The Future of Internal Medicine

The Role of the General Internist

There are two reasons why we might argue that general internal medicine's role in addressing the shortage of primary care physicians should be less than in the past. First, general internists used to be considered unique because of their deep knowledge of both simple and complex adult diseases. However, the medical knowledge base has grown to such daunting proportions that it seems impossible for any one physician to master all or even part of it. The knowledge base simply may have outstripped the capacity of the general internist to assimilate it.

Second, the increasing visibility of family medicine may have significantly undermined internal medicine's commitment to its role in primary care. Family medicine has set as its goal producing half of the nation's primary care physicians, and it has pursued this goal with more single-mindedness, vigor, and political finesse than internal medicine has pursued its own more tentative manpower goals. This year's national residency matching program shows that 238 more U.S. graduates matched to family practice residencies than last year, suggesting that the small increase that occurred last year may be the beginning of an upward trend [2]. This recent success of family medicine relative to internal medicine, which lost nearly as many U.S. recruits as family medicine gained, may reflect students' sentiments that family medicine, with its emphasis on breadth rather than depth, may be better qualified to provide primary care and that internists are best used as consultants.

Thus, the arguments denigrating general internal medicine come from opposite sides. One side contends that general internal medicine is too broad and that breadth has come at the expense of depth, that is, the scientific knowledge base has outstripped the capacity of the generalist to absorb it. The other side argues that general internal medicine is not broad enough, that primary care is best provided by family practitioners, who are equipped to deal with a greater range of both patients (children as well as adults) and problems (social and behavioral as well as medical). This double-edged sword is mirrored in medical students' two common criticisms of general internal medicine: Half protest that it is too difficult, and half protest that it is not difficult enough. Both criticisms stem largely from students' exposure to an environment that is hostile to primary care.

We believe that the general internist continues to be the best primary care physician for adults. He or she receives three times as much training in internal medicine as a family practitioner and knows much more about its subspecialties. In addition, the general internist is more adept with complex, multisystem disease and more comfortable in dealing with very sick people. Internal medicine should renew its commitment to generalism.

Internal Medicine Manpower

Goals

The internal medicine establishment has made a verbal commitment to generalism: The Association of Professors of Medicine, the American College of Physicians, the American Society of Internal Medicine, and the Federated Council of Internal Medicine have joined the quasi-federal Council on Graduate Medical Education, the American Academy of Family Practice, and the Association of American Medical Colleges in advocating that half of U.S. graduating seniors should become general internists, general pediatricians, and family physicians [3-5]. According to the Federated Council of Internal Medicine, 50% of internists should become general internists in order for internal medicine to contribute its share of the nation's ideal supply of primary care doctors [6]. This means that approximately 18% of all U.S. physicians should be general internists. Unfortunately, this goal has not been reached. On the contrary, the available data show that we are actually going in the wrong direction.

Based on the Association of American Medical Colleges' Institutional Goals Ranking Report [7], internal medicine is nowhere near meeting its manpower goals. The Association tracked the 1987 cohort of U.S. medical school graduates through postgraduate year 4 (PGY-4). Internal medicine residents who were not in fellowship programs in PGY-4 were assumed to be practicing general internal medicine. The data do not take into account general practitioners who did not complete training in any specialty, but this shortfall is roughly offset by those counted as generalists who began specialty training after PGY-4. The data also do not reflect the presence of international medical graduates who, by definition, were not graduated from U.S. medical schools.

According to this study, the cohort of 1991 included 1502 general internists who had graduated from U.S. medical schools. This is 37% of all U.S. medical school graduates entering primary care, which we believe is about the right proportion. However, this figure represents only 9.5% of all U.S. graduates, which is too low. It also falls short of the goal that 50% of internists become generalists (Table 1). The study did not include international medical graduates, but if we assume that such graduates entered general internal medicine in proportion to their representation in postgraduate year 1 (PGY-1), then internal medicine turned out 1951 general internists altogether, which is 16% (or 922 persons) short of the 50% goal. To meet its goal, internal medicine would have had to turn out roughly half again the number of general internists.

