Medical student interest in internal medicine. Initial report of the Society of General Internal Medicine Interest Group Survey on Factors Influencing Career Choice in Internal Medicine

OBJECTIVE: To determine the factors that attract students toward and push students away from a career in internal medicine. DESIGN: National survey of senior U.S. medical students using a stratified random cluster sampling of medical schools. PARTICIPANTS: The survey included 1650 U.S. senior students from 16 medical schools, of whom 1244 (76%) responded. MEASUREMENTS AND MAIN RESULTS: A survey instrument was developed and pilot tested at 17 medical schools. Twenty-four percent of the respondents to the final survey chose a career in general internal medicine (9%) or subspecialty internal medicine (15%). A career in internal medicine had been "seriously considered" by 608 respondents (50%) who finally chose a career other than internal medicine (the "switchers"). Compared with other specialties, internal medicine was perceived as being more stressful to residents, more demanding of time and workload as a career and a residency, and as an easier residency to enter. Internal medicine was also seen as providing less satisfaction for residents, having lower income potential, and allowing less leisure time. For the 608 switchers, the most important influences leading to their decision to switch were the type of patient seen in internal medicine (for example, chronically ill, alcohol and drug abusing patients) as well as dissatisfaction and stress among internal medicine residents. Factor analysis showed that three factors, "intellectual challenge of internal medicine," "primary care interests," and "the medicine clerkship" attracted students toward internal medicine, whereas three others, "taking care of chronically ill patients," "level of satisfaction among internists and medical residents," and "workload and stress" pushed students away from internal medicine. Factors pushing students away from internal medicine were significantly more negative with regard to a career in general as opposed to subspecialty internal medicine (P less than 0.001). CONCLUSION: Medical students have serious reservations about internal medicine as a career choice. Perceptions about the medical residency, the patients they expect to see, and the dissatisfaction among residents and internists are foremost in their thinking. Changes to improve the attractiveness of internal medicine should address these adverse perceptions while building on the positive influences identified by the respondents.     

Managed care, professional autonomy, and income

CONTEXT: Career satisfaction among physicians is a topic of importance to physicians in practice, physicians in training, health system administrators, physician organization executives, and consumers. The level of career satisfaction derived by physicians from their work is a basic yet essential element in the functioning of the health care system. OBJECTIVE: To examine the degree to which professional autonomy, compensation, and managed care are determinants of career satisfaction among physicians. DESIGN: Cross-sectional analysis using data from 1996-97 Community Tracking Study physician telephone survey. SETTING AND PARTICIPANTS: A nationally representative sample of 12,385 direct patient care physicians. The survey response rate was 65%. MAIN OUTCOME MEASURE: Overall career satisfaction among U.S. physicians. RESULTS: Bivariate results show that physicians with low managed care revenues are significantly more likely to be "very satisfied" than are physicians with high managed care revenue (P < .05), and that physicians with low managed care revenues are significantly more likely to report higher levels of clinical freedom than are physicians with high managed care revenue (P < .05). Multivariate analyses demonstrate that, among our measures, traditional core professional values and autonomy are the most important determinants of career satisfaction after controlling for all other factors. Relative income is also an important independent predictor. Multiple dimensions of professional autonomy hold up as strong, independent predictors of career satisfaction, while the effect of managed care does not. Managed care appears to exert its effect on satisfaction through its impact on professional autonomy, not through income reduction. CONCLUSIONS: Our results suggest that when managed care (or other influences) erode professional autonomy, the result is a highly negative impact on physician career satisfaction.     

