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

Policy perception, job satisfaction and intentions to remain in rural area: evidence from the National Compulsory Service Programme in China

BACKGROUND

Exploring factors that may influence general practitioners (GPs)' intentions to remain in rural area is necessary to inform the training and placement of future medical workforce in rural area. However, little is known about how GPs' perception towards the National Compulsory Service Programme (NCSP) and job satisfaction impact their turnover intention. This paper explores GPs' intentions to remain in rural China and how their policy perception and job satisfaction predict the intentions.

METHODS

We conducted a cross-sectional, online survey from December 2021 to February 2022 to investigate GPs' perception towards NCSP, job satisfaction, and intentions to remain in rural area. Eligible participants were GPs who were required to provide health services as part of NCSP at township health centres of 9 provinces which could represent all NCSP GPs in China. Multinomial logistic regression analyses were performed to explore the associations between policy perceptions, job satisfaction, and intentions to remain.

RESULTS

Of 3615 GPs included in the analysis, 442 (12.2%) would like to remain in rural area and 1266 (35.0%) were unsure. Results of the multinomial logistic regression analyses showed that compared with GPs who would leave, GPs with higher perception scores for the restriction on taking postgraduate exam (RRR: 1.93, 95% CI 1.72, 2.16) and the commitment to work for six years (RRR: 1.53, 95% CI 1.31, 1.78) were more likely to remain. In contrast, GPs who had higher perception scores for completing standardised residency training (RRR: 0.75, 95% CI 0.64, 0.88) and passing National Medical Licensing Examinations (RRR: 0.74, 95% CI 0.62, 0.87) were more likely to leave. GPs who were satisfied with the freedom of choosing work methods (RRR: 1.52, 95% CI 1.25, 1.84) and chances of promotion (RRR: 1.60, 95% CI 1.32, 1.94) were more likely to remain.

CONCLUSIONS

This study highlights the significance of policy perception and job satisfaction on GPs' intentions to remain in rural area. Factors such as career advancement and the empowerment of GPs to build on and use their skills and abilities should be taken into account when designing rural placement programmes.

Preferences, Career Aspects, and Factors Influencing the Choice of Specialty by Medical Students and Interns in Saudi Arabia: A Cross-Sectional Study

Background and objective Choosing a medical specialty is one of the most critical career decisions medical students and interns make. However, little is known about the factors these graduates consider when choosing their specialty. Our study assessed factors that medical students and interns consider when determining their specialty. Methods This is a cross-sectional survey-based study, conducted from November to December 2022. We utilized a previously published questionnaire for 1074 participants, including 837 medical students and 237 interns from Saudi Arabian universities. Results The majority of female participants (80.4%), compared with only 19.6% of male participants, considered interest in specific procedures and techniques typical of the specialty an important factor in choosing a specialty (p = 0.036). Dissertation research experience was an important factor for 83.5% of female participants and 16.5% of male participants (p = 0.024). Additionally, good quality teaching within the study program framework was important for 81.2% of female participants and 18.8% of male participants (p = 0.033), suggesting that male and female participants viewed the importance of good quality teaching differently. Female participants accounted for 80% of those who considered the overseas experience a factor in their specialty choice. Also, 74.4% of female and 25.6% of male participants considered friends, relatives, or other connections in the healthcare field a factor that affects their choice. Furthermore, 79.6% of female and 20.4% of male participants reported having good experiences with physician role models as an impactful factor in their specialty choice. Conclusion Female participants were most interested in obstetrics and gynecology (12.1%,), internal medicine (11.8%), and family medicine (10.8%). Male participants, on the other hand, showed more interest in family medicine (12.7%,), internal medicine (11.0%), and emergency medicine (10.1%). Medical schools and healthcare institutions must provide students and interns with enough information and resources to help them explore different specialties and make well-informed decisions about their careers.

Clerkship Experiences During Medical School: Influence on Specialty Decision

OBJECTIVE

Clinical rotations during medical school are the time when most students select their specialty. Limited or lack of exposure could deter students from certain sub-specialties, and thus, insight into the selection process is essential. This study assesses the role of limited clinical rotations and perception of students on specialty selection.

METHODS

All graduating medical students were surveyed at our US-based institution for 2 years. The survey included both open- and close-ended questions related to influence of clerkship experience and other factors on specialty choice and suggestions for improvement. The data were analyzed descriptively and thematically.

RESULTS

Majority of students (87%) had minimal exposure to their chosen residency specialty prior to the third-year clerkships. Role of a clerkship experience in selecting a specialty was significant for 70% students, especially interaction with attendings (92%) and residents (86.3%). The most influential reasons for specialty choice to change were clerkship experience (41%) and mentors (21%). Approximately 34% students chose a specialty that was not a part of third-year core clerkships, and the most significant factors influencing their choice were shadowing experience (21%) and lifestyle (18%). Further, thematic analysis suggested that earlier and more clinical exposure to various specialties and formal mentoring could make specialty selection process easier.

CONCLUSIONS

Along with specialty content, the relationship of learners and teachers in the clinical setting plays a significant role in selecting and/or rejecting certain specialty by medical students. The study provides broader baseline data for medical schools and educators in preparation of curriculum and future physician workforce composition.

Effect of medical student debt on mental health, academic performance and specialty choice: a systematic review

OBJECTIVES

With the high and rising total cost of medical school, medical student debt is an increasing concern for medical students and graduates, with significant potential to impact the well-being of physicians and their patients. We hypothesised that medical student debt levels would be negatively correlated with mental health and academic performance, and would influence career direction (ie, medical specialty choice).

