Specialization in medical education
I read with interest “Prepping IM residents for primary care” in the May 2017 ACP Internist. I am now the program director of the internal medicine residency program at Lake Cumberland Regional Hospital in rural Kentucky. I practiced as an “old school” general inpatient/outpatient internist for nearly 30 years before beginning my current position. One of the most challenging things about my current job is finding general internists to teach and proctor the 130 continuity clinic sessions required by the Accreditation Council for Graduate Medical Education (ACGME).
All of us currently filling this role are aging rapidly, and trying to find anyone at all graduating from an internal medicine training program who is interested in the outpatient arena is difficult at best. I am sure these graduates exist, but they are certainly few and far between. The clear reality currently is that the combination of demand for hospitalists nationwide and the associated current pay scale for the same, along with the frequent time off while working this schedule, are colliding with professional school debt owed by most graduates to form the perfect storm against the practice of outpatient general internal medicine.
This is particularly true in rural areas, where more and more complex primary care is being delivered by nurse practitioners, many of whom are proctored by physicians in name only. If ACGME and ACP are serious about making the management of complex outpatient medical issues the continued purview of the internist, and not the family physician or physician extender, then they must recognize the reality of these market forces.
Personally I favor, as is at least alluded to in the article, that each resident make a clear declaration after postgraduate year one about his or her intent to be an outpatient or inpatient internist and that every trainee's remaining two years then be constructed time-wise in this light. The outpatient internist needs more time in clinic, and the hospitalist trainee probably does not need as much.
Failing to recognize the above realities is going to leave many smaller training programs in real jeopardy of no longer existing.
Joseph G. Weigel, MD, MACP