Admission, recruitment, and retention: finding and keeping the generalist-oriented student. SGIM Task Force on Career Choice in Primary Care and Internal Medicine

Can medical residency keep young specialists in the place where they graduate? Cross-sectional and exploratory study of the first seven years after implementation of medical residency programs in the State of Tocantins, Brazil

BACKGROUND

New medical schools and new medical residencies in Brazil, mainly in its interior, were opened under the justification of collaborating towards distribution of these healthcare professionals and specialist doctors across the national territory. However, this proposal did not guarantee that medical practitioners would become established in the place where they graduated and specialized.

OBJECTIVE

To calculate, through interviews, how many specialists who graduated in the state of Tocantins stayed there after finishing their medical residency; and to analyze the factors that made them stay or leave the place.

DESIGN AND SETTING

Cross-sectional exploratory study conducted at a Brazilian federal public higher education institution.

METHODS

All graduates from medical residencies in Tocantins, who graduated between 2013 and 2019, were contacted by telephone and, after obtaining consent, an interview was conducted. The interviews took place between June 2020 and January 2021.

RESULTS

The permanence of medical residency graduates in the state increased from 50% in an earlier study to 55.8% in the current study, thus showing a situation of stability. In addition, we detected some reasons for staying or not. In a multivariate analysis, only working in the state capital was related to staying in the state of Tocantins, showing a 5.6 times greater chance.

CONCLUSIONS

The percentage of those who remained was just over 50%, even some years after implementation of the first programs. Most specialists remained working for the state health department, with a smaller proportion in municipal health departments, and were concentrated in the state capital.

Factors Influencing Career Decisions and Satisfaction Among Newly Practicing Ophthalmologists

PURPOSE

To describe the career choices of newly practicing ophthalmologists and explore factors influencing career decisions and satisfaction.

METHODS

A cross-sectional study was conducted using data from an electronic survey of ophthalmologists who completed training within the prior 5 years. The survey included questions about demographic information, medical education, current practice, factors affecting career choices, and career satisfaction. Statistical comparisons were made based on gender, type of practice, subspecialty training, and practice area.

RESULTS

Surveys were completed by 696 (32%) newly practicing ophthalmologists, including 276 (40%) women, 179 (29%) academicians, and 465 (67%) subspecialists. A higher proportion of female respondents entered academics than male respondents (36% vs 26%, P = .009). Female and male respondents pursued fellowship training with similar frequency (64% vs 68%, P = .32), but men were more likely to seek vitreoretinal fellowships (30% vs 11%, P < .001) and women were more likely to undertake fellowships in pediatric ophthalmology (21% vs 8%, P < .001), uveitis (10% vs 2%, P = .002), and neuro-ophthalmology (6% vs 2%, P = .042). A total of 514 (83%) respondents reported being happy with work life.

CONCLUSIONS

The career choices of newly practicing ophthalmologists differ based on gender, type of practice, subspecialty training, and practice area. Many factors affect career decisions, and they have varying influence on subgroups within ophthalmology. Ophthalmologists have high levels of career satisfaction. This information may prove useful when developing workforce strategies to meet future eye care needs. NOTE: Publication of this article is sponsored by the American Ophthalmological Society.

Baseline cultural competence in physician assistant students

Purpose

Cultural competence is a critical component in health care services. The relationship between health disparities and prejudice and discrimination is well documented. Prejudicial attitudes and discriminatory behavior are modifiable through training yet few programs have evidence-based training. No published data has reported on baseline levels of cultural competencies in medical trainees which is necessary for tailoring programs appropriate to the audience. This manuscript fills that gap by reporting on data from three cohorts of first-year Physician Assistant (PA) students (N = 216). We examined students’ baseline levels with special attention to differences in cultural competence constructs across age, gender, and ethnicity.

Methods

Students completed self-report measures for ethnic identity, ethno-cultural empathy, multicultural orientation, attitudes about diversity, health beliefs attitudes, colorblind racial attitudes, and burnout at the beginning of their first year. They completed the measures online (Qualtrics) during class time, prior to a lecture on cultural competence.

