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

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Who will take care of you and me? Facing the crisis in primary care

From the July-August ACP Observer, copyright 2006 by the American College of Physicians.

By Lynne M. Kirk, FACP

My mother is now in her late 70s and lives in a town in rural Nebraska of 500 people—not one of whom is a physician.

Instead, her general internist for the past decade, Dr. G., practices with a group of family physicians in a town of 3,500 people about 30 miles away. Because of the care Dr. G. provides, my mother no longer has to travel 250 miles to Omaha to control risk factors for her coronary artery disease or for the colonoscopies she needs to follow up on her colon cancer resection. Dr. G. clearly provides compassionate, comprehensive and crucial care to an aging and underserved patient population.

I have talked with Dr. G several times on the phone, but only met her for the first time at ACP’s Annual Session in May. She is the sort of physician we would all like for our mothers and for ourselves, as we age.

If current trends continue, however, fewer of us will have the opportunity to receive care from a doctor like Dr. G. It is becoming increasingly clear that the vitality of primary care is being undermined by attrition and by the fact that fewer physicians are choosing generalist practice. The situation is so dire that the College and other organizations are now sounding the alarm about the potential collapse of primary care.

Downward trends

In issuing these warnings, the College is responding to compelling survey data:

  • Significantly fewer physicians are entering office-based practice. Only 20% of third-year residents surveyed as a part of ACP’s in-training exam in 2005 said they intended to practice office-based general internal medicine, sharply down from the 54% who responded positively in 1998.
  • Many mid-career general internists appear to be leaving office-based practice. According to a joint ACP-ABIM survey conducted in 2004, approximately 21% of physicians who certified in general internal medicine in the early 1990s said they'd stopped practicing general internal medicine. That was compared with only 5% who'd left subspecialty practice over the same time period.

These trends will become increasingly onerous as an aging population creates a high demand for the skills general internists have to offer: the ability to provide comprehensive care to patients with chronic diseases and to coordinate that care.

Making a real change

In response to this growing crisis, the College has published a position paper calling for several changes to ensure an adequate internal medicine specialty workforce to meet Americans' needs.

The paper, points out that increasing the number of students graduating from U.S. medical schools, as several organizations now advocate, is simply not enough. Instead, significant reforms must be put in place so that graduating physicians once again view office-based internal medicine and other primary care specialties as viable, rewarding careers.

Specifically, the College paper calls for three measures that would make primary care a more attractive choice for physicians:

  • Change reimbursement that now undervalues the work of primary care physicians.
  • Provide debt relief for students completing medical education.
  • Give more exposure to top-notch primary care practices for medical students and residents.

On the national level, the College also recommends developing a health care workforce policy to reverse primary care's impending collapse while supporting the complementary but different roles played by general internists and family physicians.

A new generation?

Much has been written about the changing values of the generation of people currently entering the medical profession. That issue was the key focus of an excellent and provocative panel discussion at this year's Annual Session. (See "Bridging the generation gap from Boomers to Millennials" in the June ACP Observer.

The young internists who served on the panel—LCDR. Patrick E. Young, ACP Associate Member, and Kerry A. Donegan, ACP Medical Student Member—are like the students and residents I have the good fortune to work with here at University of Texas Southwestern Medical School: bright, articulate and motivated to become excellent physicians.

However, I am seeing firsthand how fast we are losing them. Of the 46 internal medicine residents who completed their third year of training in our program this year, only one entered the office-based practice of general internal medicine.

Drawing only 2% of graduating residents is not enough. My internist is about my age and will probably retire before I reach the age my mother is now. Who will be available to provide the kind of care that Dr. G. so ably provides to my mother and that you—and I—will need?

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