Valente E, Wyatt S M, Moy E, Levin R J, Griner P F
Association of American Medical Colleges, Washington, DC 20037, USA.
Ann Intern Med. 1998 Jun 1;128(11):915-21. doi: 10.7326/0003-4819-128-11-199806010-00010.
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.
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.
Secondary logistic regression analysis of data from the 1993 cohort of general internal medicine residents.
U.S. residency training sites.
2263 U.S. medical school graduates who completed general internal medicine residency training in 1993.
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.
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.
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.
管理式医疗降低了对内科专科医生的需求，但关于管理式医疗的增加如何影响住院医师培训选择的实证信息很少。
确定管理式医疗在住院医师培训地区的渗透率增加是否与完成普通内科培训的住院医师进行专科培训的可能性降低相关。
对1993年普通内科住院医师队列数据进行二次逻辑回归分析。
美国住院医师培训地点。
1993年完成普通内科住院医师培训的2263名美国医学院毕业生。
结果变量（专科培训入学情况）来自美国医学院协会（AAMC）的毕业后医学教育跟踪普查。健康维护组织（HMO）渗透率（可能范围为0.0至1.0；数值越高表示渗透率越高）取自Interstudy竞争优势数据库。个人和医学院协变量取自AAMC的学生和申请人信息管理系统数据库以及美国国立卫生研究院管理规划、分析和协调系统信息。美国人口普查分区作为对照协变量纳入。
980名参与者（43%）参加了专科培训。逻辑回归分析表明，管理式医疗在培训地区的渗透率与专科化几率之间存在非线性关联。当渗透率超过0.15时，管理式医疗渗透率的增加与专科化几率的降低相关。随着HMO渗透率从0增加到0.15，专科培训的选择增加。
当地市场力量在当地影响了内科住院医师的职业决策，但与年龄和性别的影响相比，这种影响较小。这些结果表明，市场力量有助于在内科实现更理想的通科医生与专科医生比例。
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