Results

Data indicate a correlation between cultural competence constructs supporting the validity of the battery of tests as a cohesive unit to measure cultural competence. There were statistically significant differences between age, gender identity, and ethnic groups across cultural competence variables.

Conclusions

Data provide baseline data that may be used to tailor educational programs. Findings suggest that our measures show promise for future educational research measuring effectiveness of cultural competence training.

Factors Associated With Osteopathic Primary Care Residency Choice Decisions

Context

The osteopathic medical profession traditionally emphasized the education of primary care physicians. A common thread for both osteopathic and allopathic residency matches, however, has been an increase in the interest in specialties outside of primary care.

Objective

To determine whether there are critical points in medical school associated with residency selection decision-making, what factors affect residency selection decisions, and whether any identifiable shifts or trends exist.

Methods

This mixed-methods study sequentially used qualitative and quantitative research approaches. The study population was a convenience sample of osteopathic medical students, interns and residents, and practicing physicians from partner medical schools, associated hospitals, and a regional association of osteopathic physicians. In the first phase, interviews and focus group discussions were analyzed for codes, categories, and themes relating to factors that influence residency selection. In the second phase, a survey was created from the results of the first phase and administered to study participants.

Results

Of the 3450 potential participants, 282 completed the survey. Ninety-one of 209 participants (43.5%) indicated that the third year of medical school was the time they will or did decide what type of residency program to pursue. There were no significant differences in the mean scores between the respondent groups (ie, students, residents, and physicians) when ranking the importance of the 10 influential factors associated with residency selection decision-making (P>.05 for all).

Conclusion

The highest percentage of participants indicated the third year of medical school was the time that they made residency selection decisions regarding what specialty they were interested in entering. No shifts regarding the importance of specific primary care residency choice factors were found between training status of respondents.

Proportion of doctors who stayed in the state of Tocantins after finishing medical residency: preliminary results from a cross-sectional study

CONTEXT AND OBJECTIVE

Few studies have assessed the impact of medical residencies on the public healthcare system. The aim here was to assess the number of specialists who remained in the state of Tocantins after finishing the medical residency program during the first two years of the first programs (2013 and 2014).

DESIGN AND SETTING

Cross-sectional and exploratory study conducted at the Federal University of Tocantins in Brazil.

METHODS

All graduates of medical residency programs in Tocantins, of the years 2013 and 2014, were interviewed by telephone and e-mail between May and July 2014.

RESULTS

Information was obtained from 37 graduates from medical residency. Seventeen (50.0%) were working in the state public healthcare system and only six (17.6%) in a municipal service in June 2014. Considering only the 24 doctors who had never worked in the state of Tocantins before their residency, it was observed that two who graduated in 2013 (20.0%) and five who graduated in 2014 (35.7%), i.e. seven out of the total number (29.2%), had established their homes in Tocantins.

CONCLUSIONS

The number of graduates from medical residency who stayed in the state of Tocantins in 2013 and 2014 was small. However, this was related to the absence of other programs for continuation of the specialization. The state healthcare system was primarily responsible for employment of these doctors within public services. On the other hand, hiring by municipal services was extremely low.

Specialty preferences among medical students in Botswana

Background

With the establishment of a new medical college in Botswana to train generalist-doctors and specialists, we set out to explore the career preferences of medical students, factors that influence their choices and attitude to local postgraduate training.

Methods

A descriptive cross-sectional questionnaire-based study was conducted among medical students in their third to fifth year, at the Faculty of Medicine, University of Botswana. The structured, self-administered questionnaires which were hand-delivered covered demographic characteristics of responders, career choices, preferred location of specialisation and factors that influenced the choices.

