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Attitudes and Perceptions of Internal Medicine Residents Regarding Pulmonary and Critical Care Subspecialty Training* FREE TO VIEW

Scott Lorin, MD; John Heffner, MD, FCCP; Shannon Carson, MD
Author and Funding Information

*From the Critical Care Education Center (Dr. Lorin), Division of Pulmonary, Critical Care, and Sleep Medicine, Mount Sinai School of Medicine, New York, NY; Center for Clinical Effectiveness and Patient Safety (Dr. Heffner), Department of Medicine, Medical University of South Carolina, Charleston, SC; and Department of Medicine (Dr. Carson), University of North Carolina, Chapel Hill, NC.

Correspondence to: Scott Lorin, MD, The Mount Sinai Medical Center, Box 1232, One Gustave L. Levy Place, New York, NY 10029-6574; e-mail: scott.lorin@mountsinai.org



Chest. 2005;127(2):630-636. doi:10.1378/chest.127.2.630
Text Size: A A A
Published online

Study objective: To evaluate the attitudes and perceptions of internal medicine residents regarding pulmonary and critical care medicine (PCCM) training.

Design: Prospective study.

Setting: Three university hospitals.

Methods: An eight-page survey was distributed and collected between March 1, 2002, and June 30, 2002. All internal medicine or internal medicine/pediatric residents training at the three institutions were eligible for the study.

Results: One hundred seventy-eight residents in internal medicine from an eligible pool of 297 residents returned the survey (61% response rate). PCCM accounted for only 3.4% of the career choices. Forty-one percent of the residents seriously considered a pulmonary and/or critical care fellowship during their residency. Of these residents, 23.5% found the combination of programs the more attractive option, while 2.8% found pulmonary alone and 14.5% found critical care alone more attractive. Key factors associated with a higher resident interest in PCCM subspecialty training included more weeks in the ICU (p = 0.008), more role models in PCCM (3.02 ± 0.78 vs 3.45 ± 0.78, p = 0.0004), and resident observations of a greater sense of satisfaction among PCCM faculty (3.07 ± 0.82 vs 3.33 ± 0.82, p = 0.04) and fellows (3.05 ± 0.69 vs 3.31 ± 0.86, p = 0.03) [mean ± SD]. The five most commonly cited attributes of PCCM fellowship that would attract residents to the field included intellectual stimulation (69%), opportunities to manage critically ill patients (51%), application of complex physiologic principles (45%), number of procedures performed (31%), and academically challenging rounds (29%). The five most commonly cited attributes of PCCM that would dissuade residents from the field included overly demanding responsibilities with lack of leisure time (54%), stress among faculty and fellows (45%), management responsibilities for chronically ill patients (30%), poor match of career with resident personality (24%), and treatment of pulmonary diseases (16%).

Conclusions: Internal medicine residents have serious reservations about PCCM as a career choice. Our survey demonstrated that a minority of US medical graduates actually would choose PCCM as a career, which suggests that efforts to expand PCCM training capacity might result in vacant fellowship slots. To promote greater interest in PCCM training, efforts are needed to improve the attractiveness of PCCM and address the negative lifestyle perceptions of residents.

Data have emerged that the growing health-care needs of an aging population will outpace the future supply of intensivists and pulmonologists.12 If current projections are correct, training programs will need to expand their capacity and encourage more residents to apply for pulmonary and critical care training. To maintain an adequate supply of physicians and to improve interest in pulmonary and critical care medicine (PCCM), it is important to evaluate the perceptions and influences of house staff officers in internal medicine residencies toward PCCM training. We report survey results that assessed these attitudes to better understand the career interests and needs of internal medicine residents and the barriers they perceive to entering PCCM fellowship training.

Three internal training medicine programs participated in the survey and included the medical centers at Mount Sinai (New York), University of North Carolina (UNC), and the Medical University of South Carolina (MUSC). Each institution is a tertiary care center affiliated with a medical school.

The content, wording, and format of the survey were developed after discussions within focus groups of internal medicine residents and PCCM fellows and attendings. A list of factors influencing subspecialty decisions was then developed taking into consideration their opinions of PCCM.

