Career In Internal Medicine Research Articles

Do Residents Benefit from Participating in Internal Medicine Interest Groups? A Study of Resident Perceptions from Two Institutions

For more than a decade, primary care residency training programs have struggled to attract graduates of U.S. medical schools. Internal medicine (IM) interest groups (IMIGs) have been widely instituted to foster student interest in careers in IM. Residents can participate in many IMIG activities. Studies have not assessed the benefits gained by resident participants in such groups. A questionnaire was sent to residents at two IM residency training programs that contribute to IMIG activities at one medical school. Both participating and nonparticipating residents were included. The questionnaire was completed by 44 of 58 IM residents (76% response rate; 25 participants and 19 nonparticipants). Free-text advantages reported were teaching (n=6), mentoring (n=8), and leadership (n=5) opportunities, staying current in IM (n=3), encouraging students to enter IM (n=6), and improving resident morale (n=6). Likert-scale responses were higher for participants than for nonparticipants for all questions; nonparticipants also reported that involvement in IMIG activities is beneficial for residents. Statistically significant results were seen for questions regarding the following: improves resident morale, fosters leadership opportunities, is a valuable experience, and feeling qualified to participate. Residents perceive that participation in an IMIG confers significant benefit, providing additional justification for conducting these interest groups.

Laparoscopy as an educational and recruiting tool

Background General surgeons can supplement traditional gross anatomy instruction by using laparoscopy to provide clinical correlations. Early, positive interaction with surgeons may stimulate student interest in this field. Methods Basic laparoscopy was performed on fresh cadavers for first year medical students in gross anatomy over 2 consecutive years. Surgical residents reviewed anatomy of the abdomen, and students manipulated intra-abdominal organs using laparoscopic instruments. Students completed pre- and post-demonstration questionnaires that were compared independently. Results More than 95% of responding students agreed the demonstration enhanced their understanding of abdominal anatomy. Regardless of planned area of specialization, students felt the demonstration reinforced the clinical relevance of gross anatomy. Among students already anticipating surgical careers, 88.2% said the demonstration increased their interest in general surgery; this was significantly higher than among those intending careers in internal medicine (27.3%) or other fields (23.5%; P < .0001). Conclusions Cadaver-based laparoscopy demonstrations by general surgeons supplement didactic sessions and enhance learning in gross anatomy. Furthermore, such demonstrations may stimulate student interest in general surgery at an early point in their medical education, particularly in those already interested in a surgical career.

Educational responses to declining student interest in internal medicine careers

Educational responses to declining student interest in internal medicine careers

Reforming internal medicine residency training. A report from the Society of General Internal Medicine's task force for residency reform.

The structure, process, and outcomes of internal medicine residency training have concerned the profession for over 20 years.1–9 Over the last decade the initiative to move to outcomes-based education redefined the competencies physicians should obtain during training.10,11 The core principle of outcomes-based education is the objective demonstration that a graduating trainee, whether from medical school or a residency, possesses the knowledge, skills, and attitudes necessary to progress to the next stage of his or her professional career.12,13 The Accreditation Council for Graduate Medical Education (ACGME) and the Institute of Medicine (IOM) have defined core competencies for physicians shown in Table 1.10,14 While both the ACGME and IOM provide a framework for the desired outcomes, medical educators bear the burden of designing the structures and processes to achieve them.15 Table 1 Comparison of the IOM and ACGME Competencies Educators face several key challenges in redesigning residency programs. First, residency programs must prepare trainees for a variety of general internal medicine and subspecialty careers. Second, the settings and resources for residency training are highly heterogeneous. Third, an aging and increasingly diverse population, combined with rapidly expanding medical information and procedural technology, challenges all internists to acquire and maintain the knowledge, skills, attitudes, and performance necessary to provide high-quality care within their chosen discipline.16,17 Finally, growing public dissatisfaction, substantial health care disparities, increased acuity but shorter lengths of stay for hospitalized patients, new work hour requirements, increasing medical student debt, and changing student demographics and lifestyle concerns further complicate residency reform.18–25 To provide recommendations for residency reform. The Society of General Internal Medicine (SGIM) convened a task force consisting of physicians representing a broad range of views within general medicine, expertise and experience in clinical education, and who represented internal medicine organizations outside of SGIM (Appendix 1). The task force focused on reform in 5 specific areas: ambulatory education, inpatient education, residency curriculum, health disparities, and life-long learning skills. To prepare this report, 4 subcommittees performed literature reviews that guided a prospective, systematic process to develop the final recommendations. The guiding principles, task force timeline, and the specific findings of the 4 subcommittees can be viewed at http://www.sgim.org. We acknowledge this report cannot cover all important aspects of residency training. The task force enthusiastically welcomes comments from other educators and internal medicine specialty organizations. Only through active collaboration and serious dialogue can we improve residency training.

