- Email: [email protected]
Subspecialization in Internal Medicine: A historical review, an analysis, and proposals for change
1
1 REVIEW
Subspecialization in Internal Medicine: A Historical Review, An Analysis, and Proposals for Change Ronald J. Anderson, MD, Boston,
Massachusetts
The recent decline in the production of primary care physicians has been associated with a decrease in the production of general internists and an increase in the number of medical subspecialists. A significant major& of entering internal medicine residents anticipate entering a medical subspecialty. This transition in the development of medical manpower, perceived by some as inappropriate, is analyzed in light of historical trends in the evolution of internal medicine and its subspecialties, and in conjunction with the roles played by the American Board of Internal Medicine and the National Institutes of Health. Evidence is presented that the creation of virtually independent subspecialty departments may have been detrimental to the education of physicians and not productive of the physician scientists they are assumed to create. Current recommendations for reform are reviewed and a new proposal is presented, suggesting increasing the length of the medical residency from 3 to 4 years, incorporating subspecialty training in one or more fields into the third year of the residency, removing “duration of training” as a requirement for board eligibilii in a subspecialty, transferring the certification of technical competence in a procedure to local institutions, and creating investigational units in basic disciplines within the department of internal medicine that would serve as a resource for all the subspecialty divisions.
T
here currently is a major concern about the declining number of US physicians entering the field of primary care, defined as general internal medicine, pediatrics, and family practice.1~2 Internal medicine is the largest of these and had undergone a steady decline in attracting residents to the field, fahing from 4,143 medical school graduates in 1986 in the United States to 3,079 in 1993. Fill rates in the National Resident Matching Program also fell for 8 consecutive years to a low of 53.1% in 1993. A small upturn in both these parameters occurred in 1994.3 A
From the Department of Rheumatology and Immunology, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts. Requests for reprints should be addressed to Ronald J. Anderson, MD, Administration B-2, Brigham and Women’s Hospital, 75 Francis Street, Boston, Massachusetts 02115. Manuscript submitted May 9, 1994 and accepted in revised form February 13, 1995.
74
July 1995
The American
Journal
of Medicine@
Volume
99
decrease has also been noted between 1982 and 1993 from 14.3% to 4.5% in the percentage of medical school graduates who plan to enter general internal medicine, while simultaneously the percentage of those planning on entering a medical subspecialty has virtually doubled from 7.6% to 14.2%.495Assuming the current supply and specialty mix of residents is left unchanged, the Council on Graduate Medical Education (COGME) recently projected a shortage of 35,000 generahsts and an oversupply of 115,000 specialists in all fields by the year 2000.2 There is also concern that internal medicine is failing to attract the best and the brightest. Levinsw has documented a downward trend in the academic qua& ifications of Boston University graduates selecting internal medicine residencies over the last decade, and a recent small decline in the scores of US medical graduates on the certifying exammation of the American Board of Internal Medicine (ABIM) has been noted.7 Between 1976 and 1992 the percentage of foreign medical graduates in US medical residency programs has increased from lO?&to 30%, while the percentage of US medical graduates has correspondingly declined.8 Recent studies of factors that attract or deter medical students from electing internal medicine as a career reveal that ambulatory rotations, Honors grades, and exposure to practicing physicians had the highest correlation with the decision to become an internist.g-13 The profile of students planning to become general internists was virtually identical to that of students planning to enter a subspeciaky of internal medicine. Observers consider that the relatively low expected income is a major deterrent to the decision to enter a primary care field, 14,15and Shulkin16 describes an almost linear relationship between anticipated income and the percentage of residency positions filled. Internal medicine was near the bottom. The level of student indebtedness does not seem to correlate, however, with the choice of a specialty.17 General internal medicine has strong support from many critical observers of health care policy in America COGME, the Pew Health Professions Commission, and the Federated Council for Internal Medicine have all advocated that 50% of all beginning residents complete a generalist program and enter practice in general internal medicine, pediatrics, or family practice.2~‘820 Much of the argument for increasing the number of general internists and other primary care physicians stems from evidence that they are cost effec-
SUBSPECIALIZATION IN INTERNAL MEDICINE/ANDERSON
tive. Greenfield et al,21 in a large study whose size and scope almost precludes it from ever being replicated, present data that cardiologists and endocrinologists utilize more health care resources for the care of similar patients than do generalists. Internists were marginally less cost effective than family practitioners. In a study of geographic variations in expenditures for physician services, Welch et alz2 showed that the most important variable associated with lower cost of care was the number of primary care physicians in the region. Neither of the studies addressed quality issues. Observations of general internists practicing in small communities with a limited access to subspe&lists compared with peers who practice closer to urban medical centers suggest that proximity and availability of subspecialists may be detrimental to the knowledge base and technical proficiency of internists.23~24 Some argue that an oversupply of subspecialists is more detrimental to the health care sys tern than is a shortage of generaJists.25,26They attribute this to an unnecessary and costly fragmentation of health care services related to subspecialists’ inability to care for conditions outside of their field. Arguments have been made that changing the physician mix to 50% generalists would save billions of dollars by reducing physician income and avoiding tests and procedures of uncertain va.lue.27 Determining the number of medical subspecialists required for our nation’s needs is controversial, and the need would vary depending upon the extent and level at which the subspecialist is involved in primary care. 28*2gHowever, data obtained from managed health care programs indicate that a significant excess exists.30,31 Although leaders in academic internal medicine support a unified department of medicine, as opposed to independent subspecialty units, as the core of an academic department of medicine, a general assumption exists that strong subspecialty divisions are essential for the development of physician scientists.3”~33 Recently the Chairman of the AE!ELJ,~ in summarizing arguments against reducing the number of subspecialty fellows, stated: “. . . We risk the extinction of an already endangered species-the clinical investigator. Where are the physician scientists of the future going to come from if not from the medical subspecialties? And where are they going to be trained if not in our subspecialty training programs?” General internal medicine therefore appears highly desirable in the eyes of health care policy makers, but is unable to recruit an adequate number of new members. At the same time it is criticized for having overemphasized the development of inefficient subspecialization. How did the subspecialties evolve into their current dominant position? Are they essential for the development of physician scientists?
The purpose of this paper is to analyze historical trends in the evolution of residency and fellowship training in internal medicine over the last 30 years, particularly as related to the development of subspecialties. The roles played by the ABIM and the National Institutes of Health (NIH) will be examined and potential solutions to what appears to be an inappropriate production of the physician workforce will be reviewed and proposed.
AMERICAN BOARD OF INTERNAL MEDICINE The ABIM was created in 1936 by the American College of Physicians (ACP) in conjunction with the American Medical Association. At its inception the Board had no formal training requirements, but did require that a 5-year period must elapse between the completion of internship and eligibility for the certifying examination, According to Bierring, “The responsibility of acquiring the knowledge . . . rests with the candidate, while the responsibility of maintaining the standard of knowledge required for certification devolves on the Board.” Board certification at that time required passing a written examination in both basic science and general internal medicine, followed by a certifying or oral examination consisting of case histories and physical examinations of actual patients performed by the candidate while being observed and questioned by a member of the ABIM. Over the next 3 decades the 5 year postinternship requirement remained, as did the format of the examinations. Three years of training eventually became required to become eligible to take the examination. The specific nature of this training remained flexible, and both research and subspecialty experience were accepted. The ABIM acknowledged at the time of its founding that consideration would be given to “the more limited specialties of internal medicine such as cardiology, gastroenterology, allergy, tuberculosis, etc.“36 In 1940, it established a policy that candidates in these four areas would have their oral examinations by representatives from these subspecialties and “an appropriate notation of proficiency in the subspecialty would appear on the certiflcate.““6 Why only these four subspecialties (tuberculosis was renamed eventually as pulmonary diseases) boards chose to be established while the “etc.” specialties opted to follow another course is unclear. Requirements for certification in these four subspecialties became somewhat more rigid over the next 3 decades. Other than that, no clear division developed between those subspecialties with boards and those without. As a year of subspecialty training could be credited for board-eligibility in internal medicine, many residents incorporated such a year into July 1995
The American
Journal
of Medicine@
Volume
99
75
SUBSPEClALlZATlON
IN INTERNAL MEDICINE/ANDERSON
their residency and eventually practiced as subspecialists with no further train@ in the field. Formal subspecialty fellowship training of 2 or more years, particularly in fields without a subspecialty board, was generally taken only by those individuals with a strong desire to develop as an investigator or acade mic physician.
