National Study of Internal Medicine Manpower: IX. Internal medicine residency and fellowship training: 1984 update

After 12 years of annual expansion, the number of entrants into internal medicine training did not increase in 1983-84. In addition, the number of United States citizens with medical degrees from other countries entering first-year residency positions in internal medicine declined in 1983-84 for the first time in many years. The number of trainees who, upon completion of residency training, chose to become subspecialty fellows increased, and the period of subspecialty training has lengthened to 3 years for one third of the fellows. The total budgets for residency stipends have not increased in real dollars since 1976-77 despite substantial rises in the number of trainees. In fact, stipend levels per resident and fellow have declined in real dollars. Internists make up about 25% of all practicing physicians. With the continuing growth in the number of practicing internists and the high rate of their subspecialization, some adjustments will be made in practice patterns over the next 2 decades.     

National Study of Internal Medicine Manpower: X. Internal medicine residency and fellowship training: 1985 update

The number of medical school graduates entering internal medicine residency training was at an all-time high in 1984-85. Although the number of first-year residents who were foreign-trained physicians did not differ greatly from the 1983-84 census, the number of first-year residents who were U.S. medical school graduates was much higher than the previous year largely because the number of graduates from U.S. medical schools increased substantially in 1984. The number of internal medicine fellowship programs and the number of fellows in 1984-85 were also at an all-time high. Foreign-trained physicians represent 22% of those in residency training and 20% of those in fellowship training. Of every 100 who completed residency training, 61 went on to a first year of subspecialty fellowship training, a number up slightly from the previous year. The increasing numbers of residents and fellows being trained in internal medicine, combined with the preference for subspecialization and the substantial proportion of foreign-trained physicians being trained, are discussed against the background of pending legislation to reduce federal assistance for graduate medical education.     

National Study of Internal Medicine Manpower. XIV: Patterns of residency and fellowship over time, 1987 update

In response to concerns among internists following the 1987 internal medicine match, this report compares internal medicine trainees with those in other specialties since 1972, describes their paths through the internal medicine "pipeline," and documents their distribution and continuation rates in residency and subspecialty fellowship programs. It is based on the National Study of Internal Medicine Manpower, 1987-1988. Between 1972 and 1986 the number of trainees in internal medicine doubled, and the percentage of trainees in internal medicine grew from 20% to 25%, while the percentage in surgical specialties declined from 28% to 19%. The numbers of women and foreign medical school graduates training in internal medicine have continued to increase, but minority representation has stabilized. Women and minorities have lower continuation rates into fellowships, and distinctive patterns of subspecialization are found among women, minorities, and foreign medical school graduates.     

National Study of Internal Medicine Manpower. XVIII: Subspecialty fellowships with a special look at hematology and oncology, 1988-1989

OBJECTIVE: To determine the number and distribution of internists in subspecialty training and compare with data collected since 1976; to determine the distribution of activity of subspecialty fellows; and to focus on hematology and oncology. DESIGN: Repeated mail survey with telephone follow-up. PARTICIPANTS: All directors of subspecialty training programs in internal medicine in the United States. RESULTS: The 1988-1989 census identified 7530 fellows in training, 55 more than in 1987-1988. There are 24 more first-year fellows. Reports on the activities of subspecialty fellows show that, overall, 53% of fellows' time is spent in direct patient care, 20% on basic research, 15% on patient-related research, and 12% in teaching. CONCLUSIONS: The number of internists entering subspecialty training has risen at a considerably slower rate in the last 5 years compared with the 5 years before that. The length of subspecialty training has increased significantly since 1976. There has been a shift in subspecialty choice from hematology to oncology and toward joint programs offering both subspecialties.     

National Study of Internal Medicine Manpower: XI. Internal medicine residency and fellowship training in the 1980s

The number of residents beginning training in internal medicine continued to increase slightly in 1985-86. However, the total number of residents in internal residency training decreased slightly from the previous year due to a decrease in the number of second- and third-year residents. The proportion of first-year residents who were foreign-trained physicians decreased from 21% to 20%, and the proportion of residents who finished training and went on to subspecialty training in 1985 decreased substantially to 56%. The number of physicians entering residency and fellowship training in internal medicine considerably exceeds the number projected by the Graduate Medical Education National Advisory Committee. In this article, we discuss implications of these trends for medical education and practice.     

National Study of Internal Medicine Manpower: XIX. Trends in internal medicine residency training programs.