Physician career satisfaction across specialties

BACKGROUND: The career satisfaction and dissatisfaction physicians experience likely influence the quality of medical care. OBJECTIVE: To compare career satisfaction across specialties among US physicians. METHODS: We analyzed data from the Community Tracking Study of 12 474 physicians (response rate, 65%) for the late 1990s. Data are cross-sectional. Two satisfaction variables were created: very satisfied and dissatisfied. Thirty-three specialty categories were analyzed. RESULTS: After adjusting for control variables, the following specialties are significantly more likely than family medicine to be very satisfying: geriatric internal medicine (odds ratio [OR], 2.04); neonatal-perinatal medicine (OR, 1.89); dermatology (OR, 1.48); and pediatrics (OR, 1.36). The following are significantly more likely than family medicine to be dissatisfying: otolaryngology (OR, 1.78); obstetrics-gynecology (OR, 1.61); ophthalmology (OR, 1.51); orthopedics (OR, 1.36); and internal medicine (OR, 1.22). Among the control variables, we also found nonlinear relations between age and satisfaction; high satisfaction among physicians in the west north Central and New England states and high dissatisfaction in the south Atlantic, west south Central, Mountain, and Pacific states; positive associations between income and satisfaction; and no differences between women and men. CONCLUSIONS: Career satisfaction and dissatisfaction vary across specialty as well as age, income, and region. These variations are likely to be of interest to residency directors, managed care administrators, students selecting a specialty, and physicians in the groups with high satisfaction and dissatisfaction.     

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.     

The effects of work-hour limitations on resident well-being, patient care, and education in an internal medicine residency program

BACKGROUND: The Accreditation Council for Graduate Medical Education work-hour limitations (WHLs) were implemented in July 2003. Effects on resident well-being, patient care, and education are not well understood. We investigated these effects of WHLs. METHODS: Self-administered survey of internal medicine residents in a university-based residency program in Seattle, Wash. Part of this survey was identical to one completed at our institution in 2001, permitting comparison of burnout, career satisfaction, and depression before and after WHLs. We surveyed 161 internal medicine residents, with 118 respondents (response rate, 73%). We measured resident well-being using the Maslach Burnout Inventory, a validated screening questionnaire for depression, and a previously described questionnaire for career satisfaction. We developed questions about overall agreement with implementation of WHLs and effects on resident well-being, patient care, and education. RESULTS: Comparison with the 2001 survey demonstrated an increase in the proportion of residents satisfied with their career (66% to 80%; P = .02) and a decrease in the proportion meeting criteria for emotional exhaustion (53% to 40%; P = .05). Slightly more residents reported a negative effect of WHLs on patient care (37%) than they did a positive (29%) or a neutral (34%) effect, and more reported a negative effect on their education (47%) than they did a positive (32%) or a neutral (21%) effect. Overall, most residents (65%) approved of WHLs. CONCLUSIONS: Internal medicine residents approve of WHLs overall and report benefits to their well-being. However, they also report negative effects on patient care and resident education.     

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.     

Attitudes and perceptions of internal medicine residents regarding pulmonary and critical care subspecialty training

STUDY OBJECTIVE: To evaluate the attitudes and perceptions of internal medicine residents regarding pulmonary and critical care medicine (PCCM) training. DESIGN: Prospective study. SETTING: Three university hospitals. METHODS: An eight-page survey was distributed and collected between March 1, 2002, and June 30, 2002. All internal medicine or internal medicine/pediatric residents training at the three institutions were eligible for the study. RESULTS: One hundred seventy-eight residents in internal medicine from an eligible pool of 297 residents returned the survey (61% response rate). PCCM accounted for only 3.4% of the career choices. Forty-one percent of the residents seriously considered a pulmonary and/or critical care fellowship during their residency. Of these residents, 23.5% found the combination of programs the more attractive option, while 2.8% found pulmonary alone and 14.5% found critical care alone more attractive. Key factors associated with a higher resident interest in PCCM subspecialty training included more weeks in the ICU (p = 0.008), more role models in PCCM (3.02 +/- 0.78 vs 3.45 +/- 0.78, p = 0.0004), and resident observations of a greater sense of satisfaction among PCCM faculty (3.07 +/- 0.82 vs 3.33 +/- 0.82, p = 0.04) and fellows (3.05 +/- 0.69 vs 3.31 +/- 0.86, p = 0.03) [mean +/- SD]. The five most commonly cited attributes of PCCM fellowship that would attract residents to the field included intellectual stimulation (69%), opportunities to manage critically ill patients (51%), application of complex physiologic principles (45%), number of procedures performed (31%), and academically challenging rounds (29%). The five most commonly cited attributes of PCCM that would dissuade residents from the field included overly demanding responsibilities with lack of leisure time (54%), stress among faculty and fellows (45%), management responsibilities for chronically ill patients (30%), poor match of career with resident personality (24%), and treatment of pulmonary diseases (16%). CONCLUSIONS: Internal medicine residents have serious reservations about PCCM as a career choice. Our survey demonstrated that a minority of US medical graduates actually would choose PCCM as a career, which suggests that efforts to expand PCCM training capacity might result in vacant fellowship slots. To promote greater interest in PCCM training, efforts are needed to improve the attractiveness of PCCM and address the negative lifestyle perceptions of residents.     

