Research training in six selected internal medicine fellowship programs.

BACKGROUND: Effective July 1997, the American Board of Internal Medicine (ABIM) established a research pathway to certification to encourage research training of general internists and subspecialists. OBJECTIVE: To document the current status of research training in six selected subspecialty programs, to examine opportunities available for trainees to undertake formal course work, and to report the percentage of subspecialty programs that might accept research pathway fellows. DESIGN: National Study of Graduate Education in Internal Medicine questionnaires from 1996-1997 and 1997-1998. SETTING: Programs in internal medicine subspecialties accredited by the Accreditation Council for Graduate Medical Education. PARTICIPANTS: 1163 (84%) and 1094 (79%) directors of internal medicine subspecialty programs in 1996-1997 and 1997-1998, respectively. MEASUREMENTS: Survey questions on the amount of time fellows usually spend conducting research and available opportunities to pursue course work leading to an advanced degree. RESULTS: On average, during their last year of training, fellows enrolled in infectious disease, nephrology, endocrinology, and rheumatology programs spent 40% to 50% of their time conducting research, whereas fellows in gastroenterology and cardiology spent 25% to 30% of their time conducting research. Compared with programs sponsored by major teaching hospitals, a greater percentage of programs sponsored by academic medical center hospitals planned to accept persons interested in pursuing the new ABIM Research Pathway (28% vs. 8%) and to provide opportunities for fellows to obtain an advanced degree (60% vs. 14%). CONCLUSIONS: Few internal medicine subspecialty programs are currently designed to provide adequate research training as defined by the Institute of Medicine and the ABIM.

Communication and professionalism.

The text of this lecture was presented in July 1999 at the international Chicago meeting on Communication in Medicine. The topic 'Communication and professionalism' has been approached by drawing on the work at the Association of American Medical Colleges (AAMC). The challenge is to align medical education content with societal needs, practice patterns and scientific developments. In this perspective, the goals of medicine have been presented, however, also related to experienced real life situations, the changes within medical practice and the erosion of the doctor-patient relationship. It is stressed that we must produce excellent clinicians, who have good communication skills, and being able to use those skills in the care of their patients. This implies that the current focus on communication in medicine is very important in the medical education.

Transformation of medical students' education: work in progress and continuing challenges.

In his book Time to Heal: American Medical Education from the Turn of the Century to the Era of Managed Care, Ludmerer expresses concern about the erosion of the environment in which medical students and residents learn the clinical skills, attitudes, and behaviors that they will need to practice high-quality medicine. Importantly, while he attributes the erosion of the clinical environment largely to the impact of managed care, he also places some responsibility within academic medicine itself, primarily the redirection of the clinical faculty's efforts away from traditional academic pursuits to the generation of clinical revenues. The Association of American Medical Colleges has information about the kinds of changes already occurring. In the preclinical curriculum, schools have introduced a wide range of new courses and topics, and there is more attention on professionalism and values. Schools are making fundamental changes in the design and conduct of the curriculum, primarily by adopting more integrated (non-departmental) approaches to course design and management. The clinical curriculum is changing primarily through the greatly expanded use of ambulatory care sites, and medical schools are developing new approaches to managing dispersed and varied instruction. Also, faculty are paying more attention to the role of residents as teachers and role models. These changes speak well for medical education. Nonetheless, substantial and sustained work remains to be done despite the present uncertainty about the future of academic medical centers. This work is essential--a challenge that the leaders of academic medicine must not fail.

Educational technology to facilitate medical students' learning: background paper 2 of the medical school objectives project.

The present article is the second in a series of Background Papers prepared as part of the AAMC's Medical School Objectives Project (MSOP). This report provides information about and insight into U.S. medical schools' use of educational technology in 1998. The authors define educational technology as the use of information technology to facilitate students' learning. They note that in the last two decades, a number of reports have recommended that medical schools incorporate educational technology into their teaching programs. To gain insight into the effects of these recommendations, particularly those of the ACME-TRI Report in 1992, the authors analyzed the responses of administrators at 125 U.S. medical schools to relevant items of the 1997-98 Liaison Committee on Medical Education Part II Medical School Questionnaire and students' responses to relevant items of the 1998 AAMC Medical Student Graduation Questionnaire. In addition, site visits were made to six medical schools believed to be among the more advanced ones in the use of educational technology, to see what was happening on the "cutting edge" of educational technology applications. Data from 20 other schools were also used. The authors found that by 1998, medical schools as a group had made limited progress in accomplishing the recommended educational technology goals, and that there was a much greater use of such technology in basic sciences courses than in clinical clerkships. However, great variability existed across schools in the use of such technology and in the administrative arrangements for it. They observe that the use of educational technology in medical schools is increasing rapidly, and recommend that each school develop a strategic approach that will guarantee that it can meet the future educational technology needs of its students.

