Non-primary Care Specialties Research Articles

Medical student debt and major life choices other than specialty

BackgroundMedian indebtedness at graduation is now more than $170,000 for graduates of US Medical Schools. Debate still exists as to whether higher debt levels influence students to choose high paying non-primary care specialties. Notably, no previous research on the topic has taken into account cost of attendance when constructing a debt model, nor has any research examined the non-career major life decisions that medical students face.MethodsMedical students were surveyed using an anonymous electronic instrument developed for this study. The survey was delivered through a link included in a study email and students were recruited from school wide listservs and through snowball sampling (students were encouraged to share a link to the survey with other medical students). No incentives were offered for survey completion.ResultsResponses were recorded from 102 US Allopathic medical schools (n=3,032), with 22 institutions (11 public, 11 private) meeting inclusion criteria of 10% student body response proportion (n=1,846). Students with higher debt relative to their peers at their home institution reported higher frequencies of feeling callous towards others, were more likely to choose a specialty with a higher average annual income, were less likely to plan to practice in underserved locations, and were less likely to choose primary care specialties. Students with higher aggregate amounts of medical student loan debt were more likely to report high levels of stress from their educational debt, to delay getting married and to report disagreement that they would choose to become a physician again, if given the opportunity to revisit that choice. Increases in both aggregate and relative debt were associated with delaying having children, delaying buying a house, concerns about managing and paying back educational debt, and worrying that educational debt will influence one's specialty choice.ConclusionsMedical student debt and particularly debt relative to peers at the same institution appears to influence the way that students approach major life choices like when to start a family, when to buy a home, and what specialty to choose. Future research should take into account cost of attendance when looking for the impact of medical student debt on major life choices.

Impact of a Workshop About Aging on the Empathy Scores of Pharmacy and Medical Students

To measure changes in pharmacy and medical students' empathy scores after a 40-minute workshop during which students observed and discussed a theatrical performance about the challenges of aging. First-year pharmacy and medical students (n = 187 and n = 183, respectively) participating in the workshop observed and discussed a 10-minute performance in which students enacted problems and concerns faced by elderly patients. The Jefferson Scale of Empathy (JSE) was administered just prior to the workshop (pretest), immediately afterward (posttest 1), and 7 or 26 days afterward (posttest 2). Empathy increased significantly from pretest to posttest 1 for students of each profession (p <0.01). Improvement in empathy scores declined by the time the JSE was readministered to pharmacy students 7 days later and to medical students 26 days later (posttest 2). Similar patterns of improved and declining empathy were found when the data were analyzed by gender and medical student specialty interest (ie, primary vs non-primary care specialties). Empathy scores increased but were not sustained for both pharmacy and medical students after a brief workshop on aging that required limited personnel resources.

The Association Among Specialty, Race, Ethnicity, and Practice Location Among California Physicians in Diverse Specialties

Minority physicians are more likely than their counterparts to work in underserved communities and care for minority, poor, and uninsured patients, but much of this research has examined primary care physicians alone. Few have investigated whether non-primary care specialists of minority backgrounds are more likely to serve the underserved than nonminority specialists. We examined whether underrepresented minority (URM) physicians from a wide variety of specialties are more likely than non-URM physicians to practice in underserved communities. Using California Medical Board Physician Licensure Survey (2007) data for 48388 physicians, we geo-coded practice zip codes to medically underserved areas (MUAs) and primary care health professional shortage areas (HPSAs). Logistic regression models adjusting for age, gender, specialty, and other characteristics were used to explore associations with race, ethnicity, specialty, and designated underserved areas. We found that African American, Latino, and Pacific Islanders were more likely to work in MUAs and HPSAs than were white physicians (adjusted odds ratio, 1.22-2.25; p < .05). Similar patterns of practice in MUAs and HPSAs by physician race and ethnicity were found when performing the analyses separately among primary care physicians and physicians in non-primary care specialties. In summary, our study underscores the importance of underrepresented minority physicians in all specialties for the physician workforce needs of disadvantaged communities. To improve health care for underserved communities, continued efforts to increase physician diversity are essential.