Results

Of the 143 medical students approached, 116 (81.0%) returned completed questionnaires. Of the responders, 102 (87.9%) intend to pursue postgraduate specialisation against 2 (1.7%) who declined; 12 (10.3%) were undecided. The four most preferred specialties which constituted 68.1% were surgery (28.4%), paediatrics (19.0%), internal medicine (12.9%), obstetrics and gynaecology (7.2%). There was male preference for surgery (p = 0.04), while women were drawn more towards paediatrics and psychiatry (p = 0.04 and p = 0.01, respectively). Personal interest and aptitude was considered the most important factor among most responders (46.2%), followed by enjoyment of the posting (19.8%). A high proportion of responders 80 (69.0%) preferred to specialise abroad for better exposure/opportunities (48.3%), while for 15.5%, their preferred courses are not currently available locally.

Conclusion

Our findings indicated that while four major specialties are preferred, significant gender differences exist with female students leaning towards non-surgical disciplines. Students prefer specialising abroad on the pretext that foreign centres offer better training opportunities, and many specialist programmes are unavailable locally.

Electronic supplementary material

The online version of this article (doi:10.1186/s13104-017-2523-y) contains supplementary material, which is available to authorized users.

A discrete choice experiment studying students' preferences for scholarships to private medical schools in Japan

BACKGROUND

The shortage of physicians in rural areas and in some specialties is a societal problem in Japan. Expensive tuition in private medical schools limits access to them particularly for students from middle- and low-income families. One way to reduce this barrier and lessen maldistribution is to offer conditional scholarships to private medical schools.

METHODS

A discrete choice experiment is carried out on a total of 374 students considering application to medical schools. The willingness to receive a conditional scholarship program to private medical schools is analyzed.

RESULTS

The probability of attending private medical schools significantly decreased because of high tuition, a postgraduate obligation to provide a service in specific specialty areas, and the length of time of this obligation. An obligation to provide a service in rural regions had no significant effect on this probability. To motivate non-applicants to private medical schools to enroll in such schools, a decrease in tuition to around 1.2 million yen (US$ 12,000) or less, which is twice that of public schools, was found to be necessary. Further, it was found that non-applicants to private medical schools choose to apply to such schools even with restrictions if they have tuition support at the public school level.

CONCLUSIONS

Conditional scholarships for private medical schools may widen access to medical education and simultaneously provide incentives to work in insufficiently served areas.

Medical career selection among newly graduated physicians in Madinah, KSA

OBJECTIVES

To study factors influencing medical career selection among newly graduated physicians in Al Madinah, KSA.

METHODS

A cross-sectional survey was conducted during the period from January through March 2011. The study recruited 170 interns and residents working at Al Madinah hospitals, KSA. An anonymous self-administered questionnaire was distributed that included personal data and factors influencing medical career selection. Appropriate statistical tests were used with p value ≤ 0.05 was used as an indicator of significant differences.

RESULTS

The response rate was 79.4% (n=135, 42.2% male). Statistically significant differences were found between male and female participants regarding all the studied medical carrier selection aspects with the higher mean scores among males. Female participants chose the following specialties more than males: ENT, obstetrics and gynecology, pediatrics and medicine. Linear regression analysis showed specialty characters to be the most important predictor in male (R(2)=0.821) and female (R(2)=0.921). Marital status and specialty training process were found to play a key role among females and personality preference and work achievement among males.

CONCLUSIONS

Medical career selection is a complex decision-making process. The study revealed specialty characters, personality preference and work achievement (males) and specialty training process and marital status (females), which are the most important predictors for selection.

Medical students' choices of specialty in The Gambia: the need for career counseling

BACKGROUND

Understanding preferences for specialties by medical students and the factors driving choices assists policy makers in ensuring optimal spread of personnel across disciplines.

METHODS

This cross-sectional survey using self-administered structured questionnaires was conducted on consenting students of the first medical school in The Gambia, established in 1999. Data collection was in June/July 2011. Questions were on sociodemographic characteristics of students, their parents, factors related to career preferences and opinions about counseling services. Data were analysed using JMP 8.0 software.

RESULTS

Respondents were 52.4% of 202 eligible students. Mean age was 24.1 ± 5.0 years. Females constituted 54.7%. Muslims were 72.7% while Gambians formed 77.0%. Commonest specialties chosen by females were Obstetrics/Gynaecology, Paediatrics and Surgery in that order, while males preferred Internal Medicine, Surgery and Obstetrics/Gynaecology. Commonest factors influencing choices by females were 'focus on urgent care' (65.5%) and 'intellectual content of specialty' (56.9%). For males, these were 'intellectual content of specialty' (60.4%) and 'focus on urgent care' / 'individual's competence' (50.0% each). More females (30.0%) than males (23.0%) had ever received career counseling, but all students desired it.