Trend Toward Subspecialization ln 1970, the ARIM initiated several major changes that had evolved in response to a developing trend to ward subspecialization, as a result of general dissa& faction with the oral examination and as an acknowledgement of the inability of physicians to master the entire field of internal medicine.37-41 The length of res idency train&j required for certification was reduced from 4 to 3 postgraduate years, the oral examination was abolished, and a single written exammation was developed certify@ a doctor as a Diploma& of the ABIM. The required &year period after internship be fore board eligibility was discarded. New subspecialty boards were created in endocrinology, hematology, infectious disease, nephrology, oncology, and rheumatology. Two additional years of formal tmining in a subspecialty was required for certification in that field. The reason that 2 years was selected as the appropriate duration of training was never clarified in published statements by the ARIM. These changes provoked controversy,42 but have remained essentially intact over the last 2 decades. Significant subsequent changes have been the lengthening of the training requirement in cardiology to 3 years, establishing the Clinical Investigator Pathway, and the addition of the new Certificates of Added Qualifications in Adolescent Medicine, Clinical Cardiac Electrophysiology, Critical Care Medicine, Geriatric Medicine, Sports Medicine, and Clinical and Laboratory Immunology.
THE NIH AND SUPPORT FOR SUBSPECIALTY TRAINING The NM consists of several institutions established largely upon the lines of categorical diseases or organ systems such as cancer, arthritis, and heart rather than specific scientific disciplines such as immunology, biochemistry, and so forth. Support by the NIH for subspecialty training is primarily channelled through the National Research Service Awards (NRSAs). These awards are restricted to programs of research training and may not be used “to support residencies, the primary purpose of which is the attainment of a medical specialty.“43 The awards consist of either fellowships, given to individuals who have obtained the sponsorship of a specific institution, or traineeships, awarded to an institution and providing funds for both the general research train76
July 1995 The American Journal of Medicine@ Volume 99
ing program and salaries for the trainees selected by that institution. Applicants to both programs are given “special consideration” when they agree to undertake a minimum of 2 years of biomedical research.43 The majority of current subspecialty trainees are supported by clinical practice income and direct and indirect financial support for graduate medical education through Medicare, which is administered by the Health Care Financing Administration. A recent analysis estimates that Medicare provides $70,000 annually through the hospitals for each resident and fel10w.~ Although only a minority of current subspecialty training programs are funded by the NIH,& most training programs conform to NIH guidelines of being research based with a minhnum duration of 2 years. One might assume that this is done with the expectation that they will ultimately be funded by the NM even when the probability that this will occur seems small. Of interest, a recent survey of rheumatology training program directors revealed that, although only 14% of their current fellows were supported by the NIH, they anticipated that 27% of the program’s fellows would be NM supported in the future.& The benefits to a division of acquiring an NIH training grant and the inflexible 2-year training requirement of the AHIM have encouraged the subspecialty divisions to develop their own separate base of research and solidified the 2-year requisite for the fellowship.
Changes in NIH Support for Medical Research Support by the NM for medical research increased dramatically during the 1960s. In addition, NM financial support for subspecialty traimng then was three times current levels, based upon the ratio of trainees supported per number of internal medicine residents.47@ That may have encouraged many to train within a medical subspecialty. In the early 197Os, federal support for fellowships declined abruptly, from a total of 2,373 positions for firs&year physician trainees and fellows in 1966 to 1,025 positions in 1978.47,48This reduction seems to have been related to the realization that the programs were developing clinical subspecialists who did not remain in academic medicine. The NRSAs were modified to include a “pay-back” requirement of equal time in an academic pursuit following the completion of the fellowship and to restrict the use of grant-supported fellows for clinical service functions.43 Despite these changes, the 60% to 70% probability that medical residents would choose to tram in a subspecialty remained relatively constant between 1976 and 1938. In recent years it has approached the 85% leve1.4*4gModifications in the NRSAs also had no apparent effect upon the probability that former recipients of NIH training support would eventually be-
come independent investigators. The percentage of fellows and trainees in the period from 1979 to 1983 who ultimately obtained an ROl award, the traditional investigational NIH grant, did not increase when compared with the identical group that trained during the period from 1963 to 1967.47j48(Table) There was also a major change in the pattern of NM support by the NRSA mechanism between 1966 and 1986 in that, while the total annual number of firstyear MDs supported decreased from 2,373 to 1,372, the total number of first-year PhDs supported rose from 766 to 1,560. This transition of support from MDs to PhDs may be justified when one observes that a PhD financed by an NRSA is twice as likely to receive an ROl award as is an MD whose training was funded by the same mechanism. Also, at either the PhD or MD level, a person supported by the NRSA fellowship mechanism is >50% more likely to eventually develop into an independent investigator, using the ROl award as the criterion, than is a person prepared by the NRSA trainee mechanism. 47,48That may be related to the requirement that fellowship applicants must contribute meaningfully to the grant proposal themselves, a process that requires more initiative.
DEVELOPMENT TRENDS OF ACADEMIC DEPARTMENTS OF MEDICINE Concurrent with these changes in the NIH and the AHIM, the publication of the Millis report50 in 1966 supported the perception that a physician shortage existed in the United States and stimulated the creation of new medical schools and the enlargement of class size in others, doubling the output of physicians within the next decade. Encouraged by a simultaneous increase in federal support for research, the new faculty were predominantly investigators in clinical and basic science whose clinical expertise was often, both by training and by necessity of remaining competitive in the grant application process, limited to a specific area of medicine. Many schools assumed that the ultimate financial support of this new faculty would be derived from their ability to generate independent grant support. Concurrently, the arrival of Medicare in the 1960s enabled the elderly and the disabled to obtain a level of medical care previously not available to them, and simultaneously encouraged the development of such hospital-based technological advances as coronary care units and highly sophisticated life-support systems. In addition, Medicare directed some of its funds to the teaching hospitals for the support of graduate medical education. Trends in the financial support of US medical schools have changed within the past decade. Adjusted for inflation with the Consumer Price Index, federal research support increased 93% between 1982 and 1992,
TABLE Trends in National Institutes of Health (NIH) Research Training Support and an Analysis of Former Recipients’ Success in Ultimately Obtaining an ROl Award First Fiscal Year of Training 1963-1967 1979-1983 11,623 Total MDs supported 5,635 9,256 4,599 NIH-supported MD trainees NIH-supported MD fellows 2,367 1,036 3,502 Total PhDs supported 8,033 1,663 4,567 NIH-supported PhD trainees NIH-supported PhD fellows 1,839 3,466 Percent ultimately obtaining ROl award 16.5 % 14.9 % Total MDs MD trainees 13.1 % 13.0 % MD fellows 29.9 % 23.4 % Total PhDs 39.5 % 26.7 % PhD trainees 32.9 % 21.2 % PhD fellows 45.6 % 33.9.%
while the revenue from clinical practice within the medical schools has increased 233%.51Together, these two sources currently comprise 66% of the total US medical school revenues. It is apparent that the schools have become increasingly dependent upon the ability of their full-time clinicians to generate income. If one accepts the premise that referrals to medical centers are most often made for specialty-oriented technical procedures, these factors would favor the development of a faculty capable of either eliciting federal research support or being clinically proficient in a specialized, predominantly technical, area. The past 2 decades have witnessed an explosive growth of subspecialty training programs in internal medicine and their evolution into almost independent institutions combining clinical services and investigational programs at various levels. One may ask at this time whether they have been effective in producing physician scientists and clinical investigators. The data above suggest that, even with the increased emphasis from the NIH in regard to ensuring that these programs would be devoted to these goals, the return on the investment in medical doctors as measured by the eventual awarding of an ROl award has been less than what one would have hoped.
DISCUSSION The historical evidence presented in this paper suggests the hypothesis that the current structure of academic departments of medicine, the training of physicians, and the policies of the AHIM may have been developed, in part, in response to standards for fmancial support established by the NIH. These NM standards are appropriately aimed at the development of physician scientists, yet they seem also to have encouraged the creation of almost independent subspeJuly 1995 The American Journal of Medicine”
Volume 99
77
cialty divisions organized to be qualihed for NM grant support. This result seems, in many ways, discordant with the greater educational goal of producing physicians responsive to national needs. Evidence may also exist that recent NIH policies have been inefficient in the development of physician scientists given the low and static rate of MD trainees and fellows who ultimately develop into independent investigators.47@ Over the past 15 years the absolute number of physician scientists in academia, government, and industry has not increased.lg Note should also be made of the progressive trend toward PhDs supplanting MDs as recipients of ROl awards. How can this apparently inappropriate trend of subspecialization within internal medicine be reversed while preserving its strengths and benefits? Can the number of medical graduates entering general internal medicine and other primary care fields be increased? Can physician scientists be nurtured and developed more effectively?
