McIntosh EW, Morley CP. Family Medicine or Primary Care Residency Selection: Effects of Family Medicine Interest Groups, MD/MPH Dual Degrees, and Rural Medical Education. Fam Med 2016;48(5):385-388.
Family Medicine or Primary Care Residency Selection: Effects of Family Medicine Interest Groups, MD/MPH Dual Degrees, and Rural Medical Education
Elizabeth Wei McIntosh; Christopher P. Morley, PhD, MA
Background and Objectives: If medical schools are to produce primary care physicians (family medicine, pediatrics, or general internal medicine), they must provide educational experiences that enable medical students to maintain existing or form new interests in such careers. This study examined three mechanisms for doing so, at one medical school: participation as an officer in a family medicine interest group (FMIG), completion of a dual medical/public health (MD/MPH) degree program, and participation in a rural medical education (RMED) clinical track.
Methods: Specialty Match data for students who graduated from the study institution between 2006 and 2015 were included as dependent variables in bivariate analysis (x2) and logistic regression models, examining FMIG, MD/MPH, and RMED participation as independent predictors of specialty choice (family medicine yes/no, or any primary care (PC) yes/no), controlling for student demographic data.
Results: In bivariate x2 analyses, FMIG officership did not significantly predict matching with family medicine or any PC; RMED and MD/MPH education were significant predictors of both family medicine and PC. Binary logistic regression analyses replicated the bivariate findings, controlling for student demographics.
ConclusionS: Dual MD/MPH and rural medical education had stronger effects in producing primary care physicians than participation in a FMIG as an officer, at one institution. Further study at multiple institutions is warranted.
(Fam Med 2016;48(5):385-8.)
Endemic and ongoing shortages exist in the US primary care (PC) workforce.1,2 However, potential interventions exist that may help improve the flow of medical students into PC specialties (ie, family medicine, pediatrics, or internal medicine), ranging from targeted admissions policies, debt forgiveness, longitudinal ambulatory care exposure, and other approaches.
Interventions designed to foster student interest in PC careers during medical school are important to consider, as student interest in PC tends to decline over the course of medical school.3-5 One approach intended to foster medical student interest in family medicine, specifically, is the formation and funding6 of student Family Medicine Interest Groups (FMIGs). However, the FMIG approach has yielded both positive7-10 and more equivocal11 results.
Other opportunities exist to indirectly foster student interest in primary care, through programs that do not have PC or family medicine production as a central goal. For example, dedicated rural medical education (RMED) tracks have a deeply intertwined relationship with PC (and particularly family medicine) output.12-18 Given increased attention to the integration of primary care and public health education,19-23 opportunities to foster PC interest may also exist in joint Medical Doctor/Master of Public Health (MD/MPH) programs. However, no published studies appear to have focused on relationships between joint MD/MPH and family medicine or PC selection. The current study examined the relative effects of FMIG, RMED, and combined MD/MPH training on family medicine and PC residency matching outcomes at one institution.
Context and Subjects
This study retrospectively examined anonymous medical student data from one institution, ranging from 2006–2015, and was granted an exemption from review by the appropriate institutional review board. Analyses were conducted in SPSS v.22.
Residency match was coded into two binary (1,0) variables, representing matching with family medicine or any PC specialty. Any PC specialty was coded as matching in family medicine, internal medicine, pediatrics, or combined internal medicine-pediatrics. Internal medicine and pediatric matches were checked for secondary residencies, and any that listed non-PC specialties were coded as not matching with PC (0).
Three educational programs were also coded as binary variables:
• The FMIG at the subject institution is a student-run club of 12 officers that organizes monthly lunch talks, community service events, and networking dinners. Attendance is open to all students, and no formal membership roster exists. Therefore, the only FMIG participation data available for the study were for those who held positions as FMIG officers.
• The RMED program at the study institution program consists of a 9-month clinical experience at a rural site during years 3–4 of medical school, incorporating family medicine clerkship with other non-PC clerkships. It was expanded in 2010 to include preclinical monthly seminars and a shorter 3–5 month clinical experience alternative. All students who participated in the rural clinical experience were counted as RMED participants. We also included a categorical variable to measure the effect of being in the long (traditional) versus short version of the program.