DESIGN

We performed a systematic literature review to identify articles that assessed associations between medical student mental health, academic performance, specialty choice and debt. The databases PubMed, Medline, Embase, Scopus and PsycINFO were searched on 12 April 2017, for combinations of the medical subject headings Medical Student and Debt as search terms. Updates were incorporated on 24 April 2019.

RESULTS

678 articles were identified, of which 52 met the inclusion criteria after being reviewed in full text. The majority of studies were conducted in the USA with some from Canada, New Zealand, Scotland and Australia. The most heavily researched aspect was the association between medical student debt and specialty choice, with the majority of studies finding that medical student debt was associated with pursuit of higher paying specialties. In addition, reported levels of financial stress were high among medical students, and correlated with debt. Finally, debt was also shown to be associated with poorer academic performance.

CONCLUSIONS

Medical student debt levels are negatively associated with mental well-being and academic outcomes, and high debt is likely to drive students towards choosing higher paying specialties. Additional prospective studies may be warranted, to better understand how educational debt loads are affecting the well-being, career preparation and career choices of physicians-in-training, which may in turn impact the quality of care provided to their current and future patients.

Medical students' attitude toward anesthesia as a future career

OBJECTIVES

The purpose of this study is to understand the attitude of medical students at King Saud bin Abdulaziz University for Health Sciences (KSAU-HS) toward anesthesia as a specialty and to determine common factors influencing their career choice options.

STUDY DESIGN

This was a cross-sectional study.

METHODS

The study was conducted between March 25, and April 20, 2017, at KSAU-HS. The survey was distributed among 5th and 6th years medical students. Data were collected through a validated hardcopy questionnaire of 16 multiple choice questions. The questionnaire included demographic characteristics, specialty preferences, what factors attract Saudi medical students to choose their preferred specialty and how they view the option of choosing anesthesiology as a career.

RESULTS

A total of 236 students completed the questionnaire. The majority of respondents were in their 5th year of medical school representing (62%). The distribution of medical field interest ranged from (38%) surgery to (1%) anesthesiology. approximately, (60%) thought that controllable lifestyle was an important factor to consider in choosing a residency program. Only (45%) of respondents thought that prestige of specialty is a major factor that would influence their choice for a specialty.

CONCLUSION

Based on the outcome of the study, it is recommended that medical undergraduate students exposure to anesthesia specialty should be magnified. Greater efforts have to be made to increase the number of medical students preferring anesthesia through emphasizing on the positive aspects of the specialty.

Role models and professional development in dentistry: an important resource: The views of early career stage dentists at one academic health science centre in England

BACKGROUND

The importance of role models, and their differing influence in early, mid- and late careers, has been identified in the process of professional development of medical doctors. There is a paucity of evidence within dentistry on role models and their attributes.

AIM

To explore the views of early career dentists on positive and negative role models across key phases of professional development, together with role models' attributes and perceived influence.

METHODS

This is a phenomenological study collecting qualitative data through semi-structured interviews based on a topic guide. Dentists in junior (core training) hospital posts in one academic health science centre were all invited to participate. Interviews were recorded, transcribed verbatim and analysed using framework analysis.

RESULTS

Twelve early career stage dentists, 10 of whom were female, reported having role models, mainly positive, in their undergraduate and early career phases. Participants defined role models' attributes in relation to three distinct domains: clinical attributes, personal qualities and teaching skills. Positive role models were described as "prioritising the patient's best interests", "delivering learner-centred teaching and training" and "exhibiting a positive personality", whilst negative role models demonstrated the converse. Early career dentists reported having largely positive dentist role models during- and post-dental school and report their impact on professional values and aspirations, learning outcomes and career choice.

CONCLUSION

The findings suggest that these early career dentists in junior hospital posts have largely experienced and benefitted from positive role models, notably dentists, perceived as playing an important and creative influence promoting professionalism and shaping the career choices of early career stage dentists.

Medical Students' Views of Medicine as a Calling and Selection of a Primary Care-Related Residency

With the US health care system facing a primary care physician shortage, we evaluated whether medical students who saw medicine as a calling were more likely to enter a family medicine, internal medicine, or pediatrics residency program. Of the 591 4th-year medical students who responded to a survey item on medicine as a calling, 237 strongly agreed that the "practice of medicine is a calling." Students who strongly agreed that medicine was a calling had higher odds (P=.003) of selecting a primary care-related residency. Identifying with medicine as a calling may increase the likelihood of pursuing a primary care career.

Medical Student Experiences on Consultation-Liaison Psychiatry Rotations: A Nationwide Survey

BACKGROUND

Consultation-liaison (C-L) psychiatry clerkship rotations may improve medical students' understanding of psychiatric principles relevant to the settings in which they will ultimately practice. This study aimed to characterize students' experiences on C-L rotations.

METHODS

This cross-sectional survey study, sponsored by the Academy of Psychosomatic Medicine Subcommittee on Medical Student Education, was conducted at 5 US medical schools between 2012 and 2016. After the C-L rotation, students completed a voluntary 17-item survey.

