Educational Debt and Reported Career Plans among Internal Medicine Residents

In reviewing the article entitled "Educational Debt and Reported Career Plans among Internal Medicine Resident" by McDonald et al, I feel compelled to urge young Internists to go into the field that they feel ultimately will make them happy. If it is a generalist, hospitalist, or specialist, the choice can be great. However, too often one choses a field based more on financial determinates, whether it be paying off debt or trying to make a good enough salary to live at a desired lifestyle.

There is a surge of "cash only" practices sprouting up in California which has several monetary advantages including higher income and less patients. However it can also leave a longtime patient stranded without their trusted physician especially in slow economic times. Career decisions are often financially based with less emphasis on providing care to a community. A neighborhood that consisted mostly of doctors 30 years ago now is occupied by lawyers and executives. Yet many have forgotten why they become Internists in the first place.

Whether helping our patients with their medical needs or attending the wedding of a longtime patient, the satisfaction that can be generated is awesome. Doctors can do well and are rewarded much more than income generated from their practices. It can be priceless.

Conflict of Interest:

None declared

Editor:

The findings of McDonald do not provide much if any consolation to those looking for a "good news spin" on the finding that significantly diminishing numbers of graduating medical school students and internal medicine residents are choosing careers in primary care internal medicine.

Dr. Grovers's accompanying editorial in the same issue tends to tread lightly, suggesting various alternative explanations and qualifiers to McDonald's position. I do agree with Dr. Grover that educational debt and salary expectations are two very different measures, and that debt alone may not be a consistent discriminating metric. Self-selection in this study may account for a fair amount of explanation of the findings.

What I find most concerning, and truly worrisome, and not concluded by either author, is the possibility that if debt is not a major issue, then primary care medicine itself is now being perceived as too intrinsically (and I hate to use the word) toxic, hence less attractive to medical residents and students as a career choice.

Lifestyle preferences are valid considerations and here to stay. Certain specialties are viewed as favorable in this regard, others including primary care and general surgery are not. I don't include hospitalist medicine as a generalist field, at least in practice, where hours are clearly defined, patient responsibilities exist only for the period of hospitalization, and all the hassles of out-patient management such as prior authorization, formulary adherence, paperwork, phone calls, and productivity pressures are minimal.

One would find it difficult to accept the counter-intuitive argument that attaining a high level of self satisfaction providing humanistic, almost egalitarian services trumps the long term financial impact of accepting about half the starting salary of the specialties; 25 years @ $100-150K salary differential adds up to $2.5-$3.75 million over a career.

If primary care "toxicity" is an issue, how can it be defined and perceived, how did it develop, and, how much is "self-inflicted". I suggest from my own experiences, observations, and conjecture as a primary care internist for 28 years:

1) Loss of autonomy-being told what medications are allowed to be used, asking permission before studies can be ordered, and the constant uncompensated time consuming, time wasting, aggravating process of dealing with payors. There are some obvious benefits to these programs, but financial benefits to the insurers and PBM's are primary.

2) Encroachment on scope of practice-being told that midlevel practitioners are capable of performing an increasing number of our daily chores (for less money) just adds to the general public's perception, and our self-perception, of increasing irrelevance.

3) Managed Care principles-the plans "lease" their "covered lives" to primary care physicians and they become our "patients", at least until the next open-enrollment period comes along and (in my practice neighborhood mostly) their employer selects a new financially favorable payor, and the patients play musical chairs. Is it any surprise that more patient's view their primary care physician as just another "contractor"; unhesitant to cancel (or "no show" for) an appointment in order not to miss a business meeting, or worse, reschedule a visit from an interior designer. Whatever prestige existed for primary care has waned.

4) Increasing demand for justification of improvement in primary care compensation-maybe I don't have all the facts on this issue, but I don't see any other specialty being asked to justify their already high salaries, (or insurers seriously balk at paying high fees), nor see any lessening demand for their services and skills. Internal Medicine (as well as all primary care) practitioners on the other hand, despite being lauded as providing essential services, and proven to be most effective economic "tool" to keep rising health care costs in check, are now being asked to reinvent their practices, as in The CP's "Patient Centered Medical Home", as a necessary requirement for consideration of (not guaranteed at this time) increased compensation. I don't envision this scenario of considerable increases in physician management time and responsibilities in exchange for "some" increase in salary as making primary care medicine more attractive. A couple more MRI's, colonoscopies, joint aspirations, hip replacements, cardiac catheterizations, nevus excisions and botox injections would generate that income a lot more easily. Additionally, as more primary care providers come into the employ of large health care delivery (hospital) systems, the productivity demands and incentive programs have become exceedingly complex and strict, creating an environment susceptible to unhealthy competition amongst providers and concerns about maintenance, or worse, sacrifice of quality. The image of primary care internal medicine as a "loss leader" for these institutions does not add to it's attractiveness.

5)"RealEconomics"-it appears the pool of dollars to compensate physicians is fairly "fixed". Redistribution of more dollars can only come from two sources: our patients-in the form of self-pay, or premium increases (not popular, nor good-will generating), or, from the specialists themselves. I doubt my colleagues and many friends in the specialties, who constantly tell me how much they appreciate me, and feel "bad" for me, actually appreciate me enough that they would fork over some of their hard-earned income. The source of increased income, and the magnitude of it for primary care physicians is far from clear.

6)"Real Observation"-how do we "appear" to the interns, residents and students that we precept in our offices? Are we hurried, irritable, impatient, hassled, unappreciated, condescending, constantly whining and complaining, distracted, harassed, living the day on a veritable treadmill as we try to do our best? Do those few precious moments of humanistic interaction with our patients as we savor the feeling of providing a valuable service to a person in need compensate for rest of the days labors-and do our "students" even notice it? Is it enough to convince them it's all worth it? Speaking for myself, the answer is yes. But we need to ask them. I believe it's far from an easy sell.

7)On "self-inflicted wounds"-how did we get here? As Grover states, interest in primary care has been waning for many years-this is not a new crisis. Are the forces leading to diminished interest in primary care irresistable, or have they not been properly confronted? The verdict is not in, yet, but there are troubling signs. The ceding of so much control over so many aspects of the daily delivery of care to the Insurance Industry by the institutions of medicine have empowered the payors, (and they continue to expand their power by consolidating and growing ever larger, with the blessing of the current Department Of Justice-the belief being that larger insurers will keep costs down by using their size as leverage to "squeeze" hospitals and physicians vis-a-vis contracted payments). The provider institutions have responded by consolidating too, engaging in cut throat competition with neighboring health care institutions, exerting ever increasing pressure on already hard working primary care doctors to see even more patients to increase revenue generation. Most primary care providers in urban areas are now employed by these ever-expanding institutions; go back 10 to 15 years in areas around Boston where there were literally hundreds of small (3-5 physician) "private" medical practices, that were desirable portals for graduating residents to enter the world of primary care internal medicine, there are now virtually none. The insurers have the power to keep primary care compensation relatively low and demand that overall physician compensation remain a "zero-sum" model. Those are the facts on the ground. It also remains a fact that just about all of our medical institutions, academic, intellectual, professional and political have "spoken" their support for primary care physicians, but when the rubber meets the road, their actions have not matched their words, nor have they produced the desired result. Primary care still remains in critical condition, and our graduates unfortunately continue to recognize that fact.

Conflict of Interest:

None declared