The purpose of this study was to evaluate if we could group residents based on how they prioritized their personal goals for their career, and we were able to group 35 of 46 residents (76%) to one of four groups. Using these personal goals groups, we had moderate agreement (kappa = 0.57) between our predicted subspecialty group and residents’ self-reported first desired subspecialty, something that we have not seen in our review of the literature.
The main advantage of Q methodology is that it forces a quasi-normal distribution so respondents cannot select the same response for every item, as they can with traditional survey methods. Horn and colleagues’ [14] Canadian survey study grouped their respondents based on subspecialties (procedural, non-procedural, and non-procedural with declining interest) and found that all three groups valued diversity of clinical spectrum. We found that only one group valued variety compared to other groups. Similarly, Horn and colleagues [14] found their three groups all valued satisfaction among staff physicians whereas only one of our groups valued positive interactions with attending physicians. Although we are not comparing the exact same statements, the differences between these two studies are likely attributable to the methodology, with Q methodology allowing better differentiation between groups.
Examining the four groups of residents (see Tables 3, 4, 5 and 6), there are some key findings. It has been established in medical students that interest in a specialty correlates strongly with future income [28]. In internal medicine, a common finding across studies is that subspecialties such as cardiology, gastroenterology, hospitalists, nephrology, and respirology value a higher remuneration more than other subspecialties. We found that the group of residents interested in gastroenterology, nephrology and respirology valued remuneration more than others, but this was not the driver for those interested in cardiology or general internal medicine (which in Canada is somewhat similar to a hospitalist in the United States). The primary driver for those interested in cardiology and critical care was willingness to extend training, which is consistent with our anecdotal experience of these residents often doing seven, eight or sometimes more years of residency before ending training.
In our previous qualitative study [19], we often heard residents referring to general internal medicine as a dumping ground for patients other subspecialties did not want. In this study, it would appear that this sentiment is only a strong motivator for those interested in cardiology and critical care and was not a major concern for the other groups. In Canada, we have recently moved from a one to two-year general internal medicine fellowship after three core years of internal medicine. Our previous study indicated this increased length of training may be a deterrent to pursuing general internal medicine, and we have now found that this applies mainly to those interested in gastroenterology, nephrology and respirology.
In the current study, it was hard to tease out the non-procedural lower income subspecialties from each other, which may be due to a smaller sample size. However, this may also be due to a similar set of goals with these residents: they do not want to do procedures, are not as concerned with income, and want a focused area of expertise. What may distinguish them from each other is the specific patients whom they are interested seeing and the positive and negative interactions the residents have had with attending physicians.
Because this study was done with Canadian residents, it is worth noting the similarities and differences in the practice of general internal medicine in Canada compared to other countries. Ghali and colleagues [29] reviewed the clinical profile of general internal medicine in Argentina, Australia, Canada, Japan, New Zealand, Switzerland, and the United States. General internal medicine in Canada is a consultative service to primary care practitioners and is often hospital based caring for complex, multisystem patients. This overall profile is similar to that of general internists in Australia and New Zealand, and somewhat similar to general internists in Switzerland. This differs from general internists in the United States, Argentina and Japan who often have a large outpatient primary care role, though many also have consultative and hospitalist roles.
That said, one of the most interesting findings of our study is why a resident desires a career in general internal medicine. It is not surprising this group enjoys variety but what is surprising is this is essentially the sole driver for choosing general internal medicine over other subspecialties as exhibited by the extremely high Z-score of 2.71. A past president of the Canadian Society of Internal Medicine may have put it best when he said, “To my mind, this clinical smorgasbord is the best advertisement for doing general internal medicine” [30]. Regardless of the differences in the clinical profile of general internal medicine globally, this thirst for variety as a driver for residents to pursue general internal medicine is likely to transcend geographical borders.
Limitations and future directions
This study was undertaken using residents at one internal medicine residency program in Canada and thus the results may be different at other institutions across Canada or in other countries. We were able to sample 59 (52%) of the 114 eligible residents; however, 13 did not complete the Q sort successfully. This resulted in only 46 participants of whom 11 did not load onto a factor and one did not complete their desired subspecialty, so they could not be included in our prediction of subspecialty compared to self-reported desired subspecialty. Though the demographics of the remaining 34 participants appear similar to the rest, this reduction in participants may reduce the generalizability of our findings. Finally, the statements used, though diverse, did not incorporate every possible personal goal such as desire for long versus short-term relationships with patients, debt load when entering residency, interest in specific issues such as health care policy, or desire for an academic versus non-academic career.
A future Q methodology study could involve residents across Canada, which might allow us to get at a more granular level (possibly 14 factors that could predict the individual subspecialties). Future research could also incorporate personal goals that were missing from this study, and could be done in a computerized format to prevent missing data. This would be helpful to further elucidate the impact of personal goals on residents’ choice in the R4 subspecialty match.