An eight-page survey was developed and organized into five sections. The first section requested residents to provide information on their personal and demographic characteristics, career plans, and PCCM experiences during their residency. In section two, residents were asked to compare their perceptions of PCCM with other careers in internal medicine and its subspecialties. A 5-point Likert scale was used to identify a range of responses (1 = much less, 2 = somewhat less, 3 = similar, 4 = somewhat more, and 5 = much more). Section three evaluated the perceptions and influences toward the PCCM fellowship compared to other subspecialty fellowships. In section four, residents chose 3 characteristics that most attracted them and 3 characteristics that most dissuaded them from a career in PCCM from a list of 17 choices. A comments section, in a free-text format, concluded the survey.

Pretesting was performed with pulmonary and critical care fellows who reviewed the questionnaire for clarity and relevance. Subsequent revisions were made based on their comments. All internal medicine or internal medicine/pediatric residents training at the three institutions were eligible for the study. The surveys were distributed and collected between March 1, 2002, and June 30, 2002. Mount Sinai was the primary coordinating center. The survey was distributed to all of the eligible residents.

All statistical analyses were performed using software (Statistica for Windows, release 5.0; StatSoft; Tulsa, OK). Continuous variables were expressed as mean ± SD. Frequencies were described for categorical variables. Univariate analyses were performed using the χ2 test for proportions and the pooled t test or Wilcoxon rank-sum test for continuous variables. A relation or difference was considered significant if p < 0.05.

Resident Demographics

One hundred seventy-eight residents in internal medicine from an eligible pool of 297 residents returned the survey (61% response rate) from the three institutions. Institutional response rates were 48% at Mount Sinai, 64% at UNC, and 72% at MUSC. Table 1 demonstrates the characteristics of the respondents.

Resident Career Goals

Ninety-four respondents (53.0%) chose private clinical practice as their career goal, followed by academic private practice (44.0%), undecided (15.0%), clinical research (10.0%), bench research (4.0%), and other (2.0%). A career in general medicine was the most popular career choice and was planned by 35 of the respondents (19.6%). PCCM accounted for only 3.4% of the career choices. General internal medicine was followed by cardiology (16.2%), undecided (12.9%), gastroenterology (12.3%), hematology/oncology (8.9%), and nephrology (8.4%). Other subspecialties accounted for the remaining 14.0%, with < 4.0% in each subspecialty.

Resident ICU Experience

Forty-five respondents (25.1%) completed < 4 weeks in an ICU setting, 52 respondents (29.1%) completed 5 to 8 weeks, 52 respondents (29.1%) completed 9 to 12 weeks, and 29 respondents (16.0%) completed > 12 weeks. Residents who completed > 4 weeks in the ICU were more likely to find role models in PCCM as compared with residents with < 4 weeks ICU experience (p = 0.04). More than 90% (n = 162) of the residents stated that they worked in a closed ICU. One hundred fifty-seven residents (88%) reported performing ICU rotations in a university hospital, 46 residents (26%) in a community hospital, and 59 residents (33%) in a Veteran Administration hospital. No residents had worked in a military setting.

Resident Interest in PCCM Fellowships

Forty-one percent of respondents seriously considered a pulmonary and/or critical care fellowship during their residency. Of these residents, 23.5% found the combination of programs the most attractive option, while 2.8% found pulmonary alone and 14.5% found critical care alone the most attractive options. Several factors were associated with a higher resident interest in PCCM subspecialty training (when compared by a 5-point Likert scale). These factors included more weeks in the ICU (p = 0.008), more role models in PCCM (3.02 ± 0.78 vs 3.45 ± 0.78, p = 0.0004), resident observations of a greater sense of satisfaction among faculty (3.07 ± 0.82 vs 3.33 ± 0.82, p = 0.04), resident receipt of more encouragement from faculty to join PCCM (2.86 ± 0.77 vs 3.11 ± 0.87, p = 0.05), resident perception of a higher level of prestige of a pulmonary and critical care fellowship as compared with other subspecialty fellowships (3.19 ± 0.67 vs 3.39 ± 0.64, p = 0.04), resident observation of a high sense of satisfaction among PCCM fellows (3.05 ± 0.69 vs 3.31 ± 0.86, p = 0.03), and resident receipt of encouragement to join the field by PCCM fellows (2.81 ± 0.67 vs 3.05 ± 0.92, p = 0.05).

