What influences career choices among graduates of a primary care training program?

OBJECTIVE: To identify factors that influence primary care residents to become generalists or specialists. DESIGN: Structured survey and interview. SETTING: A large university-based, internal medicine residency program in primary care. PARTICIPANTS: Of 92 residency graduates who completed training between 1979 and 1993, 88 (96%) participated. MAIN RESULTS: Although 82% of the participating graduates reported themselves very committed to primary care at the beginning of residency, only 68% pursued generalist careers. Factors influencing career choice that were more important to generalists than specialists included breadth of knowledge used in primary care practice (p=.04), breadth of clinical problems in practice (p=.001), and opportunity for continuity of care (p=.01). Although salary was rated “not important,” 50% of generalists and specialists advocated increased salaries for generalists as a way to increase interest in primary care. Other promoting factors included mentors, increased prestige for generalists, community-based training, lifestyle changes, and decreased paperwork. Seventy-three percent of participants felt it was easier to be a specialist than a generalist. CONCLUSIONS: A substantial minority of primary care residents pursue specialty careers. To produce more generalists, graduates recommend addressing income inequities, providing generalist role models, increasing community-based teaching, and increasing prestige for generalists.     

The generalist health care workforce

The generalist health care workforce in the United States is best characterized as those practitioners who deliver primary care services. These include most family physicians, general internists, general pediatricians, nurse practitioners, osteopathic family physicians, and physician assistants. Based on a variety of factors, including health care needs, managed care/HMO hiring practices, international comparisons, and health care costs, the case for increasing the amount and proportion of generalist providers is compelling. Projections strongly suggest a worsening shortfall of generalists if no change is made. Changing the career choices of medical students to promote generalism, even significantly, will take 20 years or more to have a meaningful impact. Therefore, retraining specialist physicians in oversupply to practice as generalists is an important option to consider. To best meet the nation’s health care needs, three issues need to be addressed in the context of health care reform: the creation of a “system” of generalist care that integrates into a coherent and collaborative framework the scopes of practice of the various generalist disciplines; the pursuit of a workable short-term model to convert specialist physicians into generalist physicians, led jointly by family medicine, general internal medicine, and general pediatrics; and a significant change in the medical education process to produce an ample supply of well-trained generalists.     

Predictors of final specialty choice by internal medicine residents

BACKGROUND: Sociodemographic factors and personality attributes predict career decisions in medical students. Determinants of internal medicine residents' specialty choices have received little attention. OBJECTIVE: To identify factors that predict the clinical practice of residents following their training. DESIGN: Prospective cohort study. PARTICIPANTS: Two hundred and four categorical residents from 2 university-based residency programs. MEASUREMENTS: Sociodemographic and personality inventories performed during residency, and actual careers 4 to 9 years later. RESULTS: International medical school graduates (IMGs) were less likely to practice general medicine than U.S. graduates (33.3% vs 70.6%, P < .001). Residents with higher loan indebtedness more often became generalists (P = .001). A corresponding trend favoring general internal medicine was observed among those who perceived General Internists to have lower potential incomes (69.0% vs 53.3%, P = .08). There was a trend for generalists to have lower scores on scales measuring authoritarianism, negative orientation to psychological problems, and Machiavellianism (0.05 < P < .10). In a logistic regression, graduation from a U.S. medical school (odds ratio [OR] 3.02; 95% confidence interval [CI], 1.00 to 9.10, P = .049) and perception of low future income (OR 1.65; 95% CI, 1.06 to 2.56, P = .03) predicted entry into general medicine, with trends apparent for higher debt (P = .05) and greater comfort caring for patients with psychological problems (P = .07). CONCLUSION: Recruitment of IMGs may not increase the supply of General Internists. Prospects of lower income, even in the face of large debt, may not discourage residents from becoming generalists. If increasing generalist manpower is a goal, residencies should consider weighing applicants' personal attributes during the selection process.     

Geriatric education for the physicians of tomorrow

The world's population is aging and there is need for more geriatricians. Current training programs, however, are not producing a sufficient number of geriatricians to meet that need, largely because students and residents lack interest in a career in geriatrics. A variety of reasons have been suggested to explain that lack of interest, and several changes in geriatrics training might increase the number of medical trainees who choose a career in geriatrics. These changes include recruiting medical students who are predisposed to geriatrics, loan forgiveness programs for those who enter careers in geriatrics, increased reimbursement for geriatric care, providing geriatric education to physicians in all specialties throughout their training, and refocusing geriatrics training so it includes the care of healthy vigorous older adults, rather than an exclusive focus on those with debility and chronic or fatal illnesses.     