CONCLUSIONS

Significant gender differences exist in specialty choices and factors influencing these choices amongst these students. All want career counseling.

Factors associated with the career choices of hematology and medical oncology fellows trained at academic institutions in the United States

PURPOSE

Factors that influence hematology-oncology fellows' choice of academic medicine as a career are not well defined. We undertook a survey of hematology-oncology fellows training at cancer centers designated by the National Cancer Institute (NCI) and the National Comprehensive Cancer Network (NCCN) to understand the factors fellows consider when making career decisions.

METHODS

Program directors at all NCI and NCCN cancer centers were invited to participate in the study. For the purpose of analysis, fellows were grouped into three groups on the basis of interest in an academic career. Demographic data were tested with the Kruskal-Wallis test and χ² test, and nondemographic data were tested by using the multiscale bootstrap method.

RESULTS

Twenty-eight of 56 eligible fellowship programs participated, and 236 fellows at participating institutions responded (62% response rate). Approximately 60% of fellows graduating from academic programs in the last 5 years chose academic career paths. Forty-nine percent of current fellows ranked an academic career as extremely important. Fellows choosing an academic career were more likely to have presented and published their research. Additional factors associated with choosing an academic career included factors related to mentorship, intellect, and practice type. Fellows selecting nonacademic careers prioritized lifestyle in their career decision.

CONCLUSION

Recruitment into academic medicine is essential for continued progress in the field. Our data suggest that fewer than half the current fellows training at academic centers believe a career in academic medicine is important. Efforts to improve retention in academics should include focusing on mentorship, research, and career development during fellowship training and improving the image of academic physicians.

The effect of rural training experiences during residency on the selection of primary care careers: a retrospective cohort study from a single large internal medicine residency program

BACKGROUND

Little is known about the factors during internal medicine residency that influence career choice.

PURPOSE

To determine if rural training experiences were associated with primary care career choice.

METHODS

We conducted a retrospective cohort study at a single, large, internal medicine residency program. We reviewed self-reported career plan at the time of graduation. Independent variables obtained from curricular data included track (categorical or primary care), gender, year of graduation, timing of clinic block, and having had a rural training experience. We studied 451 program graduates who completed all three years of training between the years 1996 and 2006.

RESULTS

Factors associated with an intended primary care career at the time of graduation were: primary care track (OR 4.5, 95% CI 2.4-8.6) and a rural training experience (OR 2.1, 95% CI 1.3-3.4).

CONCLUSIONS

These data suggest that provision of more rural training experiences might increase interest in primary care careers.

Shortage in general practice despite the feminisation of the medical workforce: a seeming paradox? A cohort study

Background

Female medical students often prefer primary care specialties, while male students appear to be attracted to hospital specialties. Notwithstanding the steady feminisation of medicine, in many countries there are still difficulties in recruiting trainees for general practice. This seeming paradox raises the question on what specific role gender plays in a specialty choice. The authors looked at the (a) the role of gender in general practice specialty choice of Dutch medical students, (b) the decisive factors in career choice and relation of gender to these, and (c) differences in how male and female students are influenced by the GP clerkship.

Methods

A cohort of 206 final year medical students at the Maastricht University, the Netherlands were asked to complete a questionnaire focusing on career preferences before and after a 12-week general practice clerkship and at graduation, a couple of months later.

Results

Gender was significantly related to willingness to become a GP in bivariate analysis. Adding variables in multivariate analysis made this effect disappear. While females expressed overall higher preference for general practice than males, after the GP clerkship likelihood of choosing general practice increased with 38% among male and 22% among female students. After graduation, interest in general practice had dropped, mainly among females. Attitudes predicting a GP career choice were: extrinsic career motivation before the clerkship, and the content of GP work (patient contacts, treatments) and motivation to work with chronic and palliative patients after the clerkship.