Resident Pulmonary Experience

Thirty-nine percent of residents enrolled in a pulmonary elective during their residency. Residents who enrolled in a pulmonary elective were more likely to respond that the income potential in PCCM as compared to other subspecialty fields was greater (3.36 ± 0.80 vs 3.63 ± 0.62, p = 0.02), the number of role models in PCCM was greater (3.01 ± 0.81 vs 3.48 ± 0.72, p = 0.0001), the encouragement to join the field by faculty is greater (2.81 ± 0.84 vs 3.20 ± 0.75, p = 0.002), the working hours in PCCM fellowship is greater (3.81 ± 0.85 vs 3.54 ± 0.91, p = 0.05), the number of fellow role models is greater (3.05 ± 0.67 vs 3.27 ± 0.68, p = 0.04), the sense of satisfaction among fellows is greater (3.03 ± 0.75 vs 3.35 ± 0.78, p = 0.007), and the encouragement to join the field by fellows is greater (2.79 ± 0.76 vs 3.10 ± 0.81, p = 0.01). A fellow was more likely to inquire whether the resident enrolled in a pulmonary elective was interested in a PCCM fellowship as compared with residents that did not take a pulmonary elective (p = 0.003). Fifty-three percent of residents had equal exposure to both pulmonary and critically ill patients during their residency, while 24% had greater involvement with pulmonary patients and 21.8% had greater involvement with critically ill patients.

Relationship Between PCCM Attending or Fellow and Residents

Thirty-nine percent of residents responded that an attending physician had inquired whether they were interested in a PCCM fellowship. Forty-two percent of residents had a fellow inquire. Residents were more likely to state interest in PCCM training if a fellow (p < 0.05) or an attending (p = 0.008) ever inquired about their interest in a PCCM fellowship. Respondents reported more frequent interactions with both the attending and fellow together (53.1%), than with the fellow (35.8%) or attending alone (7.3%). Residents with more frequent interactions with a fellow than an attending were more likely to believe that PCCM fellowship training, as compared with other subspecialty fellowships, would have a larger impact on their personal time (3.31 ± 0.76 vs 3.92 ± 0.75, p = 0.009) and require more years of training (2.77 ± 0.44 vs 3.22 ± 0.45, p = 0.002), but would offer prestige at their institution (2.92 ± 0.76 vs 3.55 ± 0.64, p = 0.003).

Resident Perceptions of PCCM

Survey responses profiled residents’ perceptions of PCCM as compared with other careers in internal medicine (Table 2 ). All of the factors assessed were considered to be associated to a greater degree with PCCM, except encouragement to join the field by faculty.

Residents were also surveyed regarding their perceptions regarding PCCM as compared with other subspecialty fellowships (Table 3 ). All of the factors were associated with PCCM to a greater degree except for length of fellowship training, competitiveness to get into the fellowship, and the encouragement to join the field by PCCM fellows.

The five most commonly cited attributes of PCCM fellowship that would attract residents to the field included intellectual stimulation (69%), opportunities to manage critically ill patients (51%), application of complex physiologic principles (45%), number of procedures performed (31%), and academically challenging rounds (29%) [Table 4] .

The five most commonly cited attributes of PCCM that would dissuade residents from the field included overly demanding responsibilities with lack of leisure time (54%), stress among faculty and fellows (45%), management responsibilities for chronically ill patients (30%), poor match of career with resident personality (24%), and treatment of pulmonary diseases (16%) [Table 5] .

This survey of internal medicine residents demonstrates that 41% seriously considered a PCCM fellowship during their residency, yet only 3.4% actually chose to enter PCCM subspecialty training. Surveyed residents cited several reasons for not entering PCCM training, which included poor lifestyle, apparent stress among faculty and fellows, treatment of chronically ill patients, and their confusion regarding the linkage and professional boundaries between pulmonary medicine and critical care medicine.