Internal medicine reformation

The number of young United States physicians pursuing a career in primary care continues to decline. From a peak Match year in 1985 when 3884 U.S. graduate physicians matched in categorical internal medicine, the number has decreased by 33%, to 2602 in 2004 (1). In primary care internal medicine, the number of United States Medical Graduates (USMGs) matched in 2004 was only 188, down 51% since 1997 (1). Internal medicine continues to experience a decrease in USMGs entering the specialty. In 2003, approximately 60% of categorical internal medicine slots were filled by international medical graduates (IMGs) (2,3). In contrast, less than 20% of preliminary (1 year) internal medicine slots in 2003 were filled by IMGs (2,3). In the 2004 National Residency match, 54% of internal medicine residency positions were filled with USMGs, a percentage that represents only a minimal decrease from 2003. Many positions in internal medicine training programs are filled by IMGs outside of the national matching process; as a result, the actual percentage of IMGs enrolled in categorical internal medicine programs is above 50% of trainees. Furthermore, anecdotal accounts suggest that the number of academically superior U.S. students choosing a career in internal medicine is also declining, except for perhaps in the more prestigious training programs. A corollary of this phenomenon is that fewer top students enter medical subspecialty training. Family medicine, the other major primary care discipline, has experienced a 49% decline in interest by U.S. senior medical students over the past 8 years.

STUDENTJAMA. Career satisfaction among physicians.

DESPITE REPORTS OF DISSATISFACTION AMONG PRACTICING PHYsicians and a 22% decrease in applications to US medical schools since 1997, recent data suggest that the majority of physicians remain satisfied with their careers, although there may be substantial variability across geographical areas. In a nationally representative telephone survey of physicians from 1997 to 2001, we found that more than 80% of physicians with direct patient care responsibilities were somewhat or very satisfied with their careers. Physician career satisfaction appears to be a complex function of a number of variables. Overall career satisfaction among physicians may remain high despite decreases in some of these domains. The Society of General Internal Medicine (SGIM) Career Satisfaction Study Group defined 10 domains of professional satisfaction. Among the highest predictors of global job satisfaction were patient care issues and relationships with patients and colleagues. The SGIM study group defined autonomy as “independence of action,” including the ability to treat patients according to the best clinical judgment. We found that both primary care physicians and specialists who rated their autonomy lower and those that reported more difficulty obtaining high-quality outpatient services and inpatient services were more likely to report decreased satisfaction with their careers over the 4-year period. Similarly, in a crosssectional study, Stoddard et al found clinical autonomy to be significantly related to career satisfaction. Conversely, while physicians may be largely satisfied with their careers in medicine, they may be less satisfied with particular aspects of practice, including income, control over personal time, and the administrative aspects of practice. In a 1999 study in Massachusetts, more than 60% of physicians reported dissatisfaction with managed care. Many of these physicians also rated the fee schedules or capitation rates they received from managed care companies as “fair” or “poor.” Similarly, the study by Stoddard et al found that the level of income was associated with satisfaction. Another study from the SGIM study group found that physicians’ dissatisfaction with pay was associated with an increased likelihood of leaving their jobs within 2 years. Rates of increases in physician income have barely kept pace with inflation. In addition, within medicine, primary care specialties have been particularly affected because of continued increases in practice expenses accompanied by relatively flat reimbursement rates. In our national longitudinal study, we found that primary care physicians who reported lower income were significantly more likely to become less satisfied, although primary care physicians with increases in income did not become more satisfied over time. Among specialists, neither increases nor decreases in income were related to changes in satisfaction. Another aspect of practice that has changed in the recent past is control over work. Whereas physicians once practiced primarily alone or in small autonomous groups, they now are more likely to be employed in large groups and are increasingly subjected to profiling, administrative requirements, and preapproval for procedures and treatments. Financial constraints are also prevalent. Patients report less trust in physicians, and physicians are no longer respected as highly as they once were. Among the most important changes related to this area of practice are control over work and personal time. Linzer et al reported that physicians in health maintenance organizations were less satisfied with their careers and that the adequacy of time with patients was an important predictor. The data on physician satisfaction cannot be fully understood without examining the principal domains determining physician career satisfaction. Although physicians have traditionally derived career satisfaction from their services to patients, other aspects of satisfaction including income and personal time are also important and appear to be more subject to change over time. If the balance between these factors continues to shift, this could potentially lead to increasing levels of dissatisfaction among physicians.

