Why it's hard to see an internist in Vermont

As my infographic (click here) shows, there has been a severe decline in internal medicine physicians in Vermont, with the result that if you have an internist in the traditional system, it is difficult to see him or her or if you do, your time is limited. This mirrors the national trend, although it's a larger drop here. But why? What is going on?

The silent exodus

First, a few more data points not included in the infographic.

  • The shortage in internal medicine physicians is projected to exceed 45,000 by 2020 and reach almost 66,000 by 2025. An excellent, more detailed study is here.
  • Almost all internists that remain in the traditional system are burned out and overwhelmed and as a result are cutting their patient hours. They become administrators, they teach, they work for electronic medical record software companies, they consult for drug companies or insurers, or they are hired by think tanks and consulting firms.
  • More than half of the 13,575 doctors who participated in a recent Physicians Foundation survey said they plan to cut back on seeing patients, work part-time, retire or take other steps that would reduce patient access to their services in the next one to three years.
  • Las Vegas presages what is coming in other areas.
  • The Affordable Care Act will add roughly 30 million people to the insurance roles who need an internist, exacerbating the shortage.
  • The exodus is even more pronounced in private practices owned by doctors.
Experts describe a doctor shortage as an "invisible problem." Patients still get care, but the process is often slow and difficult. Rationing occurs by delays and waiting. Politicians are more amenable to this because they can't be criticized with misleading phrases or terminology, as the problem itself is difficult to decipher.

Why this problem will get worse before it gets better.

My infographic (click here) shows that as the population of Vermont adults who need care explodes, the number of medical students planning to practice general internal medicine is collapsing. These curves are diverging sharply now, so this problem will get worse before it improves. In classical economics, supply should rise to meet this increase in demand, but instead it is falling. Studies have not arrived at a conclusive reason for this. In my experience, and from knowing many internists, these are the reasons:

  • Autonomy. Hoover Institution Senior Fellow Dr. Scott Atlas fears bureacratic, centralized control will cause a brain drain in medicine. "Really smart people want autonomy, and when you take that away it's naive to think you're going to get really bright people becoming doctors," says Atlas. "The best doctors could excel at any profession, so why go into medicine if they won't have the opportunity to be their best?"
  • Respect. It is no secret, especially in the nation's best medical schools and residency programs, that general internal medicine is near the bottom of the respect "pecking order." Sub-specialties are where the respect is, and almost all students figure it out by their second year. I am the only student from my class of 75 doctors at the Brigham & Women's hospital who today is practicing general internal medicine.
  • Salary. Sub-specialists are paid much higher salaries than general internists. Though byzantine compensation formulas that originated shortly after World War II and were further altered by decades of lobbying, compensation has been highly distorted. Students figure it out quickly.
  • Paperwork. Insurers and hospital systems have created a massive amount of paperwork and bureaucracy for internists. Before I started my concierge practice, over 40% of my time was devoted to this, and not patients. Now I spend less than 5% of my time on paperwork, forms, and bureacracy.
  • Education Debt. This is the issue most politicians point to as the reason people don't become internists, but in my experience it is by far the least important. Various levels of government have been trying debt forgiveness programs for three decades and the problem has only gotten worse. It's just not the main driver in students' minds.

The result of this is currently just 2% of medical students plan to practice general internal medicine. This is a drop of 78% in just two decades.

Continue reading: Why it's a good idea for you to see an internal medicine physician, always.