There has long been an institutional bias in medical education against primary care. Many doctors we have spoken with have recounted how they were steered away from primary care by preceptors in medical school. The general sentiment conveyed to medical students long has been that surgical and diagnostic specialties are for the most accomplished students and that primary care is for the less accomplished.
This bias has been combined in recent years with a growing disparity in income between primary care physicians and specialists. The result is an acute shortage of primary care doctors, and a particularly severe shortage of general internists.
Less than 30% of medical students selecting internal medicine residencies now plan to practice primary care, according to an Association of American Medical Colleges survey. The majority are opting to become hospitalists or internal medicine sub-specialists.
The recruitment challenge
Internal medicine therefore is the most challenging specialty to recruit today. Finding a traditional general internist —one who rounds on patients in the morning, maintains an office practice, then rounds again in the evening—is the recruiting equivalent of scaling Mount Everest.
While an internist practicing as a hospitalist might work 40 hours a week and, with a rotation of seven days on and seven off, enjoy 20 weeks of vacation a year, a traditional internist typically will work 60 hours a week and have four weeks of vacation. On top of this, a hospitalist is likely to earn several thousand dollars more a year than a traditional internist.
The traditional internal medicine model is close to moribund, since very few candidates are interested in this practice style. This obliges hospitals to establish hospitalist programs so that they can offer internists outpatient-only settings, which are usually more attractive than traditional internal medicine settings.
Even the outpatient-only model, however, may not be as attractive to internists as working as a hospitalist. Hospitalists typically see 15 or fewer patients per day, while internists often see 25 or more. In addition, hospitalists are employed by a hospital or a group, while many internal medicine settings feature independent practices where physicians must contend with reimbursement and other practice management issues.
Many physicians prefer the security of employment today to the uncertainty of private practice and we advise clients to employ internists where possible (some states prohibit hospitals from employing physicians, however.)
Focusing on patients
The attraction of internal medicine—whether traditional or outpatient only—is patient rapport. Hospitalists see acute patients who have "interesting" cases, but such cases can be draining when they are all the doctor sees. Hospitalists also tend to get barraged on weekends when hospital staff is reduced and they must manage heavy patient loads. In addition, hospitalists enjoy no patient continuity. Once discharged from the hospital, patients go back to their general internists.
An internist, by contrast, will see well patients and can follow patients over time. The emotional rewards of general internal medicine still trump the "shift work" of hospital practice for some physicians. While the emotional appeal of internal medicine will attract some candidates, today’s market requires that incentives be competitive.
A competitive internal medicine opportunity will feature balance—a reasonably high salary ($160,000-$170,000 for outpatient only, $180,000 - $200,000 for traditional), combined with 4-5 weeks of vacation/CME, a turn-key setting that does not require a long ramp-up time, minimal night and weekend call, employment, and, where appropriate, educational loan forgiveness.
As long as reimbursement is weighted toward procedures and away from consultative practice, and as long as medical school bias exists, the supply of primary care physicians, internists in particular, will be constrained. This challenge can be met by aggressive finding candidates who are attracted to the emotional rewards of internal medicine—and emphasizing those aspects during the recruitment process—and by offering incentives packages that are balanced and competitive.