Objective: To understand better the decline in medical student interest in internal medicine.
Design: Qualitative analysis of 500 essays from respondents who participated in a national survey of graduating medical students from the class of 1990 in 16 medical schools. Medical students were asked the open-ended question, What suggestions do you have for improving the attractiveness of internal medicine? A model of career choice was developed for the analysis that included the following factors: ambulatory care exposure and primary care (including relationships with patients); attending physician-student interactions and learning climate; stress and workload; income and prestige; and intellectual stimulation.
Participants: The original survey included 1650 fourth-year medical students; 500 essay respondents were stratified by sex and then randomly chosen for the analysis.
Results: Students most frequently suggested that ambulatory care experiences be increased and that better relationships with patients be established during medical training (65% of women and 50% of men, P < 0.01). The second most frequent suggestion was to improve internal medicine attending physicians' interactions with students (51% and 48% of women and men, respectively). Students who had seriously considered a career in medicine but switched to other primary care careers (general pediatrics, family medicine) had few concerns about income and prestige, whereas those who chose internal medicine had reservations about expected workload and income. Women were more likely than men to reject internal medicine for other primary care fields (26% of women compared with 16% of men, P = 0.05).
Conclusions: Students, particularly female students, expressed a strong interest in establishing better relationships with patients. Lack of respect by medical attendings and negative teaching methods were important sources of dissatisfaction among both men and women. Attention to these relationship issues, in addition to housestaff stress and expected future income, may improve the attractiveness of internal medicine.