Medical Student Career Choices 2010 and Beyond

The most important thing about specialty choice is a best fit for you. Because this is most important, you need to have a grasp of how much you can self-determine your final specialty choice and how much is beyond your control. The range of specialty choices may be limited for graduates of osteopathic schools, international medical schools, or more typical allopathic public schools that have more normal scores and class rank. With improvements in standardized test scores, class rank, and school rank the probability of certain specialty and subspecialty career choices improves.

Also there are single stage career choices and multiple stage choices. Family medicine represents a single stage career choice in medical school that results in 95% of graduates remaining in the broad generalist family practice mode. Retention within family medicine About half of pediatric residency graduates remain in primary care as indicated by pediatric residency seniors (Freed). Less than 20% of those planning internal medicine careers plan to remain in primary care (Garibaldi, Hauer). Internal medicine and pediatric specialties are a two stage choice. The case can be made for multiple stages of career choice in primary care internal medicine with initial choice in medical school, at choice made in residency, and choices made each year to remain in internal medicine primary care. Other careers are built with sequential training starting in a certain field with the addition of training.

Graduates of prestigious schools and residency programs have an advantage in specialty choice. Gaining admission to a program that does well in specialty choice may be important for those anticipating specialty careers such as cardiology. There is less competetion for positions that lead to mental health, women's health, primary care, and health access careers.

Long term considerations are important in career choice if there is some flexibility in career choice. If medical students are truly committed to a certain specialty, this flexibility is less of an option. If you are flexible, you might consider where the US is heading in the designs for workforce and the designs for support of workforce after practice begins.

The United States Designs

The overall design of workforce production is quite simple. Each year the United States graduates a higher percentage into specialty careers while primary care percentages grow lower. In the prestigious medical schools that rank at the top of US News and World Report, only about 10% of graduates can be counted upon for primary care careers. This includes 0 - 2% in family medicine, 2 - 4% that stay in internal medicine primary care, and 3 - 4% that stay in pediatric primary care. Often the web sites at these schools list medical students entering primary care as 30 - 45% of graduates but this is basically a distortion as so few choose permanent primary care and so few pediatric and internal medicine graduates remain in primary care after residency graduation. The graduates of exclusive schools crowd into specialties and subspecialties and avoid primary care.

The overall design of workforce support is also quite simple. About 80 - 85% of the 2.4 trillion in annual spending goes to 3400 zip codes clustered together with 75 or more physicians, 75% of physicians, 80 - 92% of specialists, and 90% of medical students, residents, researchers, and teaching physicians. The design of federal, state, and clinical funding rewards this concentration of health resources. Organized medicine and medical education consistently fight redistributions of this funding to match the population that is distributed 65% outside of these locations.

What this means to you varies with your intentions. Workforce is moving toward higher concentrations and this might be a fit for you. But your competition is heading this way as well. The open positions and those in need are likely to be outside of concentrations. These are locations that are less desirable for those born, educated, raised, and trained in top concentrations for the first 30 years of life. Experiential place is a powerful factor driving career and location choice.

The Design For Improvement of Health Access to those left behind is also quite simple - more normal and less exclusive (or better distributed and less concentrated). There can be no resolution of health access disparities without more normal and better distribution in workforce design and in the funding support design. A good way to think of this is that the funding distribution allows a certain career and location choice pattern. Admission and training can approach this career and location choice pattern or admission and training can move graduates away from this design. From the perspective of locations in concentrations, this works well as policy support as well an selection and training favor concentration. From the perspective of health access it is a worst case scenario. The amount of workforce supported is poor for locations with 65% of the population and the selection and training fails to reach the potential even allowed by the funding design. Medical associations, medical education associations, teaching hospitals, and non-clinician associations are in a poor position to support health access in workforce design or practice support design as they are constantly lobbying for higher concentrations of funding in fewer locations. Medical education has been the most successful as noted by the most lines of funding and the highest level of funding in each line of revenue.

The Physician Distribution by Concentration Coding highlights the type of physicians, specialties, and training elements that result in improved health access.

