The doctor is in

The Persistence of Specialty Disrespect: Student Perspectives

Purpose

One aspect of the hidden curriculum of medicine is specialty disrespect (SD)-an expressed lack of respect among medical specialties that occurs at all levels of training and across geographic, demographic, and professional boundaries, with quantifiable impacts on student well-being and career decision making. This study sought to identify medical students' perceptions of and responses to SD in the learning environment.

Methods

We conducted quantitative and content analysis of an annual survey collected between 2008 and 2012 from 702 third- and fourth-year students at the University of Washington School of Medicine. We describe the frequency of reported SD, its self-rated impact on student specialty choice, and major descriptive categories.

Results

Nearly 80% of respondents reported experiencing SD in the previous year. A moderate or strong impact on specialty choice was reported by 25.9% of respondents. In our sample, students matching into family medicine, obstetrics/gynecology, and emergency medicine were most likely to report exposure. Content analysis identified two new concepts not previously reported. Internecine strife describes students distancing themselves from both disrespecting and disrespected specialties, while legitimacy questions the validity of the targeted specialty.

Conclusions

SD is a consistent and ubiquitous part of clinical training that pushes students away from both disrespecting and disrespected specialties. These results emphasize the need for solutions aimed at minimizing disrespect and mitigating its effects upon students.

The practice of general internal medicine by subspecialists

To determine the proportion of specialists in internal medicine at a university medical center practicing general internal medicine in addition to their specialty, full-time and voluntary faculty were asked to complete a questionnaire concerning their practice patterns. In addition, the directories of two of the largest managed-care groups in the area were reviewed to identify physicians who were also faculty members, to determine whether faculty in these directories self-identified as general internists. Excluding those with primary research appointments, 303 faculty in the Department of Medicine were asked to participate. Of these, 187 (62%) responded, of whom 86 (46%) were full-time and 101 (54%) voluntary faculty. Of the respondents, 183 (98%) were either board certified (152; 81%) or board eligible (31; 17%) in a subspecialty. Both general internal medicine and specialty medicine were practiced by 116 (65%), with full-time faculty being more likely to have solely subspecialty practices (P < .001). The majority of faculty (150; 80%) participated in managed care. A review of directories of two managed-care groups revealed that 100 (87%) of the 115 faculty with appointments within subspecialty divisions of the Department of Medicine were listed as general internists. Subspecialists in internal medicine already spend considerable time practicing general medicine and are increasingly willing to identify themselves as generalists. Unless this is recognized, the future need for generalists may be overestimated considerably.

The challenge of defining and counting generalist physicians: an analysis of Physician Masterfile data

OBJECTIVES

The study reviewed methods for measuring the specialty distribution of the US physician workforce. It was hypothesized that current databases and measurement conventions overestimate the number of generalist physicians.

METHODS

A descriptive analysis of the American Medical Association (AMA) Physician Masterfile for California was done with different assumptions about the definition of generalists based on primary and secondary specialty information.

RESULTS

A rigorous definition of generalist physician that excludes physicians with secondary practices in specialist fields resulted in an estimate of generalist physicians 25% lower than the number estimated by conventional workforce evaluation methods. Physicians who reported practicing in both generalist and specialist fields were more likely to be older, to be international medical school graduates, and to be in solo or duo practice compared with physicians who listed only generalist or specialist fields.

CONCLUSIONS

The actual number of generalist physicians in the United States may be less than previously believed. Although the exact magnitude of the "hidden system" of specialists providing primary care is difficult to measure, at least a portion appear to already be counted as generalist physicians by current conventions.

