Garibaldi, Richard A. MD; Popkave, Carol MA; Bylsma, Wayne PhD
Primary care is in crisis.1,2 Over the past five years, there has been a significant trend among medical students to move away from internships in primary care disciplines and to select, instead, residency programs oriented to subspecialty training.3,4 Myriad explanations are proposed for this shift in career choices, including unsatisfactory experiences of medical students in primary care clerkships, the underachieved goals of family medicine and internal medicine training programs in attracting students to primary care, the unmet expectations of primary care physicians in practice, and the unfulfilled needs of patients for specialty care.2–6
The trend away from primary care has been well documented by the annual interns’ match sponsored by the National Resident Matching Program (NRMP).2,3,7 In the past five years, the number of U.S. medical school graduates who have matched in family medicine training programs has declined 35%, the number matching in primary care internal medicine training programs has decreased 33%, and those matching in medicine/pediatrics has dropped 12%. These declines have been partially offset by a 29% increase in students matching into one-year programs in preliminary medicine, which prepare them for subsequent training in non-internal medicine disciplines.7 A less dramatic decrease of 7% has occurred in the number of U.S. medical school graduates entering categorical general internal medicine residency programs.7 These programs provide a broad set of experiences in ambulatory and inpatient medicine, training physicians for careers as general internists and primary care practitioners. However, categorical general internal medicine programs are also prerequisite training for the subspecialty disciplines in internal medicine.
This report documents trends in the career plans of residents who have been enrolled in internal medicine and primary care internal medicine training programs over the past six years. It describes the career choices of today's internal medicine residents-in-training and their reasons for pursuing either generalist or subspecialist career tracks.
We used the Internal Medicine In-Training Examination (IM-ITE) as a vehicle for surveying residents-in-training regarding their intended career choices. The IM-ITE is offered annually to housestaff in internal medicine residency programs in the United States in all three years of their training.8 At the end of each examination, residents are asked to complete a questionnaire (the Resident Survey) to evaluate the examination and provide information about training issues and career choices. Residents may choose not to answer the survey questions, and responses to these questions are analyzed independently of the medical content questions of the IM-ITE.
For the past six years, over 18,000 residents have participated annually in the IM-ITE, approximately 80% of all trainees enrolled in U.S. internal medicine and primary care internal medicine programs. Each year, approximately 90% of residents who take the IM-ITE complete the Resident Survey. For example, in 2003, 19,491 residents participated in the IM-ITE; of these, 18,257 (94%) completed the Resident Survey.
In each of the past six years, one question on each Resident Survey has addressed the residents’ career plans. In October 2002, more extensive questions were included to provide greater insight into the reasons for specific career choices. One of these questions listed 11 possible reasons for making a career choice, and asked respondents to indicate which ones might have influenced their own decision. This report describes the responses to these questions to identify trends and gain a better understanding of some of the concerns that motivate residents to select specific career paths.
Since 1998, the percentage of residents planning to pursue careers in general internal medicine has declined markedly. To track the trend in the career choices over time, we restricted our analysis to third-year (PGY3) residents enrolled in categorical and primary care internal medicine programs (see Table 1). Residents at this stage of training are, for the most part, committed to their immediate postresidency career decisions. Between 1998 and 2003, the percentage of PGY3s who intended to pursue generalist careers decreased from 54% to 27%; if we include those who were undecided (6%) in the generalist category, the decline remains significant, from 54% to 33%. Correspondingly, between 1998 and 2003, there was an increase in subspecialist career choices from 42% to 57%. It is noteworthy that, in 2003, 7% of PGY3s planned to become hospitalists after graduating from their training programs, an option that was not readily available in 1998.
For a given cohort of residents moving from PGY1 to PGY2 to PGY3 over a three-year period, the choice of a career path remained relatively stable. Thus, for the cohort of categorical residents who started their internships in July 1998 and graduated in June 2001, 46% had identified a generalist career path during this PGY1 year, and 42% selected this career path as PGY3s. In the 2003 survey, only 19% of categorical PGY1s indicated they planned to pursue careers in general internal medicine, with 21% undecided; it is likely, therefore, that a low percentage of this cohort will choose careers in general medicine practice when they graduate in 2006.
