Admission, recruitment, and retention

Admission, Recruitment, and Retention:

Finding and Keeping the Generalist-oriented Student

MARK LINZER, MD, THOMAS SLAVIN, BS, SUNITA MUTHA, MD, JOHN L TAKAYAMA, MD, LUIS BBANDA, DSc, SELMA VANEYCK, PhD, JULIA E. McMURRAY, MD, HOWARD K. RABINOWlTZ, MD, and the SGIM Task Force on Career Choice in Primary Care and Internal Medicine

As the country strives to produce larger numbers of generalist physicians, considerable controversy has arisen over whether or not generalist applicants can be identified, recruited, and influenced to keep a generalist-oriented commitment throughout medical training. The authors present new and existing data to show that: 1 ) preadmission (BA/MD or post-baccalaureate) programs can help to identify generalist-oriented students; 2 ) characteristics determined at admission to medical school are predictive of future generalist career choice; 3) current inpatient-oriented training programs strongly push students away from a primary care career; 4) women are more likely than men to choose generalist careers, primarily because of those careers' in- terpersonal orientation; and 5) residency training programs are able to select applicants likely to become generalists. Therefore, to produce more generalists, attempts should be made to encourage generalist- oriented students to enter medical schools andto revise curricula to focus on outpatient settings in which students can establish effective and satisfying relationships with patients. These strategies are most likely to be successful if enacted within the context of governmental and medical school-based changes that allow for more reimbursement and respect for the generalist disciplines. Key words: medical education; medical school; residency training; primary care; generalist. J GEN INTERN MED 1994;9, Supplement 1 (April):S14-S23.

FAMILY PRACTICE, g e n e r a l i n t e r n a l m e d i c i n e , and g e n e r a l

ped i a t r i c s h a v e r e c e n t l y c o m e t o g e t h e r u n d e r t h e r u b r i c

o f " g e n e r a l i s m . " T h e U.S. g o v e r n m e n t has f o c u s e d o n

g en e ra l i sm as t h e k e y to p r o v i d i n g h e a l t h c a r e a c c e s s to

all Amer i cans , w i t h cos t - e f f ec t i ve , h i g h - q u a l i t y m e d i c i n e

as t he c o m m o n d e n o m i n a t o r . T h e c h a l l e n g e to m e d i c a l

e d u c a t o r s is to p r o d u c e m o r e genera l i s t s . A first s t ep in

that p r o c e s s is to d e t e r m i n e h o w w e can a d m i t m o r e

g e n e r a l i s t - o r i e n t e d s t u d e n t s to m e d i c a l s choo l . T h e task,

o f course , d o e s n o t s t o p t he re . O v e r t h e pas t d e c a d e ,

the n u m b e r o f g e n e r a l i s t g r a d u a t e s f r o m U.S. m e d i c a l

Received from the Department of Medicine (ML, JEM) and the Dean's Office (SVE), University of Wisconsin School of Medicine, Madison, Wisconsin; the Office of Primary Care Education and the Office of Admissions, Tufts University School of Medicine, Boston Massachusetts (TS, LB ); the Robert Wood Johnson Clinical Scholars Program, Stanford University, Palo Alto, California (SM); the Department of Pediatrics, University of California, San Francisco, San Francisco, California (JIT); the Programme for Faculty Development, Faculty of Health Services, McMaster University, Hamilton, Ontario, Canada (LB); and the De- partment of Family Medicine, Jefferson Medical College of Thomas Jefferson University, Philadelphia, Pennsylvania (HKR).

Address correspondence and reprint requests to Dr. Linzer: Uni- versity of Wisconsin Clinical Science Center, J5/210, 600 Highland Avenue, Madison, WI 53792.

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schoo l s has d e c l i n e d p r e c i p i t o u s l y , 1, 2 sugges t i ng tha t t h e

med i ca l s c h o o l t r a in ing e n v i r o n m e n t has e v o l v e d in a

d i r e c t i o n that l eads s t u d e n t s a w a y f r o m gene ra l i s t c a r e e r

choices . At t h e r e s i d e n c y leve l , i n t e r n a l m e d i c i n e and

ped ia t r i c s r e s i d e n t s a r e s u b j e c t to a c t i v e r e c r u i t m e n t to

subspec ia l ty d i s c i p l i n e s d u r i n g t ra in ing . If a r e s i d e n c y

g radua te d o e s c h o o s e a g e n e r a l i s t c a r ee r , t h e r e a re o f t en

substant ia l ba r r i e r s to e n t e r i n g a p r i m a r y c a r e p r a c t i c e .

In this p a p e r , w e r e v i e w t h e e v i d e n c e for w h a t is

k n o w n a b o u t r e c r u i t i n g for a n d r e t a i n i n g i n t e r e s t in gen-

era l is t c a r e e r s a n d p r e s e n t n e w e v i d e n c e f r o m o n g o i n g

s tud ies o f p r e d i c t o r s o f g e n e r a l i s t c a r e e r c h o i c e . I ta l ics

w i t h i n q u o t a t i o n s a r e o u r s and a re u s e d to h i g h l i g h t key

g e n e r a l i s t / s u b s p e c i a l i s t d i f f e r ences .

RECRUITMENT TO MEDICAL SCHOOL

T h e l i t e r a t u r e has p a i d l i t t l e a t t e n t i o n to p r e m e d i c a l

p r o g r a m s tha t so l i c i t s t u d e n t s w i t h an i n t e r e s t in gen-

eral ism. C o m b i n e d b a c c a l a u r e a t e - M D ( B A / M D ) p ro -

g r a m s e m e r g e d in t h e 1960s, 3 p r i m a r i l y to a t t r ac t tal-

e n t e d h igh s c h o o l s t u d e n t s i n t o a c c e l e r a t e d e d u c a t i o n a l

t racks l e a d i n g to c a r e e r s in m e d i c i n e . S o m e m e d i c a l

s c h o o l s a re n o w c r e a t i n g n e w BA/MD p r o g r a m s o r adapt-

ing ex i s t i ng p r o g r a m s to a t t r a c t a n d r e i n f o r c e s t u d e n t s '

i n t e r e s t in c a r e e r s in p r i m a r y care . O n e o f us (SVE) has

c o n d u c t e d a s u r v e y o f 18 BA/MD p r o g r a m s . 4 Tes t s c o r e s

and class r ank w e r e f o u n d to b e i m p o r t a n t d e t e r m i n a n t s

o f a c c e p t a n c e i n t o t h e s e p r o g r a m s , and p e r s o n a l char -

ac te r i s t i c s ( s u c h as e m p a t h y , m o t i v a t i o n , and e x t r a c u r -

r i cu la r a c t i v i t i e s ) w e r e o f s e c o n d a r y i m p o r t a n c e . T h e s e

resu l t s sugges t tha t i t is f ea s ib l e to d e s i g n a genera l i s t -

s eek ing p r o c e s s in w h i c h BA/MD p r o g r a m s w o u l d take

p e r s o n a l c h a r a c t e r i s t i c s i n to g r e a t e r a c c o u n t .