Subspecialization in internal medicine: a historical review, an analysis, and proposals for change

The recent decline in the production of primary care physicians has been associated with a decrease in the production of general internists and an increase in the number of medical subspecialists. A significant majority of entering internal medicine residents anticipate entering a medical subspecialty. This transition in the development of medical manpower, perceived by some as inappropriate, is analyzed in light of historical trends in the evolution of internal medicine and its subspecialties, and in conjunction with the roles played by the American Board of Internal Medicine and the National Institutes of Health. Evidence is presented that the creation of virtually independent subspecialty departments may have been detrimental to the education of physicians and not productive of the physician scientists they are assumed to create. Current recommendations for reform are reviewed and a new proposal is presented, suggesting increasing the length of the medical residency from 3 to 4 years, incorporating subspecialty training in one or more fields into the third year of the residency, removing "duration of training" as a requirement for board eligibility in a subspecialty, transferring the certification of technical competence in a procedure to local institutions, and creating investigational units in basic disciplines within the department of internal medicine that would serve as a resource for all the subspecialty divisions.

Assessment of basic medical sciences in an integrated systems-based curriculum

Basic medical sciences at Sultan Qaboos University (SQU) are taught in a systems-based curriculum. During the development of the courses different formats have been used for the written examinations and also different types of questions. This paper compares students' performance in relation to examination format and to types of questions used. The formats were non-coordinated (NCAs), each discipline having a separate paper; coordinated (CAs), questions from various disciplines being given in the same paper but with separate sections for each discipline; and integrated assessments (IAs), questions being grouped under structure, function, and problem-based integrated long essays. The types of questions used were multiple choice (MCQs), short essays (SEQs), and structured integrated long essays (SILEQs). Students performed better in SEQs than in MCQs. Our analyses also show that SILEQs measure skills similar to those of MCQs and SEQs combined. Students performed best in NCAs. In CAs, students concentrated on those disciplines carrying most weight in the final grade. Currently we use IAs consisting of two parts: part I, comprising MCQs and SEQs, and part II, comprising SILEQs. To date, students are performing better in part II than in part I. We suggest that it is prudent to use different types of questions to measure students' knowledge and skills when IAs are used for systems-based courses.

Physician manpower reform: an analysis of the effects of the COGME Fourth Report on internal medicine residency positions. Council on Graduate Medical Education

PURPOSE

To quantitate the impact of the recommendations contained in the Council on Graduate Medical Education (COGME) Fourth Report on the position distribution in internal medicine residency and fellowship programs and to recommend alternative position allocations for discussion.

DATA SOURCES

The COGME Fourth Report, the National Study of Internal Medicine Manpower, and the American Medical Association Annual Survey of Graduate Medical Education.

RESULTS

Our analysis of the COGME Fourth Report indicates that internal medicine PGY-1 positions would decrease from the 8,936 on duty in the 1992 academic year to 6,533 (-26.9%) for the class of the year 2000. Four thousand will enter generalist careers in internal medicine (approximately a 70% increase over current generalist output). The COGME Fourth Report recommendations would allocate first-year fellowship positions for 1,400 graduates of internal medicine residencies (-63.1%). Career-bound internal medicine positions will decrease from approximately 6,000 to 5,400 (-10.0%). The loss in PGY-1 positions is predominantly due to a decrease in the number of preliminary medicine positions and to individuals who switch from career-bound internal medicine positions to other disciplines after the PGY-1 or PGY-2 years. Pediatric positions would increase moderately from 2,426 available in 1993 to 2,520 (+3.9%). Pediatric subspecialty positions would decrease by 25% to 420, with 2,100 residents entering careers in general pediatrics. Family medicine PGY-1 positions would increase from the 2,657 available in 1993 to 3,400 (+28%).

CONCLUSIONS

The recommendations contained in the COGME Fourth Report would substantially reduce the number, and significantly alter the current distribution, of residency positions. The output goals of 50% generalist careers are met by an increase in career-bound generalist positions in all three generalist specialties. The limitation of total positions to the goal of 110% of 1993 U.S. graduates comes predominantly through reduction of specialty/subspecialty career-bound positions. Internal medicine residency and subspecialty fellowship positions and programs would be significantly altered by these recommendations. The reductions in internal medicine occur predominantly in loss of positions not currently destined for careers in internal medicine and in subspecialty fellowship positions. These reductions are partially offset by an increase in the complement of residents who are destined for careers in general internal medicine.

