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Dear Members of the Alliance for Academic Internal Medicine:
On behalf of the Alliance for Academic Internal Medicine (AAIM), thank you for your support of the alliance and its member organizations.
For medical students, match day is characterized by anticipation leavened by angst and anxiety. I clearly recall the moment in 1986 when I turned in my list (on paper, in pencil) and the moment two months later when the medical school dean handed me an envelope with the name of an institution where I have remained for 22 years.
As a program director, the match continues to provoke anxiety and angst. We practice in a specialty that historically has large residencies. The number of categorical internal medicine residency training positions at most large medical centers doubled or tripled from the 1960s through the 1980s. The interest of medical students in our programs kept up with the growth of residencies until the late 1980s, and the students choosing internal medicine were often the best in the class. In the 1960s, 80% of Alpha Omega Alpha students chose careers in internal medicine. Then the bottom dropped out, interest among students declined and has not recovered, and the match became a challenge for internal medicine program directors. Department chairs, fellow faculty, and hospital leaders often think of the match as it was in the heyday of internal medicine and often judge the success of program directors based upon the match an outcome which our efforts may or may not affect. Long-time program directors at all but a few programs have experienced the trauma of not filling or having a "bad match." The match remains a challenging part of the program director's and administrator’s jobs, along with the occasional problem resident or difficult faculty member, meeting accreditation requirements, measuring competency, and fighting for an education-service balance (and as Hyman Roth said to Michael Corleone, "this is the business we’ve chosen").
This year 372 programs offered 4,858 internal medicine categorical positions in the match, representing a slight increase in the number of programs and positions from 2007. Only 31 programs went unfilled.
The small number of unfilled programs is good news, but I believe this partially reflects the fact that many program directors have become quite skilled at gauging the number of positions to put in the match and interviewing the right mix of applicants. The fill rate for US seniors was 54.8%. After factoring in positions offered out of the match, approximately half of internal medicine residents are graduates of Liaison Committee on Medical Education (LCME) accredited medical schools. This year, 2,660 US seniors matched to categorical internal medicine programs. This number has remained roughly stable for several years; however, it is down from the approximately 2,800 graduates that matched in 1999-2002. For historical perspective, in 1985, 3,884 US seniors matched in categorical internal medicine, and the nadir was in 1993 with 2,473 matched US seniors. Internal medicine continues to have the second lowest ratio of positions filled by US seniors (50%) after family medicine. It does not need to be said but I will anyway— if not for the numerous talented applicants from non-LCME schools, many of our programs would be in crisis.
Overall, interest in primary care residencies has remained flat or in some cases has declined. Family medicine programs appear to have had a challenging match this year with 105 out of 455 programs unfilled. However, the fill rate for family medicine for US seniors was 44%, a small increase. Seventeen internal medicine-pediatrics (med-peds) programs out of 79 went unfilled; the total fill rate was only slightly off from last year. The number of positions (362) and number of US seniors matching to med-peds continue on the downward trend (likely due to the introduction of separate accreditation in the last year); there were 464 med-peds positions in the match in 1997. All but one primary care internal medicine residency filled, with 264 positions offered and 166 US seniors from LCME schools matching. However, the number of primary care internal medicine programs offering positions, the number of positions in the match, and the number of US seniors matching continues to decline each year. For historical perspective, in 1997 there were 608 primary care internal medicine positions in the match, and 368 US seniors matched. Current year interest in pediatrics remained flat; 40 pediatrics programs went unfilled, and the fill rate for US seniors was down to 67%.
The total number of students from US allopathic medical schools in the match continues to increase slightly each year; there were 15,692 students this year, up from 15,237 in 2004. The Association of American Medical Colleges has called for a 30% increase in medical school enrollment. It remains to be seen if this will impact the fill rate for internal medicine residencies. Participation in the match of osteopathic graduates (2,711 in 2008) and US citizens who are graduates of international medical schools (4,557) has continued to increase by approximately 10% per year, and participation of international graduates who are not US citizens has also continued to climb (11,141 in 2008).
Where does internal medicine stand and what are the prospects for the match in the future? Since the early 1990s the pendulum has swung away from general internal medicine as a career choice among students and residents and does not seem close to swinging back. I do not believe students are shying away from the three years they might spend in our training programs. They are willing to spend the three years to become an internist as a prelude to subspecialty careers (and for that we are grateful), but with the exception of hospitalist jobs, they are not attracted in large numbers to the generalist careers that follow an internal medicine residency. I believe that we are not going to see a significant increase in the number of applicants for internal medicine as long as students fail to see general internal medicine as a desirable career choice. From my interactions with many medical students and residents, and from data gathered on the Internal Medicine In-Training Examination survey—which demonstrates a continued steep decline in interest in general internal medicine among internal medicine residents—it is clear that students and residents see general internal medicine as a less attractive career than internal medicine subspecialties and other options. This is a significant change from the 1980s and early 1990s. Whether it is the practice environment, salary, lifestyle, workload, the perceived prestige of the specialty, the negative perception of the role of the general internist in our health care system, or all of the above (my belief) students and residents do not see outpatient general internal medicine as a desirable career.
I believe the general internist should play a crucial role in our health care system, but all the incentives are aligned against it. It is an outrage that the role of the internist in the longitudinal management of complex medical conditions is so undervalued by our health care system in comparison to services provided by other medical providers. The American College of Physicians is taking the lead in revitalizing ambulatory internal medicine, and AAIM will support rational proposals to help this cause. It may take fundamental changes in our health care delivery system to change the role of general internists. Perhaps if a generalist career in internal medicine becomes attractive to students and residents once again, our residencies will return to the position of facing the match with more anticipation and less angst.
Keith Armitage, MD
President, Association of Program Directors in Internal Medicine
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