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Swimming upstream: Internal medicine as career choice by medical students
What 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
Χ2 = 4.28, p =0.04
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Reasons for declining interest in IM by US medical students
1. 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 >$150K 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 1990’s)
• Students with positive IM mentor 5X as likely to choose IM as career (sev studies in 1990’s)
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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