New internists flock to hospitals as senior docs gravitate toward outpatient care, study finds

A generational divide has formed among general internists and their preferred practice settings, with more newly certified practitioners choosing to be hospitalists and senior physicians migrating toward outpatient-only care, a new study found.

Alongside demonstrating a rise in popularity of hospital medicine among younger physicians, researchers said their data highlight the “vulnerability” of outpatient primary care as older physicians retire and new ones choose to stick with hospital medicine.

“We are concerned that this trend is not sustainable and that outpatient primary care physician shortages will accelerate as outpatient-only physicians begin to retire with few additional mixed practice physicians who have been bolstering the outpatient capacity over the past decade to replace them,” Bradley Gray, senior health services researcher at the American Board of Internal Medicine (ABIM), said in a statement.

Additionally, evidence from the study, published in Annals of Internal Medicine, that fewer internists are splitting their time between both hospital and outpatient settings “suggests that the health system will need to develop improved systemic solutions to ensure effective transitions of care moving forward,” researchers from ABIM, Beth Israel Deaconess Medical Center (BIDMC) and Harvard Medical School wrote in the study.

“The physician-created boundaries between hospital and outpatient care creates urgent problems for health systems and private practices to ensure seamless patient care between settings,” Bruce Landon, M.D., professor of healthcare policy at Harvard Medical School and a professor of medicine and practicing internist at BIDMC, said in a statement.

The team’s study used ABIM board certification data and Medicare claims to identify nearly 68,000 general internists initially certified between 1990 and 2017. Evaluation and management visits were classified as either inpatient or outpatient via submitted billing codes and then used to classify internists as hospitalists, outpatient-only physicians or mixed-practice physicians.

From 2008 to 2018, the researchers found the portion of internists classified as hospitalists increased from 25% to 40% while outpatient-only physicians rose from 23% to 38%.

Mixed-practice physicians, meanwhile, fell from making up 52% of the sample to 23% as many of these doctors transitioned to outpatient-only practice, they wrote.

Retention was strong among the two exclusive settings, with 87% of those deemed hospitalists and 95% of outpatient-only physicians in 2013 remaining within the same category five years later. That five-year retention rate was just 57% for mixed-practice internists.

Newly certified internists’ preference for hospital care was stark with 71% of newly certified internists classified as hospitalists and 8% as outpatient-only physicians, according to the study.

The researchers noted that their analysis is limited by the focus on Medicare fee-for-service patients, which might not be fully representative of a physician’s care setting, but that the findings were supported in subsequent sensitivity analyses.