Friday, March 18, 2011

Irish (style) wit . . . and the 2011 IM match

Several readers of this blog answered yesterday’s call for limericks by penning some of their own. How about this one, from Dr. Daftary, on the attraction of concierge practices?

Poor Saint Paddy he must be a quaking,
At the direction Internal Medicine is taking,

Internists no more,

They head for the door,

For a course in concierge training.

Or this one, from Carol Dembe, on health care costs?

Spend less on healthcare, they all cry,
But. . . I want my MRI.

The healthcare share

Might be more fair

Like teamwork, with no "I."

Perusing the internet on my own, I found this one, which pretty much sums up how I feel about the partisan debate on health care:

Why does health care reform light a fuse
About what our citizens choose?

Can’t the Dems and the Reps

Agree to take steps

That will bring our great nation good news?

And here is a new one from me, on yesterday’s news that there has been an increase in medical students choosing internal medicine and family practice residencies:

More students have chosen primary care
Even though the pay isn’t fair.

But will this year’s match

Produce a big enough batch

To ensure that a doctor is there?

ACP said it was “cautiously optimistic” that “the increase in the number of U.S. medical students choosing internal medicine residencies in 2011 is a positive sign toward easing the primary care workforce shortage.” But ACP also pointed out that “the U.S. still has to overcome a generational shift that resulted in decreased numbers of students choosing primary care as a career. In 1985, 3,884 U.S. medical school graduates chose internal medicine residency programs. And the 18.9 percent of U.S. seniors that matched internal medicine in 2011 is the same percentage as 2007.”

The American Academy of Family Physicians attributed the gains for family medicine, at least in part, to “primary care [becoming] much more visible as a result of the discussion about improving our health care system . . . [as] “more people understand that if we’re to have high quality care at a controllable cost, we need to rebalance our system on a foundation of primary medical care.”

Kevin Pho, the internist-author of the highly respected KevinMD blog, takes a more contrarian view, blogging that “There’s a dire shortage of primary care doctors today. The 2011 Match doesn’t lead me to believe that there will be a substantial change in that trend going forward.”

Dr. Bob Centor, author of DB’s Medical rants, “begs to differ” with Kevin’s pessimistic assessment, writing that “the increases are significant, but not earth shattering” and “will likely continue.” Bob predicts that “As the number of US grads increases each year, students understand that the number of slots in radiology, anesthesiology, neurosurgery, dermatology, orthopedics, etc. will not increase. The numbers will send more US grads into internal medicine and family medicine . . . but unless we have more residency slots, we will not produce more family physicians or internists. We will have less IMGs, but the totals will not change.”

Today’s questions: What do you think—is the 2011 increase in the match rate for primary care (internal medicine, family medicine and pediatrics) a “positive step” toward easing the primary care shortage or no substantial change in the trend going forward? And why do you think more of this year’s medical student crop chose theses specialties?


PCP said...

More US medical students in IM in the match = More IM proceduralists and Sub specialists and Hospitalists and down the road and probably more Urgent Docs, more Concierge Docs, more Administrative Docs. etc.
However it will not mean more Generalists doing what they are best trained to do and did throughout the 80s and early 90s and a few battle worn ones continue to do. Generalism is in its 8th or 9th inning.
The constitution of the RUC needs to be more representative of the number of doctors in each specialty to make any meaningful changes. Of course that will not happen, so the RUC must be replaced. Private and public payers are driving the manpower shifts. No magic there. We are after all a capitalistic country and respond to incentives of all types do we not?

Unless payers change the rules of engagement, nothing changes. Younger Generalists are on a passive strike by voting with their feet however the match results might be spun. Yet, our policy makers in DC are being told access remains good. Access is certainly good if you club all "primary care providers" together. It will get even "better" when the avalanche of DNP schools/Online programs start churning out their
"docs". The future for access certainly dazzles!
The tragedy of it all is that costs will escalate while quality falls as it has for much of the past 15 yrs. But no one really cares enough to seriously think about why and/or do anything about it, if they did we would see tangible and dramatic changes to the benefit of General IM, what we see instead is fiddling.
Make no mistake about it, those kids going into IM today are aware of all this and have plans other than General IM.

Jay Larson MD said...

There is the assumption that medical students chosing family practice or internal medicine residencies will ultimately become outpatient primary care physicians. That may have been true 20 years ago, but times have changed. Many family practice physicians work at Urgent Care clinics which offer fixed schedules, no call, and no long term continuity of care. Many internal medicine residents choose to become hospitalists or become subspecialists.

I am hearing stats that maybe one out of 25-50 internal medicine residents go into out patient internal medicine.

Rather than seeing what is going into the meat grinder, I prefer to see the final product. After all, isn't that what is important.

doc777 said...

What I am hearing is consistent with the data Bob noted. At least in our state, the number of medical school graduates going into Internal Medicine is up slightly. There is still the chance that those individuals are using Internal Medicine as a route to hospitalist or specialty positions. However, let's assume there is a real increase in Primary Care interest.

Medical students have ears, and they listen more than we think. I believe that there is genuine optimism in the Primary Care ranks that better times are coming, and the students are noting that optimism. Further, I think there is growing pessimism among the ranks of highly compensated specialties that a hatchet is going to be applied to those current levels of compensation (if it has not occurred already). It's kind of like the stock market. A stock price will often go up not based solely on the companies current value, but instead based on a future perceived value. If a company does not meet the expectation, it's stock price often plummets.

I think extreme caution is necessary when interpreting these numbers. I personally feel that if the promised changes in our current reimbursement structure do not materialize, the numbers going into Primary Care may sadly plummet to even greater depths.

Jay Larson MD said...

The hard numbers are not as impressive. Of the 17,000 medical and osteopathic students enrolled in the Match, only 132 more U.S. students went to family residencies and 218 students went to internal medicine residencies than last year. The current percent of internal medicine residents going into general medicine is only 20% (the rest become hospitalists or subspecialists). So of the 218 extra students going to internal medicine residencies only 45 will become general internists. Ten years ago 54% of internal medicine residents went into general internal medicine.

About 10 years ago there was a quick drop off of internal medicine programs producing general internists from about 2000 per year to 1000 per year. So over the past decade, a production deficit of about 10,000 general internists has developed. If all internal medicine residents became general internists, it would take 2 years to recoup the deficit. The attrition rate of general internists over the past decade has accelerated. Montana has lost about a third of its general internists to hospitalists positions.

This production deficit and increased attrition will deplete the healthcare system of general internists rapidly.

To see the trends in internal medicine residencies, go to