Monday, September 14, 2009

Internists and the pursuit of happiness

Internal medicine physicians, it is often suggested, are a pretty unhappy bunch. They are overworked and underpaid. They spend too much time on paperwork and too little time on patient care. Older internists, who remember the good old days, are less happy than younger ones. Rising costs and low fees have caused most to close their practices to new Medicare patients. General internists are more dissatisfied than subspecialists.

Most of these assumptions are based on anecdotal information, but what do we really know about how internists view their careers and their profession? A new survey of over 4,500 physicians, conducted by the well-respected Center for Studying Health System Change (CSHSC), suggests that the state of internal medicine is more nuanced than the popular portrait of disgruntled practitioners looking for an exit sign. (See Wall Street Journal writer, Jacob Goldstein's, take on the new survey.)

The CSHSC found that more than three out of four internists (76.4%) are "very or somewhat satisfied" with their careers; 5.4% are neither satisfied nor dissatisfied, 14.1% are "somewhat dissatisfied"and 4.1% are "very dissatisfied". Still, a smaller proportion of internists reported that they are more satisfied than any of the other surveyed specialties. 80.3 percent of family physicians, 83.4% of medical specialists, 80.5% of psychiatrists, 81.5% of surgical specialists, 80.5% of ob/gyn physicians, and a whopping 88% of pediatricians said that they were very or somewhat satisfied. Surgical specialists reported the highest proportion (4.7%) of physicians who said they were very dissatisfied.

The survey also shows that money doesn't necessarily buy you love (of career). Among all physicians, physicians who make more than $250,000 annually reported higher levels of satisfaction (86.7%) than those who make between $150,000 and $250,000 (81.8%) and those who earn less than $150,000 (76.8% very or somewhat satisfied). Yet money isn't everything, given that more than three quarters of the lowest earners expressed satisfaction with their careers. More pediatricians say they like their careers than any other physician specialty, even though the Medical Group Management Association reports that pediatricians are second from the bottom in annual physician income. And 11% of the highest earners expressed career dissatisfaction in the CSHSC survey.

Size matters, but also not as much as you might think. More than 82% of physicians in groups of three or more are satisfied with their careers compared to 77% in solo or two physician practices. (There wasn't much difference in satisfaction based on practice size beyond three physicians.) The length of time in practice also is not a clear indicator of satisfaction: "physicians in practice for more than 20 years provided more extreme responses: they were more likely to be either very satisfied or very dissatisfied relative to newer doctors."

What about the idea that most internists have closed their doors to new Medicare patients? 54.7% of internists said they accept all, another 18.6% said they accept most, and 17.2% said they accept some new Medicare patients. Only 9.5% of internists reported that they will not see any new Medicare patients.

The CSHSC survey provides important baseline data for policymakers and the profession on what can be done to make internal medicine a more attractive career path. A glass-half-filled person would say that the good news is that most internists are satisfied, while a glass-half-empty person would point out that internists are less happy than other doctors. The nuanced responses to the survey suggest that getting to the bottom of internists' varying degrees of career (dis)satisfaction is going to more complicated than, say, just increasing pay or getting them to go into larger groups. Money and size matters, but not as much as one might have expected.

Today's questions: How would you interpret the CSHSC data and how it might inform policy decisions on making internal medicine more attractive? How does it square with your own experiences?


Jay Larson MD said...

It appears that all the internists (including myself) who I know are a bunch of whiney little cry babies. The survey suggests that I should be happier. May be I should increase my anti-depressants. With such a satisfaction among internists, why are only 2% of medical students going into general medicine? Why have over 20% of physicians completing their training in 1990 have left practice?

It would be nice to have more specific data about the survey. How many out patient general internists responded? How many physicians were from metropolitan areas verses rural areas. I don’t know about the rest of the country, but Montana is sucking wind for more internists. Only 5% of physicians in Montana are general out patient internists. There are twice as many dietitians and 3 times as many physician assistants than internists.

This survey seems to contradict the Physicians’ Foundation survey of about 12,000 primary care physicians. The Physicians’ Foundation survey found that:

60% of primary care physicians would not recommend medicine as a career to young people

49% of primary care physicians said that over the next three years they plan to reduce the number of patients they see or stop practicing entirely

Only 6% of primary care physicians described the professional morale of their colleagues as “positive.” 42% of physicians said the professional morale of their colleagues is either “poor” or “very low”. 78% of primary care physicians said medicine is either “no longer rewarding” or “less rewarding”. 76% of primary care physicians said they are either at “full capacity” or “overextended and overworked”.

Yep, we are just a bunch of whiney cry babies.

What do I think of CSHSC data? Not much.

Rich Neubauer MD said...

I think policy makers need to be extremely cautious in interpreting satisfaction data from surveys of this sort when trying to plan for the future of internal medicine.

When I’ve taken surveys like this, I answer honestly: I’m satisfied; I went into general internal medicine because that was what suited me best, and I had a wonderful and satisfying career that has taken several unexpected turns and has been marked by plenty of challenges both clinical and otherwise, and has never been boring. But I became a generalist at time when the term hospitalist had not yet been born and my practice evolved from being a hospitalist (even though such a thing didn’t exist at the time) to being a “comprehensivist” (both inpatient and outpatient practice) at a time when hospitalism was taking over inpatient medicine. After 27 years in private practice, now I’m chief of an internal medicine practice at a hospital that is evolving its hospitalist practice with different challenges and issues to deal with.

