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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