Choice of First-Year Residency Position and Long-term Generalist Career Choices

To the Editor: Accurate forecasts of the future generalist physician workforce are important for policy makers in medical schools and government. The most commonly used annual indicator of primary care outcomes has been the percentage of physicians enrolled in first-year graduate medical education (GME) programs in the 3 generalist disciplines of family practice, internal medicine, and pediatrics.^{1 - 2} Little information is available regarding the accuracy of first-year residency specialty choice in predicting subsequent primary care practice. However, since the rate of subspecialization is known to differ considerably across the 3 generalist disciplines, merely summing the number of young physicians entering generalist first-year programs is likely to overestimate the future number of primary care physicians.³

We undertook a study of 2548 medical school graduates from the classes of 1990-1992 at 6 Pennsylvania medical schools that participate in a statewide tracking system. We obtained information from the Association of American Medical Colleges regarding each graduate's first-year residency specialty, their career plans reported on the graduation questionnaire (GQ) completed during their senior year of medical school, and residency specialty at the completion of GME training.

We computed 3 different predictors of future generalist career choice. First, we determined the number and percent of graduates who entered a first-year training position in 1 of the 3 generalist diciplines. Second, we looked at the number and percent of graduating students who indicated an intent to pursue a generalist career on the GQ. Third, we looked at the GQ responses only for those who entered first-year generalist training programs. Because a proportion of each of these 3 subgroups had missing GQ data, we multiplied the number of those with missing GQ data by the respective proportions, in each of the 3 groups, of those subjects with available GQ data who had indicated an interest in pursuing a generalist career. These estimates were added to those with available GQ data to obtain a final estimate.

These 3 predictions were then compared with actual outcomes for these same physicians. Generalists were identified as those who completed GME training in 1 of the 3 primary care disciplines but who did not continue subspecialty training beyond the third year of residency.

Data were available for almost all graduates for first-year residency training (n = 2540; 99.7%) and GME training (n = 2530; 99.6%); 63% (n = 1597) of graduates had information available from the GQ (with an identical proportion of nonresponders becoming generalists). As shown in Table 1, 27% of these graduates completed GME training in primary care (which has also been highly correlated with self-reported practice specialty).⁴ Estimates of the proportion of primary care physicians based on responses on the GQ (24%) and on GQ responses for those beginning first-year training in primary care (23%) were similar and slightly underestimated (by 11%-15%) the final proportion of primary care physicians. However, predictions based on first-year residency choice (40%) overestimated the final proportion of primary care physicians by 48%.

By following a cohort of graduates from 6 medical schools, we found that beginning a residency in each of the 3 generalist disciplines was associated with very different likelihoods of pursuing a career in primary care. For example, 100% of those entering first-year residency programs in family practice continued as generalists, compared with 52% for internal medicine and 73% for pediatrics. Merely adding the number of graduates entering first-year programs in the 3 primary care disciplines, currently used to estimate generalist outcomes, resulted in a substantial overestimate of the number of actual generalists. Similarly, at the individual medical school level, differences in the proportion of graduates entering each of the generalist specialties would result in very different generalist outcomes. Prior data indicating that practicing family physicians also spend more time in primary care than general internists or pediatricians⁵ extend the importance of these results. Therefore, medical schools and policy makers can increase the accuracy of their forecasts of generalist physicians by considering the stated career plans of those entering first-year residency programs, in addition to the subspecialization rates of the 3 generalist disciplines.