Internists' pursuit of subspecialties raises the demand for generalists, although demand is weaker for family physicians and pediatricians.

The San Francisco Bay Area used to be an intensely competitive job market for physicians. But Douglas C. Tong, who recently graduated from an internal medicine residency program at UCLA, had no trouble finding a position there. He joined the Camino Medical Group, a multispecialty practice in Sunnyvale, after turning down an offer from Kaiser Permanente and interviewing with a number of other West Coast groups, including the Palo Alto Clinic.

Of the 30 residents who graduated from UCLA's internal medicine program last year, about half went on to fellowships, five became hospitalists, and just 10 entered private practice. Those 10 were "highly recruited," notes Teresa Roth, house staff coordinator for the residency program. One reason, she says, is that the pool of internists going into primary care has diminished greatly in recent years as more and more doctors have chosen higher-paying specialties.

Infectious disease specialist Alan Harris, director of the internal medicine residency program at Rush University Medical Center in Chicago, agrees that the action has moved to the specialties. Two-thirds of his 38 residency graduates last year accepted fellowships, and an increasing number of doctors are taking only one year of internal medicine training before entering such fields as ophthalmology, radiology, physical medicine/rehab, ED, radiation oncology, and neurology.

Those who complete an internal medicine residency and want to go right into practice, he says, can find jobs pretty much wherever they want them—except in the most desirable urban locations. Harris says some residents are competing for jobs on Chicago's South Side, and the North Side is pretty tight. Similarly, Tong was unable to land a job in San Francisco proper.

Family physicians are less in demand than internists; but in some fast-growing areas, they, too, can find jobs where they want to live. FP Vivian R. Hartig, a recent graduate of the Memorial Hermann Southwest Family Practice residency program in Houston, joined a local practice whose office is just a few miles from her house. She's working part time now, but has been assured she'll have a full-time position within a few months. About half of the patients she sees are new to the practice, and the number of new patients is increasing.

FP David W. Bauer, director of the Memorial residency program, says of last year's graduates, "Everyone who wanted a position found one, and it was their first choice. So we haven't seen any problems in the Houston area." By February of this year, he adds, most of his third-year residents already had job offers.

New family physicians are also finding work in the Hampton Roads area of Virginia, where there were far fewer jobs a couple of years ago. The physician market has improved "because a lot of the doctors who went through residencies in the early '70s are retiring now," says FP Charles Frazier, former director of the Riverside Family Practice Residency in Newport News. "And as the baby boomers age, they're using doctors more, and practices are hiring new partners."

Recruiters see the most potential for internists

Physician recruiters say their clients—mostly hospitals and midsized and large group practices—are more interested in internists than in family physicians or pediatricians. According to Mark Smith, executive vice president of Merritt, Hawkins & Associates in Irving, TX, this is partly a byproduct of employers' current focus on recruiting specialists. "If you're having trouble recruiting cardiologists or can't afford them, you can recruit an internist to relieve some of the demand for cardiology."

Family physicians, he says, are mainly in demand in smaller communities. But he acknowledges that the demand for FPs may be greater than what he's seen: Many groups may be bypassing recruiters and hiring FPs directly.

Charles Frazier can bear this out. He says that most of Riverside's residents are finding jobs in Hampton Roads through old-fashioned word of mouth. "When somebody wants to expand their group, they'll give us a call and ask, 'Hey, do you know anybody who's going to stay around?' And the residents will ask us whether we know of any openings. So a lot of it is networking."

Frazier adds that most new FPs are joining family practices of four or five doctors. In contrast, large multispecialty groups are reportedly reluctant to hire family doctors. "We see groups who are interested in having higher-end primary care physicians—the ob/gyns and the general internists, not the FPs," says Steve Messinger, a practice management consultant in Arlington, VA. "It's because the value they bring to the practice is much higher: There's more spinoff of ancillary revenue and referrals to the surgeons."

Germaine Lorbert, director of the physician search division at Cejka Search in St. Louis, views the decreased demand for family physicians as a function of their relatively ample supply. Compared with general internists, she says, "There's a much larger pool of candidates to choose from. So when you have an FP search, there are people to talk to and hire. We usually can find very good people."

Salary range: broad and varied

While starting salaries for internists have risen a bit, those for FPs and pediatricians have stagnated over the past few years. Nationwide, says Lorbert, the average starting salary for internists is $120,000-$140,000; for family doctors, $110,000-$120,000; and for pediatricians, $100,000-$120,000.

The pay is higher where there are fewer doctors. Beginning salaries for internists in rural areas, says Smith, are $140,000-$180,000; for family physicians, $140,000-$160,000; and for pediatricians, $125,000-$160,000. In metropolitan areas, internists are starting at $130,000-$150,000; FPs, at $120,000-$135,000; and pediatricians, at $110,000-$130,000.

