General Internal Medicine (GIM) is a unique field that offers a range of possibilities for career fulfillment through varied clinical settings and focus areas such as medical education, informatics, health services research, policy, and administration. Multiple factors have impacted the landscape of general medicine careers and the pathways that trainees pursue post-residency. Hospitalists have emerged as the fastest growing group of practicing physicians in the United States.1 Gray, et al, reviewed the American Board of Internal Medicine (ABIM) board certification database and reviewed general internists certified between 1990-2017 who did not pursue fellowship as of 2020.1 The authors found that as of 2018, 71% of newly certified generalists practiced hospital medicine, 21% mixed practice, and 8% outpatient only. While 21% were identified to do mixed practice, the retention rate was 57% v. 86% for hospitalist v. 95% for outpatient only. Fewer newly certified internists are selecting outpatient-only practice; however, the retention rate was 95% for those selecting this practice type. There is a need to explore solutions to build and sustain the nation’s primary care infrastructure. In addition to preparing the primary care workforce of the future, it is equally important that we promote the field of Academic GIM. Academic generalists play key roles in research, education, leadership, patient safety, information technology, and clinical care. However, many residents are not aware of the breadth of a generalist career. Many recent graduates are interested in career variety and have an increased awareness of work-life balance. We took a multi-pronged approach to grow interest in GIM. We will highlight the following areas: enhancing our Primary Care (PC Track), identifying a chief resident champion, and creating diverse job opportunities in general internal medicine.
Enhancing Our Primary Care Track
We aimed to enhance our PC Track by developing a Primary Care Scholars program to expose residents early in training to facets of an academic generalist career. The PC Track at Wake Forest University was established as a separate training program in 1986. Up to four medical students are competitively accepted into the three-year program through the National Residency Matching Program for a maximum of twelve PC Track residents.
Our redesign focused on four main priority areas: mentorship, networking, scholarship, and enhanced clinical experience with some opportunities supported by a donor fund. Each PC Track scholar is paired with an academic generalist mentor who provides clinical and career mentorship. The scholars meet quarterly with academic GIM faculty for a journal club and at a faculty’s home for a combined medical student, resident, GIM faculty, and GIM leadership networking event. Scholarly work in the form of Clinical Vignettes is developed in partnership with their mentor to present locally at our residency Research Day and to submit to the North Carolina American College of Physicians (ACP) meeting and nationally to the Society of General Internal Medicine (SGIM). In addition, all Primary Care Scholars attend a National SGIM meeting during their intern year to see firsthand the opportunities and breadth for Academic GIM scholarship. The PC Track residents have an enhanced continuity clinic experience across two sites allowing them to provide care at an under resourced clinic and an academic private practice clinic. Since the initiation of the program in 2017, we have had an increase of residents interested in generalist careers and academic medicine. We have had 4 Academic GIM, 1 Academic Hospitalist, 2 Academic Geriatrics and 1 Academic Obesity Medicine which is 36% of the PC track residents. In total, we have had 68% pursue generalist careers (Academic GIM, Primary Care, Academic Hospitalist, Hospitalist, Geriatrics) and 32% pursue fellowships (Obesity, Nephrology, Hematology/Oncology, and Gastroenterology).
Chief Resident Champion
As an academic medical center, there is a lot of pressure for residents to pursue subspecialty training. There has also been a decline in interest in primary care over the past 25 years.2 With success in recruiting strong residents in our PC Track, many became candidates for a chief resident position allowing us to elevate the PC Track as they rose to leadership positions. Chief residents as leaders and advocates for generalist careers can be a powerful driver of interest in generalist careers in the residency program. The creation of the role of ambulatory chief resident can be a good way to sustain this role. However, just identifying one of the chief residents to take on this role can be very important. If they are invested in PC Track, they enhance resident clinic experience which can be a big driver of maintaining interest in primary care. Kryzhanovskaya, et al, looked at primary care residencies supported by Health Resources and Services Administration (HRSA) and found that 35% of primary care residency alumni lost interest in primary care due to their continuity clinic experience.3 In addition, the chief resident adds things to the general curriculum that emphasize ambulatory care and general medicine topics which increases exposure to all residents. This role has also been a good avenue of recruitment for these chief residents to a career in academic GIM. It has allowed them to interact with GIM faculty and see the opportunities in a generalist career.
Creating Job Opportunities in General Internal Medicine
The approach to career building and recruitment process for the general medicine section has also been important to increasing interest in generalist careers and Academic GIM. The section has a strong retention rate with minimal turnover and has been expanding yearly. Many new faculty have come internally from our residency program. Therefore, section morale is high, and faculty have strong job satisfaction. There is also a sense of collegiality, mutual respect, and support among faculty in the section. Simpkins, et al, looked at physician wellness and found that respect and sense of value for employees outweighed compensation and financial incentives for job satisfaction.4 Another key principle we found important in our section has been allowing faculty to balance careers to allow them to explore both medical education opportunities, informatic roles, research interest, or leadership positions while maintaining clinical duties. Career satisfaction and allowing faculty to explore interests has been important in faculty maintaining enthusiasm for teaching, mentoring learners, and mentoring junior faculty. This also has decreased burnout and enhanced the joy of practice.
In conclusion, exposing residents early to the opportunities of a generalist career and an academic career is key to expanding the breadth and depth of the pool of generalist clinicians, educators, and researchers. Our reengineered PC Track provides a Scholars Program through enhanced mentorship, networking, focus on scholarship and clinical experiences to promote Academic GIM careers. Early feedback and career choice data suggest this may be an effective model to expose residents to the breadth of opportunities in GIM early in their training. In addition, it is paramount to this mission to create a strong culture of general medicine through ambulatory chief residents and supported GIM faculty.