Postgraduate Medical Education

Discoveries in research and changes in society have resulted in changes within established medical specialties, as well as the evolution of new specialties. A brief overview of several specialties that have taken new directions follows.

Primary Care/Family Practice

Public demand for a single, competent physician for the entire family has grown as the availability of such physicians continues to diminish. To meet this need, the specialty of family practice evolved. This specialty differs from the others in that it is defined in terms of functions performed rather than limited by treatment of certain diseases or parts of the body or on the basis of the patient's chronological age.

The specialist in family practice must acquire a basic core of knowledge in all areas of medicine. Being the physician of first contact, he or she is responsible for evaluating the patient's total health needs over an extended period of time. Family practice is thus a specialty in breadth rather than a specialty in depth.

The family practice specialty will become especially important as the U.S. health care system undergoes changes. A suitable balance between specialists and generalists will be one of the ultimate goals to ensure the success of a new system. An overabundance of specialists makes the health care system more expensive, less accessible, and less focused on prevention. The imbalance is a principal cause of the high cost of health care.

Suggestions are being made for ways to shift the trend away from specialization by limiting funding for training in subspecialalties and by creating incentives for entering the field of primary care. Among the attractive features of a primary care practice is the opportunity to treat patients ranging in age from children to the elderly. A primary care physician also sees a great variety of cases, from cardiology to rheumatology, and is responsible for providing continual care, creating a special bond between the patient and the physician.

Many physicians are becoming convinced of the value of preventive primary care. Health care reforms, emphasis on primary care, and the demand by women for more comprehensive health care have motivated obstetricians/gynecologists to seek recognition as primary care providers. Some groups, such as the American Academy of Family Physicians, strongly oppose granting such recognition, believing that it should be used for specially trained practitioners. Women frequently use ob/gyn specialists who sometimes also provide a general medical check-up. The American College of Obstetricians and Gynecologists has redefined its mission to include health care of women throughout their lifetime. They have even encouraged their members to subscribe to a journal containing generalist information.

Considerable efforts are being made to encourage medical students to choose primary care as their specialty, but there is some uncertainty about the most effective means of achieving this goal. Some feel that having generalists serve as student mentors is the best approach but a medical school survey found that faculty can do little to influence student specialty choice. A different study, however, demonstrated that, where required family practice clerkships exist, the number of students electing to become primary care physicians has significantly increased. This should be of interest to those premedical students considering primary care as their career choice.

Interest in family practice over the past few years has risen significantly, with the number of fourth year students matched with this specialty at high levels, second only to internal medicine. There has been a concerted and successful effort by the American Academy of Family Physicians to market this specialty. They have targeted medical schools to set up departments of family practice, and most now have them. Students are encouraged to take primary care clerkships within family practice settings. Such exposure, as noted above, can profoundly alter one's career goals. When the number of physicians entering family practice, internal medicine, and pediatrics for residency training — namely the primary care specialties — combined, it makes up about half of all physicians receiving postgraduate training. Of these three groups, the overwhelming majority of those entering family practice will remain in primary care, while, of the other two segments, a portion go into subspecialty training.

While the federal government is interested in reforming medical education as part of altering the health care system, these efforts are slowed down by political in-fighting. A somewhat more meaningful effort in being made by state legislatures. Their focus is to encourage the training of more primary care physicians so as to promote cost-effective medicine and to encourage physicians to practice in underserved areas. Thus, 13 (out of 21) states succeeded in enacting legislation that offers medical students financial aid or scholarships as incentives to practice in remote areas or inner city ghettos. These states include Maryland, Rhode Island, North Carolina, and Nebraska. Some states, such as Pennsylvania, have increased their funding directly for programs in family practice training. Mandating the training of primary care physicians can be successful in a state like Washington, which serves a largely rural population locally, and in adjacent states. Most other states turned down quota systems. Some schools are voluntarily setting goals of steering students to become primary care physicians in the hope of avoiding legislative coercion later on.

Pediatrics

Although some serious infectious diseases of childhood have been conquered, children will always need care for the usual viral illnesses. Now, however, more attention is being focused on the patient as a whole, especially his or her behavioral problems. Thus such issues as child abuse, drug addiction, and suicide prevention are emerging areas of concern for pediatricians.

A developing subspecialty is pediatric emergency care. Increasing recognition of the need for specialists in this area is reflected by the fact that one-third of all emergency room visits involve children. They frequently present different problems than adults. Those specializing in pediatric emergency care usually complete a pediatric residency and an emergency medicine fellowship. A special five-year program for certification is under consideration.

