National Study of Internal Medicine Manpower: VI. Factors predicting preferences of residents for careers in primary care or subspecialty care and clinical practice of academic medicine

Why Aren't More Primary Care Residents Going into Primary Care? A Qualitative Study

BACKGROUND

Workforce projections indicate a potential shortage of up to 31,000 adult primary care providers by the year 2025. Approximately 80 % of internal medicine residents and nearly two-thirds of primary care internal medicine residents do not plan to have a career in primary care or general internal medicine.

OBJECTIVE

We aimed to explore contextual and programmatic factors within primary care residency training environments that may influence career choices.

DESIGN

This was a qualitative study based on semi-structured, in-person interviews.

PARTICIPANTS

Three primary care internal medicine residency programs were purposefully selected to represent a diversity of training environments. Second and third year residents were interviewed.

APPROACH

We used a survey guide developed from pilot interviews and existing literature. Three members of the research team independently coded the transcripts and developed the code structure based on the constant comparative method. The research team identified emerging themes and refined codes. ATLAS.ti was used for the analysis.

KEY RESULTS

We completed 24 interviews (12 second-year residents, and 12 third-year residents). The age range was 27-39 years. Four recurrent themes characterized contextual and programmatic factors contributing to residents' decision-making: resident expectations of a career in primary care, navigation of the boundary between social needs and medical needs, mentorship and perceptions of primary care, and structural features of the training program.

CONCLUSIONS

Addressing aspects of training that may discourage residents from careers in primary care such as lack of diversity in outpatient experiences and resident frustration with their inability to address social needs of patients, and strengthening aspects of training that may encourage interests in careers in primary care such as mentorship and protected time away from inpatient responsibilities during primary care rotations, may increase the proportion of residents enrolled in primary care training programs who pursue a career in primary care.

The Perceived Likelihood of Outcome of Critical Care Patients and Its Impact on Triage Decisions: A Case-Based Survey of Intensivists and Internists in a Canadian, Quaternary Care Hospital Network

Introduction

There is high variability amongst physicians’ assessments of appropriate ICU admissions, which may be based on potential assessments of benefit. We aimed to examine whether opinions over benefit of ICU admissions of critically ill medical inpatients differed based on physician specialty, namely intensivists and internists.

Materials and Methods

We carried out an anonymous, web-based questionnaire survey containing 5 typical ICU cases to all ICU physicians regardless of their base specialty as well as to all internists in 3 large teaching hospitals. For each case, we asked the participants to determine if the patient was an appropriate ICU admission and to assess different parameters (e.g. baseline function, likelihood of survival to ICU discharge, etc.). Agreement was measured using kappa values.

Results

21 intensivists and 22 internists filled out the survey (response rate = 87.5% and 35% respectively). Predictions of likelihood of survival to ICU admission, hospital discharge and return to baseline were not significantly different between the two groups. However, agreement between individuals within each group was only slight to fair (kappa range = 0.09–0.22). There was no statistically significant difference in predicting ICU survival and prediction of survival to hospital discharge between both groups. The accuracy with which physicians predicted actual outcomes ranged between 35% and 100% and did not significantly differ between the two groups. A greater proportion of internists favoured non resuscitative measures (24.6% of intensivists and 46.9% internists [p = 0.002]).

Conclusion

In a case-based survey, physician specialty base did not affect assessments of ICU admission benefit or accuracy in outcome prediction, but resulted in a statistically significant difference in level of care assignments. Of note, significant disagreement amongst individuals in each group was found.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Medical student indebtedness and the propensity to enter academic medicine

This paper considers the potential impact of medical school indebtedness and other variables on the propensity of US doctors to enter academic medicine. Probit models provide some evidence that indebtedness reduces the likelihood that physicians will choose academic medicine as their primary activity. Nevertheless, the magnitude of this effect is not large. As indebtedness may be endogenous, the probits are rerun using an instrumental variables approach. These estimates imply that over time indebtedness may have an important impact on the propensity of physicians to enter academic medicine.