RESULTS

A total of 235 surveys were collected (mean response rate = 92%). The most frequently endorsed benefit of C-L was learning to manage psychiatric disorders in the context of medical illness (89%). The most frequently endorsed drawback was inconsistent/excessively variable workload (40%). Overall, 82% of respondents recommended C-L to other students; 80% reported that the ideal clerkship would include exposure to both C-L and inpatient psychiatry. Overall, 38% reported that their C-L experience increased their interest in psychiatry as a career. Effect of C-L on interest in psychiatry did not differ by study site, age, sex, clerkship length, or time spent on C-L. Respondents who noted more positive role-modeling on C-L compared to other clerkship rotations were more likely to report increased interest in a psychiatry career (odds ratio = 2.70).

CONCLUSIONS

Most medical students perceive C-L rotations favorably. Positive role modeling may increase their consideration of psychiatry specialization. The findings that C-L rotation length did not correlate with attitudes and that most students preferred exposure to both inpatient and C-L psychiatry suggest that C-L exposure can beneficially be integrated into core clerkships containing other elements.

At a Crossroads: Family Medicine Education in China

China is engaged in efforts to train 300,000 family doctors by 2020 to meet its population's health care needs. This Article discusses the family doctor shortage, compares family medicine training programs, examines the distributional challenges faced by these programs, and proposes directions for further experimentation. Despite an increasing number of family doctors, they represented only 5.6% of all doctors in 2013. Currently, three training programs run concurrently-the post-transfer training, residency training, and designated family medicine undergraduate education programs. These programs face several challenges. First, the educational qualifications of primary care practitioners (PCPs) vary greatly between rural and urban regions. From 2005 to 2013, the percentage of PCPs with three or more years of medical training in urban areas was at least 20.0% higher than in rural areas. Second, regional disparities in the number of family doctors for every 10,000 people exist. The richer eastern part of China has a ratio of 1.51 family doctors for every 10,000 people, nearly double that of central (0.70) and western China (0.86). Third, better-educated doctors are most likely going to prefer to work in hospitals, which offer a lucrative career path with higher pay and social status. Intervention packages that combine student selection policies that look at place of origin and career intent with other incentive strategies are worth implementing. Adequate clinical exposure and regular, rigorous evaluations are crucial for enhancing training quality. China should strike a balance in the distribution of family doctors between the richer and poorer areas to ensure equity.

The impact of positive doctor role modeling

BACKGROUND

Role modeling has been highlighted as an important teaching and learning strategy. The aim of this research study was to explore the influences and impact of positive doctor role modelling in twenty-first century medical education.

METHODS

This study was part of a larger study investigating the process of positive doctor role modeling in medical education. This study used focus group interviews with 52 medical students, semi-structured interviews with 25 consultants and interviews after clinics with five consultants and five medical students. A qualitative methodology using the grounded theory approach of Strauss and Corbin was then used to explore the impact of modeling in medical education.

RESULTS

Three main outcomes of role modeling were identified - the development of professional behaviors, the development of professional identity, and the shaping of career aspirations.

CONCLUSION

This study illustrates the powerful, often subconscious impact of doctor role modeling in medical education. This research illustrates that role models are critically important in the professional development, character development, and career development of the modelees. In this way, role modeling effectively enhances the transformation of the student to a doctor.

Impact of Interventions to Increase the Proportion of Medical Students Choosing a Primary Care Career: A Systematic Review

BACKGROUND

Increasing the attractiveness of primary care careers is a key step in addressing the growing shortage of primary care physicians. The purpose of this review was to (1) identify interventions aimed at increasing the proportion of undergraduate medical students choosing a primary care specialty, (2) describe the characteristics of these interventions, (3) assess the quality of the studies, and (4) compare the findings to those of a previous literature review within a global context.

METHODS

We searched MEDLINE, EMBASE, ERIC, CINAHL, PsycINFO, The Cochrane Library, and Dissertations & Theses A&I for articles published between 1993 and February 20, 2015. We included quantitative and qualitative studies reporting on primary care specialty choice outcomes of interventions in the undergraduate medical curriculum, without geographic restrictions. Data extracted included study characteristics, intervention details, and relevant outcomes. Studies were assessed for quality and strength of findings using a five-point scale.

RESULTS

The review included 72 articles reporting on 66 different interventions. Longitudinal programs were the only intervention consistently associated with an increased proportion of students choosing primary care. Successful interventions were characterized by diverse teaching formats, student selection, and good-quality teaching. Study quality had not improved since recommendations were published in 1995. Many studies used cross-sectional designs and non-validated surveys, did not include control groups, and were not based on a theory or conceptual framework.

DISCUSSION

Our review supports the value of longitudinal, multifaceted, primary care programs to increase the proportion of students choosing primary care specialties. Isolated modules or clerkships did not appear to be effective. Our results are in line with the conclusions from previous reviews and add an international perspective, but the evidence is limited by the overall low methodological quality of the included studies. Future research should use more rigorous evaluation methods and include long-term outcomes.

House officers' attitude towards family medicine and its choice as a career in Egypt

BACKGROUND

Family medicine (FM) specialty is new to Egyptian medical education and its choice as a career option is still unclear. This study aims to assess perceptions, expectations and level of information amongst house officers (HOs) in relation to FM and its choice as a future career.

METHODS

This cross-sectional descriptive study was conducted during an orientation program implemented to HOs before joining work in primary health care. Data were collected using an anonymous self-administered questionnaire.

