Tuesday, May 24, 2005

Fewer Physicians Interested in Generalist Careers

There is more information available about the decreasing number of physicians interested in being generalists.
A detailed survey based study of internal medicine residents' career choices just appeared in Academic Medicine, and was discussed in the American Medical News. [The article citation is: Garibaldi RA, Popkave C, Bylsma W. Career plans for trainees in internal medicine residency programs. Acad Med 2005; 80: 507-512.]
The article shows that the proportion of residents who go into general internal medicine has fallen from 54% in 1998 to 27% in 2003 (34% if hospitalists are added to general internists.) Reasons for going into sub-specialties admitted by survey respondents included higher income, and narrow practice area.
The American Medical News did not try to white-wash these results. It quoted a third year resident, chair of the AMA Resident's and Fellow's Section, who is going into gastroenterology because, "I'll be paid what my education is worth," and contrasted that situation with the lot of the general internist who makes "$110,000 a year.... That's a salary someone with less education and training can earn in other fields, without the debt of medical school, years spent training and commitment to a lifetime of being on call."
Steve Fihn, past President of the Society of General Internal Medicine, said "It's a pretty daunting task trying to reverse this trend when the economic forces are so strong."
On the other hand, the ASP Observer featured an article about the results of this year's internship match, i.e., how many medical students chose internal medicine training. The article was mainly positive, since the numbers choosing internal medicine have gone up slightly. "That's good news," since the numbers were dropping from 1998 to 2003.
However, the report also included the observation that internal medicine training program directors report that the proportion of residents going into general internal medicine has dropped from about 50% to about 20-25%, similar figures to those in the article by Garibaldi et al. But Steven E. Weinberger, ACP Vice President for Medical Knowledge and Education, suggested that the solution for dropping interest in general internal medicine would be the ACP's efforts to "fix Medicare reimbursement, for instance, and to help craft new chronic care models.... Creative models of high quality, team-based care offer a real opportunity to address the lifestyle issues." What sort of "chronic care models" he envisions, and how they will help generalists practice medicine, was not very obvious.
So the big question is whether our health care leaders and policy makers will make an effective attempt to reverse the decline of the generalist physician before the species becomes extinct.
At least some show understanding of the severity of stresses on generalists. Dr. Fihn, for example, is frank about the economic incentives.
However, as demonstrated by the issues discussed on this blog, not only are generalists at the bottom of the economic pecking order, they seem particularly impacted by the huge rise in health care bureaucracy, and particularly vulnerable to challenges to physicians' professional values instigated by large organizations lead by leaders with conflicting interests. They will need more than new "chronic care models" to survive these threats.


Joseph Paduda said...

As one with strong ties to the payer community, it is obvious that we are shooting ourselves in the wallet. Not only is specialist care more expensive, this extra cost is without attendant benefits in terms of better outcomes (see recent Reuters article on back pain outcomes at www.joepaduda.com).

So why do payers do this? The answer is at least in part because there are large bureaucracies staffed by lots of people at managed care firms who make their livings "managing" treating physicians. By no means am I inferring all their efforts are wasted, but there is no doubt that the individuals involved benefit from the payer-provider conflict.

Roy M. Poses MD said...

Thanks for the comment, Joe!
And let me suggest that those who read Health Care Renewal may also want to keep an eye on your excellent blog, Managed Care Matters. I just added a link to our very selective blog-roll.
I would like to try to keep this discussion going, since we seem to be in agreement on the main point. If so, how could managed care be reformed to that it starts to favor care that actually is of value to the patient?

Joseph Paduda said...

Thanks Roy.
The good news is some of this is already happening; I am involved with a project in Florida at BayCare Health – we are eliminating the discounted network contracts and implementing an integrated approach to Workers Comp injury care, using the physician as case manager. So far, results are excellent, and the staff loves it.

Be careful what you ask for - here's my soap box speech.

We must focus on productivity as the “output” of health care – simply put, all the arguments about health care in the US are pointless and irrelevant - without some consensus on what we want health care to produce we have no intelligent way to discuss how it should do that.

Thus we fight over process and cost instead of what should health care be and do to produce the highest possible level of productivity.

I suggest physicians ask a simple question of payers; What is it you want?" and keep asking until you get an intelligent answer. It may be a while, so be patient...

Lady Doc said...

After graduation from medical schools, doctors embark on what is called an “apprenticeship”. In other words, this means that you’ll learn more about medical practice 'on the job' while actually practising it within your level of competency, knowledge and skills. This is usually performed in the hospital or community setting.