Blueprint for a research career in general internal medicine

An academic career in general internal medicine is a challenging but rewarding endeavor. The strategies for success require flexibility as the ground rules may change. Nevertheless, attention to the aforementioned principles will help the academic generalist to swim with sharks and survive, and simultaneously to promote the entire field of academic general internal medicine.

Research in choice of medical specialty: a review of the literature 1977-87

Studies of the factors which influence the selection of a specialty in medicine represent a major theme in research in medical education. The journal literature in this area is reviewed for the last ten year under the headings of: Reasons for choice of specialty Timing and consistency of choice Expectations of financial success Attitudes and choice of specialty Predictive methods Effect of the curriculum Academic performance Psychiatry as a career choice General differences Personality factors It is concluded that there are a number of inadequacies in the investigations reported in this field. The research is not based on any theoretical model, focuses on only one or a few of the many possible factors and uses different study populations. Greater consistency and applicability of the findings could be achieved by a central organisation conducting appropriately designed multivariate studies using defined populations at a large number of centres.

Career development among residents completing primary care and traditional residencies in medicine at the Boston City Hospital, 1974-1983

A primary care (PC) pathway was initiated within the medical residency program at Boston City Hospital (BCH) in 1974. The authors studied the PC and traditional (TD) track graduates of the program to compare career development, goals, and practice patterns. The 185 graduates of the nine resident cohorts from 1974 through 1983 were surveyed; the overall response rate was 74%. Primary care careers have been chosen by 81% of PC graduates, compared with 38% of TD graduates (p less than 0.001); career satisfaction is equally high in the two groups. Among the PC graduates, 68% are practicing in high-need areas, compared with only 37% of TD graduates (p less than 0.001). PC graduates are more likely to make house calls, provide extended office hours, round in nursing homes or chronic care facilities, and co-practice with nurse practitioners or physician's assistants, and they are more active in women's health care, care of the terminally ill, and treating patients with sexual dysfunction (all p less than 0.05). PC graduates utilize various community agencies more frequently and supplement patient education with outside resources more intensively (p less than 0.001). The career choices and practice locations of PC graduates reflect the training goals of the PC curriculum and differ from the career choices and practices of the TD graduates from the same program.

Work satisfaction and career aspirations of internists working in teaching hospital group practices

This paper presents data on the characteristics, work activities, job-related stress, work satisfaction, and career aspirations of 150 faculty and 595 housestaff physicians who regularly provide continuous primary care in 15 teaching hospital-based group practices. The faculty were young, board-certified generalists; they had been recruited from local training programs and spent the majority of their time seeing patients and supervising housestaff. Job satisfaction among faculty and housestaff was generally high. Dissatisfaction occurred most often with aspects of work over which physicians had little control. Although work-related stress was common, it was not related to job satisfaction. Compared with housestaff in traditional residency programs, housestaff enrolled in special Primary Care Training Programs reported significantly greater job satisfaction. For all housestaff, satisfaction with work in the group practice was consistently associated with decreased interest in subspecialty training.

Patterns of diagnostic testing in the academic setting: the influence of medical attendings' subspecialty training

Internists with subspecialty training (subspecialists) constitute the majority of the medical faculty members and the test-ordering behavior of these subspecialists influences how house officers and students solve clinical problems. To assess whether test-ordering patterns are influenced by the ward attendings' subspecialty status, we identified the number of gastrointestinal endoscopic procedures, bone marrow procedures and exercise stress tests that were ordered on 9608 patients admitted to a medical service during a 3 year period. The patient management was supervised by attendings, 8 of whom were generalists and 37 of whom were subspecialists. House officers supervised by generalists ordered 23% fewer gastrointestinal procedures, 47% fewer bone marrow procedures, 43% fewer exercise stress tests and 29% fewer total procedures than house staff supervised by subspecialists (P--not significant, P less than 0.001, P less than 0.05 and P less than 0.01, respectively). House officers perceive a difference between the test-ordering patterns of subspecialists and generalists. They attribute this difference to post-residency training and believe that the use of more tests indicates a greater compulsion toward an exhaustive evaluation.