School debt helps drive medical students into specialty matches

Family practice and internal medicine leaders said Match Day 2003 wasn't the best for primary care.

By Damon Adams, amednews staff. April 7, 2003.

James C. Martin, MD, believes family physicians are the backbone of the health care system. But the San Antonio, Texas, doctor sees the spine weakening.

For the sixth year in a row, the number of graduating medical school seniors and other match applicants who chose residency programs in family medicine has dropped, according to the National Resident Matching Program.

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This year's Match Day figures show that seniors are increasingly choosing residencies in specialties. Many are driven by better-paying job opportunities for specialists, income that will take a bigger bite out of their student debts.

Some primary care organizations are worried that the students' choices will translate to fewer family doctors and internists. Dr. Martin, president of the American Academy of Family Physicians, said the decline of family medicine residency matches eventually would devastate health care, and the trend needs to be reversed. "My concern is what is this going to mean for the health care system in this country."

Internal medicine leaders also saw discouraging signs in the 2003 Match Day numbers.

Although international medical graduates and others helped internal medicine matches increase over last year, U.S. seniors seeking internal medicine residencies dropped about 10% since 1999.

There were a record 21,200 residency matches this year.

"Internal medicine doctors are unhappy people these days. They feel overregulated. They feel underappreciated. ... Students pick up on that," said Patrick Alguire, MD, director of education and career development for the American College of Physicians.

Ross Goldberg is among the medical students choosing career paths other than primary care. The fourth-year student at New York Medical College has been matched for a general surgery residency at St. Vincent's Hospital in New York City.

With about $180,000 in student loans, Goldberg said "salary does play a role" in picking general surgery. But he said his main reasons for pursuing surgery are the challenge it poses and the impact surgery can have on a patient's health.

He has concerns about rising liability premiums but hopes reforms will stop the increases. "It would really be a shame to not have someone go into a profession because of insurance rates," said Goldberg, speaker of the AMA Medical Student Section governing council.

Robert Beran, PhD, executive director of the NRMP, agreed with Goldberg's assessment that salary does play a role in students' match choices.

"It's hard to ignore when you graduate that you're going to have to pay $150,000 back," Dr. Beran said. "You won't make as much as a pediatrician as you will as a surgeon."

Searching for answers

The AAFP has conducted studies to determine the cause of declining interest. Results show students take issue with long work hours and inadequate reimbursement. They said family physicians are not as highly valued as subspecialists.

Dr. Martin said the AAFP is exploring ways to make family medicine more attractive to medical students.

A record number of residency positions were offered this year (23,365), and that led to a record number of matches (21,190). Helping the rise was a 10% increase in matches for IMGs, which reversed a five-year decline, match officials said.

But the boost doesn't necessarily mean good news for primary care.

"IMGs that come here and train are very good, but they may not stay here to deliver health care. That's a concern to me," Dr. Alguire said.

Match Day arrived March 20 in the midst of turbulent times.

A lawsuit claiming that the NRMP violates federal antitrust laws and seeking damages for residents was filed in May 2002. If plaintiffs win the case, the match process could change.

Meanwhile, the liability crisis is influencing some seniors' choice of a career path, educators said. In this year's Match Day, ob-gyn matches decreased slightly from last year.

In West Virginia, one of the liability crisis states, educators have seen a softening of the impact.

Last year at the West Virginia University School of Medicine, in Morganstown, 66% of graduating seniors decided to take out-of-state residencies. School officials braced for more students to leave the state this year.

But that didn't happen because tort reform putting a cap on noneconomic damages passed the state House and Senate before students listed their preferences for residency programs, school officials said.

This year, 43% of seniors from the university's medical school are staying in state to do their residencies.

"Students felt more comfortable that we and the state were going to address the problem. It had an impact on their decision to stay in West Virginia," said Robert D'Alessandri, MD, dean of the medical school.

ADDITIONAL INFORMATION:

What's hot, what's not

During the past five years, matches in anesthesiology have climbed while matches in family medicine have dipped, indicating interest in specialties is on the rise as primary care struggles. First-year matches:

                     2002    2003   Change
                     ----    ----   ------
Anesthesiology        375     415    10.7%
General surgery       981   1,038     5.8%
Pediatrics          1,992   2,099     5.4%
Emergency medicine  1,052   1,073     2.0%
Internal medicine   4,395   4,462     1.5%
Ob-gyn              1,067   1,050    -1.6%
Family practice     2,342   2,227    -4.9%

Source: National Resident Matching Program 2003 Match Data