Primary care internal medicine, the medical field I chose, loved, and practiced for 4 decades, is dead.
The grief and shock I feel about this is personal and transpersonal. The loss of internists (internal medicine, IM physicians) practicing primary care is a major loss to us all.
From the 1970s to ~2020 there were three groups of primary care physicians: family practice (FP), pediatricians, and internists (IM). In their 3-year residencies (after 4 years of medical school) pediatricians trained to care for children and adolescents, internists for adults, and FPs for children, adults as well as women and pregnancy. FPs are the most general of the generalists while the others’ training involves comprehensive care of complex patients in their age groups.
I was one of those kids who was hyper-focused on science, math, and the human body. By the end of high school, I was considering medicine for my career.
To explore this, I volunteered at the local hospital. In my typical style, I requested not to be one of those Candy Stripers serving drinks on the wards. Instead, they put me in the Emergency Department where I would transport patients and clean the stretchers. There I was free to watch whatever was going on if I did not interfere with the staff. On my first shift, a 20-year-old drowning victim arrived by ambulance. I watched the entire unsuccessful resuscitation and as shocked and saddened as I was, I knew (in the way only a headstrong 18-year-old can) that medicine was for me.
It was a fortuitous time to graduate as a female pre-med student.
In 1975, our country was in the midst of the women’s movement and a national effort to train primary care physicians. I was accepted to my state medical school. The University of Massachusetts Medical School had been established a few years earlier, with its main purpose to train primary care physicians and spread them around the state (especially out of the Boston metropolitan area). The curriculum was designed to expose students to primary care from year one. I was assigned to shadow a General Practice physician in inner-city Springfield who saw over 50 pts a day! The patients knew they could see and afford him, so they crammed into his waiting room until their name was called in order of their arrival. No appointments necessary. His chart notes were a few scribbled sentences. I didn’t see myself in that practice exactly, but his work ethic and dedication inspired me.
Over half of our graduating class chose to train in primary care specialties and most stayed in-state. It turned out to be a good bet on the government of Massachusetts’ part.
When I applied for residency in 1980, there were several internal medicine programs with a focus on primary care, which was my goal. I ‘matched’ at Providence St. Vincent Hospital in Portland, Oregon, and moved across the country to the Pacific Northwest never to look back. There my attendings (that’s what we called our teachers) were doctors like I wanted to be, primary care internists in the community, not in academia. It was the perfect choice and an excellent training program.
In 1984 I hung my private practice internal medicine shingle in Hillsboro, Oregon across the street from the community hospital. My primary care IM colleagues and I shared weekend calls, admitted and cared for our patients in the hospital, and when they were discharged. That is now called continuity of care. It was a time we ate in the doctors’ lounge together, met in hallways, and informally consulted each other about our patients. These were called ‘curbside’ consults. They were invaluable to our ability to provide comprehensive care to our patients in primary care, led to fewer specialty referrals, and were free. That would now be called inter-professional communication and collegiality.
Burnout was not a word you heard. We were busy and happy doing what we had spent twelve years of our precious youth to prepare for.
When I moved to Olympia, I took a position in the Woman’s Health Clinic at the American Lake Veterans Administration.
We were a small group of 2 family practice doctors, 3 nurse practitioners (NPs), and me the only internist. Many of our patients were sick and complex. 2 of the NPs asked me to take their most complicated patients. Being comfortable with complexity as an internist, I said yes.
One of the NPs was inappropriately hired as she was a Women’s Health NP. She came to me freaked out, “OMG I have no idea how to manage COPD!” The other wanted simpler patients. I don’t blame them for the patient transfers. NPs typically have 3 years of training before they practice in contrast to primary care physicians’ 8.
Guess who made friends with the custodian, staying until 8 p.m. most evenings, and who left by 530 p.m.?
What was I doing in those extra hours? I was trudging through clerical (albeit important) tasks my medical assistant and transcriptionist used to do in private practice. In the 30 minutes allotted for the patient, I needed to focus entirely on them and their multiple complex medical problems.
One-third of the primary care physician workforce and a group of doctors uniquely trained to be primary care physicians for our aging population.
At the Sommer Lectures in Portland last month, Steven D. Freer, M.D., the current director of the residency program where I trained, has not had a single of his 8 annual internal medicine graduates choose primary care in several years. Half (2 of 4) of those in my year did: one went to Tillamook (underserved Oregon coast) and me to Hillsboro.
What are internal medicine training graduates doing now? They are becoming hospitalists (caring for people in the hospital, the best-trained physicians to do so) or go on to become specialists (in cardiology, pulmonary, nephrology, oncology, etc.).
Like when the University of Massachusetts Medical School was established, there continues to be a shortage of primary care physicians and probably more severe than in the 1970s. Massachusetts was proactive. We are already years behind catching up. The shortage is no longer in rural areas alone.
Christine Laine, M.D. editor-in-chief of the internal medicine specialty journal who spoke at the Sommer lectures, lives in Philadelphia. Even there she has lost her own primary care IM physician and cannot find another primary care physician (much less IM) for herself.
Washington scores a D grade for our primary care staffing statewide.
Maybe…I was relieved to hear from Drs. Freer and Laine that efforts are beginning to revive the field.
Just like internists’ patients, the potential restoration of the field will be complex and multi-layered. It will require new laws, policies, residency programs, and incentives for students including debt reduction. Administrative burdens will need to be reduced, de-corporatization, and restoring healthcare leadership to those with in-depth medical training will need to be a part of the solution as well.