Variation in predictors of primary care career choice by year and stage of training.

It is not known whether factors associated with primary care career choice affect trainees differently at different times or stages of medical education. To examine how role models, encouragement, and personal characteristics affect career choice at different stages (medical school vs residency) and periods (1994 vs 1997) of training. A split-panel design with 2 cross-sectional telephone surveys and a panel survey in 1994 and 1997. A national probability sample of fourth-year students (307 in 1994, 219 in 1997), 645 second-year residents in 1994, and 494 third-year residents in 1997. Of the fourth-year students interviewed in 1994, 241 (78.5%) were re-interviewed as third-year residents in 1997. Primary care (general internal medicine, general pediatrics, or family medicine) career choice. Having a primary care role model was a stronger predictor of primary care career choice for residents (odds ratio [OR], 18.0; 95% confidence interval [95% CI], 11.2 to 28.8 in 1994; OR, 43.7; 95% CI, 24.4 to 78.3 in 1997) than for students (OR, 6.5; 95% CI, 4.3 to 10.2; no variation by year). Likewise, peer encouragement was more predictive for residents (OR, 5.4; 95% CI, 3.3 to 8.9 in 1994; OR, 16.6; 95% CI; 9.7 to 28.4 in 1997) than for students (OR, 2.1; 95% CI, 1.3 to 3.2; no variation by year). Orientation to the emotional aspects of care was consistently associated with primary care career choice across stages and years of training. The effect of peer encouragement and role models on career choice differed for students and residents and, in the case of residents, by year of training, suggesting that interventions to increase the primary care workforce should be tailored to stage of training.

A thyroid-stimulating life: an interview with Dr. J. Maxwell McKenzie.

BEST KNOWN to the thyroid world for the introduction of the McKenzie bioassay for thyroid-stimulating antibodies (see Box), Dr. Maxwell McKenzie has had a long and distinguished career in thyroid research and internal medicine. He retired after 13 years as chairman of medicine at the University of Miami in 1994 and continues to contribute to his department and university. I persuaded Dr. McKenzie to spend some time with me in Palm Beach to talk about old times and the following is a relatively uncensored record of our conversation. Modest and retiring, Max McKenzie has much to teach us all and I have included some key references which should be read in conjunction with this transcript. This report, along with a previous interview with Dr. Robert Volpe (1), is part of an ongoing series we would like to see continued in Thyroid.

The Opinion of Current and Recent Internal Medicine Residents Regarding a Fourth Year of Training and the Future of General Internal Medicine

OBJECTIVE: To determine the opinion of current residents and recent graduates of internal medicine training programs regarding an additional mandatory year of residency training. METHODS: A survey was made of 2,000 associate members of the American College of Physicians from five geographic regions. RESULTS: Of 917 respondents, 70.3% thought a fourth year of training would impact negatively on their choice of a career in internal medicine, and 82.9% believed a mandatory fourth year should not be required of residents choosing a subspecialty career. Furthermore, 58.1% of physicians surveyed thought a mandatory fourth year would discourage individuals from pursuing subspecialty careers. If a mandatory fourth year of training were required, 50.7% respondents indicated that it should consist of ambulatory training in a number of general fields, while 49.6% physicians believed the training should focus on one or two subspecialty fields. CONCLUSIONS: A mandatory fourth year of training is not supported by residents and recent graduates of the programs surveyed.

