Wiest FC, Ferris TG, Gokhale M, Campbell EG, Weissman JS, Blumenthal D. Preparedness of Internal Medicine and Family Practice Residents for Treating Common Conditions. JAMA. 2002;288(20):2609-2614. doi:10.1001/jama.288.20.2609
Author Affiliations: Robert Wood Johnson Clinical Scholars Program, Department of Veterans Affairs Puget Sound Healthcare System, and Department of Medicine, University of Washington, Seattle (Dr Wiest); Institute for Health Policy, Division of General Medicine, Massachusetts General Hospital, Partners Healthcare, and Harvard Medical School, Boston (Drs Ferris, Campbell, Weissman, and Blumenthal and Ms Gokhale).
On Call Section Editors: Joseph K. Lim, MD,
and Stephen J. Lurie, MD, PhD; Associate Editors: Ethan M. Basch, MD, R. Sonia
Batra, MD, MPH, Natalie Holt, MD, Alison J. Huang, MPhil, MD, Nina Kim, MD,
Vincent Lo Re, MD, Dena E. Rifkin, MD, and Mrugeshkumar K. Shah, MD, MPH.
Context Although both internal medicine (IM) and family practice (FP) physicians
frequently provide care for the same common adult conditions, IM and FP residency
programs differ in their training emphases.
Objective To assess differences in IM and FP residents' self-perceived preparedness
to diagnose and treat common adult medical conditions.
Design, Setting, and Participants Cross-sectional analysis of a national survey administered in the spring
of 1998 to residents in their final year of residency at US academic health
centers. A total of 279 IM residents in 25 programs and 326 FP residents in
75 programs responded to the survey.
Main Outcome Measures Residents' self-rated preparedness to diagnose and treat 4 inpatient
conditions (acute myocardial infarction, diabetic ketoacidosis, acute asthma,
and acute renal failure) and 8 outpatient conditions (diabetes, hypertension,
low back pain, vaginitis, headache, depression, upper respiratory tract infection,
and hyperlipidemia), controlling for resident sex, race/ethnicity, US medical
school graduate status, intent to subspecialize, and estimates of exposure
to patients in inpatient and outpatient settings.
Results Internal medicine residents were more likely to report being very prepared
for all 4 inpatient conditions (P≤.001), while
FP residents were more likely to report being very prepared for 5 of 8 outpatient
conditions (P≤.05). Differences between IM and
FP residents persisted in multivariate analyses for all inpatient conditions
and some outpatient conditions. Exposure to patients in inpatient and outpatient
settings varied by specialty and was significantly associated with resident
self-report of preparedness for a majority of conditions investigated.
Conclusions Internal medicine and FP residents report differences in preparedness
to manage common adult conditions. These differences were consistent with
the emphasis on an inpatient setting for IM residents and on office-based
care for FP residents.
Residents in internal medicine (IM) and those in family practice (FP)
are trained to provide primary care for adults, yet they have very different
residency experiences. Internal medicine training was originally hospital
based and emphasized acute care and pathophysiology of disease. More recently,
IM training has included an increased emphasis on primary care.1,2 Family
practice training, initiated in 1969, provides more experience in office-based
ambulatory and long-term settings and focuses more on preventive and psychosocial
aspects of care.1,3,4 In
addition to primary care for adults, FP residency includes training in pediatrics,
surgery, and obstetrical care. The different emphases in the 2 types of residencies
may affect how internists and family physicians approach their adult patients.
This may also influence their self-perceived preparedness to provide care
for certain types of patients and treat their associated conditions.
Previous studies suggest that IM residents assume a more technical approach
to patient care compared with FP residents, who emphasize preventive services
and counseling.5,6 Surveys of
IM residents have found that they believe they are underprepared for a variety
of primary care tasks, including treating depression7 and
performing pelvic examinations.8 Similarly,
a study using case vignettes compared the self-perceived competencies of IM
and FP residents and found that FP residents report greater competence in
managing depression whereas IM residents report greater competence in treating
acute myocardial infarction and its complications.9 These
studies, however, are limited to single training sites. Little is known about
differences in IM and FP training across programs or the extent to which these
differences may affect resident preparedness to handle common adult conditions.
