A Look at Five Career Options in Internal Medicine
From the September 2000 ACP-ASIM Observer, copyright © 2000 by the American College of Physicians-American Society of Internal Medicine.
By Ingrid Palmer
Internists leaving residency today have a variety of career options available to them, but deciding which option is best can be a daunting task. At Annual Session, a panel of internists spoke candidly to residents about the pros and cons of several career choices. Here's what they had to say about five different internal medicine practice settings.
When John R. Nelson, FACP, went to work as a hospitalist 13 years ago, he planned to do a one-year stint while waiting to start his endocrinology fellowship. He found that he enjoyed working as a hospitalist so much, though, that he passed up the endocrinology training and stayed on permanently with the Hospital Internal Medicine practice in Gainesville, Fla.
Because training to become a hospitalist is similar to internal medicine training, transitioning from residency into a career as a hospitalist is one of the smoothest in the field, according to Dr. Nelson, co-founder and former President of the National Association of Inpatient Physicians. "I feel like I'm still doing what I did when I was a resident," he said, "only it's better."
Dealing with scheduling hassles is the trickiest part of a hospitalist's career. It can be hard for doctors to take weekends off, for example. If 20 patients need to be cared for on Friday, those 20 probably need care on Saturday as well. "You're really stepping into a job that is 24 hours a day, seven days a week," Dr. Nelson said.
The bright side of a hospitalist's schedule is that days are not packed with appointments with patients who expect to see their regular physician. "You don't wake up every weekday needing to be at a certain place at eight o'clock," he said. "Sometimes you're busy, other times you're not."
In addition, scheduling vacation time often is easier and less stressful for hospitalists because your patients simply get assigned to another doctor. You can return from time off without having to "face a pile of charts five feet high," Dr. Nelson said.
That flexibility, along with the satisfaction that comes with being able to help seriously ill patients, was a big draw for Dr. Nelson. "If I need to do something unexpectedly or if my car won't start in the morning, it's usually not a disaster," he said. "I can just go in and start working later."
For instance, when old friends popped into town unannounced, Dr. Nelson had another doctor cover his patients so that he could take time off during the day to meet them. An avid cyclist, he also enjoys riding his bike in the middle of the day when things are slow.
Quoting a Canadian internist, Dr. Nelson said, "The life of a hospitalist is ruled by the beeper. It tends to be relatively unpredictable. In contrast, the life of an office-based doctor is ruled by the wristwatch."
Dr. Nelson said that hospitalist salaries are typically a little higher than what physicians with similar training receive in the same geographic area. One factor that is boosting pay for hospitalists, he said, is the fact that current demand for hospitalists far exceeds the supply.
2. Staff Model HMO
Working as part of a staff model HMO offers tremendous financial security but not much flexibility, according to Gregory A. Hood, FACP, a general internist at Southern California Permanente Medical Group, a staff model HMO in San Diego.
When working for a staff model group practice, Dr. Hood explained, you agree to practice under the health plan's formulary, guidelines, oversight, and regulations. (His practice contracts exclusively with Kaiser health plans.) The benefits of working in a staff model group include forgoing pre-authorization for tests like MRIs or for subspecialist consultations. Doctors work under just one formulary when prescribing drugs, and they can ask to go outside the formulary when they feel it is warranted.
"I didn't have to buy into the practice, advertise, or worry where my next patient or dollar was coming from," Dr. Hood said. In fact, he knows exactly what his salary will be for each year from now until he retires.
Retirement benefits, health insurance, malpractice coverage, and vacation are all provided by Kaiser. The process for becoming a partner is clearly defined. And when Dr. Hood is off duty, he doesn't have to worry about arranging cover or call schedules for his patients.
One negative aspect of working in this kind of practice, however, is a lack of flexibility. "I cannot set my own hours, choose how much time to spend with each patient, pick my support staff, decide how many patients to see each day or have a large impact on the operations and direction of the medical group," he explained.
Pay for internists entering a staff model HMO is comparable to the average take-home pay of a community internist, according to Dr. Hood.
Wayne J. Riley, FACP, assistant professor of medicine and assistant chief of medicine at Ben Taub General Hospital in Houston, said that he gets the best of both worlds as a clinician-educator who also practices as a generalist.
