Does IM training lead to decrease primary care selection?

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Category : Medical Rants

Wow – I tried for a shorter title, but that is the best I can do. This topic has received much discussion over the past decade. Yesterday at lunch a colleague posed this idea. We had lunch after hearing Dr. Fred Ralston (ACP President-elect) give a wonderful Grand Rounds on the patient centered medical home. This colleague feels that we should once again reinvent primary care internal medicine residency training, focusing primary on outpatient education with less inpatient training.

The general concept here is that training influences resident decision making about careers. While I agree that our experiences do have some impact on our decisions, I do not believe that this proposal would succeed.

In the early 90s, outpatient internal medicine had its heyday. We had a larger percentage of internal medicine residency graduates choosing to enter practice than now. Our outpatient training was no better and possibly even worse in those days. I suggest that the problem has nothing to do with training, but rather with the job itself. The primary care job has worsened over the past two decades, and medical students and residents understand.

I personally do not believe that trying to provide better outpatient education will influence residents to choose outpatient careers. The problems are several. First, it takes time to do outpatient medicine properly, and our payment system rarely allows enough time per patient. We see much higher physician satisfaction when they join practices that allow longer visits.

Second, in the early 90s, most internists functioned both in the inpatient and outpatient setting. The growth of hospital medicine has had a negative impact on the desirability of general internal medicine.

Finally, the internist does not have the same “respect” within the medical community as existed back in the day.

But I believe the problem is money – and that has impacted everything else.

One can certainly argue both sides of changing outpatient internal medicine education. I still believe that I teach outpatient medicine better during inpatient rounds than I ever did in clinic. I know that others will deride me for that thought.

We must first fix the job, and then we can tackle the training.

Comments (1)

“The growth of hospital medicine has had a negative impact on the desirability of general internal medicine.”

I am glad you agree.
Rather than castigate hospital medicine should we not address ambulatory care
As structured today the trained internist despite superior skills is not looked upon,treated or reimbursed differently than other physician extenders who populate this arena.
Is it not natural for the trained Internist to gravitate to an environment of comfort ….the hospital?
Is ambulatory care really a challenge? “health maintenance ” interventions whatever their benefits can be ordered by a school boy with a protocol list.
The sick patient is shunted to the many specialists with the ambulatory practitioner doing the paper work to satisfy some paper pushing healthcare administrator.
There is a role for the general Internist.
In the United Kingdom they are called consultant physicians. They admit patients to the hospital and direct their care in that facility, If the patient has conditions needing their continued attention they are followed in the outpatient clinics run by these physicians. If not they are returned to their geneal practitioners.
This occurs because of the National Health System (a true public option) where the use of IT involves over 90 i% of all physicians.

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