title: Market influences on internal medicine residents' decisions to subspecialize.
abstract: BACKGROUND
  Managed care reduces the demand for internal medicine subspecialists, but little empirical information is available on how increasing managed care may be affecting residents' training choices.
  
  
  OBJECTIVE
  To determine whether increased managed care penetration into an area where residents train was associated with a decreased likelihood that residents who completed general internal medicine training pursued subspecialty training.
  
  
  METHODS
  Secondary logistic regression analysis of data from the 1993 cohort of general internal medicine residents.
  
  
  METHODS
  U.S. residency training sites.
  
  
  METHODS
  2263 U.S. medical school graduates who completed general internal medicine residency training in 1993.
  
  
  METHODS
  The outcome variable (enrollment in subspecialty training) was derived from the Graduate Medical Education Tracking Census of the Association of American Medical Colleges (AAMC). Health maintenance organization (HMO) penetration (possible range, 0.0 to 1.0; higher values indicate greater penetration) was taken from the Interstudy Competitive Edge Database. Individual and medical school covariates were taken from the AAMC's Student and Applicant Information Management System database and the National Institutes of Health Information for Management Planning, Analysis, and Coordination system. The U.S. Census division was included as a control covariate.
  
  
  RESULTS
  980 participants (43%) enrolled in subspecialty training. Logistic regression analyses indicated a nonlinear association between managed care penetration into a training area and the odds of subspecialization. Increasing managed care penetration was associated with decreasing odds of subspecialization when penetration exceeded 0.15. The choice of subspecialty training increased as HMO penetration increased from 0 to 0.15.
  
  
  CONCLUSIONS
  Local market forces locally influenced the career decisions of internal medicine residents, but the influence was small compared with the effects of age and sex. These results suggest that market forces help to achieve more desirable generalist-to-specialist physician ratios in internal medicine.
authors.affiliation: Association of American Medical Colleges, Washington, DC 20037, USA.
authors.forename: E
authors.initials: E
authors.lastname: Valente
authors.forename: S M
authors.initials: SM
authors.lastname: Wyatt
authors.forename: E
authors.initials: E
authors.lastname: Moy
authors.forename: R J
authors.initials: RJ
authors.lastname: Levin
authors.forename: P F
authors.initials: PF
authors.lastname: Griner
mesh_terms: D000367:Age Factors; D002321:Career Choice; D015331:Cohort Studies; D006279:Health Maintenance Organizations / Q000191:economics* / Q000639:trends; D006801:Humans; D007388:Internal Medicine / Q000639:trends*; D007396:Internship and Residency; D012044:Regression Analysis; D012737:Sex Factors; D013038:Specialization; D014481:United States