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

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In the Match, internal medicine sees slight uptick in U.S. graduates

From the May ACP Observer, copyright 2004 by the American College of Physicians.

By Tim Gray

After sliding for six years, the number of U.S. medical school seniors who matched to internal medicine residencies finally showed a slight increase this year.

The results, released in March by the National Resident Matching Program, found that 3,086 U.S. seniors matched to categorical, primary care and medicine-pediatric residencies. Taken together, these training programs attracted 46 more seniors than in 2003. While the increase is small—about 1.5%—it is the first time in several years that internal medicine has shown an increase in the Match.

Despite those modest gains, questions remain about long-term matching trends. Since 2000, for example, internal medicine has attracted 10% fewer seniors in the Match. Still, College officials voiced optimism about this year's figures.

"Internal medicine, in all of its various flavors, seems to be turning the corner," said Steven Weinberger, FACP, ACP's Senior Vice President for Medical Knowledge and Education. While he cautioned against reading too much into a single year's statistics, he added: "I'm encouraged by the fact that our numbers aren't continuing to go down."

Dr. Weinberger attributed this year's gains to efforts spearheaded by ACP and several other national physician groups to revitalize internal medicine.

Those initiatives have trumpeted the specialty's attractiveness to aspiring doctors. They have also tried to grapple with some of the problems—lower pay compared with other specialties, the perception of less-manageable hours—that students have said are steering them away from internal medicine.

"Nowadays, medical school graduates are looking at a variety of things that they want to optimize, such as their sense of professional value, income and lifestyle," Dr. Weinberger said. "A specialty can't just stand on its laurels. We needed to do a better job of marketing internal medicine, and we're starting to do just that. Program directors and department chairs now view this as part of their jobs."

Barbara L. Schuster, MACP, a member of the College's Board of Regents and chair of the department of medicine at Wright State University in Dayton, Ohio, confirmed that department chairs and program directors are taking a much more active role.

"Residency is much more on people's agenda than it used to be," Dr. Schuster said. "Many of my colleagues are now meeting more with applicants and talking about the specialty with their own students. People used to assume that good students would come to internal medicine, but it doesn't work that way anymore. You do have to recruit."

Within the specialty's three major tracks, medicine-pediatric programs fared the best. These programs attracted 296 U.S. seniors in the 2004 Match, an increase of nearly 15% over last year's numbers. That gain reversed a loss of nearly 12% from 2002 to 2003.

U.S. seniors' interest in categorical training programs remained steady, attracting 2,602 seniors this year for an increase of 0.5% over last year. The increase reversed a 5.4% drop to matches from U.S. graduates in these programs last year.

Primary care internal medicine programs, however, did not fare as well. These programs saw a slight drop—from 192 to 188—in the number of matching U.S. seniors, continuing a downward trend that began in 1997.

The number of U.S. seniors matching to the preliminary track, who typically enter careers outside internal medicine, was virtually unchanged. That number rose from 1,468 to 1,471.

The primary care picture

While internal medicine's overall numbers rose slightly, the spectrum of primary care careers, including primary care internal medicine, pediatrics and family medicine, saw mixed results. (See chart.)

The number of U.S. students who chose pediatrics stabilized, increasing just under 1% between 2003 and 2004. Over the last five years, pediatrics' numbers in the Match have bounced up and down, so even a slight increase is welcome news.

Family medicine, on the other hand, continued to lose matching graduates. The number of U.S. seniors choosing family medicine fell just over 3% this year, continuing an overall slide of nearly 35% since 2000.

Dr. Weinberger speculated that family practice, which includes training in minor surgery and obstetrics, "may be broader than many medical students feel comfortable with."

And Phyllis A. Guze, FACP, president of the Association of Program Directors in Internal Medicine, explained that internal medicine hasn't "imploded like family medicine because a lot of the students who go into internal medicine plan to subspecialize."

That opportunity to subspecialize remains one of internal medicine's main strengths and attractions, said Dr. Guze, who's also Governor-elect for the Southern California Region I Chapter and chair of medicine at the Greater Los Angeles Veterans Administration Medical Center.

