Objective: To better understand and characterize the challenges facing internal medicine from the perspective of internal medicine residency program directors.
Methods: In 2007, internal medicine program directors were surveyed by the Association of Program Directors in Internal Medicine (APDIM). An open-ended question asked: “What are your major concerns regarding internal medicine?” Responses to this question were independently coded by two investigators and compared for agreement. Content analysis identified several major themes related to their concerns.
Results: Of the 236 program directors completing the survey, 186 (79%) answered the question and explained their concerns. Approximately one half of the informants were general internists. There was a fairly even distribution among assistant, associate, and professor ranking. All regions of the country were represented. Five themes emerged as the program directors' major concerns about internal medicine: waning interest in internal medicine, especially primary care; onerous regulatory oversight; economic pressures; the eighty-hour work week; and fragmentation within internal medicine.
Conclusion: By virtue of their role, internal medicine residency directors gain a unique understanding about the core elements that contribute to declining interest in careers in internal medicine, which is particularly relevant given the current primary care workforce crisis. Collaboration among stakeholders that can influence healthcare policy to address these concerns about internal medicine will be necessary to revive interest in the field.
* Internal medicine residency program directors are concerned about declining interest in internal medicine among medical students, and in primary care among residency graduates.
* Program directors are concerned about burdensome regulatory oversight of graduate medical education and medical practice, economic pressures affecting medical education and career choice, the eighty-hour work week, and fragmentation within internal medicine.
* The findings related to declining interest in internal medicine careers have implications for health policy reform.
3. American College of Physicians. How Is a Shortage of Primary Care Physicians Affecting the Quality and Cost of Medical Care?
Philadelphia, American College of Physicians, 2008, White Paper. (Available from American College of Physicians, 190 N. Independence Mall West, Philadelphia, PA 19106.) Available at: http://www.acponline.org/advocacy/where_we_stand/policy/primary_shortage.pdf
. Accessed February 1, 2010.
4. McMurray JE, Schwartz MD, Genero NP, et al. The attractiveness of internal medicine: a qualitative analysis of the experiences of female and male medical students. Society of General Internal Medicine Task Force on Career Choice in Internal Medicine. Ann Intern Med 1993;119:812–818.
5. Hauer KE, Alper EJ, Clayton CP, et al. Educational responses to declining student interest in internal medicine careers. Am J Med 2005;118:1164–1170.
6. Hauer KE, Durning SJ, Kernan WN, et al. Factors associated with medical students' career choices regarding internal medicine. JAMA 2008;300:1154–1164.
7. Garibaldi RA, Popkave C, Bylsma W. Career plans for trainees in internal medicine residency programs. Acad Med 2005;80:507–512.
8. Bodenheimer T, Berenson RA, Rudolf P. The primary care-specialty income gap: why it matters. Ann Intern Med 2007;146:301–306.
9. Bodenheimer T, Chen E, Bennett HD. Confronting the growing burden of chronic disease: can the U.S. health care workforce do the job? Health Aff (Millwood) 2009;28:64–74.
10. Cooper RA, Getzen TE, McKee HJ, et al. Economic and demographic trends signal an impending physician shortage. Health Aff (Millwood) 2002;21:140–154.
11. Bodenheimer T. Coordinating care—a perilous journey through the health care system. N Engl J Med 2008;358:1064–1071.
12. Colwill JM, Cultice JM, Kruse RL. Will generalist physician supply meet demands of an increasing and aging population? Health Aff (Millwood) 2008;27:w232–w241.
13. Peikes D, Chen A, Schore J, et al. Effects of care coordination on hospitalization, quality of care, and health care expenditures among Medicare beneficiaries: 15 randomized trials. JAMA 2009;301:603–618.
14. Kravet SJ, Shore AD, Miller R, et al. Health care utilization and the proportion of primary care physicians. Am J Med 2008;121:142–148.
