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

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Primary care decline threatens realization of medical home model

From the October ACP Observer, copyright © 2007 by the American College of Physicians.

Does your community have enough teachers, laborers, mechanics, police, lawyers and doctors? Are there enough internists? It is never easy to answer this type of question. Perceptions vary, but I bet that your friends, family, neighbors and patients often ask you for help with finding a good internist. Mine do!

The supply of physicians is different from the supply of personnel for most other trades, professions and specialties. In the U.S. and most countries, the possibility of becoming a physician is not open to everyone. Medical school enrollments are set and limited. Beginning a hundred years ago with the organization of the Council on Medical Education of the American Medical Association (AMA) in 1903 and the Flexner Report on medical education in the U. S. and Canada published in 1910, the stage was set for scientifically oriented medical school with limited enrollments.

Since 1942, U.S. and Canadian medical schools have been accredited and their enrollment numbers overseen by the Liaison Committee on Medical Education (LCME), a joint activity of the Association of American Medical Colleges (AAMC) and the AMA in cooperation with the Committee on Accreditation of Canadian Medical Schools. The U.S. Department of Education recognizes the LCME as the national accrediting organization. The goal of the LCME is to set standards for the structure, function and performance of medical schools, and indirectly this process serves to balance the needs for physicians with the resources for their education and training.

Under the auspices of the LCME, several new medical schools opened to expand access to medical education and the physician supply in the two decades after World War II. At that time, there was a strong movement toward specialization, driven by advances in the science and practice of medicine, particularly in internal medicine. Beginning in the mid-1960s, there was a complementary move to develop a new and better-trained cadre of primary care physicians, and several new medical schools opened to train these physicians. Many new departments of family medicine were opened and the primary care movement stimulated a resurgence of interest in general internal medicine and formation of sections or divisions of general internal medicine and the Society of General Internal Medicine.

By the late 1970s, there was a general perception that the cup was full. Intensive studies of health manpower needs for the U.S. and the Graduate Medical Education National Advisory Committee (GMENAC) reports predicted that there would be excessive numbers of physicians for the decades ahead. Based on this study, medical school enrollment in the U.S. remained essentially flat from 1980 until 2002. The predicted surpluses, however, never materialized. By the mid-1990s, the U.S. and most other Western countries recognized that changing demographics (both in the physician workforce and in the general population) as well as rapid changes in many specialties and subspecialties meant that there was more work to do and more doctors were needed. This recognition came earlier in Canada, Australia and the United Kingdom than in the U.S.

For example, Australia made plans to open seven new medical schools after no new school for 30 years. Canada increased its projected needs for physicians and opened new schools, added internationally trained physicians, and encouraged later retirements and the retention of new graduates in Canada. Around the world there are similar trends. In 2006, based on new workforce projections, the AAMC recommended a 30% increase in U.S. medical school enrollment, representing an increase in the number of medical graduates from 16,000 to about 21,000 per year. This expansion is under way and several new schools are planned or have already opened.

How do these changes affect internal medicine, both general internal medicine and the medical specialties? How will they influence the balance of international medical graduates entering the U.S. to train in and practice internal medicine? How should departments of internal medicine, residency program directors and the residency review committees (RRCs) overseeing internal medicine respond to these changes? How should ACP, a cosponsor for the beginning of the RRCs in the early 1950s, be engaged in considering the internal medicine workforce?

Over the last two years, ACP worked closely with the American Academy of Family Physicians, the American Academy of Pediatrics and the American Osteopathic Association to create a strong coalition supporting the patient-centered medical home (PCMH) as the future foundation for patient care for all adults and children. A central tenet is that every person needs a personal physician. The knowledge, skills and personal attributes of physicians working in and leading the PCMH are currently being closely examined by ACP as well as the American Board of Internal Medicine (ABIM). State and local governments as well as health maintenance organizations and insurance companies are asking about the number of physicians required to serve their segments of the population. These needs will be defined based on geography, gender, health status and the medical services to be provided. Estimates by leading authorities indicate that with the "collapse of primary care" the workforce for the PCMH is sorely lacking. The decline in interest in primary care and general internal medicine has been so severe that there may not be the workforce for its implementation. Beyond the PCMH, workforce experts also believe there are needs for more internists in many medical specialties.

ACP is working with many organizations to improve the attractiveness of internal medicine, the quality and availability of health care and the proper size of our training programs and the workforce for internal medicine. This topic is relevant to all of us, specialists or generalists, as we look for colleagues to share in patient care, in call or coverage; to be the inheritors of our practices and our values; and to care for us whenever and wherever the need arises. Your comments are welcome.

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