A case in p o i n t is t h e M e d i c a l Scho la r s P r o g r a m at

t h e Un ive r s i t y o f W i s c o n s i n ( U W ) , w h i c h has b e e n in

e x i s t e n c e for 12 years . T o b e e l ig ib le , a h i g h s c h o o l

s t u d e n t m u s t r ank in t h e t op 5% o f his o r h e r class, w i t h

a g r a d e - p o i n t a v e r a g e ( G P A ) b e t w e e n 3.8 and 4.0. He

o r she m u s t h a v e a c o m m i t m e n t to a c a r e e r in m e d i c i n e ,

a l t h o u g h an i n t e r e s t in c o m m u n i t y s e r v i c e o r g e n e r a l i s m

has n o t t r ad i t i ona l ly b e e n sough t . In an a n o n y m o u s sur-

v e y o f 45 s t u d e n t s a c c e p t e d i n t o t h e p r o g r a m th is year ,

33 ( 7 3 % ) said tha t t h e y w o u l d c o n s i d e r p a r t i c i p a t i n g

in a " p r i m a r y c a r e i n t e r e s t g r o u p . " W h e n q u e r i e d a b o u t

JOURNAL OF GENERAL INTERNAL MEDICINE, Volume 9, Supplement I (April), 1994 S15

the careers that interested them, 19 students chose family practice, 18 surgery, 16 pediatrics, and 10 internal medicine. When the students were asked about the factors that had been important in their choices of a medical career, "interest in helping people" received the most support. These data support the notion that preadmission programs may have adequate numbers of "pre-generalist" students. Our UW experience has shown that medical scholars exposed to researchers have tended to become researchers. We hypothesize that exposing them to primary care experiences and role models will result in graduates with a generalist orientation that resonates with the interests they expressed upon admission to college.

Post-baccalaureate p rograms may also be ideal training grounds for generalist-oriented students. 5 These students tend to be older and from rural backgrounds; some have already been in the health professions, and many were non-science majors in college. 6 These individuals thus possess many of the characteristics that are described below as predictive ofa generalist career choice. At Tufts, we have recently developed a direct admission arrangement with our post-baccalaureate program. Ad- ditional research on the career choices of graduates of post-baccalaureate programs is needed.

Premedical advisors are another resource to recruit primary care trainees, as they are in a position to com- municate to students the rewards of a career in primary care. It seems logical that generalism, with its devotion to primary care, relationships with patients, and commitment to helping people, could compete for students with other health professional fields such as social work, nursing, and clinical psychology. Thus, high school and college guidance counselors may be another source of individuals who can help portray the principles and practice opportunities of generalist medicine. In this regard, the Jefferson Medical College Physician Shortage Area Program (PSAP) has, for 20 years, been affiliated with six colleges in efforts to recruit PSAP applicants. 7 More recently, the SUNY-Buffalo School of Medicine estab- lished a Regional Rural College Network, a pilot inner- city high school partnership program, and a collabora- tive program with western rural New York hospitals and colleges to identify and recruit high school and college students interested in generalism. 8

ADMISSIONS TO MEDICAL SCHOOL

Does the l i terature suppor t the v iew that some

medical school appl icants possess a general is t career orientation, or is career choice de termined by the med-

ical school experience? This question is central to the debate about the role of admission policy in attaining the objective of educating more generalists. Some ed- ucators assume that students' original career preferences are unstable or even meaningless. Others assume the

opposite: that the problem could be solved simply by selecting the "right" applicants.

The work of Daniel Funkenstein 9 is the most extensive in this field. He collected longitudinal data on Harvard Medical School students from the classes be- tween 1958 and 1976. In 1975, he also collected data from a national representative sample of medical students. Funkenstein categorized medical careers as bio-

scientific or biosocial. Bioscientific careers include basic science research and subspecialty practice. Biosocial careers were subdivided into biointerpersonal (general pract ice) and biobehavioral (psychia t ry and public health). Funkenstein used the following model to ex- amine the influence of certain factors on career choice:

I. Intrinsic Factors 1. Basic characteristics: a) aptitudes, b) preparation,

and c) interests 2. Values: a) prestige and status, b) financial rewards,

c) social commitment to change in medicine, d) social responsibility of physicians, e) attitude toward patients, f) individual patient vs public health orientation, g) scientific or people orientation, and b) competit ion vs cooperat ion

3. Lifestyle: a) practice setting, b) hours worked, and c) income expectations

II. Extrinsic Factors 1. The medical school experience 2. Societal factors: a) social responsibility of physi-

cians, b) expectations of society, c) the assign- ment of priorities in medicine, and d) the funding of careers

3. Eras in which societal factors changed

Funkenstein's bioscientific students had "very high quantitative and science scores on the MCAT; extensive sc ient i f ic p r e p a r a t i o n and in t e r e s t in in te l l ec tua l achievement." Biosocial students were found to be "primarily interested in working directly with people , . . . [to be] interested in problems of patients that involve the social and psychological sc iences . . . [to have] very high verbal MCAT scores . . . [and to be] nonscience majors. ''9

Could the problem of the scarcity of generalists be solved with socioeconomic forces encouraging more bioscientific students into primary care? Funkenstein provides a warning: " . . . in following a career many of them did not [wish to] choose and that does not cor- respond to their basic characteristics, will they [bioscientific students] be satisfied, effective practitioners of primary care, or be embittered and discontent . . . ?,9 This point is particularly cogent in light of current sug- gestions to restrict entry to specialty careers and provide loan forgiveness for pre-generalist students.

In reviewing studies of personality traits, Ernst and Yett 1° concluded that primary care physicians were more sociable and less aggressive, materialistic, and authori- tarian than physicians in other specialties. In reviewing

$16 Linzer et aL, ADMISSION AND RETENTION OF GENERALIST STUDENTS

at t i tudinal studies, Ernst and Yet t found that genera l i s t s w e r e m o r e i n t e r e s t ed than subspec ia l i s t s in "establish- ing cont inuin~ principal-care relationships with patients, and less i n t e r e s t ed in research , u t i l iz ing t echn ica l diagnostic methods, consulting, and control l ing their w o r k hours ." ~o

Colwil l ' s analysis o f the 1989 G r a d u a t i o n Ques t ion- naire ( G Q ) resul ts n o t e d that "on ly 5% of the s tuden t s en te r ing genera l in te rna l m e d i c i n e se r ious ly c o n s i d e r e d an internal m e d i c i n e subspec ia l ty , bu t 38% c o n s i d e r e d family p rac t i ce or gene ra l ped ia t r ics . Converse ly , anaong those p lann ing a spec ia l ty career , only 4% had consid- e red genera l medic ine , w h e r e a s 35% c o n s i d e r e d o t h e r subspecialties of medicine, pediatrics, and surgery. These data suggest that s tuden ts . . , view themselves as either specialists or generalists. ''2

Babbot t and co l l eagues e x a m i n e d the s tabi l i ty of medica l s tudents ' init ial c a r e e r choices . 11 Of 10,000 medica l s tudents , abou t 22% of the men ' s p r e f e r e n c e s and 19% of the w o m e n ' s p r e f e r e n c e s w e r e stable. Wi th regard to the s tabi l i ty o f a p r e f e r e n c e for p r i m a r y care, "family p rac t i ce was the m o s t p o p u l a r spec ia l ty of the 1987 c o h o r t at the t ime of the MCAT, and the decline in interest in f a m i l y practice that occurred as students progressed through medical school resulted in the larg- est MCAT-to-GQ shift a m o n g all specialties . . . . ,, l t An impor tan t co ro l l a ry to these da ta was p r o v i d e d by one of us (HKR) in a s e c o n d a r y analysis of the data f rom Babbot t ' s study. In this p iece , Rab inowi tz n o t e d that "of the 3,774 s tuden ts w h o or ig ina l ly p l a n n e d to e n t e r family prac t ice , 914 ( 2 4 % ) c o n t i n u e d w i th that p r e f e r e n c e at the t ime of the i r GQ. O n the o t h e r hand, o f the 6 ,547 s tudents w h o had plans other than en t e r ing family prac- t ice at the t ime they t ook the i r MCAT, on ly 550 ( 8 % ) actual ly d e c i d e d to b e c o m e family doc to r s . ''12 These data show that, wh i l e a 24% s tabi l i ty ra te may s eem low, it is still t h r ee t imes h ighe r than the ra te at w h i c h students w h o beg in wi th o t h e r p r e f e r e n c e s migra te to family p rac t i ce careers .