The National Study of Internal Medicine Manpower (NaSIMM) reports on the results of its 1989-1990 census of residency programs. The results are integrated into an organizational model identifying inputs, process, outputs, and environment of medical training programs. The number of residents entering internal medicine continues to grow at a relatively rapid pace. This growth is largely accounted for by foreign citizens who are graduates of foreign medical schools (AFMGs). Residents are spending an increasing proportion of their time in ambulatory care settings, but, thus far, this ambulatory care training has occurred primarily in hospital clinics and emergency rooms. The proportion of a program's residents entering general internal medicine was found in a multiple regression analysis to be negatively associated with the number of subspecialty programs located in the training hospital, the percent of AFMG residents in the program, and the presence of a preliminary track in the program.     

National Study of Internal Medicine Manpower: XVII. Changes in the characteristics of internal medicine residents and their training programs, 1988-1989

The National Study of Internal Medicine Manpower (NaSimm) has been surveying program directors of internal medicine about their programs and residents for 13 years. The 1988-1989 survey results, when compared with the results for 1987-1988, show an increase in both the number of residency positions offered in internal medicine and the number of residents in internal medicine programs. Although the proportion of graduates from U.S. medical schools who choose internal medicine is not changing (34%), the proportion of U.S. medical school graduates who continue training in internal medicine after their first year is decreasing. The composition of the residents in internal medicine by medical school graduated is also changing. Almost 25% of the first-year residents (R1s) in internal medicine are now graduates of foreign medical schools (FMGs) compared with 14% in 1976. The proportion of first-year female residents in internal medicine has increased to 30%, whereas the proportion of both first-year blacks and Hispanics has remained constant at 5% each. In nearly 25% (109 of 440) of the residency programs, more than 50% of the R1s are FMGs. Hispanics, Asians, and blacks were found to be over-represented in the programs training larger proportions of FMGs. This over-representation is attributable, in part, to the fact that Hispanics and Asians may be FMGs. Training issues of concern to program directors continue to be the provision of ambulatory and primary care experiences and the scheduling of nights on call. The survey results show that many residency program directors have reported a reduction in the number of nights on call and an increase in the amount of time residents spend in ambulatory training.     

National Study of Internal Medicine Manpower: XIII. The financing of internal medicine residency and fellowship training, 1985 to 1986

Hospital revenue is the most important source for residency and fellowship stipends in internal medicine. Medicare is especially important for residency programs in voluntary hospitals and hospitals not closely affiliated with a medical school. In the last decade state and local government support and federal training grant support for residency stipends declined, whereas Veterans Administration support increased. Fellowship stipend sources are much more diverse; federal training grants, professional fees, foundations, medical school funds, and research grants contribute significantly. Medicare support appears to be focused on subspecialties particularly important to the elderly, including critical care, rheumatology, cardiology, hematology, gastroenterology, and nephrology. Geriatric medicine, however, receives substantial Veterans Administration support. With growing revenue constraints and increasing concerns about excess physicians we need to monitor the impact of government regulations and other factors on funds available for training internal medicine specialists.     

Subspecialty training in preventive cardiology: the current status and discoverable fellowship programs

Background:

Preventive cardiology is currently not an American Board of Medical Specialties‐recognized subspecialty. However, several programs offer nonaccredited fellowships throughout the country. No source currently exists listing all available programs, and finding programs requires time‐intensive search strategies. Our aim was to find all current preventive cardiology fellowships in the United States and describe their basic structure, duties, and faculty.

Methods:

We searched the Internet, contacted national organizations, and networked through any institution thought likely to have a fellowship.

Results:

We found 15 programs currently offering subspecialty training in preventive cardiology but with considerably different styles, structures, duties, clinical time, lengths, and hosting departments.

Conclusions:

We provided a list of these programs and discussed the implications for the future of formal subspecialty preventive cardiology education. © 2012 Wiley Periodicals, Inc. Dr. McBride is codirector of one of the fellowship programs listed, but otherwise has no relevant disclosures. The authors have no funding, financial relationships, or conflicts of interest to disclose.     

National study of internal medicine manpower: III. Subspecialty fellowship training 1976-1977.