Introducing Ambulatory Care During the Medicine Clerkship: Impact on Evaluation and Attitudes

This article assesses student attitudes and the overall educational impact after a major curriculum change that implemented ambulatory care in an internal medicine clerkship. The study was cross-sectional with a historical comparison group and took place in a university teaching program with third-year students from three time periods. The 8-week clerkship was changed from 8 weeks of inpatient ward medicine to 4 weeks each of inpatient and ambulatory care in both primary care and subspecialty clinics. When students’ responses before and after the curriculum change were compared, there was a significant improvement in evaluation of the clerkship experience (P = 0.001). Attitudes improved toward a general internal medicine career (P = 10−5) and there was improvement in evaluation of the inpatient experience (P = 0.01). Attitudes toward careers in subspecialty internal medicine and National Board examination scores were unchanged. The institution of ambulatory care into this internal medicine clerkship resulted in several significantly positive outcomes without a negative impact on the internal medicine knowledge base. This article assesses student attitudes and the overall educational impact after a major curriculum change that implemented ambulatory care in an internal medicine clerkship. The study was cross-sectional with a historical comparison group and took place in a university teaching program with third-year students from three time periods. The 8-week clerkship was changed from 8 weeks of inpatient ward medicine to 4 weeks each of inpatient and ambulatory care in both primary care and subspecialty clinics. When students’ responses before and after the curriculum change were compared, there was a significant improvement in evaluation of the clerkship experience (P = 0.001). Attitudes improved toward a general internal medicine career (P = 10−5) and there was improvement in evaluation of the inpatient experience (P = 0.01). Attitudes toward careers in subspecialty internal medicine and National Board examination scores were unchanged. The institution of ambulatory care into this internal medicine clerkship resulted in several significantly positive outcomes without a negative impact on the internal medicine knowledge base.

Introducing ambulatory care during the medicine clerkship: impact on evaluation and attitudes.

This article assesses student attitudes and the overall educational impact after a major curriculum change that implemented ambulatory care in an internal medicine clerkship. The study was cross-sectional with a historical comparison group and took place in a university teaching program with third-year students from three time periods. The 8-week clerkship was changed from 8 weeks of inpatient ward medicine to 4 weeks each of inpatient and ambulatory care in both primary care and subspecialty clinics. When students' responses before and after the curriculum change were compared, there was a significant improvement in evaluation of the clerkship experience (P = 0.001). Attitudes improved toward a general internal medicine career (P = 10(-5)) and there was improvement in evaluation of the inpatient experience (P = 0.01). Attitudes toward careers in subspecialty internal medicine and National Board examination scores were unchanged. The institution of ambulatory care into this internal medicine clerkship resulted in several significantly positive outcomes without a negative impact on the internal medicine knowledge base.

Career characteristics of graduates of a Medical Scientist Training Program, 1970-1990

To describe the career characteristics of the graduates of the Medical Scientist Training Program (MSTP) at Duke University School of Medicine. Surveys and information at administrative offices were used to collect data on all the 1970-1990 MSTP graduates in the summer of 1995. Of the 147 graduates, all but three had completed postgraduate training. In addition, data were available for 35 recent graduates (1991-1995), most of whom were in transition from training and fellowship positions to career positions. Of the 144 graduates from 1970 through 1990, 84 (58%) had selected careers in internal medicine or pathology. A total of 106 (74%) were involved in careers in academic medicine or research. Of these, 87 (82%) held full-time faculty appointments and devoted major efforts to basic or clinical research. Of this group, 59 (68%) were primary investigators receiving grant support from the National Institutes of Health (NIH). Of the 12 women graduates, 11 had careers in academic medicine or research, and seven were primary investigators on NIH grants. At the present time, 11 of 43 (26%) of the matriculating MSTP students are women. Five of the seven underrepresented-minority students in the MSTP have entered in the last five years. This study reinforces and extends previous conclusions concerning the success of federally funded MSTPs in producing physician scientists who compete favorably for NIH funding.

