I have to say this article made me a bit weepy. I also loved being a general internist, for all the same reasons you listed. In these days when the brightest med students are not encouraged (and in fact are discouraged) from doing general internal medicine, and our expertise is threatened by large corporate medical ownership who think midlevel providers can do our jobs just as well for less money, it’s great to be reminded of what I loved about my work. I retired 4 years ago, because I have lots of other stuff I want to do, and frankly the corporate stuff was getting to me. But I think fondly of all the good I was able to do for other humans in distress, even if I was less than perfect a lot of the time. Thank you for this essay!
For me, the things I love about be a Primary Care Physician are the things that bring me meaning in life: connecting, caring (serving others), and continually learning from my patients, my colleagues, and from a structure of evidence based science.
I especially liked your emphasis on your income—that you are more than satisfied with what you earn, even compared with physicians in more lucrative specialties. The human proclivity to compare ourselves with others not only influences specialty choice but also contributes to the geographic maldistribution of physicians.
I live in San Luis Obispo, arguably one of the most beautiful small cities in America, yet we suffer from a significant shortage of physicians. How is that possible?
Most attribute it to the fact that physician reimbursement rates are lower here than in larger urban areas, while the cost of living is almost as high. But I’m convinced that our higher quality of life more than compensates for the smaller income.
Maybe we need a different way of thinking about physician compensation. We use the concept of the Quality-Adjusted Life Year (QALY) to recognize that the value of a year of life depends not only on its length but also on its quality. Similarly, I propose the Quality-Adjusted Physician Income (QAPI): income adjusted for the quality of life. By that measure, the QAPI of San Luis Obispo—and of many other small cities and rural communities—may equal or exceed that of physicians practicing in higher-paying urban areas.
Referring back to your point about the relative income of different specialties, numerous studies have shown that physician income and physician satisfaction are only weakly correlated. In other words, the QAPIs of general internists equal or even exceed those of higher-paying specialties. That is a fact we should celebrate, elevate, and advocate!
I usually keep quiet about it since it sounds so darn self-satisfied, but I sometimes think other (non-medical) fields get paid more to compensate for the lack of satisfaction inherent in the job.
Thank you, Adam for the succinct and resonant piece. I went into IM as a rest stop to doing a fellowship in Cardiology or Oncology, but the “Holmesian” nature of the work, the critical thinking, the teaching of those following in my footsteps, the rewards of helping people that you’ve never met before, and the intellectual challenges and constant learning associated with keeping up with the medical literature and speaking with colleagues kept me running in place. I do wish, however, that the expertise associated with the cognitive expertise and experience of the work were more highly valued in the healthcare reimbursement systems.
What a remarkably complete list this is — for any medical (i.e. not surgical) specialty: the joy of acquiring expertise and using it to care for others; the rich relationships with patients and colleagues; the continuing stimulation and challenge of diagnosis. And the ability to live in comfort over the long term.
To which I, after 32 years in practice, would add the pleasure of helping junior colleagues learning to approach medical and family issues that are, by now, so familiar, but no less difficult to deal with after all this time.
There is a lot in realizing just how important many years of experience are to giving the best care one can. And much satisfaction is using that experience to teach others.
Ditto - especially “Caring for everything (with backup)” which was something I found very satisfying about my time practicing EM. Another thought - those really interesting (because uncommon) patients were memorable and ‘solving’ the clinical ‘problem’ was very satisfying (when I did), but, as both my brother and I myself have learned, it is never good news to learn you are ‘the doctor’s most interesting patient’…!
I really enjoyed this, especially your point about building and maintaining relationships over decades. Reading it, I was nodding my head by how much of what makes internal medicine rewarding comes from longitudinal stewardship rather than any single diagnosis or encounter. The relationship becomes the context that makes good judgment possible. It feels more and more like that's one of the most underappreciated aspects of primary care today.
I do love what you have highlighted. It gets even better when, as physicians, we are resolving some of the chronic diseases rather than managing and chasing them. I enjoyed being an internist, but I truly love practicing functional medicine, which engages the patient in their own care.
I enjoyed reading this. It was a refreshing break from the constant negativity around medicine. There’s already enough of that online. Vinay could probably take a page from your book every now and then.
I have to say this article made me a bit weepy. I also loved being a general internist, for all the same reasons you listed. In these days when the brightest med students are not encouraged (and in fact are discouraged) from doing general internal medicine, and our expertise is threatened by large corporate medical ownership who think midlevel providers can do our jobs just as well for less money, it’s great to be reminded of what I loved about my work. I retired 4 years ago, because I have lots of other stuff I want to do, and frankly the corporate stuff was getting to me. But I think fondly of all the good I was able to do for other humans in distress, even if I was less than perfect a lot of the time. Thank you for this essay!