• The 5-year dual MD/MPH program at the target institution requires 1 extra year of coursework in between MS2 and MS3. All students who completed the MPH requirements prior to graduation with the MD and MPH degrees were counted as participants. The program began in 2010 and graduated its first students in 2012.
Chi-squared (x2) analyses were conducted to assess bivariate relationships between family medicine or PC selection and FMIG, MD/MPH, and RMED participation (as both any RMED participation and as traditional versus short program participation). Binary logistic regression was used to calculate minimally adjusted odds ratio (OR) for each outcome, via models that only included variables representing each program. Adjusted odds ratios (AOR) were calculated through models that included the three program variables, controlling for student characteristics (age >30, race, Hispanic ethnicity, graduation year, and gender).
We analyzed records of 1,473 students who graduated from the subject institution from 2006–2015. A breakdown of program participation and specialty matches is presented in Table 1.
Similarly, binary logistic regression analyses (Table 3) revealed no association between FMIG leadership and matching with family medicine or any PC specialty. Family medicine matching was strongly predicted by both RMED (OR= 27.451, P<.001; AOR=25.768, P<.001) and MD/MPH participation (OR= 26.763, P<.001; AOR=19.702, P<.001), and both programs were predictive of matching in any PC specialty as well. Participation in the “Traditional” 9-month RMED course was more predictive of both family medicine and PC matching than participation in the “Short Course” (P<.001 for all values; see Table 3 for odds ratios).
Despite the commitment of financial support from the American Academy of Family Physicians to FMIGs,6 serving as an officer in the FMIG does not often appear to lead to family medicine specialization at the one institution examined in this study. Participation in programs not explicitly designed to produce family medicine or PC physicians had much stronger associations with family medicine and PC specialization. While a recent study by Kost et al found that FMIG participation was linked to family medicine specialization at another institution, participation in other activities, such as a rural underserved pathway, proved to have a stronger association with choice of family medicine in our study.24
There are several limitations of this study. First, we examined only one institution. Additionally, FMIG officership is not the only means of FMIG participation. It is probable that participation (other than as an officer) in FMIG activities has effects we could not measure. Additionally, the MD/MPH program at the study institution is relatively small and new. Only 10 students had completed the MPH portion of the program at time of analysis; one did not complete the MD and was not included. Of the nine remaining, six matched in family medicine and one each in pediatrics and internal medicine. The remaining MD/MPH student matched in obstetrics and gynecology. While data for this program are limited, the results suggest MD/MPH training to be a robust source of primary care recruitment. Additionally, there appears to be some relationship between the length of RMED participation and likelihood of family medicine or PC choice. This study was not designed to determine whether this is a dose-dependent effect, or if it is a manifestation of self-selection, with students who are more inclined to enter family medicine or PC tending to select the longer rural training course. Given both these results and limitations, this study should be repeated across multiple institutions and program types.
In designing strategies to increase the production of family medicine physicians, it is important to consider the broader interests of those who may be most interested in a primary care career. These may not be clearly stated as interests in family medicine or PC; interest in rural or public health training may be two examples of other interests that are linked to family medicine/PC specialization. The current study is not a final answer but is indicative of the need to examine PC recruitment and production strategies that go beyond the immediately obvious.
Acknowledgments: Funding Statement: This project was partially supported by the Health Resources and Services Administration (HRSA) of the US Department of Health and Human Services (HHS) under grant D54HP23297, “Administrative Academic Units,” (Christopher P. Morley, PI/PD; total award amount for AY 2014 $154,765; approximately 95% of this project was funded by non-governmental sources). This information or content and conclusions are those of the author and should not be construed as the official position or policy of, nor should any endorsements be inferred by HRSA, HHS, or the US Government.
Presentations: Early data for the project were presented at the 2015 Society of Teachers of Family Medicine Annual Spring Conference and at the 2015 Annual Meeting of the North American Primary Care Research Group.
Corresponding Author: Address correspondence to Dr Morley, SUNY Upstate Medical University, Department of Family Medicine, 475 Irving Ave., Suite 200, Syracuse, NY 13210. 315-464-7010. email@example.com.
From the College of Medicine (Ms McIntosh) and Department of Family Medicine, Department of Public Health and Preventive Medicine, and Department of Psychiatry and Behavioral Sciences (Dr Morley), SUNY Upstate Medical University, Syracuse, NY.
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