Increasing demands for internists

What was an internist?  What is an internist?  What will internists become?

I have written extensively on internal medicine (as have my colleagues Dr. RW, The Happy Hospitalist and KevinMD – plus several others.)  This past week I was a visiting professor at York Hospital and then attended a Board of Regents meeting for the ACP.  During that trip I pondered the growing demand for internists.

Recently, at a town hall meeting at the Southern Illinois ACP meeting, a member challenged me and the ACP to advocate for more internal medicine training slots.  This perceptive comment has stimulated my thinking about the current state of internal medicine.

As most readers know, we are increasing the number of US medical students.  This increase receives funding from student tuitions and sometimes state funds.  However, we do not currently have a planned increase in residency slots.  Unless we increase residency slots, we will produce no more trained physicians, we will only decrease the percentage of IMGs.

But in many specialties (especially family medicine and internal medicine) we actually need more graduates than we currently have.  I can speak best about internal medicine.  I will make my case with several observations.

1. Because we manage chronic disease better than in the past, we have more complex older patients living with multiple diseases.  These patients need physicians (mostly internists) to manage their conditions in the outpatient setting.
2. We have a shortage of outpatient adult physicians.  The Massachusetts experiment makes this shortage very obvious.  Having insurance is not enough, you must have a physician to see once you get insurance.
3. We have a large and growing demand for hospitalists.  Our graduates are preferentially choosing hospital medicine for intellectual, lifestyle and financial reasons.  Despite the positives, we are not producing enough hospitalists.  Morever, many hospitalists leave hospital medicine after a few years for subspecialty training  Hospital medicine is expanding as almost every other specialty and subspecialty willingly takes advantage of hospitalists to end their hospital practice, switching to a consulting practice.
4. The preference to choose hospital medicine has markedly decreased the supply of new outpatient internists.  A significant percentage of outpatient physicians have left (or will leave) practice and joined hospitalist groups.
5. Several subspecialties probably need greater numbers, especially geriatrics, nephrology, cardiology and critical care (note that many hospitalists are providing critical care.)

I hope that CMS will reconsider the current freeze on funding new positions for residency training.  Increasing medical school positions and moving towards universal coverage will accomplish little if we do not have the right number of the right types of physicians.  This unknown crisis in health care is not often addressed.  I hope other internal medicine bloggers will join me in leading the process of explicating and championing this problem. So to Happy, RW, Kevin and others – pile on.