Existing Proposals for Reform Unlike Canada, where the Royal College of Physicians and Surgeons is a relatively monolithic organization with the ability to determine the number and types of physicians trained,52 the United States has no national policy board. The education and practice of internists is supervised by a decentralized group of organizations, none of which has the power to effect a major change independently. Potentially the most powerful of these organizations, the ABIM and the Accreditation Council for Graduate Medical Education (ACGME), derive their strength from being able to certify either individuals or programs, but are not designed to be able to create new programs themselves. Over the past few years many authors and organizations have suggested reforms in regard to physician supply, specialty distribution, and the financing of graduate medical education.20 President Clinton’s September 1993 health reform proposal recommended a nationally coordinated plan for educating the nation’s physicians. 53 Senator Jay Rockefeller’s and Representative Henry Waxman’s Primary Care Workforce Act of 1993@ proposed that the aggregate number of residency training positions be restricted to 1100/oof the US medical school graduates and that 50% of entry residency positions be in the field of primary care. This policy of “llO?/o and 50%” is shared by proposals made by the COGME and the Association of Professors of Medicine.2v55 The mechanism by which these changes will be brought about are not clear. Changes have been suggested in the internal medicine residency and in the process of certification by the ABIM. Earley@ recommended that the medical residency be increased to 4 years with two separate tracks a generalist and a subspecialist pathway. After 78
July 1995
The American
Journal
of Medicine’
Volume
99
4 years, trainees would become eligible for certitication either in general internal medicine or in a medical
subspecialty, but not in both. Stein57 and Baronde@ both advocate increasing the residency to 4 years, but would admit residents to subspecialty training after the third year. Stein suggests that the extra year for those residents who plan to practice general internal medicine be devoted to 8 months of rotation in 1 or 2 subspecialties and 4 months of “off-site” ambulatory care. The Federated Council for Internal Medicine suggests that the length of subspecialty training be prolonged without increasing the number of subspecialists in training.1g Petersdo@ supports Earley’s proposal and advocates shifting subspecialty fellowship positions into general internal residency slots. I&sire@ also advocates reducing the number of subspecialty training positions and suggests that competitive examinations could be used to determine acceptance into these programs. FogelmanGo has recently described his own efforts as Chairman of the Department of Medicine at the University of California, Los Angeles. His program reduces fmancial support for subspecialty divisions that do not produce academic physicians and diverts these resources to the development of a faculty of generalists. The recruitment of these generalists is enhanced by paying them more than subspecialists and also by credentiakng them to practice and perform procedures in any area in which they have documented competence.
Goals and a Proposal The author believes that the qualities that attract individuals to internal medicine are primarily the same whether they ultimately subspecialize or not. Predominant attractions are the challenge and stimulation involved with resolving clinical problems and the humanistic satisfactions of patient care. Recent essays by FitzgeraldG1 and LaCombe62 express the enthusiasm and satisfaction felt for general internal medicine and comment upon methods of maintaining it in both residency and practice. Current factors that seem detrimental to the welfare of general internal medicine are policies aimed at developing general internists primarily as “gate keepers” and artificially restricting their clinical activities to, presumably, less challenging areas. General internal medicine may also suffer in that its intellectual base and its source of investigational activities have in large part been restricted to epidemiology, outcome studies, and similar areas, while more “basic” areas of science are excluded, and in a sense usurped, by the subspecialty divisions. An effort should be made to expand the clinical horizon and deepen the research base of general internal medicine. One should also realize that some internists prefer to incorporate a subspecialty into their profes-
SlJBSPEClALIZATlON
sional life primarily as an avocation. Currently subspecialization is viewed by many medical residents as the only avenue by which they can advance their clinical or investigational skills. At the very least, an attempt should be made to reorganize the current system of graduate medical education so that training as a medical subspecialist is not detrimental to one’s competence as a generalist. Another goal should be to ahow basic and clinical investigation to develop in the most fertile environment possible and not to confine it by the arbitrary and inflexible borders of subspecialization. The following is proposed: the duration of medical residency should be increased to 4 postgraduate years and board-eligibility in internal medicine would occur at the completion of this training. A major portion of the third postgraduate year would be devoted to training in one or more of its subspecialties. During the fourth year the resident would be offered an opportunity to continue an ambulatory and consultative experience in the same subspecialty or subspeciakies. Board-eligibility in a subspecialty would have no duration-of-training prerequisite and would require only prior certification by the ABIM in internal medicine. In addition, the subspecialty board would only certify competence in regard to having acquired an appropriate body of knowledge and not technical proficiency. This proposal should enrich the educational qua& ity of the medical residency and stems both from a consensus that more than 3 years’ training are required to become proficient in internal medicine and from a desire by the majority of medical residents to function in some manner within a subspecialty. The decision of whether to subspeciahze or not, and in which area, would be deferred until near the completion of the residency rather than during the internship, as is the usual current situation. Therefore, career decisions will be more likely to be based upon reality and perhaps more consistent with community needs. Those electing to develop investigational skills would do so because of intellectual interest rather than as a means of obtaining subspecialty training. The goal would be to produce an adaptable physician, well grounded in the discipline of internal medicine, who may have competence in, but is not restricted to, a chosen subspeciaky. A second proposal is that technical competency in all procedures, whether related to general internal medicine or one of its subspecialties, would be cert.& fied locally by the institution in which the physician chooses to practice. In regard to technical skills, there are subjective data regarding the length of training required. Gastroenterologists who are members of the ACP were surveyed and asked to defme for each techni-
IN INTERNAL MEDICINE/ANDERSON
cal procedure: (1) how often they performed the pro cedure annuahy, (2) how often the procedure needed to be done in order to become technically competent, and (3) how often the procedure should be done annually to maintain competence.@ Using these star-rdards, extrapolated data suggest that a physician in training would become a technically proficient gastroenterologist in a period of 3 to 6 months if they were as active in performing these procedures as is the average practicing gastroenterologist. A similar survey was done on practicing nephrologists,64 and using the same criteria, a physician in training would require 6 to 12 months in order to become a technically proficient nephrologist. Other subspecialties have not been studied by similar methods. Within the past decade, hospitals and other providers of health care have become increasingly active in credentiahng the clinical skills of their member physicians. Documentation of competence is then based upon current skills, rather than upon a written exam taken many years ago, and a letter from the pro gram director. The recently developed policy of timelimited certification by the ABIM is consistent with this concept. Of interest, in the previously described study of procedural skills of gastroenterologi&sm 31% of the procedures that the respondents currently perform had been learned after the completion of formal training. If a local institution lacks an individual capable of mentoring or certifying the technical skills of a physician in a particular area, an outside source could be used. A third proprosal is that NIH training grants and fellowships should be used as originally intended, to develop investigators and not as an alternative method of financing training in the subspecialties. It is to be hoped that, in the proposed system, NIH support could be more efficiently channeled into basic disciplines such as immunology, genetics, epidemiology, and so forth, which would serve as a resource for all of the clinical divisions within a department of medicine. The potentially wasteful efforts of each clinical subspeciaky unit attempting to create its own independent division of basic sciences and research would be eliminated. The creation of free-standing investigational units based upon the fundamental scientific discipline within a department of medicine, and composed of members with clinical activities in different spheres, has been previously proposed by Austen.65 The advantages of this structure would be the creation of a scientific faculty of the critical size required for cross-fertilization and the meaningful interdisciplinary education of future investigators. Basic investigators would be less constrained by the narrow boundaries of their clinical subspecialty and would be free to interact in other clinical areas related to the body of knowledge that they happen to develop. The changes described would create probJuly 1995
The American
Journal
of Medicine’
Volume
99
79
lems in regard to fundraising from both the federal government and voluntary agencies, which historically tend to focus upon organ systems and categorical diseases. A concerted effort aimed at the education of donors and federal policy makers would be required. It is assumed that the changes proposed would weaken the power and the autonomy of the subspecialty divisions and perhaps threaten their ability to continue to produce clinical teachers, improve programs of patient care, and foster the development of clinical investigation. It would be expected that a separate department combining research, teaching, and patient care will not exist in each subspecialty in each teaching hospital or medical school. Clinical programs would survive and grow by including disciplines outside the field of internal medicine. For example, an arthritis and musculoskeletal disease unit should include expertise in rheumatology, orthopedics, rehabilitation, neurology, and radiology. How will clinical teachers within a subspecialty be developed in this proposed program? Physicians with potential in this area would require a period of support following the completion of residency while the clinical and educational skills necessary to be an effective teacher or clinical investigator are refined. One solution would be to develop positions within the department of medicine for such an individual similar to that currently held by the Chief Resident. During this time, their proficiency in a chosen field would be cultivated while the entire teaching program of the department would be enriched. Their ultimate position in an academic department of medicine could be developed either in a subspecialty division or within the department of medicine, depending upon the role occupied by the subspecialty in that institution. In summary, the proposed changes should create increased flexibility and cross-fertilization in residency training, clinical practice, and scientific investigation. It is hoped that careers in internal medicine will develop along the lines of individual talent and interest while responding to the overall needs of society. The investment of an additional year of residency training would be balanced by virtually eliminating the 2 years of subspecialty fellowship taken by the vast majority of current internal medicine residents. The artificial barriers associated with subspecialization have not only separated both clinical and scientific disciplines, but have also been detrimental to both, and should be removed.
