Match: Internal medicine still lukewarm draw for grads
From the May ACP Observer, copyright © 2006 by the American College of Physicians.
Earlier this year, Erin E. Dunnigan, ACP Student Member, matched to an internal medicine residency slot at Duke University School of Medicine in Durham, N.C., her No. 1 choice. While she's drawn to practice general internal medicine, she, like many of her fellow seniors, hasn't ruled out subspecializing.
"I like the idea of long-term relationships with patients and the ability to follow their condition over years," said Ms. Dunnigan, a senior at Ohio State University College of Medicine in Columbus, Ohio, who added that she's "80% certain" about choosing a career in primary care. "But for many of my classmates, it's very important to be in an area where you can control your lifestyle."
Given those lifestyle concerns and the fact that primary care physicians typically earn less than subspecialists, it's no surprise that students continue to shy away from primary care. Even though the results of this year's National Resident Matching Program (NRMP) show a net increase of 19 U.S. students choosing primary care residencies, it's still nowhere near the high of 3,234 eight years ago—and internal medicine is still trying to figure out how to reverse the trend. At stake, the College has pointed out in a series of position papers and press conferences, is the continued viability of the nation's system of primary health care.
Primary care numbers
One bright spot in this year's Match was the fact that family medicine ended a five-year decline in its fill rate. While the number of family medicine positions was cut by 50 this year to 2,711, 85% of those were filled (41.4% by U.S. seniors), up from 82.4% last year. The fill rate for medicine-pediatrics also bumped up from 87.2% last year to 91.5% in 2006.
"It's encouraging that for the first time in many years, family medicine did not decline," said Lee R. Berkowitz, FACP, president of the Association of Program Directors in Internal Medicine (APDIM). "It suggests that people are getting more interested in these primary care disciplines."
Internal medicine saw a net gain of 19 U.S. seniors selecting residencies in either categorical internal medicine, primary care internal medicine or medicine-pediatrics, compared with a gain of 18 last year. Almost 98% of the 4,735 available slots in categorical internal medicine were filled, up from the 94% of slots filled in 2002.
However, those gains are relative. For one, the number of internal medicine residencies filled by U.S. seniors has declined from 2,930 in 1998, or 62.4% of total slots, to 2,668 or 56.3% this year, leaving almost half of internal medicine slots to be filled by non-U.S. graduates. And according to annual in-training surveys of residents, the percentage of graduating internal medicine residents planning careers in general medicine has fallen from 54% in 1998 to 20% in 2005.
"The results show that the number of students going into internal medicine is remaining stable compared with last year, but it's dropped sharply from its peak," said Steven E. Weinberger, FACP, the College's Senior Vice President for Medical Education and Publishing. "When taken in conjunction with the data from the resident surveys showing a continuing drop in the percentage of residents ultimately choosing a career in general internal medicine, we are still quite concerned."
Top three roadblocks
Graduating seniors say they and their peers are still gravitating to subspecialties and specialties outside of internal medicine because of three factors:
Lifestyle. The common thread running through many students' choices is the controllable working hours offered by fields such as anesthesiology and radiology. Those have emerged as popular choices in recent years, said Susan A. Kline, FACP, NRMP's chair and executive vice dean and vice provost of New York Medical College in Valhalla, N.Y. At the college this year, Dr. Kline noted, 20 of the 188 seniors matched to anesthesiology and 19 to radiology. That compares to two students matching in anesthesiology and 12 to radiology just five years ago.
That trend was borne out in the 2005 graduation questionnaire from the Association of American Medical Colleges (AAMC). When asked which factors had the biggest impact on their career choice, 71% of medical students said lifestyle had a moderate to strong influence. (See "Factors affecting seniors' career choice.")
Income. That same survey found 49% of respondents saying that salary expectations likewise exerted a moderate to strong influence.