Similarly, "over 80% of hospitalists are internists," she pointed out—another strong selling point for an internal medicine residency. Hospital medicine, one of the fastest growing specialties in the country, tends to attract physicians who have trained in the categorical or primary care programs.

Other specialties

Among the specialties that have seen substantial increases in their number of matched U.S. graduates over the last five years are anesthesiology, which has seen an 86% increase in PGY-1 matches, and pathology, which has risen 130%.

"Follow the money," Dr. Guze commented when asked to explain those trends. "Look at it from the perspective of a student with $100,000 to $120,000 in medical school debt, and think about the disparity between being hired at $115,000 as an internist and $350,000 as an anesthesiologist."

Internists can do little about those pay differences, other than continue to press their case to health care payers about the value of the comprehensive care they provide and their long-term relationships with patients. But they can and are making a more persuasive case to prospective residents for the specialty's nonfinancial rewards, Dr. Weinberger said.

"The essence of being a doctor is really reflected in internal medicine, and making that point clearly to trainees is important," he said. "When patients think of a doctor, they think of the physician with whom they develop a relationship through care during illness, during wellness and through emotional issues. It's important to stress the gratification that comes from that."

Internal medicine took a big hit under managed care, he added, because patients began to perceive internists as gatekeepers.

"That implies being a traffic cop, and that's not what we are," Dr. Weinberger said. "Internal medicine is all about understanding how all of the patient's complicated illnesses interact."

Breadth of training

For Alexa Oster, a senior at Philadelphia's University of Pennsylvania, the main draw of internal medicine—she'll be doing a primary care residency at the University of California, San Francisco—was the breadth of training she'll receive.

"It leaves you open to pursue whatever career you want: primary care, health care public policy or a subspecialty," she said. "I don't think I'll go into a subspecialty, but it's possible I'll go into health policy."

Ms. Oster's attraction to internal medicine is also rooted in her college years. As an undergraduate at Nashville's Vanderbilt University, she took a course in which she shadowed an internist for three hours a week.

"I came into medical school thinking I might choose internal medicine," she said. "But I loved everything in my clinical rotations. By choosing it, I don't have to give up everything else. I can deal with all sorts of patients with all sorts of problems."

Unlike Ms. Oster, senior David Zamara chose not to go into internal medicine. When he entered medical school at the University of Arizona, he was sure he'd become an internist and hewed to that goal for much of his first three years. But a rotation through the emergency room at the end of his third year changed his mind.

"I felt very comfortable in an emergency department and had a great rapport with the emergency medicine residents," he said. "I rearranged my fourth-year schedule to include two ED rotations, after which my initial feelings were confirmed."

The intensity of emergency medicine helped seal his decision. "The diagnostic challenge of having a new patient every few minutes was like a never-ending game that I couldn't get enough of."

Mr. Zamara will be doing his residency at Christiana Care Health System, in Newark, Del., which has a level-one trauma center.

Lifestyle concerns also played into Mr. Zamara's decision, especially the prospect of paying off his $150,000 of student loans on an internist's salary. "I thought hard about my future," he said, "looked at my three children and realized that I didn't want to be 60 years old, in debt because of my loans, and missing my children's lives."

IMGs

As in recent years, many of the internal medicine residency slots not filled by U.S. seniors will go to international medical graduates (IMGs).

In this year's Match, the number of international medical graduates who applied increased for the second year in a row, hitting 5,671. That number rose nearly 13% over last year's figures—when more than 10% more IMGs applied to the Match than in 2002. Their number had fallen in the three prior years.

To Dr. Guze, the increase in the number of IMGs is good news. "A lot of inner city internal medicine programs and programs serving rural indigent populations depend on IMGs," she pointed out.

She also worries that the number of IMGs in the Match could fall in coming years if foreign students can't get visas. "If issues of homeland security continue to be important," she said, "that could be a problem."

Another group that has helped fill the ranks of internal medicine programs is osteopaths. The number of osteopaths in the Match has increased every year since at least 1999, their numbers rising 58% over that period. Between 2003 and this year, the number of osteopaths in the Match rose 11%, reaching 1,559.

Tim Gray is a freelance writer based in Philadelphia.

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