The management of Chlamydia trachomatis in genitourinary medicine clinics: a national audit in 2004

The first national audit of the management of Chlamydia trachomatis was undertaken by non-consultant career grade doctors working in genitourinary (GU) medicine clinics in the UK. During the audit period of January--March 2004, 1670 data collection forms were completed (from 830 men and 840 women with chlamydia). In all, 99% (1647) were treated appropriately; 76% (1261) were followed up, of which 12% (154) required re-treatment; 71% (1186) were managed appropriately within four weeks and 942 partners (0.56 per index case) were managed satisfactorily within four weeks of the initial partner notification interview. Partner notification outcomes were significantly more successful when the index patient was followed up (P<0.0001). Outcome standards were not associated with age, gender or sexuality, but were significantly associated with ethnicity (P<0.004). GU medicine clinics are delivering high-quality care and evidence-based national outcome standards are being met.     

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.     

Long-term financial implications of specialty training for physicians

PURPOSE: Given the recent changes in physician reimbursement and managed care penetration, we examined the financial returns that might be anticipated when considering different medical careers. METHODS: We used survey data from the American Medical Association and standard financial techniques to calculate the return on educational investment (as the discounted, annual hours-adjusted, net present value of additional training) over a working lifetime for six different specialties (family practice, pediatrics, general internal medicine, gastroenterology, cardiology, and general surgery). RESULTS: From 1992 to 1998, the annual yield on specialty training (hours-adjusted internal rate of return) declined for all specialty groups, especially for primary care specialties. The difference in the average income between a given specialty and general practice decreased for general internal medicine, from $5400 (95% confidence interval [CI]: $5000 to $5800) in 1992 to $1180 (95% CI: $1160 to $1205) in 1998, and became negative for family practice (from $5200 [95% CI: $1000 to $9500] to -$2500 [95% CI: -$5800 to $800]) and pediatrics (from $4000 [95% CI: $1200 to $6800] to -$6300 [95% CI: -$9700 to -$2900]). Values for surgery decreased from $33,100 (95% CI: $29,400 to $36,400) in 1992 to $27,200 (95% CI: $21,700 to $32,100) in 1998, whereas there were increases for cardiology, from $35,100 (95% CI: $30,000 to $39,700) to $36,700 (95% CI: $26,500 to $45,700), and for gastroenterology, from $30,000 (95% CI: $21,800 to $37,200) to $34,700 (95% CI: $22,700 to $45,300). CONCLUSION: Our analysis suggests that recent efforts to use financial incentives to make primary care fields more attractive have not been effective. Financial returns and the incentives they create should be carefully considered as part of health care reform.     

