A Heartfelt Plea to Become A Primary Care General Internist
Like the paper book, the vinyl record, and Facebook, we’ve heard for years that the primary care general internist is not long for this word. However, unlike the first three in this list, I am actually worried that the fourth (otherwise known as me) is truly at risk. By way of introduction, I’ll save myself time and energy by quoting from a JGIM article (minus references), A National Survey of Internal Medicine Primary Care Residency Program Directors:
Primary care has been associated with better health outcomes, higher patient satisfaction, and decreased health care cost. However, the United States is currently facing a primary care physician shortage with recent estimates projecting a need for up to 43,000 additional physicians by 2030. General internists make up about one third of the national PCP workforce, but the numbers of internists pursuing primary care careers have been declining over the past several decades. Although increasing numbers of advanced practice providers, including nurse practitioners and physician assistants, may help alleviate some primary care demand, current workforce projections demonstrate that there will still be a significant primary care practitioner shortage. Primary care physicians may play an especially important role in managing an aging population with multiple complex conditions.
The causes of the growing primary care general internist deficit are many. Educational debt is climbing and general internists make less money than other internal medicine specialists. General internists leave practice at a higher rate than other specialists (about four times faster). Residents who begin practice right after residency without completing a fellowship are more likely to become hospitalists than primary care physicians.
So, here is my full-throated defense of my career. First, five reasons all you medicine residents should pull out of the fellowship match and become primary care general internists.
1. If you’re being honest with yourself, primary care general internal medicine is what you imagined being a doctor would be like. You can answer any patient’s concerns. You are expected to do it all. You’ll use consultants, but mostly you won’t need to. Atrial fibrillation, COPD, serous otitis media, pyelonephritis, a sprained knee, a rash, epididymitis, (I could go on and on and on) are all within your purview.
2. You get to choose what you focus on, and what you focus on can evolve. There have been times when I went deep into the evaluation and management of every one of my patients with hyperthyroidism. Then came a time when, after the initial evaluation, I would refer. Why? Because I had become interested in focusing on something else. Some of my colleagues develop a special niche (women’s care, addiction, lifestyle medicine) from which they help their colleagues.
3. You are called a primary care doctor for a reason; you will be your patients’ primary advocate. Patients will remember you, value you, and appreciate you. You will be their first line and often their last. You will bring them through pneumonias, critical illnesses, break-ups, and operative complications. They will thank other doctors for their suggestions but then consult you before making a decision because they know that you know them well and know that you know what makes the most sense for them.
4. The medicine is amazing. You will see it all. Common illnesses presenting in uncommon ways and rare illnesses masquerading as common ones. You will watch the natural history of chronic illnesses and see how acute ones present. You will be humbled by the infinite number of ways that our finite (but unknowable) number of diseases present.
5. Every specialty has the concern that can exhaust the doctor. Gastroenterology has IBS, rheumatology has myofascial pain, cardiology has atypical chest pain, pulmonary has idiopathic cough or dyspnea, critical care has families who want to pursue futile treatment... In general medicine, you deal with many difficult problems rather than one (again and again, forever and ever).
Next, four concerns raised by 20 IM residents from across the country in a VERY informal poll.
6. The money. Primary care physicians should be paid more. Primary care leads to better health outcomes, higher patient satisfaction, decreased health care costs, and the need for fewer specialists. The problem is that primary care doctors don’t “do” that much, and we have long reimbursed doing over thinking.
All that said, primary care physicians are well compensated. I don’t think the income differential keeps many people out of the field, and I am not sure we want more people to become PCPs because they want to be Masters of the Universe.
7. The respect. It is true, if you go into primary care general internal medicine you will be disrespected, too often, by colleagues, patients, and administrators. Patients will come to you with trochanteric bursitis demanding to see an orthopedist. They will come with incontinence and demand referral to urology. A neurologist will note hypertension or hypothyroidism in your patient and refer her to cardiology or endocrinology. My recommendations? A. ignore it: you know your own skills and importance, and B. have patience: with time, most of these patients come to know your worth and many of the subspecialists will ask to see you as their doctor.
8. A few of the residents I polled said, “I don’t feel like I am ready to practice” and “GIM just seems exhausting.” Once you’ve been through a medicine residency, you know enough; and you don’t. The first few years in practice are hard. Find a place with good colleagues who can guide you through situations you’ve not encountered. Master quick web searches while the patient changes into a gown. See your first few years as your (well-paid) general internal medicine fellowship – a fellowship in which you control your own education.
Yes, it is exhausting and that is because you are people’s primary physician. Your role is to answer questions, educate, diagnose, refer, treat, and counsel. You often need to offer advice that your patient does not want to hear and does not want to take. Being a PCP is an incredible privilege and no privilege comes easy.
9. “I’d much rather be a specialist…” was a common refrain. General internal medicine is a specialty, call yourself a comprehensivist. You are a specialist in diagnosis. A specialist in balancing the therapy of multiple illnesses. A specialist in coordinating care. A specialist in educating, counseling, palliative care, end of life care, and bridging the gap between psychosocial and physical suffering. Most of all, you are a specialist in tailoring complex medicine to individual patients.
And finally…
10. Primary care general internal medicine is not all wine and roses. You can make things better. Work to get us better compensation. Advocate to get better support so we are always working “at the top of our abilities.” With more and more advanced practice providers, we should be able to spend more of our time focusing on the complexities for which we were trained. Figure out ways to harness new fields like remote monitoring and AI, while knowing there will always be a deeply human need for someone a patient knows and trusts to assess a hernia, a worrisome lump, or an new pain.
You know that medicine in America will be better, more humane, and more affordable with more good, smart, dedicated primary care physicians. Be part of the solution. Meaning no disrespect to any other specialty, but we need you as a primary care physician more than we need you as another sub-sub-specialist working in another urban teaching hospital.
Adam Cifu is a primary care general internist.
I am a primary care family medicine doc, the daughter of a rural family doc. Thank you Adam, for this! The thing that constantly amazes me is how often academic specialists refer to the work of primary care as “boring”. Like you said, we get to see everything! And if you care for the uninsured, or work in a rural area, you get to manage more than you thought you would because sometimes you just can’t access specialty care. I can diagnose and treat Pernicious anemia, hand-foot-mouth disease, Parkinson’s disease, a corneal abrasion, menorrhagia, a basal cell carcinoma, renal failure in a Spanish speaking man who refuses dialysis, chest pain, schizophrenia, a marital conflict causing headaches, a toddler with a speech delay, and a pregnant woman at 32 weeks, all in the same day. There are a lot of words to describe what I do, but boring is not one of them. I actually think that physicians who teach in academic institutions have a lot of influence over medical students and residents. If more of those docs understood what primary care was really like, and if they spoke more positively (in a genuine and honest way) about primary care, that would help. Even 22 years ago, when I was in medical school, at a school known for primary care training, in a state with strong primary care, academic docs on my rotations tried to dissuade me from pursuing a career in primary care. I knew what it was really like because my dad took me on rounds from a young age and I was always at his clinic in the rural town where I grew up. But many trainees don’t know what it is really like and are easily dissuaded.
My father practiced general internal medicine for 50 years. I am in my 26th year of primary IM with Avalon Medical Group in Alabama. My oldest soon hopes to follow in my footsteps. I have done everything in medicine: outpatient, inpatient, acute medical rehab, hospice, and emergency medicine. I don’t regret any of it. Primary care physicians are the absolute cornerstones of medical care in the world.