Internists career choices point to more primary care availability woes

In a trend that may spell yet more trouble for the availability of primary care, a new study finds that doctors who once provided both inpatient and outpatient care increasingly are choosing to work only as outpatient practitioners.

The study in Annals of Internal Medicine looks at career choices among board-certified general internists over the last three decades. It found that from 2008 to 2018 the percentage of “mixed-practice” physicians—those in outpatient practices who also care for their patients who are hospitalized—dropped dramatically, with most of those who left mixed practices migrating to outpatient-only practices.

At the same time, the number of younger internists becoming full-time hospitalists has grown steadily, so that by 2018 more than 70% of newly-certified internists were practicing as hospitalists, compared with only 8% in outpatient-only practices.

The authors note that, in the short term, the shift of older internists to outpatient-only practices has compensated somewhat for the lack of younger doctors choosing that type of practice as a career. But at the same time, “workforce projection(s) may be underestimating the outpatient primary care shortage because most new physicians are focusing on hospital medicine and the flow from mixed practice to outpatient-only practice may be near its limits.”

The researchers conducted their study by linking Medicare evaluation and management (E&M) codes for inpatient and outpatient visits made between 2008 and 2017 to about 68,000 board-certified general internists who certified between 1990 and 2017. They identified physicians with fewer than 5% E&M outpatient visits as full-time hospitalists, those with 100% outpatient E&M visits as outpatient-only, and those with at least 5% but fewer than 100% as mixed-practice physicians.

They found that between 2008 and 2018, full-time hospitalists increased from 25% to 40% as a percentage of all general internists, while those in outpatient-only settings increased from 23% to 38%, and those in mixed practices declining from 52% to 23%. Most of those who left mixed practice migrated to outpatient-only practice.

The authors say their results also suggest that hospital medicine is a career decision rather than a temporary choice. They cite the finding that 86% of those classified as hospitalists in 2013 retained that classification five years later.

The study, “Evolving Practice Choices by Newly Certified and More Senior General Internists” was published online May 17.