It has been argued that the number of general internists is understated because primary care residency tracks have not been properly identified and hence, the argument goes, more generalists come from categorical tracks than is commonly believed. The Goals Ranking Report negates these arguments because it counts as general internists only those persons who are known to be in practice during PGY-4 and later. Further tracking shows that the number of generalists in the 1987 cohort was similar in 1993 and 1991. Measurements in the cohorts that were graduated in 1988 and 1989 also corroborated the 1987 cohort data. (Killian CD, Association of American Medical Colleges. Personal communication.)

It has also been argued that general internal medicine has not thrived relative to family medicine because family medicine has been treated more generously in terms of legislative subsidies than have internal medicine and pediatrics. Some persons have stated that more government support for general internal medicine training programs would result in the training of more general internists. We do not subscribe to these arguments. First, training positions in internal medicine are ample, and, as we suggest below, these positions must be transformed into general internal medicine residencies rather than subspecialty fellowships. Second, government planners see that family medicine has produced a relatively pure clone of primary care physician. In contrast, most persons who train in general internal medicine become subspecialists. We do not think that these trends will be reversed by throwing more money at the problem.

The results of the 1992 Association of American Medical Colleges' Graduation Questionnaire [8] are the most disturbing indication of the plummeting interest in general internal medicine (Table 2). Based on the responses, only 3.2% of medical school students graduating in 1992 were contemplating careers in general internal medicine. Just 10 years ago, the percentage was 14.4. If this trend continues, the nation's supply of general internists will be almost completely depleted in the near future.

Manpower Problems of Internal Medicine as a Whole

Manpower problems are not limited to the shortage of general internists. Graduates of U.S. medical schools are increasingly showing less interest in internal medicine as a whole. Residency match data (Table 3) show that internal medicine has increased its number of slots by over 1100 in the last decade; however, the number of matching U.S. graduates has decreased slightly and the percentage of positions filled by U.S. graduates has fallen sharply to only 57% in the 1993 match [2].

International medical school graduates are an increasingly important source for filling internal medicine residencies. In 1992, the PGY-1 cohort in internal medicine included 3261 international medical graduates (37% of the total group). (Lyttle CS, National Study of Internal Medicine Manpower. Personal communication.) This represents more than a twofold increase in number in just 6 years. However, despite the increase in the number of international medical graduates during this period, the total match rate for internal medicine fell by 4 percentage points.

Internal medicine's unpopularity is manifested primarily in categorical internal medicine programs (Table 4). Looking at the match for categorical programs alone, one can see that the number and percentage of U.S. graduates matching to these slots has declined sharply, although the overall match rate has been sustained by the influx of international medical graduates. In 1993, U.S. graduates matched to only 53% of available PGY-1 positions.

The data are more favorable for preliminary programs (Table 5). Although the number of U.S. graduates matching to categorical programs fell by 28% in the last 6 years, the number matching to preliminary programs grew by 29%. Clearly, internal medicine is serving more and more as a precursor training vehicle for other specialties such as neurology, dermatology, anesthesiology, and ophthalmology, a trend that will not result in more primary care physicians [2].

Specialization

The allegiance of young people is shifting from general internal medicine to other specialties and to the subspecialties of internal medicine. This is manifested by the growth in fellowship training programs. (Lyttle CS, National Study of Internal Medicine Manpower. Personal communication.) Table 6 shows both the absolute number of fellows in training and their rate of growth during the past 3 years. The total growth rate for all the fellowship programs was 19%, despite decreases in a few smaller fellowship programs. Some of this growth may be due to the lengthening of programs, but much of it is due to expansion. General internal medicine is also attracting more fellows, but its growth rate has been less than half the average.

More importantly, the growth in fellowships has been at the expense of general internal medicine residencies. In comparison to the average growth of 19% shown by fellowship programs, internal medicine residency programs have grown by only about 5% and categorical programs have grown by only 2% (Killian CD, Association of American Medical Colleges. Personal communication.) These results indicate that the proportion of students in postgraduate year 3 (PGY-3) who are going into fellowship training is increasing relative to the proportion entering general internal medicine.