FINDINGS

More than half of respondents considered FM to have an essential social function. The most influential factor on HOs' opinions regarding FM were their own experiences during the course of study (52.6%), the opinion of family physicians (43.8%). More than two fifths of HOs reported that training sessions in health centers would be useful and 29.5% stated that at least 25-50% of the total practical training in medical school should be dedicated to FM. Nearly half of HOs (48.2%) suggested that training should take place during the fourth year of medical school. Before orientation 15.8% of HOs mentioned that they will choose FM as a career, this increased to 50.4% after orientation. Rural residence and low grades in public health are the independent predictors of choosing FM as a career (OR = 1.9 and 1.7, respectively).

CONCLUSION

FM is developing rapidly as a specialty. Frequent training programs directed to HOs may encourage them to consider FM as a career.

Role modeling in medical education: the importance of a reflective imitation

The medical literature almost uniformly addresses the positive aspects of role modeling. Still, some authors have questioned its educational value, a disagreement that is probably due to differing definitions of role modeling. If defined as demonstration of skills, provision of feedback, and emulation of specific professional behaviors, then role modeling is an important component of clinical training. However, if it is defined as a learner's unselective imitation of role models and uncritical adoption of the messages of the learning environment, then the benefits of role modeling should be weighed against its unintended harm.In this Perspective, the author argues that imitation of role models may initially help students adapt to the clinical environment. However, if sustained, imitation may perpetuate undesirable practices, such as doctor-centered patient interviewing, and unintended institutional norms, such as discrimination between private and public patients. The author suggests that the value of role modeling can be advanced not only by targeting role models and improving faculty performance but also by enhancing students' reflective assessment of their preceptors' behaviors, especially so that they can better discern those that are worth imitating. This student-centered approach may be accomplished by first, warning students against uncritically imitating preceptors who are perceived as role models; second, showing students that their preceptors share their doubts and uncertainties; third, gaining an insight into possible undesirable messages of the learning environment; and finally, developing policies for faculty recruitment and promotion that consider whether a clinical preceptor is a role model.

Implicit bias and its relation to health disparities: a teaching program and survey of medical students

BACKGROUND

The varying treatment of different patients by the same physician are referred to as within provider disparities. These differences can contribute to health disparities and are thought to be the result of implicit bias due to unintentional, unconscious assumptions.

PURPOSES

The purpose is to describe an educational intervention addressing both health disparities and physician implicit bias and the results of a subsequent survey exploring medical students' attitudes and beliefs toward subconscious bias and health disparities.

METHODS

A single session within a larger required course was devoted to health disparities and the physician's potential to contribute to health disparities through implicit bias. Following the session the students were anonymously surveyed on their Implicit Association Test (IAT) results, their attitudes and experiences regarding the fairness of the health care system, and the potential impact of their own implicit bias. The students were categorized based on whether they disagreed ("deniers") or agreed ("accepters") with the statement "Unconscious bias might affect some of my clinical decisions or behaviors." Data analysis focused specifically on factors associated with this perspective.

RESULTS

The survey response rate was at least 69%. Of the responders, 22% were "deniers" and 77% were "accepters." Demographics between the two groups were not significantly different. Deniers were significantly more likely than accepters to report IAT results with implicit preferences toward self, to believe the IAT is invalid, and to believe that doctors and the health system provide equal care to all and were less likely to report having directly observed inequitable care.

CONCLUSIONS

The recognition of bias cannot be taught in a single session. Our experience supports the value of teaching medical students to recognize their own implicit biases and develop skills to overcome them in each patient encounter, and in making this instruction part of the compulsory, longitudinal undergraduate medical curriculum.

Doctor role modelling in medical education: BEME Guide No. 27

AIM

The aim of this review is to summarise the evidence currently available on role modelling by doctors in medical education.

METHODS

A systematic search of electronic databases was conducted (PubMed, Psyc- Info, Embase, Education Research Complete, Web of Knowledge, ERIC and British Education Index) from January 1990 to February 2012. Data extraction was completed by two independent reviewers and included a quality assessment of each paper. A thematic analysis was conducted on all the included papers.

RESULTS

Thirty-nine studies fulfilled the inclusion criteria for the review. Six main themes emerged from the content of high and medium quality papers: 1) the attributes of positive doctor role models; 2) the personality profiles of positive role models; 3) the influence of positive role models on students' career choice; 4) the process of positive role modelling; 5) the influence of negative role modelling; 6) the influence of culture, diversity and gender in the choice of role model.

CONCLUSIONS

This systematic review highlights role modelling as an important process for the professional development of learners. Excellence in role modelling involves demonstration of high standards of clinical competence, excellence in clinical teaching skills and humanistic personal qualities. Positive role models not only help to shape the professional development of our future physicians, they also influence their career choices. This review has highlighted two main challenges in doctor role modelling: the first challenge lies in our lack of understanding of the complex phenomenon of role modelling. Second, the literature draws attention to negative role modelling and this negative influence requires deeper exploration to identify ways to mitigate adverse effects. This BEME review offers a preliminary guide to future discovery and progress in the area of doctor role modelling.

Resident satisfaction with continuity clinic and career choice in general internal medicine

BACKGROUND

The quality of the continuity clinic experience for internal medicine (IM) residents may influence their choice to enter general internal medicine (GIM), yet few data exist to support this hypothesis.

OBJECTIVE

To assess the relationship between IM residents' satisfaction with continuity clinic and interest in GIM careers.

DESIGN

Cross-sectional survey assessing satisfaction with elements of continuity clinic and residents' likelihood of career choice in GIM.

