Some doctors need a raise

No form of health reform is going to work unless we address the growing shortage of primary care physicians.

(Unfortunately fine t-shirts like this one from Zazzle.com won't solve the problem.)

A new survey in the Journal of General Internal Medicine shows internists who have left primary care are happier than those who stayed, and primary care docs have less satisfaction than their colleagues in the specialties.

We are being hit by a double whammy. Few doctors are choosing primary care, and many who are in the field are leaving. At the same time everyone is being guaranteed check-ups by health reform, so demand is about to skyrocket.

The chief of staff for the American College of Physicians, Wayne Bylsma, was the lead author on the survey and helped pay for it. He reacted with characteristic understatement.

"The research results underscore the importance of increasing the attractiveness of careers in general internal medicine and of retaining those who enter the field."

A lot of reasons were cited, but the summary is primary care docs feel they are underpaid, that they are overworked, that new accountability is being forced upon them, and that piece work pay is driving them nuts.

All these things are true, and in the long run some aspects of health reform address it. Computerization should make payment easier and accountability automatic. But many doctors are in small practices they own or share with colleagues. Even with subsidies, IT for them is a drain on time and money.

The medical home concept, in which internists are at the top of a team which is paid based on patient count, rather than specific procedures, may also address the problems. But it means changing a business model in mid-career, with no guarantee of success.

If you're going to have to change your business model, why not change your life instead? Cooking school starts to sound nice.

Scholarships and quick repayment of loans for work in general medicine sounds nice, but even with that specialists wind up twice as wealthy at the end of their lives as internists who spend their whole career in the field.

The pay gap is narrowing, but supply-demand under health reform says it must reverse. If reform keeps people healthier longer, it means less demand for specialists and more demand for primary care. Time and bureaucratic resistance stand between that market message and on-the-ground reality.

It's not like internists don't have options. "The 'general' nature of general internal medicine may give internists more options for careers outside of internal medicine and in to some non-medical fields," said Rebecca Lipner, a vice president for the American Board of Internal Medicine, which also helped pay for the survey.

Massachusetts is already undergoing this, and has responded by increasing the role of nursing, and being more accepting of in-store clinics, which use IT as a matter of routine.

This fills in some of the gaps, but it does not address what the internists are complaining about and might actually accelerate their exit from the field.

It's something we need to address, as the doctors say, stat.

This post was originally published on Smartplanet.com