Innovative generalist programs

Academic health care centers increasingly are exploring innovative ways to increase the supply of generalist physicians. The authors review successful innovations at representative academic health centers in the areas of recruitment and admissions, undergraduate medical education, residency training, and practice support. Lessons learned focus on those areas that have demonstrated improvements in the number and quality of physicians trained in family practice, general pediatrics, and general internal medicine. Successful recruitment of generalism-oriented applicants requires identification and tracking of rural, minority, and other special groups of students at the high school and college levels. Academic health care centers that provide early, sustained, community-based, ambulatory experiences for medical students and residents encourage trainees to maintain and choose generalist careers. Finally, academic health care centers that link with community providers and with state government encourage the retention of generalist physicians through continuing education and teaching networks.     

Training generalist physicians

To train more generalist physicians, structural changes must be made along the continuum of medical education. Future generalists require in-depth exposure to primary care practice, with substantive experience in the longitudinal management of patient panels and the opportunity to work with successful generalist role models. Clinical training and course work must incorporate a wide range of skills and disciplines, including areas now under-emphasized, such as epidemiology, health services, and psychosocial medicine. Recommendations for structural changes to increase the generalist focus of medical education include: 1) the development within institutions of central authorities, involving departments of internal medicine, family medicine, and pediatrics, in joint efforts to foster all aspects of generalist training, including recruitment, curriculum development, community linkages, innovative approaches to training, and recognition and support for successful generalist teachers; 2) commitment of a minimum of 50% of clinical training to ambulatory care settings at both medical school and residency levels; 3) required longitudinal care experiences for all medical students and a 20% or greater time commitment to longitudinal care for internal medicine, pediatrics, and family medicine residents; and 4) increased numbers of generalist faculty and enhanced teaching skills among faculty in the outpatient environment, to guarantee increased exposure of medical students and residents to generalist role models.     

Innovative generalist programs Academic health care centers respond to the shortage of generalist physicians

Academic health care centers increasingly are exploring innovative ways to increase the supply of generalist physicians. The authors review successful innovations at representative academic health centers in the areas of recruitment and admissions, undergraduate medical education, residency training, and practice support. Lessons learned focus on those areas that have demonstrated improvements in the number and quality of physicians trained in family practice, general pediatrics, and general internal medicine. Successful recruitment of generalism-oriented applicants requires identification and tracking of rural, minority, and other special groups of students at the high school and college levels. Academic health care centers that provide early, sustained, community-based, ambulatory experiences for medical students and residents encourage trainees to maintain and choose generalist careers. Finally, academic health care centers that link with community providers and with state government encourage the retention of generalist physicians through continuing education and teaching networks.     

Rekindling student interest in generalist careers

Despite changes in the structure of the U.S. health care system, patients continue to need and seek out generalist physicians. However, the proportion of U.S. graduates of medical schools who choose to enter generalist residency training decreased from 50% in 1998 to less than 40% in the 2004 match. Unless we act now to reverse this trend, we may face a shortage of primary care physicians to care for the complex medical needs of an aging population. This article reviews the history of and trends in career choice and proposes 4 evidence-based recommendations to rekindle student interest in generalist careers: 1) We must improve satisfaction and enthusiasm among generalist physician role models. 2) Schools of medicine should redouble their efforts to produce primary care physicians. 3) We must facilitate the pathway from medical school to generalist residency. 4) The U.S. government should increase funding for primary care research and research training. In the absence of a major overhaul of economic incentives in favor of generalist careers, we will need to work at these multiple levels to restore balance to the generalist physician workforce and align with the desires and expectations of patients for continuing healing relationships with generalist physicians.     

The changing role of academic health care centers in generalist education and practice support

Academic medical centers have been more compatible with the training and support of specialist and subspecialist physicians than that of their generalist colleagues. To meet the increasing demand for well-prepared generalist physicians, academic centers must change the manner in which they discharge their traditional missions of patient care, education, and training. This will require alteration of their organizational structures, changes in the allocation of resources, and an evolution of the culture of academic medicine toward one that is supportive of generalist education and practice. This paper discusses 1) the present organizational, structural, and cultural elements of the academic health care center that are inadequate for that goal; 2) a model for reorganizing academic health care centers to best achieve that goal; and 3) educational programs and technologies that promise to address the continuing educational needs of generalists.     