REFERENCES 1. Schroeder SA. Training an appropriate mix of physicians to meet the nation’s needs. Acad Med. 1993;68:118-122. 2. Council on Graduate Medical Education, Fourth Report: Recommendations to Improve Access to Health Care Through Physician Workforce Reform. Washington, DC: US Department of Health and Human Services: January 1994. Draft. 80
July 1995
The American
Journal
of Medicinea
Volume
99
3. National Resident Matching Program. NRMP Data: March 1994. American Washington, DC: Association of Medical Colleges; 1994. 4. Kassebaum DG, Szenas PL. Specialty preferences of graduating medical students: 1992 update. Acad Med. 1992;67:800-806. 5. Kassebaum DG, Szenas PL. Specialty preferences of 1993 medical school graduates. Acad Med. 1993;68:866-869. 6. Levinsky NG. Recruiting for primary care. NEJM. 1993;328:656-660. 7. Norcini JJ, Shea JA, Benson JA. Changes in the medical knowledge of candidates for certification. Ann Intern Med. 1991;114:33-35. 8. Lyttle CS, Levey GS. The National Study of Internal Medicine Manpower: Xx. The changing demographics of internal medicine residency training programs. Ann Intern Med. 1994;121:435-441. 9. Schwartz MD, Linzer M, Babbott 0, et al. Medical student interest in internal medicine. Ann Intern Med. 1991;114:&15. 10. Babbott D, Levey GS, Weaver SO, Killian CD. Medical student attitudes about internal medicine: a study of U.S. medical school seniors in 1988. Ann Intern Med. 1991;114:16-22. 11. McMurray JE, Schwartz MD, Genero NP, et al. The attractiveness of internal medicine: a qualitative analysis of the experiences of female and male medical students. Ann Intern Med. 1993;119:812-818. 12. Federman DD. Relation of the internal medicine residency and the medical school curriculum. Ann Intern Med. 1992;116:1061-1064. 13. Kassenbaum DG, Szenas PL, Ruffin AL. The declining interest of medical school graduates in generalist specialties: students’ abandonment of earlier inclinations. Acad Med. 1993;68:278-280. 14. Petersdorf RG. Primary care applicants-they get no respect. NOM. 1992;326:408-409. 15. Colwill JJ. Where have all the primary care applicants gone? NEJM. 1992; 326:387-393. 16. Shulkin DJ. Choice of specialty: in’s money that matters in the USA. JAMA. 1989;262:1630-1631. 17. Kassebaum DG, Szenas PL. Relationship between indebtedness and the specialty choices of graduating medical students. Acad Med. 1992;67: 700-707. 18. Pew Health Professions Commission. Primary Care Workforce 2000: Federal Health Policy Strategies. San Francisco: Pew Foundation; March 1993. 19. Federated Council for Internal Medicine. Generating more generalists: an agenda of renewal for internal medicine. Ann Intern Med. 1993;119: 11251129. 20. Rivo ML, Jackson DM, Clare FL. Comparing physician workforce reform recommendations. JAMA. 1993;270:1083-1084. 21. Greenfield S, Nelson EC, Zubjoff M, et al. Variations rn resource utilization among medical specialties and systems of care. JAMA. 1992;267: 1624-1630. 22. Welch WP, Miller ME, Welch HG, et al. Geographic variation in expen diures for physicians’ services in the United States. NEJM. 1993;328:621-627. 23. Carline JD, lnui TS, Larson EB, et al. The knowledge base of certified internists. Arch Intern Med. 1989;149:2311-2313. 24. Wigton RS, Nicolas JA, Blank LL. Procedural skills of the general internist. Ann Intern Med. 1989;111:1023-1024. 25. Frank P. Soundtng board: gatekeeping revisited-protecting patients from overtreatment. NEJM 1992;327:424-429. 26. Barondess JA. The future of generalism. Ann Intern Med. 1993;119: 153160. 27. Rivo ML. Internal medicine and the journey to medical generalism. Ann Intern Med. 1993;119:146-152. 28. Marder WD, Meenan RF, Felson DT, et al. The present and future adequacy of rheumatology manpower. Arthritis Rheum. 1991;34:1209-1217. 29. Marder WD, Kletke PR, Silberger AB, Wilke AJ. Physician Supply and Utilization by Specialty: Trends and Projections. Chicago: American Medical Association; 1988. 30. Wennberg JE, Goodman DC, Nease RF, Keller RB. Finding equilibrium in U.S. physician supply. Health Aff. (Millwood) 1993;Summer:89-103. 31. Weiner JP. Forcasting the effects of health reform on U.S. physician workforce requirements. Evidence from HMO stafhng patterns. JAMA. 1994; 272:222-230. 32. Braunwald E. Cardiology-division or department? NEJM. 1993;329: 1887-1890.
SUBSPEClALlZATlON 33. Glickman RM, Nolan JP, Rubenstein AH, et al. United we stand. Ann Intern Med. 1993;118:903-904. 34. Cohen JJ. The country needs more generalist physicians! ABlM News Update. 1993;Summer/Fall:2. 35. Bierring WL. The American Board of Internal Medicine. Ann Intern Med. 1937;10:1946-1951. 36. Irons EE. The American Board of Internal Medicine after four years. Organization, purpose, and the effects of special boards on medical education and practice. Ann Intern Med. 1940;14:146-152. 37. American Board of Internal Medicine. Memorandum to applicants for admission to examination. Ann Intern Med. 1947;26:845-850. 38. Myers JD. The American Board of Internal Medicine: modernization of procedures. Ann Intern Med. 1970;72:423-424. 39. Futcher PH. Educational requirements for the American Board of Internal Medicine. JAMA. 1969;209:924. 40. Ebert RV. Further changes in the requirements and procedures of the Amencan Board of Internal Medicine. Ann Intern Med. 1971;75:121-123. 41. Petersdorf RG, Beck JC. The new procedure for evaluating the clinical competence of candidates to be certified by the American Board of Internal Medicine. Ann Intern Med. 1972;76:491-496. 42. Engstrom WW. Residency training in internal medicine, for what; subspecialty boards, what for? Ann Intern Med. 1969;70:621-633. 43. Service Awards: Guidelines for Individual Awards-Institutional Grants. Washington, DC: US Department of Health and Human Services; January 6, 1984. 44. Mullan F, Rivo ML, Politzer RM. Doctors, dollars and determination: making physician work-force policy. Health Aff. fMillwoodJ 1993;12(suppl):138-151, 45. AAMC Council of Teaching Hospitals. Survey of House Staff Stipends, Benefits and Funding. Washington, DC: Association of American Medical Colleges; 1991:67. 46. Arend WP. American College of Rheumatology survey of rheumatology program directors. Presented at the Annual Meeting of the American College of Rheumatology; San Antonio, Texas; September 22, 1993. 47. Quantum Research Corporation. Prospective and Retrospective Trainee Analyses. Bethesda, Maryland: National Institutes of Health; June 1991. 48. Quantum Research Corporation. Prospective and Retrospective Trainee
IN INTERNAL MEDICINE/ANDERSON
Analyses. Bethesda, Maryland: National Institutes of Health; September 1993. 49. Lyttle CS, Andersen RM, Neymare K, et al. National Study of Internal Manpower: XVIII. Subspecialty fellowships with a special look at hematology and oncology. 1988-1989. Ann Intern Med. 1991;114:36-42. 50. The report of the Citizens’ Commission on Graduate Medical Education. The Graduate Education of Physicians. Chicago: American Medical Association; 1966. 51. Krakower JY, Jolly P, Beran R. US medical school finances. JAMA. 1993; 270:1085-1091. 52. Whitcomb ME, Dessgrosseilliers JP. Primary care in Canada. NEJM. 1992; 326:1469-1472. 53. The American Health Securii Act of 1993. September 7, 1993:125-143. Draft. 54. Rockefeller J, Waxman H. The Primary Care Workforce Act of 1993. Washington, DC: US Congress (SI1315, (HRj2804. 55. Luke R, Tetwilliger J, lbrahim T. Developing a strategy for providing federal GME support. Am J Med. 1993;9(5):1-VI. 56. Earley LE. Alternative pathways for training to general internist and the medical subspecialist. Ann Intern Med. 1992;116:108&1083. 57. Stein JH. Grand cru versus generic: diierent approaches to altering the ratio of general internists to subspecialists. Ann Intern Med. 1991;114:79-82. 58. Petersdorf RG. The doctor is in. Acad Med. 199368: 113-l 17. 59. Kassirer JP. Primary care and the affliction of internal medicine. NEJM. 1993;328:648-651. 60. Fogelman AM. Strategies for training generalists and subspecialists. Ann Intern Med. 1994;120:579-583. 61. Fitzgerald FT. The case for internal medicine. NEJM. 1993;328:654-656. 62. LaCombe M. What is internal medicine? Ann Intern Med. 1993;118: 384-387. 63. Wigton RS, Blank LL, Monsour H, Nicholas JA. Procedural skills of practicing gastroenterologists. Ann Intern Med. 1990;113:540-546. 64. Tape ll, WIgton RS, Blank LL, Nicholas JA. Procedural skills of practicing nephrologists. Ann Intern Med. 1990;113:392-397. 65. Austen KF. An alternative structure in departments of medicine for the career development of physician/scientists. 1990 Presidential address, Jrans Assoc Am Physicians. 1990;CIII:CXV-CXXI.