However, the young physicians I see coming out of training now have very different challenges to deal with than in my era. Huge educational debt, the ascent of hospitalism which has and continues to carve out most of the challenging cases in inpatient medicine, two doctor families that challenge making a viable lifestyle are all against careers in general internal medicine in outpatient settings. The differential in pay between generalists and procedural sub-specialists has grown immensely since when I entered medicine. Compound this with advice against general internal medicine by their mentors in training programs, and it is a rare young physician that has the intestinal fortitude to buck the trend against being a generalist involving an outpatient practice. Further insult to injury is that there is nothing about being a hospitalist that even vaguely would lead to natural evolution to an office based practice. The statistic is that only 2% of those coming out of internal medicine training are going into general internal medicine. I think that is actually an optimistic number if anything.

I think policy makers should focus on one thing primarily: the number of young trainees coming out of their programs who are entering the field of outpatient general internal medicine. It is only that group that can adequately populate the need for outpatient management of complex medical problems that we as a nation will need in the future. Every time a physician of my generation leaves practice unable to find a young physician to take their place, a piece of intellectual infrastructure has been lost as well as an opportunity to preserve continuity. It is not a part of medicine that should be abandoned to lesser trained entities than smart, capable, devoted physicians. Policy makers need to make a conscious choice that our nation needs a robust adult primary care system.

Being a general internist is the best job in adult medicine for those who are so inclined, but that doesn’t mean that it should be left only for those willing to accept not being appropriately valued next to their colleagues. Concepts like the advanced medical home and payment systems that incorporate management fees have the potential to help attract young physicians to outpatient work. Revisions to training programs need to be made. Policy makers should not interpret survey data like that cited as a reason to hold back on needed changes.

PCP said...

This is most certainly a biased study. From the outset it has a leftist lean that ignores the realities of the real world practice of medicine that the academic elites are loathe to acknowledge. The ACP sadly gets most of its input from these academic elites, so no wonder Bob unabashedly praises the Mass. model as the one he hopes to see go national when he says the following:

"Our approach is not that unlike the Massachusetts model, championed at the time by GOP Governor and 2008 presidential candidate Mitt Romney"

My view as a generalist is this, that unless you see your role as a Community health Center worker "supervising" a bunch of mid-levels and answerable to your CEO who is bilking the "non-profit" status of the CHC to the tune of more than twice your salary and preaching about the greatness of care provided in that model with crazy inefficiency and overhead. All while you tirelessly work you tail off for a wage somewhat below the current mean for a generalist in the private market.
Unless you feel that is the most efficient model of Primary care.
Unless you think that Gov't reimbursing those entities for medicare/medicaid rates more than double that of private practices(even if they have a sliding scale) you will not feel the same way about that Mass. model for that is where it will lead. If you doubt me just look at the job postings in the northeast and see how many are employed and how many are for private practice.

Mass. BTW is not exactly attracting generalists the last time I looked despite having amongst the highest density of residency programs per population. So why the ACP believes that it is such a great model for Internists to aspire to I will never know.
This study like so many put out in the lobbysphere in DC twists the truth to the liking of the ideologues. In DC, You can get a paper to support almost any position, you just have to pay the appropriate price! Such has become the nature of our politics. In such a setting those speaking the truth, become just another voice.

"Will the real patient advocate please stand up?" Dr Alder once wrote in IM news. I'll never forget that quote. Indeed, will the real patient advocate please stand up unencumbered by the politics of today.

In this study quoted by Bob.

Where are the near 20% of Internists who have entirely left the practice of general IM represented?
Where are the now approaching 30K Hospitalists who have essentailly rejected General IM as a career represented? Surely the ACP considers them General IM too.
Where are the views of the medical students (presumably the potential future of our specialty) of whom a whopping 2% are planning General IM careers represented?

Why, every thing must be hunky dory with access for Medicare patients then, according to this study nearly 2/3 of all internists are open for business at current rates of medicare reimbursement, perhaps we ought to let the scheduled 21% SGR cut go into effect then, surely we want to be fiscally responsible as a country?
One wonders how that levels with the Gov'ts own MedPAC report stating that nearly 30% of new medicare patients are having difficulty accessing a primary care physician.

The ACP would have been far better served focusing on redressing the issues within medicine(such as the travesty that is the RUC) rather than with its leftist leaning policies which will in the end further reduce the appeal of Generalism as a career. IMHO the ACP has done a wonderful job of advocating for the ANP lobby with its position paper on that topic. It has set in motion the trajectory for a mid-level provided Primary care system probably centered around gov't sponsored entities such as CHCs and FQHCs and the like instead of fostering the independent practice of medicine inclusive of Mid-level providers that was the way of the past. I doubt many Medical students will willingly sign up for the gig that is the vision of the ACP.

PCP said...

Above post cont'd.

I most vehemently disagree that the ACP has a centrist approach. The Mass. model is most definitely not Centrist, certainly not in the USA, maybe it is centrist in Mass. where the Harvard elites live but that does not mean it is centrist in the USA! Good gosh No!

Joseph said...

As a practicing general internist, my experience has been that the general level of discontent among internists with whom I associate is worse than the survey would suggest. That said, with the shortage of primary care physicians that already exists, we need strategies in place such that satisfaction levels among general internists are the highest not the lowest. Clearly, multiple factors are involved including reimbursement levels and quality of practices. Contrary to what other commentators have indicated, I strongly support the College's efforts at promoting the the patient centered medical home because it does incorporate corrections addressing a number of the disencentives for practicing primary care. It potentially increases the financial renumeration to the physician, and it enables the physician to incorporate a team approach that takes some of the hassle load off the direct shoulders of the physician. Incorporating a number of the elements of the PCMH in our practice has helped to improve the quality performance of our care which in itself has created more satisfaction. We are presently now applying to become a Center of Excellence in Diabetes as a result of these changes. I believe if some of the naysayers really took a look at the Medical Home Builder in relation to their practices, they would come to see this may not something just for academics or political pundits.