Another way to look at the flight into the subspecialties is to examine the number of certificates in general internal medicine and the subspecialties conferred by the American Board of Internal Medicine. (Blank LL, American Board of Internal Medicine. Personal communication.) Table 7 shows the percentage by which the number of certifications in various subspecialties increased over the past decade. When the new subspecialties are included (recognized through certificates of added qualification), the total number of persons certified in the subspecialties increased by 138% in the last decade, whereas the number of persons certified in general internal medicine increased by only 72%. Although the cohorts are not in temporal sequence, the data suggest that during this period, fully 69% of the persons who were certified in general internal medicine were also certified in a subspecialty. This number is falsely elevated by the inclusion of persons holding either two specialty certificates or a subspecialty certificate and a certificate of added qualification, but, on the other hand, it is falsely lowered by the exclusion of those who completed subspecialty training but failed or did not take a subspecialty examination. Such persons usually classify themselves as subspecialists.

Despite a decade of energetic discussion about turning out a greater proportion of general internists, the subspecialization rate has remained fairly constant. Table 8 presents subspecialization rates calculated by the National Study Of Internal Medicine Manpower (Lyttle CS, National Study of Internal Medicine Manpower. Personal communication.) According to this study, the subspecialization rate of the PGY-3 cohort is about 68%. Based on the fellowship and certification data, we can argue that at least two thirds of all internists in training enter a subspecialty.

Practice Environment

Why are young physicians selecting the specialties and subspecialties over general internal medicine? Medical students who responded to the Association of American Colleges' Graduation Questionnaire indicated that the main reasons they were not interested in practicing general internal medicine stemmed from a negative clerkship experience, the perception that the specialty was too demanding, and a dislike for the type of patient with whom general internists deal [8]. In contrast to many other specialties where patients get well, more and more patients on internal medicine wards have lethal diseases such as the acquired immunodeficiency syndrome (AIDS) and cancer, and many are not conscious and coherent.

However, we cannot ignore the practice environment as an additional important factor in dampening students' interest. The hostile practice environment is evident in the decrease in internists' satisfaction after they complete their medical education and begin practice. A recent survey by the American College of Physicians showed that 90% of internists were satisfied with internal medicine when they began practice, whereas only 50% were satisfied at the time of the survey [9]. Among the dissatisfied internists, 25% would have chosen a different specialty and 25% would have chosen another profession altogether.

The practice environment penalizes internists, particularly general internists, by offering relatively modest incomes and a relatively large amount of red tape and regulation.

Income

When the median income is $441 000 for cardiovascular surgeons and $112 000 for general internists, it is not too difficult to sympathize with a graduating medical student with a $75 000 debt who opts for the higher-paying specialty [10]. In fact, income does appear to play a significant role in specialty choice. Shulkin [11] has found a near-linear correlation between the income derived from a specialty and the number of applicants per residency position.

The Medicare fee schedule, based on the resource-based relative value scale, was designed to increase the income of primary care physicians in relation to the income of specialists. However, the 1993 annual report of the Physician Payment Review Commission shows that the benefits to primary care physicians were less than intended in the first year of the scale's implementation [12]. General practitioners and family practitioners saw a 10% increase in payment rates rather than the 17% increase forecast by the Physician Payment Review Commission. The Physician Payment Review Commission predicted a 2% increase in payment rates to general internists; however, this figure is probably also optimistic. The average payment rate to all internists, including subspecialists, did not change, although changes in volume and balance billing caused an increase of 2% in total Medicare revenues. One reason that payments to primary care physicians did not achieve the predicted levels is that the overall resource-based relative value scale conversion factor was lowered. In 1992, all physicians saw an average reduction in payment of 3%. Another reason is that the practice component of the fee schedule, intended to provide reimbursement for overhead and liability expenses, disproportionately favors invasive services [13]. If the resource-based relative value scale has helped at all, it has not helped much. Most generalists have been greatly disappointed with the scale, because it reflects the major disparities in income that are present in both the U.S. public and private systems of reimbursement. We ought to start over.

Other elements of Medicare payment also penalize primary care physicians. Medicare does not offer reimbursement for many preventive and case management services or for time spent with patients on the telephone. The deletion of payment for electrocardiograms done during office visits also disproportionately affects primary care physicians. Last, but by no means least, the Omnibus Budget Reconciliation Act of 1989 limits payments to physicians in their first 4 years of practice. This is particularly onerous to young, debt-burdened graduates choosing a specialty that may never pay very well.