We hypothesized that the greater emphasis on outpatient care in FP residencies
would be associated with greater self-perceived preparedness for outpatient
conditions among FP residents than IM residents and that, similarly, the greater
emphasis on inpatient care among IM residencies would be associated with greater
self-perceived preparedness for inpatient conditions among IM residents than
FP residents. We further sought to explore the relative importance of exposure
to the settings in which the specific clinical conditions were found to IM
and FP residents' sense of preparedness. To address these hypotheses, we used
data from a national survey of resident preparedness.10
The sampling methods used in this study have been described previously.10 Briefly, we used a multistage process to assemble
a sample of residents across 8 specialties (including IM and FP) to obtain
a representative sample of residents training in their final year at US academic
health centers. The final list of academic health centers, defined as medical
schools and their closely affiliated or owned clinical facilities, contained
162 hospitals that were responsible for training 40 000 of the 98 000
residents in 1997.11 Our final sample consisted
of 578 IM residents in 25 programs (8% of accredited IM categorical programs)
and 658 FP residents in 75 programs (16% of accredited FP programs).10 We conservatively estimated that our sample represents
53% of senior residents training in IM and 27% of senior residents training
in FP, or 44% of all senior residents in both specialties. The lower percentage
of FP residents reflects the greater number in nonacademic health centers
that sponsor FP residencies.
Development of the survey instruments (1 for each specialty) was informed
by literature reviews, focus groups, review of relevant Accreditation Council
on Graduate Medical Education policies, and comments from experts in each
of the respective specialties.10 The instruments
were pretested using cognitive interviews and were designed to take 15 minutes
The survey was administered in the spring of 1998. Mailed surveys constituted
92% of the IM responses and 90% of the FP responses, with the remainder of
the responses in each group obtained via telephone surveys. Response enhancement
techniques included advance notification, multiple mailings, telephone follow-ups,
and flexible scheduling. Respondents were eligible to receive cash prizes
or (in some cases) payment for completed interviews. The initial (unadjusted)
response rate was 48% for IM and 49% for FP, reflecting relatively high invalid
identification rates (27%) of residents who had left their programs or were
assigned the wrong specialty survey. The final survey response rate, adjusted
for invalid sample, was 65%. Internal medicine and FP samples had adjusted
response rates of 59% and 68%, respectively. The Massachusetts General Hospital
(Boston) Institutional Review Board approved this protocol.
Clinical Preparedness. We asked residents how prepared they felt to diagnose and treat (1)
inpatients, critically ill patients, and ambulatory patients in general; (2)
four specific conditions typically associated with the inpatient setting (acute
myocardial infarction, diabetic ketoacidosis, acute asthma, and acute renal
failure); and (3) eight specific conditions associated with the outpatient
setting (diabetes, hypertension, low back pain, vaginitis, headache, depression,
upper respiratory tract infection, and hyperlipidemia). All of these adult
conditions were listed together on both IM and FP surveys. The FP survey contained
a separate section listing pediatric diagnoses. The response categories for
each question were very unprepared, somewhat unprepared,
somewhat prepared, and very prepared.
Resident Exposure by Setting. Because we considered exposure to patients a potentially important mediator
of differences between IM and FP preparedness, we attempted to assess the
influence of exposure to patients in different settings on IM and FP reports
of preparedness. Exposure to patients is a function of both the time spent
in a setting and the volume of patients seen in that setting. We hypothesized
that both components of exposure would be important because programs vary
in the amount of time residents are scheduled in inpatient and outpatient
settings, and medical centers and practices vary in the volume of patients
seen in each setting. We had previously tested questions related to resident
reports of the percentage of time spent and the number of patients seen in
inpatient and outpatient settings, both alone and in combination. We found
that a combined measure provided, on average, the greatest explanatory power
and the highest statistical significance in our models, and, therefore, used
those in our analyses. Inpatient exposure was calculated by multiplying the
average number of patients admitted during a shift as an intern by the percentage
of residency spent in the inpatient setting (excluding the operating room
and emergency department). Outpatient exposure was calculated by multiplying
the average number of patients typically seen in a 4-hour outpatient clinic
by the percentage of residency spent in ambulatory settings.
Other Variables. Respondents were asked about their sex, whether they attended medical
school in the United States, and their race/ethnicity (white non-Hispanic,
black non-Hispanic, Hispanic, Asian, or Alaska native/American Indian). In
separate analyses, we found that white non-Hispanic and Asian respondents
were not significantly different in demographics and responses, so we combined
their responses and compared these with the other groups constituting underrepresented
minorities. We also asked residents about their intention to subspecialize
after residency (yes, no, or undecided). Because all respondents surveyed
were in their final year of residency, "undecided" responses were combined
with "no" responses since these both reflected an absence of definite plans
for subspecialty training.
