Correspondence

Competitiveness, Peer Pressure, and Career Choice

N Engl J Med 1993; 329:1281-1282October 21, 1993

Article

To the Editor:

Much has been written in recent years about the difficulty of attracting students to internal medicine1. The results of the 1993 National Residency Matching Program again showed a substantial decline in the number of medical students choosing residency training in internal medicine. We are in the midst of a national health care reform that is likely to result in a new health care delivery system that will be largely dependent on primary care physicians2. Where will these physicians come from3,4?

As residency and clerkship director, I have had the privilege of discussing career plans with many students during their third and fourth years of medical school. This past year, I was startled by a medical student who came in to tell me that he very much enjoyed internal medicine, which was his favored career choice, but that he felt an obligation to choose an alternative field so that he would not be “letting down” his classmates. He explained that he was a top student in the class and was recognized by his peers as such. This, he felt, obligated him to choose a “competitive field.”

Subsequent conversations with other students have revealed strong peer pressure against choosing a primary care field. Many students said that they were embarrassed to tell their classmates about their interest in internal medicine, pediatrics, or family medicine. The perceived unacceptability of primary care choices and the tendency to equate the quality and desirability of a field with the difficulty of obtaining residency training in that field are clearly disturbing facts for internal medicine educators.

A major factor contributing to the noncompetitive image of internal medicine is the growth in the number of residency positions in internal medicine to meet hospital service needs5. Nationally, we offer almost twice as many positions in internal medicine as there are interested U.S. graduates. This mismatch in market forces undoubtedly contributes to the recent problems associated with resident recruitment, the numerous violations of the National Residency Matching Program, and the increasing dependence of programs in internal medicine on foreign medical graduates to fill openings.

To attract the best and the brightest students to careers in internal medicine, we need to offer equality of reimbursement, improvement in lifestyle, reductions in the “hassle factor,” reduction of student debt, enthusiastic faculty role models, and excellent training programs. In addition, we must consider reducing the size of our programs to regain a balance between supply and demand. These measures should help to restore the luster of internal medicine and result in more and better residents in the long run.

Lawrence G. Smith, M.D., F.A.C.P.
State University of New York, Stony Brook, NY 11795-8160

5 References

1. 1

   Kassirer JP. Primary care and the affliction of internal medicine. N Engl J Med 1993;328:648-651
   Full Text | Web of Science | Medline

2. 2

   Clinton B. The Clinton Health Care Plan. N Engl J Med 1992;327:804-807
   Full Text | Web of Science | Medline

3. 3

   Federated Council for Internal Medicine. General internal medicine and general internists: recognizing a national need. Ann Intern Med 1992;117:778-779
   CrossRef | Web of Science | Medline

4. 4

   Levinsky NG. Recruiting for primary care. N Engl J Med 1993;328:656-660
   Full Text | Web of Science | Medline

5. 5

   Wallace EZ. Service vs education in internal medicine residency: need for a resolution. Arch Intern Med 1988;148:1296-1296
   CrossRef | Web of Science | Medline