Teaching professionalism in undergraduate medical education.

CONTEXT: There is a growing consensus among medical educators that to promote the professional development of medical students, schools of medicine should provide explicit learning experiences in professionalism. OBJECTIVE: To determine whether and how schools of medicine were teaching professionalism in the 1998-1999 academic year. DESIGN, SETTING, AND PARTICIPANTS: A 2-stage survey was sent to 125 US medical schools in the fall of 1998. A total of 116 (92.3%) responded to the first stage of the survey. The second survey led to a qualitative analysis of curriculum materials submitted by 41 schools. MAIN OUTCOME MEASURES: Presence or absence of learning experiences (didactic or experiential) in undergraduate medical curriculum explicitly intended to promote professionalism in medical students, with curriculum evaluation based on 4 attributes commonly recognized as essential to professionalism: subordination of one's self-interests, adherence to high ethical and moral standards, response to societal needs, and demonstration of evincible core humanistic values. RESULTS: Of the 116 responding medical schools, 104 (89.7%) reported that they offer some formal instruction related to professionalism. Fewer schools have explicit methods for assessing professional behaviors (n = 64 [55.2%]) or conduct targeted faculty development programs (n = 39 [33.6%]). Schools use diverse strategies to promote professionalism, ranging from an isolated white-coat ceremony or other orientation experience (n = 71 [78.9%]) to an integrated sequence of courses over multiple years of the curriculum (n = 25 [27.8%]). Of the 41 schools that provided curriculum materials, 27 (65.9%) addressed subordinating self-interests; 31 (75.6%), adhering to high ethical and moral standards; 17 (41.5%), responding to societal needs; and 22 (53.7%), evincing core humanistic values. CONCLUSIONS: Our results suggest that the teaching of professionalism in undergraduate medical education varies widely. Although most medical schools in the United States now address this important topic in some manner, the strategies used to teach professionalism may not always be adequate.

Medical students' education in the ambulatory care setting: background paper 1 of the Medical School Objectives Project.

The present article is the first MSOP Background Paper. In planning the Medical School Objectives Project (MSOP), the Association recognized that certain changes in medical students' education were occurring already in some schools, and that it would be important to gain insight into and monitor these changes to provide ideas and information to help schools design curricular changes to foster students' achievements of the objectives and recommendations set forth in the MSOP Reports published in 1998 and reprinted in Academic Medicine. This background paper provides an overview of the strategies being developed by medical schools to carry out education in the ambulatory care setting. This report is based on site visits in 1997 to 26 U.S. medical schools conducted by two of the authors (CEH and GAK), who also used information from 12 additional schools that were not visited and consulted individuals responsible for the evaluation of five grant programs dedicated to national curriculum reform. The authors define and discuss in detail the use of the three main strategies that their research uncovered: (1) longitudinal preceptorships, (2) multispecialty clerkships, and (3) activities that are community oriented and population based to provide medical students the kinds of educational experiences they need to understand and practice in the ambulatory care setting. The authors then discuss issues and challenges related to the implementation of these curricular changes: curricular management issues; developing and maintaining a network of practicing physicians willing to serve as preceptors; evaluating curricular innovations; and assessing students' performances. The authors conclude with general observations about the need for ambulatory care education, the difficulties that have been--and continue to be--met and overcome to implement it, and the recommendation that relevant learning experiences should be incorporated into existing course work or clinical experiences.

Trends in clinical education of medical students: implications for pediatrics.

OBJECTIVES: To describe current educational imperatives and trends for curricular changes in the clinical education of medical students and to delineate the nature and extent of participation in these curricular trends by departments of pediatrics. METHODS: Site visits to 26 representative US medical schools and a review of detailed information from 12 additional schools. Evaluation of the core curriculum was developed by the Council on Medical Student Education in Pediatrics within the context of the major curricular trends observed. RESULTS: The major observed curricular trends emphasized community-based ambulatory experiences, continuity of care, integration, and population-based experiences. Supporting educational principles included student-directed learning and performance-based assessments. The 3 major curricular changes were early clinical experiences (longitudinal preceptorships), community-oriented/ population-based experiences, and multispecialty clerkships. The focus of the Council on Medical Student Education in Pediatrics objectives was the year 3 clerkship, and substantive participation by pediatric faculty in the overall curriculum was primarily related to the pediatric clerkship. CONCLUSIONS: Revising the clerkship-based Council on Medical Student Education in Pediatrics guidelines according to the new educational trends will extend clinical curricular opportunities for pediatrics beyond the traditional boundaries of the clerkship. The discipline of pediatrics will, as a consequence, be able to achieve enhanced partnership in the planning, conduct, and evaluation of a clinical curriculum for medical students that is relevant to child health issues and that extends across all 4 years.

