American College of Physicians: Internal Medicine — Doctors for Adults ®



From the September ACP Observer, copyright 2003 by the American College of Physicians.

Internal medicine's future

I apologize for being a voice of gloom but, barring a cataclysm such as conversion to a single-payer system, internists may be doomed. ("In this year's Match, internal medicine continues to lose U.S. graduates," May ACP Observer.)

Why should a medical student choose an internal medicine specialty? I believe we have three big pluses. Medical specialties operate on a gradient of closeness to patients. While all physicians want to help people, we have chosen to be "up close and personal," with all the stresses and rewards such closeness brings.

Secondly, the broadness of our field gives us the maximum leeway to figure things out, so we have the intellectual gratification of solving puzzles. Finally, while every specialty has its routine, our broadness makes our routine more varied.

Just about every other aspect of our specialty, however, is less attractive than those of our colleagues. When medical students choose other specialties, it is not because they have been misled by inferior role models. Unfortunately, they have the right idea about our lifestyles and working conditions.

We are the kings of scut of our profession. All physicians deal with multiple bureaucratic hassles, but our burden is greatest. (Just look at the number of support staff internists employ). To top it off, specialists take advantage of our philosophy that we are ultimately responsible for our patients and dump some of their scut on us.

When our Match numbers began to slide, I thought remaining internists might prosper as demand for us rose.

But society and the free market are telling us that our services are not held in high esteem. They appear to prefer a model of primary care provided by nurse practitioners and physician assistants, plus specialty physicians.

We are a privileged class: We help people, enjoy some prestige and still earn comparatively good money. We work hard, but so do most people. Internal medicine has enjoyed an admirable century. I hope our run is not coming to an end.

Daniel A. Reinharth, FACP
East Meadow, N.Y.

In 1982, the year I graduated medical school, many of my peers stated their grades were not good enough for internal medicine. In recent years, however, the students I have met say that because their grades aren't good enough for other specialties, they'll go into internal medicine.

Medical students and residents of all specialties know how difficult our training period is and how poorly reimbursed and respected the training and the attending work is. They also know the future is not bright, and that pay is expected to decline with the economy and the aging of the population.

At Kaiser Permanente Northern California, we are projecting that three years from now, the highest paid nurse practitioners (long-time employees of the group) will be paid more than starting pediatricians and internists in our medical group. They earn even more if you calculate reimbursement by the hours worked.

Our peers in other specialties and subspecialties have received substantial raises, largely so the group can compete with the non-HMO sector. Our hospital-based internists (already a separate department) will move onto a different pay scale soon, with an even higher reimbursement. We in primary care are left in the middle to sink slowly along with the rest of our fellow primary care internists in the nation.

Are we just another canary in the mineshaft of the environment of medicine? Are we following the trend of the nursing profession, with the disadvantage that we cannot gain union-level clout? Will family practice be next, or will we go down together?

Juan C. Larach, ACP Member
San Francisco

Physician assistants

I read with interest the letter about the role of physician assistants (PAs). (Letters, June ACP Observer.)

While I agree that physician assistants and nurse practitioners should not allow patients to call them "doctor," I don't agree with the assertion that a PA's "level of knowledge ... comes nowhere near a third-year medical student's in most cases."

I am the medical director of a large, multispecialty primary care group that employs nonphysician practitioners in most of our 18 offices. In our experience, they have succeeded in providing competent, compassionate and patient-centered care that produces a high degree of patient satisfaction. They are also less hurried than physicians, who are often more constrained by reimbursement and time pressures.

Well-trained physicians should have no difficulty understanding their role in today's complex health care delivery systems. They should also be able to clarify for their patients the roles of others involved in their care. And they should accept the fact that capable, nonphysician practitioners have earned their place on the team.

Louis S. Snitkoff, FACP
Albany, N.Y.


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