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Changes in Career Decisions of Internal Medicine Residents during Training

Colin P. West, MD, PhD; Carol Popkave, MA; Henry J. Schultz, MD; Steven E. Weinberger, MD; and Joseph C. Kolars, MD
[+] Article, Author, and Disclosure Information

From the Mayo Clinic, Rochester, Minnesota, and the American College of Physicians, Philadelphia, Pennsylvania.

Potential Financial Conflicts of Interest: None disclosed.

Requests for Single Reprints: Colin P. West, MD, PhD, Department of Internal Medicine, Mayo Clinic College of Medicine, 200 First Street SW, Rochester, MN 55905; e-mail, west.colin@mayo.edu.

Current Author Addresses: Drs. West, Schultz, and Kolars: Department of Internal Medicine, Mayo Clinic College of Medicine, 200 First Street SW, Rochester, MN 55905.

Ms. Popkave and Dr. Weinberger: American College of Physicians, 190 N. Independence Mall West, Philadelphia, PA 19106.

Ann Intern Med. 2006;145(10):774-779. doi:10.7326/0003-4819-145-10-200611210-00010
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Background: Little is known about the timing and stability of internal medicine resident career decisions during the course of residency training.

Objective: To assess changes in reported career plans among internal medicine trainees during their training.

Design: Observational cohort using data collected as part of the annual Internal Medicine In-Training Examination (IM-ITE) survey.

Setting: 411 internal medicine residency programs in North America participating in the annual IM-ITE.

Participants: 2638 internal medicine residents who took the IM-ITE and responded to career plan questions on the test survey in all 3 years of training (2002–2004).

Measurements: Self-reported career plans for individual residents during their postgraduate year 1 (PGY-1), postgraduate year 2 (PGY-2), and postgraduate year 3 (PGY-3) of training.

Results: 2281 of 2638 residents (86.5%) identified a specific career plan in internal medicine during PGY-3. Of these 2281 residents, 1417 (62.1%) changed career plans at least once during the study period. Career plans reported by PGY-1 and PGY-2 residents matched subsequent PGY-3 plans for 55.1% and 68.4%, respectively. Six hundred eighty-six (26.0%) PGY-1, 278 (10.5%) PGY-2, and 205 (7.8%) PGY-3 residents remained undecided about their career plans at the time of the IM-ITE. Only 25.0% of graduating residents reported plans for a general internal medicine career.

Limitations: The study cohort represents a convenience sample and is restricted to the subset of residents sitting for the IM-ITE and responding to career plan questions in all 3 years of postgraduate training. Career plans were assessed by self-report, and it is possible that residents who responded in all years of training differed from those who did not.

Conclusions: In a subset of internal medicine residents in the class of 2004, career decisions changed late into residency training and enthusiasm for careers in general internal medicine remained low.


Grahic Jump Location
Study flow diagram.

*Estimate provided by Holmboe ES. American Board of Internal Medicine. Personal communication. November 2005. †PGY-1 = postgraduate year 1; IM-ITE = Internal Medicine In-Training Examination.

Grahic Jump Location




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Career Decisions of Internal Medicine Residents: Considering International Medical Graduates
Posted on December 1, 2006
Vineet Arora
University of Chicago
Conflict of Interest: None Declared

We commend West and colleagues on their examination of the changes in career decisions of internal medicine residents during training especially during this critical period of ongoing discussion regarding internal medicine residency redesign.(1) However, we wish to highlight that the career intentions of international medical graduates-both foreign born and U.S. born, remain overlooked in the analyses presented. Given that more than 40% of internal medicine residency positions are filled by non U.S. seniors, it is especially important to understand the career intentions of this group.(2) While earlier cross-sectional studies of career choice of internal medicine residents elicited during the internal medicine in- training exam suggest that no major differences exist between career intentions of international medical graduates and U.S. medical graduates, understanding how career intentions of international medical graduates change during their internal medicine training remains especially important.(3) As discussed in both the article and accompanying editorial, a likely explanation for a resident switching into general internal medicine or hospital medicine after their PGY2 year would be inability to successfully obtain a position in a competitive subspecialty fellowship, such as gastroenterology or cardiology.(1,4) This is especially true for international foreign-born medical graduates who face limited subspecialty fellowship opportunities for several reasons including increased competition for positions, and current NIH funding restrictions to non U.S. citizens making them ineligible for many fellowship training opportunities.(5) In fact, anecdotes suggest that despite personal preferences, foreign-born international medical graduates must often make career decisions based on the "best case visa scenario."(2) Because of these reasons, we encourage the authors to consider examination of their data to better understand the changing career intentions of this group, which constitutes a key portion of the internal medicine residency workforce.

(1) West CP, Popkave C, Schultz HJ, Weinberger SE, Kolars JC. Changes in Career Decisions of Internal Medicine Residents during Training. Ann Intern Med. 2006;145 (10):774-9.

(2) Residents, programs try to finesse complex visa issues. ACP Observer. Available online at: http://doctorsforadults.com/journals/news/july06/visas.htm. Accessed November 29, 2006.

(3) Garibaldi RA, Popkave C, Bylsma W. Career plans for trainees in internal medicine residency programs. Acad Med. 2005;80(5):507-12.

(4) Sox HC. Career changes in medicine: Part II. Ann Intern Med. 2006;145(10):782-3.

(5) McMahon GT. Coming to America--international medical graduates in the United States. N Engl J Med. 2004;350(24):2435-7.

Conflict of Interest:

None declared

Changes in career decisions
Posted on January 4, 2007
Colin P. West
Mayo Clinic College of Medicine
Conflict of Interest: None Declared

We appreciate the comments of Dr. Arora and colleagues. We agree that international medical graduates are an important part of the internal medicine residency workforce. As noted by Arora and colleagues, only a very limited literature addresses the development of career decisions of international medical graduates. In our study, we elected to examine factors clearly shown previously to affect career choice, so that other potentially important variables such as medical training site were not evaluated.

Our data do allow some insight into how the career plans of international medical graduates may change over the course of training, but we have not yet conducted formal analyses to address this. We agree with Arora and colleagues that this is a worthwhile question to pursue. Because our data do not provide information on why career plans are chosen, the possible influences of factors uniquely affecting international medical graduates cannot be assessed.

These questions highlight the fact that selecting a career is a complex process, and issues pertinent to career choice may differ across groups of residents. Our report represents an initial step toward understanding the choices residents make during their training. Further work is necessary to better understand why residents make these choices, and why their choices change during training.

Colin P. West, MD, PhD Joseph C. Kolars, MD

Mayo Clinic College of Medicine Rochester, MN west.colin@mayo.edu

Conflict of Interest:

None declared

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