"Primary care has gained the reputation that it isn't the most lucrative field to go into and many students are worried about paying back debt," said Kerry Donegan, ACP Student Member, a senior at Mount Sinai School of Medicine in New York who matched in internal medicine at New York Presbyterian Hospital/Weill Cornell Medical Center. "General internal medicine requires long-term care of chronic disease—and much of primary care's expertise is not recognized or reimbursed with the financial rewards enjoyed by other specialties."
Role models. Other physicians' experiences also factor into students' decisions. In the AAMC survey, 74% of seniors said that role models or mentors had a moderate to strong influence on which field they chose—more than lifestyle or income.
Ms. Donegan, who is immediate past Chair of ACP's Council of Student Members, said that working with enthusiastic residents during medical school was a big factor in her decision to choose internal medicine. She noted, however, that many of her classmates were influenced by the problems they perceived in primary care.
"It is often difficult to change patients' habits, particularly those affected by diseases with modifiable risk factors like diabetes and hypertension," she said. With the inherent rewards of good patient care overshadowed by administrative hassles, she added, "primary care seems like more of a struggle compared to high-tech subspecialties like ophthalmology."
"We need to see doctors who are happy with the path they've chosen, who look forward to seeing their patients on a daily basis," agreed Ms. Dunnigan, who is immediate past Vice Chair of the Council of Student Members. "Having positive role models is the biggest factor in encouraging medical students to become internists."
Reversing the trend
Experts warn that the flat interest in primary care has far-reaching implications for the aging U.S. population. Within five years, the first wave of 76 million baby boomers will become eligible for Medicare, while the population of people over age 85—those most in need of chronic care—is expected to rise by 50% this decade.
"We have to really define what the workforce needs are for general internal medicine and make it clear that a shortage both now and in the future will really pose significant difficulties for patients," Dr. Weinberger said. To that end, the College is working with other internal medicine groups to bring about sweeping changes.
An ACP position paper posted last month on the Annals of Internal Medicine Web Site maps out sweeping redesign options for training programs to make internal medicine residencies more attractive to students. The College also continues to strongly advocate for changing both how physicians are paid and how chronic care gets delivered.
Earlier this year, the College unveiled details of its "Advanced Medical Home" model, which would put general internists and subspecialists providing principal care of patients at the center of patient care and reimburse them for coordinating the needs of chronically ill patients. Instead of paying physicians for the quantity of services they provide, the proposal advocates rewarding physicians for such things as following evidence-based guidelines and harnessing information technology for continuous quality improvement.
Fundamental reforms to internal medicine training, reimbursement and care delivery would address many of the concerns students have about lifestyle by making practices more effective—and ambulatory care, particularly general internal medicine, more attractive, Dr. Weinberger said. He noted that "efficient, effective, team-based care in well-designed practices simultaneously provides better patient care and is more satisfying and less stressful for the clinician."
Concerned that internal medicine slots rely so heavily on non-U.S. graduates to fill residencies, the Alliance for Academic Internal Medicine (AAIM) and its member organizations have likewise made redesigning undergraduate and graduate internal medicine education a top priority, said APDIM'S Dr. Berkowitz. (APDIM is a division of AAIM.)
"We have to rethink how we train residents and come up with a more modern approach that reflects practice," he said. "If we don't, we can't expect to attract the top students."
Part of that effort is repositioning internal medicine as a specialty. "If you look historically at internal medicine, for a long time a generalist was considered more of a consultant than a provider of primary care," said Dr. Berkowitz. "That orientation has flip-flopped and we've lost some of the specialty perception at the generalist level."
Experts agree that fundamental reforms are needed, not stopgap measures. A case in point: New York Medical College began a student loan program in 1989, offering to forgive some loans for top students who agreed to enter primary care practice within six months of completing a primary care residency. However, said NRMP's Dr. Kline, as few as eight students per class signed up for the program.
"They intend to specialize, and in medical school they already have some notion of what they want," she said. "They are committed to medicine but they also want to have a life, and that's not going to change very quickly or easily."
It used to be, she added, that most of the honor students went into internal medicine. "That's not the case any more—and, in the long run, it's not a healthy thing to have one of the most demanding specialties failing to draw a large number of the best and the brightest."
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