Friday, March 26, 2010

Why IM trainees choose hospital medicine and subspecialties over primary care

Although available slots in IM, FP and Peds in the 2010 match far exceeded those who matched, there was a slim increase over 2009 in the number of graduates matching in all three specialties. While that may be regarded by some as good news, very few IM trainees are opting for primary care, choosing instead susbpecialty and hospitalist positions. DB asks why and suggests better job conditions for hospitalists as one of the reasons.

His analysis is only partially correct and ignores one of the key issues: General Internal Medicine is losing its identity as a unique specialty. Its distinction from Family Practice is diminishing. It has been proposed for dissolution by merger with FP and may no longer exist in a decade or two. The American College of Physicians, Internal Medicine's leading professional organization, has been complicit in this trend.

I hope DB takes advantage of his leadership position in the ACP to make a difference here.


WhydoIneedthe ACP? said...

I remember during my residency, Academic Internal Medicine attendings, for whom I had great respect, would descend from on high for their 4 week rotations in the hospital and present knowledge and experience accumulated over decades in practice as somehow esoteric and elusive. There was an aura of austerity that to a young, very motivated but as yet inexperienced resident seemed almost unattainable.
As I progressed through training, I remember watching a rheumatologist for whom I also had great respect, really struggling with an application for Fellowship in the ACP.
She was an assistant professor of medicine at a university affiliated medical school, had taught a generation of medical students and residents a practical and useful approach to rheumatology, and had done a great deal in the community. She had won a number of teaching awards, and was revered by her patients. She had not, however, published much in the way of research. As such, she felt, as I suspect many do that she wouldn’t be welcomed in this exclusive club. Later in my first few years of private practice general internal medicine, one of my senior partners went through the same process and was denied fellowship. I remember wondering if this organization was for internists or just meant for researchers?
I am now 5 years out of residency, have gained some of that, not-so-esoteric-after-all, knowledge and experience, and severed ties with GIM for good to become a hospitalist.
In my 500 bed community hospital I have done a host of QI projects (although I share Dr. Donnell’s views on quality measurement), sit on committees, started and monitored several patient safety initiatives and a discharge reengineering project. I even participated in a research project. I eventually became the medical director of a 12 physician hospitalist group, have written a little, and consider myself fully engaged in a satisfying and productive career in internal medicine.
But you know what? I still don’t feel “good enough” for the ACP.
I will soon earn Fellowship in the SHM, which has a totally different vibe. A young, energetic, thriving organization, I look forward to the annual meetings.
So this leaves me wondering… do I need the ACP?
Don’t get me wrong, I am not trying to rant or be negative here, but, maybe, just maybe, those grumpy old (albeit exceptionally bright) academic internists have somehow created an atmosphere within the ACP that has pushed away a generation of young internists.

And maybe, just maybe, this has led to further divide hospitalists (most of whom still wish to be called internists and identify strongly with internal medicine) from non-hospitalist.

Michael Kirsch, M.D. said...

One reason that primary care identity is fading is that it is practicing differently today. In the past, internists prided themselves on managing the whole patient and requested consultations judiciously to address a specific clinical question. Nowadays, and for many reasons, primary care physicians pull the consultation trigger repeatedly. It is very typical for a hospital patient to have several specialty consultants on the case simultaneously from the day of admission.

R. W. Donnell said...

To WhydoIneedthe ACP?

I have been criticizing the ACP for not supporting Internal Medicine. You have raised another issue: the ACP is an elitist organization. I fully agree. It's just one of many reasons I never joined.

About 20 years or so ago they made it easier to advance to fellowship---you didn't have to be an academic. But then what did they go and do? They created another even more elite category above fellowship: the Master of the American College of Physicians.

A little off topic but very true. You could really get me going.

rcentor said...

I must take umbrage in your characterization of ACP as an elitist organization. ACP really has a wonderful mixture of academicians and private practice physicians in its leadership. ACP has changed dramatically over the past decade. No other organization even tries to consider the breadth of internal medicine in its mission.

You really should reconsider ACP as an incredibly important society.