By Debra L. Glasser, MD

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.

How and when the field of primary care internal medicine flourished is my story.

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.

What did Internists offer to Primary Care? That is also part of my story.

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.

What is lost with the death of primary care internal medicine?

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.).

Why are they not choosing primary care?

-Primary care is the lowest-paid specialty at a time when medical education is not strongly subsidized (medical students can incur up to $500K of debt).

-It no longer offers the professional satisfaction that continuity of care and collegiality provided.

-Primary care physicians are the most overburdened by administrative tasks like I was at the VA.

-They are increasingly pressured to see more patients, in shorter time slots in which it feels impossible to offer quality care.

-Many work for large systems in which they feel powerless to effect change.

-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.

Is there hope for the future of primary care in general? Or for the restoration of primary care internal medicine?

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.

In the meantime, what you can do?

-Get a PCP

-Know your PCP’s degree, level of education, strengths, and weaknesses.

-Go to appointments prepared, with your questions and your needs

- If you are unsatisfied and want a physician, ask for a referral or get a physician yourself if necessary. You will likely need to book months out.

-If whatever is ailing you cannot wait, seek care in an urgent care clinic. Ask around and read reviews. My personal experience at Providence Westside Urgent Care has been positive. Providence has Urgent Care Clinics in Lacey on College St and one in Hawk’s Prairie on Marvin Road. Kaiser’s Urgent Care is highly regarded if that is where you are insured.

-If you have only specialists caring for you, they would be grateful for you to have a primary care physician as none of them typically want to take on that important role of integration of your care. Your specialists would be good sources for primary care referrals.

-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.