Specialty Choice in Graduate Medical Education

Over the past year, I have had the opportunity to meet with residents at national meetings as well as during my time in Washington when they participated in their specialty advocacy meetings. In general I have noted that Congressional staff would listen intently to the stories of residents and ask them about their career goals and intended sites of practice. Residents tended to express themselves clearly, succinctly, and confidently, perhaps as an extension of their daily requirements for succinct and effective presentations during rounds. They discussed their hopes for improving health, uncertainty about the impact of health reform as well as loans, debt, family stress, and concern about the amount of information they had to master.

Eventually we would get around to where the residents intended to practice and what they hoped to do. Were they going to practice primary or specialty care in rural or urban underserved areas? How would their intentions align with the anticipated needs of the Affordable Care Act? As I would listen to them, I noticed certain recurring themes. Many residents preferred to continue training after completing their core residency. It did not matter what the initial specialty training might have been. The orthopedists were planning to do foot, hand, spine, or sports fellowships. The general surgeons were going to do fellowships in trauma or colon or breast surgery. The internal medicine residents were becoming cardiologists or gastroenterologists. Family Medicine seemed to be the only exception, and even some of them were considering sports medicine or women’s health.

My informal survey has reinforced the data presented by Jolly and colleagues in the April issue of Academic Medicine. In their analysis of residency specialty choice trends over ten years, they showed that residency training positions were rising more slowly than the increases in medical student positions, and the increases that did occur were in the area of subspecialties or subsubspecialties. There was a 6.3% decrease in those expected to enter primary care practice over the ten-year period, although, according to the report, “the number and percentage of new program year 1 residents expected to enter primary care for the most recent year are essentially unchanged from the prior year, offering some hope that the declining interest in primary care careers may be ending.” General surgery also demonstrated substantial decreases in the number of residents intending a general surgery practice.

This study raises several disturbing problems. First of all it reinforces the notion that our number of medical school graduates is on the road to equal the number of residency positions. The IMG and DO graduates, who have traditionally helped fill the gap, will face a prospect of an ever diminishing number of slots that are not filled by US medical school graduates, and we may see some US graduates unable to find any graduate training after completion of medical school. Certainly, students’ choice of specialty will be reduced as the supply of students begins to equal or exceed the demand from residencies. Second, the move toward increased specialization has taken root and will likely continue to grow. The reasons for specialization include financial incentives, concerns about the expanding knowledge and skills requirements in all areas of medicine, and desires for a controllable, focused practice that will allow for a good work-life balance. Third, the supply of primary care doctors does not show any signs of increasing. Who will provide the needed primary care for our population in such a scenario? Will alternatives to physicians provide this care?

I recommend that anyone interested in our future healthcare workforce review the article by Jolly et al and consider the policy implications. It is possible that governmental leaders may take note of the data and consider incentives to alter the projected shortages through higher payment for primary care or restrictions in federal support of certain fellowship training. Whether these policy incentives will effectively address the projected physician deficits is not clear. But one way or another, through market forces or governmental action, we can anticipate changes in our current graduate medical education specialty choice environment. It would behoove us to consider what we could do to smooth the transition from our current approach to workforce to one that aligns more with our future healthcare needs and honors the goals and sacrifices of our medical students and residents.

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3 Comments

  1. Matt k
    April 5, 2013 at 10:02 PM

    First, increasing physicians are employed, and employers have made clear to most physicians that they expect sub-specialization. I know of a number of orthopedic surgeons entering practice after fellowship in rural areas. One was told point blank that fellowship training was required. As an employer, suppose their is a shortage of fellowship trained hand surgeons. The easy solution is find an orthopedic surgeon with an interest in hands, sign him to a long term contract and let him operate on all the hands that come in. Problem solved.

    Second, attempts to engineer medicine by playing around with GME slots will fail as they have in the past. Until the government decides to meaningfully incentivize primary care and generalists this will continue to occur either formally or informally. Suppose they decrease fellowship funding, what will happen? Many of my fellow residents have said they are not confident in doing X or Y without a fellowship and do not wish to do A thru V which leads me to believe that young physicians will self specialize or restrict their practice because of this (be it by going over seas, finding a mentor, taking classes, working less etc).

    Among those unable to specialize and want to, those that are forced to do A thru V will not be happy. This is the most important consideration because my guess is many will not to stay medicine for long and if they do they will curtail their practice. Given the aging population, we do not need more part time physicians accepting only private insurance. Worst case scenario, you have doctors that are disgruntled and don’t care. Not caring about patient care is, in one word, bad.

    Continuing to play with GME slots has not worked in the past and is a clear example of the law of unintended consequences at work. You are seeking the solution to a complex problem in the wrong place.

  2. David P. Sklar
    April 12, 2013 at 6:57 PM

    I agree that increasing slots for primary care alone may not solve the workforce problems in health care. Specialty choice is complex and is dependent upon the anticipated employment opportunities, the reimbursement, work schedule, passion for a particular specialty or type of work, societal needs, and individual personalty. I heard a lot of concern about the expanding amount of knowledge and skills to master as a driver for many residents who decided to subspecialize. As we attempt to understand the trends in resident specialty choice we also need to be aware of our compact with the public to provide needed resources for health care. The government currently supports graduate medical education through Medicare payments and thus has a strong reason to make sure that their investment in medical education is going to yield the needed mix and number of physicians. The more that we can understand about how to best match the public need with needs and desires of our current group of students and residents, the more likely it is that we will continue to receive support for graduate medical education from the government.

  3. Kemi Tomobi
    July 10, 2013 at 9:36 PM

    This is a very timely and relevant post to the future of undergraduate and graduate medical education in an attempt to address the physician shortage.

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