The impact of an ambulatory rotation on medical student interest in internal medicine

To determine whether students who take ambulatory rotations in internal medicine are more likely to choose internal medicine careers. National survey. The intended sample was 1,650 senior U.S. medical students from 16 medical schools, of whom 1,244 (76%) responded. Representative schools nationwide were selected using a stratified, random-sampling method. The questionnaire asked about characteristics of the ambulatory rotation, perceptions of internal medicine, and factors influencing students toward or away from an internal medicine career. Ambulatory rotations were taken by 543 students (43%). Of these rotations, 73% were required, 74% were during the fourth year, 77% were in general internal medicine, 73% provided continuity of care, and 19% were during the medicine clerkship. Overall, 24% of the students chose careers in general (9%) or subspecialty internal medicine (15%). Thirty percent of the students who did ambulatory rotations planned internal medicine careers, compared with 19% of the students who had no rotation [odds ratio (OR) = 1.8, 95% confidence interval (CI) 1.3 to 2.4, p = 0.0001]. This association was of similar magnitudes for students completing required rotations (OR = 1.6, 95% CI 1.2 to 2.2, p = 0.002) and for students completing rotations before or in proximity to when they chose careers (OR = 1.7, 95% CI 1.1 to 2.4, p = 0.01). Ninety percent of the 543 students who had ambulatory rotations were satisfied with the experience. Thirty-eight percent of the highly satisfied students chose internal medicine careers, compared with 21% of the students who had low or moderate satisfaction (p = 0.0001). An ambulatory rotation is strongly associated with positive perceptions of, attraction to, and choice of a career in internal medicine. Research is needed to determine specific components of an effective rotation. Further development of ambulatory rotations could help attract more students to internal medicine.

A surgeon's valedictory.

PERSPECTIVES IN BIOLOGY AND MEDICINE Volume 37 ¦ Number 2 ¦ Winter 1994 A SURGEON'S VALEDICTORY SHERWIN B. NULAND* A year has passed since I walked out of an operating room for the last time. After a career of three decades in a large universitycommunity hospital, preceded by six years of training in general surgery , the time had come to pass the burden and the pleasure into younger hands. General surgeons love to operate; general surgeons (at least general surgeons of my generation) love to sit at a bedside, or some other quiet place, and puzzle out a complex problem in diagnosis and therapy; general surgeons love clinical conferences and rounds, where they can match wits with their most agile colleagues; general surgeons are among the most vigorous and outspoken participants in the hurly-burly of hospital politics, and they love the corridors of power. I was by no means an exception to any of those characterizations. I have been, in fact, the whole package writ large. And yet, I don't for a moment miss the surgical life that has brought me so much fulfillment since I first discovered it almost forty years ago. As so often happens over the course of a long career, the field that was such an endless source of gratification when it first beckoned has become something else. The something else nonetheless had until recently seemed so much the natural progression of the original that its very evolution continued to provide immense satisfaction. No matter the new discoveries and innovations in technique, the values and viewpoints ofthe specialty did not change in any basic way during most ofmy professional lifetime. The Weltanschauung with which general surgeons envisioned pathophysiology and treatment remained steady and certain. A little personal history is in order here. In 1953, I was a third-year medical student determined to pursue a career in internal medicine, when I was one day taken in hand by an imaginative surgical resident who introduced me to an unanticipated aesthetic in his specialty. The *Address: P. O. Box 6356, Hamden, Connecticut 06517.© 1994 by The University of Chicago. All rights reserved. 003 1-5982/94/3702-086 1$0 1 .00 Perspectives in Biology and Medicine, 37, 2 ¦ Winter 1994 159 secrets of disease and the body's wondrous skill at restoring itself, I was made to realize, are discoverable less by words than by the visual and tactile elements that exist within human curiosity. From this perspective, a surgeon's uniquely cultivated skills could be seen as a way to reveal and express the beauty to be found through his mind's engagement with sickness and healing. Tissue teaches more than text, pathophysiology more than the printed page. Touching and seeing open the most direct paths to the surgeon's mind. I soon came to view surgeons as expeditors of nature's response to disease. An inflamed organ is removed, an obstruction is bypassed, excessive hormone levels are reduced, a cancerous region is swept clean of tumor-bearing tissue; surgeons are agents of the process by which an offending force may be sufficiently held at bay to aid physiology in its natural tendency to restore health. Surgery is the distilled essence of W. H. Auden's perceptive précis of all medicine: "Healing," said the poet, "is not a science, but the intuitive art of wooing Nature." For the wooing to take place, it is necessary not only to make an accurate diagnosis, but actually to visualize in one's mind a pathological process in all its multicolored, palpable, tangible reality. To predict the image of the territory I would enter—this became the ultimate diagnostic aim, just as the correction of disharmony is the ultimate goal of the operation. To me, surgery was a form of artistry, and the surgeon the personification of the art of medicine. There was in this clinical epiphany the kind of exhilaration that Percy Shelley must have been feeling when at twenty-four, the same age at which I began my surgical internship, he wrote his "Hymn to Intellectual Beauty." The poem now took on a new meaning for me, and I even heard an authentic note in two...

