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.     

Grand cru versus generic: different approaches to altering the ratio of general internists to subspecialists

In the last decade internal medicine has become a less popular career choice among medical school graduates. In addition, there has been an increase in the percentage of internal medicine residents choosing subspecialty training. The factors that have led to the change in the ratio of subspecialists to general internists are discussed, and a plan is proposed that would make the practice of general internal medicine more attractive and reduce the number of subspecialty training positions in the United States.     

Internal medicine and the training of international medical graduates: a time for open discussion and new approaches.

The number of foreign national medical graduates entering internal medicine residency training programs in the United States has doubled since 1986. A rigorous, standardized preresidency evaluation of the basic clinical skills and language abilities of international medical graduates should be implemented. Those found to have significant deficits should undertake a preparatory curriculum designed to meet special educational needs before entry into the formal training program. A relevant curriculum might include formal lectures, reading assignments, physical diagnosis sessions, language classes, patient encounter sessions, and a tutorial on U.S medical culture that includes medical ethics and the basics of the our health care system. All or only some of these may be required for any given individual. The Educational Commission for Foreign Medical Graduates (ECFMG) could provide many of the methods needed for an evaluation program and work collaboratively with program directors. This new approach to training of international medical graduates will require an evaluation system to to measure its effectiveness. Important questions about the funding of graduate medical education for international medical graduates must also be addressed.     

Strengthening academic generalist departments and divisions

Academic departments of family medicine and divisions of general internal medicine and general pediatrics exist in the majority of medical schools in the United States and have important roles in generalist medical education. The major organizational issues facing these units concern institutional influence, faculty development, role in medical education, research productivity, financial stability, and clinical responsibilities. These issues must be understood in order for medical schools and teaching hospitals to achieve the societal goal of producing necessary generalist physicians.     

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 survey of geriatric medicine fellowship programs: comparing findings in 2006/07 and 2001/02 from the American Geriatrics Society and Association of Directors of Geriatric Academic Programs Geriatrics Workforce Policy Studies Center

This article documents the development of geriatric medicine fellowship training in the United States through 2009. Results from a national cross-sectional survey of all geriatric medicine fellowship training programs conducted in 2007 is compared with results from a similar survey in 2002. Secondary data sources were used to supplement the survey results. The 2007 survey response rate was 71%. Sixty-seven percent of responding programs directors have completed formal geriatric medicine fellowship training and are board certified in geriatrics, and 29% are board certified through the practice pathway. The number of Accreditation Council for Graduate Medical Education-accredited fellowship programs has slowly increased, from 120 (23 family medicine (FM) and 97 internal medicine (IM)) in 2001/02 to 145 in 2008/09 (40 FM and 105 IM), resulting in a 21% increase in fellowship programs and a 13% increase in the number of first-year fellows (259 to 293). In 2008/09, the growth in programs and first-year slots, combined with the weak demand for geriatrics training, resulted in more than one-third of first-year fellow positions being unfilled. The number of advanced fellows decreased slightly from 72 in 2001/00 to 65 in 2006/07. In 2006/07, 55% of the advanced fellows were enrolled at four training programs. In 2008/09, 66% of fellows were international medical school graduates. The small numbers of graduating geriatric medicine fellows are insufficient to care for the expanding population of older frail patients, train other disciples in the care of complex older adults, conduct research in aging, and be leaders in the field.     

