Making the Choice
Residency Training prepares physicians for particular medical specialties
This month, nearly 22,000 freshly-minted medical school graduates will begin in their new roles as residents-in-training in hospitals and medical centers throughout the country. They have just completed four years of intense study to earn their medical degrees, and are embarking on the next phase of education, lasting three to five years, to gain more specific knowledge and skills necessary to practice a particular specialty of medicine, such as family medicine, internal medicine, surgery, psychiatry or one of a host of others.
Although some students know from day one of medical school (or earlier) what kind of physician they want to become, others take longer to decide, sometimes changing their minds several times as they go through clinical rotations. More than likely, each has done the soul-searching, information-gathering and self-assessment it takes to choose the specialty they believe will be most compatible with their interests, needs and desires.
“Medical school prepares you to know the language and understand concepts in medicine,” says Robert Sticca, M.D., chair and professor of surgery and director of the surgery residency program, Grand Forks. “The residency ‘polishes’ you, helps you to interact with patients. There’s a tremendous amount of material to master in order to work with the patient and, hopefully, benefit the patient.”
In each field, the program director must meet the training criteria, document that the resident has received the required training, and certify that the resident-graduate is competent and proficient.
Internal medicine: the more complex, the better
For instance, medical students who are attracted to internal medicine “like the depth of medicine,” says William Newman, M.D. (B.S. Med. ’72), chair and professor of internal medicine and chief of endocrinology and metabolism, Fargo. “They’re curious; they like to investigate things in depth. They like the complexity of medicine.”
UND’s three-year internal medicine residency program, based in Fargo, provides residents with broad, general internal medicine training, he says, which prepares them for practice as a hospitalist or for clinic-based general internal medicine. The program also prepares residents who plan to pursue fellowship training in subspecialties, such as nephrology, endocrinology, pulmonary medicine and critical care medicine, for which graduates must leave North Dakota.
Providing in-state training in internal medicine is “absolutely critical” to supply the state’s physician manpower needs, Newman says. Further, medical students are able to see residents in action and learn from them, which may affect their choice of specialty and training program. And “the faculty develop themselves better” with a training program in place.
UND’s internal medicine graduates are “really high quality,” he says, noting that “the VA wants to take our grads first because they are well-trained, they know the system and they know the town.”
“The reports we get back about our residents are generally glowing,” he adds. Many residency “graduates will say, ‘I’m glad for the quality of training I got here.’”
Committed to surgery, especially in smaller towns
When reviewing applicants, Sticca says he and his colleagues “look for somebody who’s committed to surgery, and will be willing to work hard. The five years of surgery training can be a long and difficult task but the rewards at the end of training are great. The surgical trainees must exhibit a professional behavior and attitude, and often become leaders in their communities.”
But in particular, we tend to attract residents who are or have an interest in practicing in smaller communities, “because we train people very well for that,” he says, noting that UND residents benefit from “a very wide and broad-based experience” in preparation for their careers.
Practicing surgery in smaller communities, “most people would agree that it’s a different type of practice,” he says, “and that there’s a growing need for rural surgeons... We have a reputation of producing good, competent, well-trained general surgeons who can function in many types of practice situations and do a good job.”
Psychiatry’s contribution to state
According to David Abbott, M.D., associate professor of clinical neuroscience and director of the UND psychiatry residency program, Fargo, “there are 81 psychiatrists practicing in North Dakota, not counting current residents with full licensure. Of those, 29, or 36 percent, trained in our residency program.”
Also significant, he says, “is that, since the program graduated its first resident in 1984, a total of 61 have completed their general psychiatry training with us, of whom 37, or 61 percent, have practiced in North Dakota... An additional four have practiced in nearby Minnesota, including one who lives in North Dakota but practices in Breckenridge.”
Critical to retention of physicians
Residency training is an important, and proven, factor in predicting physician retention. Studies have shown that most residency program graduates, as much as 85 percent, establish their practices within a 100-mile radius of where they trained, says Jeff Hostetter, M.D. (Family Medicine Residency ’03), director of UND family medicine program in Bismarck.
15 (UND Center for Family Medicine Minot, three-year)
15 (UND Center for Family Medicine Bismarck, three-year)
24 (Fargo, three-year)
17 (Fargo, four-year)
10 (Grand Forks, five-year)
2 (Grand Forks, one-year preliminary)
8 (Fargo, one-year)
* Residents in the transitional program are, in most cases, planning to pursue careers in programs which require one year
of training prior to admittance, such as anesthesiology, diagnostic radiology and others.
“In Montana, they’ve started a residency program (in family medicine) in Billings because no one was coming back from WWAMI,” he says. WWAMI, a consortium for medical education that includes Washington, Wyoming, Alaska, Montana and Idaho is based at the University of Washington in Seattle.
“Twenty students a year, from Montana, go to the University of Washington, and there’s been a very low return” of these physicians coming back to Montana, he says. “That’s why it’s really important to have a residency program” in states where physician recruitment may be difficult.
“We have retained many more physicians in our state because we have residency training.”
Why do residency grads stay to practice?
“A resident gets to know the people they are working with – they know the doctors, and can refer people” to specialists and others with confidence, Hostetter says.
Also, “by the time most residents reach the end of their training, they’re at least seven years out of college; most have started a family” — important ties have been made, he adds. “The family is connected, the spouse is connected... the kids have been in the schools.”