Conclusion

Gender 'as such' appeared not to be a distinctive predictor of specialty choice. It is students' attitudes towards GP work and preferred patient category that determine the career choice in general practice. However, more male students were positively influenced by the GP clerkship than female students. The motivating effect of the clerkship is not long lasting. Especially female graduates change their interest in favour of other specialties, which may explain why eventually few students choose general practice. It might be worthwhile to reinforce an initial preference for general practice by motivational guidance throughout the whole period of clerkships.

Factors associated with the subspecialty choices of internal medicine residents in Canada

BACKGROUND

Currently, there are more residents enrolled in cardiology training programs in Canada than in immunology, pharmacology, rheumatology, infectious diseases, geriatrics and endocrinology combined. There is no published data regarding the proportion of Canadian internal medicine residents applying to the various subspecialties, or the factors that residents consider important when deciding which subspecialty to pursue. To address the concern about physician imbalances in internal medicine subspecialties, we need to examine the factors that motivate residents when making career decisions.

METHODS

In this two-phase study, Canadian internal medicine residents participating in the post graduate year 4 (PGY4) subspecialty match were invited to participate in a web-based survey and focus group discussions. The focus group discussions were based on issues identified from the survey results. Analysis of focus group transcripts grew on grounded theory.

RESULTS

110 PGY3 residents participating in the PGY4 subspecialty match from 10 participating Canadian universities participated in the web-based survey (54% response rate). 22 residents from 3 different training programs participated in 4 focus groups held across Canada. Our study found that residents are choosing careers that provide intellectual stimulation, are consistent with their personality, and that provide a challenge in diagnosis. From our focus group discussions it appears that lifestyle, role models, mentorship and the experience of the resident with the specialty appear to be equally important in career decisions. Males are more likely to choose procedure based specialties and are more concerned with the reputation of the specialty as well as the anticipated salary. In contrast, residents choosing non-procedure based specialties are more concerned with issues related to lifestyle, including work-related stress, work hours and time for leisure as well as the patient populations they are treating.

CONCLUSION

This study suggests that internal medicine trainees, and particularly males, are increasingly choosing procedure-based specialties while non-procedure based specialties, and in particular general internal medicine, are losing appeal. We need to implement strategies to ensure positive rotation experiences, exposure to role models, improved lifestyle and job satisfaction as well as payment schedules that are equitable between disciplines in order to attract residents to less popular career choices.

Factors considered by medical students when formulating their specialty preferences in Japan: findings from a qualitative study

BACKGROUND

Little research addresses how medical students develop their choice of specialty training in Japan. The purpose of this research was to elucidate factors considered by Japanese medical students when formulating their specialty choice.

METHODS

We conducted qualitative interviews with 25 Japanese medical students regarding factors influencing specialty preference and their views on roles of primary versus specialty care. We qualitatively analyzed the data to identify factors students consider when developing specialty preferences, to understand their views about primary and subspecialty care, and to construct models depicting the pathways to specialization.

RESULTS

Students mention factors such as illness in self or close others, respect for family member in the profession, preclinical experiences in the curriculum such as labs and dissection, and aspects of patient care such as the clinical atmosphere, charismatic role models, and doctor-patient communication as influential on their specialty preferences. Participating students could generally distinguish between subspecialty care and primary care, but not primary care and family medicine. Our analysis yields a "Two Career" model depicting how medical graduates can first train for hospital-based specialty practice, and then switch to mixed primary/specialty care outpatient practice years later without any requirement for systematic training in principles of primary care practice.

CONCLUSION

Preclinical and clinical experiences as well as role models are reported by Japanese students as influential factors when formulating their specialty preferences. Student understanding of family medicine as a discipline is low in Japan. Students with ultimate aspirations to practice outpatient primary care medicine do not need to commit to systematic primary care training after graduation. The Two Career model of specialization leaves the door open for medical graduates to enter primary care practice at anytime regardless of post-graduate residency training choice.

