Swimming upstream: Internal medicine as career choice by medical students What is the role of academic internists?

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Swimming upstream Internal medicine as career
choice by medical studentsWhat is the role of
academic internists?

• Hospitalists Best Practices Conference
• April 29, 2010
• J Rush Pierce Jr, MD, MPH

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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?

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U.S. physicians
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Change in US medical school graduate career
choice, 1998 - 2007
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Career plans of IM residents
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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

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Percentage of UNM categorical IM residency
positions filled by UNM students
average of other years vs 2010 ?2 4.28, p 0.04
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Reasons for declining interest in IM by US
medical students

• Rising medical school debt
• 2. Lifestyle issues
• 3. Reimbursement

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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 gt150K 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

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Change in physician compensation by specialty
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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

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Role models and primary care

• Preceptorship with general internists assoc with
  choosing career in IM (2 studies pos, 1 study
  neg, all in 1990s)
• Students with positive IM mentor 5X as likely to
  choose IM as career (sev studies in 1990s)

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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

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Demographic predictors
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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

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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)

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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

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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

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ACP recommendations for faculty
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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