Subspecialties flourish as IM residents shun primary care

A new study documents how many internal medicine residents are choosing a subspecialty, where they are going and why.

By Myrle Croasdale — Posted May 16, 2005

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It's well-known that fewer U.S. medical graduates are choosing primary care, a trend that the National Residency Matching Program has followed. Now in a study unlike others before it, researchers dig deeper, tracking internal medicine residents to find out exactly how many were going into primary care and how many were planning to subspecialize.

They found that only 27% of graduating residents were picking primary care careers in 2003, compared with 54% in 1998. There was even less interest among first-year interns in 2003, with just 19% expressing a desire for a primary care path.

"More and more over the past few years, we've been seeing them choosing subspecialties instead of primary care. It's a trend most people in the trenches are aware of. The data verify these impressions," said Richard Garibaldi, MD, chair of the Dept. of Internal Medicine at the University of Connecticut Health Center, who decided to study the issue more closely.

Dr. Garibaldi's study -- "Career Plans for Trainees in Internal Medicine Residency Programs" published in the May Academic Medicine -- expands on what's been widely observed within the medical profession.

Other studies have focused on why students are turning away from primary care disciplines and have found that declining reimbursement for nonprocedural care, the opportunity for a controllable lifestyle and a medical culture in which subspecialists are seen as more prestigious have played a big part.

Dr. Garibaldi's study focused on internal medicine residents and quantifying precisely where they are going and why. The study found that more than half of these residents were seeking subspecialties, and the bulk of this group was choosing the higher-paid procedural disciplines.

Richard Cooper, MD, director of the Medical College of Wisconsin's Health Policy Institute, said the results were no surprise.

"Those are the realities, and you'll see even more in the current Match and the current students," Dr. Cooper said. "They just aren't thinking generalist careers."

The pull toward subspecialties

Jeff Gonzalez, MD, a third-year gastroenterology fellow, said he had considered general medicine during the first few months of his internship, but before the year was out he instead found himself deciding between two procedural subspecialties, cardiology and gastroenterology.

Dr. Gonzalez, chair of the American Medical Association's Resident and Fellow Section, said being able to work with his hands and finding a narrow field of expertise were among the factors that helped him make his gastroenterology career choice.

Though Dr. Gonzalez enjoyed his time in general medicine, he said he preferred tackling problems for which the outcome was clear.

"If it's a screening colonoscopy, and I see a polyp, I take it out," he said. "There's immediate satisfaction in doing something and seeing the result."

Dr. Gonzalez's preference for procedures is growing increasingly common. Among the internal medicine residents surveyed in 2002 and 2003 who said they intended to pursue subspecialties -- more than half of the residents in each year -- 73% wanted to specialize in procedure-oriented disciplines. Of this group, the breakdown of the fields chosen was:

  • 24% cardiology.
  • 15% gastroenterology.
  • 14% hematology/oncology.
  • 10% nephrology.
  • 10% pulmonary/critical care.

Of those wanting to subspecialize, but preferring nonprocedural disciplines, 7% chose endocrinology, 6% chose infectious diseases and 5% chose rheumatology.

Although Dr. Gonzalez said narrowing his expertise was important, he also said income played a role in his decision, something primary care leaders have speculated was a factor in residents' decisions today.

"Even though I have to put in another three years, I'll be paid what my education is worth," he said.

He didn't think that would be the case if he went into primary care, where he might earn $110,000 a year and take home $70,000 to $80,000 after taxes. That's a salary someone with less education and training can earn in other fields, without the debt of medical school, years spent training and commitment to a lifetime of being on call, he said.

Re-igniting interest in primary care

Steve Fihn, MD, past president of the Society of General Internal Medicine and a professor at the University of Washington School of Medicine, said the mounting data show a strong need to take action to rekindle students' interest in primary care.

"Not only are the current numbers bad, but the [longer-term] trends are pretty profound as well," he said.

The number of students choosing internal medicine has held fairly steady during the same period that the number choosing to go into family medicine has declined. Dr. Fihn said this was most likely because students and trainees are heading into subspecialties instead of general medicine, an assumption Dr. Garibaldi's study upholds.

