Study Analyzes The Lack Of Internal Medicine Specialists

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Main Category: Medical Students / Training
Article Date: 10 Sep 2008 - 0:00 PDT

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Due to patient complexity, the practice environment, and the lifestyle, medical students are becoming increasingly less likely to choose internal medicine as a career specialty. These findings are published in the medical education-themed September 10 issue of JAMA.

Much of the chronic care for older and medically complex patients is provided by internists in primary care and subspecialty practice. Students, however, have not been choosing residency training that prepares them for general internal medicine (IM), and young general IM physicians are leaving the field. These two factors are leading to serious projected shortfalls of physicians in the specialty - predictions that even may be greatly underestimating the future problem. As the number of older adults doubles between the years 2005 and 2030, some models forecast a 200,000-physician shortfall in the United States by 2020. Reversing the trend requires an understanding of the perceptions that current students have about IM careers as well as the factors that motivate them to choose the field.

To learn more about the decision-making process of medical students, Karen E. Hauer, M.D. (University of California, San Francisco) and colleagues conducted a study that focuses on current students' impressions and concerns about careers in IM. The researchers hoped to be able to specify any potentially manipulable factors in students' specialty decision-making processes. Data came from a survey of 1,177 fourth-year medical students at 11 U.S. medical schools in the spring of 2007, and the students responded to questions pertaining to educational experiences and career choice.

Of the total sample, 23.2% (274 students) indicated that they would most likely choose a career in IM, with 2% (24 students) looking towards general IM. In comparing other chosen or considered specialties with IM:

• 68% said IM required more paperwork.
• 62.1% said IM required a greater breadth of knowledge.
• 64.6% said income potential was lower in IM.

Students also cited factors such as the types of patients an internist sees and the attractiveness of non-IM specialties as reasons to no select IM.

Students who ultimately chose to pursue a career in IM were attracted to the intellectual challenge, teaching on the IM rotation, continuity of care, and the competence of IM residents.

"Current students recognize the increasing demands on internists, particularly primary care physicians, to accomplish large numbers of preventive and therapeutic interventions during short visits with chronically ill patients while also managing increasing administrative expectations," explain the authors. "Career interest in general IM is particularly low, reflecting the challenges in the primary care practice environment. A national effort to address the factors affecting students' career choice regarding IM is needed and should include interventions to modify the nature of work and lifestyle in the field."

David C. Goodman, M.D., M.S. (Dartmouth Medical School, Hanover, N.H.) writes in an accompanying comment that the U.S. should establish a permanent health workforce commission to aid in overcoming the limitations of health professions training. Dr. Goodman also details the commission's guiding principles:

"Five principles should guide the commission's charter. First, the public interest in the workforce should be articulated. … The specific aims should be to craft evidence-based policy that improves access to care, quality of care, health outcomes, and the affordability of care. Second, the membership of the commission should be broad and include experts in public health, patient-centered care, and epidemiology, as well as clinicians, consumers, innovative and efficient health systems, payers, and medical educators. Third, the commission should consider policy related to health clinicians of all types. … Fourth, an evidence-based approach to workforce policy formulation requires a dedicated staff to develop the expertise for evaluating the workforce and the likely effect of policy recommendations. … Fifth, Congress should provide the commission with an increasing degree of regulatory responsibility that insulates reform from the self-interests of training programs and clinicians."

"The expected argument against accountability is that it is wiser to allow market forces to decide the fundamental questions of workforce size and composition. However, doing so practically assures maintaining the status quo. It is unreasonable to expect that market forces will self-organize an effective health workforce. It is time to try public health workforce planning," concludes Dr. Goodman.

Factors Associated With Medical Students' Career Choices Regarding Internal Medicine
Karen E. Hauer; Steven J. Durning; Walter N. Kernan; Mark J. Fagan; Matthew Mintz; Patricia S. O'Sullivan; Michael Battistone; Thomas DeFer; Michael Elnicki; Heather Harrell; Shalini Reddy; Christy K. Boscardin; Mark D. Schwartz
JAMA (2008). 300(10):1154-1164.
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Written by: Peter M Crosta
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