Changes in job aspirations during physician training in Australia

Background: There is uncertainty regarding the effects of physician training on planned practice features of Australian physician trainees, for example plans for urban or rural, full-time or part-time and academic/research or purely clinical practice. These plans may differ between male and female trainees and between generalists and sub-specialists. Aim: To examine the changes in anticipated practice patterns over the course of advanced physician training. Methods: Longitudinal study of doctors in Australia who passed the Part I clinical examination of the Royal Australasian College of Physicians in 1991, 1992 and 1993, followed annually up until 1995. Changes in future practice plans regarding full- or part-time work, rural or urban practice and pure clinical work or a mixture with research were examined among generalist and specialist trainees and among men and women. Statistical analysis included the calculation of chi square for trend statistics and intraclass correlation coefficients. Results: At least one follow-up questionnaire was received from 80% of the 334 original respondents. The majority had been able to obtain their training job of choice. By the time of last follow-up, around 80% planned to practise in a capital city, indicating a shift during training from those who initially stated no preference. There was also a shift towards combining research with clinical practice and among women wishing to practise part-time only. Generalists were more likely to wish to practise outside a capital city than specialists. Conclusions: The training programme should be revised so that careers in rural and provincial centres are encouraged and so that it is sensitive to the needs for physicians to develop research capacity. Training and career opportunities should allow all candidates (particularly women) wishing part-time employment to achieve their full career potential.     

What Can I Do With a Doctoral Degree in Gerontology? Expanding Your Options

An endless number of career trajectories are possible for gerontologists. With a growing aging population, our skills and areas of expertise are of high value to numerous industries. The purpose of this study is to describe the professional development and career trajectories of alumni of U.S. doctoral gerontology programs obtained through the Gerontology Education Longitudinal Study (GELS). Specifically, the authors examine how professional identification, doctoral program career preparation, and perception of job prospects affect alumni decisions to pursue “traditional” (i.e., academic) versus “nontraditional” (i.e., non-academic) careers. Results from the GELS revealed a fairly even split in the alumni sample of careers in traditional and nontraditional settings. The decision to pursue a traditional versus nontraditional career was not significantly associated with personal identification, doctoral program career preparation, or perception of employment options. These results suggest that the skill set obtained in doctoral gerontology programs is useful and is in demand in a variety of careers; therefore, doctoral programs may want to consider tailoring training to meet students’ future career goals in both academic and non-academic settings.     

Primary care internal medicine: a challenging career choice for the 1990s

A career in primary care internal medicine can be challenging and rewarding, yet during the last decade fewer medical students have selected training in internal medicine. We wish to inform medical students, their advisors, and other physicians about the field of primary care internal medicine. We define the discipline, compare it with traditional internal medicine and with family practice, and describe features of strong primary care internal medicine training programs. We discuss common misconceptions and concerns about training programs and the career and give examples of career paths chosen by graduates of primary care programs. We encourage students to consider the option of primary care internal medicine when making career decisions and provide faculty advisors unfamiliar with primary care internal medicine training programs with a reference resource.     

Contributions of general internal medicine teaching units

OBJECTIVE: To identify and describe general internal medicine teaching units and their educational activities. DESIGN: A cross-sectional mailed survey of heads of general internal medicine teaching units affiliated with U.S. internal medicine training programs who responded between December 1996 and December 1997. MEASUREMENTS AND MAIN RESULTS: Responses were received from 249 (61%) of 409 eligible programs. Responding and nonresponding programs were similar in terms of university affiliation, geographic region, and size of residency program. Fifty percent of faculty received no funding from teaching units, 37% received full-time (50% or more time), and 13% received part-time (under 50% time) funding from units. Only 23% of faculty were primarily located at universities or medical schools. The majority of faculty were classified as clinicians (15% or less time spent in teaching) or clinician-educators (more than 15% time spent in teaching), and few were clinician-researchers (30% or more time spent in research). Thirty-six percent of faculty were internal medicine subspecialists. All units were involved in training internal medicine residents and medical students, and 21% trained fellows of various types. Half of the units had teaching clinics located in underserved areas, and one fourth had teaching clinics serving more than 50% managed care patients. Heads of teaching units reported that 54% of recent graduating residents chose careers in general internal medicine. CONCLUSIONS: General internal medicine teaching units surveyed contributed substantial faculty effort, much of it unfunded and located off-campus, to training medical students, residents, and fellows. A majority of their graduating residents chose generalist careers. Presented at the national meeting of the Society of General Internal Medicine, April 1998, and the Bureau of Health Professions, June 1998. This work was supported by the Division of Medicine, Bureau of Health Professions, Health Resources and Services Administration, U.S. Department of Health and Human Services, Rockville, Md, grant 103HR960470P000-000; and the Society of General Internal Medicine.     

