Swimming upstream: Internal medicine as career choice by medical students

What is the role of academic internists?

Hospitalists Best Practices Conference April 29, 2010

J Rush Pierce Jr, MD, MPH

Questions?

• To what extent are US medical students choosing general internal medicine as a career?

• What influences career choice of US medical students?

• What do our professional organizations say?• What should we do?

U.S. physicians

Change in US medical school graduate career choice, 1998 - 2007

Career plans of IM residents

UNM students matching into categorical IM residencies, 2010

• Muskan Behl Emory• Heidi Hillesland Univ Washington• Jonas Hines UCSF• Brandon Peterson Univ Virginia

4/71 matched = 5.6%

Percentage of UNM categorical IM residency positions filled by UNM students

average of other years vs 2010

Χ2 = 4.28, p =0.04

Reasons for declining interest in IM by US medical students

1. Rising medical school debt

2. Lifestyle issues

3. Reimbursement

Medical School Debt and career choice

• AAMC: over 86% graduates have educational debt, averaging $145K from public schools and $180K from private schools

• AAMC: Students with debt >$150K less likely to select primary care residency

• Univ Minn: students with more debt chose specialties over primary care

• Student surveys have not shown consistent correlation

Change in physician compensation by specialty

Older data on career choices

• 1990 survey: deterrents from IM = time and workload demands; perceived physician satisfaction, types of patients seen

• 2002: Controllable lifestyle accounts for 55% of variance in student specialty choice

• 2003 survey: residents are willing to trade income for lifestyle benefits of more vacation and more predictable schedule

Role models and primary care

• Preceptorship with general internists assoc with choosing career in IM (2 studies pos, 1 study neg, all in 1990’s)

• Students with positive IM mentor 5X as likely to choose IM as career (sev studies in 1990’s)

Characteristics of study

• Surveyed 1,439 MS4 at 10 US medical schools, after submitted rank list and before match

• Demographics, perception of IM compared to other specialties

• What influenced career decision• Sponsored by CDIM• 82% response rate, 23% into IM,

demographics same as US medical students

Demographic predictors

IM Core Clerkship

• 78% satisfied with core clerkship• 19% felt that core clerkship made career in

general IM attractive• 49% that core clerkship made career in

subspecialty IM attractive• 78% felt that medical school experience

provided them with enough insight into what internist does to make informed career decision

Perceptions of IM training and career

• IM requires more paperwork (68%)• IM requires greater breadth of knowledge

(62%)• IM has lower income potential (65%)• IM residency less competitive (58%)• IM residents less satisfied that residents in

other specialties (51%)

Career choice influences• Positives:

– Intellectual challenge of IM– Continuity of care in IM– Competence of IM residents– Level of responsibility for patient care during core clerkship and sub-I

• Negatives:– Paperwork and charting– Attractiveness of other specialties– Types of pts seen– Need to bring home work

Role modeling

• Role modeling by internists, as manifested by encouraging students to choose the field and job satisfaction, was less favorable than role modeling in other specialties

• Internal medicine, family medicine, and surgery were the specialties most likely not to be chosen based on “bad mouthing” of the discipline by physicians and other students

ACP recommendations for faculty

Options for us• Mentorship

– How should we mentor students?– How do we encourage this in residents?

• IM Interest group– What can we do?– Should we have Phase 1 students shadow us?

• Curriculum– Should we modify core clerkship, sub-I?

• Advocacy