Questionnaire II of the National Study of Internal Medicine Manpower was directed to all of the 1502 subspecialty training programs in the United States and Puerto Rico. The overall response rate was 86%. For the years 1972-1973 through 1976-1977 the number of fellows in subspecialty training grew at an average rate of 10.6% per year, or one and one-half times greater than the growth rate of 7.2% in the number of first-year residents in training for the same time period. In 1976-1977 there were 5826 fellows in subspecialty fellowship training, of whom 26% were foreign medical graduates. Stipends for subspecialty fellows in 1976-1977 amounted to $90 million, 40% of which was derived from direct federal funds and 33% from hospital revenues. Most of the subspecialty fellowship programs were in large teaching hospitals, which are closely affiliated with the nation's medical schools. The 1976-1977 professional activities of former subspecialty trainees who had finished their training between 1972 and 1976 were distributed roughly in thirds between research-teaching, teaching-practice, and practice. We discuss public policy implications of the data.     

National Study of Internal Medicine Manpower: XV. A decade of change in residency training in internal medicine

We report on trends in the characteristics of residency training programs in internal medicine from 1976 to 1988 and make some comparisons with other specialties. Internal medicine is faring less well in the residency match compared with other specialties than it did 10 years ago. It has also increased the number of residency positions offered more than other major specialties. A sizable proportion of first-year residency positions in internal medicine are not filled through the Match. Foreign medical graduates account for almost 50% of the first-year resident (R1) positions filled outside the Match. Programs most dependent on foreign medical graduates are in hospitals with limited medical school affiliation, smaller size, operated by churches or the Veterans Administration, and located in eastern states and large metropolitan areas. Despite concerns about quality and oversupply, almost 50% of the program directors expected to increase the size of their programs in 1988-1990. Residents are not being scheduled for fewer hours per week than they were 12 years ago but they are being scheduled for fewer nights. No trends were noted toward increased ambulatory care training sites away from the hospital campus.     

National Study of Internal Medicine Manpower. XII. The future of graduate medical education in internal medicine: what do program directors predict?

The 1985-1986 National Study of Internal Medicine Manpower asked directors of residency and fellowship programs about their plans to change the size of their programs in the near future. The vast majority (71% to 76%) of the directors expected their programs to remain about the same size for the next couple of years. For fellowship directors, this reflects a decline in the number planning to increase their program size since 1976-1977 from 32% to 18%. Directors of programs that are principal affiliates of medical schools are more likely to plan a decrease, while Veterans Administration directors are more likely to plan an increase in program size. The reason residency directors cited most frequently as important to their plans to increase program size was a perceived shortage of internists. Fellowship directors most frequently cited the need for fellows in clinical research. Stipend availability was the most important factor that influenced plans to decrease program size. Overall, residency and fellowship directors planned to increase the size of their programs around 1%. Program directors and others in the internal medicine community should consider how they can change the stipend availability, admissions criteria, and other incentives to channel trainees into the areas of greatest potential need and demand for the profession.     

Journal of Internal Medicine – editorial update for 2009

Several important advances have been made over the last 2 years, since the last international workshop on multiple endocrine neoplasias (MENs) that was held in Marseilles, France (MEN2006). The series of articles that are included in this issue summarize the most important of these advances as they were presented in Delphi, Greece, during the 11th International Workshop on MENs, September 25–27, 2008 (MEN2008). This editorial summarizes some of these advances: the identification of the AIP, and the PDE11A and PDE8B genes by genome‐wide association (GWA) studies as predisposing genes for pituitary and adrenal tumours, respectively, the discovery of p27 mutations in a new form of MEN similar to MEN type 1 (MEN 1) that is now known as MEN 4, the molecular investigations of Carney triad (CT), a disorder that associates paragangliomas (PGLs), gastrointestinal stromal tumour (GISTs), and pulmonary chondromas (PCH) with pheochromocytomas and adrenocortical adenomas and other lesions, and the molecular elucidation of the association of GISTs with paragangliomas (Carney–Stratakis syndrome) that is now known to be because of SDHB, SDHC, and SDHD mutations. Molecular investigations in Carney complex (another MEN also described by Dr. Carney, who during the meeting, along with Dr. Charles E. (‘Gene’) Jackson was honoured for his life‐long and many contributions to the field) have also revealed the role of cyclic AMP signalling in tumorigenesis. As our knowledge of the molecular causes of MENs increases, the challenge is to translate these discoveries in better treatments for our patients. Indeed, new advances in the preventive diagnosis and molecular treatment of MEN 1 and MEN 2, respectively, continued unabated, and an update on this front was also presented at MEN2008 and is included in this issue.     

