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


Internal medicine programs maintain a steady draw in this year's Match

But experts still say Match figures reflect an ongoing decline in the pull of primary care careers

From the May ACP Observer, copyright 2005 by the American College of Physicians.

By Deborah Gesensway

This winter, Sumeet Subherwal, ACP Student Member and a senior at the University of California, Irvine School of Medicine, appreciates the breadth of practice that internal medicine has to offer. That's why he is among the slightly growing number of medical school seniors who matched to an internal medicine residency program that will begin next year.

Sumeet Subherwal, ACP Student Member, is among the 86% of U.S. seniors this year who matched to one of their top three choices.

This year, there was a net gain of 18 more U.S. seniors who selected slots in either categorical internal medicine, primary care internal medicine or medicine-pediatrics, as compared to last year. That means that more than one-fifth of all first-year residents entering programs in July will be in internal medicine programs.

That's good news, particularly given the fact that the number of U.S. seniors matching to internal medicine residency positions declined every year between 1998 and 2003.

"Overall, I am encouraged by the numbers," said Steven E. Weinberger, FACP, the College's Senior Vice President for Medical Knowledge and Education. "Certainly the number of seniors interested in internal medicine is not falling, and if anything, it is going up a little bit."

He cautioned, however, against reading too much into such a slight uptick. "We still have a continued challenge to try and get as many of the graduates and as good a crop of graduates as possible," he said. And as in those years when internal medicine's Match figures kept slipping, this year's results don't signal a rise in the number of U.S. seniors interested in primary care careers.

Instead, experts say, the slight upturn in numbers indicates the continued strong pull of subspecialty tracks—especially those that seniors see as answering their "lifestyle" needs.

The draw of subspecialties

For John P. Fitzgibbons, FACP, president of the Association of Program Directors in Internal Medicine (APDIM) and Governor for ACP's Pennsylvania Eastern Chapter, this year's Match figures are cause for cautious optimism. "If internal medicine training programs were a patient," he said, "I would describe the patient's condition as stable, but guarded."

However, he underscored the fact that Match results continue to indicate an ongoing shift away from primary care—one that is backed up by trend data and anecdotal evidence from program directors.

"We know from the program directors themselves that for a while, it was close to a 50-50 split of graduates of internal medicine residency entering general internal medicine and the subspecialties," Dr. Fitzgibbons said. "But now, people in programs are reporting that between 75%-80% of graduates are going into a subspecialty."

Overall, 57 more U.S. seniors this year matched to categorical internal medicine slots than in 2004. However, the number of seniors matching to primary care and med-peds positions fell, with 18 fewer U.S. seniors opting for primary care positions and 21 fewer for med-peds slots than last year. U.S. seniors matched to 170 primary care positions this year—down from 376 in 1998. That was also the year that 374 U.S. seniors matched to med-peds positions, which this year attracted 275.

Mr. Subherwal—who sits on ACP's Council of Student Members--is a case in point. He is full of praise about the Match process, being one of the 86% of U.S. seniors who matched to either their first, second or third program choice. (He matches to Barnes Jewish Hospital in St. Louis.) And he credits strong mentorship and the enthusiastic faculty who convinced him to select internal medicine.

But like many other graduates matched to slots in the categorical track, Mr. Subherwal doesn't intend to pursue general internal medicine. Instead, he said, he plans to start applying for cardiology fellowships after next year.

"Since the end of the first year of medical school, I have been involved with clinical research in cardiology, and have developed a passion for the field," said Mr. Subherwal. "I am personally interested in pursuing a career in academic medicine with an emphasis in cardiovascular clinical research."

The "steady-as-she-goes" course that internal medicine is taking stands in sharp contrast to family medicine's path—another indicator of declining interest in primary care careers.

For the eighth consecutive year, the number of graduating U.S. medical students filling first-year family practice residency positions dropped. Figures for family practice fell both in terms of positions offered (2,761 this year, compared with 3,074 in 2001 and 3,244 in 1999) and in the percentage of positions filled by U.S. medical school graduates. This year, U.S. graduates filled 40.5% of those slots, compared with about 48% in 2001 and 2002.

That trend comes at a time when a growing number of organizations are pointing to what they say is a looming physician workforce shortage. Earlier this year, for instance, the Association of American Medical Colleges issued a position paper that called for increasing enrollment over the next 10 years at U.S. medical schools by 15%.

Boosting desirability

Compared to family medicine, the number of internal medicine positions offered—and the interest of U.S. graduates in filling them—has been relatively stable: Close to 56% of the categorical internal medicine slots were matched by U.S. students this year, making this year's categorical fill rate similar to those in the last three. Dr. Weinberger attributes such consistency to internal medicine's broad range of career opportunities.

Although many other specialties saw fairly stable medical student interest this year, a few continued growing in popularity. According to Mona Signer, director of the National Resident Matching Program, which conducts the Match, the most competitive specialties continue to be those that people think offer the best post-training "lifestyle."

The most popular residencies this year were dermatology, emergency medicine, general surgery, orthopedic surgery and plastic surgery. At least 95% of these available positions were filled, Ms. Signer said, with at least 80% of the slots taken by U.S. seniors.

Anesthesiology also continues to boom. It has gone from offering 330 PGY-1 positions in 1999 to 463 this year, with the percentage matched by U.S. medical students rising from 64% in 2001 to 70% this year.

The fact that medical students may consider these other specialties more of a draw than internal medicine, noted Dr. Weinberger, indicates that College efforts to change that perception—through its efforts to fix Medicare reimbursement, for instance, and to help craft new chronic care models—continue to be necessary.

"Creative models of high quality, team-based care offer a real opportunity to address the 'lifestyle' issues," he said, "and put internal medicine on a more level playing field with those specialties that are currently particularly popular."


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