Expert ratings of primary care goals and objectives

OBJECTIVE: To develop consensus on proficiencies internal medicine residents should master in the area of primary and managed care. DESIGN: A draft compendium of primary care educational objectives including important clinical topics was developed at the Sepulveda Veterans Health Administration Medical Center Pilot Ambulatory Care and Education (PACE) Program as part of a local and regional primary care curricular review. Fifty-one experts, including leaders in the Society of General Internal Medicine, the Association of Program Directors in Internal Medicine, the American College of Physicians, general internal medicine division chiefs, and Veterans Affairs (VA) associate chiefs of staff for ambulatory care rated the compendium. MEASUREMENTS AND MAIN RESULTS: Eleven objectives and nine clinical topics were rated “critically important” (4.7 or above on a five-point scale). General internal medicine chiefs and associate chiefs of staff for ambulatory care judged them to be covered adequately in fewer than half of the 17 VA Western Region-affiliated internal medicine programs. Forty-five objectives and 77 clinical topics were considered at least somewhat important to the education of general internal medicine residents in primary care. The VA raters reported that in the prior academic year, their housestaffs had spent between 21% (postgraduate year I) and 33% (postgraduate year III) of their time in ambulatory care settings. CONCLUSION: With the emphasis on primary and managed care, there is a need for national consensus on educational objectives in primary care general internal medicine. This review provides educators with a benchmark to test the adequacy of their institutions’ curricula in primary care internal medicine. Presented in abstract Jorm at the annual meeting of the Society of General Internal Medicine, April 28, 1994, Washington, DC.     

The impact of educational loan burden on housestaff career decisions

The past decade has seen declining interest in primary care medicine and a dramatic increase in the cost of a medical degree. Seventy-nine percent of housestaff in an internal medicine residency program responded to a survey to determine whether medical school loan burden was related to career choice in a primary care field or specialty area. Overall mean indebtedness was $45,185 (median $40,000). Thirty-eight percent of residents with debts < $40,000 chose a career in primary care, compared with 10% with debts > $40,000 (chi square =9.44, p<0.01). Fourteen percent of those with debts <40,000 and 59% with debts > $40,000 stated that financial conditions had a moderate to marked impact on their career decision making. Excessive loan burden has a significant influence on residents’ career decision making and a negative influence on choosing careers in primary care internal medicine.     

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.     

Is Training in a Primary Care Internal Medicine Residency Associated with a Career in Primary Care Medicine?

PURPOSE

Professional and governmental organizations recommend an ideal US physician workforce composed of at least 40 % primary care physicians. They also support primary care residencies to promote careers in primary care. Our study examines the relationship between graduation from a primary care or categorical internal medicine residency program and subsequent career choice.

METHODS

We conducted a cross-sectional electronic survey of a cohort of internal medicine residency alumni who graduated between 2001 and 2010 from a large academic center. Our primary predictor was graduation from a primary care versus a categorical internal medicine program and our primary outcome is current career role. We performed chi-square analysis comparing responses of primary care and categorical residents.

RESULTS

We contacted 481 out of 513 alumni, of whom 322 responded (67 %). We compared 106 responses from primary care alumni to 169 responses from categorical alumni. Fifty-four percent of primary care alumni agreed that the majority of their current clinical work is in outpatient primary care vs. 20 % of categorical alumni (p < 0.001). While 92.5 % of primary-care alumni were interested in a primary care career prior to residency, only 63 % remained interested after residency. Thirty of the 34 primary care alumni (88 %) who lost interest in a primary care career during residency agreed that their ambulatory experience during residency influenced their subsequent career choice.

CONCLUSIONS

A higher percentage of primary care alumni practice outpatient primary care as compared to categorical alumni. Some alumni lost interest in primary care during residency. The outpatient clinic experience may impact interest in primary care.

Electronic supplementary material

The online version of this article (doi:10.1007/s11606-015-3356-9) contains supplementary material, which is available to authorized users.KEY WORDS: primary care, medical education-career choice, medical education-outcomes research, workforce     

Effect of Managed Care on Cardiovascular Specialists: Involvement, Attitudes and Practice Adaptations

Objectives. This study was undertaken to determine the extent to which cardiovascular specialists are involved with and affected by managed care and to ascertain their attitudes toward it. This survey also served as the follow-up to an initial study on the subject performed by the American College of Cardiology in 1993.