PARTICIPANTS

IM residents at three urban medical centers.

MAIN MEASURES

Bivariate and multivariate associations between satisfaction with 32 elements of outpatient clinic in 6 domains (clinical preceptors, educational environment, ancillary staff, time management, administrative, personal experience) and likelihood of considering a GIM career.

KEY RESULTS

Of the 225 (90 %) residents who completed surveys, 48 % planned to enter GIM before beginning their continuity clinic, whereas only 38 % did as a result of continuity clinic. Comparing residents' likelihood to enter GIM as a result of clinic to likelihood to enter a career in GIM before clinic showed that 59 % of residents had no difference in likelihood, 28 % reported a lower likelihood as a result of clinic, and 11 % reported higher likelihood as a result of clinic. Most residents were very satisfied or satisfied with all clinic elements. Significantly more residents (p ≤ 0.002) were likely vs. unlikely to enter GIM if they were very satisfied with faculty mentorship (76 % vs. 53 %), time for appointments (28 % vs. 11 %), number of patients seen (33 % vs. 15 %), personal reward from work (51 % vs. 23 %), relationship with patients (64 % vs. 42 %), and continuity with patients (57 % vs. 33 %). In the multivariate analysis, being likely to enter GIM before clinic (OR 29.0, 95 % CI 24.0-34.8) and being very satisfied with the continuity of relationships with patients (OR 4.08, 95 % CI 2.50-6.64) were the strongest independent predictors of likelihood to enter GIM as a result of clinic.

CONCLUSIONS

Resident satisfaction with most aspects of continuity clinic was high; yet, continuity clinic had an overall negative influence on residents' attitudes toward GIM careers. Targeting resources toward improving ambulatory patient continuity, workflow efficiency and increasing pre-residency interest in primary care may help build the primary care workforce.

Specialty preferences: trends and perceptions among Saudi undergraduate medical students

BACKGROUND

The exploration of specialty choices by medical students is a hot debate as it affects several important determinants of health care delivery. This study was carried out to determine variation in specialty preferences during medical school training and the perceptions that affect students' specialty choice.

METHODS

A cross-sectional questionnaire-based study was performed on 590 students with a 93.22% response rate and covered queries on demography, specialty choices, and perceptions influencing specialty choices. Class-wise analysis of specialty choices was carried out.

RESULTS

The most preferred specialty expressed by male students was surgery, followed by internal medicine and orthopedics, while most preferred by female students were surgery, followed by pediatrics and ophthalmology. Male students' emphasized factors like less competitive field, shortage of specialists, and diversity of patients while the prestige of specialty and teaching opportunities had a greater impact on female students.

CONCLUSIONS

Surgery, internal medicine, pediatrics, orthopedics, and ophthalmology were the most preferred specialty choices. Gender preference was observed to affect choices of few specialties such as orthopedics and obstetrics/gynecology. Perceptions which have an impact on specialty selection of male and female students may reflect a different tempo of growing up in men and women.

An academic-community partnership to improve care for the underserved

Despite the need for a robust primary care workforce, the number of students and residents choosing general internal medicine careers continues to decline. In this article, the authors describe their efforts at the University of California, Davis School of Medicine to bolster interest in internal medicine careers and improve the quality of care for medically underserved populations through a tailored third-year residency track developed in partnership with the Sacramento County Department of Health and Human Services. The Transforming Education and Community Health (TEACH) Program improves continuity of care between inpatient and outpatient settings, creates a new multidisciplinary teaching clinic in the Sacramento County health system, and prepares residents to provide coordinated care for vulnerable populations. Since its inception in 2005, 25 residents have graduated from the TEACH Program. Compared with national rates, TEACH graduates are more likely to practice general internal medicine and to practice in medically underserved settings. TEACH residents report high job satisfaction and provide equal or higher-quality diabetes care than that indicated by national benchmarks. The authors provide an overview of the TEACH Program, including curriculum details, preliminary outcomes, barriers to continued and expanded implementation, and thoughts about the future of the program.

The evolution of a Department of Internal Medicine under an integrated clinical enterprise model: the University of Kentucky experience

The impact on the Department of Internal Medicine of the emergence of the University of Kentucky Healthcare Enterprise as an integrated clinical model has been enormous. In fiscal year 2004, the department was financially insolvent and on the verge of implementing plans to decrease faculty from 127 to 65. Since that time, the department has changed dramatically with a corresponding improvement in its clinical, academic, and financial activity. The department has grown to 175 faculty, with a healthy financial outlook and a shared vision with the clinical enterprise. Departmental clinical growth has been accompanied by growth in extramural research funding. The clinical growth of the department, in turn, supported the growth of the integrated clinical enterprise overall.The purpose of this article is to present a case history of the impact of transition to an integrated clinical enterprise financial model on the clinical, research, and educational functions of a department of internal medicine, and the opportunities and lessons learned from this transition. The implementation of an enterprise model allowed revival and expansion of the clinical programs of the department. This expansion did not occur at the expense of the research and educational missions of the department but, rather, was associated with improved performance in these areas. The processes which were established during the conversion to the enterprise model, which involve strategic planning, monitoring of plan implementation, recalibration of objectives, financial transparency, and accountability of leadership and faculty, may better prepare the institution to face the challenges of the rapidly changing economic environment.

