Students enjoy internal medicine as a clerkship, not a career

Medical students enjoy their internal medicine clerkships but are less likely than ever to become general internists, citing educational debt, perceived workloads and stress as disincentives, according to a comparison of students in 1990 and 2007.

Researchers compared results from two similar national surveys of senior medical students from 1990 and 2007 that asked about their clerkship experiences and perceptions of internal medicine careers. Results appeared in the April 25 Archives of Internal Medicine.

The two surveys included 1,244 students at 16 schools in 1990 (response rate, 75%) and 1,177 students at 11 schools in 2007 (82%). More students in 2007 reported high satisfaction with their internal medicine clerkships (78% vs. 38%, P<0.001) and more students in 2007 than in 1990 (58% vs. 42%, P<0.001) felt that opportunities for meaningful work in internal medicine were greater than in other specialties.

However, while similar numbers of students planned internal medicine careers in the two survey years (23% vs. 24%), the percentage intending to go into general internal medicine dropped from 9% to 2% (P<0.001).

Students in 2007 were less likely than their 1990 counterparts to say that:

• the appeal of primary care attracted them to internal medicine (33% vs. 57%, P<0.001)
• they were attracted to internal medicine by their outpatient rotation (31% vs. 35%, P<0.001), and
• their overall internal medicine clerkship made a career in general internal medicine more attractive (19% vs. 24%, P<0.001).

But they were more likely in 2007 to say their clerkship made a career in subspecialty internal medicine more attractive (49% vs. 35%, P<0.001).

Educational loans were a deterrent for more students in 2007 (26% vs. 16%, P<0.001). For the class of 2009, average total educational debt was $132,000 ($158,000 for the 86% of students with debt), and one in four students owed more than $200,000. Meanwhile, the income gap between primary care and subspecialist physicians has grown to nearly threefold, or $3.5 million during a 40-year career, the study authors said.

“Bolder payment and practice reform will be required to reduce the remuneration gap between primary care and subspecialty physicians and to address the adverse work conditions in general internal medicine that students identify in clerkships,” the authors wrote. Such policies might include:

• expanding scholarships and loans,
• addressing work-life balance through new and more satisfying practice models, and
• slowing the “treadmill” pace by replacing fee-for-service reimbursement.