The push toward generalism: a view from surgery

Recent proposals for health care reform center on restructuring the physician workforce in favor of more "generalists." These plans are based on several assumptions that have been neither clearly argued nor proved. Despite this, each of the plans enunciated thus far dictate that primary care physicians comprise at least 50% of the nation's physician workforce. Such a mandate has enormous repercussions for medical education. This paper takes issue with several assumptions underlying these reform initiatives, particularly the assumption that primary care does not include surgery. Because of the primary nature of surgical care, the prevalence of surgical diseases, the projected shortage of physicians entering general surgery, and the fact that surgical care is most effectively and efficiently provided by general surgeons, general surgery should not be handicapped as it would under present reform proposals. We recommend that the assumptions underlying plans to restructure the nation's physician workforce be tested, and that any reform enacted be based on rational criteria linked to the projected prevalence of disease in the nation as well as a determination of which practitioners care for those diseases most effectively and efficiently. We further recommend that medical students' time in surgical activities be increased rather than decreased, that general surgeons increase their activity in medical school curricular development and teaching, and that surgeons become involved more actively in the graduate training of primary care physicians.

Preparing generalist physicians: the organizational and policy context

A combination of financial, regulatory, and professional factors have led to a gradual but pronounced decline in generalist training and practice in the United States. This trend is likely to undergo dramatic reversal, however, as reflected by the diverse range of health care reform proposals incorporating incentives to promote generalist education and primary care practice. Considerable consensus has been reached by a number of professional organizations and public policy groups regarding the broad details of reform of generalist physician training, but key areas of controversy remain with important implications for academic medical centers. In addition, the generalist professional organizations, particularly those of family practice, general internal medicine, and general pediatrics, are being challenged to reconcile historic differences in the definitions and training of generalist competence. In this, the cell for "retraining subspecialists" with both offer an opportunity and entail a risk. Finally, academic medical centers will need new organizational structures that can combine the distinctive intellectual traditions and the expertise of the generalist medical disciplines to develop new approaches to the education and practice of primary care.

Collaboration in the preparation of the generalist physician

Collaborative efforts among health care professionals and institutions at all levels will be essential to the increased production of generalist physicians. There have been many successful collaborations in education and patient care among certifying boards, faculty, physicians in practice, specialists, generalists, and non-physician health professionals, as well as among the three generalist specialties. Recommended strategies to encourage collaboration in the preparation of generalist physicians include: creation of an institutional collaborative curriculum committee; design of a longitudinal curriculum on collaboration for physicians-in-training and other health professionals; implementation of collaborative patient care in ambulatory care teaching clinics; development of integrated systems of care that link inpatient, outpatient, and community-based health services; and education of physicians-in-training in these and other collaborative and co-practice models of patient care.

Evaluating generalist education programs: a conceptual framework. Generalist program evaluation working group

This paper provides and applies a conceptual framework and a list of guiding principles for evaluation of generalist education programs. Programs are systematic efforts to achieve specified objectives. Evaluations gather data in order to improve or appraise programs and have a continuum of purposes and methods. Descriptive evaluations characterize the structures, processes, and outcomes of programs; research evaluations definitively assess the effectiveness of a program in terms of outcomes. Intermediate outcomes are changes in knowledge, attitudes, and skills of program participants; conclusive outcomes reflect the quality of performance of graduates in actual clinical situations. Outcomes are affected by inputs--the qualities of students entering the program. Guiding principles of program evaluation ensure that data gathered are useful. The authors illustrate the guiding principles with an actual pilot study that determined that expert pediatricians, general internists, and family practitioners could agree on key generalist competencies and that explores evaluation design based on these competencies. Finally, they consider the implications of undertaking generalist education evaluation.