Medical students are shying away from careers in general internal medicine, which could exacerbate the U.S. doctor shortage expected by the time the youngest Baby Boomers head into their senior years, researchers report today.
Only 2% of 1,177 respondents to a survey of students at 11 U.S. medical schools said they planned to pursue careers in general internal medicine, according to the new study.
General internists provide a large portion of care for older and chronically ill patients, the authors write in the Journal of the American Medical Association. Yet, the rate of medical students opting for general internal medicine is declining as the number of older adults rises, they write.
According to one estimate, the USA will have 200,000 fewer doctors overall than it needs by 2020, according to the new report. Meanwhile, the number of older Americans is expected to nearly double between 2005 and 2030.
Old news. Pediatricians disappeared a long time ago. They were replaced by nurse practitioners, and more recently by “med techs”.
I imagine the boomers will be taken care of by “med techs” too. Those med techs will refer to specialists if they have something complicated.
I also think that in the future folks will take more responsibility for their health care. Just as folks are now expected to do their own taxes, and tutur their own children, they will be expected to use easily accessible forms to check and track their medications, insulin, glucoses, etc. I imagine that most of the history will be typed out on computer prompts by the patient before he/she is seen by the medtech, so as to expedite care. That way the med tech can do a quicko physical exam in 5 minutes and “complete” the work up.
The move to the “smart card” that holds all the patient’s clinical information will assist with this. So will “evidence based guidelines”, so that when the computer kicks out a diagnosis, the med tech will avoid providing “unnecessary care”.
For smart, educated, health folks with straightforward problems, (hypertension asthma etc) it will be a very good thing. Just like taxes. Smart educated folk are pretty good with their taxes, too.
Less so with the ill, the poor, the dumb and the irresponsible. However they may learn to rely on their families for assistance, and they may come to actually provide for their families, rather than abandoning them when their kids interfere with their self actualization.
It all works out in the end.
Clueless, I wish I could be as sanguine about the picture that you paint. As an MD who relies on primary care docs to help get patients ready for surgery, I despair over the dwindling number of good internists, and the move to medical “extenders.” They may be cost-effective for the savvy, well-educated types you describe, but I strongly suspect those folks WANT a real doc to go to. And, for the less-well-educated, medically complex patients, I fear that the quality of care will go down, and that families won’t be able to pick up the slack.
Not that having a primary care doc ensures that things won’t get missed, either. I help care for my elderly dad, who’s got several serious chronic conditions. After at least a few “near misses” with medications and symptoms that I had to harp about to his internist’s office, I wonder where he’d be without a medically-savvy family advocating for him…and, he’s a retired MD!! FWIW, his primary care group uses non-MD practitioners as the “first filter,” and most office visits consist of the RNP or MD sitting at a computer, taking their “history” and making little eye contact. Far different from my med school or internship days, when we actually talked with patients…sigh.
#2. That was a combination of sarcasm and despair, not being “sanguine”.
I already deal with the kids and their “med tech” providers in the community clinic. (It is always a disaster, with the kids on an average of 12 meds, since the med techs, PAs and NPs just keep adding new medications at them, whenever they have side effects from the old medications, instead of trying to take folks off stuff). I see new kid patients at the end of the day, and plan to spend an hour and a half (obviously not getting paid for it).
It is sick folks who need a physician, not the healthy. The system currently focuses on the sickest people (which is why it is so expensive). In the future, it will focus on the healthiest people, and costs will come down.
In addition, since “medical care” is measured by asking such questions as “did your doctor offer you a flu shot?” or “did your doctor tell you to stop smoking?” rather than “did your doctor get your angina to stop?” medical “care” will be found to have “improved” under the med techs, rather than under the internists.
Lower costs and “improved care”. Yay. Who needs docs anyway. They are all a bunch of overpaid, underworked, arrogant set of jerks who think they’re God. (Actually those numbers seemed a bit high. In California internists get 60,000 which is less than physician assistants who clock in at 70,000).
Whatever.
