Why general internists are quitting clinical medicine

The Association of American Medical Colleges predicts that by 2025, the US health system will have 46,000 fewer primary care physicians than it needs.

If the prediction proves correct and we fail to develop effective mitigation strategies, the manpower shortage will create quite a mess. Ironically, the health reform law signed by President Obama in March will exacerbate the problem by increasing demand for services provided by primary care physicians.

The American College of Physicians and the American Board of Internal Medicine attribute the shortfall to declining numbers of medical graduates who choose to enter general internal medicine. There is plenty of evidence to support their assertion.

But a new study suggests there’s another factor that contributes as well—attrition from the ranks of general internal medicine—and it is occurring at a stunningly rapid rate. That’s the conclusion of Wayne Bylsma and colleagues, who published their findings last month in the Journal of General Internal Medicine.

In fact according to Bylsma’s group, nearly one in six general internists had left the practice of medicine before reaching the age of 50. By comparison, only one in 25 internal medicine subspecialists left the profession by midcareer.

To reach these conclusions, Bylsma’s group surveyed 3,610 physicians that passed an ABIM certification exam in general internal medicine or an IM subspecialty between 1990 and 1995.

Among the general internists who had left practice by midcareer, about two-thirds had begun practicing another field of medicine (usually Emergency Room medicine). The remaining physicians had either retired, quit practice altogether, or claimed to be only temporarily not working.

Bylsma’s group also found that three-quarters of general internists reported being somewhat or very satisfied with their careers. These numbers were slightly higher for subspecialists (70% vs. 77%).

Interestingly, a higher percentage of physicians who left internal medicine were satisfied with their new career (87%) than those remaining in practice (74%).

Bylsma’s group agreed with conventional wisdom that unpredictable work hours, growing expectations and accountability for providing high quality care, hassling with insurance companies and inadequate compensation contributed to high attrition rates among general internists.

But they also noted that of the internists who left practice, a majority (57%) did so for proactive reasons: “a change in interest or to take advantage of a preferred opportunity” (such as ‘looking for new challenges,’ ‘preferred Emergency Medicine,’ or ‘change in clinical interest’, for example).

“In the words of one respondent,” Bylsma’s team wrote, “[I] didn’t ‘leave [IM]’ per se—had always been focused on prevention and policy. IM was an important stepping stone in my training.”

Bylsma’s team concluded that general internists acquire an unusually broad skill set during training and while in practice, and this creates a natural springboard to pursue alternative careers.

To reduce the problem, the ACP wants to increase reimbursement from Medicaid and Medicare and implement patient-centered medical homes, which it believes will foster a better payment structure and perhaps cover the costs of electronic health records as well.

“Anything that can help change the practice environment by making it more rewarding for doctors … may make a difference in attracting new doctors and keeping doctors happily working,” Bylsma concluded.

Glenn Laffel is Sr. VP, Clinical Affairs at Practice Fusion.

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  • http://fertilityfile.com IVF-MD

    I believe this. With my own ears, I’ve heard my medical students say they are deciding more against IM and I’ve heard talk in the doctors’ dining room of disgruntled older doctors tossing around the idea of early retirement or switching to doing other things including one guy incredibly contemplating the crazy notion of going into a multi-level-marketing venture (yikes!).

    So if this really does continue as a trend, what can we expect? As the relative supply of Int Med doctors declines and the relative demand goes up, then the natural thing would be for the fees they command to go up. Over time, as the fees goes up, more doctors will have incentive to stay in or go into Int Med. Other options might arise innovatively to fill the need (either more efficient ways to practice Int Med or better use of ancillary personnel to help streamline the workflow). Also, the demand might go down when the fees go up, as patients decide to wait longer in between their doctor visits in order to save money. So the problem will solve itself. Yes, the above progression solves the problem, BUT it would only occur this way in an unfettered market, which is not what we have. So then what will happen in reality, given the system as it is now? Who knows?

  • http://onhealthtech.blogspot.com/ Margalit Gur-Arie

    Glenn,
    I’m not entirely certain that money will be enough of an enticement. I think the definition of primary care has been steadily eroding into irrelevancy.
    We need to empower the primary care doc to be the conductor of the specialists/hospitals orchestra (which is now playing with no direction). I think such a Maestro role will no longer be viewed as a mere springboard to a third violin sub specialty.

    • rwatkins

      “I think the definition of primary care has been steadily eroding into irrelevancy.”

