1. Swimming upstream: Internal medicine as career choice by medical students What is the role of academic internists? Hospitalists Best Practices Conference April 29, 2010 J Rush Pierce Jr, MD, MPH

2. Questions? To what extent are US medical students choosing general internal medicine as a career? What influences career choice of US medical students? What do our professional organizations say? What should we do?

3. U.S. physicians

10. Change in US medical school graduate career choice, 1998 - 2007

11. Career plans of IM residents

12. UNM students matching into categorical IM residencies, 2010 Muskan BehlEmory Heidi HilleslandUniv Washington Jonas HinesUCSF Brandon PetersonUniv Virginia 4/71 matched = 5.6%

13. Percentage of UNM categorical IM residency positions filled by UNM students average of other years vs 2010 Χ 2 = 4.28, p =0.04

14. Reasons for declining interest in IM by US medical students 1.Rising medical school debt 2. Lifestyle issues 3. Reimbursement

15. Medical School Debt and career choice AAMC: over 86% graduates have educational debt, averaging $145K from public schools and $180K from private schools AAMC: Students with debt >$150K less likely to select primary care residency Univ Minn: students with more debt chose specialties over primary care Student surveys have not shown consistent correlation

16. Change in physician compensation by specialty

17. Older data on career choices 1990 survey: deterrents from IM = time and workload demands; perceived physician satisfaction, types of patients seen 2002: Controllable lifestyle accounts for 55% of variance in student specialty choice 2003 survey: residents are willing to trade income for lifestyle benefits of more vacation and more predictable schedule

18. Role models and primary care Preceptorship with general internists assoc with choosing career in IM (2 studies pos, 1 study neg, all in 1990s) Students with positive IM mentor 5X as likely to choose IM as career (sev studies in 1990s)

20. Characteristics of study Surveyed 1,439 MS4 at 10 US medical schools, after submitted rank list and before match Demographics, perception of IM compared to other specialties What influenced career decision Sponsored by CDIM 82% response rate, 23% into IM, demographics same as US medical students

21. Demographic predictors

22. IM Core Clerkship 78% satisfied with core clerkship 19% felt that core clerkship made career in general IM attractive 49% that core clerkship made career in subspecialty IM attractive 78% felt that medical school experience provided them with enough insight into what internist does to make informed career decision

23. Perceptions of IM training and career IM requires more paperwork (68%) IM requires greater breadth of knowledge (62%) IM has lower income potential (65%) IM residency less competitive (58%) IM residents less satisfied that residents in other specialties (51%)

24. Career choice influences Positives: – Intellectual challenge of IM – Continuity of care in IM – Competence of IM residents – Level of responsibility for patient care during core clerkship and sub-I Negatives: – Paperwork and charting – Attractiveness of other specialties – Types of pts seen – Need to bring home work

27. Role modeling Role modeling by internists, as manifested by encouraging students to choose the field and job satisfaction, was less favorable than role modeling in other specialties Internal medicine, family medicine, and surgery were the specialties most likely not to be chosen based on bad mouthing of the discipline by physicians and other students

28. ACP recommendations for faculty

29. Options for us Mentorship – How should we mentor students? – How do we encourage this in residents? IM Interest group – What can we do? – Should we have Phase 1 students shadow us? Curriculum – Should we modify core clerkship, sub-I? Advocacy