The Hassle Factor

The second hostile element of the practice environment is the hassle factor imposed on physicians by third-party payers [14]. Medicare and Medicaid claims include thousands of diagnosis and procedure codes. There are between 200 and 300 utilization review firms, each with its own medical necessity rules and preauthorization requirements, working for private insurers [14]. Physicians receive phone calls and letters questioning the appropriateness of their services, both before and after the services are rendered. To add to the frustration of this regulatory environment, insurers often do not divulge the utilization review standards by which they judge physicians [15].

In 1991, 4.4% of the average physician's professional time was devoted to billing claims, and many contracted with outside billing firms [16]. Internists have fared worse than most: In 1986, internists spent 18% of their time on administrative tasks, and this percentage has increased. This administrative burden is expensive. In 1991, overhead and billing expenses consumed about 44% of all physicians' gross income [16].

The hassle factor affects all physicians, but particularly general internists and other physicians providing primary care. Primary care physicians see more patients than other physicians, and their practices consist of a higher proportion of Medicare patients. Their paperwork and overhead expenses can be almost twice as great as those of other physicians. To pay for their high overhead, primary care physicians must work long hours and spend as little time as possible with each patient. Some feel they can no longer afford to treat Medicare patients, and many do so at their own expense [14, 15, 17]. The consequences are that many general internists and other primary care givers are overworked, underpaid, and frustrated. Given the current hassle factor and inequities in income, it is no wonder that medical students and residents, no matter how idealistic, become wary of entering primary care.

Correcting the Shortage of General Internists

The Consequences of Specialization

The trend toward specialization and away from general internal medicine, accelerated by the practice environment, has had several profound consequences. First, the excessive number of specialists in our country means that some specialists cannot find enough work to keep themselves competent in certain procedures. In response to an inadequate workload and patient demand, many provide generalist care for which they may have trained many years previously and for which they have little enthusiasm. Second, a specialist-dominated system leads to the excessive use of procedures and ultimately to more expensive care. Third, the shortage of generalists means that many people, particularly those in rural and inner city areas, do not have access to primary and preventive care.

The Market

Will market forces alone eventually generate the appropriate specialty mix? We doubt it. Market forces have worked in only one direction: to promote specialism. Motivated by income and lifestyle, two thirds of board-certified internists have opted to subspecialize and have eschewed careers in general internal medicine. Despite the market's poor record in promoting generalism, a few persons still maintain that the law of supply and demand will ultimately make everything right. They argue that, however sluggishly, the market is responding to the shortage of generalists. Health maintenance organizations, for example, are hiring more primary care physicians and are paying them more. In 1989, the starting salary for general internists at Kaiser Northern California was $72 000; for 1993, it will be $98 400a 37% increase in 4 years. (Sams B, Kaiser Northern California. Personal communication.) It is not surprising, therefore, that many internists are leaving solo private and group practice for the relative financial security of managed-care organizations.

Government

As long ago as 1976, in an effort to correct the shortage of primary care physicians, the U.S. Senate gave serious consideration to a proposal (S. 3239) that would have given the federal government control over the specialty mix and size of training programs. Under this proposal, the Secretary of the Department of Health, Education and Welfare, advised by national and regional councils, would establish the number and type of first-year residency positions and certify them at each hospital. Hospitals with uncertified residency positions would face withdrawal of all federal funds except Medicare and Medicaid reimbursement, and, furthermore, could be fined up to $10 000 per day.

In retrospect, this proposal seems draconianand it isbut the United States is the only Western, industrialized country without a centralized system of determining physician manpower. In this context, and considering the severity of the proposal that was floated as long ago as 1976, our profession should probably consider itself lucky that there has not been specific legislation mandating changes in graduate medical education to achieve the goal of increasing the number of primary care physicians. Perhaps we can credit this respite to the change in the philosophy of what government should do, as opposed to what it can do, that accompanied the Reagan revolution.

However, the Reagan revolution is over, and Washington now houses an administration with a more hands on approach. Even before the change in leadership, there was renewed interest in government participation in health manpower planning. The Bush administration and some members of the Congress have proposed changes in Medicare direct graduate medical education payments intended to provide incentives for primary care training. Under these proposals, payments to hospitals for residents in primary care specialties would be more generous than for trainees in non-primary care disciplines. Most of these proposals, if enacted, would reduce total payments for the direct costs of graduate medical education or, at the very least, reduce support for non-primary care training programs. President Clinton, following in his predecessor's footsteps, has put forth one such proposal in the administration's fiscal year 1994 budget document [18]. According to this plan, Medicare would base direct graduate medical education payments on the national average salary of residents. It would pay 240% of this figure for each primary care residency slot, 140% for non-primary care residency slots for an initial period, and 100% for non-primary care residency slots beyond this period.

