Medical Student Career Choices 2010 and Beyond

The most important thing about specialty choice is a best fit for you. Because this is most important, you need to have a grasp of how much you can self-determine your final specialty choice and how much is beyond your control. The range of specialty choices may be limited for graduates of osteopathic schools, international medical schools, or more typical allopathic public schools that have more normal scores and class rank. With improvements in standardized test scores, class rank, and school rank the probability of certain specialty and subspecialty career choices improves.

Also there are single stage career choices and multiple stage choices. Family medicine represents a single stage career choice in medical school that results in 95% of graduates remaining in the broad generalist family practice mode. Retention within family medicine About half of pediatric residency graduates remain in primary care as indicated by pediatric residency seniors (Freed). Less than 20% of those planning internal medicine careers plan to remain in primary care (Garibaldi, Hauer). Internal medicine and pediatric specialties are a two stage choice. The case can be made for multiple stages of career choice in primary care internal medicine with initial choice in medical school, at choice made in residency, and choices made each year to remain in internal medicine primary care. Other careers are built with sequential training starting in a certain field with the addition of training.

Graduates of prestigious schools and residency programs have an advantage in specialty choice. Gaining admission to a program that does well in specialty choice may be important for those anticipating specialty careers such as cardiology. There is less competetion for positions that lead to mental health, women's health, primary care, and health access careers.

Long term considerations are important in career choice if there is some flexibility in career choice. If medical students are truly committed to a certain specialty, this flexibility is less of an option. If you are flexible, you might consider where the US is heading in the designs for workforce and the designs for support of workforce after practice begins.

The United States Designs

The overall design of workforce production is quite simple. Each year the United States graduates a higher percentage into specialty careers while primary care percentages grow lower. In the prestigious medical schools that rank at the top of US News and World Report, only about 10% of graduates can be counted upon for primary care careers. This includes 0 - 2% in family medicine, 2 - 4% that stay in internal medicine primary care, and 3 - 4% that stay in pediatric primary care. Often the web sites at these schools list medical students entering primary care as 30 - 45% of graduates but this is basically a distortion as so few choose permanent primary care and so few pediatric and internal medicine graduates remain in primary care after residency graduation. The graduates of exclusive schools crowd into specialties and subspecialties and avoid primary care.

The overall design of workforce support is also quite simple. About 80 - 85% of the 2.4 trillion in annual spending goes to 3400 zip codes clustered together with 75 or more physicians, 75% of physicians, 80 - 92% of specialists, and 90% of medical students, residents, researchers, and teaching physicians. The design of federal, state, and clinical funding rewards this concentration of health resources. Organized medicine and medical education consistently fight redistributions of this funding to match the population that is distributed 65% outside of these locations.

What this means to you varies with your intentions. Workforce is moving toward higher concentrations and this might be a fit for you. But your competition is heading this way as well. The open positions and those in need are likely to be outside of concentrations. These are locations that are less desirable for those born, educated, raised, and trained in top concentrations for the first 30 years of life. Experiential place is a powerful factor driving career and location choice.

The Design For Improvement of Health Access to those left behind is also quite simple - more normal and less exclusive (or better distributed and less concentrated). There can be no resolution of health access disparities without more normal and better distribution in workforce design and in the funding support design. A good way to think of this is that the funding distribution allows a certain career and location choice pattern. Admission and training can approach this career and location choice pattern or admission and training can move graduates away from this design. From the perspective of locations in concentrations, this works well as policy support as well an selection and training favor concentration. From the perspective of health access it is a worst case scenario. The amount of workforce supported is poor for locations with 65% of the population and the selection and training fails to reach the potential even allowed by the funding design. Medical associations, medical education associations, teaching hospitals, and non-clinician associations are in a poor position to support health access in workforce design or practice support design as they are constantly lobbying for higher concentrations of funding in fewer locations. Medical education has been the most successful as noted by the most lines of funding and the highest level of funding in each line of revenue.

The Physician Distribution by Concentration Coding highlights the type of physicians, specialties, and training elements that result in improved health access.

More normal in origin, older at medical school graduation, family practice broad generalist careers, and more normal in training result in distribution and health access. (Basic Health Access, They Really Do Go)

The populations in the United States left outside of the design are spread across urban and rural locations in marginal and underserved settings. These are 28,000 zip codes that have higher concentrations of elderly (70%), lower income, middle income, less educated, poor, and Community Health Center populations. These are locations that have far more than a majority of the population, that have the populations in need of the most care, that have the most complex populations requiring care, and the health care must be delivered with the least resources. Only about 23% of physicians and 30% of non-physician clinicians are found in these locations outside of concentrations.

