Medical student intentions to practice internal medicine in ... - BMC Medical Education

We believe that this is the first national study focused on investigating potential factors influencing medical student intention to specifically pursue IM and work in MUAs. Our study had three major findings related to students interested in IM who also expressed an intention to practice in MUAs. These students were: 1) more likely to identify as NH Asian, NH Black/African American, or NH Unknown/Other race, 2) more likely to report extracurricular experiences centered on community-based research, health disparities, or global health, and 3) more likely to report greater debt loads ($100,000-$199,999 or > $300,000) and/or attainment of a scholarship. These findings confirm our initial hypothesis, but are especially striking when compared with some of our other findings, which showed students interested in IM overall were: 1) more likely to report lower debt loads, 2) less likely to identify as URiM, 3) less likely to report the above-noted extracurricular experiences, and 4) less likely to report interest in working in MUAs (as compared to the overall graduating medical student population).

Conducting this research study enabled us to identify experiences and characteristics that correlate with intent to practice IM in MUAs, and reinforced existing evidence examining characteristics of trainees pursuing practice in rural and urban MUAs. Based on the findings of our quantitative study, we call for specific actions by medical school leadership to promote capacity among their school's students to alleviate the ever-growing gaps in health care delivery in MUAs. Furthermore, we believe that our study findings can aid decisions promoting curricular redesign by medical schools to foster increased comprehension of health disparities, access to community-based research, and global health experiences. The current state of healthcare access disparities in the US combined with our study's analysis results suggests strongly that undergraduate institutions and medical schools should actively promote specific extracurricular opportunities to work in community settings and MUAs; solidifying existing evidence on a smaller scale indicating participation in MUAs as early as high school and as late as residency training is an independent predictor of intention to practice in MUAs [1, 18, 19].

Additionally, programs can look to previous medical training practices successfully implemented to increase the proportion of graduates who practice in medically underserved areas. One meta-analysis examining 130 studies of interventions found that attending a medical school or experiencing postgraduate training in an underserved area were positively associated with eventual practice in said areas [20]. Maximizing exposure to medical practice in MUAs early in the medical school experience by offering, promoting, and/or requiring community or global health volunteering and involvement among students could be a potent solution to address physician shortages in IM MUAs [19, 21].

Our findings support the notion that a more diverse medical school student body may result in more physicians practicing in MUAs. It is well understood that URiM physicians are more likely to want to serve members of their own ethno-racial population group, even after accounting for socioeconomic differences of the practice setting [1, 19]. By supporting URiM students through these interventions, medical institutions can play a tangible role in creating a more representative physician workforce better equipped to specifically address gaps in MUAs, consisting of patients in most need of healthcare.

We can also look to other medical specialties for successful measures implemented to recruit and retain a diverse physician population and practice in MUAs. One study examined the implementation of a four-year extracurricular experience during medical school that included dedicated clerkship, mentoring, and scholarly projects focused on underserved populations and found a statistically significantly higher proportion of those who graduated from the program matched into Family Medicine as compared to non-participants [22]. In the field of Emergency Medicine, "The Council of Emergency Residency Directors" (CORD) outlined 7 diverse recruitment practices which included recognition of applicant/faculty diversity in the interview process, development of curriculum to address topics of diversity, implicit bias and cultural competence. Residency programs that have implemented a minimum of 2 of these CORD practices have both more diverse faculty and residents [23].

In addition, addressing disparities in student debt (and debt influence on practice choice) could also promote increased student intent to practice IM in MUAs. Currently, non-military loan assistance programs in the US are centered around Public Service Loan Forgiveness (PSLF). The PSLF Program forgives the remainder of participant student loans following 10 years of qualifying payments, as long as the physician in any specialty remains employed at a not-for-profit institution during their loan payback period, and the National Health Service Corps (NHSC), which provides a limited number of applicants up to $50,000 in payments towards student loans for physicians who elect to practice primary care (General IM, Obstetrics and Gynecology, Family Medicine, or Psychiatry) for at least 2 years in eligible MUAs, and has been shown to provide high-value care [24, 25]. While participation and interest in the PSLF program is clearly present (62% of 2014 AAMC GQ respondents seeking loan forgiveness reported interest in this program), this is not the case for the more targeted NHSC program, as future physicians intend to use PSLF more than the NHSC [26]. Problematically, many students who would be inclined to practice Internal Medicine in MUAs with financial assistance are deterred by the often complex and narrow eligibility requirements of these programs. In turn, this leaves these students at a financial disadvantage as compared to those practicing care outside of MUAs [14, 27]. Modifying these programs to be both better promoted and simpler to access for students choosing to practice Internal Medicine and other specialties in MUAs would be a sensible approach to address shortages in these areas. It is crucial to focus on URiMs who indicate an interest in practicing in MUAs when restructuring loan repayment programs. Our study shows that students with higher debts were more likely to express intent to practice in MUAs. Studies also demonstrate that URiM have a disproportional medical education debt burden [27]. These two factors combined are drivers for action to decrease education debt, particularly for those serving MUAs.

Medical student intentions to practice internal medicine in ... - BMC Medical Education