Is nursing profession my first choice? A follow up survey in pre-registeration student nurses

The purpose of this study was to explore how nursing students' value factors, motivational factors, institutional factors and competence factors contributed to career intent. All fifth-year nursing students (n=231) in a college in eastern Taiwan completed a survey which followed-up a study done 1 year previously in the same population were followed for 1 year. A validated and reliable self-administered questionnaire developed by the investigators in 2004 and modified in 2005 was used in the study. Data on value factors, competence factors, motivational factors, and situational factors were collected. The overall response rate was 87.4%. The rates of considering nursing as their first choice improved from 19.1% at the point of college-entry to 34.6% in 2004 and 46.5% in 2005 in the same cohort students. Past experience with being ill, degree of stress, self-rated clinical competency, perceived support from staff nurses, and perceived value were associated with career decision after the completion of a whole year of clinical practice (p<0.05-0.01). In multivariate analysis, perceived support from staff nurses, past experience with being ill, and perceived value proved to be significant predictors of the career intent of pre-registration student nurses. Nursing faculty and nurse administrators need to provide assistance to reduce nursing students' career attrition.

The impact of clerkships on students' specialty preferences: what do undergraduates learn for their profession?

OBJECTIVE

Clinical experiences and gender have been shown to influence medical students' specialty choices. It remains unclear, however, which aspects of experiences make students favour some specialties and reject others. This study aimed to clarify the effects of clerkships on specialty choice and to identify explanatory factors.

METHODS

We carried out a longitudinal cohort study to collect data on career preferences and attitudes towards future careers among 3 cohorts of students before and after clerkships in surgery (n = 200), internal medicine (n = 277) and general practice (n = 184). Regression analyses were performed to identify the determinants of career choice and the role of gender.

RESULTS

Exposure to clinical settings encourages students to opt for a career in the corresponding specialty. Men were more stimulated than women by the general practice clerkship. Gender had no clear role as a predictor of career preference. The major predictor of career choice in all 3 specialties was positive evaluation of work-intrinsic factors. A preference for working with acute patients and technology-oriented work, prestige orientation and insignificance of a controllable lifestyle were determinants of a preference for surgery. Students with a preference for general practice had almost opposite preferences. Those who chose internal medicine favoured a controllable lifestyle.

DISCUSSION

Factors other than gender appear to drive specialty decisions. Work content, type of patients and lifestyle options play major roles. Consequently, along with teaching about the practice of medicine, the matching of specialty preferences with reality is an essential outcome of clerkships.

Factors affecting medical students in formulating their specialty preferences in Jordan

BACKGROUND

In recent years there has been a growing appreciation of the issues of career preference in medicine as it may affect student learning and academic performance. However, no such studies have been undertaken in medical schools in Jordan. Therefore, we carried out this study to investigate the career preferences of medical students at Jordan University of Science and Technology and determine factors that might influence their career decisions.

METHODS

A cross-sectional questionnaire-based survey was carried out among second, fourth and sixth year medical students at the Jordan University of Science and Technology, Irbid, Jordan during the academic year 2006/2007. A total of 440 students answered the questionnaire which covered demographic characteristics, specialty preferences, and the factors that influenced these career preferences. Possible influences were selected on the basis of a literature review and discussions with groups of medical students and physicians. Students were asked to consider 14 specialty options and select the most preferred career preference.

RESULTS

The most preferred specialty expressed by male students was surgery, followed by internal medicine and orthopaedics, while the specialty most preferred by female students was obstetrics and gynaecology, followed by pediatrics and surgery. Students showed little interest in orthopedics, ophthalmology, and dermatology. While 3.1% of females expressed interest in anesthesiology, no male students did. Other specialties were less attractive to most students. Intellectual content of the specialty and the individual's competencies were the most influential on their preference of specialty. Other influential factors were the "reputation of the specialty", "anticipated income", and "focus on urgent care".

CONCLUSION

Surgery, internal medicine, pediatrics, and obstetrics and gynaecology were the most preferred specialty preferences of medical students at Jordan University of Science and Technology.

When, what and how South Australian pre-registration junior medical officers' career choices are made

OBJECTIVES

This study aimed to provide better understanding of how pre-registration junior medical officers (PJMOs) make their career choices by investigating when decisions are made, what factors impact on choices, and the role of experience in this process.

METHODS

A third (n = 54) of PJMOs from the 2003 cohort at South Australian teaching hospitals participated in the current research. Inductive content analysis was used to discover themes in data gathered from semistructured interviews.

RESULTS

Interviews revealed that although 26% (14/54) of participants had made their career decisions in their pre-registration year, 50% (27/54) had still to decide on a career choice. The factors identified as impacting on career choice were grouped into 5 main categories: job satisfaction; lifestyle; career path; training programme, and the wider environment. Depending on the demographic profile of the PJMO, different relative importance was assigned to these factors. The most important elements used to confirm or disconfirm PJMOs' potential career choices were the experiences they had of different specialty areas.

DISCUSSION

This study allowed an in-depth exploration of the factors that affect the decision-making process of PJMOs. It also found that defined groups of PJMOs place different degrees of importance on these factors, which may have implications for medical workforce planning. It is clear that experience and role models are a crucial component of the career decision-making process. This has importance for specialties that are not incorporated into junior medical training.

