Anyone who has tried to visit a primary care physician lately likely knows first hand that there is a shortage of general practice physicians in the United States. Primary care physicians provide half of the health care obtained in the outpatient setting, but over the past several decades, career interest in internal medicine, particularly general internal medicine — the specialty primarily responsible for providing care to adults — has declined among medical students.

A recent issue of the Journal of the American Medical Association published a study examining the factors that influence medical students’ choices in choosing a medical specialty, particularly internal medicine. The study consisted of a survey of nearly 1200 fourth-year medical students at 11 medical schools, which assessed demographics, debt, educational experiences, and career considerations. Of those surveyed, only 2% of the students planned careers in general internal medicine. These students were more likely to have experienced positive education and training in internal medicine clerkships than those students choosing a different specialty. Further, the students choosing internal medicine were more likely male and were more likely to be attending a private medical school. They also reported a favorable impression of an internist’s lifestyle and felt positive about caring for internal medicine patients.

Of the 4798 medical school graduates entering residency-training programs in 2007, 22% chose internal medicine. Only 274 graduates entered primary care internal medicine training programs, as opposed to subspecialties of internal medicine.

Interestingly, only 55% of the physicians pursuing internal medicine training were graduates of medical schools in the United States. While the number of United States graduates interested in generalist careers has been declining, the number of international medical graduates entering primary care fields is increasing. Also increasing in primary care fields is the number of graduates of osteopathic medical schools.

While factors of training, flexibility, and salary may seem obvious as far as career decisions go, this study does underscore the shortage of primary care physicians that we face in the United States. Many studies devoted to addressing this decline in primary care physicians conclude that virtually all medical students value their internal medicine training, and view it as an important foundation in their education, but many still have reservations about pursuing a career in general internal medicine.

As reported in the JAMA study, a satisfying internal medicine training rotation encouraged positive feelings about careers in internal medicine. However, many students suffer negative impressions of internal medicine based on their experience with chronically ill, hospitalized patients. Further, one study cites training in inadequately equipped primary care offices as a deterrent to internal medicine as a career. Lifestyle also plays a major role in the choice of a medical specialty, and internal medicine is viewed as having less flexible and less controllable hours than other subspecialties. Salary is an understandably important consideration, as many medical students graduate with considerable debt and internal medicine pays less than many medical specialties. Last, prestige and value placed on internal medicine as a career influences many career decisions.

Ideally, primary care physicians provide comprehensive and integrated health care. They offer ongoing patient-physician relationships and emphasize disease prevention, acute intervention, and chronic disease management. The lack of primary care providers in the United States has led to poor health outcomes for Americans, and the United States is ranked lowest among industrialized nations in primary care functions, in spite of having the highest level of health care spending. A primary care focused health system leads to reduced all-cause mortality rates, less use of emergency services, increased disease prevention, improved patient satisfaction, and reduced disparities in health care provision.

The medical establishment needs to find a way to encourage medical students to pursue general internal medicine as a specialty. With a nation full of medical specialists, who will coordinate the primary care of an aging America?

References

S. E. Brotherton (2005). US Graduate Medical Education, 2004-2005: Trends in Primary Care Specialties JAMA: The Journal of the American Medical Association, 294 (9), 1075-1082 DOI: 10.1001/jama.294.9.1075

K. E. Hauer, S. J. Durning, W. N. Kernan, M. J. Fagan, M. Mintz, P. S. O’Sullivan, M. Battistone, T. DeFer, M. Elnicki, H. Harrell, S. Reddy, C. K. Boscardin, M. D. Schwartz (2008). Factors Associated With Medical Students’ Career Choices Regarding Internal Medicine JAMA: The Journal of the American Medical Association, 300 (10), 1154-1164 DOI: 10.1001/jama.300.10.1154

Karen E. Hauer, Mark J. Fagan, Walter Kernan, Matthew Mintz, Steven J. Durning (2008). Internal Medicine Clerkship Directors’ Perceptions About Student Interest in Internal Medicine Careers Journal of General Internal Medicine, 23 (7), 1101-1104 DOI: 10.1007/s11606-008-0640-y

E. Salsberg, P. H. Rockey, K. L. Rivers, S. E. Brotherton, G. R. Jackson (2008). US Residency Training Before and After the 1997 Balanced Budget Act JAMA: The Journal of the American Medical Association, 300 (10), 1174-1180 DOI: 10.1001/jama.300.10.1174