What is medicine and what is a doctor? Medical students' perceptions and expectations of their academic and professional career

BACKGROUND

Research was conducted at the University of Cape Town in South Africa where a new medical curriculum was introduced in 2002. This curriculum is largely problem-based and primary health care (PHC) driven.

AIM

To qualitatively explore medical students' perceptions of medicine and doctors and their expectations of studying medicine and practising as a doctor.

METHODS

A questionnaire was administered to all first-year students (n = 193) that assessed their perceptions of doctors, and their expectations of studying medicine and practising as a doctor. Interviews and focus groups were conducted with purposively selected first-, second-, third- and fourth-year students.

RESULTS

Medical students at the University of Cape Town were found to have generally positive perceptions of medicine and doctors, and depicted the medical profession as one that is very significant because of its influence within society, to the point of being perceived as almost noble. Some of the more challenging and difficult aspects of a career in medicine were mentioned, but these seem to be minor compared to the positive aspects. Some students regarded the medical profession as having a biomedical and curative emphasis, although there seemed to be a strong move towards a more holistic view. However, students expected their degree to concentrate on the biomedical aspects of medicine, and therefore did not expect particular components of their degree, such as the psychosocial component.

CONCLUSIONS

Unmet expectations regarding their curriculum seem to be a very significant issue for students. It is therefore important for educators who deliver the curriculum to be aware of and to understand medical students' perceptions and expectations of medicine and doctors, in order to detect and deal with conflict between these perceptions and expectations and what may be an educational institution's 'hidden curriculum'.

Predictors of final specialty choice by internal medicine residents

BACKGROUND

Sociodemographic factors and personality attributes predict career decisions in medical students. Determinants of internal medicine residents' specialty choices have received little attention.

OBJECTIVE

To identify factors that predict the clinical practice of residents following their training.

DESIGN

Prospective cohort study.

PARTICIPANTS

Two hundred and four categorical residents from 2 university-based residency programs.

MEASUREMENTS

Sociodemographic and personality inventories performed during residency, and actual careers 4 to 9 years later.

RESULTS

International medical school graduates (IMGs) were less likely to practice general medicine than U.S. graduates (33.3% vs 70.6%, P < .001). Residents with higher loan indebtedness more often became generalists (P = .001). A corresponding trend favoring general internal medicine was observed among those who perceived General Internists to have lower potential incomes (69.0% vs 53.3%, P = .08). There was a trend for generalists to have lower scores on scales measuring authoritarianism, negative orientation to psychological problems, and Machiavellianism (0.05 < P < .10). In a logistic regression, graduation from a U.S. medical school (odds ratio [OR] 3.02; 95% confidence interval [CI], 1.00 to 9.10, P = .049) and perception of low future income (OR 1.65; 95% CI, 1.06 to 2.56, P = .03) predicted entry into general medicine, with trends apparent for higher debt (P = .05) and greater comfort caring for patients with psychological problems (P = .07).

CONCLUSION

Recruitment of IMGs may not increase the supply of General Internists. Prospects of lower income, even in the face of large debt, may not discourage residents from becoming generalists. If increasing generalist manpower is a goal, residencies should consider weighing applicants' personal attributes during the selection process.

What students bring to medical school: attitudes toward health promotion and prevention

INTRODUCTION

Health care providers' positive attitudes toward prevention and health promotion are important in achieving national health care goals. Limited studies of incoming medical students have been conducted that measure predictors of positive attitudes toward health promotion and prevention.

METHODS

Data were obtained from a 1993 curriculum evaluation survey of first-year students at five different medical schools in California. Attitudes toward health promotion and prevention were measured using a nine-question Prevention Attitude Scale (PAS). We developed 2 multivariate linear regression models using demographics, education choices, and personal social values and beliefs to predict PAS scores. We also performed bivariate analysis.