Factors associated with career decision in Taiwanese nursing students: A questionnaire survey

The vocational decisions of nursing students have always been a concern for nursing educators and administrators. It is unclear, however, what factors play a role in determining the professional choices made by these students. Limited research into this area has been undertaken in Taiwan. This study, therefore, was designed to investigate the factors associated with career choices in Taiwan's nursing students. The convenience sample included all fourth-year nursing students of a college in eastern Taiwan. A validated and reliable self-administered questionnaire developed by the investigators was used in the study. The sample population consisted of 231 fourth-year nursing students. Notably, 65.4% reported that they would not choose nursing as a career after graduation. Significant variables associated with this career decision were clinical ability (t=2.35, p<0.05), degree of stress during clinical practice (t=-3.04, p<0.01), and perceived support from staff nurses (t=2.28, p<0.05). These results suggest that both educators and administrators need to reconsider the way nursing students are educated, and indicate that strategies must be developed to enhance students' motivation to select nursing as a career.

Effect of the inpatient general medicine rotation on student pursuit of a generalist career

BACKGROUND

Entry into general internal medicine (GIM) has declined. The effect of the inpatient general medicine rotation on medical student career choices is uncertain.

OBJECTIVE

To assess the effect of student satisfaction with the inpatient general medicine rotation on pursuit of a career in GIM.

DESIGN

Multicenter cohort study.

PARTICIPANTS

Third-year medical students between July 2001 and June 2003.

MEASUREMENTS

End-of-internal medicine clerkship survey assessed satisfaction with the rotation using a 5-point Likert scale. Pursuit of a career in GIM defined as: (1) response of "Very Likely" or "Certain" to the question "How likely are you to pursue a career in GIM?"; and (2) entry into an internal medicine residency using institutional match data.

RESULTS

Four hundred and two of 751 (54%) students responded. Of the student respondents, 307 (75%) matched in the 2 years following their rotations. Twenty-eight percent (87) of those that matched chose an internal medicine residency. Of these, 8% (25/307) were pursuing a career in GIM. Adjusting for site and preclerkship interest, overall satisfaction with the rotation predicted pursuit of a career in GIM (odds ratio [OR] 3.91, P<.001). Although satisfaction with individual items did not predict pursuit of a generalist career, factor analysis revealed 3 components of satisfaction (attending, resident, and teaching). Adjusting for preclerkship interest, 2 factors (attending and teaching) were associated with student pursuit of a career in GIM (P<.01).

CONCLUSIONS

Increased satisfaction with the inpatient general medicine rotation promotes pursuit of a career in GIM.

The views of U.S. medical school deans toward academic primary care

PURPOSE

To understand the views of U.S. medical school deans about their primary care faculties.

METHOD

In 2000, the authors mailed a questionnaire containing 43 multipart items to deans of 130 U.S. allopathic medical schools. The questionnaire assessed the deans' attitudes about and evaluation of primary care at their school and their school's efforts to strengthen it. Deans were asked to compare family medicine, general internal medicine, and general pediatrics with nonprimary care clinical departments at their schools.

RESULTS

Of the 83 (64%) deans who responded, 82% reported their school had departments or divisions of family medicine, general internal medicine, and general pediatrics. Deans rated general internal medicine and general pediatrics higher than nonprimary care faculty on clinical expertise and productivity (p < .001) and family medicine equivalent to nonprimary care faculty. Deans rated all three primary care faculties superior to nonprimary care faculty for teaching skills (p < .001) and programs (p < .05), but lower than nonprimary care disciplines for research productivity (p < .01) and revenues (p < .001). They rated family medicine and general pediatrics lower for research skills (p < .001), but 73% of deans stated research was equally important for primary care and nonprimary care departments. Deans considered overall financial resources to be equivalent for primary care and nonprimary care departments, but 77% of deans felt primary care departments or divisions needed financial support from the medical school to survive. Most deans attempted to strengthen primary care by changing the curriculum to promote primary care and by providing financial support.

CONCLUSIONS

Deans ranked primary care faculty high on clinical and teaching measures. Although they considered research to be an important activity for primary care faculty, they evaluated it low relative to nonprimary care departments.

Variation in predictors of primary care career choice by year and stage of training

CONTEXT

It is not known whether factors associated with primary care career choice affect trainees differently at different times or stages of medical education.

OBJECTIVE

To examine how role models, encouragement, and personal characteristics affect career choice at different stages (medical school vs residency) and periods (1994 vs 1997) of training.

DESIGN

A split-panel design with 2 cross-sectional telephone surveys and a panel survey in 1994 and 1997.

PARTICIPANTS

A national probability sample of fourth-year students (307 in 1994, 219 in 1997), 645 second-year residents in 1994, and 494 third-year residents in 1997. Of the fourth-year students interviewed in 1994, 241 (78.5%) were re-interviewed as third-year residents in 1997.

MAIN OUTCOME MEASURE

Primary care (general internal medicine, general pediatrics, or family medicine) career choice.

RESULTS

Having a primary care role model was a stronger predictor of primary care career choice for residents (odds ratio [OR], 18.0; 95% confidence interval [95% CI], 11.2 to 28.8 in 1994; OR, 43.7; 95% CI, 24.4 to 78.3 in 1997) than for students (OR, 6.5; 95% CI, 4.3 to 10.2; no variation by year). Likewise, peer encouragement was more predictive for residents (OR, 5.4; 95% CI, 3.3 to 8.9 in 1994; OR, 16.6; 95% CI; 9.7 to 28.4 in 1997) than for students (OR, 2.1; 95% CI, 1.3 to 3.2; no variation by year). Orientation to the emotional aspects of care was consistently associated with primary care career choice across stages and years of training.

