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J Gen Intern Med. 2001 Dec; 16(12): 860–863.
PMCID: PMC1495307

Impact of a First-year Primary Care Experience on Residency Choice

Martha S Grayson, MD,1,2 Martin Klein, PhD, MPH,1 and Kathleen B Franke, MPH1

Abstract

We designed a retrospective cohort study of first-year medical students to assess the impact of a community-based primary care course, Introduction to Primary Care (IPC), on residency choice. In the group that took IPC (n = 282), 48.2% entered generalist residencies (internal medicine, pediatrics, family medicine, or medicine/pediatrics), compared to 38.2% in the group that wanted IPC (n = 398) and 39.6% in the group that did not want IPC (n = 245). Controlling for gender, students who took IPC had a 40% higher odds of selecting a generalist residency than those who wanted to take IPC (odds ratio [OR], 1.42; 95% confidence interval [CI], 1.04 to 1.95). There was no difference between those who wanted IPC and those who did not (OR, 1.08; CI, 0.78 to 1.52). The community-based primary care experience was positively associated with students' selection of generalist residencies.

Keywords: career choice, community-based training

Maintaining the number of medical students who enter primary care careers remains a national priority.1,2 Although there was a marked increase in the percentage of students choosing generalist residencies during the mid 90s, this percentage peaked at 56% for the class of 1997, and has steadily declined for the subsequent graduating classes.3 Several factors, such as student demographics, student-held values, career preference at matriculation, and the medical school curriculum have been cited as influences on student career choice.4,5

In an attempt to stimulate more interest in generalism, many medical schools have instituted curricular innovations that increase student exposure to primary care physicians. Studies on the impact of these educational interventions on career choice have been conflicting. While literature reviews on the effect of experiences during the clerkship years have revealed an increase in primary care career choice if there is a required third-year family medicine clerkship, the literature on preclinical primary care experiences has been inconclusive, with multiple confounders.6,7 The vast majority of studies of preclinical primary care experiences have had a self-selected group of students with a greater baseline interest in primary care prior to the educational experience.8,9

To determine which types of preclinical primary care courses might have the greatest impact on student residency choice, it would be useful to compare students with similar interest in participating in the primary care experience prior to the educational intervention. The purpose of our study was to determine the effect of an elective first-year longitudinal primary care experience on residency selection. We hypothesized that first-year students who participated in this experience would be more likely to choose a generalist residency than students who wanted this experience but were closed out.

METHODS

Study Population

During the 6 academic years of this study, 1988–89 through 1993–94, all New York Medical College (NYMC) first-year students chose 1 elective course from among a half-dozen courses, including Introduction to Primary Care (IPC). In each of these years, the number of students wanting IPC exceeded the available number of placements and students were randomly selected via a lottery. Through this selection process, 3 groups were formed (N = 925): the students selected for IPC (Selected, n = 282), students who wanted but were not selected for IPC (Not Selected, n = 398), and students who chose another elective (Did Not Want IPC, n = 245). Demographic data were collected for the sample, and students were matched to their PGY-1 residency choice. An additional 161 students who withdrew or were dismissed from NYMC (n = 94), or whose records did not indicate whether they were not selected or did not want IPC (n = 67) were excluded from the study sample.

Curriculum

Introduction to Primary Care consisted of 10 three-hour sessions in the office of a community-based primary care physician and 7 half-day lectures and small-group sessions on the NYMC campus. A student manual provided detailed objectives for each unit, a review of the topic, selected readings, and specific tasks to perform in the preceptor's office. The 7 curricular areas were: introduction to clinical skills, patient education, health care teams, health maintenance, ethics, cultural determinants of health care, and food and nutrition. Full-time primary care faculty led lectures and small group sessions. (Unit objectives are available at http://www.nymec.edu/medical/general.htm#primcaredocs. For a copy of the complete course manual, please contact Dr. Grayson.) Although students did not do direct patient care or treatment, they did observe what primary care practice entails and participated in guided exercises to experience some facets of the physician-patient relationship. In addition, the didactic portion of the course gave students a solid foundation in generalist competencies, many of which are useful regardless of ultimate specialty choice.

For the study years, 50% of the preceptors were internists, 33% were pediatricians, 16% were family physicians, and 1% specialized in medicine-pediatrics. Preceptors were drawn from a 9-county area, encompassing New York City, its suburbs, and several rural counties. Practices spanned all ethnic and income groups. Preceptors received no monetary payment, but did receive faculty appointments, CME credit for faculty development courses, and library privileges.

Data Analysis

Gender, race, and age were evaluated as potential confounders in the relationship between IPC status and residency choice. Demographic data were available for all participants, with the exception of race (2.6% missing). These data were obtained from the NYMC student database. Race and age were dichotomized as nonminority and minority, and below the median age and equal to or above the median age, respectively. The dependent variable, PGY-1 specialty choice, was obtained from the National Residency Matching Program and dichotomized into generalist residencies (internal medicine, pediatrics, medicine-pediatrics, and family medicine) and nongeneralist residencies (all other specialties). Because a significant percentage of residents in categorical residencies plan subspecialty careers, we also performed a secondary analysis dichotomizing the dependent variable, PGY-1 residency choice, into primary care residencies (primary care internal medicine, primary care pediatrics, and family medicine) versus all other residencies.