” FWIW, his primary care group uses non-MD practitioners as the “first filter,†and most office visits consist of the RNP or MD sitting at a computer, taking their “history†and making little eye contact. Far different from my med school or internship days, when we actually talked “with patients..”
Well the good news is that in the future it will be the patient sitting at a computer, typing in their “history”, and doubtless getting a nice little computer generated “check list” for the PA/NP to look for on the exam, before generating a nice little “diagnosis” at the end of it. And the patient will get plenty of eye contact with his computer. (sarcasm off).
General internists are primary care doctors for adults. They generally handle the more complicated patients, e.g., a diabetic with some renal dysfunction and have had a heart attack in the past and some COPD and heart failure. Most of us are destined to be “complicated patients.” When we go in to see the nurse practitioner with a problem list 20 items long, we will be in trouble. I am not saying anything against nurse practitioners or PA’s. (I employ one myself and she is wonderful.) But to care for such complicated patients, one needs medical school, residency and then some. Fifteen minute time slots are not appropriate. But the reimbursement is shrinking for “routine” office visits.
Another issue. The medicare payment formula for yearly adjustments is flawed. This was known when it was implemented. If it is implemented, it would result in big reductions in reimbursement. Thus, every January, we have to go to congress and beg them to ignore the fantasy pay scales and maintain the status quo in payments. This blows our limited political capital on something that doesn’t serve the patient. I would rather be lobbying congress to implement insurance reform.
But if the pay formula is actually heeded this year or the next, and payments fall, it will be disastrous for the general internists. Most of the ones I know are saying they will retire. And the grave situation will be catastrophic.
Couldn’t have said it better, robroy. I respect nurse practitioners and PAs, but their training is NOT equivalent to MDs. There are sound reasons why physicians have four years of medical school plus anywhere from three to eight years of residency training, depending on specialty, and it’s not just for bragging rights. Primary care for complex adult or pediatric patients is tremendously challenging, and is NOT something that can be reduced to 10 or 15 minute “encounters,” or worse yet the impersonal, cookbook “physician extender” approach that our colleague Clueless describes (I always think of Hamburger Helper when I hear “physician extender.” Ecch).
The annual Medicare dog and pony show over the flawed payment formula and the “sustainable growth rate” is another quagmire that most laypeople don’t begin to comprehend. But I’m sure that it will magically improve once BO gets elected, and we get national health care (sarcasm off).
What will happen — and is happening — is that doctors are simply not taking new medicare or medicaid patients.
Because for every new one you take on — you are officially losing [i]even more money[/i].
Oh well . . .
Things’ll get better when they all become officially government employees. ; > )
What may happen is that some doctors will get hired to be Official Government Healthcare Workers, and all medicare and medicaid patients will be sent to those official workers, and slotted into their 15-minute slots.
And the non-Government Healthcare Workers — normal physicians — will only see non-medicare and non-medicaid patients, and forbidden — as they are now — to do any “charity” work, which under law is fraud.
There are two principles at work here.
First, you get what you pay for
Second, there ain’t no such thing as a free lunch
The government and insurance companies do not want to pay for quality health care. They do want to promise it and tax for it, however, so they can buy votes.
The overall costs of healthcare continue to rise, but not because the doctors are making more. Clearly, the reimbursement is not sufficient to induce people to go into primary care. You may say that people should care enough to go into primary care in spite of lawyers and government hassles and making less money than they could make elsewhere, and that may be true.
However, I would not base a national health care policy on the hope that doctors will happily work more for less money.
That hope, however, and change for hope and hope for change…… you get the picture, I think, is what the Obama plan relies on, (along with inflating our tires properly) to correct the health care situation.
Something is deeply wrong when you can go to another country and get your triple bypass surgery with accredited US trained doctors, for a fraction of the price here in the USA.
Folks, it will get worse before it gets better. The current plan, as I understand it, is to simply print up a bunch of little cards that say “insurance” on them and mail them out to people. Obviously, that monopoly money won’t spend at your local doctor, because we can’t provide the service for what is paid now.