What are the predictors o f health care career choice? Fincher and co l leagues ~3 s u r v e y e d 509 g radua tes f rom the Medical College of Georgia School of Medic ine classes of 1988, 1989, and 1990. O n e of the f o r e m o s t reasons that s tudents chose p r i m a r y ca re ca ree r s was the op- portuni ty fo r longitudinal pa t i en t care. O s b o r n ~ 4 sur- veyed one gradua t ing class at the Univers i ty o f California at San Francisco. Fu tu re i n c o m e and w o r k i n g w i th n e w t echno logy w e r e s ignif icant fac tors for those c h o o s i n g n o n - p r i m a r y care fields, and the influence o f facul ty advisors was signif icant for those c h o o s i n g p r i m a r y ca re ( see be low) .

Kassler, War tman , and Si l l iman ~ 5 c o n d u c t e d a s tudy of ca ree r cho ices of 381 four th -yea r med i ca l s tuden t s at e ight New England med ica l schools . S tudents w h o chose p r imary ca re w a n t e d to p r o v i d e primary, continuous, andpsychosocially oriented m e d i c a l care. S tudents w h o chose h igh - t echno logy spec ia l t i e s w a n t e d to do re-

search, pe r fo rm p r o c e d u r e s , and have a h igh i n c o m e and favorable lifestyle.

Rezler 16 s tud ied s tuden t s in the Univers i ty o f N e w Mexico e x p e r i m e n t a l P r imary Care Cur r i cu lum (PCC). Of 43 PCC s tuden ts w h o d e c l a r e d an initial in t e res t in family medic ine , 24 s w i t c h e d to a spec ia l ty and 19 w e r e stable in the i r c a r e e r goal. The s table gene ra l i s t -o r i en ted group was m o r e l ikely to: come f r o m a smal l town ( fewer than 100,000 p e o p l e ) , g radua te f rom a publ ic college, and have a lower science GPA (3 .37 vs 3.76). This g roup was m o t i v a t e d b y a "'genuine desire to be o f service to others, to p rovide comprehensive pat ient care, to be involved in communi ty -based f a m i l y care, and to work in a smal l communi ty ." Those choos ing to special ize "va lued the cha l l enge o f m e d i c i n e and w a n t e d to focus in d e p t h on a pa r t i cu l a r area. The i r n e e d to exp lore ideas was s t ronge r than the i r need for c lose pat ient con tac t . . . [ they] w e r e seek ing more certainty regarding the i r abi l i ty to se lec t c o r r e c t med ica l inter- v e n t i o n s . . . [and] a t t e m p t e d to have more control over their t ime bo th in a p rofess iona l and pe r sona l sense." ] 7

In ano the r s tudy of GQ data, Babbo t t and C o f f i n 17

showed a p r e f e r e nc e by w o m e n for p r ima ry ca re careers. This s tudy focused on c a r e e r c h o i c e in pedia t r ics , a l though o the r s tudies 9, t8 have s u p p o r t e d the f inding that w o m e n m o r e than men t e n d to se lec t p r ima ry care careers ( see sec t ion on Medica l School Re ten t ion and Gender be low) .

Nowacek and Sacks 19 r e v i e w e d the l i t e ra tu re on

demograph ic var iables in m e d i c a l s choo l admissions. In their study, they h ighl ight a w a r n i n g to admin i s t ra to r s planning to use se lec t ive admiss ions to inc rease the number of mat r i cu lan t s l ikely to p u r s u e p r imary care careers. "To c o m p l y w i th the e q u a l - p r o t e c t i o n and due- process r equ i remen t s , admiss ion officers mus t assure that the use of d e m o g r a p h i c in fo rma t ion in the admissions p rocess is exp l i c i t in bu l l e t ins and is un i fo rmly appl ied in the eva lua t ion of all appl ica t ions ." ~9

The valuable ro le of se l f -se lec t ion is seen in the success of the Jef ferson PSAP Program. Appl ican ts to Jefferson are inv i ted to app ly to the PSAP if t hey have ties to rural u n d e r s e r v e d areas and are c o m m i t t e d to a family p rac t i ce career . PSAP app l i can t s r ece ive special cons idera t ion in admissions , p re fe ren t i a l se lec t ion of family m e d i c i n e courses , and e x t r a f inancial aid. In Ra- binowitz's descr ip t ion of the admissions criteria, he noted that "only academica l ly qual i f ied s tuden t s w e r e rec- o m m e n d e d for accep tance , b u t s tuden t s w i th less competit ive academic credentials w e r e accep ted ff they came from a rural background and w e r e j udged to have a strong c o m m i t m e n t to p r a c t i c e family m e d i c i n e in an unde r se rved a rea . . . . Seventy-e ight p e r c e n t of the PSAP s tudents w e r e no t a c c e p t e d by may med ica l schoo l o t h e r than Jefferson." 2o

In summar iz ing the resul t s o f e ight years of the PSAP, Rabinowitz s ta ted that " the a c a d e m i c p e r f o r m a n c e of PSAP s tudents in med ica l s choo l . . . [ including] mean

JOURNAL OF GENERAL INTERNAL MEDICINE, Volume 9, Supplement I (April), 1994 S17

grade po in t average, e x a m i n a t i o n grades , and scores on the National Boards was ve ry s l ight ly l o w e r than that of their peers . The re was no s ignif icant d i f fe rence in the medica l school a t t r i t ion ra te b e t w e e n PSAP s tuden t s and their p e e r s . . . [and] PSAP gradua tes w e r e 7 to 10 t imes as l ikely as the i r p e e r s to c o m b i n e a c a r e e r in family m e d i c i n e w i t h p r a c t i c e in a r u r a l o r u n d e r s e r v e d area . . . . ,,2o Of note , in the mos t r e c e n t PSAP fo l low-up article, PSAP gradua tes had h igher Par t III Nat iona l Board scores than d id non-PSAP s tudents ," and eva lua t ions of PSAP and non-PSAP s tuden t s in t he c l in ical years w e r e equivalent .

O the r p r o g r a m s that have a l t e r ed b o t h the admis- s ion p roce s s and the t ra in ing e n v i r o n m e n t to p r o d u c e genera l i s t g radua tes i nc lude the Univers i ty of Minneso ta Rural Physic ian Assoc ia t ion P rog ram (RPAP) and the Universi ty of Washing ton , in the Washington , Alaska, Montana, Idaho ( W A M I ) Program, w h i c h offers se lec t ive admiss ion to app l i can t s and c o m m u n i t y - b a s e d educa- t ional e x p e r i e n c e s to s tuden t s f r o m those states in ter- e s t ed in ca ree rs in p r i m a r y care. 8 Some med ica l schools , such as U W - M a d i s o n and the Robe r t W o o d J o h n s o n School of Medic ine , have d e v e l o p e d f lex ib le c u r r i c u l u m p rog rams that a t t r ac t s tuden t s w i th family respons ib i l i - t ies or con t inu ing e m p l o y m e n t . 8 G e o r g e Wash ing ton , Tufts, and the Rober t W o o d J o h n s o n School of Med ic ine have c o m b i n e d MD/MPH p r o g r a m s w h e r e a ma jo r i t y o f graduates c h o o s e genera l i s t careers . 8

Should admission commit tees select students on the basis o f generalist careerpredictors, even i f it means selecting applicants with lower grades and test scores? A few s tudies c i t ed above have f o u n d l o w e r tes t s co res and sc ience GPAs a m o n g genera l i s t s tudents . It is alto- ge the r unc lea r w h e t h e r these assoc ia t ions wi l l be rep- l i ca ted in s tudies in the 1990s. F u r t h e r m o r e , it has no t b e e n d e m o n s t r a t e d tha t l o w e r tes t s co res a re p r e d i c t i v e o f p e r f o r m a n c e in med i ca l s choo l o r res idency . None- theless, this ques t i on can b e a d d r e s s e d w i th t h r e e pos- s ible s trategies: 1 ) s e l ec t ing app l i can t s in to a genera l i s t track, even if grades and test scores are lower than those of appl icants s e l e c t e d for the t rad i t iona l p rog ram; 2 ) se lec t ing app l i can t s in to a t r ad i t iona l p r o g r a m w h o are l ikely to p u r s u e genera l i s t c a ree r s ove r o t h e r app l i can t s wi th equivalent grades and test scores; and 3) se lec t ing appl icants into a t r ad i t iona l p r o g r a m w h o are l ike ly to pu r sue genera l i s t c a ree r s bu t who have inferior grades and test scores.