July 1995
The American
Journal
of Medicine@
Volume
99
81
1 REVIEW
Subspecialization in Internal Medicine: A Historical Review, An Analysis, and Proposals for Change Ronald J. Anderson, MD, Boston,
Massachusetts
The recent decline in the production of primary care physicians has been associated with a decrease in the production of general internists and an increase in the number of medical subspecialists. A significant major& of entering internal medicine residents anticipate entering a medical subspecialty. This transition in the development of medical manpower, perceived by some as inappropriate, is analyzed in light of historical trends in the evolution of internal medicine and its subspecialties, and in conjunction with the roles played by the American Board of Internal Medicine and the National Institutes of Health. Evidence is presented that the creation of virtually independent subspecialty departments may have been detrimental to the education of physicians and not productive of the physician scientists they are assumed to create. Current recommendations for reform are reviewed and a new proposal is presented, suggesting increasing the length of the medical residency from 3 to 4 years, incorporating subspecialty training in one or more fields into the third year of the residency, removing “duration of training” as a requirement for board eligibilii in a subspecialty, transferring the certification of technical competence in a procedure to local institutions, and creating investigational units in basic disciplines within the department of internal medicine that would serve as a resource for all the subspecialty divisions.
T
here currently is a major concern about the declining number of US physicians entering the field of primary care, defined as general internal medicine, pediatrics, and family practice.1~2 Internal medicine is the largest of these and had undergone a steady decline in attracting residents to the field, fahing from 4,143 medical school graduates in 1986 in the United States to 3,079 in 1993. Fill rates in the National Resident Matching Program also fell for 8 consecutive years to a low of 53.1% in 1993. A small upturn in both these parameters occurred in 1994.3 A
From the Department of Rheumatology and Immunology, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts. Requests for reprints should be addressed to Ronald J. Anderson, MD, Administration B-2, Brigham and Women’s Hospital, 75 Francis Street, Boston, Massachusetts 02115. Manuscript submitted May 9, 1994 and accepted in revised form February 13, 1995.
74
July 1995
The American
Journal
of Medicine@
Volume
99
decrease has also been noted between 1982 and 1993 from 14.3% to 4.5% in the percentage of medical school graduates who plan to enter general internal medicine, while simultaneously the percentage of those planning on entering a medical subspecialty has virtually doubled from 7.6% to 14.2%.495Assuming the current supply and specialty mix of residents is left unchanged, the Council on Graduate Medical Education (COGME) recently projected a shortage of 35,000 generahsts and an oversupply of 115,000 specialists in all fields by the year 2000.2 There is also concern that internal medicine is failing to attract the best and the brightest. Levinsw has documented a downward trend in the academic qua& ifications of Boston University graduates selecting internal medicine residencies over the last decade, and a recent small decline in the scores of US medical graduates on the certifying exammation of the American Board of Internal Medicine (ABIM) has been noted.7 Between 1976 and 1992 the percentage of foreign medical graduates in US medical residency programs has increased from lO?&to 30%, while the percentage of US medical graduates has correspondingly declined.8 Recent studies of factors that attract or deter medical students from electing internal medicine as a career reveal that ambulatory rotations, Honors grades, and exposure to practicing physicians had the highest correlation with the decision to become an internist.g-13 The profile of students planning to become general internists was virtually identical to that of students planning to enter a subspeciaky of internal medicine. Observers consider that the relatively low expected income is a major deterrent to the decision to enter a primary care field, 14,15and Shulkin16 describes an almost linear relationship between anticipated income and the percentage of residency positions filled. Internal medicine was near the bottom. The level of student indebtedness does not seem to correlate, however, with the choice of a specialty.17 General internal medicine has strong support from many critical observers of health care policy in America COGME, the Pew Health Professions Commission, and the Federated Council for Internal Medicine have all advocated that 50% of all beginning residents complete a generalist program and enter practice in general internal medicine, pediatrics, or family practice.2~‘820 Much of the argument for increasing the number of general internists and other primary care physicians stems from evidence that they are cost effec-
SUBSPECIALIZATION IN INTERNAL MEDICINE/ANDERSON
tive. Greenfield et al,21 in a large study whose size and scope almost precludes it from ever being replicated, present data that cardiologists and endocrinologists utilize more health care resources for the care of similar patients than do generalists. Internists were marginally less cost effective than family practitioners. In a study of geographic variations in expenditures for physician services, Welch et alz2 showed that the most important variable associated with lower cost of care was the number of primary care physicians in the region. Neither of the studies addressed quality issues. Observations of general internists practicing in small communities with a limited access to subspe&lists compared with peers who practice closer to urban medical centers suggest that proximity and availability of subspecialists may be detrimental to the knowledge base and technical proficiency of internists.23~24 Some argue that an oversupply of subspecialists is more detrimental to the health care sys tern than is a shortage of generaJists.25,26They attribute this to an unnecessary and costly fragmentation of health care services related to subspecialists’ inability to care for conditions outside of their field. Arguments have been made that changing the physician mix to 50% generalists would save billions of dollars by reducing physician income and avoiding tests and procedures of uncertain va.lue.27 Determining the number of medical subspecialists required for our nation’s needs is controversial, and the need would vary depending upon the extent and level at which the subspecialist is involved in primary care. 28*2gHowever, data obtained from managed health care programs indicate that a significant excess exists.30,31 Although leaders in academic internal medicine support a unified department of medicine, as opposed to independent subspecialty units, as the core of an academic department of medicine, a general assumption exists that strong subspecialty divisions are essential for the development of physician scientists.3”~33 Recently the Chairman of the AE!ELJ,~ in summarizing arguments against reducing the number of subspecialty fellows, stated: “. . . We risk the extinction of an already endangered species-the clinical investigator. Where are the physician scientists of the future going to come from if not from the medical subspecialties? And where are they going to be trained if not in our subspecialty training programs?” General internal medicine therefore appears highly desirable in the eyes of health care policy makers, but is unable to recruit an adequate number of new members. At the same time it is criticized for having overemphasized the development of inefficient subspecialization. How did the subspecialties evolve into their current dominant position? Are they essential for the development of physician scientists?
The purpose of this paper is to analyze historical trends in the evolution of residency and fellowship training in internal medicine over the last 30 years, particularly as related to the development of subspecialties. The roles played by the ABIM and the National Institutes of Health (NIH) will be examined and potential solutions to what appears to be an inappropriate production of the physician workforce will be reviewed and proposed.
AMERICAN BOARD OF INTERNAL MEDICINE The ABIM was created in 1936 by the American College of Physicians (ACP) in conjunction with the American Medical Association. At its inception the Board had no formal training requirements, but did require that a 5-year period must elapse between the completion of internship and eligibility for the certifying examination, According to Bierring, “The responsibility of acquiring the knowledge . . . rests with the candidate, while the responsibility of maintaining the standard of knowledge required for certification devolves on the Board.” Board certification at that time required passing a written examination in both basic science and general internal medicine, followed by a certifying or oral examination consisting of case histories and physical examinations of actual patients performed by the candidate while being observed and questioned by a member of the ABIM. Over the next 3 decades the 5 year postinternship requirement remained, as did the format of the examinations. Three years of training eventually became required to become eligible to take the examination. The specific nature of this training remained flexible, and both research and subspecialty experience were accepted. The ABIM acknowledged at the time of its founding that consideration would be given to “the more limited specialties of internal medicine such as cardiology, gastroenterology, allergy, tuberculosis, etc.“36 In 1940, it established a policy that candidates in these four areas would have their oral examinations by representatives from these subspecialties and “an appropriate notation of proficiency in the subspecialty would appear on the certiflcate.““6 Why only these four subspecialties (tuberculosis was renamed eventually as pulmonary diseases) boards chose to be established while the “etc.” specialties opted to follow another course is unclear. Requirements for certification in these four subspecialties became somewhat more rigid over the next 3 decades. Other than that, no clear division developed between those subspecialties with boards and those without. As a year of subspecialty training could be credited for board-eligibility in internal medicine, many residents incorporated such a year into July 1995
The American
Journal
of Medicine@
Volume
99
75
SUBSPEClALlZATlON
IN INTERNAL MEDICINE/ANDERSON
their residency and eventually practiced as subspecialists with no further train@ in the field. Formal subspecialty fellowship training of 2 or more years, particularly in fields without a subspecialty board, was generally taken only by those individuals with a strong desire to develop as an investigator or acade mic physician.
Trend Toward Subspecialization ln 1970, the ARIM initiated several major changes that had evolved in response to a developing trend to ward subspecialization, as a result of general dissa& faction with the oral examination and as an acknowledgement of the inability of physicians to master the entire field of internal medicine.37-41 The length of res idency train&j required for certification was reduced from 4 to 3 postgraduate years, the oral examination was abolished, and a single written exammation was developed certify@ a doctor as a Diploma& of the ABIM. The required &year period after internship be fore board eligibility was discarded. New subspecialty boards were created in endocrinology, hematology, infectious disease, nephrology, oncology, and rheumatology. Two additional years of formal tmining in a subspecialty was required for certification in that field. The reason that 2 years was selected as the appropriate duration of training was never clarified in published statements by the ARIM. These changes provoked controversy,42 but have remained essentially intact over the last 2 decades. Significant subsequent changes have been the lengthening of the training requirement in cardiology to 3 years, establishing the Clinical Investigator Pathway, and the addition of the new Certificates of Added Qualifications in Adolescent Medicine, Clinical Cardiac Electrophysiology, Critical Care Medicine, Geriatric Medicine, Sports Medicine, and Clinical and Laboratory Immunology.
