The fill rate for internal medicine positions increased slightly for this year's resident match, but the American College of Physicians remained concerned about what appeared to be a decreased level of interest in general internal medicine.
This year, 4,735 internal medicine residency positions were offered. Of those, 97.9% were filled, with slightly more than half—56.3%—filled by U.S. medical graduates. In 2005, 97.2% of slots were filled, although a slightly higher number of positions were offered (4,768).
“We're not as much concerned about internal medicine overall if you look at all the subspecialties,” said Dr. Steven E. Weinberger, senior vice president for medical knowledge and education at the American College of Physicians, in Philadelphia. “The concern is with the number of people going into primary care.”
Match Day itself doesn't reveal how many medical students plan to go into internal medicine subspecialties instead of primary care, “in part because a lot of them don't know yet,” Dr. Weinberger noted.
But the ACP also gives residents a questionnaire asking about their plans. “In 1998, 54% of graduating residents were choosing to go into general internal medicine. The comparable number for residents graduating in 2005 was only 20%,” he said. “With the aging of Baby Boomers who have more complex chronic diseases, it's going to be harder to find people to coordinate their care, so that's going to be a concern.”
As for the relatively low number of U.S. graduates choosing internal medicine, Dr. Weinberger said there were two reasons for that. “One is financial: It tends to be procedural-based specialties and subspecialties that have much higher reimbursement rates than primary care,” he said. “The so-called cognitive specialties have not been reimbursed as well, which is part of our whole dysfunctional payment system.”
Perceived lifestyle issues also play a part. “Medical students are going into things they view as having more regular hours and a better lifestyle,” he said. “Some of that is attributed to 'Generation Y' having a different set of values and priorities than an older generation of physicians had. I don't know whether that is truly the case or not, but people do say lifestyle is an issue.”
That view was echoed by the National Resident Matching Program (NRMP), which runs Match Day. In a statement, NRMP noted that graduates continued their increasing interest in “lifestyle” specialties that are considered to have more reasonable work hours. For example, 100% of first-year dermatology residency slots were filled, with U.S. seniors filling 93.3% of the slots. In anesthesiology, 97% of the positions were filled, including more than 80% by U.S. seniors.
The ACP is trying to address some of these issues, Dr. Weinberger said. First, the college is developing the concept of the “advanced medical home,” which would identify physicians who can provide comprehensive care for chronically ill complex patients. These physicians work in teams that coordinate all care for these patients, integrating an understanding of cardiology problems, gastrointestinal problems, and other conditions. The concept includes an endorsement of reimbursement changes to help provide funding for these practices, he said.
The ACP is not the only organization concerned about primary care reimbursement. The American Academy of Family Physicians is working with the Centers for Medicare and Medicaid Services to increase the number of relative value units Medicare assigns to evaluation and management codes; that would increase the payment rates for many services provided to Medicare beneficiaries, said AAFP President Larry Fields. “We hope to see some efforts come to fruition fairly soon.”
The ACP also is beginning to redesign internal medicine outpatient training, Dr. Weinberger said. “When residents go through training, they don't have particularly good ambulatory experiences.”
One issue is that outpatient training is only one afternoon a week. To go to the outpatient clinic, residents must leave the inpatients they are caring for, which leaves many feeling conflicted and wanting to just get the clinic over with, Dr. Weinberger said. “If they don't have a great ambulatory experience during training, they are less likely to want to go into it.”
Another possible factor in the declining interest in primary care careers has been the rise of hospitalists, he added. “Of the people not interested in a specialty, a reasonable number are deciding to go into hospital medicine versus ambulatory medicine.” In the resident survey, 12% of respondents said they were planning to become hospitalists, compared with 20% who said they would go into general internal medicine. “So [the hospitalists] are catching up.”
Overall, more than 26,000 seniors graduating from medical schools—including more than 15,000 U.S. seniors—participated in the match. Nearly 22% of available slots were in internal medicine, making it the largest specialty, according to the NRMP. Family practice had 2,711 slots; 85.1% of those were filled, a slight increase over last year. The filled positions include 41.4% filled by U.S. seniors.