Emotional intelligence and medical specialty choice: findings from three empirical studies

Despite only modest evidence linking personality-type variables to medical specialty choice, stereotypes involving empathy and 'emotional connectedness' persist, especially between primary care providers and surgeons or subspecialists. This paper examines emotional intelligence (EI) and specialty choice among students at three US medical schools. Results from three independent studies are presented. Study 1 used the Mayer-Salovey-Caruso Emotional Intelligence Test (MSCEIT) administered to a single cohort of 84 Year 4 medical students. Study 2 used the Trait Meta-Mood Scale (TMMS) and Davis' Interpersonal Reactivity Index (IRI) administered to three cohorts (n = 250) of Year 3 medical students. Study 3 used the Bar-On Emotional Quotient Inventory (EQ-I) administered to two cohorts of Year 1 medical students (n = 292). Results were linked to specialty choice data retrieved from the National Residency Match Program (NRMP). Classifications of specialty choice included: (i) primary care (family practice, internal medicine, paediatrics) versus non-primary care (all others), and (ii) primary care, hospital-based specialties (anaesthesiology, emergency medicine, pathology, radiology), and technical and surgical specialties (neurology, obstetrics and gynaecology, ophthalmology, and all surgical fields). Across all three studies - and using both classifications of specialty choice - no significant differences in EI were found between students entering primary care and non-primary care specialties. Limitations are acknowledged, and future directions for research involving EI are identified.

Change in Residents’ Perceptions of Teaching: Following a One Day “Residents as Teachers” (RasT) Workshop

The objective of this study was to assess the perceptions and attitudes of resident physicians toward teaching before and after participation in a mandatory "Residents as Teachers" (RasT) workshop in four domains: (1) setting goals and expectations, (2) use of clinical microskills in teaching, (3) evaluation and feedback, and (4) enthusiasm and preparedness toward teaching. Pre- and postintervention questionnaires were utilized. Data were analyzed for all respondents. Subgroup analyses were performed for each academic year and for primary care versus nonprimary care specialties. Over a 5-year period, 15 RasT workshops were presented to 276 residents from 10 different residency programs. Eighty-six percent completed the questionnaire before participation in the workshop, and 88% completed the questionnaire immediately after participation. The difference between the mean post-RasT and pre-RasT ratings on each item was used to measure the change in that item resulting from participation in the workshop. Overall, residents' self-assessed ratings of their attitudes toward teaching were positively impacted by participation in a RasT workshop. Further subanalysis showed that residents in primary care specialties showed a significantly greater increase in their ratings than residents in nonprimary care specialties.

Public Roles of US Physicians

Whether physicians have a professional responsibility to address health-related issues beyond providing care to individual patients has been vigorously debated. Yet little is known about practicing physicians' attitudes about or the extent to which they participate in public roles, which we defined as community participation, political involvement, and collective advocacy. To determine the importance physicians assign to public roles, their participation in related activities, and sociodemographic and practice factors related to physicians' rated levels of importance and activity. Mail survey conducted between November 2003 and June 2004 of 1662 US physicians engaged in direct patient care selected from primary care specialties (family practice, internal medicine, pediatrics) and 3 non-primary care specialties (anesthesiology, general surgery, cardiology). Rated importance of community participation, political involvement, collective advocacy, and relevant self-reported activities encompassing the previous 3 years; rated importance of physician action on different issues. Community participation, political involvement, and collective advocacy were rated as important by more than 90% of respondents, and a majority rated community participation and collective advocacy as very important. Nutrition, immunization, substance abuse, and road safety issues were rated as very important by more physicians than were access-to-care issues, unemployment, or illiteracy. Two thirds of respondents had participated in at least 1 of the 3 types of activities in the previous 3 years. Factors independently related to high overall rating of importance (civic-mindedness) included age, female sex, underrepresented race/ethnicity, and graduation from a non-US or non-Canadian medical school. Civic mindedness, medical specialty, practice type, underrepresented race/ethnicity, preceptors of physicians in training, rural practice, and graduation from a non-US or non-Canadian medical school were independently related to civic activity. Public roles are definable entities that have widespread support among physicians. Civic-mindedness is associated primarily with sociodemographic factors, but civic action is associated with specialty and practice-based factors.

Using relationship styles based on attachment theory to improve understanding of specialty choice in medicine.

