I had the pleasure of participating in the American College of Physician’s International Forum. The question posed to the Forum was, “what is the future of Internal Medicine?” Physicians from other nations described the more traditional roles of Internists as consultants to primary care providers and physicians for patients with multiple co-morbidities. But the ACP sees Internists as custodians of the “Medical Home,” a broad and inclusive model of care that is more conceptual than practical and only minimally tested among adult populations. Yet even if it proves to be valid, it faces the reality that there won’t be enough Internists, or Family Physicians, to make it happen.
This lack isn’t simply because Internists and FPs aren’t paid enough, although they aren’t. It’s because there won’t be enough physicians overall. There already are too few general surgeons and too few urologists, and the oncologists project a 40% shortfall within ten years. Faced with shortages like these, physicians will have to gravitate to roles that only physicians can play, while most of what goes on in a Medical Home is undertaken by Nurse Practitioners and others.
But the problem for Internists goes even deeper. With the demand for hospitalists and internal medicine subspecialists growing steadily, it is unlikely that there will be enough Internists even for the absolutely essential roles of serving as consultants and providing care to patients with multiple infirmities. The reason is unambiguous. Too few doctors are being trained, and that is because Medicare capped its support for residency training in 1996, while population and the economy have continued to grow.
Some see this as good – it’s a form or rationing. But it’s not good. America will never ration care for profoundly ill patients. And, sadly, the creation of physician shortages assures that there will be many more patients who present with late disease, simply because access to earlier care was not available.
So the message to the ACP is that it will not be possible to build a bigger workforce of Internists unless the entire physician workforce is expanded, and the physician-directed Medical Home will remain a distant dream.