Researchers at Johns Hopkins have found that how training is organized for doctors-in-training might impact their decision to go into primary care. The study, appearing online today in the Journal of General Internal Medicine suggests that a significant number of primary care internal medicine residents pursue careers in primary care, but perhaps could be more positively influenced if institutions paid more attention to how training is structured.

“There is strong evidence that having more primary care physicians leads to better health outcomes and decreased health care costs for society,” says Paul O’Rourke, M.D., M.P.H., an assistant professor of general internal medicine at the Johns Hopkins University School of Medicine and lead author of the study. “The United States is facing a primary care physician shortage, and while primary care internal medicine residency programs have expanded over the past several decades to accommodate the training of more primary care physicians, we don’t know how successful those programs are at actually producing graduates who commit to the field.”

To begin to understand how internal medicine primary care residents decide to pursue a career in primary care, O’Rourke and colleagues surveyed 100 internal medicine primary care residency program directors across the country and asked about training program characteristics, curricula, clinical training experiences and graduate outcomes. They then analyzed the data to identify which of these characteristics are associated with programs where more than half of graduates pursued primary care.

There are more than 400 internal medicine residency programs across the country, says O’Rourke, but only about 100 of them offer specific primary care tracks. These primary care tracks were first launched in the 1970s, he says, in hopes of increasing the primary care physician workforce, and more programs have been launched since. Of the 100 primary care residency program directors surveyed, 70 responded. About 57 percent of internal medicine primary care residency graduates go directly into primary care. The primary care residency program at Johns Hopkins Bayview Medical Center, where O’Rourke practices, is one of the oldest in the country, and over the last two years has seen 100 percent of graduates pursue primary care careers.

Analysis of survey data revealed that scheduling of patient care time was the one factor that appeared to be associated with whether or not programs were successful in graduating primary care physicians. The so-called X+Y scheduling, where X refers to hospital training time treating inpatients and Y refers to time spent in clinics outside hospitals treating ambulatory patients, seems to be negatively associated with choosing a career in primary care.

Historically, says O’Rourke, most internal medicine training was done in hospitals with the inpatient populations, with residents spending a half-day each week at an outpatient clinic. But in recent decades, programs changed to incorporate more outpatient training opportunities in various ways. Some programs utilized X+Y scheduling in which residents would spend a block of weeks in the hospital, then a block of weeks in clinics off-site. “It was thought that this Y-block immersion would bring more joy to the outpatient setting and pique more interest in the primary care path, but our data don’t seem to support that.”

But O’Rourke wouldn’t recommend scrapping X+Y just yet.

“Even in light of these results, just this one study wouldn’t convince me to forgo X+Y,” he says. “The most important thing is to provide quality outpatient training to better prepare trainees for a career in primary care.”

Other authors on the paper are Eva Tseng and Scott Wright from Johns Hopkins, Karen Chacko of the University of Colorado School of Medicine, Marc Shalaby of the Perelman School of Medicine at the University of Pennsylvania, and Anne Cioletti of The University of Texas at Austin Dell Medical School.

This study was funded by the Johns Hopkins University School of Medicine. Wright is the Anne Gaines and G. Thomas Miller Professor of Medicine, which is supported through the Johns Hopkins Center for Innovative Medicine.


Current residents and recent graduates from the Johns Hopkins Bayview Internal Medicine Residency Program:

• Deborah Freeland, M.D.

• Karla Kendrick, M.D.

• Jarratt Pytell, M.D.

• Orion Courtin, M.D. at MedStar Health Geriatrics

• Amanda Rosecrans, M.D.

On the Web: 

• General Internal Medicine