Influencing career choice during residency.

During the 1990s we have encouraged internal medicine residents, even those in some specialist-oriented programs, to enter primary care because of workforce projections,1 HMO growth,2 and public sentiment. The programs themselves have facilitated this trend by adding ambulatory medicine curricula, general medicine interest groups, and primary care training programs. Can we go further and predict who will become a generalist? In this issue, Adams and colleagues report that statements by residency candidates do predict fellowship training and practice choice.3 The authors examined answers to a single question on Georgetown University's application for a categorical medicine residency that were written by the 162 candidates who were accepted into the residency program from 1990 to 1998, and then compared the answers with the residents' ultimate career choices. When they applied, 27 candidates intended to become generalists, 103 intended to become specialists (including 39 who listed a specific specialty), and 32 were undecided. The authors found that 78 of the 130 residents who declared an intention to generalize or specialize when they applied indeed went on to generalize or specialize. Many residents, however, changed course during residency. Of the 27 who planned to be generalists, 9 became specialists. Of the 103 who declared they would specialize, 43 became generalists and 19 chose a specialty field different from the one they had planned. In total, 71 (54%) of the 130 candidates with a defined sense of career when they applied changed their career direction during residency. If we add the 32 originally undecided candidates, 64% of residents came to a new career decision during residency training. It is fortunate that general medicine attracted almost half the trainees who changed their minds, because only 18 of the 79 residents who ultimately chose to be generalists had declared generalism as their career goal. Many of those who switched into primary care fields may have thought that market conditions were changing.2 Others may have had little preference either way but thought their applications would be treated more favorably by a tertiary-care institution if they indicated interest in a specialty field. I hope that some chose primary care because they were exposed to ambulatory medicine and to outstanding role models. Because so many residents change their career goals during residency, we have an opportunity to influence their career choices and a responsibility to do it well. As faculty members, program directors, and advisers, we should educate residents about the different specialties of internal medicine. Because most fellowship applications are due during the junior residency year (at least for those who desire uninterrupted training ), there should be elective time during an internship or early during junior residency. Also, ambulatory block rotations during that time could expose residents to multiple specialties. Later deadlines for fellowship applications would allow more time in the second year for elective experiences. Finally, faculty members in each specialty could be identified as advisers to help with fellowship applications and career planning. As much as we should help residents identify and cultivate their specialty interests during residency training, we also should recognize the opportunity to help more students and residents choose general medicine or primary care. One of the most important reasons that medical students choose a career is the availability of role models within that specialty.4–6 Other factors include the perceived type and quality of patient contact and relationships7 and “intellectual opportunities” such as diagnostic challenges and research opportunities.4 Early exposure to general internist role models, as ward attending physicians, preceptors, or practitioners, could encourage undecided students and interns to think about ambulatory medicine as a career. Residents interested in primary care can serve as role models for more junior residents and for students; chief residents interested in primary care can advance the concept that primary care is rigorous and academic and held in high regard. General medicine fellows, if available, can take an active teaching role in the residency program, and fellows may have time available for mentoring or modeling. The data from medical schools suggest that patient contact in a given field is critical to student interest. Therefore, a resident's own continuity practice should be a priority for the program director; it should be clinically busy, start from the very beginning of internship, and be accompanied by “intellectual opportunities.” These opportunities could be as simple as case-based conferences at the end of clinic sessions or ambulatory-based reports showcasing interesting problems in primary care. Although we know a bit about how students choose fields and can extrapolate that to residents, we know little about how residents make career choices once they are in training. DeWitt and colleagues surveyed graduates of a university-based primary care internal medicine program, asking what factors could produce more generalists.8 Respondents listed better salaries and status in general medicine and more “real world” or community experiences as the most important influences. Community practice experiences should be available to residents in all programs and in all career tracks. By working closely with a physician practicing in the community, residents have the opportunity to see “real world” medicine and to see a greater diversity of patients. They also have the opportunity to build a close relationship with a potential mentor. As valuable as they are, community practice experiences are not easy to create. They require practitioners dedicated to teaching (even when it might compromise productivity), institutional letters of agreement so that residents are covered by malpractice insurance, and a program administration open to the value of the experience and committed to complicated scheduling. The American College of Physicians has an excellent resource book for those interested in developing community-based teaching experiences.9 Primary care residency programs have multiplied in recent years and enlisted many applicants with interests in primary care. Some other residency programs have responded by increasing their emphasis on specialization or on basic-science research. However, the work by Adams and colleagues reminds us that most incoming residents will change career direction during their 3 years of training and that many graduates of categorical residency programs will choose generalist careers, including some who do not identify an interest in primary care when they start. To recruit these residents to careers in general medicine, we should expose all residents to generalist role models, busy ambulatory medicine experiences, community practice experiences, and the intellectual challenges of our field.