BackgroundPatient-provider relationships in primary care are characterized by greater continuity and depth than in non-primary care specialties. We hypothesized that relationship styles of medical students based on attachment theory are associated with specialty choice factors and that such factors will mediate the association between relationship style and ultimately matching in a primary care specialty.MethodsWe determined the relationship styles, demographic characteristics and resident specialty match of 106 fourth-year medical students. We assessed the associations between 1) relationship style and specialty choice factors; 2) specialty choice factors and specialty match, and 3) relationship style and specialty match. We also conducted mediation analyses to determine if factors examined in a specialty choice questionnaire mediate the association between relationship style and ultimately matching in a primary care specialty.ResultsPrevalence of attachment styles was similar to that found in the general population and other medical school settings with 59% of students rating themselves as having a secure relationship style. Patient centeredness was directly associated, and career rewards inversely associated with matching in a primary care specialty. Students with a self-reliant relationship style were significantly more likely to match in a non-primary care specialty as compared to students with secure relationship style (OR = 5.3, 95% CI 1.8, 15.6). There was full mediation of the association between relationship style and specialty match by the specialty choice factor characterized by patient centeredness.ConclusionAssessing relationship styles based on attachment theory may be a potentially useful way to improve understanding and counsel medical students about specialty choice.

Factors Affecting Medical Students' Choice of Residency: A Preliminary Study

Purpose. Recruiting enough residents has become a major issue for hospitals in recent years, especially for traditionally major specialties. To improve recruitment, factors affecting medical students' career choices need to be investigated and analyzed. This study investigated factors affecting medical students' choice of residency programs using a detailed comprehensive questionnaire. The result will be used to improve resident recruitment and for a future nationwide study design. Methods. A total of 99 questionnaires were distributed to all seventh-year medical students serving as intern doctors in a university hospital in 2004. Seventy questions were categorized into 7 sections, including basic data, professional training, financial factors, life quality and workload, working environment, career planning, and hospital and specialty training. Forty-one questions used a 5 point Likert-type scale (5=strongly agree, 4=agree, 3=neutral, 2=disagree, 1=strongly disagree) and 30 used single choice, multiple choice, ranking, and fill in the blank. Students were grouped into a primary care specialty group (internal medicine, surgery, pediatrics, gynecology and obstetrics) and a non-primary care specialty group; differences between groups were compared. Factor analysis, reliability analysis, student ttest, chi-square test and descriptive statistics were used for statistical analysis. Results. Five factors containing 20 Likert-type questions were extracted from all 41 Likert-type questions. Working atmosphere, life style, academic environment, private practice and modernity explained 72% of the variance of the survey. National Taiwan University Hospital and internal medicine were ranked highest for hospital and specialty choice, respectively. Students who chose primary care specialties gave more weight to ”chances of further academic advancement” (p=0.03) and ”opportunity to get teaching positions” (p=0.04). Conclusions. Hospitals can increase their attractiveness by improving the working atmosphere, strengthening academic training, and trying to cut unnecessary work load. The establishment of a career consulting office may improve the general image of the hospital and provide a communication channel between the hospital, medical students and residents.

Attachment theory in health care: the influence of relationship style on medical students' specialty choice.

Converging sources suggest that patient-provider relationships in primary care are generally of greater intensity and duration than those in non-primary care specialties. In this study, we hypothesised that Year 2 medical students whose close relationships were characterised by security and flexibility would be more likely than students who were less comfortable in close relationships to plan to pursue primary over non-primary care postgraduate training. We determined the relationship styles and demographic characteristics of 144 Year 2 medical students. We also gathered information regarding their predicted choices of postgraduate training, which were clustered into primary or non-primary care categories. We compared student choices with respect to their interpersonal relationship styles based on attachment theory. Prevalences of attachment styles were similar to those found in the general population, with 56% of students rating themselves as having a secure relationship style. Students with a secure style were more likely to choose primary care (61%) over non-primary care compared to those whose styles were characterised by self-reliance, support-seeking or caution (41% chose primary care). Compared to those with a secure relationship style, students with a cautious style [OR = 5.9 (1.9, 18.7)] and students with a self-reliant style [OR = 2.4 (0.96, 5.9)] were more likely to choose non-primary over primary care, after controlling for gender. Assessing relationship styles using attachment theory is a potentially useful way to understand and counsel medical students about specialty choice.