The structure and content of the medical subinternship: a national survey

OBJECTIVE: To describe the educational and administrative structure and content of internal medicine subinternship (SI) programs at medical schools throughout the United States. DESIGN: A cross-sectional mailed survey of internal medicine SI directors at U.S. medical schools. MAIN RESULTS: Responses were received from 100 (80%) of 125 eligible programs. Seventy-five percent of schools require a SI for graduation; 26% of these schools require the completion of a medical SI. Nationally, about 75% of all medical students opt to complete a medical SI. Dedicated SI administrative committees exist at 46% of medical schools. A minority of programs provide students with explicit curricula (31%) or exclusive conference time (36%). In 44% of programs, subinterns are used by hospital departments of medicine as intern substitutes. Subinterns are responsible for sign-out and cross-coverage in about half of the programs, and all patient orders entered by subinterns require cosignature. Subintern evaluation criteria include attending evaluation (100%), resident evaluation (80%), case write-ups (27%), supervised clinical examination (20%), written examination (14%), and oral examination (3%). CONCLUSION: Although most medical schools offer an SI in internal medicine and many require it, the experience often lacks clearly defined curricular goals and often does not provide medical students with house-staff-level responsibilities. In an effort to ease the transition from undergraduate to postgraduate training, further studies are needed to define which educational and structural components of the medicine SI should be developed and emphasized.     

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.     

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.     

Certification in internal medicine: 1989–1992

Objective: To determine whether changes in the demographic/educational mix of those entering internal medicine from 1986 to 1989 were associated with differences among them at the time of certification. Participants: Included in the study were all candidates for the 1989 to 1992 American Board of Internal Medicine certifying examinations in internal medicine. Measurements: Demographic information and medical school, residency training, and examination experience were available for each candidate. Data defining quality, size, and number of subspecialties were available for internal medicine training programs. Results: From 1990 to 1992, the total number of men and women candidates increased as did the numbers of foreign-citizen non-U.S. medical school graduates and osteopathic medical school graduates; the number of U.S. medical school graduates remained nearly constant and the number of U.S.-citizen graduates of non-U.S. medical schools declined. The pass rates for all groups of first-time examination takers decreased, while the ratings of program directors remained relatively constant. Program quality, size, and number of subspecialty programs had modest positive relationships with examination performance. Conclusions: Changes in the characteristics of those entering internal medicine from 1986 to 1989 were associated with declines in performance at the time of certification. These declines occurred in all content areas of the test and were apparent regardless of program quality. These data identify some of the challenges internal medicine faces in the years ahead. Received from the American Board of Internal Medicine, Philadelphia, Pennsylvania. This research was supported by the American Board of Internal Medicine but does not necessarily reflect its opinions or policies.     

Progress and challenges in graduate education in gerontology: the U.S. Experience

The history and current status of graduate programs in gerontology in the United States are reviewed. Masters degree programs began in 1967, and currently exist at 57 universities in the United States. Challenges for these programs include maintaining enrollment and identifying employment for program graduates, given competition from graduates from other disciplines that have advantages such as state licensure. Doctoral programs in aging began in 1989, with nine current programs. Results to date suggest that graduates with doctorates in gerontology can succeed in academic, policy, research, and business settings. Challenges for these programs include competition from traditional disciplinary doctoral programs. The U.S. experience suggests that successful development of graduate programs in gerontology must be attentive to providing stable academic structures for these programs, and careful consideration of how gerontology graduates will compete with graduates from traditional disciplines and professions.     

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.     

The use of complementary and alternative medical therapies among older persons around the world

Defining complementary and alternative medicine (CAM) helps in understanding what it offers, why older patients are attracted to and find effectiveness in these therapies, and how conventional practitioners can deal with their increasing use. The most common definition in United States medical literature is "those practices neither taught widely in United States medical schools nor gene-rally available in United States hospitals." Patient interviews must include inquiry into CAM use; providers need to know about potentially risky therapies. Integration of CAM into our health care system, although burdensome in the short term, will benefit patients in the long run, where benefit is due. Integration of CAM into treatment does not mean acknowledging its effectiveness, but taking advantage of any benefits it has to offer.     

