Predictors of final specialty choice by internal medicine residents

Differences In Debt Among Postgraduate Medical Residents By Self-Designated Race And Ethnicity, 2014-19

The US physician workforce does not reflect the racial and ethnic makeup of the country's population, despite efforts to promote diversity. Becoming a physician requires significant time and financial investment, and populations that are underrepresented in medicine have also been excluded from building wealth. Understanding the differential burden of debt by race and ethnicity may inform strategies to improve workforce diversity. We used 2014-19 data on postgraduate resident trainees from the Association of American Medical Colleges to examine the association between race and ethnicity and debt independent of other demographics and residency characteristics. Black trainees were significantly more likely to have every type of debt than the overall sample and all other racial and ethnic groups (96 percent of Black trainees had any debt versus 83 percent overall; 60 percent had premedical education loans versus 35 percent overall, and 50 percent had consumer debt versus 25 percent overall). American Indian/Alaska Native, Hispanic, and Native Hawaiian/Pacific Islander trainees were more likely to have debt compared with White and Asian trainees. Overall, debt prevalence decreased over time and varied by specialty; however, for Black trainees, debt decreased minimally over time and was stable across specialties. Scholarships, debt relief, and financial guidance should be explored to improve diversity and inclusion in medicine across specialties.

Exploring US internal medicine resident career preferences: a Q-methodology study

Career selection in medicine is a complex and underexplored process. Most medical career studies performed in the U.S. focused on the effect of demographic variables and medical education debt on career choice. Considering ongoing U.S. physician workforce shortages and the trilateral adaptive model of career decision making, a robust assessment of professional attitudes and work-life preferences is necessary. The objective of this study was to explore and define the dominant viewpoints related to career choice selection in a cohort of U.S. IM residents. We administered an electronic Q-sort in which 218 IM residents sorted 50 statements reflecting the spectrum of opinions that influence postgraduate career choice decisions. Participants provided comments that explained the reasoning behind their individual responses. In the final year of residency training, we ascertained participating residents' chosen career. Factor analysis grouped similar sorts and revealed four distinct viewpoints. We characterized the viewpoints as "Fellowship-Bound-Academic," "Altruistic-Longitudinal-Generalist," "Inpatient-Burnout-Aware," and "Lifestyle-Focused-Consultant." There is concordance between residents who loaded significantly onto a viewpoint and their ultimate career choice. Four dominant career choice viewpoints were found among contemporary U.S. IM residents. These viewpoints reflect the intersection of competing priorities, personal interests, professional identity, socio-economic factors, and work/life satisfaction. Better appreciation of determinants of IM residents' career choices may help address workforce shortages and enhance professional satisfaction.

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.

Characteristics of Pulmonary Critical Care Medicine and Pulmonary Medicine Applicants and Fellowships

Background: Little is known about historical and recent application trends for pulmonary critical care medicine (PCCM) or pulmonary medicine (PM) fellowship programs. Describing trends in and characteristics of PCCM and PM applications, applicants, and fellowship programs can help program directors and medical educators understand trainees’ interest in and application patterns for these fellowship programs.

Objective: The objective of this study was to use National Residency Match Program data to assess recent trends in PCCM and PM fellowship applications and compare characteristics of applicants and fellowship programs.

Methods: In 2019, we used National Residency Match Program data to evaluate applicant ranking and matching in PCCM and PM fellowship programs and to compare applicant and fellowship program characteristics.

Results: From 2008 through 2019, the majority of applicants (59.1%) matched into PCCM were graduates of U.S. allopathic or osteopathic medical schools, whereas 87% of PM fellows were non-U.S. graduates. PCCM was the preferred specialty for 90.8% of matched applicants versus only 31.6% of matched PM applicants (P < 0.001). The match rate for PCCM applicants was 67.2% versus 23.8% for PM applicants (P < 0.001). Of PCCM applicants, 36.6% matched into their top choice versus 10.8% of PM applicants (P < 0.001). There are far fewer PM fellowship positions (n = 23) and programs (n = 12) than PCCM positions (n = 450) and programs (n = 131). The mean fill rates from the 2004 through 2016 appointment years are 94.1% in PCCM and 97.4% in PM (P = 0.009).