Third-Year Medical Student Attitudes Toward Internal Medicine

Student attitudes offer insight into career decisions and may suggest causes of the diminished interest in internal medicine. Students entering a salaried managed health care environment may have different attitudes about careers and potential income. Additionally, we evaluate the effect of an ambulatory experience on student attitudes and career selection. We surveyed 163 medical students from the Uniformed Services University of the Health Sciences, Bethesda, Md, at the successful completion of the third year to determine their attitudes regarding the work, lifestyle, prestige, patient type, and challenge of internal medicine, as well as primary care interest, and the importance of income in career selection. A subgroup of 107 volunteers was randomized to either the traditional internal medicine clerkship (n = 69), or to 6 weeks of ambulatory medicine and 6 weeks of ward medicine (n = 38). The selection rate was low for internal medicine (10%) and was high for family practice and transitional internships (37%). Although most students highly valued their internal medicine training, relatively few selected internal medicine as a career. Students saw chronic illness and type of work, but not lifestyle, as disincentives toward choosing an internal medicine career. Half of the students believed that income potential would be a major factor in attracting students into internal medicine, and that reimbursement should be shifted from procedural fields to primary care. The ambulatory clerkship did not affect student attitudes nor type of internship selected. Medicine clerkships, whether traditional or ambulatory, are highly valued educational experiences yet may be insufficient by themselves to attract students to an internal medicine career. Income potential remains an important concern in the setting of salaried managed care, even for students who lack financial debt.

Physician manpower reform: An analysis of the effects of the COGME Fourth Report on internal medicine residency positions

purpose: To quantitate the impact of the recommendations contained in the Council on Graduate Medical Education (COGME) Fourth Report 1 on the position distribution in internal medicine residency and fellowship programs and to recommend alternative position allocations for discussion. data sources: The COGME Fourth Report, the National Study of Internal Medicine Manpower, 3 and the American Medical Association Annual Survey of Graduate Medical Education. 4 results: Our analysis of the COGME Fourth Report indicates that internal medicine PGY-1 positions would decrease from the 8,936 on duty in the 1992 academic year to 6,533 (−26.9%) for the class of the year 2000. Four thousand will enter generalist careers in internal medicine (approximately a 70% increase over current generalist output). The COGME Fourth Report recommendations would allocate first-year fellowship positions for 1,400 graduates of internal medicine residencies (−63.1%). Career-bound internal medicine positions will decrease from approximately 6,000 to 5,400 (−10.0%). The loss in PGY-1 positions is predominantly due to a decrease in the number of preliminary medicine positions and to individuals who switch from career-bound internal medicine positions to other disciplines after the PGY-1 or PGY-2 years. Pediatric positions would increase moderately from 2,426 available in 1993 to 2,520 (+3.9%). Pediatric subspecialty positions would decrease by 25% to 420, with 2,100 residents entering careers in general pediatrics. Family medicine PGY-1 positions would increase from the 2,657 available in 1993 to 3,400 (+28%). conclusions: The recommendations contained in the COGME Fourth Report would substantially reduce the number, and significantly alter the current distribution, of residency positions. The output goals of 50% generalist careers are met by an increase in career-bound generalist positions in all three generalist specialties. The limitation of total positions to the goal of 110% of 1993 U.S. graduates comes predominantly through reduction of specialty/subspecialty career-bound positions. Internal medicine residency and subspecialty fellowship positions and programs would be significantly altered by these recommendations. The reductions in internal medicine occur predominantly in loss of positions not currently destined for careers in internal medicine and in subspecialty fellowship positions. These reductions are partially offset by an increase in the complement of residents who are destined for careers in general internal medicine.

