of 44%.

Pediatrics was the sole primary care track that gained this year among matching U.S. seniors, with a 2% increase in its Match figures.

Income and lifestyle

According to Patrick C. Alguire, FACP, the College's Director of Education and Career Development, this year's Match results show that a combination of factors continues to hurt primary care.

He noted that ACP has identified many of those factors as part of its ongoing "revitalization of internal medicine initiative." That effort seeks to identify reasons why U.S. students are turning away from internal medicine programs and attract more students to the specialty. (For more information, see "ACP leaders seek ways to revitalize internal medicine.")

High on the list of problems, Dr. Alguire said, is mounting educational debt, which stops students from choosing specialties like primary care that offer relatively lower incomes. Debt structure is another problem: Because young physicians have to start repaying debt during residency, he explained, many students may be drawn to specialties that pay relatively higher salaries after three-year training programs.

Dermatology, for example, has seen a 7% increase in matching U.S. seniors over the past six years. And 1,468 U.S. seniors matched to the preliminary internal medicine track for a 5% gain over last year and a 56% increase since 1998. (Students entering the preliminary track train in internal medicine for only one year before going onto other specialties, like dermatology.)

While money is always a factor, Dr. Alguire said that lifestyle concerns appear to be gaining an edge in students' decision-making. "There is a perception-which I don't think is accurate—-that an internal medicine career is incompatible with raising a family," he said.

Those concerns have helped send more students to specialties like anesthesiology, which has posted a 124% gain in matched seniors since 1998. Physical medicine and rehabilitation has been another big winner, with a six-year gain of 111%. Other winners include pathology, which has seen a 107% increase in six years, and radiation oncology, which has had a 106% rise since 1998. (Diagnostic radiation posted a six-year jump of 44%.)

"Those increases are very telling," Dr. Alguire continued. "These specialties offer controllable lifestyles with weekends off and predictable days. You start at 8 a.m. and leave at 5 p.m., and if you do have call, you have an entire hospital system between you and the patient."

Strains in medical education

Dr. Alguire also pointed to possible deterrents in the medical school setting. As faculty face increasing pressure to see more patients and generate revenue for teaching hospitals, they have far less time to spend with students.

"We know that role modeling is extremely important in influencing what careers students choose," he said. "But students may not have a chance to interact with the best and the brightest."

He pointed to studies that show students almost never choose the same specialties as faculty members they've spent time with who rated in the bottom 10% of their peers, based on student evaluations. "Interestingly, studies indicate that students don't necessarily have to be exposed to the best, or those in the top 10%," said Dr. Alguire. "They just have to avoid the worst." Declining interest in internal medicine may indicate, he added, that educators need to pay more attention to faculty development.

Educators may also need to focus more on developing students' disease management skills, he said. Many students claim to be turned off by the prospect of caring for patients with chronic diseases, which could indicate that students aren't building the skills they need to feel competent in managing those conditions.

Students may also need more opportunities for community-based learning, he continued, since many equate a career in internal medicine with caring for an unending stream of patients with chronic illnesses or substance abuse problems.

"When students spend so much time in hospitals, particularly city hospitals, they aren't exposed to what practitioners see in private practice," Dr. Alguire said. "It can be very gratifying to work with patients over many years, but students may not see those kinds of intrinsic rewards."

Increasing numbers of IMGs

While fewer U.S. medical seniors are matching to internal medicine programs, the total number of internal medicine residency positions filled in the Match actually rose (though by less than 1%).

Many of those extra slots were filled by non-U.S. foreign medical graduates. Reversing a five-year downward trend, 9% more non-U.S. foreign graduates applied to the Match this year than in 2002. Even with that gain, however, the number of non-U.S. foreign graduates applying to this year's Match still represents a 38% decline from the 8,090 who applied in 1997.

(Meanwhile, the number of osteopaths participating in the Match has steadily increased, with 7% more applying this year than in 2002. Since 1998, 58% more osteopaths have applied to the Match.)

According to this year's results, U.S. seniors filled 44% of Match positions in the categorical, medicine-pediatrics and primary internal medicine tracks. International medical graduates (IMGs) filled most of the rest.

But Lawrence G. Smith, FACP, Governor for the College's New York Downstate I Chapter and immediate past president of the Association of Program Directors in Internal Medicine, pointed out that Match figures don't reflect the true number of internal medicine residency slots being filled by IMGs. That's because a growing number of internal medicine programs are filling training slots outside the Match.

"In medicine, one-quarter to one-third of all residency positions don't even appear in the Match," Dr. Smith said. With fewer U.S. seniors interested in internal medicine, he explained, small training programs have a hard time competing with larger institutions for U.S. graduates. To solve that recruiting dilemma, smaller programs are offering contracts to promising IMG candidates, often months before Match results are announced. Another advantage of filling slots before the Match is giving IMGs more time to arrange visas.

Dr. Smith predicted that even more internal medicine training slots may be filled outside the Match next year. The National Residency Matching Program is considering a policy to no longer allow teaching programs to fill some available slots through the Match while filling other positions in the same program through independently negotiated contracts. The new policy could take effect as early as next year.

"Training programs will have to be either in or out [of the Match]," Dr. Smith said of the proposed policy, which should be finalized this month. "That may force more training programs to stay out because it's not clear the Match offers them any real advantage."

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