Conclusion: PCCM is a prevailing specialty choice over PM among residency graduates, with matched applicants more likely to list PCCM than PM as their preferred specialty. Further exploration into applicants’ interest in critical care compared with PM may prove beneficial in guiding applicants to programs that will best meet their career goals.

Interprofessional simulation in a student community clinic: insights from an educational framework and contact theory

Introduction

Simulation in community care is a relatively understudied area. In this paper, we report a qualitative evaluation of the Simulated Client Interprofessional Education (SCIPE) program in a community clinic for undergraduate health and social care students in a rural setting. We sought to explore the stakeholders’ perceptions and experiences of training for, and conduct of, a simulated client-based activity to support the development of collaborative practice of students. We used an educational framework (presage, process, product–3P) and contact theory to analyse the evaluation data and suggest improvement strategies.

Methods

Data on professional characteristics was collected from facilitators, simulated client and students. Facilitators and simulated clients received training. Written evaluations were collected after training and after the simulated clinics. Purposively sampled facilitators, students and community partner agencies participated in individual semi-structured interviews to gain deeper insights into experiences.

Results

Fourteen clinics involved 5 facilitators, 12 simulated clients and 40 students. Fifteen interviews were conducted. The SCIPE program led to perceived improvements in students’ communication and awareness of interprofessional collaboration. Participation in the program enabled students to experience a holistic approach to client interviewing and development of competency in collaborative goal setting. Further attention to presage and ability of facilitators to build positive contact conditions was identified. Coordination from a central site facilitated exchange and quality assurance for all elements of the program. Scoping of conditions of positive contact enabled a greater understanding of students’ and facilitators’ evaluation of the experience and constraints which would be modifiable for future improvement and sustainability.

Discussion

Although the SCIPE program benefited students, the need for more explicit organisational engagement and support was revealed in interviews. The use of 3P and contact theory was helpful in identifying elements of the program for maintenance and development. Future research could follow students into practice to see if the behaviours are sustained and translated. Strengths included broad stakeholder involvement and immediate feedback. The key limitation was that the activity lacked explicit institutional support, facilitators required further training in briefing and the outcomes largely refer to participants’ perceptions and may not translate to practice.

Prestige of neurological disorders among future neurologists in Norway

BACKGROUND

Neurology has increasing subspecialization. Some disorders, such as cerebrovascular diseases, dementia and headache, are highly prevalent in the general population, while others, such as movement disorders and multiple sclerosis, are rarer. Thus, there may be a mismatch between neurologists' interests and the population needs.

AIMS OF THE STUDY

To investigate the perceived prestige of neurological disorders among residents in neurology.

METHODS

The study was conducted as a questionnaire survey among residents in neurology in Norway.

RESULTS

All the 17 neurological departments in Norway participated. In total, 143 residents participated (86% response rate). Mean age was 32.5 years. The respondents had on average 28 months of clinical training in neurology. The subspecialty with the highest prestige was cerebrovascular diseases, scored by 62% as the most prestigious, followed by multiple sclerosis (36%) and epilepsy (7%). The subspecialties with the lowest prestige were headache (2.8%) and dementia (1.4%). None of the tested variables (gender, age, months in clinical training or type of hospital) were associated with the perceived prestige of neurological disorders.

CONCLUSION

Cerebrovascular disease was perceived as the most prestigious subspecialty. Headache and dementia, which are major contributors to worldwide disability, have low status among residents in neurology.

Debt and the Emerging Physician Workforce: The Relationship Between Educational Debt and Family Medicine Residents' Practice and Fellowship Intentions

PURPOSE

Educational debt is increasing and may affect physicians' career choices. High debt may influence family medicine residents' initial practice setting and fellowship training decisions, adversely affecting the distribution of primary care physicians. The purpose of this study was to determine whether debt was associated with graduating family medicine residents' practice and fellowship intentions.