Employment-seeking experiences of resident physicians completing training during 1996.

CONTEXT: Studies analyzing the physician workforce have concluded that the United States is verging on a physician oversupply, yet we lack persuasive evidence that this is resulting in physician underemployment and/or unemployment. OBJECTIVE: To determine the degree to which graduating residents have difficulty finding or are unable to find employment in their primary career choices. DESIGN: Two 1-page surveys sent separately to residents and to program directors to collect information on the employment status of residents who were completing a graduate medical education program at the end of the 1995-1996 academic year. SETTING: A total of 25 067 resident physicians scheduled in the spring of 1996 to complete a residency program accredited by the Accreditation Council on Graduate Medical Education, and 4569 program directors in 31 specialties and subspecialties. MAIN OUTCOME MEASURE: Both the graduates' employment status and the degree of difficulty they experienced securing a practice position, as reported by resident physicians and program directors. RESULTS: After 6 months of data collection, 12135 (48.4%) of 25 067 resident physicians responded to the survey. Of the respondents, 11 200 had completed their training, and 7628 (68.1%) were attempting to enter the workforce, 28.4% were seeking additional training, and 3.5% were fulfilling their military obligations. Of the 7628 resident physicians who sought employment, 67.3% obtained clinical practice positions in their specialties, 15.5% took academic positions, 5.0% found clinical positions in other specialties, 5.1% had other plans, and 7.1% did not yet have positions but were actively looking. In addition, 22.4% of resident physicians who found clinical positions reported significant difficulty finding them. The subgroup reporting greater difficulty finding clinical positions included international medical graduates (more than 40%),those completing programs in the Pacific or East North Central region, and those in several specialties. The 1996 graduating residents reported significantly higher rates of difficulty finding suitable employment than program directors reported for their graduates (22.4% vs 6.0%); however, the percentage of graduates reported by both groups as entering the workforce was the same (68.1%). Program directors reported an unemployment rate of only 1.2%, for their 1996 graduates, which was less than the rate reported by the resident physicians (7.1%). CONCLUSIONS: Resident physicians' direct reports of their employment-seeking experiences differ from what program directors report. Program directors accurately determined the number of residents pursuing further training; however, they did not have complete information about the employment difficulties experienced by their graduates. Based on graduates' reports, we conclude that employment difficulties are greatest among international medical graduates and vary by specialty and geographic region.

The National Health Service Corps: rural physician service and retention.

BACKGROUND: The National Health Service Corps (NHSC) scholarship program is the most ambitious program in the United States designed to supply physicians to medically underserved areas. In addition to providing medical service to underserved populations, the NHSC promotes long-term retention of physicians in the areas to which they were initially assigned. This study uses existing secondary data to explore some of the issues involved in retention in rural areas. METHODS: The December 1991 American Medical Association (AMA) Masterfile was used to determine the practice location and specialty of the 2903 NHSC scholarship recipients who graduated from US medical schools from 1975 through 1983 and were initially assigned to nonmetropolitan counties. We used the AMA Masterfile to determine what percentage of the original cohort was still practicing in their initial county of assignment and the relation of original practice specialty and assignment period to long-term retention. RESULTS: Twenty percent of the physicians assigned to rural areas were still located in the county of their initial assignment, and an additional 20 percent were in some other rural location in 1991. Retention was highest for family physicians and lowest for scholarship recipients who had not completed residency training when they were first assigned. Retention rates were also higher for those with longer periods of obligated service. Substantial medical care service was provided to rural underserved communities through obligated and postobligation service. Nearly 20 percent of all students graduating from medical schools between 1975 and 1983 who are currently practicing in rural counties with small urbanized populations were initially NHSC assignees. CONCLUSIONS: Although most NHSC physicians did not remain in their initial rural practice locations, a substantial minority are still rural practitioners; those remaining account for a considerable proportion of all physicians in the most rural US counties. This study suggests that rural retention can be enhanced by selecting more assignees who were committed to and then completed family medicine residencies before assignment.

Initial employment status of resident physicians completing training in 1995.