The PSAP p r o g r a m at Jef ferson uses the first strat- egy, w h i c h involves app l i ca t ion to a sepa ra te t r ack and self-selection. Schools op t i ng for this a p p r o a c h shou ld establ ish m i n i m u m s tandards neces sa ry to ensu re a rea- sonable l i ke l ihood of success at the i r ins t i tu t ions .

The s e c o n d s t r a t egy does n o t e m p l o y self-select ion, as all applicants are applying to the same program. Schools op t ing for this a p p r o a c h migh t c o n s i d e r fo l lowing the appl ican ts s e l e c t e d on this basis to ensu re the p r e d i c t o r s of p r imary ca re c a r e e r c h o i c e are valid fo r the i r insti-

tut ions. Schools also have a legal ob l iga t ion to pub l i sh the i r admiss ion cr i ter ia .

The th i rd s t ra tegy invo lves se lec t ing po ten t i a l l y less qual if ied appl ican ts on the basis o f the i r l ike l ihoods to pu r sue p r i m a r y ca re careers . Such schools mus t be pre- p a r e d to justify the i r d e c i s i o n to d e n y sca rce social and educa t iona l o p p o r t u n i t i e s to app l i can t s w i t h os tens ib ly supe r io r a c a d e m i c c redent ia l s . Such a po l i cy may c r ea t e the p e r c e p t i o n that admis s ion to a pa r t i cu la r med i ca l schoo l is b e c o m i n g less d e p e n d e n t on ob j ec t i ve cr i ter ia , and the re fo re is less fair and equi table .

The s e c o n d and th i rd s t ra teg ies assume that admis- s ion c o m m i t t e e s have val id and re l i ab le means to identify genera l i s t appl icants . W h i l e a n u m b e r o f p r e d i c t i v e var iables have b e e n n o t e d ear l ie r in this paper , us ing many of t h e m may be p r o b l e m a t i c . For example , p r i m a r y ca re c a r e e r p r e f e r e n c e e x p r e s s e d at admiss ion has, in the past , b e e n h ighly p r e d i c t i v e of a genera l i s t c a r e e r choice ; howeve r , in the c o n t e x t o f the me d i c a l s choo l admiss ion p rocess , answer s to this ques t ion may b e less valid. D e m o g r a p h i c cha rac te r i s t i c s such as g e n d e r and age may be i l legal to use as admiss ion cr i ter ia . Home- t own size appears to be a v iab le p r e d i c t o r , bu t the num- be r o f rural app l i can t s is l imi ted. Resea rch to d e v e l o p and tes t admiss ion i n s t r u m e n t s that e m p l o y legal, valid, and re l iab le c r i t e r ia that ident i fy gene ra l i s t -o r i en t ed ap- p l icants is u n d e r w a y at Tufts Universi ty.

The issue of GPA or MCAT scores can b e ap- p r o a c h e d in a var ie ty of ways. O n e w a y is to d e t e r m i n e a m i n i m u m level ( say a GPA of 3.0 or 3 .2) and a c c e p t into a " to be c o n s i d e r e d " p i le all s tuden t s at o r above this level. Then remove all m e n t i o n of GPA and MCAT scores f rom the file. Dec i s ions on w h e t h e r to i n t e rv i ew or admi t these s tuden t s can then focus on o t h e r c r i t e r ia to be d e t e r m i n e d by the ind iv idua l ins t i tu t ion. Since this a p p r o a c h r e m o v e s a s imple quant i t a t ive va lue ( t he GPA) from considerat ion, o the r quantifiable measures of quality shou ld b e d e v e l o p e d to b e d i sp l ayed by admiss ion of- rices, m u c h as GPA and MCAT scores are n o w used to d o c u m e n t the "qual i ty" o f app l i can t s and enrol lees . This a rea is r ipe for inves t igat ion.

Can the personal interview be developed to collect information abou t personal characteristics and experiences to identify "pre-generalist'" applicants? Med- ical schools that s h o w h igh p e r c e n t a g e s of the i r graduates going into p r i m a r y ca re (e.g., McMas te r ) use in the i r s e l ec t ion p r o c e s s e s i n fo rma t ion abou t the pe r sona l charac te r i s t i c s of the appl icants . Some of the in fo rmat ion abou t pe r sona l cha rac te r i s t i c s can b e c o l l e c t e d f rom an appl ican t ' s w r i t t e n a u t o b i o g r a p h i c a l submiss ion . O t h e r areas can b e e x p l o r e d by p e r s o n a l in te rv iewers .

Personal i n t e r v i e w e r s can c o l l e c t i n fo rma t ion in severa l key areas. To avo id app l ican t s ' l ea rn ing to say w h a t is w a n t e d of them, i n t e r v i e w e r s shou ld emphas i ze experiences applicants have had re levant to specific areas, w h a t t hey l e a rne d f rom those e x p e r i e n c e s , and h o w this was of he lp in p r e p a r i n g t h e m for med ic ine . The focus

S18 Linzer et aL, ADMISSION AND RETENTION OF GENERALIST STUDENTS

areas described be low overlap heavily with the factors in Funkenstein's model of career choice. "Faculty development" of interviewers to enhance their abilities to solicit this information could be a valuable aid to admission commit tee members . Research is needed to test the "clinical utility" of the following proposed items to establish an affinity for generalism.

1. Current health care issues that require the attention o f the public, the government , and the medical profession (e.g., availability/accessibility of care; costs of the health care system; the physician as a gatekeeper/ resource manager)

2. Impor tance o f illness preven t ion and health p r o m o t i o n (e.g., effect of the envi ronment on health; role of physician in public education and advocacy)

3. Impor tance o f the f a m i l y and the c o m m u n i t y (e.g., exper ience with multicultural and low-income groups)

4. Ethical values in prov id ing health care: pre- ventive, curative, or support ive (e.g., exper ience with groups with special needs, such as women, seniors, chronically ill, disabled, isolated communities, minori- ties, survivors of domest ic violence, homeless)

5. Impor tance o f the health care team (e.g., working in an interdependent relationship in a group/team; thoughtful, considerate and aware of needs of cowork- ers; tolerant of divergent viewpoints, maintains rapport easily)

6. Role o f the phys ic ian in society (e.g., role of physician in health promotion, health advocacy; role of community in defining expectat ions f rom health profes- sionals)

7. Readiness to learn abou t se l f (e.g., personal in- sight; self-evaluation)

8. E n j o y m e n t o f work a n d self-discipline (e.g., ability to see a project to completion; acceptance of being personally accountable for difficult tasks)

9. The phys ic ian as a c o m m u n i c a t o r (e.g., communication skills; anticipation of and sensitivity to patients' needs; negotiating skills)

What is the role o f the general is t as personal in- terviewer? More generalists should join admission committees, as they would have first-hand exper ience in dealing with issues related to the above-listed areas. Their experience would provide examples to help elicit the relevant information f rom the interviewees. Finally, an interview format that highlights generalism (e.g., one held in a generalist 's office) could have a favorable influence on applicants.