RESULTS

Five hundred ninety-nine completed surveys were analyzed, with a response rate of 95%. Mean PAS score was 36.47 +/- 3.7 on a 0 to 44 scale. Female gender, Democratic party preference, and a planned specialty choice in preventive medicine or primary care predicted the highest PAS scores on bivariate analysis (p < 0.002). Significant correlation ( p < 0. 001) was shown between PAS scores and 2 additional scales regarding beliefs in associations of social factors and illness and in the importance of caring for the poor. Linear regression model using personal social values and beliefs explained 34% of the variance, as opposed to the demographic model that explained only 9% of the variance.

CONCLUSIONS

In the schools studied, participating first-year medical students had moderately positive attitudes toward health promotion and prevention, as measured by PAS scores. In designing curriculum to improve medical students' attitudes toward health promotion and prevention, medical educators may need to consider other personal and social values held by medical students and to address the "political" aspects of health promotion and prevention. Future studies are needed to longitudinally follow medical student attitudes.

Residency application statements can predict postresidency training

We sought to evaluate whether residency application statements regarding expected career paths are accurate predictors of early postresidency career paths. We evaluated 162 residents who completed a categorical medicine residency at Georgetown University Hospital between 1990 and 1998 to determine if their stated career plans (generalist practice, subspecialization, or undecided) at application predicted activity immediately after residency. Of 130 residents with defined postresidency plans at application, most 78 (60%) followed those career paths after graduation; 18 (67%) of 27 pursued their initial interest in generalist practice, and 60 (58%) of 103 pursued their stated interest in subspecialty training. We also noted a movement of residents toward generalism (79 [49%] of 162), despite low initial interest (27 [17%] of 162).

Student loan debt does not predict female physicians' choice of primary care specialty

OBJECTIVE

There has never been a conclusive test of whether there is a relation between ultimately choosing to be a primary care physician and one's amount of student loan debt at medical school graduation.

DESIGN/SETTING/PARTICIPANTS

To test this question, we examined data from the Women Physicians' Health Study, a large, nationally representative, questionnaire-based study of 4,501 U.S. women physicians.

MEASUREMENTS AND MAIN RESULTS

We found that the youngest physicians were more than five times as likely as the oldest to have had some student loan debt and far more likely to have had high debt levels (p <.0001). However, younger women physicians were also more likely to choose a primary care specialty (p <.002). There was no relation between being a primary care physician and amount of indebtedness (p =.77); this was true even when the results were adjusted for the physicians' decade of graduation and ethnicity (p =.79).

CONCLUSIONS

Although there may be other reasons for reducing student loan debt, at least among U.S. women physicians, encouraging primary care as a specialty choice may not be a reason for doing so.

The role of curriculum in influencing students to select generalist training: a 21-year longitudinal study

To determine if specific curricula or backgrounds influence selection of generalist careers, the curricular choices of graduates of Mount Sinai School of Medicine between 1970 and 1990 were reviewed based on admission category. Students were divided into three groups: Group 1, those who started their first year of training at the School of Medicine; Group 2, those accepted with advanced standing into their third year of training from the Sophie Davis School of Biomedical Education, a five-year program developed to select and produce students likely to enter primary care fields; and Group 3, those accepted with advanced standing into the third year who spent the first two years at a foreign medical school. All three groups took the identical last two years of clinical training at the School of Medicine. These were no significant differences with respect to initial choice of generalist training programs among all three groups, with 46% of the total cohort selecting generalist training. Of those students who chose generalist programs, 58% in Group 1, 51% in Group 2, and 41% in Group 3 remained in these fields rather than progressing to fellowship training. This difference was significant only with respect to Group 3. However, when an analysis was performed among those students providing only primary care as compared to only specialty care, there were no significant differences. Analysis by gender revealed women to be more likely to select generalist fields and remain in these fields without taking specialty training (P < .0001). Differentiating characteristics with respect to choosing generalist fields were not related to either Part I or Part II scores on National Board Examinations or selection to AOA. However, with respect to those specific specialties considered quite competitive (general surgery, obstetrics and gynecology, and ophthalmology), total test scores on Part I and Part II were significantly higher than those of all other students. The analysis indicated that, despite the diverse characteristics of students entering the third year at the School of Medicine, no one group produced a statistically greater proportion of generalists positions than any other, and academic performance while in medical school did not have a significant influence on whether a student entered a generalist field.