I have the same feeling about critical care medicine. Wonderful article! I wish every physician is like Adam Cifu.
For me, the things I love about be a Primary Care Physician are the things that bring me meaning in life: connecting, caring (serving others), and continually learning from my patients, my colleagues, and from a structure of evidence based science.
Hello, and I agree. Learning is a pleasure and sometimes we make a real and positive difference.
I love it. It's why I love being an internist too.
The point "Caring for everything (with backup)" is one of the most beautiful parts of it -- medicine never declines a patient
I especially liked your emphasis on your income—that you are more than satisfied with what you earn, even compared with physicians in more lucrative specialties. The human proclivity to compare ourselves with others not only influences specialty choice but also contributes to the geographic maldistribution of physicians.
I live in San Luis Obispo, arguably one of the most beautiful small cities in America, yet we suffer from a significant shortage of physicians. How is that possible?
Most attribute it to the fact that physician reimbursement rates are lower here than in larger urban areas, while the cost of living is almost as high. But I’m convinced that our higher quality of life more than compensates for the smaller income.
Maybe we need a different way of thinking about physician compensation. We use the concept of the Quality-Adjusted Life Year (QALY) to recognize that the value of a year of life depends not only on its length but also on its quality. Similarly, I propose the Quality-Adjusted Physician Income (QAPI): income adjusted for the quality of life. By that measure, the QAPI of San Luis Obispo—and of many other small cities and rural communities—may equal or exceed that of physicians practicing in higher-paying urban areas.
Referring back to your point about the relative income of different specialties, numerous studies have shown that physician income and physician satisfaction are only weakly correlated. In other words, the QAPIs of general internists equal or even exceed those of higher-paying specialties. That is a fact we should celebrate, elevate, and advocate!
I usually keep quiet about it since it sounds so darn self-satisfied, but I sometimes think other (non-medical) fields get paid more to compensate for the lack of satisfaction inherent in the job.
Thank you, Adam for the succinct and resonant piece. I went into IM as a rest stop to doing a fellowship in Cardiology or Oncology, but the “Holmesian” nature of the work, the critical thinking, the teaching of those following in my footsteps, the rewards of helping people that you’ve never met before, and the intellectual challenges and constant learning associated with keeping up with the medical literature and speaking with colleagues kept me running in place. I do wish, however, that the expertise associated with the cognitive expertise and experience of the work were more highly valued in the healthcare reimbursement systems.
What a remarkably complete list this is — for any medical (i.e. not surgical) specialty: the joy of acquiring expertise and using it to care for others; the rich relationships with patients and colleagues; the continuing stimulation and challenge of diagnosis. And the ability to live in comfort over the long term.
To which I, after 32 years in practice, would add the pleasure of helping junior colleagues learning to approach medical and family issues that are, by now, so familiar, but no less difficult to deal with after all this time.
There is a lot in realizing just how important many years of experience are to giving the best care one can. And much satisfaction is using that experience to teach others.
Ditto - especially “Caring for everything (with backup)” which was something I found very satisfying about my time practicing EM. Another thought - those really interesting (because uncommon) patients were memorable and ‘solving’ the clinical ‘problem’ was very satisfying (when I did), but, as both my brother and I myself have learned, it is never good news to learn you are ‘the doctor’s most interesting patient’…!
Thank you for writing this article! We general internist don’t tout our own specialty enough.
I really enjoyed this, especially your point about building and maintaining relationships over decades. Reading it, I was nodding my head by how much of what makes internal medicine rewarding comes from longitudinal stewardship rather than any single diagnosis or encounter. The relationship becomes the context that makes good judgment possible. It feels more and more like that's one of the most underappreciated aspects of primary care today.
So well said. Thanks.
Adam
I do love what you have highlighted. It gets even better when, as physicians, we are resolving some of the chronic diseases rather than managing and chasing them. I enjoyed being an internist, but I truly love practicing functional medicine, which engages the patient in their own care.
I enjoyed reading this. It was a refreshing break from the constant negativity around medicine. There’s already enough of that online. Vinay could probably take a page from your book every now and then.
“I don’t deserve those kinds of riches. I’ve taken no risks; I just chose a path, worked hard, and got lucky.”
I’m going to add, “I’ve loved GOD, and loved people.”
Good article my friend. Thank you.