Clinical Geriatrics

I was recently asked to participate in a panel discussion regarding the “future of primary care.” At first, I thought they asked me to discuss the future of internal medicine, and I had envisioned a lively discussion regarding new technology and procedures that are quickly becoming the standard of care in cardiology, pulmonology, and other subspecialty areas. Manpower issues were not forefront in my mind, since my residents are eagerly applying to fellowships in these areas and dreaming of future careers viewed as exciting and highly compensated.

When I was informed that this was to be a discussion on primary care aspects only, I quickly put to paper major concerns I have had for a long time. Primary care medicine as it currently stands is in peril of vanishing, and the time for change has come to prevent it from continuing on its current course of slow death. We have all heard of the diminishing number of U.S. medical graduates pursuing careers in family medicine, and few international graduates leave their native countries to seek training in this area. Internal medicine is no exception. We must not be complacent in hearing that the number of U.S. medical school graduates seeking careers in internal medicine has leveled off or even increased slightly, because it is the final career path and not the residency training program that counts. The majority of internal medicine residents choose to become subspecialists, especially those international graduates who fill 50% of our internal medicine residency slots at the present time. The development of the hospitalist profession in recent years has become another challenge to primary care medicine, with the number of residents in medicine choosing this highly structured and well-paid career path that has been growing in recent years.

I just finished the annual rite of interviewing prospective residents for a residency program in internal medicine that I direct. While we are a community teaching hospital, I was surprised with the results. Yes, we had close to 2000 applicants—a new high—and we interviewed more than 400 worthy candidates. I was quite disappointed to learn, however, that when asked about future career plans, less than 5% expressed any interest in pursuing a career in primary care medicine!

Who will be the primary care providers of tomorrow? Will the nurse practitioner replace the internist and the family medicine physician? Will the nation eventually recognize the crisis and do something to bring physicians back to what was once considered a most noble and rewarding profession? Clearly, economics is a major obstacle, with primary care physician salaries far below that of subspecialists. Internal medicine must already compete with other higher-paying specialties such as anesthesia and ophthalmology, among many others, for graduating medical students, and those who do choose internal medicine residencies still have many options to pursue, most as subspecialists.

The cost of running a primary care office has risen, and administrative demands such as the Health Insurance Portability and Accountability Act (HIPAA) and self-reporting for Medicare have become more difficult to comply with without increases in office staff. Prestige remains an issue, and one must not forget the challenging lifestyle. Our medical residents have grown accustomed to regulated hours and “CAPS” for numbers of patients to be seen and admitted to the hospital; these restrictions will most likely carry over as expectations for their future and will have an impact on their career choice. Medicare fees continue to decline, with the 4.5% drop this year hopefully being reversed by the legislature. Every year the threat to survival becomes a greater challenge. New “billing codes” add expense to a regulated budget and mandate reductions in fees for future professional activities.