With the author’s kind permission, below is DB’s Medrants full post on the subject of what’s happening with medical students who do not choose internal medicine outpatient practices—the kind of doctors who  practice in their own offices rather than hospitals and health systems.

Health care reform efforts need these doctors to be in place but this is beyond the ability of any legislation to deliver.

As a former primary care physician, now medical professor and administrator, he has a 360 degree view of the medical world. The author’s heart is with primary care and, as a medical educator, he all but certain to be in the minority.

Bear in mind that DB is writing for other medical  professionals, not a lay audience. Still, what he has to say will help patients understand the problem in internal medicine, one specialty whose members care for adults.

I have no issue with doctors joining larger practices associated with the hospital they would use anyway to get the benefits the scale offers. They still see patients every day. (Disclosure: I worked in a hospital which organized a group practice, part of my responsibilities, but, thankfully, responsibility shared with others, too. As much as I liked the doctors joining, there is something about trying to get them into a group which, um, does not bring out their caring side. We will leave it at that. This hospital group then decided to keep the group but to go back to independent status. Everybody’s okay with it. For patients, there likely is little difference now and before this group was formed.)

But what happens to a community when there is no such hospital providing doctors with the resources they need? What happens when there is no hospital which will handle the hassles that take doctors away from patients—which is where they want to be?

Who will be able to take care of patients in those communities? These newly-graduated doctors are not choosing this path very often.

DB’s Medrants

“Many factors have decreased the number of internal medicine graduates choosing outpatient internal medicine.  Outpatient medicine has deteriorated during my 30 years teaching internal medicine.  Our payment structure discourages excellent outpatient medicine and encourages spending too little time with patients.

“Unfortunately, the growth of hospital medicine has had the greatest impact on the percentage of graduates choosing general internal medicine.  As one who loves hospital medicine, I see the benefits of the growth of hospital medicine, but I also see the unintended consequences of that growth.

“Until hospital medicine became ubiquitous, we always had significant numbers of graduates who chose the specialty rather than a sub-specialty.  Internists practiced both in the hospital and the outpatient setting.  As overhead costs increased, remaining a “dualist” became less financially sound.  While we still have outstanding internists who do both, few new internists join practices that encourage both inpatient and outpatient medicine.

“The easy target here is our training.  Internal medicine has always focused on inpatient training.  Osler championed the hospital wards for teaching internal medicine.  Our training has not changed dramatically in over 100 years, yet our graduates choose different fields.

“I personally believe the problem is the job.  The hospitalist job is a better one than the outpatient job today.  The availability of the hospitalist job with a higher salary, less work hours and usually better defined patient load trumps the current outpatient job for most young internists.

“I recommend this article that addresses some of the issues – Primary Care in Medical Education: The Problems, The Solutions”

Source: DB’s Medrants, March 25, 2010