Attributes of excellent attending-physician role models

BACKGROUND

Although effective role models are important in medical education, little is known about the characteristics of physicians who serve as excellent clinical role models. We therefore conducted a case-control study to identify attributes that distinguish such physicians from their colleagues.

METHODS

We asked members of the internal-medicine house staff at four teaching hospitals to name physicians whom they considered to be excellent role models. A total of 165 physicians named by one or more house-staff members were classified as excellent role models (these served as the case physicians in our study). A questionnaire was sent to them as well as to 246 physicians who had residency-level teaching responsibilities but who were not named (controls). Of these 411 physicians, 341 (83 percent) completed questionnaires while unaware of their case-control status.

RESULTS

Of the 341 attending physicians who responded, 144 (42 percent) had been identified as excellent role models. Having greater assigned teaching responsibilities was strongly associated with being identified as an excellent role model. In the multivariate analysis, five attributes were independently associated with being named as an excellent role model: spending more than 25 percent of one's time teaching (odds ratio, 5.12; 95 percent confidence interval, 1.81 to 14.47), spending 25 or more hours per week teaching and conducting rounds when serving as an attending physician (odds ratio, 2.48; 95 percent confidence interval, 1.15 to 5.37), stressing the importance of the doctor-patient relationship in one's teaching (odds ratio, 2.58; 95 percent confidence interval, 1.03 to 6.43), teaching the psychosocial aspects of medicine (odds ratio, 2.31; 95 percent confidence interval, 1.23 to 4.35), and having served as a chief resident (odds ratio, 2.07; 95 percent confidence interval, 1.07 to 3.98).

CONCLUSIONS

These data suggest that many of the attributes associated with being an excellent role model are related to skills that can be acquired and to modifiable behavior.

General internists influence students to choose primary care careers: the power of role modeling

PURPOSE

To determine whether medical students supervised by general internist attendings during the third-year medicine clerkship are more likely to choose primary care careers than students supervised by subspecialist attendings.

METHODS

One hundred forty-four consecutive medical students rotating on the general medicine inpatient service during the 1993-1994 academic year were surveyed about their career choice and professional expectations, both at the beginning and end of the clerkship; an additional 50 students completed a post-clerkship survey only. The cohort of students was surveyed at graduation to determine stability of their career preferences.

RESULTS

Both pre- and post-clerkship surveys were completed by 138 of 144 students (96%); post-clerkship surveys were completed by 181/194 (93%); and graduation surveys were completed by 137/188 (73%). Fifty-eight students (32%) designated primary care (general internal medicine, general pediatrics, or family practice) as their career choice post-clerkship; of these, 45 students (78%) also indicated a primary care career choice at graduation. Characteristics associated with choosing primary care post-clerkship were: low income expectation, desire to interact closely with patients, desire to contribute to society, low class rank, female gender, and high educational debt. Having a physician parent was negatively associated with choosing primary care. After controlling for important demographic, academic and attitudinal characteristics, increasing exposure to a general internist attending was associated with choosing primary care (OR = 5.1, comparing highest to lowest amount). Among students choosing primary care, exposure to a general internist attending was associated with choosing general internal medicine in a dose-dependent fashion (OR = 4.2, comparing highest to lowest amount).

CONCLUSIONS

Although career choice is clearly related to personal characteristics such as socioeconomic background and humanistic qualities, a high degree of exposure to general internists during the medicine clerkship is associated with choosing primary care. Exposure of students interested in primary care to general internist attendings may also influence them to consider general internal medicine over family practice and pediatrics.

Medical students' specialty choice and the need for primary care. Our future

Recent changes in the health care environment have directed increasing attention to the recognized oversupply of specialists and relative lack of primary care physicians. Despite this imbalance and the need for more primary care physicians, US medical schools are not producing them in adequate numbers. To effect change in the production of primary care physicians, a comprehensive approach that addresses key factors in medical student specialty choice is needed. This article discusses such factors and how they affect medical students during the course of their training. Issues concerning primary care specialty choice and the physician work force are important to the development of the future US health care system.