Yes, I am a primary care physician. I love my job. However, I’m downsizing my life even now and selling my house, because I can see that the future for me is not so bright. My newest car is 6 years old. I love my job, though, and couldn’t dream of doing anything else. I just hope to retire soon enough to go into missionary medicine so I won’t have to deal with what is coming.
#8 I am downsizing my life even now.
Yep. Me too. I’ve paid off my house, paid off my cars, and have enough money set aside to send the kids through college. Paid off my debt, gotten rid of the credit cards and am learning to enjoy living on minimum wage, canuing, camping, hunting and fishing.
I will be “apprenticing” on weekends with a local farmer, and hope to be a subsistance farmer when “Body Odor” comes in, so I don’t need to practice medicine. That plus substitute teaching should do me fine.
Lots of folk I know are quietly doing the same.
Oh I might add that “BO” universal health plan is part of my strategy. Free health care! No taxation for the “working poor”. Once I give up the big salary and the equally big expenses, that would be me. Only my lifestyle will change for the better, not the worse, because I will have more time, and essentially no expenses. What’s not to like?
Since, all them “rich folks” whom BO is planing to tax are planning to downsize their lives and salaries, I’m not sure how he will pay for his “universal health scheme” however it will be interesting to watch, I am sure.
Captn. Sparrow, where do you do your medical mission work? I would like to do so also, but it needs to be out of the country to avoid malpractice liability.
Primary care: internist, famil medicine, pediatrics is already changing now and will be replaced by factory government medicine. All specialities are continually narrowing there scope of care. This is for three reasons: 1. Liability, general medicine is too complicated and perfection is demanded. The first thing they ask you in court is are you board certified in—what ever the organ that didn’t do perfectly under your inferior, non-boarded care. Neurosurgeon don’t do pediatric neurosurgery now. They leave it to the handful of boarded pediatric neurosurgeons. Often dire things happen when the superspecialist can’t be found. 2. The hassel factor. Government, insurance companies, and the lawyers require a term paper on each case. All I need is a 3×5 card for necessary records. I have a nurse that spends at least 30% of her time dealing with insurance companies so the patients can get necessary treatment and medications. Some doctors don’t do this non-reimbursable service. They just tell the patients that their insurance is no good. 3 is the pay. Government medicine is below overhead and insurance companies are following the government pay scales. I have a state of the art lab and xray in my office that has been locked up for over six years since the reimbursment is below cost. Now patients just go to the hospital and line up all day and make a new appointment back whenever the results come in. Or they just go direct to the ER for care—it is “free” there due to the COBRA laws. I have changed specialities now four times. I am one of the few boarded geriatricians in our end of the state, but I don’t take new medicare patients. I am one of three doctors in our community that still goes to the nursing home. The number of geritricians peaked at half the number the government said were needed. 50% do not renew their boards in ten years and only about 250 go into it each year, less than die off each year. I can’t afford a nurse practitioner, because the reimbursment is below their salary cost. Remember, PRICE CONTROLS ALWAYS EQUAL SHORTAGES. Remember Jimmy Carter’s long gas lines. I am definitly fading away. It was fun and I loved it but now everyone will just have to depend on the politicians for care. That is what they vote for and I say “enjoy.”
In some ways it will be better, at least if you have a healthy person.
You have a “smart card” with your basic history on it.
You get an ear infection. YOu go to your pharmacy or urgent care. Your card is swiped, you check “ear” and “throat” on body system, and then “pain”, “3” under days, check all the rest negative.
The tech comes by, with computer-modulated otoscope –
ear infection confirmed
Computer generates list of government approved meds, cross checked against your smart card for allergies,
Tech checks “ok”
You have a filled prescription and you are out of there in five minutes.
It will be great for the healthy. For the 72 year old with mild dementia, living at home, who has discombobulation but doesn’t think it is the same as “lightheadedness”, and unpleasant sensations that he isn’t sure counts as “chest pain” or trouble breathing that he thinks might not count as “shortness of breath” who is unable to sit down and figure out how to do the “history” on the computer, (and any way he has trouble reading the tiny screen, and his arthritic hands makes the mouse difficult) it will be pretty dreadful, even if he spends a couple of hours plugging away at it.