Resident perceptions regarding professional lifestyle dominated factors that dissuaded residents from choosing a PCCM career. Residents consistently graded the level of stress, work hours, and impact on personal time with PCCM more negatively as compared to other careers in internal medicine and other subspecialties. The negative lifestyle perceptions outweighed positive perceptions of higher prestige within the profession and greater income potential with PCCM as compared with other careers in internal medicine. Almost 20% of surveyed residents chose general internal medicine as their career choice. These observed perceptions regarding lifestyle and career satisfaction contrast with those of Wetterneck and colleagues,3 who demonstrated in a survey of practicing physicians that the satisfaction variable of personal time was similar between general internists and subspecialists, and that general internists were less satisfied with their careers as compared with subspecialists. This study, however, considered all subspecialties in aggregate and did not compare perceptions between general medicine and PCCM specifically. This study combined with our results does suggest, however, that residents need assistance in reconciling their impressions with reality in regard to perceived lifestyle differences between specialties. However, no association was found in our study between “lifestyle variables” and resident gender, marital status, or loan indebtedness.

While it appears that medical students’ specialty choice may be driven at least partially by better-paying job opportunities in order to reduce educational debt, it is unclear whether financial concerns steer internal medicine residents toward training positions in higher-paying subspecialties.4Although the surveyed residents indicated that they perceived PCCM to have similar to somewhat greater income potential as compared with other subspecialties (Likert score, 3.5 ± 0.7), cardiology and gastroenterology were two of the top three most popular career choices in our study. These two subspecialties are among the most highly reimbursed in internal medicine and experienced the largest increases in compensation from 2003 to 2004 according to the American Medical Group Association 2004 Medical Group Compensation and Financial Survey.5 We did not specifically survey residents as to the importance of income in decisions not to pursue PCCM training. Further studies will be needed to assess this relationship.

Residents in our study noted increased stress among PCCM fellows and faculty, which discouraged interest in PCCM training. Critical care medicine clearly entails extensive responsibilities for severely ill patients and long hours that can induce professional stress, leading to burnout.6No studies exist that measure the frequency of burnout among trainees or practitioners of combined pulmonary and critical care. Guntupalli and Fromm,7 however, demonstrated the common occurrence of burnout among general internists trained in critical care medicine without pulmonary subspecialty training. Emotional exhaustion and depersonalization derived from critical care work-related stress and the absence of adequate support systems were noted,7as has been reported for other medical specialties.8It is not known if the ability to modulate the critical care component of a combined pulmonary and critical care practice attenuates risk for burnout. To encourage interest in PCCM along with other career choices associated with long hours and work-related stress, resident training programs should include curricula that address factual data regarding work-related stress and support structures that can modify the personal impact of stress. Further research is required in this area considering that most of the existing literature regarding burnout in critical care pertains to ICU nurses.911

Management of chronically ill patients was an additional factor in our study that dissuaded interest in PCCM. Davis and coworkers12 showed that 91% of students entering medical school voice an interest in caring for chronically ill patients. This positive attitude eroded after completion of their clinical rotations with 25% of respondents stating they would seek another career specialty if the proportion of chronically ill patients increased in their chosen field. Considering that an aging population underscores an increasing need to prepare providers in multiple specialties to manage chronically ill patients, efforts during residency to stimulate interest in long-term care might promote PCCM recruitment.

Residents in our study appeared to have difficulty understanding the relationship between pulmonary medicine and critical care medicine and expressed lower interest in pulmonary training. Sixteen percent of residents stated that the pulmonary component of training would dissuade them from a career in PCCM, which is twice the proportion who found pulmonary an attractive component. Among the 41% who seriously considered a PCCM fellowship, almost 24% would pursue a combined pulmonary critical care fellowship, while only 2.8% would pursue pulmonary alone. This observation contrasted with the 14.5% who would pursue critical care training alone.

