Most Internal Medicine Residents Plan Subspecialty Careers

Diedtra Henderson

December 04, 2012

By their third year of general internal medicine (GIM) residency, just 21.5% of graduating residents were likely to continue a career as a general internist. Instead, GIM residents were much more likely to opt for subspecialty career tracks, a trend that is more pronounced for men, categorical residents, and international medical graduates, according to a new national survey.

Colin P. West, MD, PhD, from the Division of General Internal Medicine, Department of Medicine, and Division of Biomedical Statistics and Informatics, Department of Health Sciences Research, and Denise M. Dupras, MD, PhD, from the Division of Primary Care Internal Medicine, Department of Medicine, Mayo Clinic, Rochester, Minnesota, report their findings in an article published online December 4 in JAMA.

General internists are expected to play increasingly pivotal roles in providing comprehensive and coordinated medical care as Americans age, the incidence rate of chronic disease grows, and health care reform extends insurance to tens of millions of new beneficiaries. Yet the nation faces a severe shortage of generalist physicians.

As recently as the 1970s, more than half of all internal medicine residency graduates pursued careers in general medicine. In the intervening decades, however, that percentage has plummeted to only 20% to 25% of internal medicine residency graduates pursuing general medical careers.

Therefore, Dr. West and Dr. Dupras sought to better understand the career plans of internal medicine residents and how those career plans evolve as residents undergo training. The researchers tapped the Internal Medicine In-Training Examination, a survey of internal medicine residents conducted every October at more than 400 residency programs. In addition to the survey, residents are asked to voluntarily complete a brief survey that includes questions about their career plans.

Of 67,207 eligible residents, 51,390 completed all of the items, returned the survey, and had demographic data available. The authors focused on data submitted by 16,781 third-year residents.

The researchers found that primary care program residents were much more likely to report a GIM career plan than categorical residents (39.6% vs 19.9%; adjusted odds ratio [AOR], 2.76; 99% confidence interval [CI], 2.35 - 3.23; P < .001). In contrast, some 65.3% of categorical residents reported subspecialty career plans.

GIM careers were more popular among women than men (26.7% vs 17.3%; AOR, 1.69; 99% CI, 1.53 - 1.87; P < .001), and in adjusted models, US medical graduates were more likely to report a GIM career plan than their international counterparts (AOR, 1.76; 99% CI, 1.50 - 2.06; P < .001).

"[T]his is the first national study to our knowledge reporting that even in primary care internal medicine residency programs dedicated to generalist and primary care training, a majority of graduates still reported plans to pursue subspecialty careers," the authors write. "Thus, although primary care program graduates were twice as likely as categorical residents to report generalist career plans in their year of graduation, the early promise of these programs for producing general internists has been tempered by the more global decline in interest in general medicine."

Solutions Needed

The authors write that these results call for carefully constructed solutions to meet the need for generalist physicians. "Expanding medical school enrollment or the number of internal medicine residency positions may simply result in more subspecialists, if the number of specialty and fellowship slots is also increased," they continue.

Mark D. Schwartz, MD, from the Department of Population Health, New York University School of Medicine, Department of Veterans Affairs New York Harbor Healthcare System, New York City, notes in an accompanying editorial that "[e]ven if half of all internal medicine residents chose primary care, the proportion of all graduates practicing primary care would increase, but only from 20% to 27%, still far short of the 40% rate recommended by the Council on Graduate Medical Education."

Dr. Schwartz advocates for changes in graduate medical education (GME) policy to better align taxpayers' investments in physician training "with the health care workforce that society needs." So far, Congress has rebuffed efforts to increase the number of federally funded GME positions by 15% and is hearing conflicting predictions about the nation's future physician workforce, underscoring the need for "an unbiased, nonpartisan, national consensus on workforce needs and GME policy," Dr. Schwartz writes.

Dr. West and Dr. Dupras note that follow-up data were not available to confirm that the students actually pursued their reported career paths. Other study limitations included the likelihood that residents might switch to alternate careers even after initially entering the workforce in general medicine, as well as the possibility that residents who supplied career plans may differ from nonresponders.

"[G]raduates of primary care internal medicine training programs, women, and US medical school graduates were more likely than their counterparts to report generalist career plans," the authors conclude. "The reasons underlying the observed patterns of career plans during residency training require additional study to effectively inform efforts to stimulate greater numbers of practicing general internists."

The study received no external funding. The study authors have disclosed no relevant financial relationships. Dr. Schwartz was a paid consultant for the American College of Physicians and was a paid Health Policy Fellow at the Robert Wood Johnson Foundation while serving on the professional staff of the Health Subcommittee of the Committee on Ways and Means in the US House of Representatives during the 111th Congress.

JAMA. Published online December 4, 2012.