RETENTION DURING TRAINING IN MEDICAL SCHOOL

The commi tmen t to generalism voiced by many students entering medical school seems to diminish dur-

ing training. Although the rigors of clinical training have been cited as a contributing factor, the "de-generalizing" process is at once variable and complex. In this section, we discuss previous and current research that illustrates the variety of factors that influence the retention of interest in generalism during medical education.

Exposure to Ambulatory Care during Training

While many medical schools offer opportunit ies for preclinical students to visit patients in their homes and to shadow physicians in their clinical activities, very few data exist to demonstrate that such experiences during the preclinical years p romo te selection of generalist careers. Harris and colleagues showed that a four-year ambulatory track was effective in increasing the number of students matching in family medicine. Among randomly assigned volunteers, 16% of nonparticipants and 46% of participants matched in family medicine, z~ Erney et al. found that third-year students randomly assigned to a year-long primary care clerkship entered family medicine at a significantly higher rate than did those without this experience, z2 Crucial factors in the career choice process may be the particular physicians who precept, the frequency and duration of the experience, and the type of patients to whom students are exposed.

A required family medicine clerkship has been associated with selection of family practice careers. Kas- sebaum and Haynes studied 121 U.S. medical schools, 57 of which required third-year family medicine clerkships. Among students at these institutions, 16% chose family medicine, compared with only 7% of students from other medical schools. 23 Stine also showed that a required clerkship was present at schools with higher percentages of graduates choosing family medicineZ4; however, the opt imum duration of such experiences is not clear. 25 It should be noted that the existence of a required family medicine clerkship may be associated with other, unmeasured institutional qualities that direct medical students toward generalist careers.

In internal medicine, one-third of medical schools do not require any clerkship t ime in ambulatory settings. Among schools that do offer such settings, only 15% of the clerkship time is spent in outpatient sites. 26 At the Medical College of Georgia, an ambulatory medicine rotation appeared to slow the decline in numbers of students choosing internal medicine careers. 27 In our National Medical Student Career Choice survey, students planning to enter internal medicine were more likely to have had an ambulatory medicine rotation; overall, 90% of the students who had had such a rotation were mod- erately or highly satisfied wi th the experience. Students in this study also indicated a desire for more ambulatory care experiences in internal medicine, as It is crucial to bear in mind that satisfaction with such experiences was remarkably variable among different institutions, with the high satisfaction rates ranging from 17% to 71% .29

S18 Linzer et aL, ADMISSION AND RETENTION OF GENERALIST STUDENTS

areas described be low overlap heavily with the factors in Funkenstein's model of career choice. "Faculty development" of interviewers to enhance their abilities to solicit this information could be a valuable aid to admission commit tee members . Research is needed to test the "clinical utility" of the following proposed items to establish an affinity for generalism.

1. Current health care issues that require the attention o f the public, the government , and the medical profession (e.g., availability/accessibility of care; costs of the health care system; the physician as a gatekeeper/ resource manager)

2. Impor tance o f illness preven t ion and health p r o m o t i o n (e.g., effect of the envi ronment on health; role of physician in public education and advocacy)

3. Impor tance o f the f a m i l y and the c o m m u n i t y (e.g., exper ience with multicultural and low-income groups)

4. Ethical values in prov id ing health care: pre- ventive, curative, or support ive (e.g., exper ience with groups with special needs, such as women, seniors, chronically ill, disabled, isolated communities, minori- ties, survivors of domest ic violence, homeless)

5. Impor tance o f the health care team (e.g., working in an interdependent relationship in a group/team; thoughtful, considerate and aware of needs of cowork- ers; tolerant of divergent viewpoints, maintains rapport easily)

6. Role o f the phys ic ian in society (e.g., role of physician in health promotion, health advocacy; role of community in defining expectat ions f rom health profes- sionals)

7. Readiness to learn abou t se l f (e.g., personal in- sight; self-evaluation)

8. E n j o y m e n t o f work a n d self-discipline (e.g., ability to see a project to completion; acceptance of being personally accountable for difficult tasks)

9. The phys ic ian as a c o m m u n i c a t o r (e.g., communication skills; anticipation of and sensitivity to patients' needs; negotiating skills)

What is the role o f the general is t as personal in- terviewer? More generalists should join admission committees, as they would have first-hand exper ience in dealing with issues related to the above-listed areas. Their experience would provide examples to help elicit the relevant information f rom the interviewees. Finally, an interview format that highlights generalism (e.g., one held in a generalist 's office) could have a favorable influence on applicants.

RETENTION DURING TRAINING IN MEDICAL SCHOOL

The commi tmen t to generalism voiced by many students entering medical school seems to diminish dur-

ing training. Although the rigors of clinical training have been cited as a contributing factor, the "de-generalizing" process is at once variable and complex. In this section, we discuss previous and current research that illustrates the variety of factors that influence the retention of interest in generalism during medical education.

Exposure to Ambulatory Care during Training

While many medical schools offer opportunit ies for preclinical students to visit patients in their homes and to shadow physicians in their clinical activities, very few data exist to demonstrate that such experiences during the preclinical years p romo te selection of generalist careers. Harris and colleagues showed that a four-year ambulatory track was effective in increasing the number of students matching in family medicine. Among randomly assigned volunteers, 16% of nonparticipants and 46% of participants matched in family medicine, z~ Erney et al. found that third-year students randomly assigned to a year-long primary care clerkship entered family medicine at a significantly higher rate than did those without this experience, z2 Crucial factors in the career choice process may be the particular physicians who precept, the frequency and duration of the experience, and the type of patients to whom students are exposed.

A required family medicine clerkship has been associated with selection of family practice careers. Kas- sebaum and Haynes studied 121 U.S. medical schools, 57 of which required third-year family medicine clerkships. Among students at these institutions, 16% chose family medicine, compared with only 7% of students from other medical schools. 23 Stine also showed that a required clerkship was present at schools with higher percentages of graduates choosing family medicineZ4; however, the opt imum duration of such experiences is not clear. 25 It should be noted that the existence of a required family medicine clerkship may be associated with other, unmeasured institutional qualities that direct medical students toward generalist careers.

In internal medicine, one-third of medical schools do not require any clerkship t ime in ambulatory settings. Among schools that do offer such settings, only 15% of the clerkship time is spent in outpatient sites. 26 At the Medical College of Georgia, an ambulatory medicine rotation appeared to slow the decline in numbers of students choosing internal medicine careers. 27 In our National Medical Student Career Choice survey, students planning to enter internal medicine were more likely to have had an ambulatory medicine rotation; overall, 90% of the students who had had such a rotation were mod- erately or highly satisfied wi th the experience. Students in this study also indicated a desire for more ambulatory care experiences in internal medicine, as It is crucial to bear in mind that satisfaction with such experiences was remarkably variable among different institutions, with the high satisfaction rates ranging from 17% to 71% .29


other things, the "care, no t c u r e " aspec ts of m a n y of these re la t ionships .

Whi le c le rksh ips c o u l d p r o v i d e an o p p o r t u n i t y for general is ts to exempl i fy these i n t e rpe r sona l re la t ionships, medica l s tuden t s of ten o b s e r v e the oppos i t e . The denigration o fpa t i en t s by re s iden t s and a t t end ing physicians was c i t ed by med ica l s tuden t s in Cal i fornia as one reason for r e j ec t ing a c a r e e r in in te rna l med ic ine . Family p rac t i t i one r s and ped ia t r i c ians , in contras t , w e r e found to exh ib i t m o r e pos i t i ve p a t i e n t - p h y s i c i a n inter- act ions (Mutha S, Takayama JI, O 'Ne i l EH, u n p u b l i s h e d data). As n o t e d above, m o r e a m b u l a t o r y m e d i c i n e training with suppor t for s tudents dur ing clerkships is needed.