On the 2002 Resident Survey, the reasons for selecting a particular career track varied widely among those choosing careers in general internal medicine, hospital medicine, and the subspecialties (see Table 2). Eighty five percent of residents planning to pursue general internal medicine indicated their choice was a good match with their interests, compared with 90% who choose careers as hospitalists and 94% selecting subspecialty disciplines. The next four reasons for selecting a career path in general internal medicine were preferences for long-term relationships with patients, a broad area of practice, caring for ambulatory patients, and more time with family. On the other hand, only 7% of residents selecting general internal medicine indicated that a need for higher income was a reason for their career choice. Residents choosing careers as hospitalists sought a broad area of practice, a preference for caring for critically ill patients, more time with family, and more time for nonwork activities. Residents who planned to pursue subspecialty fellowships indicated that they preferred long-term relationships with patients, a narrow area of practice, and caring for critically ill patients. However, the specific reasons for choosing one subspecialty area over another varied greatly among the subspecialty disciplines.
On the 2002 and 2003 Resident Surveys, more than half the residents indicated they planned to pursue subspecialty fellowships after graduation from their internal medicine residency training programs. In both years, 73% of the residents who planned to subspecialize chose procedure-oriented disciplines. Of these, 24% planned to seek additional training in cardiology, 15% in gastroenterology, 14% in hematology/oncology, 10% in nephrology, and 10% in pulmonary/critical care medicine. Of the remainder, 7% planned to pursue fellowship training in endocrinology, 6% in infectious diseases, 5% in rheumatology, and 2% in geriatrics; 7% chose “other” or more than one fellowship.
Table 3 presents reasons given by residents for choosing particular subspecialty career paths on the 2002 Resident Survey. For instance, 84% of the residents seeking rheumatology fellowships cited family time as an important consideration for their career choice, as did 81% choosing endocrinology, and 65% choosing geriatrics. Residents pursuing careers in cardiology and pulmonary/critical care medicine did not consider time with family to be an important factor. Similar trends were observed in response to a question about time for non-work-related activities. As expected, residents choosing career paths in pulmonary/critical care medicine, cardiology, nephrology, and hematology/oncology indicated the opportunity to participate in the care of critically ill patients was a reason for their decision. Sixty-five percent of residents attracted to rheumatology and 58% attracted to endocrinology reported they were influenced by a preference for treating ambulatory patients. A preference for long-term relationships with patients was cited most frequently by residents seeking fellowships in rheumatology, geriatrics, nephrology, endocrinology and hematology/oncology. Fifty-one percent of residents who said they planned a career in geriatrics cited health policy issues as a reason for their career choice. A need for higher income was an important consideration for residents seeking fellowships in gastroenterology, nephrology, and cardiology. Income was not a major consideration for residents planning careers in endocrinology, infectious diseases, geriatrics, and rheumatology.
There were only slight differences between the career plans of international medical graduates (IMGs) and U.S. medical graduates (USMGs) who responded to the 2003 Residents’ Survey (see Figure 1). Similar percentages of USMGs and IMGs planned to become generalists (22% and 23%) or hospitalists (5% and 4%); a slightly greater percentage of IMGs (56%) than USMGs (52%) planned on pursuing subspecialist careers. Of those planning to subspecialize, a similar percentage of IMGs and USMGs planned on pursuing fellowships in each of the individual subspecialty disciplines, except that more USMGs selected gastroenterology and more IMGs preferred nephrology and endocrinology. More IMGs than USMGs indicated they intended to participate in research after graduating from residency training. The reasons for selecting a particular subspecialty were virtually identical between IMGs and USMGs.
The differences in career plans between men and women were more dramatic than were the differences were for IMGs and USMGs on the 2003 Resident Survey (see Figure 2). Women were more likely than men to seek careers in general medicine (27% versus 19%, respectively) and less likely to pursue subspecialty training (47% versus 58%) or basic research (7% versus 13%). Women planning subspecialty careers differed markedly from their male counterparts in their preferences for particular subspecialty disciplines. Endocrinology, rheumatology, hematology/oncology, infectious diseases and geriatrics were more popular for women, whereas cardiology, gastroenterology, and pulmonary/critical care medicine were more popular for men. Women tended to choose subspecialties that enabled them to have more time with family or more time for nonwork activities, rather than a need for higher income. As summarized in Table 3, men's and women's reasons for choosing one subspecialty over another differed greatly among the subspecialties; however, the reasons for choosing a specific subspecialty were virtually identical for both men and women. For example, 85% of women and 82% of men cited more time with family as an important reason for their planning fellowships in rheumatology, whereas only 6% of both women and men planning to pursue cardiology fellowships cited this as an important reason. Similarly, 36% of women and 44% or men cited a need for higher income for selecting a career in gastroenterology. Both sexes were attracted to a particular subspecialty for similar reasons.