However, the reason the system will come in is liability. The computer will record your responses. If you didn’t “report” chest pain and shortness of breath, it will not be the techs fault he didn’t get an EKG or cardiac enzymes. It would be your fault for just checking “funny feelings”. Then the tech will check your pulse and blood pressure, give you a lollipop and send you home. There will be nobody to sue, because you screwed up on the history.
It will definately improve the expenses of the healthy, while reducing “unnecessary” care, and possibly reducing litigation as well.
An interesting world. But as a doc, I think I would have no difficulty navigating it for either myself or those I love.
Perhaps the matter is simply money. Consider the incomes of the specialists. What I have read tells me they are astronomical. Why be a commonplace doctor and merely join the really well-heeled when you can become fabulously rich as an oncologist? The discussion here has been interesting, but somehow it has left sheer greed out.
And I like your plan, Clueless. All you have to be is rich to begin with and then you can play at being a farmer and live the simple life. I am a real farmer, and permit me to tell you what the rest of us, who really farm, think of your pretending to join our ranks. Or at least, I will let you guess. Larry
Hi Larry. I consider myself “retiring”. It is helpful to have a food source and shelter when retired. I doubt I will be able to farm well enough to make a profit. That is why I intend to be a substitute teacher in order to make sure I can pay taxes.
I dont consider myself “rich”. I simply have no debt. (I cashed in my 401k in order to have no debt. Before I was “working rich” meaning rich as long as I worked. Currently I am simply making sure that my kids will make it through college, and that I will be able to buy a farm, and the training to be a teacher.
A good life means that your inflows are greater than your outflows. That can either be done by having high income and less high expenses, or by having low income and no expenses
Most physicians have the former. Most farmers have the latter.
As regards the “astronomical income” of some specialists, this varies. Hematology Oncologists get about 250,000 (after 7 years at miminum wage after 8 years post secondary school education) and 200,000 in debt. They are sued at higher rates. They also essentially get no sleep as cancer patients come into the ER sick more frequently. Neurosurgeons make about 400,000, this is after 9 years at subminimum wage, and the above debt. They realize that one train wreck can result in your salary and assets being confiscated by law for the rest of your life. (This has happened to one neurosurgeon friend of mine). He committed suicide, and his partners took early retirement. Now we send our brain cases over a hundred miles a way as the rest just do spines now.
I personally would have made a whole lot more had I become a plumber after high school, and so would my partners. And I would have more time.
What I see is that the US encourages physicians to go deeply into debt (150,000 average for med school and college) and an average of 75-100,000 to start your practice and then says “You greedy rich doctor, you should work for free, and we are going to sue you if anything bad happens because you are screwing the poor.” And indeed we do work for free. I’m on call one night out of three and I don’t get paid since everybody is uninsured. Neither my medicaid or medicare patients pay the costs of overhead (and I see both).
Maybe it is “greed” to wish to be compensated for taking on debt, and spending most of ones free time working when other people seem to make it to their children’s soccer games.
However this discussion has also left out “envy” and “theft” and “bait and switch” and “intimidation” using the legal process.
I might add that the US government deliberately ensnares physicians in debt in order to keep their serfs on the plantation. The only reason medical school costs are so high is to pay for the ininsured patients at the University hospital. Private hospitals in wealthy areas aren’t permitted to set up a medical school.
Similarly, the government encourages hospitals to set physicians up in practice. My last practice the nice non-profit hospital set me up, encouraged (heavily) me to buy a house, and the contract (which appeared the day before I started work) had a 50 mile geographic restriction if I ever left, meaning I could not practice within 50 miles of the hospital. There was also a payback scheme, but I managed to get out of that by simply refusing to sign and staying home. Then two years later the hospital announced that every physician needed to sign a contract being personally responsible for the mortgage on the hospital’s medical office building. Again, if was “sign here, and now or leave and start over 50 miles away, if you can find a place”. Since I didn’t wish to take on responsibility for 2 million worth of overpriced offices I didn’t want in the first place, I left. (They called me back two weeks after I signed with a more reasonable hospital to say “can we talk”. They still haven’t replaced me, two years later, my former patients treck up to see me.
