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Saturday, April 30, 2011

Desperately seeking primary care internists

I practice primary care internal medicine in a group that consists of a few family practitioners, a few nurse practitioners and 7 internists, two of whom are also specialists. (An internist is defined as a physician who specializes in the detection, prevention and treatment of illnesses in adults.)  My office is across the state line from our primary office and has consisted of 3 internists and sometimes a nurse practitioner. I see patients in the office 4 days a week and also take care of  hospitalized patients.  The hospital is a very good but small (25 bed) facility, with cool features like an MRI machine, fully staffed emergency department and rooftop helicopter pad for transferring very sick patients to larger centers, and is a 20 second walk from my office. I think, right now, that mine is about the best job a person could have.

In two weeks, the third internist in my small office will be moving to another state.  He has been very productive and has been doing both general internal medicine on some very complex patients as well as practicing gastroenterology.  As a gastroenterologist, he does many well reimbursed procedures, and as a general internist he is very efficient, able to see many patients in a relatively short time.  He seems to be able to hear the most important issues and deal with them quickly, something I find very difficult, even after over 20 years of practice. When he leaves, many of his patients will want to continue to come to our office, and I and my partner, who is employed by the hospital doing hospital medicine in addition to her outpatient responsibilities, will attempt to absorb these new folks and meet their needs in addition to the needs of our already adequate patient panels while we attempt to find another internist to fill our empty position.

Simple, you might think, to find a person who would want to step into a job with a good salary, a terrific office atmosphere, in a town where mountain hiking is a 10 minute drive away, you can walk to work through a vibrant downtown, and where there are two major universities within only 7 miles. This job is really not a hard sell.  This week my partner and I went south to the closest internal medicine residency in the state to personally advertise the availability of this dream job.  We attended a job fair at the largest hospital in the capital city, catering to residents at that hospital and some of the other hospitals in the area. It turns out that nearly all of the residents attending the fair were family practitioners who generally have a different spectrum of practice than internists, including children and often providing obstetrical care. There were 4 internal medicine residents who would have been eligible for our job opening in the whole city and none of them showed up. I did really appreciate the chance to talk to representatives of hospitals and clinics all over the state, and to get a feel for the family practice residents. The food was also excellent.

This was only my first personal attempt to find a new partner, so I might still remain optimistic, except that the real numerical data about primary care internal medicine suggests that recruiting a new partner may be way more difficult than I had expected.  At this job fair I spoke with an internist who taught at the program and practiced at the hospital.  He had it on good authority that this year, 2011, only 175 physicians would enter the work force as general internists after completing residencies.  175 new primary care internal medicine doctors for the whole US.  I reviewed what data is available online and found that his numbers could not be far off.  There are about 3000 internal medicine residents in each year at the programs around the country and of those, 80% go on to become specialists such as cardiologists or oncologists, and of the remaining 20% more than half go on to practice pure hospital medicine.  So at best there might be 300 new primary care internists.  When I was a resident, nearly half of the internal medicine residents went into primary care, so attrition undoubtedly significantly outpaces replacement.  There is less than 1 new primary care internist for every million people in the US and so a city of a million might expect to get a replacement for a vacated position, but probably not.  A town our size, just over 20,000, would have to win the lottery to get a new internist who is capable and amiable and likes what we have to offer. Some older physicians are looking for new jobs, wanting to move to a new place or relocate closer to family. This is another source we can hope to draw from, but these numbers do not hold out much hope for success.

Because it is difficult to hire a physician, some groups use professional recruiters, the same brand of headhunter that many other professions depend upon.  Recruiters are a little like the matchmaker from The Fiddler on the Roof, making their money from putting two players together without any real stake in whether the match really works in the long run.  Both the job and the physician hiree are often misrepresented. The recruiter is expensive and the process of cleaning up the mess after a mismatch is even more expensive. When a group as small as ours does hire a new partner, that person is guaranteed a salary for the first year, and often it takes longer than that to attract enough patients to be busy.  This is not due to any fear of the new doctor, but just a mathematical phenomenon based on the fact that a small office has a correspondingly small flow of patients so accruing new ones is a slow process.

The shortage of primary care physicians is a real phenomenon and will probably be felt by most Americans.  With an increased focus on the importance of primary care, there has been a gradual increase in medical students choosing both family practice and internal medicine over the last few years, but not nearly to the extent that is necessary to fill the need.  This year there are over 10,000 family practitioners finishing training, which is gradually approaching the maximum number ever (nearly 11,000 in 1996). Medical students entering residency in internal medicine are also increasing, but not to historic levels. Most residents complete their training in big cities, and most want to stay in those same cities when they start practice, so some places are very well endowed with doctors.  Boston, for instance, has the highest ratio of primary care MDs to population of any city in the US.

For those of us who live in rural areas or middle America, expectations of medical care will need to change. I have thought that after the age of 65, most people would be best served by having an internal medicine doctor as their primary physician.  Since people as they age become more complex, it just seemed sensible that they would want to see a doctor who specialized in the practice of adult medicine. When I first went into practice the family practitioners actively avoided collecting elderly patients and encouraged them to establish with an internist.  Unless a person lives in Boston, expecting to have an internist as one ages will be unrealistic.  Patients will mainly be seeing family doctors and increasingly midlevel providers such as nurse practitioners or physicians' assistants.  There is absolutely nothing wrong with a good midlevel or family practitioner, but a doctor does get better at doing what he or she does, and it is internists who see entirely adult patients, and so we do get quite good at handling very complex problems. Much like the elves in Tolkien's Lord of the Rings it will be sad to see us go.

Why, you may ask, would it be difficult to get people to be primary care internists? It truly is a great job.  It is intellectually satisfying, gratifying to be able to share peoples' stories, we are well respected and the pay is not bad. Unfortunately it often does come down to the pay.  I have made the same amount of money for nearly 20 years, not corrected for inflation. Most residents enter the job market with nearly a quarter of a million dollars of educational debt, and a job in a specialty offers the chance to pay off this debt more than twice as fast as if one practices primary care. Because of the shortage of primary care internists, many doctors who are employed by large clinics are expected to see 20 or 30 patients in a day which is neither satisfactory for the doctor or the patient.  Documenting these encounters often takes many additional hours impinging on family time and quality of life. In my job, since I am self employed, I can sacrifice pay for a pace that makes both me and my patients happy. Specialists are paid more highly for similar hours of work, provide less comprehensive care, and often lead to both more expensive and more fragmented care for patients.

One of the most immediate solutions to the problem of too many specialists and not enough generalists would be to fund the education of doctors who would provide primary care.  There are loan forgiveness programs for doctors who serve rural communities, but it is not just rural communities that are underserved, and medical school is still incredibly expensive, outside of loans accrued.  In many graduate programs, a student can support him or herself on stipends, but even though medical students provide unpaid care for hospitalized patients, they receive no financial support at all through the four years of medical school. Changing reimbursement to favor primary care, though unpopular with specialists, would certainly provide an incentive to  move the best and the brightest into general internal medicine.

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