OBJECTIVE: To assess the degree and type of difficulty encountered by resident physicians attempting to enter the workforce in 1995. DESIGN: Employment information derived from a 1-page descriptive survey completed by residency program directors from January 1, 1996, to June 15,1996, is described and compared with the results of a similar survey completed 1 year earlier. SETTING: Directors of 4568 residency programs in 31 specialties and subspecialties accredited by the Accreditation Council for Graduate Medical Education. MAIN OUTCOME MEASURE: The number of 1995 program graduates, their current professional status, and program directors' characterization of the experience of graduates who entered clinical practice, including the number who experienced major difficulties securing an acceptable practice position. Program directors reported actual and anticipated decreases in the number of residency positions and the likely availability of future professional opportunities. RESULTS: The 3819 program directors (83.6%) who completed the survey reported that 20065 resident physicians completed a residency program during 1995. Of those seeking employment (n = 13215), most entered clinical practice (80.1%) or took an academic position (15.6%); 2.2% were unemployed or had taken a position in a specialty or subspecialty different from the one in which they were last trained. A portion (6.3%) of graduates who entered clinical practice in their specialty or subspecialty experienced difficulty finding a suitable position; the percentage was lowest among graduates of general surgery, psychiatry, and primary care specialties. CONCLUSIONS: Survey results regarding the 1995 graduates are consistent with those obtained regarding the 1994 graduates and suggest that the market for physician services in some disciplines continues to be restrictive. We found that graduates of the specialties of anesthesiology and plastic surgery, whom we reported had the greatest difficulty finding acceptable positions in 1994, had less difficulty in 1995, suggesting a possible improvement in the market, less competition, a change in the respondents' perception of "acceptable," or a change in the resident physicians' willingness to pursue different opportunities. The general consistency of our results and their congruence with other published data suggest that this method is useful to identify and monitor trends in the physician market.

Are the recommendations of the AAMC's task force on the generalist physician still valid?

A few years ago, most opinion leaders and workforce analysts believed that the number of generalist physicians in the United States was much too low. The AAMC responded to this concern by convening a task force to review the evidence bearing on the U.S. supply of generalist physicians and to make recommendations for action by the AAMC and its member institutions. In 1992, the task force called for at least half the graduates of U.S. allopathic medical schools to enter practice as generalists and for medical schools to design their educational programs to promote an affinity for generalism among their students. Since that time, however, research findings have suggested that the current size of the country's generalist physician workforce in relation to projected need may indeed be adequate. In light of these recent observations, the authors asked whether the task force's major recommendations remain valid. In this article, they state their reasons for thinking that it definitely does. After reviewing the recent research findings mentioned above, the authors show that simply to maintain the current size of the generalist physician workforce, a marked increase will be needed in the number of U.S. medical school graduates who choose to become generalists. In the aggregate, this amounts to roughly half the graduating classes of LCME-accredited medical schools, as called for by the AAMC in 1992. (The authors predict that international medical graduates will not make up a significant percentage of the country's generalist workforce, and that U.S. medical school graduates will be the predominant source of these physicians in the future.) Equally important, the new educational approaches being created by medical schools to embed generalism in their curricula are necessary to ensure that all graduates, regardless of their specialty choices, be well grounded in the principles and skills of "general physicians" so they can function well in the new health care system that is rapidly evolving.

Comparison of IMG-dependent and non-IMG-dependent residencies in the National Resident Matching Program.

OBJECTIVE: To provide insight into the dynamics that determine the pattern of participation of international medical graduates (IMGs) in graduate medical education (GME). DESIGN: Data on IMG-dependent programs (ie., those having at least 50% of first-year positions filled by IMGs) and non-IMG-dependent programs in 6 core specialties (internal medicine, family practice, obstetrics and gynecology, surgery, pediatrics, and psychiatry) were matched with application data from the 1989 and 1995 National Resident Matching Program (NRMP). MAIN OUTCOME MEASURES: Participation of IMG-dependent and non-IMG-dependent programs in the 1995 NRMP and the pattern of US medical graduate (USMG) and IMG applications to these programs in 1989 and 1995. RESULTS: Of the 1634 programs in the 6 specialties, 93.5% participated in the 1995 NRMP. The 1165 non-IMG-dependent programs were significantly more likely to participate in the NRMP and were slightly more likely to fill their offered positions than were the 469 IMG-dependent programs. Specifically, IMGs constituted 76% of applicants to IMG-dependent programs and only 14% of applicants to non-IMG-dependent programs. Changes in NRMP data between 1989 and 1995 indicated that the number of IMG applications to IMG-dependent programs increased 88.7%, as did the number of applicants ranked. CONCLUSIONS: Persistent differences exist in the mix of USMGs and IMGs applying through the NRMP to IMG-dependent and non-IMG-dependent programs. Over time, programs that enroll large numbers of IMGs are likely to experience an increase in the number and proportion of applications from IMGs and a decrease in the number and proportion of applications from USMGs. If policies are adopted to limit IMG access to GME, IMG-dependent programs may be unable to recruit USMGs unless the total number of GME programs or the quality of existing programs fundamentally changes.