Primary care professional associations have task forces looking at the issue, but Dr. Fihn said solutions have been difficult to find.

"It's a pretty daunting task trying to reverse this trend when the economic forces are so strong," Dr. Fihn said. "Right now, the perception of the life of a primary care physician is justifiably not very attractive."

Students and residents realize they can work as much as or even less than primary care doctors while making a whole lot more money, Dr. Fihn said, so they subspecialize. "There's a feeling if you don't work for a large organization, you can't make a living in primary care."

Dr. Garibaldi said he thought medicine was headed for a crisis in primary care. "We're not going to have the physician people power that we've had in the past. We're going to have to come up with new strategies for handling patients."

Subspecialists could find they're becoming the principal caregiver for some patients, Dr. Garibaldi said.

While some in the physician work force debate say medical students and residents are in sync with public demand, Dr. Fihn noted that other developed nations had more primary care physicians than subspecialists. The United States health care structure is getting perilously out of balance, he said.

"I can't help but believe something important will be lost if we all decide to just see specialists," Dr. Fihn said. "Specialists are only one piece of the health care system."

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General medicine vs. subspecialties

The number of third-year internal medicine residents choosing a subspecialty has risen each year for the past six years. The newly emerging field of hospital medicine was not tracked as a career choice until 2002.

Respondents Generalist Hospitalist Subspecialist Other
1998 4,008 54% -- 42% 4%
1999 4,338 49% -- 47% 4%
2000 4,562 44% -- 51% 6%
2001 4,565 40% -- 54% 6%
2002 3,495 28% 4% 56% 12%
2003 4,732 27% 7% 57% 9%

Note: The "other" category includes respondents who did not respond to the resident survey portion of the internal medicine in-training exam, those who selected "other" as their career option and those who were undecided.

Source: "Career Plans for Trainees in Internal Medicine Residency Programs," Academic Medicine, May

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Behind the decisions

When asked what led them to choose primary care or a subspecialty, internal medicine residents who chose a subspecialty cited a need for a narrow practice area and long-term relationships with patients as among the top reasons.

Reason for career path Generalist Hospitalist Subspecialist
Good match with interests 85% 90% 94%
More time for nonwork activities 52% 59% 33%
More time with family 60% 62% 39%
Higher income 7% 24% 27%
Caring for ambulatory patients 62% 5% 26%
Broad practice area 73% 65% 27%
Narrow practice area 4% 9% 52%
Long-term relationships with patients 74% 14% 55%
Short-term relationships with patients 5% 47% 14%
Caring for critical care patients 16% 65% 46%
Interest in health care policy issues 21% 28% 16%

Note: Residents could list more than one reason.

Source: "Career Plans for Trainees in Internal Medicine Residency Programs," Academic Medicine, May; data for this table came from a 2002 internal medicine in-training examination survey

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Women say primary care can allow more family time

Women physicians training in internal medicine programs are more likely than their male counterparts to factor in time with their families and other nonwork activities when deciding their specialties.

Consequently, they are more likely to choose primary care than men, according to the new study "Career Plans for Trainees in Internal Medicine Residency Programs."

Though primary care can demand long hours, women told researchers that they believe the field would allow them to more easily limit their work hours, share a job, restrict their practices to office hours only or join large group practices where they would be on call less of the time.

The result: 27% of women in internal medicine choose a primary care route; 19% of men do.

Women accounted for 40% of the internal medicine residents surveyed in the study, and their answers show that time for family and nonwork activities continue to be big factors when women pick fellowships. Women who pursued fellowships favored endocrinology, rheumatology, hematology/oncology, infectious diseases and geriatrics, according to the study.

Women were less likely than men to go into subspecialties, with 47% of women choosing that path versus 58% of men. But there wasn't a gender gap in the reasons men and women gave for becoming subspecialists, the research showed. Both genders said control over their time was less important, while higher income was more important.

Richard Garibaldi, MD, lead author of the study, said medical schools and residency programs need to find ways to support residents balancing family with work.

"We all have to be aware that more women are in medical school now, and some of their desires and needs are different than the traditional graduate of 30 years ago," Dr. Garibaldi said. "We need to be more sensitive to those needs."

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