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General Internal Medicine Losing Popularity Among Internal Medicine Residents

More internal medicine residents would prefer careers in subspecialty medicine over general internal medicine.

Medical students-- by Julia Haskins

The Gist

If you're a medical student considering a career in general internal medicine, you're probably in the minority. While general internal medicine (GIM) is in high demand, the practice is declining in popularity among internal medicine residents. The study "General Medicine vs Subspecialty Career Plans Among Internal Medicine Residents" shows that GIM, which deals with the prevention, diagnosis, and treatment of diseases in older patients, is becoming a rare choice for future practitioners. 
“This study of a large national sample of internal medicine residents confirms that general medicine remains a less common career plan overall than subspecialty medicine," the study's authors Colin P. West and Denise M. Dupras, said. "Combined with the fact that only a small minority of medical students express interest in general medicine and primary care careers, the small number of internal medicine residents reporting plans for generalist careers means a very limited number of generalists can be expected to enter practice each year.” 
Out of the graduating residents surveyed, 21.5 percent reported a GIM career plan, with 39.6 percent of primary care program residents and 19.9 percent of categorical residents planning to go into GIM. Subspecialty career plans were far more promising, with 63.5 percent of categorical residents and 52.5 percent of primary care program residents planning to pursue the career trajectory. 

The Expert Take

The disconnect between training in GIM and its actual practice is at the heart of the issue. “Current medical training models in the United States are unlikely to produce sufficient numbers of general internists and primary care physicians," West and Dupras said. "Differences in general internal medicine (GIM) career plans between internal medicine residency program types and across resident demographics are not well understood.”  While residents in the U.S., women, and those in primary care programs were reported to have a slightly higher interest in GIM careers than international students, the numbers for students in the U.S. are still a cause for concern. GIM is still struggling to compete with the draw of subspeciality medicine. 
"GIM and primary care careers are very demanding, yet these 'front line' specialties bear the brunt of insurance disputes, paperwork requirements, and other bureaucratic concerns which have little to do with why people choose careers in medicine," Dr. West said. These “front line” areas have the highest burnout rates in medicine, and learners are not blind to what they see in these role models. The problems likely have less to do with patient care and more to do with all of the other things that now interfere with the physician-patient relationship. What then happens is that only the truly dedicated or those who want to pursue other areas but can’t get them end up practicing general medicine and primary care. Training programs have fallen short in producing enough graduates dedicated to GIM, but it’s hard to fault them too much given the practice environments these graduates see in their future."

Jake*, a first-year medical student at Northwestern University's Feinberg School of Medicine, outlined his own reasons for not wanting to pursue GIM. "General internists have a broad knowledge base, but they do not have complete mastery of one particular organ system, and I want to have that," he said. Jake adds, "There will always be a dearth of general internists because a lot of medical students see it as a somewhat boring field that does not allow them the specialist status or standing that they want to see themselves in. And moreover, there will always be a dearth of general internists as long as there is a huge earning discrepancy between general internists and specialists." 
Adam*, another first-year Feinberg student, agrees. "To be completely truthful, I have never considered a career in general internal medicine," he said. "There are a lot of physicians in my family from various specialities, but none practice general internal medicine, so I have not been exposed to that field as much as I have gastroenterology, pediatrics, infectious disease, or OB/GYN." Furthermore, "I think that a common perception in medical school is that while general internal medicine is important, it is not compensated as well as more specialized fields. For many medical students who consider the amount of time they spend in school and the high loans they have to take to pay for medical school, the higher compensation awarded by more specialized fields becomes more attractive."

Source and Method

The study used a survey given to residents after completing their Internal Medicine In-Training Examination taken in October 2009-2011. The survey, which was submitted along with their test booklets, asked residents about their training and future career plans. Residents were evaluated based on training program, sex, and medical school location. Data were analyzed from the almost 17,000 third-year residents in a sample of which over 50,000 residents responded to all survey items. However, follow-up information is not yet available, so there is the possibility that some of these same residents could change their minds to pursue careers in GIM.  

The Takeaway

Older patients especially need the services that generalist physicians provide, and should fewer medical students take this route, an increasingly crucial demographic could be losing much-needed experts. To ensure that older patients are getting the care they need, GIM training programs need to adapt to changing attitudes and to make the practice more appealing to medical students. Further research could also offer insight as to what would make medical students more apt to explore careers in GIM. 

"The results of this study are concerning because they confirm that we can expect inadequate numbers of GIM physicians to deal with the care access issues we face in the next decade," West said. "As access to GIM and primary care are critical to the success of healthcare reform, it is absolutely mandatory that this issue be addressed constructively. We cannot simply increase the number of medical school, residency, and fellowship slots and expect sufficient numbers of GIM doctors to magically result. We need to make GIM careers truly viable and desirable, which will require massive changes to the current structure of these practices."

He adds, "Insufficient GIM practitioners will result in diminished access to medical care at a time when more insured people than ever will be entering the healthcare system. There are also good data internationally to show that primary care doctors provide more efficient care than subspecialists, with lower costs and better outcomes across a broad range of medical conditions. We can’t afford our current healthcare system, but we can afford a system with an inadequate generalist foundation even less."

Other Research

In a 1996 study published in Medical Education, Junji Ohtaki and fellow researchers had Japanese medical students use a questionnaire to report their choices in specialty care, and to analyze their understanding of primary care. While a sizable number of students purported an interest in a primary care career, many had inadequate understandings of what the role of a primary care provider entailed. 
A survey of medical students' views of internal medicine from 1990 to 2007, discussed in a 2011 Archives of Internal Medicine study, shed light on why fewer medical students wanted to go into primary care career. Mark D. Schwartz and fellow researchers found that students cited stress and debt among main factors in their choices.
*names have been changed
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