Reasons for outpatient referrals from generalists to specialists

OBJECTIVE: To determine the relative importance of medical and nonmedical factors influencing generalists' decisions to refer, and of the factors that might avert unnecessary referrals. DESIGN: Prospective survey of all referrals from generalists to subspecialists over a 5-month period. SETTING: University hospital outpatient clinics. PARTICIPANTS: Fifty-seven staff physicians in general internal medicine, family medicine, dermatology, orthopedics, gastroenterology, and rheumatology. MEASUREMENTS AND MAIN RESULTS: For each referral, the generalist rated a number of medical and nonmedical reasons for referral, as well as factors that may have helped avert the referral; the specialist seeing the patient then rated the appropriateness, timeliness, and complexity of the referral. Both physicians rated the potential avoidability of the referral by telephone consultation. Generalists were influenced by a combination of both medical and nonmedical reasons for 76% of the referrals, by only medical reasons in 20%, and by only nonmedical reasons in 3%. In 33% of all referrals, generalists felt that training in simple procedures or communication with a generalist or specialist colleague would have allowed them to avoid referral. Specialists felt that the vast majority of referrals were timely (as opposed to premature or delayed) and of average complexity. Although specialists rated most referrals as appropriate, 30% were rated as possibly appropriate or inappropriate. Generalists and specialists failed to agree on the avoidability of 34% of referrals. CONCLUSIONS: Generalists made most referrals for a combination of medical and nonmedical reasons, and many referrals were considered avoidable. Increasing procedural training for generalists and enhancing informal channels of communication between generalists and subspecialists might result in more appropriate referrals at lower cost.     

NHLBI Workshop: Respiratory Medicine-Related Research Training for Adult and Pediatric Fellows

The pulmonary physician-scientist has a special niche to generate basic research findings and apply them to a clinical disease and perhaps impact its medical care. The availability of new high throughput-based scientific technologies in the “omics era” has made this an opportune time for physician scientists to prepare and embark on an academic career in respiratory disease research. However, maintaining an adequate flow through the research pipeline of physician-scientist investigators studying respiratory system diseases is currently a challenge. There may not be a sufficient workforce emerging to capitalize on current research opportunities. The National Heart, Lung, and Blood Institute (NHLBI) organized a workshop to assess ways to attract and properly train advanced fellows to pursue research careers in adult and pediatric lung diseases. Participants included representatives from the various pulmonary training programs, respiratory-related professional societies, and NHLBI staff. Deliberation centered on present barriers that might affect interest in pursuing research training, devising better incentives to attract more trainees, and how current research support offered by the NHLBI and the Professional Societies (in partnership with Industry and Patient Support groups) might be better coordinated and optimized to ensure a continued pipeline of pulmonary investigators. Major recommendations offered are: (1) Attract trainees to pulmonary/critical care medicine-based research careers by increasing research exposure and opportunities for high school, college, and medical students. (2) Increase awareness of the outstanding physician-scientist role models in the lung community for trainees. (3) Facilitate mechanisms by which the lung community (NHLBI, professional societies, and partners) can better support and bridge senior fellows as they transition from Institutional Training Grants (T32) to Career Series (K) awards in their early faculty career development.     

An applicant's evaluation of an emergency medicine internship and residency

Applicants to emergency medicine residencies face an increasingly difficult task of evaluating a greater number of training programs. High-quality information must be obtained by applicants prior to their submission of a ranking list to the National Intern and Residency Matching Program. Resources to assist applicants in this task have been limited; personal interviews are critical in this process. In the relatively new specialty of emergency medicine, medical students may fail to obtain optimal information during interviews. A list of suggested interview questions is provided. Judicious use of appropriate questions can help applicants obtain the proper information. Residency program directors and staff may also use these questions to assist applicants.     