There are also regional differences. A 2002 survey by the Center for Health Workforce Studies at the State University of New York at Albany found that New York internists, FPs, and pediatricians received median starting salaries of $118,000, $119,000, and $99,000, respectively. In California, the salaries for those groups were $126,000, $122,000, and $109,000. Typical starting salaries for FPs in the high-paying Houston area, says Bauer, range from $120,000-$130,000.

Physicians who are willing to work in smaller, less prestigious cities can make more than those in desirable metropolitan areas. For instance, a hospitalist fresh out of residency can start at $150,000 in California's Central Valley, says internist Douglas Tong. New FP Vivian Hartig says she could have gotten a position for that amount in a town about 60 miles from Houston. High-paying FP positions are also available in Charlotte, NC, and some other Southern cities, says Frazier.

What does the future hold for primary care?

Until a few years ago, many observers believed that the nation was headed for an overall surplus of physicians. This view was reinforced by the managed care emphasis on limiting access to specialists and new medical technologies. But the backlash against managed care has brought the pendulum back toward high-tech, specialist-dominated medicine. The expected surplus never developed, and, instead, there are shortages in some areas of the country. A consensus is emerging among medical leaders that the US should step up specialist education to avert more-serious deficiencies in the future.

Meanwhile, past educational trends are still shaping the market. In the '90s, when jobs were scarce in many specialties, a lot of young doctors went into primary care, and fewer residents entered specialty residencies and fellowships. Now the situation has been reversed, and fewer doctors are becoming generalists. But because of the primary care trend that began 10 years ago, the overall market for generalists is still fairly soft.

According to the AMA, the number of internists (including subspecialists) rose 11 percent in the five years ending in 2002—from 128,435 to 143,191. The number of family physicians jumped 18 percent in that same period, from 64,611 to 76,511 in 2002. "That sharp increase in FPs may have been more than the marketplace could handle," says Edward Salsberg, director of workforce studies for the Association of American Medical Colleges.

"Internal medicine has had a different pattern. With the resurgence in job opportunities in the subspecialties, more internists are going into gastroenterology and cardiology and so on, which means a drop in the number of general internists going into practice."

More doctors are needed, but maybe not more generalists

Salsberg headed the research effort that lay behind last year's reversal of direction by the Council on Graduate Medical Education, which advises Congress on the physician workforce. He defends COGME's call for a 15 percent increase in medical school output by citing expected population growth, the aging of the baby boom generation, and the increasing use of medical services. But he favors keeping the number of family medicine residencies at their current level.

"The US Census Bureau predicts that the US population is going to grow by 50 million between 2000 and 2020, and those people will all need primary care," he says. "But I wouldn't recommend expansion in family medicine or pediatric residency slots. Family physicians had this big ramp-up in the '90s, and you have to give it a little more time to see whether demand is going to pick up."

But the AMA is less cautious. Alarmed by reports of physician shortages in some areas, the association's leadership favors raising the number of residency positions for both specialists and primary care physicians, says AMA Trustee Rebecca J. Patchin, a pain medicine specialist. All that the association has officially done, however, is to call for a study of workforce needs. While not a dramatic move, this is a sharp turn away from the AMA's previous warnings about a looming surplus.

The American Academy of Family Physicians, which has long supported an increase in the supply of family doctors, is also re-examining its workforce policy. According to FP Norman Kahn Jr., the AAFP's vice president for science and education, the academy will base its conclusions on what it perceives as the nation's need rather than on market demand.

Will demand for generalists be filled by IMGs?

In the residency match this spring, only 79 percent of the available family practice positions were filled, and the percentage of total slots matched by US medical graduates sank to 41 percent. In internal medicine, 97 percent of residency positions were filled (up slightly from the previous year), and US seniors took 55 percent of the available positions. But if the residency programs cited in this article are typical, two-thirds of those doctors will go into subspecialties.

International medical graduates are still key to beefing up the ranks of new primary care physicians. They filled 37 percent of FP residency slots and 43 percent of internal medicine positions in this year's match. Many big-city public hospitals couldn't operate without them.

But a couple of factors have limited the number of IMGs in the US: Since 1998, IMGs have not only had to pass the US Medical Licensing Examination, but have also had to take a clinical skills assessment exam. The events of Sept. 11 have also made it harder for IMGs to obtain residency positions. Teresa Roth of UCLA, for instance, notes that besides federal obstacles, before an IMG can enter a California residency program he now needs a "state letter." To obtain that, he has to get his government to send his documents directly to the state.

The AAFP's Norman Kahn thinks the real solution to the shortfall of qualified applicants lies in raising reimbursement for primary care doctors to better reflect their value to the healthcare system. Kahn would also like to see a big change in the attitudes of medical school faculties toward family physicians. "The academic milieu actively denigrates family medicine," he says, "and that has a big influence on students."

 

Ken Terry. Jobs 2004: Primary care outlook. Medical Economics May 21, 2004;81:84.