Are Primary Care Doctors a Vanishing Breed?

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Dec. 4, 2012 — Doctors who practice general internal medicine, known as internists, may be a vanishing breed, according to a new study.

In the new research, few medical residents in general internal medicine programs say they plan to pursue that career path. Instead, they plan to become specialists.

“What this study is showing is, only one in five graduating internal medicine residents is planning a career in general medicine or primary care,” says researcher Colin West, MD, PhD, associate professor of medicine and general internal medicine physician at Mayo Clinic in Rochester.

The study is published in the Journal of the American Medical Association.

Internists: The Survey

West used an annual survey that is linked to an exam. He focused on data from nearly 17,000 third-year residents in 2009, 2010, and 2011.

These residents told which career paths they planned to follow. 

Overall, just 21.5%, or about one in five, said they planned to pursue a general internal medicine career.

Of those who enrolled in a primary care program (typically with the goal of entering primary care), only about 40% said they still planned to stay with general internal medicine. Of those who entered a traditional “categorical” program, about 20% planned to be general internists.

The others planned to specialize in cardiology, gastroenterology, pulmonary medicine, or other areas, West says.

Internists’ Shortage by the Numbers

West and others have long predicted a shortage of generalist doctors. The new study is yet more evidence, he says.

Research published in 1992 found that more than half of all internal medicine residency graduates stayed with general internal medicine, so West’s findings have slashed that number even more.

In a 2010 report, the Association of American Medical Colleges predicted that the doctor shortage will reach 91,500 by 2020. It says about half of that will be primary care doctors.

The situation may be even worse than expected, West says, as the provisions of the Affordable Care Act (ACA) go into effect. Health care reform focuses on coverage of tens of million of people in the U.S. who are uninsured.

Internal medicine doctors would be expected to be the caregivers for many.

The ACA includes many provisions to expand the workforce of primary care doctors, writes Mark D. Schwartz, MD, of the VA’s New York Harbor Healthcare System, but implementation depends on getting enough money from Congress.

Schwartz wrote an editorial to West’s study in JAMA.

Explaining Career Goals

While the survey did not ask residents to explain their career decisions, West cites two possibilities.

  • Life-work balance. “A major consideration is lifestyle and work-life balance, particularly from younger residents,” he says. Some specialists may have more control over their schedule and office hours.
  • Money. “Subspecialists can make twice as much,” he says. While a general internist may make about $200,000, West says, citing a 2011 report, specialists such as a cardiologist often make twice that annually.

Doctor Shortage: Perspectives

Income is a major factor driving residents to become specialists, says David Battinelli, MD, chief academic officer at North Shore-LIJ Health System in Great Neck, N.Y., and dean of medical education at Hofstra North Shore-LIJ School of Medicine.

He cites the hours, as well, with schedules for specialists often more predictable. “The general internist by and large takes care of the patient when he is sick, as opposed to when the doctor’s office is open,” he says.

Economics is a driver, agrees Martha S. Grayson, MD, senior associate dean for medical education and professor of clinical medicine, Albert Einstein College of Medicine, the Bronx, citing her own research.

“We found that the students who valued research, prestige, higher income, and better lifestyles were more likely to choose subspecialties for both pediatrics and internal medicine,” she says.

Work-life balance is a factor, according to Christiane Mitchell, director of federal affairs for the Association of American Medical Colleges.

“Students in general are increasingly more likely to choose specialties that allow part-time hours, highly flexible schedules, and don’t require significant ‘on-call’ responsibilities,” Mitchell says in a statement.

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