The next frontier to become open to pediatricians will undoubtedly involve the treatment of genetic diseases with drugs that will become common because of advances in genetic engineering technology that are expected to take place in the near future.

Psychiatry

The field of psychiatry is undergoing “remedicalization” in that the emphasis is now on using medical therapy in the context of hospital practice and closer affiliations with other specialties. In addition, a strong move toward subspecialization is developing, and such areas as geriatric psychiatry, clinical psychopharmacology, and forensic psychiatry are emerging.

Diagnostic Radiology

New patterns of health care delivery coupled with advances in imaging technology are altering the professional schedules of radiologists. They are now more frequently on call, and more of them are practicing in outpatient settings.

The expanded use of magnetic resonance imaging (MRI), ultrasound, CAT scans, and other technologies has brought radiologists more intimately into the core of medical practice. Nevertheless, radiological techniques are used by other specialists as well, and an intense jurisdictional debate is in progress.

Subspecialization by means of fellowship training in such areas as ultrasound or pediatric radiology is increasing.

Emergency Medicine

The relatively new specialty is emerging as a distinct entity, as indicated by the fact that board certification now requires specialized training in this area rather than merely passing the qualifying examinations.

Academic emergency medicine centers are now aiming at securing high-quality physicians with four years of training. As more medical students are exposed to this area, a very substantial upswing in the numbers seeking admission to residency programs is expected.

Physical Medicine and Rehabilitation

War injuries and polio epidemics led to the development of physicians especially trained in treating pain and in rehabilitation therapy. Although debilitating diseases such as polio have been eradicated, accident and stroke victims and paralytics live much longer today, and thus the need for the services of physiatrists has increased.

Physiatrists are largely hospital based in terms of their practice, but more are moving into part-time private practice. Moreover, the approach of customizing treatment plans within the context of the patient's quality of life and maximal potential is becoming the norm. This specialty continues to use the multidisciplinary approach in patient care, which is an especially attractive feature for those who choose training in this area.

Sports Medicine

This specialty is still in its infancy, and there are as yet no formal residency programs. Nevertheless an increasing number of physicians, including those trained in orthopedics and family practice, are entering full-time sports medicine. This field is developing because of the dramatic increase in popularity of physical fitness. In addition, the field is expanding beyond treatment to an understanding of the disease process and to prevention. In time, certification and a clearer definition of this specialty will evolve.

Cosmetic Surgery

This developing field is an offshoot of reconstructive surgery. It comes in response to a more affluent society and the desire to obtain a greater degree of self-worth. Technical advances have also promoted cosmetic surgery as a distinct area of specialization. Breast reconstruction, liposuction, and certain kinds of laser surgery are but a few of the more recent developments that are encompassed by this field. In 1979 the American Board of Cosmetic Surgery was established; it certifies physicians from varying specialties who are primarily involved in cosmetic surgery.

Geriatrics

This emerging specialty deals with medical care of the aged, usually defined as being over 65. It involves review of a patient's medical and social history, marital status, and functional ability. The geriatrician aims to address the patient as a whole.

The need for geriatricians is great and will increase as the percentage of the aged in the population gradually increases. The aged spend more than double the nation's health care dollars in proportion to their group size.

Geriatricians are usually initially trained in a specialty such as internal medicine or other relevant area and spend a two-year fellowship training period. Standards for fellowships are being developed.

Career Placement

National trends in career placement are not directly available, and specialty imbalances change from year to year as well. The activities of the AMA Physician's Placement Service for the past few years do provide an insight into what is happening. The AMA's statistics show that there is a general pattern of undersupply of physicians for general and family practice and an oversupply of anesthesiologists, dermatologists, pediatricians, psychiatrists, radiologists, surgeons, and urologists. The only area other than general practice in which there currently seems to be a shortage is otolaryngology, with fewer specialists in this field in proportion to the opportunities available. Note, however, that the oversupply of particular specialists reflects the desires for prime locations, rather than a national oversupply.

Perhaps a good indicator of the current specialty trends is the residency choices of medical school graduates. For a very recent year these choices were approximately as follows:

Internal medicine, 27%

Pediatrics, 11%

Family practice, 12%

Surgery, 10%

Obstetrics and gynecology, 8%

Psychiatry, 6%

Orthopedic surgery, 5%

Radiology, 4%

Anesthesiology, 3%

Emergency medicine, 3%

Others, 11%