Knowledge and Mastery

The vast k n o w l e d g e base r e q u i r e d to be a ski l led cl inician has b e e n c i t ed as a r ea son for tu rn ing away from general ism. P re l iminary da ta f rom the California- based s tudy suggest that c o n c e r n s abou t the inabi l i ty to master this k n o w l e d g e and the desire to be an expert lead some s tuden t s to se lec t subspec i a l t y ca ree r s (Mutha S, Takayama JI, O 'Ne i l EH, u n p u b l i s h e d data) .

Dur ing the p rec l in i ca l years , med ica l s tuden t s are t ra ined and r e w a r d e d for a s ty le of l ea rn ing charac te r - ized by the i nd i sc r imina t e m e m o r i z i n g of large bod i e s of informat ion. In the c l in ica l years , s tuden t s mus t sift t h rough an even g rea te r b o d y of data wh i l e c o n t e n d i n g wi th the d ive r se c o n t e x t s u r r o u n d i n g each ind iv idua l pat ient . These se t t ings p r o v i d e an o p p o r t u n i t y for general ists to d e m o n s t r a t e skills in ga the r ing and analyzing c o m p l e x informat ion . Instead, the p r e d o m i n a n c e of specialists emphas izes a r e l i ance on referrals that can un- d e r m i n e the ro le o f general is ts . S tudents n e e d to learn f rom genera l i s t s w h o are c o m f o r t a b l e wi th the knowledge base n e e d e d to p r a c t i c e genera l i sm.

Perception of Lifestyle of Primary Care Physicians

The l ifestyle of p r o c e d u r e - o r i e n t e d phys ic ians has been shown to b e an i m p o r t a n t in f luence in a t t rac t ing s tudents . A survey of c a r e e r c h o i c e s a m o n g the t op 15% of s tuden t s at t h r e e schoo l s du r ing a t en-year p e r i o d demonst ra ted an increasing t rend toward specialt ies wi th controllable lifestyles. Schwar tz def ines these special- t ies as ones tha t "a l low the phys ic i an to c o n t r o l the n u m b e r o f h o u r s d e v o t e d to p r a c t i c i n g t h e s p e - cialty. ''s9.6° Resul ts of " l i festyle" s tudies, howeve r , are of ten difficult to in te rpre t . The d i r e c t i o n in w h i c h life- s tyles inf luence c a r e e r c h o i c e ( t h a t is, genera l i s t versus subspecial ty) is somet imes no t clear. In a s tudy by Fincher, 74% of s tuden t s c h o o s i n g n o n - p r i m a r y ca re ca ree r s and 60% of s tuden t s c h o o s i n g p r i m a r y ca re ca ree r s c i t ed l ifestyle as a pos i t ive inf luence. 6t I m p o r t a n t c o n f o u n d e r s in these s tudies i nc lude var ious def in i t ions of l ifestyle, s tuden t p e r c e p t i o n s of l i festyle after r e s idency , and the over lap b e t w e e n l i festyle and income .

Some r e c e n t da ta imply tha t s tuden t s c h o o s e the i r

fu ture ca ree rs based on ex t ens ive e x p o s u r e to res idents , assuming a c o n c o r d a n c e b e t w e e n r e s i d e n t w o r k l o a d and fu ture lifestyle. In one study, s t uden t s v i e w e d in te rna l m e d i c i n e as d e m a n d i n g m o r e t ime than o the r spec ia l t ies and having a g rea t e r work load , du r ing bo th r e s i d e n c y and career . 2s W o r k l o a d issues may have pa r t i cu la r rel- evance to w o m e n d u e to the i r c o n c e r n s abou t ba lanc ing family wi th career . 43, 4s, ~9 Kassler ' s su rvey s h o w e d that

regula r hours, l e i su re and family t ime, and r e s idency call schedule were m o r e impor tant to s tudents enter ing "high- t ech specia l t ies" than to genera l i s t s tuden t s? 5 Ambula- tory m e d i c i n e and c o m m u n i t T e x p e r i e n c e s may p r o v i d e a m o r e real is t ic v i ew of the l i festyles of genera l i s t prac- t i t ioners.

Debt and Finances

Studies have b e e n incons i s t en t in showing d e b t to be an impor t an t fac tor in ca r ee r cho ice . At one med ica l school , ne i the r f inancial cons ide ra t i ons nor d e b t had a ma jo r impac t on c a r e e r p re fe rence . 34 Bazzoli 's s tudy of the effect of loan t ype on c a r e e r c h o i c e found that d e b t was less i m p o r t a n t than factors such as mari ta l status, spouse ' s income, po t en t i a l earn ings in p r ima ry care, and paren ta l educa t ion , c'2 In a survey of th i rd-year res idents , 80% of w h o m had an average d e b t of over $41,000, 82% c la imed that d e b t d id no t in f luence cho i ce of specialty. Many residents, however , indica ted that their plans for p r ac t i ce type and loca t ion and dec i s ions to subspecial ize w o u l d be in f luenced by debt . ~'3 Berg s h o w e d that s tuden ts w h o had higher debt burdens w e r e less l ikely to d e m o n s t r a t e an in t e re s t in p r i m a r y care. Se l f - repor ted impact of deb t on career decis ion was modera te to marked for 14% of those w i th l ow d e b t c o m p a r e d wi th 59% of those wi th high debt . a~ Analysis o f the ro le of d e b t in ca r ee r cho i ce may be h a m p e r e d by r epo r t i ng bias.

Whi le some s tud ies suggest that bo th deb t and in- c o m e e x p e c t a t i o n s may be s ignif icant factors in c a r e e r decisions, as the average income of physicians places them in the top 5th p e r c e n t i l e of wage earners . Thus, med i ca l students may be unnecessari ly c o n c e r n e d wi th their ability to r epay debts . Efforts by med ica l and financial inst i tu- t ions to ins t ruc t s tuden t s on rea l i s t ic d e b t - r e p a y m e n t m e t h o d s may r e d u c e w h a t e v e r i m p a c t d e b t has on ca- r ee r choice .

Prestige and Respect for Primary Care within the Medical Center

The inpa t ien t focus of me d i c a l s choo l t ra ining en- sures g rea te r e x p o s u r e of s tuden t s to subspecia l i s t and surgical services. In b o t h formaD s and informal surveys, s tuden ts have r e p e a t e d l y n o t e d a lack of r e spec t for the p r imary ca re d isc ip l ines . In a c a d e m i c med ica l cen te rs , m e m b e r s of one f ie ld of ten c r i t i c ize the k n o w l e d g e and skills of those in o t h e r fields. Hosp i ta l -based phys ic ians are f requen t ly cr i t ica l o f phys ic ians in the communi ty . Genera l i s t s of ten b e a r t he b r u n t of such cr i t ic isms. These

JOURNAL OF GENERAL INTERNAL MEDICINE,, Volume 9, Supplement 1 (April), 1994 $21

practices may deter medical students from considering their fields. Deans and department chairs can lead the way in encouraging an end to such practices by pro- moting institutional respect for primary care.

