This article comes as no surprise to this observer of residency trends. Subspecialties flourish as IM residents shun primary care

They found that only 27% of graduating residents were picking primary care careers in 2003, compared with 54% in 1998. There was even less interest among first-year interns in 2003, with just 19% expressing a desire for a primary care path.

“More and more over the past few years, we’ve been seeing them choosing subspecialties instead of primary care. It’s a trend most people in the trenches are aware of. The data verify these impressions,” said Richard Garibaldi, MD, chair of the Dept. of Internal Medicine at the University of Connecticut Health Center, who decided to study the issue more closely.

Dr. Garibaldi’s study — “Career Plans for Trainees in Internal Medicine Residency Programs” published in the May Academic Medicine — expands on what’s been widely observed within the medical profession.

Other studies have focused on why students are turning away from primary care disciplines and have found that declining reimbursement for nonprocedural care, the opportunity for a controllable lifestyle and a medical culture in which subspecialists are seen as more prestigious have played a big part.

Dr. Garibaldi’s study focused on internal medicine residents and quantifying precisely where they are going and why. The study found that more than half of these residents were seeking subspecialties, and the bulk of this group was choosing the higher-paid procedural disciplines.

Richard Cooper, MD, director of the Medical College of Wisconsin’s Health Policy Institute, said the results were no surprise.

“Those are the realities, and you’ll see even more in the current Match and the current students,” Dr. Cooper said. “They just aren’t thinking generalist careers.”

When the insurance companies and CMS devalue generalist care, then residents will look elsewhere. I write often about the problem of increasing overhead due to malpractice costs, compliance with federal regulations (e.g., HIPAA), documentation and personnel costs. I am not aware of any other business which has gross income constrained in the face of increasing overhead. Thus, as the article states eloquently, net income must decrease.

Although Dr. Gonzalez said narrowing his expertise was important, he also said income played a role in his decision, something primary care leaders have speculated was a factor in residents’ decisions today.

“Even though I have to put in another three years, I’ll be paid what my education is worth,” he said.

He didn’t think that would be the case if he went into primary care, where he might earn $110,000 a year and take home $70,000 to $80,000 after taxes. That’s a salary someone with less education and training can earn in other fields, without the debt of medical school, years spent training and commitment to a lifetime of being on call, he said.

I know that $110, 000 represents a very nice salary, but one must consider that salary in context. As he states, the training costs and time are very significant. Today’s medical students often acquire $100k – $200k in indebtedness. Moreover, they do not start earning the above salary until 7 years of combined medical school and residency training. If one goes straight through college, medical school and residency, one starts that salary at age 29. The investment of money and time is significant.

Perhaps, our health care system will function well with fewer generalists. I doubt it seriously, but we may well find out. I plan to speak on this issue widely. In the near future, I will have an opportunity to speak with some congressional leaders and hope to raise this subject. Without the “conductors” our health care symphony sound will become cacophonous. I cannot believe decreasing excellent generalist physicians will do anything other than raise costs. Only generalists look at the entire patient and put his/her various complaints and ailments into perspective. Always remember the Maslow quote listed to the left – If the only tool you have is a hammer, you tend to see every problem as a nail.

We need more physicians with complete toolboxes.