More normal in origin, older at medical school graduation, family practice broad generalist careers, and more normal in training result in distribution and health access. (Basic Health Access, They Really Do Go)

The populations in the United States left outside of the design are spread across urban and rural locations in marginal and underserved settings. These are 28,000 zip codes that have higher concentrations of elderly (70%), lower income, middle income, less educated, poor, and Community Health Center populations. These are locations that have far more than a majority of the population, that have the populations in need of the most care, that have the most complex populations requiring care, and the health care must be delivered with the least resources. Only about 23% of physicians and 30% of non-physician clinicians are found in these locations outside of concentrations.

The United States prepares, admits, trains, and supports physicians and non-physician clinicians inside of concentrations at the highest levels. The US is poorly aware of the magnitude of disparity. For example less than 10% of health spending goes to primary care, less than 5% to rural health (20% of the population), and less than 5% to underserved health care (21% of the population). When the areas of concentrations of resources are combined together (as they cluster together geographically), the inequities in the designs are illustrated.

Solutions involve preparation and admission of a more representative population from the 65% left behind, older graduates that are often delayed in admission by barriers related to income and education and parents, more emphasis on generalists and primary care, and training focused on health access. Studies by Ferrer, Rosenblatt, and others demonstrate that family physicians are multiple times more likely to match up to all of these populations. The reason is equitable distribution of family practice forms according to the population - not according to concentrations of physicians.

Only the family practice MD, DO, NP, and PA forms are found with 53 - 60% matching up to the 65% of the United States population left behind in workforce training design and practice support design. Family physicians, rural physicians, and underserved physicians can be tracked back to birth origins and all are more likely to match up to the populations that they are found serving. Lower and middle income origin and lower and middle population density origin medical students match up to this population as they distribute as physicians, but these are populations with 20 - 50% of the probability of medical school admission.

Also regardless of origins, when medical students choose certain specialties they limit their ultimate practice choices to locations with top concentrations and sometimes even specific cities where a particular specialty job is available. This is a contrast with family medicine with 30 - 40 per 100,000 throughout most of the United States. There are locations that are not preferred by family physicians that are important to understand. Locations with 200 or more physicians in the United States claim about half of US physicians but these are locations with only 5% family physicians or less than half of the national average (PDC Coding). United States medical schools only have 4% of full time faculty as family physicians (Barzansky, JAMA). Boston, Washington DC, and New York City zip codes in top concentrations only have 2% family physicians.

If you are interested in practicing in one of the types of locations noted above immersed in top concentrations of physicians, family medicine may not be a good choice.

Questions are a good way to explore options. If you give permission I can post your question along with my response. [email protected]

 

Future Discussions To Consider

• Why filling out EValue forms may be helpful with well over 500 residency programs and institutions are using EValue already (Residency program documentation has been critical for hospital privileges, medical student documentation may enhance selection particularly when residency programs tire of residents that have had little real world health care experience during medical school)
• Specific routes to specialty careers - Front Doors and Back Doors, Realistic and Not So Realistic
• The 200% increase in physician assistants entering specialty workforce in the past decade with declines to only 33% in primary care and only 28% of new PAs entering primary care - PAs are growing to 250,000 to 300,000 with 35% in ER, ortho, and surgical subspecialties.
• The 40% increase in specialty graduates from all physician sources along with 30% increases in US MD graduates and 100% increases in osteopathic graduates resulting in new record levels of physician specialist workforce (also existing primary care IM, NP, and PA departing for specialty workforce after graduation)
• Rapidly rising health care costs and the impacts on personnel intensive businesses and governments from federal to state to school districts
• Reversals of nurse practitioners from 65% primary care to 65% specialty workforce. NPs will have 189,000 or more who are age 30 - 65 in future decades and likely 2 - 3 times the physician percentages in cardiology (8% of NP), 3 other major internal medicine subspecialties, women's health, geriatrics, and psychiatry.
• Steady departures of PA and NP from family practice resulting in less primary care, rural, and underserved workforce
• National studies indicating no additional need of medical specialties until 2020 and beyond and then modest growth
• Studies indicating greater benefit for existing specialists such as cardiologists by hiring an NP or PA rather than a cardiology physician.
• Studies indicating the need for general specialists - general surgeons, general orthopedists, general obstetricians, general cardiologists yet production is subspecialty.
• Steady decreases in osteopathic family medicine choice from 70% to 40% by the 1990s to 22% in 2004 to less than 15% likely for a steady 500 - 600 entering family medicine each year for decades
• Balancing residency choice, location of choice, personal needs, and family needs
• Why current health reform proposals will have minimal impact on primary care choice
• Major journal articles raising concerns about the impact of hospitalists upon resident teaching volumes in internal medicine and in pediatric inpatient training (potentially all residency training)
• Why Loan Repayments are too late to influence health access choices (
• Why family medicine represents the most yield of health access for the lowest cost of education, higher education, college, health professional school, and residency
• Why Alaska spends 2 million more dollars a year to still have grossly insufficient health access workforce
• Who does delivery primary care in the United States - the Standard Primary Care Year
• Why Nurse Practitioners are not primary care solutions  
  