Family Practice/General Internal Medicine/ General Pediatrics: Differences and Similarities

Although many of the issues related to generalism are common to all three primary care disciplines, the generalist specialties have until now spent more energy on reinforcing their differences than on working toward shared goals. Separate professional organizations and his- torical roots have fostered "turf" and control issues, which have only worsened recently as the potential resident applicant pool has decreased. The result is that few medical schools have developed strong primary care training in all three generalist disciplines. However, while the differences among the three specialties may seem of critical importance to their respective practitioners, they are of less concern to patients, the government, and insurers who want compassionate and cost-effective patient care. Cooperation among the three discipfines could yield increased numbers of generalists and their accom- panying influence to improve training, research, and academic viability. At a national level, societies such as the Primary Care Organizations Consortium (PCOC) have made significant progress toward cooperation. 66. 67 At a local level, generalists at each medical school could meet on a regular basis to plan common strategies to recruit and train generalist-oriented students. The Robert Wood Johnson Generalist Initiatives, for example, have pro- vided funding to encourage such cooperat ion at 18 U.S. medical schools.

RECRUITING AND ADMITTING GENERALIST-ORIENTED RESIDENTS

If a student leaves medical school with an intact commitment to generalism, then he or she may enter either a dedicated generalist residency (family practice; general internal medicine; general pediatrics; med ic ine - pediatrics) or a traditional residency in medicine or pediatrics, declining to differentiate into a specialist by the end of training. Since the transition into a generalist career is dependent upon successfully negotiating the residency years with a thriving interest in generalist practice, the choice of a residency by the student (or the choice of the student by residency programs wishing to produce more generalists) is key. Yet it is striking how little research has been done in this area.

In a recent editorial, "Recruiting for Primary Care," Norman Levinsky notes that the number and perceived quality of students entering primary care residencies have decreased significantly over the past six years. 68 He remains skeptical that such steps as curriculum re- form or lengthening the residency to four years will achieve any increase in numbers or quality. He points

to society's inadequate reimbursement of primary care physicians and suggests (as have others) that the trend of decreasing numbers of residents entering primary care careers will not be reversed until society changes its reward system.

An early article by Taggart, Wartman, and Wessen 58 presents data from a 1982 survey of an 80% sample of fourth-year medical students at 44 U.S. medical schools. In this report, the single most important reason for choosing a primary care residency was the type and quality of relationships with patients. Observed role models were the next most important influence. These data suggest that interviewers looking for student graduates interested in primary care should query the applicant's interest in relating to patients, as well as his or her chosen role models during training. A method for inquiring about such issues is outlined in the section above on developing the personal interview.

A survey of graduates of the University of Washing- ton School of Medicine 69 showed that those graduates who had chosen family practice careers had made up their minds in the first two years of medical school, while the majority of the remainder had decided well into the third or fourth year of training. These findings, coupled with the work of Rabinowitz ~z and others showing rel- ative stability of family practice preferences during medical training, suggest that selecting primary care residents who have decided early on a primary care career might be more likely to result in, as David Babbott calls them, "steadfast generalists" throughout residency training.

There are few existing data concerning predictors of medicine and pediatrics residents who will not differentiate into specialists (see below). However, it seems prudent to maintain an awareness of some of the same factors that predict medical student primary care career choice, such as female gender, smaller hometown size, psychosocial interests, minority status, community service, interest in relating to people, and affinity for longitudinal care. These issues and attributes can be determined in the application imerview for residency training. It should be recognized that lifestyle concerns and interests in research are less likely to predict eventual primary care career choice.

RESIDENT RETENTION IN PRIMARY CARE

Loss of interest in family practice during residency is not a major issue. Among physicians entering residencies in family practice, over 95% complete all three years. TM However, the number of residents in medicine and pediatrics training programs exceeds that in almost all primmry care training programs. Thus, there are large numbers of residents in training each year who, by choosing not to differentiate into specialists, could sup- ply very large numbers of generalist graduates. The predictors of non-differentiation are poorly understood.


Various investigators 71-73 have documented the success of primary care residency programs in yielding propor- tionately more primary care physicians than traditional medicine or pediatrics programs. An example is the Resi- dency Program in Social Medicine, in which family physicians, general internists, and general pediatricians have been training primary care doctors collaboratively for over 20 years. This inner-ci ty-based program produces many graduates who provide care for the underserved. 74

But the question remains as to what will influence traditional medicine and pediatrics residents to remain generalists after training. To our knowledge, not a single study has been published that defines the issues in this key area. For internal medicine, this may be a landmark issue, as the number of graduates of medicine residency programs choosing general medicine as a career has plummeted in recent years. In a recent editorial, Jerome Kassirer suggests that calls for 50% of residency program graduates to be generalists "have little chance of influ- encing the decisions of [internal medicine] residents . . . " as the proposals "do not specify which programs are expected to comply or what individual program di- rectors are expected to d o . ' '75 He then goes on to say, "If I were a program d i r ec to r . . . I would have no idea how to c o n v i n c e - - o r c o e r c e - - h a l f of the graduating residents to pursue careers as generalists."

Clearly, increasing the amount of ambulatory-based education will be useful, as will incorporating generalist role models into the training process at critical junc- tures. Respect for primary care within the academic training environment may be another key issue. Until research is performed in this area, our knowledge of how to encourage traditional medicine and pediatrics residents to remain generalists will be purely specula- tive.

With regard to family practice residency training, almost 90% of graduates enter family practice (personal communication with American Academy of Family Phy- sicians, including AAFP Graduate Survey, July 1993). Approximately 4% practice in emergency rooms, and about 6% go on for "faculty development" fellowship training. Thus, the vast majority of graduates of family practice residency programs are "retained" during training and ultimately practice primary care.

PRACTICE ENTRY INTO PRIMARY CARE

Traditional medicine and pediatrics programs have typically devoted little curriculum time to preparing residents to enter primary care practice. In the 1990s, the relevant question may be whether training programs are preparing their graduates to enter a managed care environment, with abilities to balance judicious use of resources with the need to provide quality care. Family practice programs have for years been teaching their residents "practice management," while many internal medicine programs have forsaken these issues. Training

in these areas and post-graduation help in negotiating entry into practice are invaluable parts of the process of producing more generalists.

Another area of concern is how to produce graduates who will go out to serve the underserved. Pro- grams that train their residents in underserved areas are more likely to see their graduates in these environs, 74 although self-selection by committed residents is a certain confounder in these programs. Entry into rural practice is more likely when a resident comes from and/or trains in a rural area (as in the Jefferson PSAP 2° and Minnesota RPAP s programs). Three recent pieces 76-78 describe the characteristics of residency graduates who settle in rural, underserved areas. Graduating residents had particular concerns about the size of the community, access to medical consultation, the availability of high- quality continuing education, and the quality of community services (such as schools). Spouses may be key people who encourage or discourage graduates from settling in rural areas, 79 and attention to the physician family is important when recruiting graduates into rural practices.

CONCLUSIONS

It has been demonstrated that individuals are pre- disposed to being either generalists or specialists prior to medical training. Finding "pre-generalists," selecting them for medical school, and nurturing them during training are essential to producing more primary care physicians. We know, too, that premedical programs can be a suitable training ground for generalists. Admission committees need more generalist members and interviewers. Admission criteria favoring generalist-oriented applicants need to be put in place, and interviewers should be developed to solicit information concerning an applicant's interest and ability in relating to people.

The current medical school environment is highly discouraging of a career in generalism. More opportunities are needed for students to relate to patients in ambulatory settings with generalist role models. Primary care residency programs will continue to produce generalist graduates, but the methods by which traditional medicine and pediatrics programs can encourage generalist career choices remain to be defined. Generalist practice entry needs to be facilitated, and ways to produce more doctors to work in underserved areas should be a routine part of all residency training programs. We are optimistic that, by means of these and other mech- anisms, more generalists will be recruited and retained within U.S. medical schools.

