General Medicine vs Subspecialty Career Plans Among Internal Medicine Residents

By Colin P. West, MD, PhD and Denise M. Dupras, MD, PhD
JAMA, December 5, 2012

This study of a large national sample of internal medicine residents confirms that general medicine remains a less common career plan overall than subspecialty medicine. Combined with the fact that only a small minority of medical students express interest in general medicine and primary care careers, the small number of internal medicine residents reporting plans for generalist careers means a very limited number of generalists can be expected to enter practice each year.

This update confirms that internal medicine residents are selecting the subspecialties in preference to general medicine and primary care. In light of the pressing need for improving our primary care infrastructure, what policies should we support?

Since family medicine residents almost always eventually enter primary care, should training programs de-emphasize general internal medicine and place more emphasis on family medicine, while relegating internal medicine to the subspecialties? That would improve the allocation of residency slots since you would not be losing general medicine residents to the subspecialties after their residencies began. This is not to suggest that subspecialists should skip all training in general medicine. The purpose would be to stem the loss of generalists from the training programs.

Also many agree that the role of nurse practitioners in primary care should be expanded. This would be especially valuable in integrated health systems and medical homes. If so, the expansion should be coordinated with the family medicine programs to achieve an optimal balance of primary care professionals.

Since we aren’t getting the numbers right, shouldn’t we consider an alternative approach? If we had a federally funded national health program, wouldn’t we be striving to improve the use of our resources to be sure that our health care infrastructure is better balanced? Our current dysfunctional, fragmented method of financing our health care system doesn’t seem to be doing the job very well.