Questions with multiple response categories were collapsed to form dichotomous
variables. For our main outcome variable, preparedness, we compared very prepared
with somewhat prepared/somewhat unprepared/very unprepared because we were
interested in factors that determine superior preparation for diagnosis and
treatment of the conditions surveyed. Because differences between very prepared
and somewhat prepared may not be clinically meaningful, we compared all conditions
using very prepared and somewhat prepared with somewhat unprepared and very
unprepared in a secondary analysis. The patient exposure variables were entered
into our models as continuous variables.
We tested differences between IM and FP characteristics using the χ2 statistic (dichotomous variables) and the t test
(continuous variables). We tested for differences between IM and FP in responses
to questions regarding site-specific preparedness (inpatient, outpatient,
or critically ill setting) as well as differences in reported preparedness
for each of the 4 inpatient and 8 outpatient conditions. All dichotomous comparisons
of preparedness between IM and FP were initially tested using the χ2 test. In addition, we conducted multivariate analyses of comparisons
of preparedness between IM and FP residents controlling for exposure to patients,
sex, US medical school graduate status, race/ethnicity, and plans to pursue
a subspecialty or fellowship. Odds ratios (ORs) from multivariate analyses
were converted to adjusted relative risks following the method described by
Zhang and Yu.12 Analyses were weighted to adjust
for differences in sampling and response rates among the strata. Multivariate
analyses included adjustment for the multistage sampling design. Analyses
were computed using SUDAAN software version 7.5.1(Research Triangle Institute,
Research Triangle Park, NC). P≤.05 was considered
Internal medicine and FP residents were similar in race/ethnicity and
the proportion who graduated from a US medical school. Family practice respondents
were more likely to be women and were less likely to be planning subspecialty
training (Table 1). Differences
between IM and FP exposure to patients differed by clinical setting. Internal
medicine residents reported greater exposure to inpatients, and FP residents
reported greater exposure to outpatients (P<.001
for both comparisons).
We tested differences in resident-reported preparedness to treat 3 different
types of patients: inpatients, critically ill patients, and outpatients. Internal
medicine residents were more likely than FP residents to report being very
prepared to treat inpatients (252/277 [91%] vs 179/320 [55%]; P<.001) and critically ill patients (183/278 [68%] vs 57/321 [17%]; P<.001). Family practice residents were more likely
than IM residents to report being very prepared to treat outpatients (262/320
[82%] vs 134/277 [48%], P<.001).
Internal medicine residents were significantly more likely than FP residents
to report being very prepared to care for patients with acute myocardial infarction,
diabetic ketoacidosis, acute asthma, and acute renal failure (Table 2). These findings persisted in multivariate analyses. Resident
characteristics were not significantly associated with preparedness for any
of the 4 inpatient conditions (data not shown). Our measure of resident exposure
to inpatients was generally not associated with reports of preparedness for
inpatient conditions. One exception was diabetic ketoacidosis, which residents
reporting increased inpatient exposure were more likely to report being very
prepared to manage (OR, 1.34; 95% confidence interval [CI], 1.05-1.72; P = .02).
The results were more variable for the 8 outpatient conditions (Table 2). More IM residents than FP residents
reported being very prepared to treat diabetes. In contrast, FP residents
were significantly more likely than IM residents to report being very prepared
to treat depression, headache, low back pain, upper respiratory tract infection,
and vaginitis. Differences between IM and FP residents were not statistically
significant for hyperlipidemia and hypertension. The direction of the associations
between specialty and preparedness did not change when we recategorized the
dependent variable to very prepared and somewhat prepared vs somewhat unprepared
and very unprepared, but most differences were no longer statistically significant.
In the multivariate analysis controlling for exposure to patients, IM
residents reported greater preparedness to treat diabetes, hyperlipidemia,
and hypertension. Reports of greater preparedness by FP residents remained
significant for vaginitis and marginally significant for depression (Table 2). We found that increased exposure
to patients in the outpatient setting was associated with greater preparedness
to treat outpatient conditions for 6 of the 8 conditions studied (Table 3). The effects of exposure to outpatients
on resident reports of preparedness were most marked for headache and depression
and somewhat less marked for low back pain.
Some resident characteristics other than specialty were significantly
related to preparedness to diagnosis and treat the outpatient conditions.
Women were significantly more likely than men to report being very prepared
to diagnose and treat depression (OR, 1.70; 95% CI, 0.99-3.06; P = .02) and vaginitis (OR, 2.53; 95% CI, 1.63-3.94; P<.001). Also, residents who did not intend to subspecialize were
more likely to report being very prepared to treat vaginitis (OR, 2.04; 95%
CI, 1.36-3.05; P = .005).