THE NIH AND SUPPORT FOR SUBSPECIALTY TRAINING The NM consists of several institutions established largely upon the lines of categorical diseases or organ systems such as cancer, arthritis, and heart rather than specific scientific disciplines such as immunology, biochemistry, and so forth. Support by the NIH for subspecialty training is primarily channelled through the National Research Service Awards (NRSAs). These awards are restricted to programs of research training and may not be used “to support residencies, the primary purpose of which is the attainment of a medical specialty.“43 The awards consist of either fellowships, given to individuals who have obtained the sponsorship of a specific institution, or traineeships, awarded to an institution and providing funds for both the general research train76
July 1995 The American Journal of Medicine@ Volume 99
ing program and salaries for the trainees selected by that institution. Applicants to both programs are given “special consideration” when they agree to undertake a minimum of 2 years of biomedical research.43 The majority of current subspecialty trainees are supported by clinical practice income and direct and indirect financial support for graduate medical education through Medicare, which is administered by the Health Care Financing Administration. A recent analysis estimates that Medicare provides $70,000 annually through the hospitals for each resident and fel10w.~ Although only a minority of current subspecialty training programs are funded by the NIH,& most training programs conform to NIH guidelines of being research based with a minhnum duration of 2 years. One might assume that this is done with the expectation that they will ultimately be funded by the NM even when the probability that this will occur seems small. Of interest, a recent survey of rheumatology training program directors revealed that, although only 14% of their current fellows were supported by the NIH, they anticipated that 27% of the program’s fellows would be NM supported in the future.& The benefits to a division of acquiring an NIH training grant and the inflexible 2-year training requirement of the AHIM have encouraged the subspecialty divisions to develop their own separate base of research and solidified the 2-year requisite for the fellowship.
Changes in NIH Support for Medical Research Support by the NM for medical research increased dramatically during the 1960s. In addition, NM financial support for subspecialty traimng then was three times current levels, based upon the ratio of trainees supported per number of internal medicine residents.47@ That may have encouraged many to train within a medical subspecialty. In the early 197Os, federal support for fellowships declined abruptly, from a total of 2,373 positions for firs&year physician trainees and fellows in 1966 to 1,025 positions in 1978.47,48This reduction seems to have been related to the realization that the programs were developing clinical subspecialists who did not remain in academic medicine. The NRSAs were modified to include a “pay-back” requirement of equal time in an academic pursuit following the completion of the fellowship and to restrict the use of grant-supported fellows for clinical service functions.43 Despite these changes, the 60% to 70% probability that medical residents would choose to tram in a subspecialty remained relatively constant between 1976 and 1938. In recent years it has approached the 85% leve1.4*4gModifications in the NRSAs also had no apparent effect upon the probability that former recipients of NIH training support would eventually be-
come independent investigators. The percentage of fellows and trainees in the period from 1979 to 1983 who ultimately obtained an ROl award, the traditional investigational NIH grant, did not increase when compared with the identical group that trained during the period from 1963 to 1967.47j48(Table) There was also a major change in the pattern of NM support by the NRSA mechanism between 1966 and 1986 in that, while the total annual number of firstyear MDs supported decreased from 2,373 to 1,372, the total number of first-year PhDs supported rose from 766 to 1,560. This transition of support from MDs to PhDs may be justified when one observes that a PhD financed by an NRSA is twice as likely to receive an ROl award as is an MD whose training was funded by the same mechanism. Also, at either the PhD or MD level, a person supported by the NRSA fellowship mechanism is >50% more likely to eventually develop into an independent investigator, using the ROl award as the criterion, than is a person prepared by the NRSA trainee mechanism. 47,48That may be related to the requirement that fellowship applicants must contribute meaningfully to the grant proposal themselves, a process that requires more initiative.
DEVELOPMENT TRENDS OF ACADEMIC DEPARTMENTS OF MEDICINE Concurrent with these changes in the NIH and the AHIM, the publication of the Millis report50 in 1966 supported the perception that a physician shortage existed in the United States and stimulated the creation of new medical schools and the enlargement of class size in others, doubling the output of physicians within the next decade. Encouraged by a simultaneous increase in federal support for research, the new faculty were predominantly investigators in clinical and basic science whose clinical expertise was often, both by training and by necessity of remaining competitive in the grant application process, limited to a specific area of medicine. Many schools assumed that the ultimate financial support of this new faculty would be derived from their ability to generate independent grant support. Concurrently, the arrival of Medicare in the 1960s enabled the elderly and the disabled to obtain a level of medical care previously not available to them, and simultaneously encouraged the development of such hospital-based technological advances as coronary care units and highly sophisticated life-support systems. In addition, Medicare directed some of its funds to the teaching hospitals for the support of graduate medical education. Trends in the financial support of US medical schools have changed within the past decade. Adjusted for inflation with the Consumer Price Index, federal research support increased 93% between 1982 and 1992,
TABLE Trends in National Institutes of Health (NIH) Research Training Support and an Analysis of Former Recipients’ Success in Ultimately Obtaining an ROl Award First Fiscal Year of Training 1963-1967 1979-1983 11,623 Total MDs supported 5,635 9,256 4,599 NIH-supported MD trainees NIH-supported MD fellows 2,367 1,036 3,502 Total PhDs supported 8,033 1,663 4,567 NIH-supported PhD trainees NIH-supported PhD fellows 1,839 3,466 Percent ultimately obtaining ROl award 16.5 % 14.9 % Total MDs MD trainees 13.1 % 13.0 % MD fellows 29.9 % 23.4 % Total PhDs 39.5 % 26.7 % PhD trainees 32.9 % 21.2 % PhD fellows 45.6 % 33.9.%
while the revenue from clinical practice within the medical schools has increased 233%.51Together, these two sources currently comprise 66% of the total US medical school revenues. It is apparent that the schools have become increasingly dependent upon the ability of their full-time clinicians to generate income. If one accepts the premise that referrals to medical centers are most often made for specialty-oriented technical procedures, these factors would favor the development of a faculty capable of either eliciting federal research support or being clinically proficient in a specialized, predominantly technical, area. The past 2 decades have witnessed an explosive growth of subspecialty training programs in internal medicine and their evolution into almost independent institutions combining clinical services and investigational programs at various levels. One may ask at this time whether they have been effective in producing physician scientists and clinical investigators. The data above suggest that, even with the increased emphasis from the NIH in regard to ensuring that these programs would be devoted to these goals, the return on the investment in medical doctors as measured by the eventual awarding of an ROl award has been less than what one would have hoped.
DISCUSSION The historical evidence presented in this paper suggests the hypothesis that the current structure of academic departments of medicine, the training of physicians, and the policies of the AHIM may have been developed, in part, in response to standards for fmancial support established by the NIH. These NM standards are appropriately aimed at the development of physician scientists, yet they seem also to have encouraged the creation of almost independent subspeJuly 1995 The American Journal of Medicine”
Volume 99
77
cialty divisions organized to be qualihed for NM grant support. This result seems, in many ways, discordant with the greater educational goal of producing physicians responsive to national needs. Evidence may also exist that recent NIH policies have been inefficient in the development of physician scientists given the low and static rate of MD trainees and fellows who ultimately develop into independent investigators.47@ Over the past 15 years the absolute number of physician scientists in academia, government, and industry has not increased.lg Note should also be made of the progressive trend toward PhDs supplanting MDs as recipients of ROl awards. How can this apparently inappropriate trend of subspecialization within internal medicine be reversed while preserving its strengths and benefits? Can the number of medical graduates entering general internal medicine and other primary care fields be increased? Can physician scientists be nurtured and developed more effectively?