15. Starfield B, Shi L, Macinko J. Contribution of primary care to health systems and health. Milbank Q2005;83:457–502.
17. Crabtree BF, Miller WL. Doing Qualitative Research. Thousand Oaks, Sage Publications, 1999, ed 2.
19. Lipner RS, Bylsma WH, Arnold GK, et al. Who is maintaining certification in internal medicine—and why? A national survey 10 years after initial certification. Ann Intern Med 2006;144:29–36.
20. Block SD, Clark-Chiarelli N, Singer JD. Mixed messages about primary care in the culture of U.S. medical schools. Acad Med 1998;73:1087–1094.
21. Colwill JM, Perkoff GT, Blake RL Jr, et al. Modifying the culture of medical education: the first three years of the RWJ Generalist Physician Initiative. Acad Med 1997;72:745–753.
22. Wright SM, Carrese JA. Serving as a physician role model for a diverse population of medical learners. Acad Med 2003;78:623–628.
23. Rosenblatt RA, Andrilla CH. The impact of U.S. medical students' debt on their choice of primary care careers: an analysis of data from the 2002 medical school graduation questionnaire. Acad Med2005;80:815–819.
24. Kahn MJ, Markert RJ, Lopez FA, et al. Is medical student choice of a primary care residency influenced by debt? MedGenMed 2006;8:18.
25. McDonald FS, West CP, Popkave C, et al. Educational debt and reported career plans among internal medicine residents. Ann Intern Med 2008;149:416–420.
26. Linzer M, Konrad TR, Douglas J, et al. Managed care, time pressure, and physician job satisfaction: results from the physician worklife study. J Gen Intern Med 2000;15:441–450.
27. Hadley J, Mitchell JM. The growth of managed care and changes in physicians' incomes, autonomy, and satisfaction, 1991–1997. Int J Health Care Finance Econ 2002;2:37–50.
28. Linzer M, Manwell LB, Williams ES, et al; MEMO (Minimizing Error, Maximizing Outcome) Investigators. Working conditions in primary care: physician reactions and care quality. Ann Intern Med 2009;151:28–36, W6–W9.
29. Charap MH, Levin RI, Pearlman RE, et al. Internal medicine residency training in the 21st century: aligning requirements with professional needs. Am J Med 2005;118:1042–1046.
31. Goroll AH, Sirio C, Duffy FD, et al; Residency Review Committee for Internal Medicine. A new model for accreditation of residency programs in internal medicine. Ann Intern Med 2004;140:902–909.
34. Warm EJ, Schauer DP, Diers T, et al. The ambulatory long-block: an accreditation council for graduate medical education (ACGME) educational innovations project (EIP). J Gen Intern Med 2008;23:921–926.
35. Holmboe ES, Bowen JL, Green M, et al. Reforming internal medicine residency training. A report from the Society of General Internal Medicine's task force for residency reform. J Gen Intern Med 2005;20:1165–1172.
36. Morelock JA, Stern DT; Association of Professors of Medicine. Shifting patients: how residency programs respond to residency review committee requirements. Am J Med 2003;115:163–169.
37. Henderson MC, Meyers FJ, Ibrahim T, et al. Confronting the brutal facts in health care. Am J Med 2005;118:1061–1063.
38. Association of Program Directors in Internal Medicine; Fitzgibbons JP, Bordley DR, Berkowitz LR, et al. Redesigning residency education in internal medicine: a position paper from the Association of Program Directors in Internal Medicine. Ann Intern Med 2006;144:920–926.
39. Asch DA, Jedrziewski MK, Christakis NA. Response rates to mail surveys published in medical journals. J Clin Epidemiol 1997;50:1129–1136.
40. Cummings SM, Savitz LA, Konrad TR. Reported response rates to mailed physician questionnaires. Health Serv Res 2001;35:1347–1355.
41. Starfield B. The future of primary care: refocusing the system. N Engl J Med 2008;359:2087, 2091.