Mary Kay Schleiter

National Study of Internal Medicine Manpower: IX. Internal Medicine Residency and Fellowship Training: 1984 Update.

After 12 years of annual expansion, the number of entrants into internal medicine training did not increase in 1983-84. In addition, the number of United States citizens with medical degrees from other countries entering first-year residency positions in internal medicine declined in 1983-84 for the first time in many years. The number of trainees who, upon completion of residency training, chose to become subspecialty fellows increased, and the period of subspecialty training has lengthened to 3 years for one third of the fellows. The total budgets for residency stipends have not increased in real dollars since 1976-77 despite substantial rises in the number of trainees. In fact, stipend levels per resident and fellow have declined in real dollars. Internists make up about 25% of all practicing physicians. With the continuing growth in the number of practicing internists and the high rate of their subspecialization, some adjustments will be made in practice patterns over the next 2 decades.

Changes in the Supply of Internists: The Internal Medicine Population from 1978 to 1998

Between 1978 and 1985, the number of active internists in the United States increased from 64,000 to 91,000, and by 1998 the number will have increased to 141,000. This growth represents an increase of 121% for a 20-year period, during which time the population of the United States is expected to increase only 19%. Thus, the number of adults older than 17 years per active internist will drop from 2464 to 1401. Between 1978 and 1998, we expect the number of subspecialty internists to increase 206%, in contrast to a 77% increase expected for general internists. The proportion of female internists will increase from 7% to 21%. The proportion of the active internist population who are foreign medical graduates will remain stable at about 21% throughout the projection period, but within this group the proportion who are United States citizens is expected to increase while the proportion who are foreign citizens is expected to decline.

National Study of Internal Medicine Manpower: VI. Factors Predicting Preferences of Residents for Careers in Primary Care or Subspecialty Care and Clinical Practice or Academic Medicine

With data collected from a national sample of residents in internal medicine (Questionnaire III of the National Study of Internal Medicine Manpower), two models are empirically tested: the first predicting interest in primary care medicine in contrast to subspecialty medicine and the second predicting interest in academic medicine in contrast to clinical practice. Correlation and multiple regression (path analysis) show that background and personal variables specific to each person such as religion, personality type, and desire for control over working conditions have greater predictive power than variables describing the environment such as the type of medical school or residency program the trainee attends. The single most important predictor in terms of unique variance explained in both models is the desire for control over working conditions. The variables positively related to interest in primary care are negatively related to interest in academic careers.

National study of internal medicine manpower: IV. Residency and fellowship training 1977-1978 and 1978-1979.

The National Study of Internal Medicine Manpower gathered data on the number of residents in training in internal medicine and the number of fellows in subspecialty training, for 1977-1978 and for 1978-1979. In the latter period, there were 16720 residents in all years of training. The 7.2% average annual increase in the number of first-year residents during the earlier half of the 1970s slowed in 1977-1978 and 1978-1979 to 4.6% and 4.2%, respectively, reflecting a similar decline in the number of medical school graduates. The most important finding of the study is that the steep rise (10.6% per year) in the number of subspecialty fellowship trainees characteristic of the years 1972-1973 through 1976-1977 has abated. The number of fellows in subspecialty training has remained essentially constant in the past 2 years. Thus, although the number of residents continued to increase and the number of fellows remained constant, the number (and percentage) of internists in training who intend to practice general internal medicine rose.

National study of internal medicine manpower: II. A typology of residency training programs in internal medicine.

This second paper of the National Study of Internal Medicine Manpower describes the differing environments of residency training programs. Using previous studies as prototypes, the authors apply factor analysis to data from questionnaires returned by residency training directors and residents to illustrate the myriad interrelations within training programs. The most important result of this study is the demonstration that the largest residency programs have the most subspecialty programs, and their residents are more likely to pursue subspecialty fellowships after completing their third residency year. However, preliminary findings show no associations between the typology (typologic categories of residencies and their trainees) used and desired practice locations in states having few physicians relative to the population or in states with fewer urban inhabitants. The typology also does not predict the future practice aspirations of residents who are more likely to care for the poor or minority populations. A separate set of factors, possibly unrelated to training environments, will help to predict such career outcomes. Further specification of these factors will be the subject of a later paper in this series.

National Study of Internal Medicine Manpower: V. Comparison of Residents in Internal Medicine—Future Generalists and Subspecialists

Questionnaire III of the National Study of internal Medicine Manpower was directed to a random sample of residents (and subspecialty fellows) in the spring of 1977. Residents were classified according to whether they sought careers as predominantly general internists (49%) or subspecialty internists (51%), and the two groups were compared. Future generalists, more often, tended to be non-Jewish, to have incurred higher debts, and to have trained in medical schools in the states where they had spent their childhoods. Training experiences also were different. Future generalists, more than subspecialists, were attracted to the field because of the ability to retain independence in their work. Subspecialists, more often, intended to have academic careers and locate in the largest cities. Although subspecialists expected greater financial rewards, neither group selected their fields on this basis. By controlling for the main criterion used to select the medical school attended, we were able to explain several factors that differentiated the two groups.

National Study of Internal Medicine Manpower: VII. Residency and Fellowship Training 1976-1977 Through 1980-1981

A complete census of the number of residents training in internal medicine and fellows in subspecialty training for 1979-1980 and 1980-1981 has been compiled by the National Study of Internal Medicine Manpower. Complete information is now available for the 5-year period from 1976-1977 through 1980-1981. The number of first year residents in internal medicine continues to rise. A constant percentage (35% to 38%) of the graduating class of United States medical schools has entered these programs each year for over a decade. The number of first year fellows in subspecialty training, which in the first half of the 1970s rose 10% to 11% annually, has declined slightly in the second half of the 1970s and has been stable in the past 2 years. The net result of the increasing number of residents and the decreasing number of fellows is a rising proportion of internists entering general internal medicine and a proportionate decline in those choosing subspecialty careers.

National Study of Internal Medicine Manpower: III. Subspecialty Fellowship Training 1976-1977

Questionnaire II of the National Study of Internal Medicine Manpower was directed to all of the 1502 subspecialty training programs in the United States and Puerto Rico. The overall response rate was 86%. For the years 1972-1973 through 1976-1977 the number of fellows in subspecialty training grew at an average rate of 10.6% per year, or one and one-half times greater than the growth rate of 7.2% in the number of first-year residents in training for the same time period. In 1976-1977 there were 5826 fellows in subspecialty fellowship training, of whom 26% were foreign medical graduates. Stipends for subspecialty fellows in 1976-1977 amounted to

Primary care training.

90 million, 40% of which was derived from direct federal funds and 33% from hospital revenues. Most of the subspecialty fellowship programs were in large teaching hospitals, which are closely affiliated with the nations medical schools. The 1976-1977 professional activities of former subspecialty trainees who had finished their training between 1972 and 1976 were distributed roughly in thirds between research-teaching, teaching-practice, and practice. We discuss public policy implications of the data.

Reviews and Notes: The Empathic Practitioner: Empathy, Gender, and Medicine

Excerpt To the editor: The paper by Goldenberg and colleagues (1) represents an important contribution to the large literature that can be expected to emerge from the development of primary care pa...