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Most medical students get good news on Match Day

Internal medicine's filled positions edged upward but students still shied away from careers in primary care

From the May ACP Observer, copyright 2007 by the American College of Physicians.

By Stacey Butterfield

It didn't require a warning from a prophet to make a medical student worry about the Ides of March this year. On the morning of March 15, almost 28,000 medical seniors around the world were anxiously awaiting the results of the National Resident Matching Program.

Yale students Zofia Piotrowska, Lara Suh, Viral Juthani scan a match letter.


Yale students Zofia Piotrowska, Lara Suh and Viral Juthani scan a match letter.



Lucy Goddard, a representative on the ACP Council of Student Members (CSM), was one of them. A senior at the Yale School of Medicine, she had a very short match list. After many interviews, she and her husband, a fellow classmate, had decided to aim for residencies in the San Francisco Bay Area. He matched early in neurosurgery at Stanford University, so Ms. Goddard was hoping for a position in San Francisco.

At noon, the doors of Yale's Harkness Ballroom were opened, and Ms. Goddard and her classmates raced in and tore open the envelopes containing their matches. She got her wish—a spot in the internal medicine primary care track at the University of California San Francisco. "I'm thrilled!" she said later.

Top choices, specialty choices

In matching with one of her top choices, Ms. Goddard landed among the majority of U.S. applicants. Of the 15,206 U.S. seniors in this year's match, 93% matched to a residency position, and 84% of those got one of their top three choices.

Lucy Goddard, a representative on the ACP Council of Student Members (center), earned a match in internal medicine at University of California San Francisco. Joining Ms. Goddard on Match Day are her husband, Paul Kalanithi (left), and Stephen Holt, the Residency Director of Yale's Primary Care Internal Medicine and Medicine/Pediatrics residencies.


Lucy Goddard, a representative on the ACP Council of Student Members (center), earned a match in internal medicine at University of California San Francisco. Joining Ms. Goddard on Match Day are her husband, Paul Kalanithi (left), and Stephen Holt, the Residency Director of Yale's Primary Care Internal Medicine and Medicine/Pediatrics residencies.



Her decision to go into primary care, however, is more unusual. While the number of filled positions in internal medicine increased slightly this year, the primary care track within internal medicine saw a decrease in positions offered and filled. Overall, more than 98% of the 4,798 categorical internal medicine positions were filled, 56% of those by U.S. seniors. Accompanying a decrease in the number of available primary care slots from 295 to 274 was an expected decrease in the number of matched slots from 284 to 264, with a 96% fill rate for both 2006 and 2007.

Family medicine saw a more dramatic decline, with 100 fewer positions available than in 2006 and more than 500 fewer than in the 2000 match. Of the 2,603 offered positions, 88% were filled, 42% by U.S. medical school seniors.

Experts cited the usual causes for the lack of interest in primary care. "It's lifestyle. It's salary. It's the perceived lack of stature," said Deborah M. DeMarco, FACP, president of the Association of Program Directors in Internal Medicine.

Ms. Goddard agreed that some of those factors may have influenced her peers, but the appeal of internal medicine, and specifically primary care, outweighed them for her. "Having long-term relationships with patients is by far the most fun thing for me. Once I was in the clinic, I couldn't think of doing anything else," she said.

The atmosphere on her medicine clerkship also impacted Ms. Goddard's decision. "I really thought that it was the most intellectually rigorous of the clerkships that I did. The residents and attendings were really interested in finding the evidence for what they were doing and finding scientifically the best ways to treat their patients," she said.

Positive role models

Her positive clerkship experience is typical, said Dr. DeMarco. "It's very interesting that the medicine clerkships are among the highest rated, yet our students still don't choose internal medicine as a career. And of the ones that do choose internal medicine, a high percentage are doing it as a stepping stone to fellowships," she said.

Heather Strah, a CSM member and senior at the University of Iowa, may end up joining that group. She matched with the University of Pittsburgh's general internal medicine program, but she is thinking about going on to specialize in pulmonary medicine.

Her choice of residency programs was influenced by the people involved in the program, she said. "University of Pittsburgh has a really well-respected internal medicine program and a young, excited residency director. I just felt very comfortable there."

Internists can have a major impact on students' opinions about internal medicine, said Rosemarie L. Fisher, FACP, chair of the Residency Review Committee for Internal Medicine.

"I think we're going to have to show students what's good about internal medicine," she said. "I know we as role models haven't been fantastic—complaining about reimbursement and things like that. I think we can try to do better with that."

Students are well aware of the differences in income among specialties, said Tony R. Tarchichi, CSM member and senior at the University of Medicine and Dentistry of New Jersey. "In my class this year, anesthesia is huge. I think there are more people going into anesthesia than medicine. It's because you can work a 50- to 60-hour week and make $350,000," he said.

Despite the economic enticements of other specialties, Mr. Tarchichi chose a residency in internal medicine-pediatrics at his home school. "If I want my own practice, I can tailor it to my needs and my desires. I probably won't make $300,000 if I do medicine-peds but I don't really need $300,000," he said.

Mr. Tarchichi was one of 275 U.S. seniors matching in med-peds, a decline of 19 from last year. Overall, the specialty saw a slight increase in the number of positions offered and filled, with the difference made up by international medical graduates.

The number of international applicants to the match increased again this year, noted Dr. Fisher. The international graduates face much tougher odds than U.S. seniors, matching in only 45% of applications. They filled a large portion of the internal medicine slots, however, with 2,040 of the matches going to non-U.S. senior applicants compared with 1,968 last year. In comparison, U.S. senior matches in internal medicine increased by only 12.

That is a problem, said Steven E. Weinberger, ACP senior vice president for Medical Education and Publishing. "If trends continue, there will not be enough general internists to take care of an aging population with growing incidences of chronic diseases. The health care system will become increasingly fragmented, over-specialized and inefficient, leading to poorer quality care at higher costs," he said.

The College has proposed several reforms intended to encourage more students to go into internal medicine, including calling for a patient-centered health care system that builds upon the relationship between patients and their primary and principal care physicians. ACP leaders have also called for a redesign of training in internal medicine.

Until those systemic changes are made, the task of encouraging students to go into medicine falls on practicing and academic internists, said Dr. Fisher. "We've got to continue to show people why we went into internal medicine and how much fun it can be."

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