  

Graphics to Review

AAMC 2008 Projections of Physician Workforce Overall

AAMC 2008 Projections Verses Reality in Primary Care

Primary Care Retention Declines in Overall Graduates

Primary Care Retention Declines in Newest Graduates Entering the Workforce

Primary

Residents Listed in their Final Year in the AMA Masterfile

Specialty		Last Year Residents
Internal Medicine	IM	6339
Family Practice	FP	2981
Pediatrics	PD	2610
Anesthesiology	AN	1439
Emergency Medicine	EM	1408
General Surgery	GS	1269
Obstetrics & Gynecology	OBG	1153
Diagnostic Radiology	DR	1041
Psychiatry	P	902
Cardiovascular Diseases	CD	737
Orthopedic Surgery	ORS	631
Pathology-Anatomic/clinical	PTH	540
Neurology	N	474
Hematology/oncology	HO	431
Ophthalmology	OPH	405
PulmonaryCriticalCareMed.	PCC	405
Gastroenterology	GE	396
Dermatology	D	368
PhysicalMedicine&Rehab	PM	359
Nephrology	NEP	351
InfectiousDiseases	ID	350
InternalMedicine Pediatrics	MPD	346
ChildPsychiatry	CHP	337
Otolaryngology	OTO	251
Endocrinology	END	235
InternalMedicine Geriatrics	IMG	224
InterventionalCardiology	IC	222
Neuroradiology	RNR	216
UrologicalSurgery	U	214
PlasticSurgery	PS	187
Rheumatology	RHU	187
Neonatal-PerinatalMedicine	NPM	170
NeurologicalSurgery	NS	142
Vascular&InterventionalRad	VIR	136
RadiationOncology	RO	134
ClinicalNeurophysiology	CN	132
OrthopedicSportsMedicine	OSM	129
Family Prac/sportsMedicine	FSM	128
Allergy&Immunology	AI	125
Im-CardiacElectrophysiology	ICE	125
CriticalCare-Pediatric	CCP	115
PediatricAnesthesiology	PAN	115
PediatricHematologyOncology	PHO	112
VascularSurgery	VS	111
Pathology-Cytopathology	PCP	101
ThoracicSurgery	TS	97
PediatricCardiology	PDC	92
GeneralPreventiveMedicine	GPM	91
Hematology/pathology	HMP	84
PediatricEmergencyMedicine	PEM	84
CriticalCareMedicine	CCM	77
ChildNeurology	CHN	73
Colon&RectalSurgery	CRS	72
CriticalCare-Anesthesiology	CCA	70
SelectivePathology	SP	65
PediatricGastroenterology	PG	64
PediatricEndocrinology	PDE	62
FamilyPractice/geriatric Med	FPG	60
ForensicPsychiatry	PFP	59
Oncology	ON	57
Dermatopathology	DMP	55
Dermatopathology	DMP	55
GeriatricPsychiatry	PYG	51
PediatricRadiology	PDR	48
PediatricInfectiousDiseases	PDI	47
PulmonaryDisease	PUD	42
AbdominalRadiology	AR	39
AddictionPsychiatry	ADP	38
PediatricPulmonology	PDP	36
MedicalGenetics	MG	31
PsychosomaticMedicine	PYM	31
PediatricSurgery	PDS	30
BloodBanking	BBK	28
ForensicPathology	FOP	26
NuclearMedicine	NM	26
InternalMedicine-EmergencyMedicine	MEM	24
MusculoskeletalRadiology	MSR	24
PediatricRheumatology	PPR	24
VascularNeurolgy	VN	24