Geriatric medicine fellowship programs: a national study from the Association of Directors of Geriatric Academic Programs' Longitudinal Study of Training and Practice in Geriatric Medicine

This report documents the development and growth of geriatric medicine fellowship training in the United States through 2002. A cross-sectional survey of geriatric medicine fellowship programs was conducted in the fall 2001. All allopathic (119) and osteopathic (7) accredited geriatric medicine fellowship-training programs in the United States were involved. Data were collected using self-administered mailed and Web-based survey instruments. Longitudinal data from the American Medical Association (AMA) and the Association of American Medical Colleges' (AAMC) National Graduate Medical Education (GME) Census, the Accreditation Council for Graduate Medical Education (ACGME), and the American Osteopathic Association (AOA) were also analyzed. The survey instrument was designed to gather data about faculty, fellows, program curricula, and program directors (PDs). In addition, annual AMA/AAMC data from 1991 to the present was compiled to examine trends in the number of fellowship programs and the number of fellows. The overall survey response rate was 76% (96 of 126 PDs). Most (54%) of the PDs had been in their current position 4 or more years (range: <1-20 years), and 59% of PDs reported that they had completed formal geriatric medicine fellowship training. The number of fellowship programs and the number of fellows entering programs has slowly increased over the past decade. During 2001-02, 338 fellows were training in allopathic programs and seven in osteopathic programs (all years of training). Forty-six percent (n = 44) of responding programs offered only 1-year fellowship-training experiences. PDs reported that application rates for fellowship positions were stable during the academic years (AYs) 1999-2002, with the median number of applications per first year position available in AY 2000-01 being 10 (range: 1-77). In 2001-02, data from the AMA/AAMC National GME Census indicated a fill rate for first-year geriatric medicine fellowship positions of 69% (259 first-year fellows for 373 positions). During 2001-02, more than half of programs (53%) reported having two or fewer first-year fellows, whereas 31% had three or four first-year fellows. Thirty-three programs (36%) reported having no U.S. medical school graduate first-year fellows, and another 25 (28%) reported having only one. Of the 51 programs offering second-year fellowship training, PDs reported 61 post-first-year fellows (median 1, range: 0-7). During the past 10 years, 27 new allopathic geriatric medicine fellowship programs opened; there are now 119 programs. There are also seven osteopathic programs. The recruitment of high-quality U.S. medical school graduates into these programs remains a challenge for the discipline. Furthermore, the retention of first-year fellows for additional years of academic training has been difficult. Incentives will be needed to attract the best graduates of U.S. family practice and internal medicine training programs into academic careers in geriatric medicine.     

Barriers to Accessing Nighttime Supervisors: a National Survey of Internal Medicine Residents

BackgroundSingle-center studies have reported residents experience barriers to accessing supervising physicians overnight, but no national dataset has described barriers perceived by residents or the association between supervision models and perceived barriers.ObjectiveTo explore residents’ perception of barriers to accessing overnight supervision.DesignQuestions about overnight supervision and barriers to accessing it were included on the American College of Physicians Internal Medicine In-Training Examination® (IM-ITE®) Resident Survey in Fall 2017.ParticipantsAll US-based internal medicine residents who completed the 2017 IM-ITE®. Responses from 20,744 residents (84%) were analyzed.Main MeasuresFor our main outcome, we calculated percentages of responses for eight barriers and tested for association with the presence or absence of nocturnists. For our secondary outcome, we categorized free-text responses enumerating barriers from all residents into the five Systems Engineering Initiative for Patient Safety (SEIPS) categories to elucidate future areas for study or intervention.Key ResultsInternal medicine residents working in hospitals without nocturnists more commonly reported having at least one barrier to accessing a supervising physician “always” or “most of the time” (5075/9842, 51.6%) compared to residents in hospitals with nocturnists (3074/10,902, 28.2%, p < 0.001). Among residents in hospitals without nocturnists, the most frequently reported barrier to accessing attending supervision was attendings not being present in the hospital (30.4% “always” or “most of the time”); residents in hospitals with nocturnists most frequently reported desire to make their own decisions as a barrier to contacting attendings (15.7% “always” or “most of the time”). Free-text responses from residents with and without nocturnists most commonly revealed organization (47%) barriers to accessing supervision; 28% cited person barriers, and 23% cited tools/technology barriers.ConclusionsPresence of nocturnists is associated with fewer reported barriers to contacting supervising physicians overnight. Organizational culture, work schedules, desire for independence, interpersonal interactions, and technology may present important barriers.Supplementary InformationThe online version contains supplementary material available at 10.1007/s11606-020-06516-4.KEY WORDS: graduate medical education, supervision, nocturnist, hospitalist