Background. The initial 1993 study was performed to address the lack of any comprehensive examination of the impact of managed care on cardiovascular specialists. In 1995, to reexplore this question and follow up the 1993 findings, the College conducted a survey of its membership in the following areas: 1) physician relationship with managed care plans; 2) number of managed care contracts; 3) breakdown of revenue by payment source; 4) changes in practice in response to managed care; and 5) physician attitudes toward managed care. To the extent feasible, the 1995 questionnaire paralleled the 1993 instrument to facilitate comparisons.

Methods. A questionnaire was mailed to 5,147 practicing College members in the United States, who were categorized by specialty as pediatric cardiologists, adult cardiologists or cardiovascular surgeons. Mailings were sent to 1) all pediatric cardiologists and cardiovascular surgeons; 2) randomly selected adult cardiologists practicing in 10 states with high managed care penetration; and 3) randomly selected adult cardiologists in the nine U.S. census areas who were not practicing in the 10 states with high managed care penetration.

Results. Usable surveys were returned by 1,236 respondents, for an overall response rate of 24%. Involvement with at least one type of managed care organization was reported by 89% of respondents, up from 76% in 1993. Although managed care relationships had increased across physician age, region, practice and specialty, respondents indicated that, on average, well below 50% of their practice revenues stem from managed care contracts. To adapt to the managed care environment, strategic practice changes, such as joining a cardiovascular network, implementing continuous quality improvement systems and adopting clinical pathways, were being instituted by most respondent practices of nine or more physicians. Smaller groups were less active. Most respondents involved with managed care disliked its effects, particularly in clinical matters. Their attitudes toward the assumption of risk, managed fee-for-service arrangements and a private versus single-payer system show that there is no uniformity of opinion regarding the best means to contain costs and promote efficiency.

Conclusions. Managed care has become an established part of cardiovascular specialist practice in the United States. Although this trend is viewed with some disfavor, most respondents are making practice changes to adapt to this new environment.

(J Am Coll Cardiol 1996;28:1884–95)>     

Redesigning training for internal medicine

The American College of Physicians supports the need for reform throughout the continuum of training in internal medicine. Today's internists must have the necessary knowledge, skills, and attitudes to meet the challenges of an expanding body of medical knowledge and a rapidly evolving system of health care delivery. Suggested priorities for undergraduate medical education include redesigning curricular experiences to afford students earlier and more exposure to career opportunities in internal medicine, improving ambulatory education, exposing students to outstanding faculty role models in internal medicine, and incorporating educational experiences during the fourth year that optimize its value and relevance to the student's future career plans in internal medicine. Internal medicine residency training should remain a 3-year experience, with a component of core education common to all trainees and a component of customized training in the third year targeted toward the resident's career goals. Residency programs should be designed around educational rather than institutional service needs. The ambulatory component of training requires substantial reform in its structure, sites, content, and timing. Team-based models should be used both for patient care and for flexibility in design of residency training. Better faculty models must be developed that build on the concept of a "core faculty," improve the rewards for teaching faculty, and provide appropriate faculty development focusing on a necessary set of educator competencies.     

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.     

Practice,clinical management,and financial arrangements of practicing generalists

