Factors Affecting Medical Students’ Selection: DISCUSSION

Our study reveals that the most important factors in choosing a particular internal medicine residency program are similar for all applicants and reflect the program location and characteristics of the program, such as good house staff morale, academic reputation and variety of clinical experiences provided. Although location characteristics are fixed, our study suggests there are several factors that a program may improve or emphasize to make their residency more attractive to applicants. The most important of these appears to be creating a positive environment that reflects good house staff morale and a positive, rather than competitive, interview experience. In addition, applicants are looking for a program with a diversity of clinical experiences. Program directors should emphasize the variety of hospitals, clinics and specialty rotations available to their residency applicants and expand such opportunities if not already available. Although these findings may seem intuitive, there are no previously published empiric data from applicants that support these observations. An earlier survey of family medicine program directors also found high-quality residents and faculty as well as having residents with “good attitudes” to be markers of success.

Several other modifiable factors were of particular importance to women applicants. For example, women place significant emphasis on issues of gender diversity among the faculty and house staff. Thus, increasing the number and visibility of women faculty and residents may improve recruitment of highly qualified female applicants. Women also place a high value on family-friendly program characteristics and location characteristics that are favorable for their spouse/SO. Simple measures, such as clearly stating maternity and paternity leave policies and demonstrating support of residents with children, may also improve recruitment. A survey of matriculating and graduating medical students in 1993-1994 showed that compared to men, women rated specific curricu-lar areas as having had inadequate instruction and that women were more likely to select a generalist specialty. However, data on factors influencing choice of program have not been reported.
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Both women and ethnic minorities place more importance on the ethnic diversity of the faculty and house staff. This suggests that increasing the number and visibility of faculty and house staff from diverse ethnic backgrounds is important for recruitment of these groups. Ethnic minorities also value a feeling of being wanted by the program, implying the importance of developing and implementing outreach efforts to such individuals.

Attracting minority physicians is of key importance to caring for all patients in the United States. Studies have demonstrated that minority physicians tend to serve members of their own racial or ethnic population group significantly more than they serve members of other groups, even after accounting for socioeconomic differences of area. Minority physicians are also more likely to serve in a health workforce shortage area and are more likely to care for patients with Medicaid and with no insurance. In addition to providing a disproportionate amount of the care to ethnic minority groups and medically indigent patients, there is also evidence to suggest that language-concordant physicians provide better quality of care to monolingual Spanish-speaking Latino patients. Furthermore, minority physicians can help to increase cultural awareness and reduce the language and cultural barriers that limit access to care for many minority patients. Given these studies, recruitment of highly qualified minority applicants needs to be a priority among residency programs, particularly those serving ethnically diverse and medically underserved populations.
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In our study, ethnic minorities placed significant importance on the ethnic diversity of patients and serving the medically indigent; this is consistent with data demonstrating the likelihood of minority physicians to care for medically underserved. In addition, our data suggest that women may be more likely to have an interest in serving these populations as well. These results are supported by the other surveys of graduating medical students showing that women viewed caring for the medically indigent more positively than men.

The most significant limitation to our study is the low response rate of 36% that introduces the possibility of bias. The challenge of distributing a survey to students from across the country at a time when many may be traveling and with only one-month window of time to complete follow-up was daunting. It is unclear how this low response rate may bias the results, if at all. Because we could not obtain significant demographic information on nonrespon-ders, it is difficult to assess how this may have influenced our results. Importantly, the gender and ethnicity characteristics of the respondents were similar to those applying to internal medicine residencies nationally, indicating less likelihood of significant response bias based on those variables. Our study did have a greater proportion of Asian respondents and fewer African-American respondents in comparison to the national statistics, but this is likely secondary to the geography of the institutions surveyed. Furthermore, although response rate was low, we were able to survey more than 1,000 students, a large sample size for such a study. We were also able to survey applicants applying to multiple institutions, and representing a broad geographic range. It is important to note that the institutions studied represented the east and west coasts, and not the midwest and south, and therefore may not be generaliz-able to applicants primarily interested in those geographic areas of the country.
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Another limitation is that the class standing of our applicants represents the top of the applicant pool. Although this information is limited by self-report, it is likely correct, as the four institutions participating in the study tend to be among the most competitive internal medicine programs nationally. Our study was specifically designed to obtain information from these top applicants and because the study does not attempt to obtain information from the entire applicant pool, it may limit generalizability to other programs.

The survey nature of the study may limit the completeness of the information obtained. It is possible that there are other factors that applicants value highly that were not asked in the survey. We attempted to limit the chance of this with a thorough review of the literature, discussions with program directors and pretests of the survey with residents to assess for completeness. Finally, we recognize that many of the numerical differences seen between applicant groups, although statistically significant, are small and may not represent meaningful differences. Furthermore, because we tested for multiple associations, it is possible that some of the differences seen are simply a matter of chance. We attempted to limit this possibility by adjusting for multiple comparisons using the Scheffe method. Despite these limitations, to our knowledge, we are the first to report on the relative importance of various factors in choosing a residency program among minority applicants.
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In summary, we conclude that internal medicine residency applicants value programmatic and location factors most highly in choosing a particular internal medicine residency program. Creating a positive experience for applicants and improving house staff morale may enhance applicant interest in an internal medicine residency program, as these factors appear to be key in applicants’ choice of residency program. Diversity of clinical experiences should also be emphasized and enhanced. For those programs with particular interest in recruiting women and ethnic minorities, emphasis might be placed on expanding gender and ethnic diversity among residents and faculty in the long-term. In the short-term, program directors can pay particular attention to voicing an interest in these issues and in the case of ethnic minorities, reaching out to them to make them feel more wanted. These interventions should be studied further to evaluate their effect on the ability of residency programs to recruit highly qualified female and minority applicants.

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Tags: ethnic minority, internal medicine, medical education, medical students, residency selection, women