Originally from Montana, he is an example of this, he says. “I was going to go back to Montana. I was a WWAMI student, and was planning to practice in Miles City.” Instead, after taking residency training at the UND Center for Family Medicine in Bismarck, he and his family decided to stay.
When he completed family medicine training, his children were well-ensconced in school and their youngest, a little adopted Chinese girl, had built a very supportive group of friends. The idea of uprooting and moving the family to Montana, “I was not going to do that to them,” he says. “But that was not the initial plan when we came for residency here.”
According to Sticca, “residents who take training here – they may not even be North Dakota residents (when they begin training) – have a tendency to stay here.”
As a recent example, he points to Robin Hape, M.D. ’02 (Surgery Residency ‘07), originally from Montana, who joined Altru Health System in Grand Forks after completing five years of general surgery training this summer.
One quarter of the general sugeons currently practicing in North Dakota are graduates of UND’s program.
Nationally primary care less attractive
The downturn in medical students’ interest in pursuing careers in primary care (family medicine, general internal medicine and general pediatrics) is a widespread concern in North Dakota and “is clearly a trend,” says Newman. “Trends tend to be cycles of duration. This trend began in the mid-1980s, and it is really driven by lifestyle.”
Interest in family medicine – a field noted for long workdays, more on-call obligations, relatively lower compensation and the need to keep up-to-date on an array medical fronts — has declined in the past nine years, leaving many to wonder and worry about who will provide broad, general care for the swelling ranks of retired babyboomers in years to come.
Recent surveys of medical students reveal that, while compensation is a consideration, it’s not the most compelling factor in students’ choice of specialty. Lifestyle is number one, Newman says; compensation is two, and the inherent qualities of the specialty is three.
“Lifestyle is now a key feature in how (students) choose” their career, Newman says. Unlike physicians of yesteryear, today’s students are increasingly unwilling to sacrifice personal interests and family time for the sake of their careers.
And “primary care is more difficult,” he says. “You spend more time with the patient and more time with the family, in an increasingly bureaucratic and recalcitrant health care system.
“This really discourages students” from going into primary care, he says. “Students aren’t stupid; they see what’s going on.” They see that other fields of medicine offer more attractive characteristics such as higher earning potential, less on-call requirements and more control over one’s work schedule.
These trends have undoubtedly contributed to the national decline in the popularity of primary care specialties, but “it’s not just us (North Dakota) — I think that gets lost sometimes,” Hostetter declares. “It’s a national debate... It’s a big problem and nobody has a solution for it.”
Debt vs. compensation
Nationally, on average, medical students rack up debt approaching $150,000 by the time they earn the Doctor of Medicine (M.D.) degree, Hostetter says. (At UND, average indebtedness of graduates of the M.D. Class of 2007 is $140,400.)
At the same time medical school debt has been rising, reimbursement for primary care physicians has been decreasing, he observes. “A student may be considering primary care but, after looking at the numbers – how much they’ll have to earn just to pay back loans and to pay 30 to 40 percent of their salary in taxes — primary care becomes less and less practical for a lot of people to consider.”
Students take into account variations in compensation when considering what specialty to pursue. And, while North Dakota ranks in the upper tier of states in terms of salaries paid to primary care physicians, it remains a crucial priority to attract and retain such doctors, especially in rural areas.
“Practicing family medicine in North Dakota is wonderful,” says Kim Krohn, M.D. ‘96 (Family Medicine Residency ‘99), director of the UND family medicine residency in Minot. “We earn an adequate salary that is comparable to the rest of the country... Family physicians practicing elsewhere in the U.S. may have a less-busy practice, because of restrictions on their scope of practice.
“Many in academic medical education think we should bring more money and other resources to bear on the problem... We hate to see people go into (a particular) field of medicine because of financial pressure.”
Why choose family medicine?
“There’s really a feeling of authenticity among those who choose family medicine,” says Krohn. “Some think it may be more satisfying to go into a subspecialty - where they deeply embrace the depth of knowledge of a field... But there’s the sense that you’re not a whole doctor...
Students interested in family medicine “may have more public-health background,” she observes. “They see the public health impact, down to the individual. They see the family members in the (patient’s) care and the consideration of care.
“They have an appreciation for a more global scope of medicine.”
For herself, as a medical student, she says, “I had really low awareness of the variations in compensation (for different specialties). I was looking for a profession that would be fulfilling and rewarding, and would help me reach the goals I had in life.”
In the Upper Midwest, probably more than other region, “it is easier to practice primary care,” she says, “there’s a great respect for primary care.”
Providing family medicine training here “is extremely important because we have a large number of openings for family physicians in our state,” she says. “Our programs are very good and our graduates can go anywhere they want” to establish their practice.
“We need more of them than we can train.”
Whether the decline in interest in primary care is a trend or a cycle, Krohn says, “medicine and health care are always in evolution... Employers are still trying to hire primary care physicians.”
A physician who really knows you
“The patients we have really express the value of having a physician who really knows them and really knows our parts,” she explains. “Patients also like the idea of having the technology and the subspecialists right next door, when they’re needed.”
No matter what influences affect the viability of this field of medicine, she says, “I think there will always be a role for primary care.”
-Pamela D. Knudson
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