METHOD

The authors completed a cross-sectional secondary analysis of 2014 and 2015 American Board of Family Medicine (ABFM) examination registration questionnaire data and ABFM administrative data. They used multivariate logistic regression to determine whether educational debt was associated with graduating residents' practice (ownership and type) and fellowship intentions.

RESULTS

Most residents (89.7%; 3,368) intended to pursue an employed position, but this intention was not associated with their debt. Residents with high debt ($150,000-$249,999) had lower odds of intending to work for a government organization (odds ratio [OR] 0.57; confidence interval [CI] 0.41-0.79). Those with high or very high debt (> $250,000) had lower odds of choosing academic practice (OR 0.55, CI 0.36-0.85 and OR 0.62, CI 0.40-0.96, respectively) or a geriatrics fellowship (OR 0.36, CI 0.20-0.67 and OR 0.29, CI 0.15-0.55, respectively).

CONCLUSIONS

High educational debt may contribute to national shortages of academic primary care physicians and geriatricians. Existing National Health Service Corps loan repayment opportunities may not offer adequate incentives to primary care physicians with high debt. The medical community should advocate for policies that better align financial incentives with workforce needs.

Distribution of Medical Education Debt by Specialty, 2010-2016

This survey study analyzes the trends in the distribution of medical education debt by focusing on the increase in graduates without such debt.

Application of career related research in Pakistan: The case of apples vs mangoes

Career choice of medical graduates is dependent on a number of factors as identified in literature across the globe. This article presents an overview of contemporary research on career choices of medical graduates and the generalisation of findings in Pakistan. A number of issues are highlighted which include lack of standardised instruments, classification of specialties and mixed evidence regarding variables and socio cultural differences..

Impact of personal goals on the internal medicine R4 subspecialty match: a Q methodology study

BACKGROUND

There has been a decline in interest in general internal medicine that has resulted in a discrepancy between internal medicine residents' choice in the R4 subspecialty match and societal need. Few studies have focused on the relative importance of personal goals and their impact on residents' choice. The purpose of this study was to assess if internal medicine residents can be grouped based on their personal goals and how each group prioritizes these goals compared to each other. A secondary objective was to explore whether we could predict a resident's desired subspecialty choice based on their constellation of personal goals.

METHODS

We used Q methodology to examine how postgraduate year 1-3 internal medicine residents could be grouped based on their rankings of 36 statements (derived from our previous qualitative study). Using each groups' defining and distinguishing statements, we predicted their subspecialties of interest. We also collected the residents' first choice in the subspecialty match and used a kappa test to compare our predicted subspecialty group to the residents' self-reported first choice.

RESULTS

Fifty-nine internal medicine residents at the University of Alberta participated between 2009 and 2010 with 46 Q sorts suitable for analysis. The residents loaded onto four factors (groups) based on how they ranked statements. Our prediction of each groups' desired subspecialties with their defining and/or distinguishing statements are as follows: group 1 - general internal medicine (variety in practice); group 2 - gastroenterology, nephrology, and respirology (higher income); group 3 - cardiology and critical care (procedural, willing to entertain longer training); group 4 - rest of subspecialties (non-procedural, focused practice, and valuing more time for personal life). There was moderate agreement (kappa = 0.57) between our predicted desired subspecialty group and residents' self-reported first choice (p < 0.001).

CONCLUSION

This study suggests that most residents fall into four groups based on a constellation of personal goals when choosing an internal medicine subspecialty. The key goals that define and/or distinguish between these groups are breadth of practice, lifestyle, desire to do procedures, length of training, and future income potential. Using these groups, we were able to predict residents' first subspecialty group with moderate success.

Pediatric resident debt and career intentions

OBJECTIVE

To examine current levels of educational debt among pediatric residents and the relationship between educational debt and career intentions.