Let’s all hope the new resuscitation efforts will be successful for the field of primary care in general and primary care internal medicine specifically. It will be good for healthcare and for you!
Debra L. Glasser, M.D., is a retired internal medicine physician in Olympia. Got a question for her? Write drdebra@theJOLTnews.com
10 comments on this item Please log in to comment by clicking here
AugieH
I remember when my Dad, a General Practitioner in the 50s and 60s, took and interpreted his own x-rays, did minor surgery, delivered babies, and made house calls. RIP the GP of old. Today's primary care physicians are nothing more than the intermediary that refers patients on to specialists.
Wednesday, May 22 Report this
JulesJames
Thank you. I've been hearing horror stories from friends about trying to get an appointment when looking for a new PCP. Now I understand the problem isn't their short-term misfortune. It a prelude to my future. And thank you for a career well-chosen! Satisfying and inspiring to read the details of a life's success.
Wednesday, May 22 Report this
KatAshe
I trained as a nurse in the 1960s and have seen a total change in the practice of medicine since then.
In my opinion, the worst change has occurred in the last 15-20 years, with the Catholic Church run hospitals first buying up secular hospitals, then buying up secular medical practices. Once your primary physician become an ‘employee’ of a religiously run hospital, they must follow the churches religious doctrine. This prevents that physician from advising or even discussing many options for reproduction choices and end of life choices.
Personally, I've been blessed with a local independent physician. When my partner of 29 years was diagnosed with stage 4 terminal cancer, our physician was totally supportive of my partners end of life decisions and actively assisted in the process. A physician who could practice inside Providence in addition to having admitting privileges would not end have been able to discuss options for end of life.
AugieH. Your father was exactly as I remember my family’s physician. House calls, appointments within days, doctor’s office with their on lab, etc.
Wednesday, May 22 Report this
tommull
Thank You for this article. T0M =)
Wednesday, May 22 Report this
dlg2022
Thanks for all your comments!
AugieH - yup that's exactly what my GP colleagues did. The loss of primary care docs and the bloating of specialty care has divided people into systems vs. whole.
JJ - it is no short-term misfortune I am afraid.
KatAshe - you so aptly point out the unique limitations that church run healthcare leaves us with. I have met a number of non-profit lawyers and state legislatures working to address these important issues around reproductive care and death - thank goodness. Glad you are one of the lucky ones with a still practicing independent and supportive physician.
Tom - thank you for reading and commenting!
Dr.. Glasser
Wednesday, May 22 Report this
KarenSharp
Dr. Glasser was the best primary care doctor that I have ever had at the American Lake VA women's clinic!! Boy, I really miss her.
Wednesday, May 22 Report this
dlg2022
Aw shucks...thank you Karen and HI!
Dr G
Wednesday, May 22 Report this
DianaMigchelbrink
My father was a private practice IM pratictioner in the 60s and 70s and all. 4 of his kids went into the field. My brother was with Group Health as a OB/GYN here in Olympia and all three daughters went into Nursing. As a child I remember that my father was rarely around with hospital rounds 7 days a week, office 5 days for 10 hours/day and house calls on Saturday and Sunday. Little time for family and none for himself. Things had to change.
Wednesday, May 22 Report this
IleneP
Thank for this excellent assessment of our Primary Care crisis.
Moving from King Co. to Oly and trying to find a new PCP (our preference was an Internal Medicine MD) proved extremely difficult. The challenge of finding one who also accepted new patients and Medicare was insurmountable and we stayed with the Dr. we had at Swedish Seattle for over 28 years. Not practical.
Finally found one at Capital Medical (prior to the Multicare takeover) who promptly resigned less than a year in. Then the NP I found who was quite good, also resigned in less than 9 months.
We now have an NP whose role is mostly doing referrals for specialists and conducting the annual Wellness “exam”. I truly miss our IM Primary care Dr. as we age, continuity of care is critical. Too much falls through the cracks. Let’s hope we can solve this critical health care crisis.
Thursday, May 23 Report this
Jerry50
Debra Glasser MD
It’s been a while since we last spoke. I remember one discussion at the time was about the trend in Internal Medicine training for a young physician to become a hospitalist rather than a primary care physician. I sensed at the time that primary care Internal Medicine would be shaken to the core and would in all likelihood not survive as we knew it. Much of this move by young physicians was financially motivated. Working for and being paid by a hospital system allowed Internists to continue the tradition of excellent hospital care yet having no long-term attachment to a patient. A hospitalist also has a guaranteed significantly greater income without the hassle of running their own office (hiring personnel, maintaining an office site and information systems crucial to reimbursement).
Despite my concerns I continued to practice the old Internal Medicine tradition of both outpatient and inpatient care. I saw how many hospitalists soon became pawns of the hospital system often following “check boxes” to document quality care which often did not exist. Doctors changed almost daily. Patients were losing their priority as guaranteeing hospital reimbursement became a new focus of the hospital system. I was proud to be among the last Primary Care Internists to admit and take care of his own patients. I could expedite their admissions, discharges and office follow-up.
Isn’t it ironic that the pillar of academic medicine which gave rise to all the subspecialties should meet such a fate. Also ironically, as I contemplated retirement, almost every medical subspecialist complained of the loss of primary care Internal Medicine as they viewed patients referred from primary care Internal Medicine as having excellent evaluations while those from other primary care sources not uncommonly were referred with little to no evaluation.
G.Fay MD
Saturday, May 25 Report this