The development of academic geriatric medicine: progress toward preparing the nation's physicians to care for an aging population

Academic geriatric medicine programs are critical for training the physician workforce to care effectively for aging Americans. This article describes the progress made by medical schools in developing these programs. Academic leaders in geriatrics at all 145 accredited allopathic and osteopathic medical schools in the United States were surveyed in the winter of 2005 (68% response rate) and results compared with findings from a similar 2001 survey. Physician faculty in geriatrics at U.S. medical schools increased from 7.5 (mean) full-time equivalents (FTEs) in 2001 to 9.6 FTEs in 2005. Faculty and staff effort is mostly devoted to clinical practice (mean 36.9%) and education (mean 34.6%). A small number of programs focus on research; only six responding schools devote more than 40% of faculty effort to research. Seventy-one percent reported that their medical school required a geriatrics medical student clerkship or that their geriatric training was integrated into a required clinical rotation. In summary, from 2001 to 2005, more fellows and faculty have been recruited and trained, and some academic programs have emerged with strong education, research, and clinical initiatives. Medical student exposure to geriatrics curriculum has increased, although few academic geriatricians are pursuing research careers, and the number of practicing geriatricians is declining. An expanded investment in training the physician workforce to care for older adults will be required to ensure adequate care for aging Americans.     

Primary Care Careers Among Recent Graduates of Research-Intensive Private and Public Medical Schools

BACKGROUND

Despite a growing need for primary care physicians in the United States, the proportion of medical school graduates pursuing primary care careers has declined over the past decade.

OBJECTIVE

To assess the association of medical school research funding with graduates matching in family medicine residencies and practicing primary care.

DESIGN

Observational study of United States medical schools.

PARTICIPANTS

One hundred twenty-one allopathic medical schools.

MAIN MEASURES

The primary outcomes included the proportion of each school’s graduates from 1999 to 2001 who were primary care physicians in 2008, and the proportion of each school’s graduates who entered family medicine residencies during 2007 through 2009. The 25 medical schools with the highest levels of research funding from the National Institutes of Health in 2010 were designated as “research-intensive.”

KEY RESULTS

Among research-intensive medical schools, the 16 private medical schools produced significantly fewer practicing primary care physicians (median 24.1 % vs. 33.4 %, p?<?0.001) and fewer recent graduates matching in family medicine residencies (median 2.4 % vs. 6.2 %, p?<?0.001) than the other 30 private schools. In contrast, the nine research-intensive public medical schools produced comparable proportions of graduates pursuing primary care careers (median 36.1 % vs. 36.3 %, p?=?0.87) and matching in family medicine residencies (median 7.4 % vs. 10.0 %, p?=?0.37) relative to the other 66 public medical schools.

CONCLUSIONS

To meet the health care needs of the US population, research-intensive private medical schools should play a more active role in promoting primary care careers for their students and graduates.     

Luxury primary care,academic medical centers,and the erosion of science and professional ethics

Medical schools and teaching hospitals have been hit particularly hard by the financial crisis affecting health care in the United States. To compete financially, many academic medical centers have recruited wealthy foreign patients and established luxury primary care clinics. At these clinics, patients are offered tests supported by little evidence of their clinical and/or cost effectiveness, which erodes the scientific underpinnings of medical practice. Given widespread disparities in health, wealth, and access to care, as well as growing cynicism and dissatisfaction with medicine among trainees, the promotion by these institutions of an overt, two-tiered system of care, which exacerbates inequities and injustice, erodes professional ethics. Academic medical centers should divert their intellectual and financial resources away from luxury primary care and toward more equitable and just programs designed to promote individual, community, and global health. The public and its legislators should, in turn, provide adequate funds to enable this. Ways for academic medicine to facilitate this largesse are discussed.     

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. 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.     

Specialty choices and board certifications of ''fifth pathway'' graduates

We studied the specialty choices and board certification status of 258 graduates over a ten-year period of a single "fifth pathway" program. Not including obstetrics and gynecology as a primary care specialty, 54% of our graduates chose primary care specialties. Including obstetrics and gynecology, the number increased to 63%. Thirty-five of 158 graduates through 1978 are specialty board certified and another 49 are board eligible. We believe that our program has fulfilled the need of assisting Americans studying medicine abroad, primarily in Mexico, to overcome their clinical deficits and become integrated into the mainstream of American medicine. The future role of fifth pathway programs must be reevaluated in light of the 1980 Graduate Medical Education National Advisory Committee report, which concluded that by 1990, there will be an overabundance of physicians in the United States.     

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.