These resident perceptions vary from the realities of pulmonary and critical care training in the United States. While there are four different Accreditation Council for Graduate Medical Education-approved pathways to train in critical care (ie, internal medicine, surgery, anesthesia, and pulmonary), 71% of the critical care fellows train through PCCM. Reshetar and colleagues13reviewed the first decade experience of the American Board of Internal Medicine certification in critical care medicine and reported that 87% of diplomates certified were trained in pulmonary medicine. Those with PCCM training performed better on the certifying examination than those with other subspecialty training experience, which may relate to several factors other than the relative quality of training programs or abilities of fellowship graduates.14 Nevertheless, the extensive curricular and professional practice overlap between pulmonary medicine and critical care medicine has promoted it as the most popular training route for practitioners of both pulmonary medicine and critical care medicine. Recruitment into PCCM may benefit from exposing medical residents to the natural affinities between pulmonary medicine and critical care medicine and the benefits of combined training, which relate to a greater variety of marketable skills in both academic and clinical practice, more variation in professional practice, and greater flexibility for altering the focus of clinical practice over time.

There are several limitations to our study. First, we surveyed a sample of predominantly allopathic residents at only three training programs within the United States, all of which were at major academic institutions. We were interested, however, in studying perceptions of resident graduates who would stay in the United States, where they trained in PCCM. Moreover, we believe that the geographic separation of our study sites supports the generalization of our findings. Also, absence of data from community hospital training sites does not limit our findings because the majority of PCCM fellows come from academic residency programs. Because the majority of residents in our study worked in closed ICUs, it is possible that experiences in an open ICU may present residents with more positive experiences. We doubt the importance of this factor, however, because of the improved outcomes demonstrated in closed ICUs and the greater exposure to pulmonary critical care physicians that a closed ICU affords. The overall response rate of 61% was sufficient for this study; no systematic bias was introduced in failing to assess the perceptions of nonresponders who were unavailable for the survey because of off-site rotations and vacation schedules, or those who had negative or indifferent attitudes toward the specialty and therefore had no interest in the survey. As an observational study, we do not imply any causation between the explanatory variables and the outcomes measured.

The present study has implications regarding the importance of role modeling and mentoring by faculty and fellows to promote resident interest in PCCM. The influence of a role model is a frequently cited factor in choosing a specialty choice among medical students.15Haponik and coworkers16 demonstrated that the reorganization of their pulmonary and critical care division with greater emphasis on educational opportunities resulted in more residents selecting pulmonary consultation electives and entering PCCM fellowships. They also found that the presence of role models offered by a thriving fellowship program had a measurable beneficial impact on residents choosing pulmonary fellowships after completion of residency training. Our study complements these findings in that length of time spent by residents in the ICU or enrolled in a pulmonary elective was associated with a greater number of role models within PCCM, a higher regard for the prestige of PCCM, and a greater likelihood of entering PCCM training. The potential for negative mentoring, however, does exist considering that residents with a greater exposure to fellows had a stronger impression regarding the impact of PCCM training and practice on their personal time and lives.

In conclusion, we found that internal medicine residents demonstrated varying interests in PCCM training and perceptions regarding the nature of PCCM and its impact on their professional lives. Some of these perceptions may underlie the low interest in entering PCCM training demonstrated in the survey responses. Critical care medicine faces an emerging workforce shortage that will negatively impact ICU resources and critical care for an aging population. One potential solution is to increase the amount of critical care fellowship positions. Our survey demonstrated that even if the amount of spots and programs to train PCCM fellows were to increase, few US medical graduates actually choose PCCM as a career and therefore those extra spots would either remain vacant or filled by foreign medical graduates, not satisfying the predicted shortfalls. To promote greater interest in PCCM training, efforts are needed to improve the attractiveness of PCCM and address the negative lifestyle perceptions of residents. These efforts can build on positive resident perceptions of PCCM, such as high intellectual stimulation, opportunities to treat acutely ill patients, challenges of complex physiology, and the appeal of the interventional procedures attached to the field. Successful efforts, however, will require examination of the attitudes of fellows and faculty in PCCM to provide positive mentoring and greater research into support systems and practice modifications that can attenuate the negative impact of PCCM on lifestyles and the risk for burnout. These challenges have broad implications for the revision of PCCM educational curricula.