METHODS

Annual national random samples of 1000 graduating pediatric residents from 2006 through 2010 were surveyed. Responses were combined. We used t tests and 1-way analysis of variance to compare debt, linear regression to examine factors associated with educational debt, and logistic regression to assess the influence of debt on clinical practice goal. Response rate was 61%.

RESULTS

Three in 4 residents reported having educational debt. The mean debt (in 2010 dollars) among all residents, which included spouse's debt if married, increased 34% from $104 000 in 2006 to $139 000 in 2010. Among the subgroup who reported having any debt, the mean debt increased 24% from $146 000 in 2006 to $181 000 in 2010. Residents had varied clinical practice goals; 43% had goals that required fellowship training (subspecialty and combined primary-subspecialty) and 57% had goals not typically requiring fellowship training (primary care and hospitalist). In multivariate analyses, debt level (low, medium, high) remained an independent predictor of practice goal. Residents with medium debt (adjusted odds ratio: 1.46, 95% confidence interval: 1.16-1.84) and high debt (adjusted odds ratio: 1.51; 95% confidence interval: 1.20-1.90) had higher odds than residents with low debt of having a practice goal that does not typically require fellowship training. Other factors also had an independent association with career choice.

CONCLUSIONS

Multiple factors shape decisions about careers. Higher educational debt is one factor that may push residents toward primary care or hospitalist practice, rather than pursuing fellowship training.

Determinants of internal medicine residents' choice in the Canadian R4 fellowship match: a qualitative study

BACKGROUND

There is currently a discrepancy between Internal Medicine residents' decisions in the Canadian subspecialty fellowship match (known as the R4 match) and societal need. Some studies have been published examining factors that influence career choices. However, these were either demographic factors or factors pre-determined by the authors' opinion as possibly being important to incorporate into a survey.

METHODS

A qualitative study was undertaken to identify factors that determine the residents choice in the subspecialty (R4) fellowship match using focus group discussions involving third and fourth year internal medicine residents

RESULTS

Based on content analysis of the discussion data, we identified five themes:1) Practice environment including acuity of practice, ability to do procedures, lifestyle, job prospects and income 2) Exposure in rotations and to role models 3) Interest in subspecialty's patient population and common diseases 4) Prestige and respect of subspecialty 5) Fellowship training environment including fellowship program resources and length of training

CONCLUSIONS

There are a variety of factors that contribute to Internal Medicine residents' fellowship choice in Canada, many of which have been identified in previous survey studies. However, we found additional factors such as the resources available in a fellowship program, the prestige and respect of a subspecialty/career, and the recent trend towards a two-year General Internal Medicine fellowship in our country.

Policy and attitude-related reasons for gender disparity in post allocation for graduate medical education in Austria

OBJECTIVE

A previous study found that in Austria 50.3% physicians (m: 43.2%, f: 58.6%) have not attained their chosen specialty. We aimed to explore the policy - and attitude-related reasons for gender disparity in training post allocation.

METHODS

This cross-sectional study used a quantitative and a qualitative method. A self-administered 12-item questionnaire was sent twice to all 8127 licensed Viennese physicians. Physicians' opinions regarding why the chosen medical specialty was not attained were analyzed. To estimate the responder bias respondents from the first and second mailing were compared.

RESULTS

A total of 2736 questionnaires (34%) were returned. When a specialty is favored by men, the chance for women to achieve that specialty decreases. According to the qualitative results, men were more often ready to accept training in a specialty different from the one originally desired. Female physicians were put at a disadvantage by consultants due to organizational considerations and sex-stereotyping.

CONCLUSIONS

According to physicians' self-reported opinions, consultants do not place female candidates at disadvantage as a result of an unconscious process but mainly based on reasoning about organizational aspects and sex-stereotyping. Several explanations for the phenomenon that men are more often ready to accept training in a specialty different from the one originally desired were identified.