OrthopedicAdultReconSurg	OAR	20
PediatricEmergencyMedicine-EM	PE	20
Developmental-BehavioralPediatrics	DBP	19
EmergencyMedicalToxic	ETX	19
Hematology	HEM	19
Neuropathology	NP	18
OrthopaedicSurgeryOfSpine	OSS	18
OrthopedicPediatricSurgery	OP	18
AdolescentMedicine-Peds	ADL	17
InternalMedicine-Psychiatry	MP	17
PediatricNephrology	PN	15
Orthopedics(foot&Ankle)	OFA	14
Pediatrics/Psych/ChildandAdolPsych	CPP	14
CriticalCareSurgery	CCS	13
OrthopedicMusculoOncology	OMO	13
OrthopedicSurgery-Trauma	OTR	12
PediatricPathology	PP	12
PediatricUrology	UP	12
Psychiatry-FamilyPractice	FPP	12
PediatricSportsMedicine	PSM	10
SpinalCordInjury	SCI	10
InternalMedicine-PreventiveMedicine	IPM	8
MedicalMicrobiology	MM	6
NuclearRadiology	NR	6
Emergency/sportsMedicine	ESM	5
OccupationalMedicine	OM	5
PediatricOtolaryngology	PDO	5
Pediatrics/PhysicalMedicineandRehabilitation	PPM	5
InternalMedicine-FamilyPractice	IFP	4
InternalMedicine-Neurology	MN	4
Neurology/diagnosticRadiology/Neuroradiology	NRN	4
Neurology/diagnosticRadiology/Neuroradiology	NRN	4
Neurology/diagnosticRadiology/Neuroradiology	NRN	4
Pediatrics-EmergencyMedicine	EMP	4
PreventiveMedicalToxicology	PTX	4
Neurotology(Otolaryngology)	NO	3
PainMedicine	PMM	3
PediatricRehabMedicine	RPM	3
Psychiatry-Neurology	PYN	3
CardiothoracicRadiology	CTR	2
CraniofacialSurgery	CFS	2
Pediatrics-MedicalGenetics	PMG	2
AdultCardiothoracicAnest	ACA	1
AerospaceMedicine	AM	1
EndovascularSurgicalNeuroradiology	ESN	1
GeneralPractice	GP	1
InternalMedicine/Dermatology	IMD	1
NeurodevelopmentalDisabilities	NDN	1
PediatricDermatology	PDM	1
TransitionalYear	TY	1
		30985

Due to variations in the years required for training in certain specialties, the number of 30,985 is higher than the number entering training of about 25,000.

Primary Care Decline: Declining Retention and Primary Care Failure Despite Expansions of Primary Care Graduates    The US design for primary care fails as 22,000 of 28,000 Annual Primary Care Graduates are Flexible and Leave Primary Care.

Why Medical Students Should Ask Congress to Vote No Regarding Last Minute Expansions of Residents Until Expansion Does Care for the Health Access Needs of the Nation, and For Them     yes for expansion, but expansion that is well planned and implemented

Primary Care Workforce 1980 to 2040 - More of the Same Still Fails More

Estimated 2009 Class Year Primary Care, Rural Primary Care, and Underserved Primary care Contributions by Individual Medical Schools with Comparisons to NP and PA 2009 Contributions

www.basichealthaccess.org