The popularity of primary care and general internal medicine as career choices is declining. One marker for this trend, documented elsewhere, is the decrease in the number of medical students seeking training in the primary care disciplines.2–4,7 Another, described in this report, is the marked drop in the number of residents who plan to pursue careers in general internal medicine. In the 2003 IM-ITE Resident Survey, only 27% of categorical and primary care internal medicine PGY3s planned to pursue careers in general internal medicine, whereas 57% intended to pursue subspecialty training. The observation that less than 20% of PGY1s in internal medicine programs in 2003 intended to pursue generalist careers predicts a continuing decline in graduates who will enter primary care.
Many reasons for the decline in interest in generalist careers have been described. These include both positive features that are attracting residents to subspecialty careers and negative forces that are perceived by medical students and residents that make general internal medicine and primary care less appealing. The positive features attracting residents to subspecialty careers include the intellectual content of the subspecialty field, technologic innovations, increased prestige, controllable lifestyle, a growing demand among consumers for subspecialty care, and higher income potential.4,9–14 Conversely, the negative factors making primary care less appealing include the trainees’ perceptions of job dissatisfaction among primary care practitioners, lack of prestige, indebtedness, lower income potential, greater stress, bureaucracy, changing consumer preferences away from primary care, and a lack of clarity about the future of primary care practice as other types of providers enter the field.1,4,6,15,16 These perceptions are formulated in the medical school curriculum and the students’ clerkship experiences and reinforced during residency training.2,6,16 Academic health centers that rely on subspecialty divisions or disease-specific centers to achieve their research, education, and patient care missions have further promoted the concept of subspecialization to their trainees.17
Residents are attracted to specific subspecialty careers for reasons that vary greatly from discipline to discipline. Most residents seeking subspecialty training are attracted by their interest in the content area of their chosen subspecialty and by their anticipation for long-term relationships with these patients. In fact, our study found that 94% of residents planning subspecialty careers thought their choice was a good match with their interests compared with 85% of residents entering careers in general medicine. Most residents pursuing subspecialty fellowships preferred dealing with a relatively narrow spectrum of diseases, although in some subspecialties, residents are split between those seeking narrow and broad content areas. A large group of residents, 73% of those seeking fellowships, planned on careers in the procedure-oriented subspecialties. These residents frequently cited the desire for a higher income as one of the reasons for their choice; this was most prevalent for those planning to enter the subspecialties of gastroenterology, cardiology, and nephrology. Geriatrics had a particular attraction for residents who wanted to become involved in health care policy issues. Residents were willing to add two, three, or even more years of training to their education in order to pursue fellowship experiences.
Others have reported that the pursuit of a controllable lifestyle is an important consideration for medical students in choosing specialty-specific internships.2,4,6,9,10,16 We found lifestyle issues were also important factors for residents planning to pursue subspecialty fellowships in rheumatology, endocrinology, and geriatrics. Interestingly, we observed that residents who wanted more time for family were also attracted to general internal medicine, reflecting the feeling that primary care physicians have greater control of their time by limiting their work hours, sharing jobs, restricting their practices to the office only, or joining large groups with less individual call. The emergence of hospitalist medicine as a new inpatient specialty has enabled generalists engaged in primary care to better control their work time. It is noteworthy that, in the 2003 Resident Survey, 7% of PGY3s planned to become hospitalists; this number is greater or equal to the percentage of residents who planned to seek fellowships in endocrinology, infectious diseases, rheumatology, or geriatrics. The trend towards careers in hospital medicine will likely continue in the future,18 further depleting the pool of residents who might otherwise have selected primary care general internal medicine as their career choice.