We believe this proposal and others like it are misguided. First, they assume that there is a shortage of primary care residency positions. On the contrary, there is an ample supply of these positions; the problem lies in finding medical students who are willing to fill them. Second, medical students' selection of residency training programs is unlikely to be affected by Medicare payments to hospitals, and third, preferential payments are likely to cause divisiveness among an institution's departments and divisions.

However, as Kassirer [19] suggested in a recent editorial, linkage between the financing of graduate medical education and control over the number and specialty mix of training positions now seems inevitable. This linkage will probably be unpopular with training programs in internal medicine, as indeed it will be with all graduate medical education programs. However, internal medicine is not in a good position to complain. By failing to make responsible decisions about manpower within our pluralistic system, internal medicine has invited the imposition of government control.

Academic Medicine

In our view, the nation's health manpower problems can be addressed most effectively from within academic medicine, and we would argue that academic medicine has an obligation to assume this responsibility.

Here is what we can do, beginning with undergraduate medical education. First, medical school admissions committees should attempt to select applicants who are interested in primary care. However, although applicant interest is important, it can be overestimated in relation to the importance of the medical school experience. The importance of the medical school culture has been emphasized by Kassebaum and colleagues [20]. They showed that students interested in general internal medicine retained that interest during the 4 years in medical school if they were enrolled in a school that is a good producer of primary care physicians. Exactly the opposite is true in schools that have poor records in turning out primary care physicians.

Solutions

What can be done to make the medical school environment more friendly to primary care [21]? In general, students' exposure to the generalist specialties should be greater and more valued within the medical school experience. We make the following suggestions:

1. Medical schools should devote significant portions of their curricula to generalist and ambulatory experiences and enlist the teaching expertise of community-based generalists.

2. Students should be exposed to strong generalist role models and mentors, and, to this end, medical schools should provide appropriate academic recognition for such teaching and role-modeling. There should be increased emphasis on teaching general internal medicine, particularly in an ambulatory office setting.

3. Generalists should be offered, and encouraged to accept, prominent positions within academic medicine as chairpersons, deans, and members of administrative and curriculum planning bodies, including admissions committees.

4. Medical schools should strengthen their primary care departments and their divisions of general internal medicine.

5. Financial incentives such as loan forgiveness should be established to encourage medical students to choose generalist careers.

6. Perhaps most importantly, faculty should change their attitude toward primary care and cease deprecating careers in the primary care disciplines.

We believe these changes would greatly increase medical students' interest in the primary care specialties. However, significant changes must be made in graduate medical education as well:

1. The American Board of Internal Medicine and other specialty boards should put a stop to the current epidemic of certifimania [22]. We question the appropriateness of many certificates of added qualification, including those in transfusion medicine, sports medicine for internists, and the joint certificate between internal medicine and psychiatry. The proliferation of subspecialty boards gives enhanced standing to subspecialties and will naturally lead to more subspecialization.

2. We should increase the number and size of primary care tracks, because good evidence exists that more graduates of primary care tracks actually enter general internal medicine. Although it is true that there are some residency programs where there is active competition between primary care and categorical tracks and where the number of generalists coming from each track is approximately equal, such programs are the exception rather than the rule. All of the manpower data presented earlier show that the number of persons training for a career in general internal medicine is decreasing. Primary care tracks are often self-designated and not separately accredited. The Association of Professors of Medicine and Program Directors in Internal Medicine should clearly designate primary care tracks, should see that they obtain separate National Resident Matching Program numbers for them, and should persuade the Residency Review Committee in Internal Medicine to accredit them separately from categorical tracks.

3. Divisions of general internal medicine should be strengthened [1]. Certainly, they need to improve their research and fellowship training programs, but, more importantly, they should turn out more community practitioners in general internal medicine.