Existing Proposals for Reform Unlike Canada, where the Royal College of Physicians and Surgeons is a relatively monolithic organization with the ability to determine the number and types of physicians trained,52 the United States has no national policy board. The education and practice of internists is supervised by a decentralized group of organizations, none of which has the power to effect a major change independently. Potentially the most powerful of these organizations, the ABIM and the Accreditation Council for Graduate Medical Education (ACGME), derive their strength from being able to certify either individuals or programs, but are not designed to be able to create new programs themselves. Over the past few years many authors and organizations have suggested reforms in regard to physician supply, specialty distribution, and the financing of graduate medical education.20 President Clinton’s September 1993 health reform proposal recommended a nationally coordinated plan for educating the nation’s physicians. 53 Senator Jay Rockefeller’s and Representative Henry Waxman’s Primary Care Workforce Act of 1993@ proposed that the aggregate number of residency training positions be restricted to 1100/oof the US medical school graduates and that 50% of entry residency positions be in the field of primary care. This policy of “llO?/o and 50%” is shared by proposals made by the COGME and the Association of Professors of Medicine.2v55 The mechanism by which these changes will be brought about are not clear. Changes have been suggested in the internal medicine residency and in the process of certification by the ABIM. Earley@ recommended that the medical residency be increased to 4 years with two separate tracks a generalist and a subspecialist pathway. After 78
July 1995
The American
Journal
of Medicine’
Volume
99
4 years, trainees would become eligible for certitication either in general internal medicine or in a medical
subspecialty, but not in both. Stein57 and Baronde@ both advocate increasing the residency to 4 years, but would admit residents to subspecialty training after the third year. Stein suggests that the extra year for those residents who plan to practice general internal medicine be devoted to 8 months of rotation in 1 or 2 subspecialties and 4 months of “off-site” ambulatory care. The Federated Council for Internal Medicine suggests that the length of subspecialty training be prolonged without increasing the number of subspecialists in training.1g Petersdo@ supports Earley’s proposal and advocates shifting subspecialty fellowship positions into general internal residency slots. I&sire@ also advocates reducing the number of subspecialty training positions and suggests that competitive examinations could be used to determine acceptance into these programs. FogelmanGo has recently described his own efforts as Chairman of the Department of Medicine at the University of California, Los Angeles. His program reduces fmancial support for subspecialty divisions that do not produce academic physicians and diverts these resources to the development of a faculty of generalists. The recruitment of these generalists is enhanced by paying them more than subspecialists and also by credentiakng them to practice and perform procedures in any area in which they have documented competence.
Goals and a Proposal The author believes that the qualities that attract individuals to internal medicine are primarily the same whether they ultimately subspecialize or not. Predominant attractions are the challenge and stimulation involved with resolving clinical problems and the humanistic satisfactions of patient care. Recent essays by FitzgeraldG1 and LaCombe62 express the enthusiasm and satisfaction felt for general internal medicine and comment upon methods of maintaining it in both residency and practice. Current factors that seem detrimental to the welfare of general internal medicine are policies aimed at developing general internists primarily as “gate keepers” and artificially restricting their clinical activities to, presumably, less challenging areas. General internal medicine may also suffer in that its intellectual base and its source of investigational activities have in large part been restricted to epidemiology, outcome studies, and similar areas, while more “basic” areas of science are excluded, and in a sense usurped, by the subspecialty divisions. An effort should be made to expand the clinical horizon and deepen the research base of general internal medicine. One should also realize that some internists prefer to incorporate a subspecialty into their profes-
SlJBSPEClALIZATlON
sional life primarily as an avocation. Currently subspecialization is viewed by many medical residents as the only avenue by which they can advance their clinical or investigational skills. At the very least, an attempt should be made to reorganize the current system of graduate medical education so that training as a medical subspecialist is not detrimental to one’s competence as a generalist. Another goal should be to ahow basic and clinical investigation to develop in the most fertile environment possible and not to confine it by the arbitrary and inflexible borders of subspecialization. The following is proposed: the duration of medical residency should be increased to 4 postgraduate years and board-eligibility in internal medicine would occur at the completion of this training. A major portion of the third postgraduate year would be devoted to training in one or more of its subspecialties. During the fourth year the resident would be offered an opportunity to continue an ambulatory and consultative experience in the same subspecialty or subspeciakies. Board-eligibility in a subspecialty would have no duration-of-training prerequisite and would require only prior certification by the ABIM in internal medicine. In addition, the subspecialty board would only certify competence in regard to having acquired an appropriate body of knowledge and not technical proficiency. This proposal should enrich the educational qua& ity of the medical residency and stems both from a consensus that more than 3 years’ training are required to become proficient in internal medicine and from a desire by the majority of medical residents to function in some manner within a subspecialty. The decision of whether to subspeciahze or not, and in which area, would be deferred until near the completion of the residency rather than during the internship, as is the usual current situation. Therefore, career decisions will be more likely to be based upon reality and perhaps more consistent with community needs. Those electing to develop investigational skills would do so because of intellectual interest rather than as a means of obtaining subspecialty training. The goal would be to produce an adaptable physician, well grounded in the discipline of internal medicine, who may have competence in, but is not restricted to, a chosen subspeciaky. A second proposal is that technical competency in all procedures, whether related to general internal medicine or one of its subspecialties, would be cert.& fied locally by the institution in which the physician chooses to practice. In regard to technical skills, there are subjective data regarding the length of training required. Gastroenterologists who are members of the ACP were surveyed and asked to defme for each techni-
IN INTERNAL MEDICINE/ANDERSON
cal procedure: (1) how often they performed the pro cedure annuahy, (2) how often the procedure needed to be done in order to become technically competent, and (3) how often the procedure should be done annually to maintain competence.@ Using these star-rdards, extrapolated data suggest that a physician in training would become a technically proficient gastroenterologist in a period of 3 to 6 months if they were as active in performing these procedures as is the average practicing gastroenterologist. A similar survey was done on practicing nephrologists,64 and using the same criteria, a physician in training would require 6 to 12 months in order to become a technically proficient nephrologist. Other subspecialties have not been studied by similar methods. Within the past decade, hospitals and other providers of health care have become increasingly active in credentiahng the clinical skills of their member physicians. Documentation of competence is then based upon current skills, rather than upon a written exam taken many years ago, and a letter from the pro gram director. The recently developed policy of timelimited certification by the ABIM is consistent with this concept. Of interest, in the previously described study of procedural skills of gastroenterologi&sm 31% of the procedures that the respondents currently perform had been learned after the completion of formal training. If a local institution lacks an individual capable of mentoring or certifying the technical skills of a physician in a particular area, an outside source could be used. A third proprosal is that NIH training grants and fellowships should be used as originally intended, to develop investigators and not as an alternative method of financing training in the subspecialties. It is to be hoped that, in the proposed system, NIH support could be more efficiently channeled into basic disciplines such as immunology, genetics, epidemiology, and so forth, which would serve as a resource for all of the clinical divisions within a department of medicine. The potentially wasteful efforts of each clinical subspeciaky unit attempting to create its own independent division of basic sciences and research would be eliminated. The creation of free-standing investigational units based upon the fundamental scientific discipline within a department of medicine, and composed of members with clinical activities in different spheres, has been previously proposed by Austen.65 The advantages of this structure would be the creation of a scientific faculty of the critical size required for cross-fertilization and the meaningful interdisciplinary education of future investigators. Basic investigators would be less constrained by the narrow boundaries of their clinical subspecialty and would be free to interact in other clinical areas related to the body of knowledge that they happen to develop. The changes described would create probJuly 1995
The American
Journal
of Medicine’
Volume
99
79
lems in regard to fundraising from both the federal government and voluntary agencies, which historically tend to focus upon organ systems and categorical diseases. A concerted effort aimed at the education of donors and federal policy makers would be required. It is assumed that the changes proposed would weaken the power and the autonomy of the subspecialty divisions and perhaps threaten their ability to continue to produce clinical teachers, improve programs of patient care, and foster the development of clinical investigation. It would be expected that a separate department combining research, teaching, and patient care will not exist in each subspecialty in each teaching hospital or medical school. Clinical programs would survive and grow by including disciplines outside the field of internal medicine. For example, an arthritis and musculoskeletal disease unit should include expertise in rheumatology, orthopedics, rehabilitation, neurology, and radiology. How will clinical teachers within a subspecialty be developed in this proposed program? Physicians with potential in this area would require a period of support following the completion of residency while the clinical and educational skills necessary to be an effective teacher or clinical investigator are refined. One solution would be to develop positions within the department of medicine for such an individual similar to that currently held by the Chief Resident. During this time, their proficiency in a chosen field would be cultivated while the entire teaching program of the department would be enriched. Their ultimate position in an academic department of medicine could be developed either in a subspecialty division or within the department of medicine, depending upon the role occupied by the subspecialty in that institution. In summary, the proposed changes should create increased flexibility and cross-fertilization in residency training, clinical practice, and scientific investigation. It is hoped that careers in internal medicine will develop along the lines of individual talent and interest while responding to the overall needs of society. The investment of an additional year of residency training would be balanced by virtually eliminating the 2 years of subspecialty fellowship taken by the vast majority of current internal medicine residents. The artificial barriers associated with subspecialization have not only separated both clinical and scientific disciplines, but have also been detrimental to both, and should be removed.