The impact of an ambulatory rotation on medical student interest in internal medicine

OBJECTIVE: To determine whether students who take ambulatory rotations in internal medicine are more likely to choose internal medicine careers. DESIGN: National survey. SETTING AND PARTICIPANTS: The intended sample was 1,650 senior U.S. medical students from 16 medical schools, of whom 1,244 (76%) responded. Representative schools nationwide were selected using a stratified, random-sampling method. MEASUREMENTS: The questionnaire asked about characteristics of the ambulatory rotation, perceptions of internal medicine, and factors influencing students toward or away from an internal medicine career. RESULTS: Ambulatory rotations were taken by 543 students (43%). Of these rotations, 73% were required, 74% were during the fourth year, 77% were in general internal medicine, 73% provided continuity of care, and 19% were during the medicine clerkship. Overall, 24% of the students chose careers in general (9%) or subspecialty internal medicine (15%). Thirty percent of the students who did ambulatory rotations planned internal medicine careers, compared with 19% of the students who had no rotation [odds ratio (OR)=1.8,95% confidence interval (CI) 1.3 to 2.4, p=0.0001]. This association was of similar magnitudes for students completing required rotations (OR=1.6, 95% CI 1.2 to 2.2, p=0.002) and for students completing rotations before or in proximity to when they chose careers (OR=1.7, 95% CI 1.1 to 2.4, p=0.01). Ninety percent of the 543 students who had ambulatory rotations were satisfied with the experience. Thirty-eight percent of the highly satisfied students chose internal medicine careers, compared with 21% of the students who had low or moderate satisfaction (p=0.0001). CONCLUSIONS: An ambulatory rotation is strongly associated with positive perceptions of, attraction to, and choice of a career in internal medicine. Research is needed to determine specific components of an effective rotation. Further development of ambulatory rotations could help attract more students to internal medicine.     

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.     

Integrating student-focused career planning into undergraduate gerontology programs

As our global older adult populations are increasing, university programs are well-positioned to produce an effective, gerontology-trained workforce (Morgan, 2012; Silverstein & Fitzgerald, 2017). A gerontology curriculum comprehensively can offer students an aligned career development track that encourages them to: (a) learn more about themselves as a foundation for negotiating career paths; (b) develop and refine career skills; (c) participate in experiential learning experiences; and (d) complete competency-focused opportunities. In this article, we discuss a programmatic effort to help undergraduate gerontology students integrate development-based career planning and decision-making into their academic programs and achieve postgraduation goals.     

Attitudes of clinical faculty about career progress, career success and recognition, and commitment to academic medicine. Results of a survey

OBJECTIVE: To assess attitudes about career progress, resources for career development, and commitment to academic medicine in physician faculty at an academic medical center who spend more than 50% of their time in clinical care. DESIGN: Faculty survey. SETTING: Academic medical center and associated Veterans Affairs medical center. RESULTS: A total of 310 physician faculty responded to the survey. Half of the faculty reported spending 50% or less of their time in clinical care (mean, 31% of time) (group 1) and half reported spending more than 50% of their time in clinical care (mean, 72% of time) (group 2). Group 2 faculty had one third of the time for scholarly activities, reported slower career progress, and were less likely to be at the rank of professor (40% and 16% for groups 1 and 2, respectively; P<.001) or to be tenured (52% and 26%, respectively; P<.001) despite similar age and years on faculty. Group 2 faculty were 50% more likely to report that tenure and promotion criteria were not reviewed at their annual progress report (P =.003) and that they did not understand the criteria (P<.001). Group 2 faculty valued excellence in patient care over scholarship and national visibility. Group 2 faculty reported greater dissatisfaction with academic medicine and less commitment to a career in academic medicine. CONCLUSIONS: Physician faculty who spend more than 50% of their time in clinical care have less time, mentoring, and resources needed for development of an academic career. These obstacles plus differences in their attitudes about career success and recognition contribute to significant differences in promotion. These factors are associated with greater dissatisfaction with academic medicine and lower commitment to academic careers.