      Every general internist I know is managing diabetes, coronary disease, hypertension,depression, etc., etc. for thousands of patients. I don’t consider that irrelevancy.

      Yes, the problem is money (and the secondary issue of administrative hassles that result from seeing too many patients in order to pay the bills).

      • http://onhealthtech.blogspot.com/ Margalit Gur-Arie

        Money is a prerequisite of course, but somehow I don’t think it is enough.
        People are increasingly self referring to specialists and hospitals are buying primary care practices for the sole purpose of controlling the supply chain, turning them into referral machines.
        I just think this is upside down and I think the UK has reached the same conclusion and are now planning to give GPs much more control over both structure and budget.

        • rwatkins

          “People are increasingly self referring to specialists”

          We say that, but do we have any data that it’s true?
          Most specialists I know require a referral from the PCP. My point is that every general internist I know is swamped with business: the majority of patients want a long term relationship with a PCP that they trust.

  • KP Internist

    Internists are generally a pretty mild mannered group of doctors. We can generally put up with quite a bit until a certain breaking point and we then vote with our feet.

  • SmartDoc

    Who in their right mind wants to sacrifice their youth, go in debt $200K, work 80 hour weeks, and be subject to the John Edwards crooked lawyer industry to be an irregularly/ill-payed, hyper-regulated enslaved de facto employee of truly loathsome politicians and petit tyrant bureaucrats?

    Medical students are fleeing for safer grounds than highly Medicare dependent practices. Internal Medicine is therefore to be avoided like the plague.
    .

    • http://fertilityfile.com IVF-MD

      When I lecture to my medical students, I always encourage them to make an active effort to explore the the true world of medicine, by learning from the real-life doctors who are out there in the trenches. I also encourage them all to check out KevinMD (free plug for your, Kev).

      SmartDoc, you are right, though. If students knew more about the reality of practicing medicine, they would be more informed and better at making decisions about their life pathway.

      When I discuss with them why they are choosing the fields they are choosing, instead of answers that reflect an understanding of a real-world medical practice, they give answers like “I want to go into GI, because I think the intestines are kinda cool and I like how digestion works”.

      Although the majority of students seem to just go along with the crowd, I do notice that there is a subset of medical students who are savvy and ambitious and making the extra effort to learn about the practical aspects of being a doctor and those are the ones who I believe will ultimately be happier because they’ll choose areas that are good for the particular criteria that they value, whether it be complexity, autonomy, a chance to interact with people, a chance to use their hands, easy hours in exchange for low pay, or rigorous hours in exchange for higher pay, etc.

      (And yes, I realize there are some who will semi-jokingly interject that it can end being rigorous hours for low pay)

  • Erik

    IVF-MD:

    Medicine is not an open economy where normal supply/demand forces are at work. Increased demand doesn’t result in increased prices.

    This problem will not resolve on it’s own using the invisible hand. Other forces are required to elicit the change needed to solve the problem.

    • http://fertilityfile.com IVF-MD

      Yes!
      Realizing the problem is half the battle.

      So let’s take this to the next step and ask WHY? What (or who) is preventing the natural power of voluntary market forces from solving the problem of health care delivery?

      Once we realize the answer, the light bulb will come on and we can work on the solution. However, it requires a lot of critical thinking “outside the box” for us to get there.

  • Dr Pi

    I left Primary care at age 65, because I could not run that hard, all day long, with patients scheduled every 10 minutes and stillgive the kind of medical care I had been taght and really value. I made NO money, but that wasn’t why I left–it wasn’t a question of money–it was the problem of RUNNING to see patients all day long and them 3-4 hours of paperwork, call backs, insurance “hold-pleases”, and the non-medical, patient -punishing system we have.
    I am now working in a sub-specialty and loving it–I don’t see nearly as many patients, I make more money and I can take the necessary time to teach (“doctor” means teacher) my patients what they actually came to hear from me. Primary Care as it is is doomed–it serves no one (OK, maybe the insurance companies and plantiffs lawers, but not the patients it claims to serve. I hate to sound like a scold, but I could not continue to pretend I was really truly helping patients the way I had been taught and they had come to expect from us physicians.

    • Max

      Dr. Pi,

      How did you go back for subspecialty training at age 65? How did you get a spot in a fellowship?

  • gerridoc

    I don’t think that paying Primary Care physicians more money is going to solve the problem. We need support for all the extra duties that we are expected to perform.