Frequencies were generated for all variables. The 3 groups (Selected, Not Selected, Did Not Want IPC) were examined for differences in gender, race, and age using the likelihood ratio χ2test. To assess whether IPC status, age, race, and gender were associated with residency choice, 2 × 2 table testing was used to determine whether the proportion of students who entered generalist residencies differed between the IPC groups, gender, race, and age categories.

Bivariate testing between IPC status, categorical student descriptors (gender, race, and age) and residency choice was performed and presented as unadjusted odds ratios together with 95% confidence intervals and χ2P values. Using a forced entry logistic regression procedure, the impact of IPC on residency choice, while controlling for variables found significant in the bivariate analysis, was explored. Odds ratios, χ2likelihood ratio P values, and 95% confidence intervals for the regression coefficients of each variable in the model were computed to quantify their adjusted impact on residency choice.

RESULTS

A total of 385 students (41.6%) entered generalist residencies. In the group that was selected for IPC, 48.2% entered generalist residencies, compared to 38.2% in the group that was not selected for IPC and 39.6% in the group that did not want IPC (Table 1) The median age of the sample was 23, 67% were male, and 9% were members of underrepresented minority groups.

Table 1
Specialty Choices of Students by Course Status

There were no significant differences in the 3 groups by gender, race, and age. The relationship between IPC status and PGY-1 residency choice was significant (P < .05) in bivariate analysis (Table 2) The odds of entering a generalist residency were 50% higher among the students who were selected for IPC compared to students who were not selected for IPC (odds ratio [OR], 1.51; 95% confidence interval [CI], 1.11 to 2.05). There was no difference between students who were not selected for IPC and those who did not want IPC (OR, 1.09; 95% CI, 0.79 to 1.51). Of the remaining independent variables, being female was associated with generalist residency choice (OR, 1.68; 95% CI, 1.28 to 2.22) while race and age were not associated with specialty choice.

Table 2
Factors Associated with Selecting a Primary Care Residency

In the logistic model, only the variables significant in the bivariate analysis, IPC status and gender, were included. Controlling for gender, the association between students who took IPC and generalist residency choice persisted. Students who were selected for IPC had a 40% higher odds of selecting a generalist residency than those not selected for IPC (OR, 1.42; 95% CI, 1.04 to 1.95); again there was no difference between those not selected for IPC and those who did not want IPC (OR, 1.08; 95% CI, 0.78 to 1.52). Being female continued to be associated with selecting a generalist residency (OR, 1.70; 95% CI, 1.28 to 2.26).

Results of the secondary analysis of the 70 students entering the primary care residencies of family medicine, primary care internal medicine, or primary care pediatrics were similar to our results for the generalist residencies. Of the students selected for IPC, 10.6% entered primary care residencies; 5.3% of students who were not selected for IPC entered primary care residencies; and 7.8% who did not want IPC entered primary care residencies. An unadjusted χ2analysis of these results was significant at the 0.05 level.

DISCUSSION

We found that a community-based primary care experience in the first year of medical school was positively associated with students' selection of generalist residencies. Using students who wanted to take IPC but were not selected as the primary control group, we found a significant association between taking IPC and entering a generalist residency. This finding is similar to that of Radecki et al.,10 who found an association between a primary care preclinical experience and selecting a primary care specialty at graduation. On the other hand, the results differ from those of Herold et al.,11 who found that students' initial desire to participate in a longitudinal primary care training program was more predictive of specialty choice than participation in the experience. In addition, we found that the specialty choices of the group that wanted but did not get IPC were not different from the group that did not want IPC, suggesting that medical school socialization reduced student interest in generalist residencies for those who initially wanted a primary care experience.

This study had several limitations. First, it was conducted at a single medical school, raising issues of generalizability. Second, PGY-1 residency choice was used as a proxy for career choice, and therefore did not take into account the possible differential effects of attrition to subspecialties. A recent study of the posttraining plans of U.S. medical graduates (USMGs) and international graduates in New York State found that 36% of USMGs in internal medicine in 1999 intended to subspecialize and 19% of pediatrics residents intended to subspecialize.12 Although our secondary analysis of students entering primary care residencies, in which the attrition rate into subspecialties is much lower, confirmed our results, this analysis was based on a relatively small number of students. Finally, we recognize that there may be other unmeasured differences among the 3 groups that might have had an effect on ultimate career choice. For example, we did not assess and, therefore, could not control for pre-rotation career plans.

The results of this and other studies raise important questions for educators. With increasing demands on medical student and faculty time, coupled with decreasing resources, it is important to determine which elements of primary care training impact most significantly on career choice and clinical competency. Research issues to be addressed include: the timing of courses within the medical school curriculum; the length and duration of primary care experiences; the effectiveness of block versus longitudinal experiences; the influence of preceptor specialty on career choice and primary care skills; and the relative impact of various curricular elements. The medical education community has made a substantial and laudable commitment to educating students in community-based settings. As more of these experiences are evaluated and studied, answers to these important and pivotal questions are likely to emerge.

Introduction to Primary Care was started with the twin goals of encouraging students to enter primary care careers and providing students with a basic introduction to the principles of primary care practice. These goals remain as relevant today as they were when the course was launched over 10 years ago. The growth of preclinical generalist courses promises to both enrich the educational experience of students and offer new laboratories in which to test and evaluate primary care training programs. In at least one case, we know that a modest commitment of time has produced significant effects.

Acknowledgments

The authors thank Katherine Hudson for her analytic support throughout this project.

This research was funded by New York Medical College and a grant from the Robert Wood Johnson Foundation's Generalist Physician Initiative.

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