Challenges in primary care education.

Despite these grim statistics, more recent trends suggest an increase in medical student interest in primary care fields. In 2010, Family Medicine saw an increase in applicant numbers, filling more than 44% of an increased number of positions offered in the NRMP. Combined Medicine-Pediatrics programs saw a considerable increase in popularity among US senior medical students as well, filling 83% of a stable number of positions. Although these trends towards improvement are small, they represent an upward trend in medical student interest since what appears to be a nadir during the 2005-2007 academic years. Career choices within some primary care disciplines have changed dramatically over the past decade. Among recently surveyed PGY-3 US Medical Graduates (USMG) in Internal Medicine training programs, 22.8% planned to enter general internal medicine (GIM) while 60.4% planned a subspecialty career. In contrast, PGY-3 International Medical Graduates (IMGs) were more likely to choose GIM. According to the American Board of Internal Medicine Workforce data, there were 4340 first year subspecialty fellows in academic year 2008-2009, compared with 3298 in 1999-2000, an increase of 32%. In contrast, a recent survey of 279 categorical medicine residents, 44% were considering a hospital medicine career. While students entering internal medicine residency programs may have increased, fewer of those students eventually choose careers in primary care. There has been a steady decline in the percentage of internal medicine residents planning to pursue generalist careers. In 1998, 54% of PGY-3s planned to practice general internal medicine compared with 27% in 2003. Ominously, in 2003, only 19% of PGY-1s surveyed nationally planned to pursue careers in general medicine. Lifestyle and income have been found to increasingly influence medical students’ career choices away from primary care disciplines. The face of residency education, especially in Internal Medicine, has changed dramatically over the past decade with respect to resident exposure to primary care role models and mentors, many of whom have left the inpatient care of patients in favor of a more focused office-based clinical career. In one recent study 54% of teaching hospitals employed hospitalists before implementation of resident work-hour limitations, while 73% did so afterwards. Specific teaching activities of hospitalists included: attending on teaching service (92%) and conducting rounds (81%). Lack of exposure to generalists results in less consideration of that career option by residents. The curriculum and assessment of residency training is regulated through the Accreditation Council for Graduate Medical Education (ACGME), which accredits the majority of allopathic training programs in the USA. Since 2003, the ACGME has developed rules limiting Duty Hours for residents in all disciplines of medicine. Self-reported weekly hours worked by residents before 2003 averaged 65.7 before dropping to 59.3 upon implementation of resident duty hour restriction in 2003. Since that time, all residents are required to adhere to four principal duty hour rules: