The words “primary care” tend to conjure up thoughts of pediatricians and family medicine practitioners. While these physicians certainly do make up a decent chunk of primary care physicians (PCPs), the field is much broader. In fact, in my state of North Carolina, data from 2018 showed that about 30% of physicians in the state practiced primary care. Of these PCPs, 44% were family medicine physicians and 25% were pediatricians. Who made up the final third? Internists, of course!
Why is internal medicine often forgotten as primary care?
Why do we often forget about internist PCPs? It’s because many people view internal medicine as the entry point for various medical specialties. Any cardiologist, oncologist, pulmonologist, gastroenterologist, endocrinologist…indeed, most “ologists” in non-surgical specialties were first internists. They completed a three-year residency in internal medicine before pursuing further specialized training, or a “fellowship,” in their chosen branch of medicine.
Pursuing a fellowship after residency tends to be the expectation rather than the exception for internists. In fact, the most common question I get after “What is your residency?” is, “What will you specialize in after internal medicine?”
How many internists will become PCPs?
It’s hard to pin down exactly how many internists leaving residency will go on to practice general internal medicine versus pursue a subspecialty, considering it is common to take “gap years” before returning for fellowship. However, the American Journal of Medicine notes that in 2015, “88% of those completing a 3-year residency in internal medicine entered a medical subspecialty, leaving only 12% to practice general internal medicine.”
Furthermore, a significant proportion of those physicians didn’t become PCPs but rather work as hospitalists. The fact that fewer than 12% of internal medicine graduates can still make up one-third of all PCPs speaks to the volume of internists across the country—it is the largest training program by leaps and bounds. According to the AAMC, “In 2019, the specialties with the largest numbers of first-year ACGME residents and fellows were the primary care specialties of internal medicine (10,379), family medicine/general practice (4,456), and pediatrics (2,993).”
How do internist PCPs compare to other specialties?
While internists care for adults and pediatricians care for adolescents, family practitioners can care for all ages because of their broad training. Still, both family medicine physicians and internists who become primary care physicians have similar practices despite very different training. In fact, many primary care offices include a mix of internists and family medicine folks!
So, what is the difference between internal medicine and family medicine? Family medicine tends to produce more broadly-trained physicians who have experience with inpatient and outpatient pediatrics, psychiatry, OB/GYN, orthopedics, and surgery in addition to general adult medicine. In contrast to internal medicine, the majority of family medicine physicians will enter some type of primary care with the minority pursuing specialized training in a one-year specialty like sports medicine or addiction medicine. In addition to seeing patients of all ages, they are well-trained in bedside procedures, from steroid injections to IUD insertion to vasectomies. Their strength lies in the breadth of patients and pathologies they see, and their training lends itself well to a “jack of all trades” PCP who cares for families from cradle to grave.
By comparison, internists spend their time exclusively taking care of adults within the medical specialties such as the cardiac and medical ICUs, oncology wards, nephrology floors, etc. in addition to general medicine. Thus, their procedure training leans heavily toward inpatient skills such as placing central lines. The ACGME also requires internal medicine residents to spend a third of their time in the outpatient setting, which is generally split between their own continuity clinic of primary care patients and specialty clinics like cardiology. These experiences provide the internist PCP with a deep understanding of how multiple organ systems interact, and they are well-prepared for the complex adult patient.
Is there a shortage of PCPs?
Unfortunately, the gap between PCP demand and supply continues to widen in the United States. The AAMC predicts that there could be a shortage of up to 48,000 general practitioners by 2034. The complex reasons for and the solutions to the PCP shortage go far beyond the purview of this brief article.
Fortunately, whether your dream is to take care of kids, adults, the elderly or all of the above, there is a position (indeed, many positions) waiting for you in the primary care world—and many different training programs to get you there!
If you’re interested in exploring your options for medical specialties, check out this FREE Medical Specialties Breakdown Guide! Go beyond the data with qualitative insights from residents, practicing physicians, and med school tutors who have been in your shoes.
