As a specialty, internal medicine (IM) has been getting a lot of attention lately.
Of course, last March, internists were on the front lines fighting a global pandemic, as well as chronicling medical news and information on TV, radio, and across the internet.
“As a discipline, IM really stepped up and stepped in and truly took the lead in managing the pandemic,” said Philip A. Masters, MD, FACP, ACP's Vice President of Membership and Global Engagement. “It was an incredible demonstration of the value and essential nature of IM to the world's health care system.”
Then, in December 2020, the Association of American Medical Colleges reported that the number of students applying to medical school for the 2021 academic year was up about 18% from the same time in the previous year. Some attributed the increase to the “Fauci effect,” positing that Anthony S. Fauci, MD, the internist and longtime director of the National Institute of Allergy and Infectious Diseases who serves as chief medical advisor to the president, encouraged a new crop of future doctors.
In March 2021, the IM specialty had its largest Match in history. The 2021 Main Residency Match showed that IM remains the largest training specialty, offering 25.6% of all PGY-1 positions in the Match. IM programs offered a record-high 9,024 categorical positions and 441 primary care positions.
But it is difficult to attribute the growth in IM to the pandemic, said Dr. Masters. “As far as interest in IM related to the pandemic is concerned, those who matched this year actually applied before the pandemic started, as it takes pretty much a year for the application process to play out,” he said.
IM got another boost in April, when a study by physicians at the University of California, San Francisco (UCSF), School of Medicine reported that both the number of applicants and applications submitted per applicant for IM residency and subspecialty fellowships increased from 2020 to 2021. The annual increase for IM residency was 6%, more than twice the rate of the annual increase in any of the previous five years, which ranged from 0.2% to 2.7%, according to results published as a research letter April 28 by JAMA Network Open.
“This was on top of an already huge burden of applications for residencies in IM. … It isn't clear how related the choice of IM is to the pandemic, but as [the study authors] noted, the lack of in-person interviews and suspension of some of the prerequisites for applying to residencies removed many barriers to doing so which more typically temper people's application lists,” said Dr. Masters.
Study coauthors Laura A. Huppert, MD, a UCSF hematology/oncology fellow; Lekshmi Santhosh, MD, MAEd, an assistant professor of medicine and associate program director for the UCSF pulmonary/critical care medicine fellowship program; and Jennifer M. Babik, MD, PhD, an associate professor of medicine and associate program director for the UCSF IM residency program and infectious diseases fellowship program, recently shared additional insights on the study in an email interview with ACP Internist.
Q: What led you to study this issue?
A: All of us are involved in IM residency and/or fellowship admissions at our institution, so we were particularly interested in application trends this year given the new challenges faced by applicants and programs during this application cycle. Due to the impact of the COVID-19 pandemic and the new virtual interview process, many hypothesized that the number of applicants may increase. It was also hypothesized that applicants may apply to more programs given the time/money savings due to virtual interviews, so we also wanted to evaluate the average number of applications submitted per applicant. Therefore, when ERAS [Electronic Residency Application Service] released the preliminary application data, we were eager to analyze the application trends.
Q: What are some potential reasons for the increase you observed in the number of IM residency/most fellowship applications?
A: We reported the trends in applicant numbers but did not evaluate the reasons for these changes in our study, so we do not know for certain what factors are driving the changes in applicant numbers. It is possible that applicants were impacted by personal and professional factors during the COVID-19 pandemic, such as family/financial constraints, travel/visa issues, and/or decreased opportunity for research/clinical electives. Virtual interviews were also introduced at most programs to comply with public health recommendations, which may have enabled applicants to apply to more programs with decreased time/travel/financial constraints. Future work is needed to better understand the causes of these IM application trends.
Q: What effect do you think COVID-19 had on the number of applicants?
A: In our analysis, we found an increase in the number of applicants to IM residency and most fellowship programs this year, as compared to prior years. Interestingly, there was a greater rate of increase this year compared to prior years for most programs, suggesting that factors related to the pandemic (e.g., virtual interviewing, personal and professional factors affecting applicants) may have been at play. However, our analysis did not evaluate the factors driving the changes in application patterns, so we cannot say for certain exactly how the COVID-19 pandemic affected IM applicant numbers. Future studies are needed to better understand the factors contributing to these changes in application trends.
Q: Do you think COVID-19 has played a role in what kind of subspecialist medical graduates are choosing to become? Why or why not?
A: We found that the number of applicants increased from 2020 to 2021 in certain fields that were central to the care of patients with COVID-19, such as infectious diseases (17% annual increase), hospice and palliative care medicine (20.5%), geriatric medicine (13%), and pulmonary/critical care medicine (6.6%). Many of these were greater increases than in prior years studied. It remains to be seen whether these trends will continue in future application cycles. At many institutions, trainees provided essential care to patients with COVID-19, so these experiences may continue to impact subspecialty choices in years to come.
Q: What are the implications of having more than usual IM and fellowship applications this year?
A: There are both advantages and disadvantages of having an increased number of applicants to IM residency and fellowships. When more applicants apply to residency/fellowship and when each applicant applies to more programs, it may increase the diversity of training programs, as discussed in an excellent paper by our colleagues Marbin et al. in Academic Medicine in 2021. However, these increases may be time-intensive for both applicants and programs, congesting the application process. It will be important to continue to evaluate trends in applicant numbers in future years to ensure that the application process is equitable and sustainable for both applicants and programs.
Q: Do you have any predictions for whether the increased number of applications will stay up or decline next year?
A: This is a tough question! In our analysis, we found that the number of applicants were increasing in IM residency and most IM subspecialties even before the pandemic, although the rate of increase was more pronounced in the 2021 ERAS application year. Given the overall trend of increasing numbers of applicants, we hypothesize that there will continue to be an increase in the number of applicants to IM residency and subspecialties in future years, although it is hard to predict whether the rate of annual increase will continue to be as high. We are eager to see what trends the future years will hold!