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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.

Saturday, April 9, 2011

What is an impaired physician?

A hot topic in medicine is the "impaired physician". There was a whole series in the throw-away journal Pain Medicine written by a doctor who spectacularly screwed his life up by getting addicted to opiate pain medications, then overprescribing those same drugs to patients and defrauding Medicare and Medicaid by charging for procedures that he didn't do. He proceeded to run off to various foreign countries where he managed to keep himself fed and housed until finally returning to the US to serve his time and probably not practice medicine. The articles he wrote were luridly exciting, definitely not in the category of "there but for the grace of God go I."

Most of us in medicine have had contact with a colleague who has some kind of a substance abuse problem. I personally have had 3 colleagues with whom I worked closely who had trouble with both drugs and alcohol to the extent that their work was affected and they had to take time off, do a treatment program and be supervised after returning to practice. All three were excellent physicians when they were straight, and jeopardized others when they were not. I think the system probably worked for them, preventing irreversible harm and letting them get rid of their demons and return to practice. The stories these physician addicts tell are often pretty similar. They start self prescribing medications for pain, often headaches, find that when medicated they can work through the pain and maybe the work is just a little more fun. Eventually the dose required to treat their condition increases and it becomes harder to maintain normal work habits. The physician starts missing work and is moodier. Finally there is a mistake that leads to disciplinary action or legal action and the jig is up. The physician gets help.

Substance abuse is the impairment we usually talk about, but by far the least common. Training in medicine is painful. The amount of information to be learned is huge, and the competition to even begin the process is fierce. Once the part of training that involves direct care of patients starts, the patient takes precedence and nothing but incapacitating illness is a good enough excuse for not doing the job. Some medical students or residents have been known to do rounds while hooked up to an IV. Because I was out of town, another doctor in my practice worked with the stomach flu, which she had gotten from a patient in the hospital, pregnant, until she went into premature labor and called me to see if I would come back early to cover the patients. I have worked with influenza until the office canceled all of my patients without my permission, then went home and was unable to move from the couch for 12 hours. It was pretty hard to concentrate on that last patient's questions. At least one of the patients at my office caught the flu one incubation period from when they saw me, and got dangerously ill. My fault.

Another physician impairment that affects patient care is fatigue and burnout. Taking call is a fact of life for most physicians, and can involve sleepless nights. Although rules have been enacted to prevent physicians in training from spending too long at work, this is not the case for physicians in practice. A busy night often means a busy day, since sick patients frequently stay sick and require ongoing care. Doctors who work too hard often begin to get a "God complex" believing that they are so important that life cannot go on without them. They agree to work longer and longer hours and become more irritable and unreasonable. They worry about making more money, since only retirement will ease their suffering. 

I attended the funeral of the nurse practitioner who shared my office this afternoon. She was a wonderful woman with a big laugh, a delightful smile, a quirky sense of humor, big ideas for changing the world and a huge wealth of expertise and experience formed over 25 years of study and practice. Over the last few months she had been missing more work and had seemed more fatigued. I knew that she had chronic pain related to a motor vehicle accident in the past and a couple of chronic medical conditions, autoimmune, that gave her daily trouble. Her gradual decrease in life force seemed like it might be just a bump in the road, an exacerbation of the conditions that she had learned to deal with over many years. I never questioned her about being sick, since she knew that I was there if she needed me, and I didn't want to intrude on her privacy. She worked until one day she couldn't stand up and so she had her husband bring her to the office. She was profoundly anemic and iron deficient, related to slow intestinal bleeding. She knew it was a problem, but not how bad it had gotten. It is not hard to treat iron deficiency. A blood transfusion provides instant relief, though at the risk of overloading a heart that might have weakened by chronic muscle iron deficiency and overwork. Her color was better after getting blood, but she was still feeling bad. A couple of days after going home from the hospital she became more short of breath and died. An autopsy showed that a large blood clot had migrated from her leg to her lung, a completely unexpected event. She had also had small clots in her lungs over the preceding weeks, which must have been a huge strain on a system already weakened by anemia. I will miss her a great deal.

The solution to the problem of "impaired physicians", myself, my stoic partners and colleagues is not in any way simple. With the looming problem of a primary care physician shortage, there will be even more of a conflict between the need to take care of ourselves and the need to care for our very sick patients.  All I can think of to honor my nurse practitioner partner's sacrifice is to consider the many ways in which we can take care of our patients more efficiently, ministering to them in a way that honors what is truly important and backing away from medicine we practice that is defensive or based on reimbursement. Re-working payment strategies and training programs to train adequate numbers of providers is vital. It is also vital to extend the concept of compassion to include the individuals who take care of patients.