OBJECTIVE: To describe the practice settings, financial arrangements, and management strategies experienced by generalist physicians and identify factors associated with reporting pressure to limit referrals, pressure to see more patients, and career dissatisfaction. DESIGN: Cross-sectional mail survey. PARTICIPANTS AND SETTING: Six hundred nineteen generalist physicians (62% response rate) caring for managed care patients in 3 Minnesota health plans during 1999. MEASUREMENTS AND MAIN RESULTS: Twenty-six percent of physicians reported pressure to limit referrals. In adjusted analyses, female physicians and those who were board certified acted as gatekeepers for most of their patients, received incentives based on performance reports and quality profiles, and received direct income from capitation, and were more likely than others to report this pressure (all P<.05). Sixty-two percent reported pressure to see more patients. In adjusted analyses, this pressure was more frequent among physicians in practices owned by health systems, those using physician extenders, and among physicians paid by salary with performance adjustment or those receiving at least some capitation (all P<.05). One-quarter (24%) of physicians were dissatisfied with their career in medicine. In adjusted analyses, physicians reporting pressure to limit referrals (risk ratio, 1.12; 95% confidence interval, 1.01 to 1.19) and those reporting pressure to see more patients (risk ratio, 1.37; 95% confidence interval, 1.08 to 1.66) were more likely to be dissatisfied than other physicians. CONCLUSIONS: Pressures to limit referrals and to see more patients are common, particularly among physicians paid based on productivity or capitation, and they are associated with career dissatisfaction. Whether future changes in practice arrangements or compensation strategies can decrease such physician-reported pressures, and ultimately improve physician satisfaction, will be an important area for future study. This work was supported by grant HS09936 from the Agency for Healthcare Research and Quality and grant HS98-005 from the American Association of Health Plans.     

Work, career satisfaction, and the position of general internists in the south of Spain

BACKGROUND: A progressive dissatisfaction has been noted among many internists, and the future of the specialty represents a matter of concern. The objectives of this study were to analyze career satisfaction among 182 internists from 34 hospitals in the south of Spain and to assess the opinion of 47 other health care professionals who frequently interact with internists on the present and future role of the specialty. METHODS: Ours was a multi-institutional, cross-sectional survey of internists that focused on demographics/practice characteristics, education/research, career satisfaction, and opinions regarding the future of internal medicine. Also included were interactive, interdisciplinary focus groups of family physicians, sub-specialists, and managers. The internists were asked to complete a questionnaire that contained items and factors that were measured on a 5-point Likert scale and quantitatively analyzed; the opinions of the focus groups were qualitatively analyzed. RESULTS: The internists surveyed dedicated most of their time to treating hospitalized patients rather than to diagnostic procedures and technical assessment. Some 54% and 57% of the internists pursued continuing medical education and research, respectively, in their free time. The internists were satisfied with the content of their work and with their interpersonal relationships, but they were dissatisfied with their physical/instrumental environment, management policies, and degree of work stability. No differences were detected in relation to age, gender, community factor, or professional category. With regard to the future of the specialty, the main opportunity detected by internists was a closer collaboration with primary care. An analysis of the strengths, weaknesses, future opportunities and threats to internal medicine expressed by the seven focus groups was highly concordant and added worthwhile information and clear proposals for the development of the specialty. CONCLUSIONS: Internists in the south of Spain were satisfied with the content of their work and dissatisfied with health care management and job stability. The future of internal medicine was felt to lie in a deeper collaboration between internists and their colleagues in primary care.     

Medical student interest in combined internal medicine-pediatrics

OBJECTIVE: To determine the level of interest in and perceptions of the field of internal medicine-pediatrics among third-year medical students. DESIGN: A questionnaire was sent to medical students assessing their career choices, how they envision their future practices, the importance of selected professional goals in relation to their career choices, and their impressions of the likelihood of achieving these goals in given medical fields. SETTING: Two large Midwestern medical schools. PARTICIPANTS: Medical students at the end of their third year. INTERVENTIONS: None. RESULTS: Three hundred of 425 students (70%) participated. One hundred thirty-three students (44%) chose a primary care field as their first choice. Seventy-one (54% of the 133) chose internal medicine-pediatrics as their first, second, or third choice. Students rated the likelihood of achieving certain professional goals by specialty. Internal medicine-pediatrics was ranked almost identically with internal medicine and pediatrics. However, internal medicine-pediatrics differed from family medicine in that it was ranked higher in intellectual stimulation, association with interesting colleagues, attaining a position of leadership, entering a respected profession, and involvement in science and research (p less than 0.0001). CONCLUSIONS: The field of internal medicine-pediatrics attracts significant interest among medical students and is viewed as similar to internal medicine and less similar to family medicine.