The United States prepares, admits, trains, and supports physicians and non-physician clinicians inside of concentrations at the highest levels. The US is poorly aware of the magnitude of disparity. For example less than 10% of health spending goes to primary care, less than 5% to rural health (20% of the population), and less than 5% to underserved health care (21% of the population). When the areas of concentrations of resources are combined together (as they cluster together geographically), the inequities in the designs are illustrated.

Solutions involve preparation and admission of a more representative population from the 65% left behind, older graduates that are often delayed in admission by barriers related to income and education and parents, more emphasis on generalists and primary care, and training focused on health access. Studies by Ferrer, Rosenblatt, and others demonstrate that family physicians are multiple times more likely to match up to all of these populations. The reason is equitable distribution of family practice forms according to the population - not according to concentrations of physicians.

Only the family practice MD, DO, NP, and PA forms are found with 53 - 60% matching up to the 65% of the United States population left behind in workforce training design and practice support design. Family physicians, rural physicians, and underserved physicians can be tracked back to birth origins and all are more likely to match up to the populations that they are found serving. Lower and middle income origin and lower and middle population density origin medical students match up to this population as they distribute as physicians, but these are populations with 20 - 50% of the probability of medical school admission.

Also regardless of origins, when medical students choose certain specialties they limit their ultimate practice choices to locations with top concentrations and sometimes even specific cities where a particular specialty job is available. This is a contrast with family medicine with 30 - 40 per 100,000 throughout most of the United States. There are locations that are not preferred by family physicians that are important to understand. Locations with 200 or more physicians in the United States claim about half of US physicians but these are locations with only 5% family physicians or less than half of the national average (PDC Coding). United States medical schools only have 4% of full time faculty as family physicians (Barzansky, JAMA). Boston, Washington DC, and New York City zip codes in top concentrations only have 2% family physicians.

If you are interested in practicing in one of the types of locations noted above immersed in top concentrations of physicians, family medicine may not be a good choice.

Questions are a good way to explore options. If you give permission I can post your question along with my response.