REFERENCES 1. Schroeder SA. The splendor of internal medicine: it begins with

patient care. J Gen Intern Med. 1992;7:528-31. 2. Colwili J. Where have all the primary care applicants gone?

N Engl J Med. 1992;326:387-93.

JOURNAL OF GENERAL |NTERNAL MEDICINE, Volume 9, Supplement I (April), 1994 523

7. Rabinowitz HK. Recruitment, retention and follow-up of graduates of a program to increase the number of family physicians in rural and underserved areas. N Engl J Med. 1993;328:934-9.

8. Association of American Medical Colleges. Generalist Physician Initiatives in U.S. Medical Schools. Washington, DC: AAMC, 1993.

9. Funkenstein DH. Medical students, medical schools, and society during five eras. Cambridge, MA: Ballinger Publishing, 1978.

13. Fincher RME, Lewis LA, Rogers LQ. Classification model that pre- dicts medical students' choices of primary care. Acad Med. 1992; 67:324-7.

15. Kassler wJ, Wartman SA, SiUiman RA. Why medical students choose primary care careers. Acad Med. 1991;66:41-3.

26. Rivo ML. Internal medicine and the journey to medical generalism. Ann Intern Med. 1993;119:146- 52.

28. Schwartz MD, Linzer M, Babbott D, Divine GW, Broadhead E. Medical student interest in internal medicine. Ann Intern Med. 1991;114:6-15.

29. Schwartz MD, Linzer M, Divine GW, Babbott D, Broadhead WE. Medical student interest in internal medicine: impact of an ambulatory rotation. Clin Res. 1991;39:622A.

32. Lieu TA, Schroeder SA, Altman DF. Specialty choices at one medical school: recent trends and analysis of predictive factors. Acad Med. 1989;64:622-9.

35. McMurray JE, Schwartz MD, Genero NP, Linzer M. The attrac- tiveness of internal medicine. Ann Intern Med. 1993;119:812-8.

42. Grant L. The gender climate of medical school. JAMWA. 1988; 43:109-19.

47. Baker-Miller J. Towards a new psychology of women. Boston: Beacon Press, 1976.

51. BigbyJ, Schwartz MD, McMurrayJE, Genero NP, Linzer M. Career choice in internal medicine: not for African-American students. Clin Res. 1993;41:554A.

58. Taggart MP, Wartman SA, Wessen AF. Influences on choice of primary care. Med Care. 1987;25:671-4.

74. Strelnick AH, Bateman WB, Jones C, et al. Graduate primary care training. Ann Intern Med. 1988;109:324-34.

Other references may be obtained from Dr. Linzer by e-mail ([email protected]), by phone (608/263-5259), or by fax (608/ 262-6743).

Training Generalist Physicians: Structural Elements of the Curriculum

WYLIE BURKE, MD, PhD, ROBERT B. BARON, MD, MS, MAURICE LEMON, MD, DAVID LOSH, MD, ALVIN NOVACK, MD

To train more generalist physicians, structural changes must be made along the continuum of medical education. Future generalists require in-depth exposure to primary care practice, with substantive experience in the longitudinal management of patient panels and the op- portunity to work with successful generalist role models. Clinical training and course work must incorporate a wide range of skills and disciplines, including areas now under-emphasized, such as epide- miology, health services, and psychosocial medicine. Recommenda- tions for structural changes to increase the generalist focus of medical education include: 1 ) the development within institutions of central authorities, involving departments of internal medicine, family medicine, and pediatrics, in joint efforts to foster all aspects of generalist training, including recruitment, curriculum development, community linkages, innovative approaches to training, and recognition and support for successful generalist teachers; 2) commitment of a minimum of 50% of clinical training to ambulatory care settings at both medical school and residency levels; 3) required longitudinal care experiences for all medical students and a 20% or greater time commitment to longitudinal care for internal medicine, pediatrics, and family medicine residents; and 4 ) increased numbers of generalist faculty and enhanced teaching skills among faculty in the outpatient environment, to guar- antee increased exposure of medical students and residents to generalist role models. Key words: curriculum; education; generalists; training. J GEN INTERN MED 1994;9, Supplement 1 (April):S23 S30.

Received from the Departments of Medicine (WB), Family Medicine (DL), and Pediatrics (AN), University of Washington, Seattle, Wash- ington; the Department of Medicine, University of California, San Fran- cisco, San Francisco, California (RB); and the Department of Medicine, Cook County Hospital, Chicago, Illinois (ML).

Addres~ correspondence and reprint requests to Dr. Burke: De- partment of Medicine RG-21, University of Washington, 1959 NE Pa- cific Street, Seattle, WA 98195.

THE PURPOSE OF MEDICAL EDUCATION is tO d e v e l o p t h e skills

and k n o w l e d g e r e q u i r e d f o r e f f e c t i v e c l in ica l p r a c t i c e .

The p u r s u i t o f th is goa l l e d in t h e ea r ly 1 9 9 0 s to t h e

d e v e l o p m e n t o f h o s p i t a l - b a s e d , p a t i e n t - c e n t e r e d c l in ica l

t r a in ingJ As m e d i c i n e s u b s p e c i a l i z e d a n d t e c h n i c a l ca-

pac i ty g r e w , h o s p i t a l - c e n t e r e d t e a c h i n g e m p h a s i z e d t h e

ca re o f a c u t e l y ill p a t i e n t s a n d t h e i m p o r t a n c e o f sci-

ent i f ic k n o w l e d g e a n d t e c h n i c a l e x p e r t i s e as t h e bas i s

for m e d i c a l p r a c t i c e . Th i s e m p h a s i s c o n t i n u e s in t o d a y ' s

p r e m e d i c a l a n d m e d i c a l c u r r i c u l u m .

T h e p e r s i s t e n c e o f h o s p i t a l - b a s e d t r a i n i n g is f u r t h e r

d r i v e n by e c o n o m i c p r e s s u r e s a n d t h e n e e d s a n d ex-

p e c t a t i o n s o f m e d i c a l facu l ty . Staff ing o f t e a c h i n g h o s -

pi ta ls is p r e d i c a t e d o n t h e 2 4 - h o u r avai labi l i ty o f i nex -

p e n s i v e h o u s e s t a f f l abor , t o t h e b e n e f i t o f b o t h f acu l ty

and hosp i t a l a d m i n i s t r a t o r s . 2-4 W i t h t h e i n c r e a s i n g se-

ver i ty o f i n p a t i e n t s ' c o n d i t i o n s a n d s h o r t e r h o s p i t a l s tays ,

s o m e e d u c a t o r s a n d a d m i n i s t r a t o r s p e r c e i v e t h e n e e d

for g rea te r houses t a f f c o v e r a g e o f i npa t i en t se rv ices r a t h e r

t h a n less.

T h e f o c u s o f p a t i e n t c a r e h a s s h i f t e d f r o m i n p a t i e n t

t o o u t p a t i e n t s e t t i ngs , a n d t h e r a t i o n a l e o f c l in ica l rel-

e v a n c e n o w p o i n t s t o o u t p a t i e n t s e t t i n g s as t h e p r i m a r y

s i te fo r m e d i c a l e d u c a t i o n . C o n c u r r e n t l y , t h e r e is an

i n c r e a s i n g r e c o g n i t i o n o f t h e n e e d f o r g e n e r a t i s t p h y -

s ic ians a n d t h e n e e d fo r t r a i n i n g tha t p r e p a r e s i n d i v i d u a l s

fo r p r i m a r y c a r e p r a c t i c e . 5-9 T h e s e n e e d s a r e b e s t m e t

by t r a i n i n g p r o g r a m s t h a t e m p h a s i z e c l in ica l e x p e r i -

e n c e s in a m b u l a t o r y s e t t i ngs .

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