General internists are expected to play a pivotal role in providing healthcare as the population ages, the burden of chronic disease grows, and healthcare reform tries to improve coverage for millions of currently uninsured patients. Studies suggest that only 20% to 25% of internal medicine (IM) residency grad­uates pursue general medical careers. Complicating the problem is that fewer medical students appear to be interested in general medicine and primary care.

Career Plans Among Internal Medicine Residents

It’s unclear to what degree primary care training program graduates favor general IM careers, and few studies have explored how career plans may differ across sociodemographic factors. In JAMA, Denise M. Dupras, MD, PhD, and I had a study published that looked at the career plans of IM residents by training program, sex, and medical school location. We also looked at how career plans evolved during training.

According to our results, graduates of primary care IM training programs, women, and medical school graduates were more likely than their counterparts to report generalist career plans. These residents were also more likely to remain interested in generalist careers over the course of their training. However, general medicine career plans were less common than subspecialty career plans in each of these groups. The small number of IM residents reporting plans for generalist careers means that only a limited number of generalists can be expected to enter practice each year.

Serious Implications on General Internal Medicine

Overall, only one in five IM graduates planned a career in general internal medicine. Even in primary care IM residency programs that are dedicated to generalist and primary care training, most graduates still appear to be planning to pursue subspecialty careers. The promise of these programs for producing general internists has been tempered by the declining interest in general medicine. Understanding and addressing the low rates of general medicine career plans in all groups may have important implications for how we improve upon numbers of general internists.

Solutions to meet the need for generalist physicians must be carefully constructed. We need to do more than simply expand medical school enrollment or the number of IM residency positions because our observed trends are likely to continue. It’s also critical to consider lifestyle, anticipated income, and the career aspirations and desires of residents as their careers unfold. If we wish to revitalize our stock of general medicine practitioners successfully, more information is needed on the reasons behind career plan patterns and the factors that change career decisions. Ultimately, the goal should be to stimulate greater numbers of practicing general internists with measures that can be effectively executed to make general medicine careers more desirable.

References

West CP, Dupras DM. General medicine vs subspecialty career plans among internal medicine residents. JAMA. 2012;308:2241-2247. Available at: http://jama.jamanetwork.com/article.aspx?doi=10.1001/jama.2012.47535.

West CP, Popkave C, Schultz HJ, Weinberger SE, Kolars JC. Changes in career decisions of internal medicine residents during training. Ann Intern Med. 2006;145:774-779.

West CP, Drefahl MM, Popkave C, Kolars JC. Internal medicine resident self-report of factors associated with career decisions. J Gen Intern Med. 2009;24:946-949.

West CP, Shanafelt TD, Kolars JC. Quality of life, burnout, educational debt, and medical knowledge among internal medicine residents. JAMA. 2011;306:952-960.

Institute of Medicine.  Retooling for an aging America: building the healthcare workforce. Available at: http://www.iom.edu/Reports/2008/Retooling-for-an-Aging-America-Building-the-Health-Care-Workforce.aspx.

Landon BE, Reschovsky JD, Pham HH, Blumenthal D. Leaving medicine: the consequences of physician dissatisfaction. Med Care. 2006;44:234-242.