National Study of Internal Medicine Manpower: XIX. Trends in internal medicine residency training programs.

The National Study of Internal Medicine Manpower (NaSIMM) reports on the results of its 1989-1990 census of residency programs. The results are integrated into an organizational model identifying inputs, process, outputs, and environment of medical training programs. The number of residents entering internal medicine continues to grow at a relatively rapid pace. This growth is largely accounted for by foreign citizens who are graduates of foreign medical schools (AFMGs). Residents are spending an increasing proportion of their time in ambulatory care settings, but, thus far, this ambulatory care training has occurred primarily in hospital clinics and emergency rooms. The proportion of a program's residents entering general internal medicine was found in a multiple regression analysis to be negatively associated with the number of subspecialty programs located in the training hospital, the percent of AFMG residents in the program, and the presence of a preliminary track in the program.

National Study of Internal Medicine Manpower. XVIII: Subspecialty fellowships with a special look at hematology and oncology, 1988-1989.

OBJECTIVE: To determine the number and distribution of internists in subspecialty training and compare with data collected since 1976; to determine the distribution of activity of subspecialty fellows; and to focus on hematology and oncology. DESIGN: Repeated mail survey with telephone follow-up. PARTICIPANTS: All directors of subspecialty training programs in internal medicine in the United States. RESULTS: The 1988-1989 census identified 7530 fellows in training, 55 more than in 1987-1988. There are 24 more first-year fellows. Reports on the activities of subspecialty fellows show that, overall, 53% of fellows' time is spent in direct patient care, 20% on basic research, 15% on patient-related research, and 12% in teaching. CONCLUSIONS: The number of internists entering subspecialty training has risen at a considerably slower rate in the last 5 years compared with the 5 years before that. The length of subspecialty training has increased significantly since 1976. There has been a shift in subspecialty choice from hematology to oncology and toward joint programs offering both subspecialties.

National Study of Internal Medicine Manpower: XVII. Changes in the characteristics of internal medicine residents and their training programs, 1988-1989.

The National Study of Internal Medicine Manpower (NaSimm) has been surveying program directors of internal medicine about their programs and residents for 13 years. The 1988-1989 survey results, when compared with the results for 1987-1988, show an increase in both the number of residency positions offered in internal medicine and the number of residents in internal medicine programs. Although the proportion of graduates from U.S. medical schools who choose internal medicine is not changing (34%), the proportion of U.S. medical school graduates who continue training in internal medicine after their first year is decreasing. The composition of the residents in internal medicine by medical school graduated is also changing. Almost 25% of the first-year residents (R1s) in internal medicine are now graduates of foreign medical schools (FMGs) compared with 14% in 1976. The proportion of first-year female residents in internal medicine has increased to 30%, whereas the proportion of both first-year blacks and Hispanics has remained constant at 5% each. In nearly 25% (109 of 440) of the residency programs, more than 50% of the R1s are FMGs. Hispanics, Asians, and blacks were found to be over-represented in the programs training larger proportions of FMGs. This over-representation is attributable, in part, to the fact that Hispanics and Asians may be FMGs. Training issues of concern to program directors continue to be the provision of ambulatory and primary care experiences and the scheduling of nights on call. The survey results show that many residency program directors have reported a reduction in the number of nights on call and an increase in the amount of time residents spend in ambulatory training.

National Study of Internal Medicine Manpower. XIV: Patterns of residency and fellowship over time, 1987 update.

In response to concerns among internists following the 1987 internal medicine match, this report compares internal medicine trainees with those in other specialties since 1972, describes their paths through the internal medicine "pipeline," and documents their distribution and continuation rates in residency and subspecialty fellowship programs. It is based on the National Study of Internal Medicine Manpower, 1987-1988. Between 1972 and 1986 the number of trainees in internal medicine doubled, and the percentage of trainees in internal medicine grew from 20% to 25%, while the percentage in surgical specialties declined from 28% to 19%. The numbers of women and foreign medical school graduates training in internal medicine have continued to increase, but minority representation has stabilized. Women and minorities have lower continuation rates into fellowships, and distinctive patterns of subspecialization are found among women, minorities, and foreign medical school graduates.

National Study of Internal Medicine Manpower: XVI. Subspecialty fellowship programs, 1988 update.

Much of the debate about medical manpower during the 1980s has focused on the growing number of medical subspecialists. We examined the number of subspecialty fellows since 1976, paying particular attention to data collected in the 1987-1988 academic year. The number of fellows in subspecialty training at a given time has increased by 27% since 1976; however, much of this increase is due to the increased length of the training programs. The number of first-year fellows has increased only 7% since 1976. Growth in the number of fellowships has varied by subspecialty. The number of fellowships in geriatrics, critical care, and general internal medicine has increased dramatically. Additionally, the traditional subspecialties-cardiology, pulmonary disease, gastroenterology, infectious diseases, rheumatology, and allergy-immunology-have all grown to some extent. Program directors in all subspecialties anticipate continued growth in the coming years.

Medical practice where HMOs dominate: the perspective of physicians in Minneapolis-St. Paul.

Physicians in the Twin Cities are part of a progressive medical community which has traditionally participated in and often provided leadership for innovation and change in healthcare delivery. Recently, the health maintenance organizations (HMOs) and other managed care systems in which they have participated and even founded have grown to dominate the medical care of Minneapolis-St. Paul with 50% of the population enrolled. Although in this healthy, homogeneous, and middle-class community physicians say they are satisfied that the quality of healthcare for patients still continues to be good, the lives of physicians--their mode of practice and their interactions with patients, colleagues, and hospitals--have changed fundamentally. Whether physicians practice in staff or group HMOs or continue to practice in their own offices, they say they are no longer "in control"; the plans "call the tune".