Predicting performance using background characteristics of international medical graduates in an inner-city university-affiliated Internal Medicine residency training program

BACKGROUND

IMGs constitute about a third of the United States (US) internal medicine graduates. US residency training programs face challenges in selection of IMGs with varied background features. However data on this topic is limited. We analyzed whether any pre-selection characteristics of IMG residents in our internal medicine program are associated with selected outcomes, namely competency based evaluation, examination performance and success in acquiring fellowship positions after graduation.

METHODS

We conducted a retrospective study of 51 IMGs at our ACGME accredited teaching institution between 2004 and 2007. Background resident features namely age, gender, self-reported ethnicity, time between medical school graduation to residency (pre-hire time), USMLE step I & II clinical skills scores, pre-GME clinical experience, US externship and interest in pursuing fellowship after graduation expressed in their personal statements were noted. Data on competency-based evaluations, in-service exam scores, research presentation and publications, fellowship pursuance were collected. There were no fellowships offered in our hospital in this study period. Background features were compared between resident groups according to following outcomes: (a) annual aggregate graduate PGY-level specific competency-based evaluation (CBE) score above versus below the median score within our program (scoring scale of 1 - 10), (b) US graduate PGY-level specific resident in-training exam (ITE) score higher versus lower than the median score, and (c) those who succeeded to secure a fellowship within the study period. Using appropriate statistical tests & adjusted regression analysis, odds ratio with 95% confidence intervals were calculated.

RESULTS

94% of the study sample were IMGs; median age was 35 years (Inter-Quartile range 25th - 75th percentile (IQR): 33-37 years); 43% women and 59% were Asian physicians. The median pre-hire time was 5 years (IQR: 4-7 years) and USMLE step I & step II clinical skills scores were 85 (IQR: 80-88) & 82 (IQR: 79-87) respectively. The median aggregate CBE scores during training were: PG1 5.8 (IQR: 5.6-6.3); PG2 6.3 (IQR 6-6.8) & PG3 6.7 (IQR: 6.7 - 7.1). 25% of our residents scored consistently above US national median ITE scores in all 3 years of training and 16% pursued a fellowship.Younger residents had higher aggregate annual CBE score than the program median (p < 0.05). Higher USMLE scores were associated with higher than US median ITE scores, reflecting exam-taking skills. Success in acquiring a fellowship was associated with consistent fellowship interest (p < 0.05) and research publications or presentations (p <0.05). None of the other characteristics including visa status were associated with the outcomes.

CONCLUSION

Background IMG features namely, age and USMLE scores predict performance evaluation and in-training examination scores during residency training. In addition enhanced research activities during residency training could facilitate fellowship goals among interested IMGs.

Emotional intelligence and medical specialty choice: findings from three empirical studies

CONTEXT

Despite only modest evidence linking personality-type variables to medical specialty choice, stereotypes involving empathy and 'emotional connectedness' persist, especially between primary care providers and surgeons or subspecialists. This paper examines emotional intelligence (EI) and specialty choice among students at three US medical schools.

METHODS

Results from three independent studies are presented. Study 1 used the Mayer-Salovey-Caruso Emotional Intelligence Test (MSCEIT) administered to a single cohort of 84 Year 4 medical students. Study 2 used the Trait Meta-Mood Scale (TMMS) and Davis' Interpersonal Reactivity Index (IRI) administered to three cohorts (n = 250) of Year 3 medical students. Study 3 used the Bar-On Emotional Quotient Inventory (EQ-I) administered to two cohorts of Year 1 medical students (n = 292). Results were linked to specialty choice data retrieved from the National Residency Match Program (NRMP). Classifications of specialty choice included: (i) primary care (family practice, internal medicine, paediatrics) versus non-primary care (all others), and (ii) primary care, hospital-based specialties (anaesthesiology, emergency medicine, pathology, radiology), and technical and surgical specialties (neurology, obstetrics and gynaecology, ophthalmology, and all surgical fields).

CONCLUSIONS

Across all three studies - and using both classifications of specialty choice - no significant differences in EI were found between students entering primary care and non-primary care specialties. Limitations are acknowledged, and future directions for research involving EI are identified.

