Why Aren’t More Primary Care Residents Going into Primary Care? A Qualitative Study

Abstract

BACKGROUND:Workforce projections indicate a potential shortage of up to 31,000 adult primary care providers by the year 2025. Approximately 80 % of internal medicine residents and nearly two-thirds of primary care internal medicine residents do not plan to have a career in primary care or general internal medicine. OBJECTIVE: We aimed to explore contextual and programmatic factors within primary care residency training environments that may influence career choices. DESIGN: This was a qualitative study based on semistructured, in-person interviews. PARTICIPANTS: Three primary care internal medicine residency programs were purposefully selected to represent a diversity of training environments. Second and third year residents were interviewed. APPROACH: We used a survey guide developed from pilot interviews and existing literature. Three members of the research team independently coded the transcripts and developed the code structure based on the constant comparative method. The research team identified emerging themes and refined codes. ATLAS.ti was used for the analysis. KEY RESULTS: We completed 24 interviews (12 secondyear residents, and 12 third-year residents). The age range was 27-39 years. Four recurrent themes characterized contextual and programmatic factors contributing to residents' decision-making: resident expectations of a career in primary care, navigation of the boundary between social needs and medical needs, mentorship and perceptions of primary care, and structural features of the training program. CONCLUSIONS: Addressing aspects of training that may discourage residents from careers in primary care such as lack of diversity in outpatient experiences and resident frustration with their inability to address social needs of patients, and strengthening aspects of training that may encourage interests in careers in primary care such as mentorship and protected time away from inpatient responsibilities during primary care rotations, may increase the proportion of residents enrolled in primary care training programs who pursue a career in primary care.

How Influences on Residency Choice Change Through Medical School

“…One published work observed that status among peers was considered important by more than 40% of fourth-year medical students (Osborn, et al, 2017). In another, residents noted that there was a cultural sense that primary care medicine lacked the prestige of other specialties (Long, et al, 2016), especially by other physicians who viewed general medicine negatively. This highlights the need for mentors and faculty who not only practice primary care medicine, but who are able to convey to their students the positive aspects of pursuing primary care early on in the student's training, which can include the opportunity to impact a patient's total health by establishing a doctor-patient relationship.…”

A National Survey of Internal Medicine Primary Care Residency Program Directors

“…22 A recent qualitative study examining such factors discovered that more patients seen‚ a diversity of outpatient experiences, and supportive resources that address social determinants of health all positively influence the pursuit of primary care careers among trainees. 23 Not surprisingly, scheduling models that limit inpatient and outpatient conflict for residents may translate into greater resident satisfaction with their training. 24 X + Y scheduling, a model that schedules residents' inpatient or non-ambulatory rotations (BX^blocks) in discrete periods with alternating ambulatory or BY^blocks, is instituted specifically to decrease the conflict between inpatient and outpatient patient care responsibilities.…”

Capsule Commentary on Thorp et al., Implementation of 2011 Duty Hours Regulations Through a Workload Reduction Strategy and Impact on Residency Training

“…3 In addition to the single-center study design, interpretation of the findings may be confounded by institutional modifications impacting patient outcome measures. In our era of the Affordable Care Act (ACA) and the primary care crisis, 4 addressing inpatient and ambulatory training disparities is fertile ground for research and innovation. This study helps us recognize the impact of workload reduction on resident experience, but does not analyze ultimate career determinations.…”