This report presents the results of a national survey of IM and FP residents
in their final year of training in 162 US academic health center hospitals.
We found significant differences between IM and FP residents' self-reported
preparedness to diagnose and treat common conditions in inpatient and outpatient
settings. Internal medicine residents reported greater preparedness than FP
residents to diagnose and treat all 4 inpatient conditions, while FP residents
reported greater preparedness to diagnosis and treat most of the 8 outpatient
conditions included in our survey.
In this study, we measured residents' perceptions of their preparedness.
The technique of self-assessment has been widely used,5,6,13- 16 although
how well residents' perceptions match some objective standard of preparedness
is not well known.17 Some authors have found
little correlation between physician self-assessment and objectively measured
competency,18- 20 but
others have found that physicians are able to predict their performance reliably.21- 24 Residents,
however, may underrate themselves compared with the ratings of their supervisors.25,26 Therefore, our results must be interpreted
within the limitations of self-assessment.
There are several possible explanations for the differences in IM and
FP residents' reports of preparedness found in this study. Internal medicine
and FP programs differ in their training emphases and their residency review
committee requirements for exposure to inpatients and outpatients. Internal
medicine residents spend at least 12 months in inpatient teaching services
compared with 6 months of adult inpatient care for FP residents. The greater
time spent on inpatient care for IM residents and outpatient care for FP residents
was reflected in our findings. The IM residency review committee has noted
internists are distinguished by their diagnostic skills2 whereas
the FP residency review committee highlights abilities in providing continuous
and comprehensive care.4 In addition, differences
in self-reported preparedness may reflect differences in the interests and
career choices of the residents in each specialty.27 Internal
medicine is a gateway for many subspecialties, whereas FP is predicated on
providing comprehensive primary care for a broad range of patients.
Exposure to patients in inpatient and outpatient settings was significantly
associated with preparedness for several conditions included in the study.
It is unlikely that the variable we used for patient exposure reflects the
complexity of patient-resident interactions; nonetheless, our results do reflect
the importance of patient exposure on resident reports of preparedness for
certain inpatient and outpatient conditions. Of note, the 3 outpatient conditions
for which IM residents rated themselves higher than did FP residents (diabetes,
hypertension, and hyperlipidemia) were conditions also commonly found in inpatient
settings. Additional condition and training program characteristics influencing
the relationship between exposure and preparedness may include diagnostic
and therapeutic complexity, evidence base, frequency of comorbidities, likelihood
of complications, resident workload, and quality of resident instruction.
In addition, there may be a lower limit (threshold) of necessary exposure.
Internal medicine and FP residents may all have sufficient exposure to several
conditions, which may explain the lack of association between exposure and
preparedness for several of the inpatient and outpatient conditions.
Sex of the resident was the most significant factor for care of patients
with vaginitis. This is consistent with a previous study of IM and FP physicians
that found that both types of physicians rated their skill and comfort with
sex-specific examinations higher with patients of the same sex. Because female
patients often prefer female physicians,28- 31 it
is possible that female residents encountered more cases of vaginitis in their
Although we found that IM and FP residents reported differences in preparedness,
there are several limitations to our conclusions. There may be systematic
biases in the way IM and FP residents respond to questions about preparedness.
Individuals with a particular approach to self-assessment may be drawn more
to one specialty than the other, or residents within each specialty may become
acculturated to rate themselves a certain way. Although we separated adult
and pediatric diagnoses in our survey, FP residents may have factored their
feelings of preparedness with pediatric care into their responses for preparedness
on the adult conditions where these overlap. Additionally, IM and FP practices
may not be directly comparable because FP adult outpatient populations have
been found, on average, to be younger and to have fewer chronic conditions.32 The generalizability of our results may be limited
by our sample, which targeted residents at academic health centers.
In summary, in a national survey of residents, we found differences
in IM and FP resident reports of preparedness to diagnose and treat common
inpatient and outpatient conditions. This study found IM and FP reports of
preparedness to be generally consistent with the differing emphases of these
distinct specialty training programs. These differences raise an important
policy question. If different training regimens result in differing levels
of preparedness, can training programs be designed to optimize preparedness
for the anticipated practice setting? To improve residency education and the
care physicians provide for adult patients, we must continue to investigate
the factors promoting better resident preparedness as well as the best means
to measure them.