Changing Attitudes Among Medical
Students Toward Internal Medicine
By Susan Maas, freelance writer,
written for the Association of Staff Physician Recruiters
First, the good news: medical students today see internal medicine as a more rewarding career choice than students two decades ago did.
But their higher regard of the work itself is offset by some stubborn realities — especially when it comes to primary care, according to a study in the April 25 issue of the Archives of Internal Medicine.
The study compared medical students’ changes in attitudes toward internal medicine from 1990 to 2007. Students graduating in 2007 had more positive views of internal medicine than those graduating in 1990 — in part thanks to changes in medical school training — but were less likely to consider primary care.
“More students are saying internal medicine looks attractive to them,” says lead author Mark Schwartz, M.D., Director of New York University School of Medicine’s General Internal Medicine Fellowship Program. “It’s gratifying that students are viewing internal medicine more positively; many [shortcomings] in the medical school experience have been addressed since 1991.” The percentage of students seeing opportunities for “meaningful” work in internal medicine increased in those two decades from 42 percent to 58 percent.
Loan debt, pay gap influencing students
Yet the number of students planning to practice primary care internal medicine, as opposed to pursuing subspecialty careers, dwindled from 9 percent to 2 percent. That’s likely due to several factors, including the one-two punch of massive medical school debt and the primary care “compensation gap,” Schwartz says. The authors point to a 2007 study, published in the Annals of Internal Medicine, showing that the income gap between generalists and subspecialists has nearly tripled since 1990 — resulting in an income disparity of $3.5 million throughout a 40-year career. That gap could influence students’ career choices “directly and indirectly by sending ‘market signals’ about status, prestige, work life and lifestyle,” the new study says.
Both the 1990 and the 2007 cohorts thought that workload and stress were greater in internal medicine than in other fields. Given the tremendous debt many students are saddled with today — the 2007 group owed a mean of $101,000, vs. $63,000 (inflation-adjusted) for the 1990 cohort – it’s going to take “bolder payment and practice reform” to increase the number of students choosing general practice internal medicine, the authors say.
In fact, the study reported that a higher proportion of students — 26 percent, vs. 16 percent in 1990 — were deterred from pursuing a career in internal medicine by their student loan debt. Primary care internal medicine residents Elizabeth Goelz and Tyler Dunphy, both of whom work with study co-author Mark Linzer, M.D., at Hennepin County Medical Center in Minneapolis, say debt was a factor for many of their peers. “Some of my classmates are coming out with upwards of $200,000 in loan debt,” Goelz says.
Some partial solutions, such as the National Health Service Corps’ loan repayment program for primary care clinicians, were approved as part of the Affordable Care Act. But whether they’ll be fully funded remains unclear, and even if funding is allocated, the effect is likely to be only “modestly” helpful, Schwartz says.
Given the anticipated explosion in primary care demand, with “aging, chronically ill baby boomers... and an obesity epidemic,” the shortage of primary care physicians spells looming crisis. The study cites an Institute of Medicine report predicting a shortage of 35,000 to 44,000 adult care generalists by 2025. Medical education has made great strides in offering a more satisfying internal medicine experience, the authors say, but the pending dearth of primary care providers demands significant changes in health policy and work conditions.
Perceptions of heavy workload and stress improved slightly between 1990 and 2007, notes coauthor Linzer, Director of the Division of General Internal Medicine at Hennepin County Medical Center in Minneapolis. But they’re still relatively high — and today’s students place a premium on work-life balance, Linzer says.
“They want flexibility, they want family life,” Linzer says. “So they’ve given us a challenge. They’re saying, ‘Look, I’d like to do this — but I’d like to see my family, and I have to pay off my debt.’”
One potential way to meet that desire, Schwartz and Linzer say, is by creating more part-time work opportunities. “Part-time is coming,” Linzer says, and could give many internal medicine primary care providers a “less stressful, more controllable” work life.
Emerging care model offers promise
Another hopeful trend, the authors say, is that of the patient-centered medical home (PCMH) practice model. The PCMH is a coordinated approach to patient care in which a personal physician collaborates with other health professionals to provide preventive care, treatment of acute and chronic illness, and end-of-life care. This team-based approach to integrating every aspect of a patient’s care has shown promise in improving outcomes, reducing costs — and decreasing physician burnout. The PCMH model may be ushering in a “new era” of health care, Linzer says — one that’s better both for patients and primary care providers.
“I’m really interested in that type of primary care,” Dunphy says. “A lot of that administrative stuff, that perceived ‘busy work,’ could be triaged throughout the team and [allow us] to increase the amount of actual medicine we practice.”
For some young physicians, many of whom are both “idealistic and practical,” a combination of fulfillment and flexibility might be enough to mitigate the financial disadvantages of practicing general care internal medicine, Linzer believes.
“I thought the study had a lot of good news, actually,” Linzer says. “[Students today] are choosing IM both for the intellectual stimulation and for the relationship with the patient.” Both Dunphy and Goelz agree, emphasizing that the privilege of providing continuous care to a wide range of interesting and “inspiring” people far outweighs the downsides of internal medicine primary care. “This is 100 percent the right fit for me,” Goelz says. “It’s the patients I work with.”
Susan Maas is a freelance writer at MaasMedia in the Minneapolis area and a freelance copy editor at Minnesota magazine.