The evolution of divergences in physician supply policy in Canada and the United States.

The size, geographic distribution, and specialty mix of the US physician workforce continue to interest American health policy analysts. Evidence suggests that the United States is on the verge of a serious oversupply of physicians, particularly nongeneralist physicians. Canada faces some of the same problems in physician supply, cost, and distribution as does the United States. Unlike the American states, however, the Canadian provinces, which have responsibility for financing health care, have in recent years made changes in their physician workforce policies that address these problems. Of particular note, Canadian provinces have developed policies that limit medical school enrollments, adjust the specialty training mix to better accord with needs, and establish physician practice location incentives. This article proceeds on the assumption that historical and contemporary similarities between medical care systems in Canada and the United States make comparisons between them potentially valuable. It offers a historical perspective on the evolution of workforce planning in the 2 countries and identifies 3 periods of policy development. It also compares and contrasts the relative size and specialty composition of the Canadian and US workforces and discusses how Canadian initiatives have diverged from American policy. Unless the United States devises its own coordinated workforce strategy, it will have considerable difficulty limiting physician workforce growth and influencing specialization and distribution in the future.

The initial employment status of physicians completing training in 1994.

OBJECTIVE: To gain information about the career status of residents who completed graduate medical education training programs in selected specialties and subspecialties during the 1993-1994 academic year. DESIGN: A descriptive one-page survey of residency program directors, including two mailed follow-up surveys, was conducted from January 1, 1995 to June 1, 1995. SETTING: Directors of residency programs in 26 specialties and subspecialties accredited by the Accreditation Council for Graduate Medical Education, totaling 4369 programs. MAIN OUTCOME MEASURES: Program directors identified the number of resident physicians who completed the program, the known career status of those physicians, the number of physicians who had experienced difficulty finding a practice position, the characteristics of the full-time clinical practice positions, and the number of physicians who could not find full-time employment. The perceptions about likely trends in the availability of practice opportunities for graduates in the future and the likely change in the number of resident positions were also assessed. RESULTS: A total of 3090 program directors (70.7%) completed the survey. Respondents reported that 15999 resident physicians completed training in one of the 26 specialties and subspecialties, and 63.2% of these graduates were potentially seeking a professional position. Most of those not seeking a position were pursuing additional training (92.9%). Of those seeking employment, the percentage who did not find a full-time position in their specialty or subspecialty ranged between none in urology to 10.8% in pathology. Across all specialties, about 70% of graduates looking for full-time positions entered clinical practice in their specialty of training. Physicians pursuing generalist careers had fewer problems finding preferred positions than those pursuing nongeneralist specialties. Finally, program directors in most nongeneralist specialties believed that the degree of difficulty their graduates will experience in finding a full-time practice position will increase during the next year. CONCLUSIONS: Physicians attempting to enter practice in some specialties and in some regions of the country are experiencing difficulty. In some cases up to 10% of the resident physicians did not find full-time positions in their specialty or subspecialty. The differences noted between the generalist and nongeneralist specialties are consistent with widespread perceptions about the current market. These data establish the baseline for analyzing trends.

A cross-national comparison of generalist physician workforce data. Evidence for US supply adequacy.

OBJECTIVE: To assess the adequacy of the US generalist physician workforce using population-based, cross-national physician workforce data. DESIGN: A comparative analysis of physician workforce data obtained from primary sources in Canada in 1991 and from England and Germany in 1993. METHODS: Generalist physician-to-population ratios were calculated for each country and the results compared in the context of how primary care services are delivered. The findings were used to create a framework for analyzing the adequacy of the generalist physician workforce of the United States. MAIN OUTCOME MEASURE: The comparability of the number of primary care providers per 100 000 population in the US physician workforce with the number in Canada, England, and Germany. RESULTS: On a population basis, the size of the full-time US generalist physician workforce is larger than that of England, similar to that of Germany, and smaller than that of Canada. These size differences are largely reconciled when one takes into account differences in the way primary care services are delivered, the degree to which nurse practitioners are employed in each country, and the degree to which nongeneralist physicians provide primary care services. CONCLUSIONS: The size of the US generalist physician workforce is currently adequate to meet the needs of the population. Policies designed to greatly expand the size of the US generalist physician workforce are ill-conceived.