Trends in career choice by US medical school graduates.

Trends in career choice among specialties have varied greatly. Most notable is the recent decrease in the percentage of US medical student graduates choosing a primary care career, which has important implications for the US physician workforce. To review temporal trends in career choice by graduates of allopathic US medical schools, focusing on US medical doctors entering residencies since 1987. Three databases, the Association of American Medical Colleges Graduation Questionnaire (AAMC GQ), the National Resident Matching Program, and the national Graduate Medical Education census, were used to review temporal trends in the number of US medical doctors entering residencies in primary care, general or subspecialty surgical, and non-primary care and nonsurgical specialties from 1987 to 2002. In 1987, 49.2% of all medical school graduates matched to one of the generalist residencies (internal medicine, pediatrics, or family medicine). The percentage of students matching to primary care specialties declined in the early 1990s, peaked at 53.2% in 1998, and declined to 44.2% in 2002. Concurrent with the latter decline, AAMC GQ data showed a decrease in medical student interest in primary care careers (35.6% in 1999 to 21.5% in 2002). The total percentage of US medical doctors matching to general or subspecialty surgical residencies remained stable at 11% to 12% from 1987 to 2002. During this same period, emergency medicine and plastic surgery increased as a match choice, while anesthesiology, pathology, and psychiatry were more variable over time. Distribution of medical students' career choices among specialties varied considerably from 1987 to 2002. The debate will continue regarding the appropriate specialty mix within the physician workforce.

A statement of principles: toward improved care of older patients in surgical and medical specialties.

A statement of principles: toward improved care of older patients in surgical and medical specialties.

In pursuit of generalism: Basic factors influencing the specialty decisions of osteopathic medical school seniors in 1995

An analysis of survey responses of seniors graduating from osteopathic medical school in 1995 shows that the selection of the medical specialty they planned to pursue in their postgraduate training was considerably influenced by 10 common factors. These factors ranged from the students' orientation to people or techniques, to prestige and income associated with the specialty. The People orientation factor exerted a strong influence on students planning to pursue primary care specialties (defined as Family Practice, General Internal Medicine, and General Pediatrics) Similarly, for students planning to pursue a nonprimary care specialty, the Prestige/income, the Intellectual Content factor, and the Research Factor, with its absence of stress and opportunity for research in other nonprimary care fields, swayed their decision. These findings have implications for the medical school admissions process. If that process can be used to identify students who relate well to people and are more oriented to dealing with preventive medicine and the broad spectrum of health problems presented by individual patients, then it could become an even greater force in the movement toward generalism in medicine.

Why students choose a primary care or nonprimary care career

purpose: To analyze the factors influencing students to choose residency training in primary care (internal medicine, family medicine, and pediatrics) or nonprimary care specialties and study the combined effect of reported responses on their choice. materials and methods: A 12-item questionnaire using a 7-point Likert scale was mailed to the 1,164 graduating seniors from 9 medical schools in 1991. Responses ranged from 1, very negative influence, to 7, very positive influence. Four indicated no influence. The overall response rate was 69%. Univariate analysis of factors associated with specialty choice was done with the Mantel-Haenzsel chi-square test. Odds ratios were calculated for each significant variable without controlling for other variables. Factors found to have univariate significance were then tested for combined significance with logistic regression analysis. The regression was performed on a randomly chosen training sample, and validated on a test sample. results: Forty-five percent of respondents chose an internship and planned residency training in a primary care specialty. Factors that remained positively associated with choosing a primary care specialty when controlling for other factors were desire to provide comprehensive care, to keep options open, and to undertake ambulatory care. Desire for monetary reward was negatively associated with choice of a primary care specialty. conclusions: Positive educational experiences in the ambulatory setting should be enhanced, and disparity in remuneration among disciplines reduced.