Approximately 40% of internal medicine residents in our study were women, and the differences in career choices between men and women in residency training were striking. Greater percentages of women than men planned to pursue generalist careers as well as fellowships in endocrinology, rheumatology, hematology/oncology, infectious diseases, and geriatrics. Their career choices were influenced by a desire for more time for family and other nonwork activities, factors that are less controllable in cardiology, gastroenterology, and pulmonary/critical care medicine. Interestingly, women planning careers in the procedure-based subspecialties had virtually identical preferences and reasons for selecting those disciplines as did their male counterparts. Women were less interested than were men in pursuing basic or clinical research following residency training, a trend that has also been observed among women medical students.19
If the trend in career choices away from primary care and towards the subspecialties continues, we may need to redefine the traditional paradigms for training physicians and caring for people.3,6,20–22 In fact, we may be able to take advantage of the trends noted in our study by focusing generalists on careers as either primary care providers or hospitalists, and by training subspecialists to provide primary care for those patients with chronic diseases who fall within their disciplines. Office-based and hospital-based generalists would then be responsible for caring for patients with as yet no defined chronic disease, managing patients with multisystem diseases, and serving as generalist consultants for subspecialists. In so doing, general internists might return to their historic role as consultant physicians, this time for subspecialists rather than for family practitioners.21 This type of paradigm shift in caring for patients will require changes in the training of both generalist and subspecialist physicians.21,22 Because career decisions are often made during medical school clerkships,2,6 these changes might need to be initiated in medical school and reinforced through residency training.
Our data suggest that the trend away from primary care general internal medicine careers will continue for at least the next several years. Now is a critical time to address these issues and prepare for the future.
The authors thank Charlotte Fierman, American College of Physicians, for her editorial assistance, members of the IM-ITE Executive Subcommittee for their suggestions, and Evelyn Passan and Barbara Cusati for their secretarial help.
The ITE-IM and Resident Survey are administered by the American College of Physicians, Association of Professors of Medicine, and Association of Program Directors in Internal Medicine. Dr. Garibaldi served as chair of the Executive Committee for the ITE-IM from 1998–2004. The opinions expressed in this report are those of the authors.
1Moore G, Showstack J. Primary care medicine in crisis: toward reconstruction and renewal. Ann Intern Med. 2003;138:244–7.
2Whitcomb ME, Cohen JJ. The Future of Primary Care Medicine. N Engl J Med. 2004;351:710–2.
3Newton DA, Grayson MS. Trends in career choice by US medical school graduates. JAMA. 2003;290:1179–82.
4Dorsey ER, Jarjoura D, Rutecki GW. Influence of controllable lifestyle on recent trends in specialty choice by US medical students. JAMA. 2003;290:1173–8.
5Schroeder SA. Primary care at a crossroads. Acad Med. 2002;77:767–73.
6Fincher RME. Becoming a physician. The road less traveled—attracting students to primary care. N Engl J Med 2004;351:630–2.
8Garibaldi RA, Trontell MC, Waxman H, et al. The in-training examination in internal medicine. Ann Intern Med. 1994;121:117–24.
9Schwartz RW, Haley JV, Williams C, et al. The controllable lifestyle factor and students’ attitudes about specialty selection. Acad Med. 1990;65:207–10.
10Schwartz RW, Jarecky RK, Strodel WE, Haley JV, Young B, Griffen WO Jr. Controllable lifestyle: a new factor in career choice by medical students. Acad Med. 1989;64:606–9.
11Fincher RE, Lewis LA, Rogers LQ. Classification model that predicts medical students’ choices of primary care or non-primary care specialties. Acad Med. 1992;67:324–7.
12Jarecky RK, Schwartz RW, Haley JV, Donnelly MB. Stability of medical specialty selection at the University of Kentucky. Acad Med. 1991;66:756–61.
13Kassebaum DG, Szenas PL. Factors influencing the specialty choices of 1993 medical school graduates. Acad Med. 1994;69:164–70.
14Cooper RA. There's a shortage of specialists. Is anyone listening? Acad Med. 2002;77:761–6.
15Wetterneck TB, Linzer M, McMurray JE, et al. Worklife and satisfaction of general internists. Arch Intern Med. 2002;162:649–56.
16Ibrahim T. The case for invigorating internal medicine. Am J Med. 2004;117.5:365–9.
17Shafer AI. The fault lines of academic medicine. Perspect Biol Med. 2002;45:416–25.
18Williams MV. The future of hospital medicine: evolution or revolution. Am J Med. 2004;117.6:446–50.
19Guelich JM, Singer BH, Castro MC, Rosenberg LE. A gender gap in the next generation of physician-scientists: medical student interest and participation in research. J Invest Med. 2002;50:412–8.
20Showstack J, Lurie N, Larson EB, Rothman AA, Hassmiller S. Future of primary care. Ann Intern Med. 2003;138:268–73.
21Goldman L. Modernizing the paths to certification in internal medicine and its subspecialties. Am J Med. 2004;05.1:133–6.
22Larsen EG, Fihn SD, Kirk LM, et al. The future of general internal medicine. J Gen Intern Med. 2004;19:69–77.