Reasons vary for decline by medical students in choosing internal medicine as career choice

CHICAGO – Medical students express reservations about internal medicine as a career because of patient complexity, the practice environment and the lifestyle, compared with other specialties, according to a study in the September 10 issue of JAMA, a theme issue on medical education.

Internists in primary care and subspecialty practice provide a large portion of the chronic care for older and medically complex patients. However, the number of students choosing residency training in general internal medicine (IM) has declined, and young physicians are leaving general IM, suggesting that projected shortfalls may greatly underestimate the future problem, according to background information in the article. The number of older adults in the United States is expected to nearly double between the years 2005 and 2030, and one planning model predicts that the United States will have 200,000 too few physicians by 2020. Current students' perceptions about IM careers and the factors that motivate them to choose the field are not well understood.

Karen E. Hauer, M.D., of the University of California, San Francisco, and colleagues conducted a study to understand current students' impressions and concerns about careers in IM and to identify potentially modifiable factors in their decision making. The researchers surveyed 1,177 fourth-year medical students at 11 U.S. medical schools in the spring of 2007, who were questioned regarding their educational experiences and career choice.

Overall, 274 students (23.2 percent) reported they were most likely to enter careers in IM, including 24 (2.0 percent of the total sample) in general IM. Compared with other specialties they had chosen or considered, students perceived IM as requiring more paperwork (68.0 percent of respondents), requiring a greater breadth of knowledge (62.1 percent), and having a lower income potential (64.6 percent). Other reasons cited by students for not selecting IM careers included the attractiveness of other (non-IM) specialties and the types of patients an internist sees.

Factors cited by students for choosing IM included the intellectual challenge, teaching on the IM rotation, the 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," the authors write. "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."

(JAMA. 2008;300[10]:1154-1164. Available pre-embargo to the media at www.jamamedia.org)

Editor's Note: Please see the article for additional information, including other authors, author contributions and affiliations, financial disclosures, funding and support, etc.

In an accompanying editorial, David C. Goodman, M.D., M.S., of Dartmouth Medical School, Hanover, N.H., comments on the articles in this issue of JAMA regarding the health workforce, and writes that the U.S. should establish a permanent health workforce commission that can help overcome the current limitations of health professions training.

"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."

(JAMA. 2008;300[10]:1205-1207. Available pre-embargo to the media at www.jamamedia.org)

Editor's Note: Please see the article for additional information, including financial disclosures, funding and support, etc.