Specialty Choice Among Students Entering the Fourth Year of Medical School

In this article, the authors explore senior medical students' specialty preferences and investigate factors that influence those preferences. The design of the study was a written questionnaire. The setting was a large, state-supported university-based southern medical school. The patients/participants were students entering the fourth year of medical school. One hundred seventy-six students (97% of the class) completed the questionnaire. Of those students, 12.5% were interested only in primary care, 43.2% were interested in both primary and nonprimary care, and 44.3% were interested in nonprimary care careers. Most students considering both primary and nonprimary care careers were interested in general internal medicine or general pediatrics and subspecialties within those fields. Career choice was influenced most strongly by several factors--clerkship experiences, the fact that it fit with skills/abilities, physician role models, the challenge, and intellectual content. Encouragement from family and other students, prestige, and income potential had the least impact on career choice. Students interested in primary care careers valued providing continuity of care much higher than did those interested in nonprimary care specialties. The authors conclude that students' experiences in medical school, particularly during the clerkships, have a significant impact on their specialty choice.

Influence of Income, Hours Worked, and Loan Repayment on Medical Students' Decision to Pursue a Primary Care Career

To assess the specialty plans of current fourth-year medical students and, for those not choosing primary care specialties, to investigate the potential effect that changes in key economic or lifestyle factors could have in attracting such students to primary care. A survey study was sent to 901 fourth-year medical students in the 1993 graduating classes of six US medical schools. Comparisons were made between students choosing and not choosing primary care specialties. For the non-primary care students, we also evaluated whether alteration of income, hours worked, or loan repayment could attract them to primary care careers. Of the 688 responses (76% response rate), primary care specialties were chosen by 27% of the students and non-primary care specialties by 73%. One quarter (25%) of the non-primary care students indicated they would change to primary care for one of the following factors: income (10%), hours worked (11%), or loan repayment (4%). For students whose debt was $50,000 or greater, the loan repayment option became much more important than for students with lesser debt. In all, a total of 45% (n = 313) of the students indicated either they were planning to enter primary care (n = 188) or they would change to a primary care specialty (n = 125) with appropriate adjustments in income, hours worked, or loan repayment. Significant changes in economic and lifestyle factors could have a direct effect on the ability to attract students to primary care. Including such changes as part of health system reform, especially within the context of a supportive medical school environment, could enable the United States to approach a goal of graduating 50% generalist physicians.

Specialty choice: development of a questionnaire

Determination of factors which influence medical students' choice of a specialty is potentially important for decisions regarding medical school curricular changes that might influence students' specialty choice. Beginning in 1988, we developed and annually revised a specialty choice questionnaire which was administered to the senior class at the Medical College of Georgia School of Medicine from 1988 to 1991. This paper presents reliability and validity data regarding the questionnaire. Validation procedures involved driving a multiple discriminant function to determine the significance of relationships between a variable and choice of a primary care (PC) or non-primary care (NPC) specialty. Structure coefficients for the multiple discriminant functions that were statistically and practically significant were desire for longitudinal patient care opportunities and desire for monetary rewards. Estimates of internal consistency were derived using Cronbach's alpha. Cronbach's alpha coefficients for this item set were 0.71, 0.59 and 0.46 for 1988, 1989 and 1990 respectively. Test-retest coefficients for the 1991 12-item questionnaire ranged from 0.51 to 0.81.

Family medicine role models at US medical schools. Why their relative numbers are declining.

A decline in medical student interest in family practice combined with an increasing demand for family physicians by managed care systems and the need to replace family and general practice physicians nearing retirement age make it likely that the future supply of family physicians will not be adequate. Specialty selection by medical students is influenced by the medical education environment, especially the presence of faculty role models. Due to a decline in federal support for family medicine and a growth in sources of medical school support that favor nonprimary care specialties, the proportion of clinical faculty in family medicine has declined. This has occurred simultaneously with declining student interest in family medicine. Suggestions are offered to increase the number and influence of family medicine role models at US medical schools.

Internal medicine and the journey to medical generalism.

