The promise of the Affordable Care Act is that all Americans will have access to health care. But there are hurdles in the way to fulfilling that promise. Among them: the shortage of general internists to care for all those newly insured Americans. And a recent study in JAMA that took the pulse of internal medicine residents shows that the shortage of primary care physicians is likely to continue into the foreseeable future.
Researchers at the Mayo Clinic in Rochester, Minn., took a close look at the residents’ intended career paths. What they found confirmed what many studies and years of Match Days have shown: that general internal medicine continues to hold very little interest, and certainly not growing interest, as is needed.
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Dr. Colin P. West and Dr. Denise M. Dupras, both of Mayo, analyzed responses to survey questions from more than 16,000 third-year residents who graduated from medical school in 2009, 2010, and 2011. The career questions are add-ons to the Internal Medicine In-Training Examination, which is given every October to all residents.
More than 90% of residents (15,361) were in a subspecialty or categorical residency program; the remainder were in a primary care residency. Overall, about 40% of the primary care residents and 20% of the categorical residents said they would go into general internal medicine. Women were more likely than were men to choose primary care, as were international medical graduates (JAMA. 2012;308:2241-7 [doi:10.1001/jama.2012.47535]).
So what were they choosing instead? Sixty-four percent of categorical residents said they would subspecialize, with the largest number (14%) pursuing cardiology followed by pulmonary/critical care medicine, hematology/oncology, and gastroenterology. Nephrology, endocrinology, infectious disease, and rheumatology also were named.
Fifty-two percent of primary care residents said they too would seek out a subspecialty. The interest in various specialties was similar, with cardiology also holding the top position, followed by pulmonary/critical care, oncology, and gastroenterology.
Some 10% of categorical residents said they would become hospitalists, as did 3% of primary care residents. One percent of categorical residents and 2% of primary care residents said they were headed into geriatrics.
Thus, the nation’s medical schools continue to produce a glut of cardiologists at a time when the government and private insurers are doing everything possible to rein in reimbursement for that specialty, and when what is urgently needed is a coterie of geriatricians and general internists who can promote preventive care and coordinate care.
So what is to be done? Dr. West and Dr. Dupras offered a few solutions. One is counterintuitive: Don’t blanket-increase the number of internal medicine residencies.
"Expanding medical school enrollment or the number of internal medicine residency positions may simply result in more subspecialists, if the number of specialty and fellowship slots is also increased," they wrote. Instead, putting a lid on those slots could guide more residents toward a career in general internal medicine.
They also suggested studying how to increase the appeal of primary care to residents. And that may just take more time. The Affordable Care Act should reduce administrative burdens and improve payment for general internal medicine. "But learners will need to observe evidence that these measures can be effectively executed to make general medicine careers more desirable," they wrote.
–Alicia Ault (on Twitter @aliciaault)