Abbreviations: MUSC = Medical University of South Carolina; PCCM = pulmonary and critical care medicine; UNC = University of North Carolina

Table Graphic Jump Location
Table 1. Characteristics of Internal Medicine Residents*
* 

Data are presented as mean (SD) or % unless otherwise indicated.

Table Graphic Jump Location
Table 2. Resident Perceptions of PCCM Experiences as Compared With Other Careers in Internal Medicine*
* 

Scores are presented as mean ± SD response on a 5-point Likert scale: 1 = much less, 2 = somewhat less, 3 = similar, 4 = somewhat more, 5 = much more.

Table Graphic Jump Location
Table 3. Resident Perceptions Regarding PCCM Fellowship Compared to Other Subspecialty Fellowships*
* 

Scores are presented as mean ± SD response on a 5-point Likert scale: 1 = much less, 2 = somewhat less, 3 = similar, 4 = somewhat more, 5 = much more.

Table Graphic Jump Location
Table 4. Features That Most Attract the Resident Toward a Career in PCCM*
* 

Residents were asked to choose up to 3 features that most attract them toward a career in PCCM from a list of 17 features.

Table Graphic Jump Location
Table 5. Features That Most Dissuade the Resident From a Career in PCCM*
* 

Residents were asked to choose up to 3 features that most dissuade them from a career in PCCM from a list of 16 features.

Angus, DC, Kelley, MA, Schmitz, RJ, et al (2000) Current and projected workforce requirements for care of the critically ill and patients with pulmonary disease (COMPACCS).JAMA284,2762-2770. [CrossRef] [PubMed]
 
Kelley, MA, Angus, DA, Chalfin, DB, et al The critical care crisis in the United States.Chest2004;125,1514-1517. [CrossRef] [PubMed]
 
Wetterneck, TB, Linzer, M, McMurray, JE, et al Worklife and satisfaction of general internists.Arch Intern Med2002;162,649-656. [CrossRef] [PubMed]
 
Adams D. School debt helps drive medical students into specialty matches. American Medical News. Available at: www.ama-assn.org/amednews/index.htm. Accessed November 5, 2004.
 
American Medical Group Association. American Medical Group Associations’s 2004 medical group compensation and financial survey. Available at: www.amga.org. Accessed November 5, 2004.
 
Gundersen, L Physician burnout.Ann Intern Med2001;135,145-148. [PubMed]
 
Guntupalli, KK, Fromm, RE, Jr Burnout in the internist-intensivist.Intensive Care Med1996;22,625-630. [CrossRef] [PubMed]
 
Freeborn, DK Satisfaction, commitment, and psychological well-being among HMO physicians.West J Med2001;174,13-18. [CrossRef] [PubMed]
 
Caine, RM, Ter-Bagdasarian, L Early identification and management of critical incident stress.Crit Care Nurse2003;23,59-65. [PubMed]
 
Chen, SM, McMurray, A “Burnout” in intensive care nurses.J Nurs Res2001;9,152-164. [CrossRef] [PubMed]
 
Sundin-Huard, D, Fahy, K Moral distress, advocacy and burnout: theorizing the relationships.Int J Nurs Pract1999;5,8-13. [CrossRef] [PubMed]
 
Davis, BE, Nelson, DB, Sahler, OJ, et al Do clerkship experiences affect medical students’ attitudes toward chronically ill patients?Acad Med2001;76,815-820. [CrossRef] [PubMed]
 
Reshetar, RA, Norcini, JJ, Mills, , et al The first decade of the American Board of Internal Medicine certification in critical care medicine: an overview of examinees and certificate holders from 1987 through 1996.Crit Care Med2000;28,1191-1195. [CrossRef] [PubMed]
 
Dellinger, RP Internal medicine based critical care training: straight internal medicine versus pulmonary.Crit Care Med2000;28,1251-1252. [CrossRef] [PubMed]
 
Wright, SM, Carrese, JA Excellence in role modeling: insight and perspectives from the pros.Can Med Assoc J2002;167,638-643
 
Haponik, E, Bowton, D, Chin, R, et al Pulmonary section development influences general medicine house officer interests and ABIM certifying examination performance.Chest1996;110,533-538. [CrossRef] [PubMed]
 

Figures

Tables

Table Graphic Jump Location
Table 1. Characteristics of Internal Medicine Residents*
* 

Data are presented as mean (SD) or % unless otherwise indicated.

