Internists worried as concern about general medicine's future spreads

As family medicine licked its wounds following a dismal first round of the 2003 residency match, some other specialties started doing the same.

Halifax internist Sander van Zanten says the recruiting problems facing family medicine, which saw 29% of its residency slots go unfilled in February (CMAJ 2003;168[7]:881-2), are spreading. “We are heading for a crisis in general care,” he says, with fewer doctors choosing fields such as general internal medicine and general surgery. This year, about 15% of general surgery residencies were vacant after the first round of the match.

Van Zanten, who recently stepped down as director of the core program in internal medicine at Dalhousie University, said a tiny fraction of internal medicine residents now pursue careers as generalists, and the results are being seen in Nova Scotia. “General internists are being run ragged here — they don't have time to breathe.”

He said internal medicine residents almost invariably choose a subspecialty after their third year of training, probably because subspecialists concentrate on specific problems while generalists provide “very labour intensive and very complex care.” The need may be greatest in the latter area, said van Zanten, but the glory is in the former.

He warns that the fallout from general medicine's declining prestige will be felt throughout medicine, but particularly in community hospitals where generalists handle most patient care.

Dr. George Goldsand, a former dean of postgraduate medicine at the University of Alberta, agreed that general internal medicine appears to have lost its lustre. “What we're seeing is that when it comes time to fill R-4 positions, not many people are applying for general medicine,” he said.

One factor is concern about the amount of knowledge generalists must retain. “Many people are very concerned about trying to remain current in such a vast field,” he said, and as a result subspecialties — and their narrower focus — look more appealing.

The president of the Canadian Anesthesiologists' Society (CAS) says general medicine, and family medicine in particular, won't start overcoming their problems until they can paint a more positive picture for potential recruits.

Dr. John Scovil of Saint John, NB, says anesthesia programs learned this the hard way 6 years ago when 20% of its residency slots went unfilled. “We recognized that we were getting in serious trouble. As it was, we didn't think we had enough positions to meet future demand, and things would only get worse if we couldn't even fill the spots we did have.”

Scovil said the CAS realized it had to change its focus from practising physicians, particularly GPs who wanted to re-enter training, to undergraduate students, and this meant every anesthetist had to make a sales pitch when students spent time with them during clerkships. This appears to have paid off, because all 69 positions in anesthesia were filled in 2003.

“Once the students are in the OR, they see pretty quickly if you're happy at your job,” he said. “And right now morale in anesthesia is pretty good. It offers a good lifestyle, maternity [plans], no overhead costs and good mobility, and students see that.

“Frankly, if I was a medical student today I'd be a little scared if I was looking at family medicine as a career. All you hear about is primary care reform, and the students have to be wondering what they would be getting in to. You also have to wonder how happy their role models are, because they are living through these reforms.”

Dr. Lynne McLeod, cochair of a Promotion of the Specialty Committee created by the Society of Obstetricians and Gynaecologists of Canada, says there is no simple solution to the problems facing family medicine recruiters. When a quarter of obstetrical slots remained unfilled 4 years ago, “one of our main efforts was to recognize that students are choosing their career paths very early. Now we're trying to give students a better experience at the clerkship level, and we're also trying to increase exposure for the Med 1s and 2s.” This year, 48 of 49 spots were filled in the first round of the match.

The recruiting effort now extends to career nights and to having students shadow a practising obstetrician/gynecologist. “We think this 1-on-1 mentorship is crucial,” said McLeod, who practises at Mount Sinai Hospital in Toronto. “I also think we realized that it wasn't the medical students who were the problem, that maybe it was the specialty itself.” — Patrick Sullivan, CMAJ