The overspecialized U.S. physician workforce and mix of graduating residents undermine strategies to provide quality and affordable health care to all Americans. Several respected advisory bodies have recently proposed fundamental changes in federal policy to better match physician supply and specialty mix with health care needs. They recommend that Congress limit the total number of filled first-year resident positions to 110% of the number of U.S. medical school graduates, a 20% reduction from current levels. They have proposed that positions and funding be allocated to medical schools, teaching hospitals, residency programs, or consortia of such entities to ensure that at least 50% of each graduating residency class enters generalist practice. An all-payer, graduate medical education pool and financing system have been suggested as ways to uncouple the physician workforce from hospital service needs and to eliminate disincentives toward ambulatory and primary care training. Increases in generalist production must be accompanied by decreases in nonprimary care specialty and subspecialty positions. In addition, generalist physicians must be better prepared in managed care competencies. Given today's subspecialist surplus, managed care organizations are considering how to retrain subspecialists as generalists. The Federated Council of Internal Medicine's goal that 50% of its graduates become general internists is an important step because internists compose one sixth of all physicians and one third of all first-year residents. This article identifies the challenges that lay ahead on the road to medical generalism and what it may take to get there.

Classification model that predicts medical students' choices of primary care or non-primary care specialties.

To identify factors that influence students to choose primary care or non-primary care specialties, the authors surveyed the 509 graduating students at the Medical College of Georgia School of Medicine in 1988, 1989, and 1990. Using a Likert-type scale, the 404 responding students rated potential influences on their specialty choices from 1, very negative, to 7, very positive. The students choosing primary care specialties were positively influenced significantly more often by their desire to keep options open (85% versus 58%, p less than .001) and their desire for longitudinal patient care opportunities (95% versus 54%, p less than .001). Those choosing non-primary care specialties were more often influenced by their desire for monetary rewards (69% versus 35%, p less than .001) and by their perceptions of lifestyle following residency (74% versus 60%, p less than .01) and prestige of the specialty (57% versus 36%, p less than .001). The authors used multiple discriminant analysis to derive a discriminant function that would permit classification of students into primary care and non-primary care groups. The potential influences of desire for longitudinal care opportunities and desire for monetary rewards were statistically and clinically significant for all three years. Using the discriminant function, the authors correctly classified 81%, 79%, and 78% of the students' specialty choices for 1988, 1989, and 1990, respectively. The authors suggest that addressing the issue of monetary rewards will be necessary before the primary care fields again become attractive to students.

Anesthesia in Canada's health care system

Much has been. written about Canada's health care system as all countries wrestle with rising health costs. Few, however, have attempted to describe the influence of a system of health care on a nonprimary care specialty such as anesthesia. The purpose o f this review is to describe the Canadian system, contrast it with that of the United States, and outline the impact that Canadian Medicare has had on anesthetic practice. A centrally controlled health care system is potentially blessed with the stability (and rigidity) inherent in any program perceived by the public as being their right and privilege. Changes are slow to occur, be they changes of new technology or alterations in the form of physician reimbursement. However, such stability means that control of health care costs can be achieved without intrusion into physician-patient relationships and professional, freedom is preserved. Similarly, the acquisition. of technological support for the practice of anesthesia, necessary to ensure a high standard of public safety, has not been perceived as a problem in Canada. Anesthesia in Canada is a physician-only specialty, and nurse-administered anesthesia does not exist. It is highly dependent on the functioning of the hospitals, for widespread development of freestanding health care institutions has not occurred. Compensation is on a fee-for-service basis, although alternative compensation for certain aspects of practice exists in some jurisdictions. In general, fees are indexed to the surgical procedure at hand, with time (duration) modifiers, as well as modifiers for specific is techniques. Overhead is minimal, so although fees for a given procedure are lower than in the United States, the disparity in earned income is reduced. Unfortunately, recent initiatives to control physician use have limited the ability o f the profession to compensate completely for this North American discrepancy in fees. Since health care in Canada is a provincial responsibility, there are eleven separate plans linked only by the guiding principles of the National Health Act of 1971. Each provincial medical association is responsible for negotiating the fee schedules with the provinces on behalf of its members. Since these associations must respond to the majority of their members, it has been the perception of specialty groups such as anesthesia. that the emphasis of allocations in recent years has been on primary care fields. Anesthetists have therefore found themselves increasingly involved with the collective negotiation process as an unwanted necessity of practice. This collectivism of interests has been the most striking consequence of Canadian Medicare on anesthesia practice, as it has influenced all aspects of patient-physician interactions.