Table Graphic Jump Location
Table 2. Resident Perceptions of PCCM Experiences as Compared With Other Careers in Internal Medicine*
* 

Scores are presented as mean ± SD response on a 5-point Likert scale: 1 = much less, 2 = somewhat less, 3 = similar, 4 = somewhat more, 5 = much more.

Table Graphic Jump Location
Table 3. Resident Perceptions Regarding PCCM Fellowship Compared to Other Subspecialty Fellowships*
* 

Scores are presented as mean ± SD response on a 5-point Likert scale: 1 = much less, 2 = somewhat less, 3 = similar, 4 = somewhat more, 5 = much more.

Table Graphic Jump Location
Table 4. Features That Most Attract the Resident Toward a Career in PCCM*
* 

Residents were asked to choose up to 3 features that most attract them toward a career in PCCM from a list of 17 features.

Table Graphic Jump Location
Table 5. Features That Most Dissuade the Resident From a Career in PCCM*
* 

Residents were asked to choose up to 3 features that most dissuade them from a career in PCCM from a list of 16 features.

References

Angus, DC, Kelley, MA, Schmitz, RJ, et al (2000) Current and projected workforce requirements for care of the critically ill and patients with pulmonary disease (COMPACCS).JAMA284,2762-2770. [CrossRef] [PubMed]
 
Kelley, MA, Angus, DA, Chalfin, DB, et al The critical care crisis in the United States.Chest2004;125,1514-1517. [CrossRef] [PubMed]
 
Wetterneck, TB, Linzer, M, McMurray, JE, et al Worklife and satisfaction of general internists.Arch Intern Med2002;162,649-656. [CrossRef] [PubMed]
 
Adams D. School debt helps drive medical students into specialty matches. American Medical News. Available at: www.ama-assn.org/amednews/index.htm. Accessed November 5, 2004.
 
American Medical Group Association. American Medical Group Associations’s 2004 medical group compensation and financial survey. Available at: www.amga.org. Accessed November 5, 2004.
 
Gundersen, L Physician burnout.Ann Intern Med2001;135,145-148. [PubMed]
 
Guntupalli, KK, Fromm, RE, Jr Burnout in the internist-intensivist.Intensive Care Med1996;22,625-630. [CrossRef] [PubMed]
 
Freeborn, DK Satisfaction, commitment, and psychological well-being among HMO physicians.West J Med2001;174,13-18. [CrossRef] [PubMed]
 
Caine, RM, Ter-Bagdasarian, L Early identification and management of critical incident stress.Crit Care Nurse2003;23,59-65. [PubMed]
 
Chen, SM, McMurray, A “Burnout” in intensive care nurses.J Nurs Res2001;9,152-164. [CrossRef] [PubMed]
 
Sundin-Huard, D, Fahy, K Moral distress, advocacy and burnout: theorizing the relationships.Int J Nurs Pract1999;5,8-13. [CrossRef] [PubMed]
 
Davis, BE, Nelson, DB, Sahler, OJ, et al Do clerkship experiences affect medical students’ attitudes toward chronically ill patients?Acad Med2001;76,815-820. [CrossRef] [PubMed]
 
Reshetar, RA, Norcini, JJ, Mills, , et al The first decade of the American Board of Internal Medicine certification in critical care medicine: an overview of examinees and certificate holders from 1987 through 1996.Crit Care Med2000;28,1191-1195. [CrossRef] [PubMed]
 
Dellinger, RP Internal medicine based critical care training: straight internal medicine versus pulmonary.Crit Care Med2000;28,1251-1252. [CrossRef] [PubMed]
 
Wright, SM, Carrese, JA Excellence in role modeling: insight and perspectives from the pros.Can Med Assoc J2002;167,638-643
 
Haponik, E, Bowton, D, Chin, R, et al Pulmonary section development influences general medicine house officer interests and ABIM certifying examination performance.Chest1996;110,533-538. [CrossRef] [PubMed]
 
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