Future Discussions To Consider

Graphics to Review

AAMC 2008 Projections of Physician Workforce Overall

AAMC 2008 Projections Verses Reality in Primary Care

Primary Care Retention Declines in Overall Graduates

Primary Care Retention Declines in Newest Graduates Entering the Workforce



Residents Listed in their Final Year in the AMA Masterfile

Specialty Last Year Residents
Internal Medicine IM 6339
Family Practice FP 2981
Pediatrics PD 2610
Anesthesiology AN 1439
Emergency Medicine EM 1408
General Surgery GS 1269
Obstetrics & Gynecology OBG 1153
Diagnostic Radiology DR 1041
Psychiatry P 902
Cardiovascular Diseases CD 737
Orthopedic Surgery ORS 631
Pathology-Anatomic/clinical PTH 540
Neurology N 474
Hematology/oncology HO 431
Ophthalmology OPH 405
PulmonaryCriticalCareMed. PCC 405
Gastroenterology GE 396
Dermatology D 368
PhysicalMedicine&Rehab PM 359
Nephrology NEP 351
InfectiousDiseases ID 350
InternalMedicine Pediatrics MPD 346
ChildPsychiatry CHP 337
Otolaryngology OTO 251
Endocrinology END 235
InternalMedicine Geriatrics IMG 224
InterventionalCardiology IC 222
Neuroradiology RNR 216
UrologicalSurgery U 214
PlasticSurgery PS 187
Rheumatology RHU 187
Neonatal-PerinatalMedicine NPM 170
NeurologicalSurgery NS 142
Vascular&InterventionalRad VIR 136
RadiationOncology RO 134
ClinicalNeurophysiology CN 132
OrthopedicSportsMedicine OSM 129
Family Prac/sportsMedicine FSM 128
Allergy&Immunology AI 125
Im-CardiacElectrophysiology ICE 125
CriticalCare-Pediatric CCP 115
PediatricAnesthesiology PAN 115
PediatricHematologyOncology PHO 112
VascularSurgery VS 111
Pathology-Cytopathology PCP 101
ThoracicSurgery TS 97
PediatricCardiology PDC 92
GeneralPreventiveMedicine GPM 91
Hematology/pathology HMP 84
PediatricEmergencyMedicine PEM 84
CriticalCareMedicine CCM 77
ChildNeurology CHN 73
Colon&RectalSurgery CRS 72
CriticalCare-Anesthesiology CCA 70
SelectivePathology SP 65
PediatricGastroenterology PG 64
PediatricEndocrinology PDE 62
FamilyPractice/geriatric Med FPG 60
ForensicPsychiatry PFP 59
Oncology ON 57
Dermatopathology DMP 55
Dermatopathology DMP 55
GeriatricPsychiatry PYG 51
PediatricRadiology PDR 48
PediatricInfectiousDiseases PDI 47
PulmonaryDisease PUD 42
AbdominalRadiology AR 39
AddictionPsychiatry ADP 38
PediatricPulmonology PDP 36
MedicalGenetics MG 31
PsychosomaticMedicine PYM 31
PediatricSurgery PDS 30
BloodBanking BBK 28
ForensicPathology FOP 26
NuclearMedicine NM 26
InternalMedicine-EmergencyMedicine MEM 24
MusculoskeletalRadiology MSR 24
PediatricRheumatology PPR 24
VascularNeurolgy VN 24
OrthopedicAdultReconSurg OAR 20
PediatricEmergencyMedicine-EM PE 20
Developmental-BehavioralPediatrics DBP 19
EmergencyMedicalToxic ETX 19
Hematology HEM 19
Neuropathology NP 18
OrthopaedicSurgeryOfSpine OSS 18
OrthopedicPediatricSurgery OP 18
AdolescentMedicine-Peds ADL 17
InternalMedicine-Psychiatry MP 17
PediatricNephrology PN 15
Orthopedics(foot&Ankle) OFA 14
Pediatrics/Psych/ChildandAdolPsych CPP 14
CriticalCareSurgery CCS 13
OrthopedicMusculoOncology OMO 13
OrthopedicSurgery-Trauma OTR 12
PediatricPathology PP 12
PediatricUrology UP 12
Psychiatry-FamilyPractice FPP 12
PediatricSportsMedicine PSM 10
SpinalCordInjury SCI 10
InternalMedicine-PreventiveMedicine IPM 8
MedicalMicrobiology MM 6
NuclearRadiology NR 6
Emergency/sportsMedicine ESM 5
OccupationalMedicine OM 5
PediatricOtolaryngology PDO 5
Pediatrics/PhysicalMedicineandRehabilitation PPM 5
InternalMedicine-FamilyPractice IFP 4
InternalMedicine-Neurology MN 4
Neurology/diagnosticRadiology/Neuroradiology NRN 4
Neurology/diagnosticRadiology/Neuroradiology NRN 4
Neurology/diagnosticRadiology/Neuroradiology NRN 4
Pediatrics-EmergencyMedicine EMP 4
PreventiveMedicalToxicology PTX 4
Neurotology(Otolaryngology) NO 3
PainMedicine PMM 3
PediatricRehabMedicine RPM 3
Psychiatry-Neurology PYN 3
CardiothoracicRadiology CTR 2
CraniofacialSurgery CFS 2
Pediatrics-MedicalGenetics PMG 2
AdultCardiothoracicAnest ACA 1
AerospaceMedicine AM 1
EndovascularSurgicalNeuroradiology ESN 1
GeneralPractice GP 1
InternalMedicine/Dermatology IMD 1
NeurodevelopmentalDisabilities NDN 1
PediatricDermatology PDM 1
TransitionalYear TY 1

Due to variations in the years required for training in certain specialties, the number of 30,985 is higher than the number entering training of about 25,000.

Primary Care Decline: Declining Retention and Primary Care Failure Despite Expansions of Primary Care Graduates    The US design for primary care fails as 22,000 of 28,000 Annual Primary Care Graduates are Flexible and Leave Primary Care.

Why Medical Students Should Ask Congress to Vote No Regarding Last Minute Expansions of Residents Until Expansion Does Care for the Health Access Needs of the Nation, and For Them     yes for expansion, but expansion that is well planned and implemented

Primary Care Workforce 1980 to 2040 - More of the Same Still Fails More

Estimated 2009 Class Year Primary Care, Rural Primary Care, and Underserved Primary care Contributions by Individual Medical Schools with Comparisons to NP and PA 2009 Contributions