REFERENCES 1. Schroeder SA. Training an appropriate mix of physicians to meet the nation’s needs. Acad Med. 1993;68:118-122. 2. Council on Graduate Medical Education, Fourth Report: Recommendations to Improve Access to Health Care Through Physician Workforce Reform. Washington, DC: US Department of Health and Human Services: January 1994. Draft. 80
July 1995
The American
Journal
of Medicinea
Volume
99
3. National Resident Matching Program. NRMP Data: March 1994. American Washington, DC: Association of Medical Colleges; 1994. 4. Kassebaum DG, Szenas PL. Specialty preferences of graduating medical students: 1992 update. Acad Med. 1992;67:800-806. 5. Kassebaum DG, Szenas PL. Specialty preferences of 1993 medical school graduates. Acad Med. 1993;68:866-869. 6. Levinsky NG. Recruiting for primary care. NEJM. 1993;328:656-660. 7. Norcini JJ, Shea JA, Benson JA. Changes in the medical knowledge of candidates for certification. Ann Intern Med. 1991;114:33-35. 8. Lyttle CS, Levey GS. The National Study of Internal Medicine Manpower: Xx. The changing demographics of internal medicine residency training programs. Ann Intern Med. 1994;121:435-441. 9. Schwartz MD, Linzer M, Babbott 0, et al. Medical student interest in internal medicine. Ann Intern Med. 1991;114:&15. 10. Babbott D, Levey GS, Weaver SO, Killian CD. Medical student attitudes about internal medicine: a study of U.S. medical school seniors in 1988. Ann Intern Med. 1991;114:16-22. 11. McMurray JE, Schwartz MD, Genero NP, et al. The attractiveness of internal medicine: a qualitative analysis of the experiences of female and male medical students. Ann Intern Med. 1993;119:812-818. 12. Federman DD. Relation of the internal medicine residency and the medical school curriculum. Ann Intern Med. 1992;116:1061-1064. 13. Kassenbaum DG, Szenas PL, Ruffin AL. The declining interest of medical school graduates in generalist specialties: students’ abandonment of earlier inclinations. Acad Med. 1993;68:278-280. 14. Petersdorf RG. Primary care applicants-they get no respect. NOM. 1992;326:408-409. 15. Colwill JJ. Where have all the primary care applicants gone? NEJM. 1992; 326:387-393. 16. Shulkin DJ. Choice of specialty: in’s money that matters in the USA. JAMA. 1989;262:1630-1631. 17. Kassebaum DG, Szenas PL. Relationship between indebtedness and the specialty choices of graduating medical students. Acad Med. 1992;67: 700-707. 18. Pew Health Professions Commission. Primary Care Workforce 2000: Federal Health Policy Strategies. San Francisco: Pew Foundation; March 1993. 19. Federated Council for Internal Medicine. Generating more generalists: an agenda of renewal for internal medicine. Ann Intern Med. 1993;119: 11251129. 20. Rivo ML, Jackson DM, Clare FL. Comparing physician workforce reform recommendations. JAMA. 1993;270:1083-1084. 21. Greenfield S, Nelson EC, Zubjoff M, et al. Variations rn resource utilization among medical specialties and systems of care. JAMA. 1992;267: 1624-1630. 22. Welch WP, Miller ME, Welch HG, et al. Geographic variation in expen diures for physicians’ services in the United States. NEJM. 1993;328:621-627. 23. Carline JD, lnui TS, Larson EB, et al. The knowledge base of certified internists. Arch Intern Med. 1989;149:2311-2313. 24. Wigton RS, Nicolas JA, Blank LL. Procedural skills of the general internist. Ann Intern Med. 1989;111:1023-1024. 25. Frank P. Soundtng board: gatekeeping revisited-protecting patients from overtreatment. NEJM 1992;327:424-429. 26. Barondess JA. The future of generalism. Ann Intern Med. 1993;119: 153160. 27. Rivo ML. Internal medicine and the journey to medical generalism. Ann Intern Med. 1993;119:146-152. 28. Marder WD, Meenan RF, Felson DT, et al. The present and future adequacy of rheumatology manpower. Arthritis Rheum. 1991;34:1209-1217. 29. Marder WD, Kletke PR, Silberger AB, Wilke AJ. Physician Supply and Utilization by Specialty: Trends and Projections. Chicago: American Medical Association; 1988. 30. Wennberg JE, Goodman DC, Nease RF, Keller RB. Finding equilibrium in U.S. physician supply. Health Aff. (Millwood) 1993;Summer:89-103. 31. Weiner JP. Forcasting the effects of health reform on U.S. physician workforce requirements. Evidence from HMO stafhng patterns. JAMA. 1994; 272:222-230. 32. Braunwald E. Cardiology-division or department? NEJM. 1993;329: 1887-1890.
SUBSPEClALlZATlON 33. Glickman RM, Nolan JP, Rubenstein AH, et al. United we stand. Ann Intern Med. 1993;118:903-904. 34. Cohen JJ. The country needs more generalist physicians! ABlM News Update. 1993;Summer/Fall:2. 35. Bierring WL. The American Board of Internal Medicine. Ann Intern Med. 1937;10:1946-1951. 36. Irons EE. The American Board of Internal Medicine after four years. Organization, purpose, and the effects of special boards on medical education and practice. Ann Intern Med. 1940;14:146-152. 37. American Board of Internal Medicine. Memorandum to applicants for admission to examination. Ann Intern Med. 1947;26:845-850. 38. Myers JD. The American Board of Internal Medicine: modernization of procedures. Ann Intern Med. 1970;72:423-424. 39. Futcher PH. Educational requirements for the American Board of Internal Medicine. JAMA. 1969;209:924. 40. Ebert RV. Further changes in the requirements and procedures of the Amencan Board of Internal Medicine. Ann Intern Med. 1971;75:121-123. 41. Petersdorf RG, Beck JC. The new procedure for evaluating the clinical competence of candidates to be certified by the American Board of Internal Medicine. Ann Intern Med. 1972;76:491-496. 42. Engstrom WW. Residency training in internal medicine, for what; subspecialty boards, what for? Ann Intern Med. 1969;70:621-633. 43. Service Awards: Guidelines for Individual Awards-Institutional Grants. Washington, DC: US Department of Health and Human Services; January 6, 1984. 44. Mullan F, Rivo ML, Politzer RM. Doctors, dollars and determination: making physician work-force policy. Health Aff. fMillwoodJ 1993;12(suppl):138-151, 45. AAMC Council of Teaching Hospitals. Survey of House Staff Stipends, Benefits and Funding. Washington, DC: Association of American Medical Colleges; 1991:67. 46. Arend WP. American College of Rheumatology survey of rheumatology program directors. Presented at the Annual Meeting of the American College of Rheumatology; San Antonio, Texas; September 22, 1993. 47. Quantum Research Corporation. Prospective and Retrospective Trainee Analyses. Bethesda, Maryland: National Institutes of Health; June 1991. 48. Quantum Research Corporation. Prospective and Retrospective Trainee
IN INTERNAL MEDICINE/ANDERSON
Analyses. Bethesda, Maryland: National Institutes of Health; September 1993. 49. Lyttle CS, Andersen RM, Neymare K, et al. National Study of Internal Manpower: XVIII. Subspecialty fellowships with a special look at hematology and oncology. 1988-1989. Ann Intern Med. 1991;114:36-42. 50. The report of the Citizens’ Commission on Graduate Medical Education. The Graduate Education of Physicians. Chicago: American Medical Association; 1966. 51. Krakower JY, Jolly P, Beran R. US medical school finances. JAMA. 1993; 270:1085-1091. 52. Whitcomb ME, Dessgrosseilliers JP. Primary care in Canada. NEJM. 1992; 326:1469-1472. 53. The American Health Securii Act of 1993. September 7, 1993:125-143. Draft. 54. Rockefeller J, Waxman H. The Primary Care Workforce Act of 1993. Washington, DC: US Congress (SI1315, (HRj2804. 55. Luke R, Tetwilliger J, lbrahim T. Developing a strategy for providing federal GME support. Am J Med. 1993;9(5):1-VI. 56. Earley LE. Alternative pathways for training to general internist and the medical subspecialist. Ann Intern Med. 1992;116:108&1083. 57. Stein JH. Grand cru versus generic: diierent approaches to altering the ratio of general internists to subspecialists. Ann Intern Med. 1991;114:79-82. 58. Petersdorf RG. The doctor is in. Acad Med. 199368: 113-l 17. 59. Kassirer JP. Primary care and the affliction of internal medicine. NEJM. 1993;328:648-651. 60. Fogelman AM. Strategies for training generalists and subspecialists. Ann Intern Med. 1994;120:579-583. 61. Fitzgerald FT. The case for internal medicine. NEJM. 1993;328:654-656. 62. LaCombe M. What is internal medicine? Ann Intern Med. 1993;118: 384-387. 63. Wigton RS, Blank LL, Monsour H, Nicholas JA. Procedural skills of practicing gastroenterologists. Ann Intern Med. 1990;113:540-546. 64. Tape ll, WIgton RS, Blank LL, Nicholas JA. Procedural skills of practicing nephrologists. Ann Intern Med. 1990;113:392-397. 65. Austen KF. An alternative structure in departments of medicine for the career development of physician/scientists. 1990 Presidential address, Jrans Assoc Am Physicians. 1990;CIII:CXV-CXXI.
July 1995
The American
Journal
of Medicine@
Volume
99
81