4. Probably most necessary, however, is a phased reduction in the size of categorical internal medicine residency programs and subspecialty fellowship programs. This is a painful prescription because housestaff constitute relatively inexpensive labor and because the indirect medical education formula increases payments to hospitals as the ratio of interns and residents to beds increases. However, downsizing is necessary. Cutting back on the number of categorical PGY-1 positions presents an opportunity for shifting applicants into primary care tracks and reducing the number of fellowships.

5. Strong arguments have been made that residents and, most particularly, subspecialty fellows are necessary to provide in patient services. Although this may be true, it does not make it right. Many subspecialties have shown that advanced nurse practitioners, well-trained physicians' assistants, and other health-related personnel can subsume such service roles. Unfortunately, these other health professionals are usually considerably more expensive than residents and fellows. The issue of who pays for essential inpatient services in hospitals must be addressed much more forthrightly than has been the case heretofore.

We believe that internal medicine can meet the goal of turning out 50% generalists if it adopts the following three strategies:

1. Limit the number of categorical PGY-1 positions to 110% of the number of applicants who are graduates of Liaison Committee on Medical Education accredited medical schools [3].

2. Reduce the number of fellowship positions by 5.6% each year for 7 years. A decrease of this magnitude would result in a 50-50 generalist-specialty mix, 7 years after it is initiated.

3. Retain fellowship stipends within departments of medicine and shift these resources to general internal medicine residencies.

A Centralized Planning Structure within Academic Medicine

Having lambasted government intervention, we think it only fair to point out that not everything government touches goes awry. After 20 years of waiting for the private sector to respond to its conscience alone, we have concluded that it has accomplished little. Perhaps the best solution is a joint government-private sector venture. The Macy Conference on Graduate Education in February of 1992 issued a proposal for such a system, in which a physician work force commission, advised by regional or state consortia of medical institutions, would set overall manpower goals [23]. The consortia and the central commission would consist predominantly of private citizens. Such a system would provide a rational way to respond to manpower needs, while at the same time preserving medicine's place at the negotiating table.

Conclusion

The future of internal medicine could go one of two ways. On the one hand, internal medicine could continue to respond ineffectively to the nation's manpower needs and to persist in its overproduction of subspecialists. If this happens, the federal government will soon assume a role in manpower planning that will compromise the autonomy of internal medicine, and it would not be surprising if this happens in the context of comprehensive health care reform. In addition, if government or market forces prevail, internal medicine may lose its franchise to provide generalist care to family physicians and nurse practitioners. The latter group, in particular, has uttered strong rhetoric to the effect that they can render primary care as effectively as physicians for 80% to 90% of patients. If this scenario were to evolve, there would need to be major downsizing in the medical education and graduate medical education establishments.

We hold the view, however, that internal medicine must renew its commitment to generalism and must pursue that commitment aggressively. This may require a change in faculty mix: Presently, subspecialty sections have an overwhelming numerical advantage in terms of faculty; we propose a model where the division of general internal medicine is perhaps the largest in the department and serves as the hub of the departmental wheel, with the subspecialty divisions serving as the spokes. Although few data exist, there is anecdotal evidence that both academic and clinical faculty in divisions of general internal medicine are increasing. It has been argued that an increased emphasis on generalist faculty will weaken the thrust in biomolecular medicine that must be part of the medical education of the future. We do not subscribe to this argument. Nothing proscribes academic generalists from pursuing a career in the basic science laboratory. As molecular medicine becomes less differentiated, linkages to categorical clinical specialties will inevitably become weaker.

At the same time that the teaching of general internal medicine is strengthened in the ambulatory setting, we need to review the content and process of the third-year clinical clerkship. This is already happening in many departments of medicine. Indeed, a better integration of inpatient and outpatient teaching and training might do much to improve the popularity of internal medicine for both medical students and graduate trainees [24].

Such an intellectual reorientation of internal medicine will provide the specialty with three beneficial outcomes. First, it will enable internal medicine to salvage its position of power and leadership in academic medicine, perhaps in the context of a cooperative venture with the government. Second, it will bring back the general internist, whom we consider to be the most appropriate clinician for adults, to a position of prominence. Third, we will once again have the right to consider ourselves responsive to the needs of our patients.

To return to the Wagnerian allegorywill internal medicine fade from twilight into darkness, or will it survive to see a bright new dawn?

Adapted from a presentation to the Washington State Society of Internal Medicine, Spokane, Washington, 15 May 1993.