This would be considered fraud in another profession. But the government favors hospitals and insurance companies, because a physician who is in debt is a physician who must keep working, no matter how onerous the terms. There is no other industry, where your employer will come to you and say, “sign for a loan for my business” or be fired and never work in this community again.
Again, the key is NO DEBT. Debt is slavery. No debt is freedom.
Why do you resent the idea that physicians should also have freedom?
I am a little curious why y’all are so angry that a physician would rather leave and earn in the lower income range than remain a “rich doctor”.
I thought the reason we were resented was because we are “rich doctors”.
Now, as you see thee of the four docs on this thread (all the non surgeons) are retiring (but not to sit around, since I at least can’t afford (at 51) to completely retire. I’m just going to be an ordinary worker (though with less debt than most).
So why the resentment?
I love cluless’s new technology. The only problem is my patients arrive with no ID or drug list or bottles even if they were given written instructions to do so. Only abot 30% of Medicaid patients keep confirmed appointments. I am sure none of them could find their smart card if they had it. Cluless is correct that more will be placed on the patients. The downtrodden class have such chaotic lives, lack of responsibility, no family support that hey will just fall through. Lets face it, most medical problems that clutter up the ER and doctor offices are due to bad choices, life style, sin, ignoracne or indifference. Expensive medical care won’t touch that. Right now my nurse takes the detailed history from the patient after he fills out a questionair. I do disability exams for the Social Security people for a fixed rate that is modest. They referred a complaint to me that the patients complained that it takes too long! After questioning them as to what they really want, we now have a policy that if the patient does not answer the questions or reply to one time being asked about it then it is simply reported “patient refused to answer.” No more picking the chicken trying to get to the bottom of their problem. And if they even hint that certain parts of the exam they don’t like, it is entered as refused by patient. I don’t know if they ever get on disability, but I have cut my cost and risk. Really can be fun. As soon as I can get my debt gone, I’ll be only doing the fun things. When we are all working for the government, then we will work like government workers. Ah, brave new world.
#17 Yup. Them’s my patients too. One third of the Medicaid no shows, and we expect to be calling their pharmacies for the med list they never bring in and to help them fill out their intake forms. My nurse spends most of her time sorting them out, and it is always the medicaid/uninsured (less so the medicare) who are unprepared. The private payers, who pay for all the above usually arrive on time, prepared, and follow instructions.
It will be interesting to see how the coming “smart card” that we are expected by government mandate to adopt and pay for will work, but I hope to be gone in 4 years if Obama comes in, and 8 if McCain comes in. Sooner if necessary, and if I do well in my apprenticeship.
Speaking of serfdom, it is not just the government and hospitals who try to snare physicians in debt while making it difficult for them to leave. My sister interviewed at a large multistate corporation that had health clinics all over the country. She was presented with a contract to sign “on the spot”. Embedded in the fine print was the agreement that if she left for any reason including failure to be paid, she would not only not practice medicine in any state they worked in (which was most states) but she would pay all their costs for recruiting another physician and replacing her (that can run into several six figures). Needless to say she didn’t sign, though many other physicians did. (When you have student loans coming due, you figure you need to get a job fast).
There is no other profession that puts up with what physicians put up with, and are resented so greatly for matters that for the most part are out of their control.
I am still a little curious as to why Larry Morse resents my attempting to leave medicine and become a subsistance farmer and substitute teacher.
Do you feel “entitled” to my labor as a physician at whatever terms you wish?
Do you feel threatened by my buying and developing 20 acres so as to ensure a food supply? Lots of folk around here farm part time; in fact I don’t know any full time farmers. Most people farm to put food on their tables, and work at something else. They work 12 hour days, but they work at something they enjoy that is unlikely to suddenly result in legal trouble, jail time and penury, while exciting the envy of their neighbors.
What is wrong with it? And why are you resentful?