When Money Doesn't Change Everything

Several authors have suggested that primary care is in crisis because of a decline in interest in generalism among new physicians, particularly graduates of U.S. medical schools (1, 2). According to the National Resident Matching Program, the number of U.S. medical school graduates choosing family medicine initially rose from a nadir of 1374 in 1991 to 2340 in 1997, but decreased to 1156 in 2008 (3). Subspecialization rates are increasing, particularly among graduates of internal medicine programs, but also within pediatrics, general surgery, and psychiatry (4).

The literature examining the recent trends in specialization is, at best, conflicting about why young physicians are choosing careers outside of generalism. Compensation, debt, lifestyle, prestige, personality, and demographic factors have all been identified as likely issues but their relative importance is not clear.

In this issue, McDonald and colleagues (5) have attempted to better demonstrate the relationship between student debt and specialization among internal medicine residents. Using the Internal Medicine In-Training Examination Residents Questionnaire, the authors related the career plans of internal medicine residents in their final year of training to their educational debt. With 74% of all potential respondents participating, the authors found that, as debt level increased, residents were less likely to choose subspecialty careers.

This surprising result is consistent with another empirical study done on a similar population (6), but it is in stark contrast to the opinions of many authors who assert that money, whether in the form …