Time to Reexamine the American Board of Internal Medicine

We appreciate Glaser's comments regarding board certification affecting medical student interest in internal medicine. 1 While many senior students review residency program data regarding the passage of the American Board of Internal Medicine examination, we are not aware of students not choosing a career in internal medicine because of such concerns. Although the overall passage rate in 1993 was 54%, when you review the statistics looking at US and Canadian physicians taking the examination for the first time, the passage rate for 1993 is much higher, at 75%, and this rate has been consistently maintained over the years. 2 The American Board of Internal Medicine considers the examination for certification in internal medicine a standard of excellence rather than a standard of competence. Certainly, there are outstanding internists who have difficulty with certifying examinations that, unfortunately, may limit their practice opportunities. However, we do not believe that the examination statistics,

Medical students’ motivation for internal medicine

To verify that motivational concepts tested in other educational settings are relevant to understanding medical students' choice of a career in internal medicine. More specifically, to compare the effects of "facilitating students' interest" versus "controlling students' learning" as educational models during the internal medicine clerkship. An observational retrospective study of 89 fourth-year medical students. Structural equation modeling compared the two models statistically. Student choice of internal medicine residency. Instructors who supported students' autonomy engendered in students greater feelings of competence and interest in internal medicine than did controlling instructors. Perceived competence further enhanced students' interest in internal medicine. In turn, interest predicted students' choosing an internal medicine residency. Overall, the facilitating students' interest model better explained students' choice of internal medicine than did the controlling students' learning model. The results verify that the nature of the learning climate during the internal medicine clerkship is an important predictor of students' subsequent pursuit of internal medicine training. Instructors who teach in an autonomy-supportive manner enhance students' perceived competence and interest in internal medicine, which increases the likelihood they will select an internal medicine residency.

Effect of a Simple Ambulatory Experience on Career Choice and Attitudes of Medical Students

Students were allocated randomly to participate in a simple ambulatory experience during their third-year medicine clerkship. A convenience sample was surveyed by questionnaire in the fall of their fourth year, after decisions were made regarding future career plans. The questionnaire assessed medical student attitudes toward general internal medicine and career choice. Valuation of the effectiveness of the clerkship was associated with choosing a career in internal medicine (p = 0.007); having an ambulatory experience was not associated with subsequent career choice. Sixty-two percent of all students felt the clerkship affected their career choice a great deal or moderately; these students were likely to find a career in general internal medicine less attractive as a result of their clerkship (p = 0.008). When stratified, this association disappeared in those students who participated in the ambulatory experience (p = 0.39) but persisted in those who did not (p = 0.01). A simple experience in internal medicine clinics during a third-year clerkship was not associated with subsequent career choice, but had some positive effects on attitudes toward general internal medicine as a career.

The Impact of Educational Loan Burden on Housestaff Career Decisions

The past decade has seen declining interest in primary care medicine and a dramatic increase in the cost of a medical degree. Seventy-nine percent of housestaff in an internal medicine residency program responded to a survey to determine whether medical school loan burden was related to career choice in a primary care field or specialty area. Overall mean indebtedness was $45,185 (median $40,000). Thirty-eight percent of residents with debts $40,000 (chi square =9.44, p $40,000 stated that financial conditions had a moderate to marked impact on their career decision making. Excessive loan burden has a significant influence on residents’ career decision making and a negative influence on choosing careers in primary care internal medicine.