"I have a very varied life," said Dr. Riley, who spends his days teaching, seeing patients, and serving on committees. He typically spends about five hours a day pursuing academic activities and another five hours on direct patient care.
"This position has really opened up some marvelous opportunities for me, areas I never thought I'd pursue," Dr. Riley added. For instance, he lectures; works on health policy, health management, and curriculum reform; and teaches a medical ethics course to medical students. And while Dr. Riley said he is able to interact with patients, he also has protected educational time that allows him to learn while keeping his clinical skills sharp.
He also enjoys the opportunity to teach. "One of the joys is working with medical students and residents in training, and I try to serve as a good role model," he said. Unlike doctors in full-time practice, clinician-educators get the satisfaction of seeing a resident practice what they've taught.
Teaching residents about managed care, a challenge for physicians today, is another part of Dr. Riley's job. "We try to show our residents how to become their patients' advocate in dealing with managed care," he said.
One drawback: Dr. Riley said he earns 10% to 15% less per year than doctors in full-time practice. "The pay is a little lower than a comparable group practice or HMO setting," he said, but his work schedule is what some doctors would call "cushy." He's on call just five weekends and one holiday per year. "You work hard," he said, "but there are certain benefits to working in an academic setting, such as having readily accessible coverage for vacations or personal leave."
4. Academic Medicine
As part of the teaching faculty at the Mayo Clinic in Rochester, Minn., Mark C. Lee, ACP Member, said the best thing about his position as an academician at a medical group is that he gets "truly protected" educational time.
While academic internists at universities are increasingly being pressured to help the bottom line by seeing more patients, Dr. Lee's academic position at a private group practice puts him in a unique position. "As a salaried physician," he said, "I don't have to worry about the economic pressures that other productivity-based institutions might have."
As the Mayo Clinic's chair of education for general internal medicine, Dr. Lee dedicates much of his time to education and research. Though academic responsibilities vary from one institution to another, he spends a good deal of time working one-on-one with medical students and residents, as well as pursuing clinical studies and working with publications. Dr. Lee spends 15 weeks of the year in the hospital supervising residents and treating patients. He also gives second or third opinions for other doctors.
"Our main commitment as academic physicians is clearly to patient care, but with the added responsibility of medical education and research," he explained. Going into this field gives doctors a unique opportunity to broaden their knowledge and educate younger doctors and colleagues.
Dr. Lee calls his lifestyle "comfortable." Though he and his colleagues have traditionally earned less than most full-time practicing physicians, Dr. Lee said that pay in his field has been steadily increasing. And clinician investigators' salaries are still sometimes lower because pay is often linked to grant funding, he said.
5. Rural Doctor
Although Donald E. Ware, FACP, is not an academic physician, he is constantly learning. As part of a six-physician private practice in rural Maine, he and his partners work in a 60-bed hospital and cover all areas of internal medicine.
Dr. Ware and his partners collaborate regularly because they see a broad range of cases. Though four of the six doctors are trained as generalists, they all work in various subspecialties. The range of illnesses he encounters is so broad that he often looks up medical information in the practice's extensive library.
Unlike Michael J. Fox's character in the movie Doc Hollywood, Dr. Ware did not end up in Norway, Maine by accident. After medical school, he and his college roommate decided they wanted to start a practice "somewhere we could make a difference." A small town was the logical choice. In his practice, all six physicians get the chance to treat many different illnesses and diseases, as well as take responsibility for all aspects of care.
One unique aspect of rural practice is living in the community with your patients, Dr. Ware said, so you see them at Little League, at church, and even in the grocery store. While patients occasionally ask medical questions at inappropriate times, most are very respectful. He is on call once every five nights, but patients sometimes call him at home, since his phone number is listed in the phone book.
Dr. Ware urged residents to consider what kind of practice and lifestyle they want before jumping into a situation like his. He wanted to live in the country, near a lake. He cautioned that single people should think long and hard about rural practice because it can be difficult to meet people in the country.
He added that if you're a stargazer, however, there's nothing quite like this laid-back lifestyle. "We can see the Milky Way every night," he said.
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