CONCLUSIONS

The effect of peer encouragement and role models on career choice differed for students and residents and, in the case of residents, by year of training, suggesting that interventions to increase the primary care workforce should be tailored to stage of training.

Implications of the hospitalist model for medical students' education

At many academic health centers, medical students in internal medicine, family medicine, and pediatrics are working with a new form of attending physician, the hospitalist. Although a growing literature demonstrates the benefits of hospitalists for patients and housestaff, the influence of hospitalists on students has been underemphasized. Advantages of the hospitalist model for students can include hospitalists' expertise in general inpatient medicine, their availability to teach throughout the day, and their role-modeling of the provision of high-quality and efficient care. However, the change in the ward attending workforce from non-hospitalist generalists, subspecialists, and biomedical researchers to generalist-hospitalists potentially limits students' exposure to the broad range of career opportunities the former group represents. The authors propose a research agenda to investigate the educational impact of the hospitalist model, suggest strategies to mitigate the limitations in students' exposures to subspecialty faculty, and recommend professional development in teaching for hospitalists to ensure that student education thrives in this new environment of inpatient medicine.

Integrating clinician-educators into Academic Medical Centers: challenges and potential solutions

During the last decade academic medical centers (AMCs) have hired large numbers of clinician-educators to teach and provide clinical care. However, these clinician-educators often do not advance in academic rank, since excellence in clinical care and teaching alone is not adequate justification for advancement. The authors articulate the problems with the present system of recognition for clinician-educators-i.e., the requirement for regional and national reputation, the lack of reliable measures of clinical and teaching excellence, and the lack of training opportunities for young clinician-educators. They call for solutions, including fundamental changes in promotion criteria (e.g., focus criteria for promotion on clinician-educators' accomplishments within their institutions) and the development of valid and feasible methods to measure outcomes of teaching programs. Further, they recommend the development of a new faculty position, a "clinician-educator researcher," to foster the scholarship of discovery in medical education and clinical practice. Investments in clinician-educator researchers will ultimately help AMCs to achieve their threefold mission-excellence in patient care, teaching, and research.

Specialty choices of students who actually have choices: the influence of excellent clinical teachers

PURPOSE

To determine the influence of the quality of attending physicians and residents on the specialty choices of excellent medical students, who actually have a broad choice of specialties.

METHOD

In 1993-94 and 1994-95, 169 third-year students at the University of Kentucky College of Medicine were randomly assigned to two one-month rotations on general medicine inpatient wards. At the end of each rotation, the students confidentially evaluated the attending physician and the supervising resident (different for each rotation) with whom they had worked. Data were collected for 62 attending physicians and 89 residents. The authors analyzed the influences of the "best" and "worst" clinical instructors (those rated in the top and the bottom 20% by all students with whom they had worked over the two years) on "excellent" medical students (the 52 students whose USMLE I scores were in the top 30% of their class).

RESULTS

Using regression approaches from the general linear model, the authors found that independent predictors of internal medicine residency choice for excellent medical students were exposure to highly rated internal medicine attendings (p = .02) and residents (p = .03). Nine of 29 (30%) of the excellent students who worked with a "best" medicine clinical instructor chose an internal medicine residency, while none of the 23 excellent medical students who did not work with a "best" medicine clinical instructor did so. The authors found no correlation in students' ratings of their pairs of attendings and residents, suggesting that rater bias did not explain the results.

CONCLUSION

Better medical students who work with the best internal medicine attending physicians and residents in their internal medicine clerkship are more likely to choose an internal medicine residency.

Educational and career outcomes of an internal medicine preceptorship for first-year medical students

OBJECTIVE

Medical educators have attempted in recent years to provide quality clinical experiences for medical students early in their medical training. We questioned whether participating in a preceptorship in internal medicine (PIM) resulted in better performances on subsequent clinical rotations and increased interest in internal medicine.

PARTICIPANTS

Fifty-four students have participated in the PIM to date, with control groups consisting of students who applied for it but were not selected (n = 36), students participating in a preceptorship in family medicine (n = 168), and the remaining students (n = 330).

DESIGN

Prospective cohort study.

SETTING

University medical center and community practices.

INTERVENTION

A 2-month, clinical preceptorship following the first year of medical school.

MEASUREMENTS AND MAIN RESULTS

The following outcomes were assessed: scores in the introduction to clinical medicine course; grades in the medical ethics course; scores from the internal medicine clerkship; and choosing a career in internal medicine. In their second year, PIM students scored higher in both semesters of the introduction to clinical medicine course (87% and 86% vs 84% and 84%, p's <.01) and were more likely to receive honors in ethics (50% vs 29%, p <.01) than non-PIM students. During the internal medicine clerkship, PIM students' scores were significantly higher on an objective structured clinical examination (79% vs 76%, p =.05), ambulatory clinical evaluations (80% vs 76%, p <.01), and overall clerkship scores (78% vs 75%, p =.03) but not on inpatient clinical evaluations or on the National Board of Medical Examiners Subject Examination. Preceptorship students were more likely to receive honors grades in the medicine clerkship (33% vs 10%, p <.01), and they were more likely to match into internal medicine residencies than control students (54% vs 27%, p <.01).

CONCLUSIONS

The PIM course is an intervention, early in students' careers, which appears to benefit them academically and increase their interest in internal medicine as a career.