Educational debt of physicians-in-training: determining the level of interest in a loan repayment program for service in a medically underserved area

PURPOSE

The amount of financial debt incurred by Texas medical students and residents during training was examined as well as the impact of this debt on these trainees' career choices.

METHOD

An invitation to participate was sent in a Web-based survey to medical students and residents at 6 university programs in Texas during the 2005-2006 academic year.

RESULTS

Overall, 818 students (20%) and 529 residents (14%) responded to the survey. Of these, 96% of students and 85% of residents had taken out educational loans, and approximately 62% of students and residents expected their debt to exceed $100,000. More than half of students and residents expected educational debt to influence their choice of practice type and practice area and to affect important personal decisions. Approximately 52% of students and 38% of residents indicated an interest in participating in a loan repayment program that involved service in a medically underserved area. In general, women and members of minority groups were more likely to express such an interest.

CONCLUSIONS

Medical students and residents incur considerable financial debt, which seems to affect their career choices. Approximately half of the students and one third of the residents surveyed indicated that they would consider participating in a loan repayment program that required practice in an underserved area.

Students who wish to specialize in forensic medicine vs. their fellow students: motivations, attitudes and reactions during autopsy practice

PURPOSE

To investigate the particular features of students who express the desire to follow a forensic career.

METHODS AND MATERIALS

Three hundred and four 6th-year students attending the compulsory practice in forensic medicine in the academic year 2005-2006 were asked to fill in a self-administered questionnaire at the end of the course.

RESULTS

The predominant motivation for following forensics was the scientific interest (39.7%). Gender, marital status, religion, place of residence, number of siblings, father/mother being a health professional, being a religious individual were not associated with forensics. Higher grades were a negative predictor for the forensic specialty. A trend linking rejection of an afterlife and orientation towards forensic medicine was found. The fear of death was more intense in students rejecting forensics. Feelings of fear, aversion and grief during the last day of autopsy seemed to be important negative predictors. Stereotypes about forensic doctors (such as "forensic doctors have a peculiar character") significantly modified the decision of students, but the beliefs about the role of the autopsy practice (cause of anxiety for death, stimulus to live every moment in life) did not.

CONCLUSION

Medical students who want to follow forensics present only small differences concerning their inherent features, beliefs, reactions, emotions and attitudes, compared with the rest of their fellow students.

Educational debt and reported career plans among internal medicine residents

BACKGROUND

Physicians often enter the workplace with substantial debt. The relationship between debt and reported career plans among internal medicine residents is unknown.

OBJECTIVE

To determine distributions of educational debt among internal medicine residents and associations of debt with reported career plans.

DESIGN

Cross-sectional survey using data from the annual Internal Medicine In-Training Examination Residents Questionnaire completed by U.S. categorical internal medicine residents.

SETTING

Categorical internal medicine residencies in the United States.

PARTICIPANTS

22,563 residents in their third (final) year of residency, representing 74.1% of all eligible U.S. categorical internal medicine residents from 2003 through 2007.

MEASUREMENTS

Distributions of educational debt were tabulated. Proportions of residents choosing career plans were calculated for various levels of debt.

RESULTS

International medical graduates represented 48.7% of the cross section and had considerably less debt than U.S. medical graduates: 53.8% of U.S. medical graduates had debt of 100,000 dollars or greater and 60.2% of international medical graduates had none. U.S. medical graduates with debt of 100,000 dollars to 150,000 dollars were less likely than those with no debt to choose a subspecialty career (57.5% vs. 63.5%). U.S. medical graduates with debt of 50,000 dollars to 99,999 dollars were more likely than those with no debt to choose a hospitalist career (8.5% vs. 6.2%), and this preference increased with increasing debt level (10.0% for those with >150,000 dollars debt). These associations are more pronounced for U.S. medical graduates than for international medical graduates.

LIMITATION

The study addressed total educational debt, but not when it was incurred, and did not allow inferences related to causality.

CONCLUSION

Educational debt is associated with differences in reported career plans among internal medicine residents.