ACP: A practice model for increasing the appeal of General Internal Medicine

The following is the first in a series of original guest columns by the American College of Physicians.

by Steven Weinberger, MD, FACP

Much is written and discussed these days about the importance of care coordination by a primary care physician, not only to facilitate patient-centered quality of care, but also to curb the unsustainable growth in the nation’s health care tab. Yet, we hear that the current shortage of primary care physicians providing ambulatory care is only going to get worse, not better, as the baby boomers increasingly become senior citizens and require more health care.

We know that there are many reasons for the decreasing number of medical students and residents choosing general internal medicine – ranging from a dysfunctional payment system to the “practice hassles” of paperwork to the increasing pressures for seeing larger numbers of patients in progressively shorter periods of time. I’m not going to discuss how the various components of health care reform need to address this problem.

Rather, I want to suggest that one potential way to increase professional satisfaction of general internal medicine specialists is to revisit the practice model that has increasingly fragmented the specialty into those internists who provide only ambulatory care and those who provide only hospital-based care.

Variety is the Spice of Life

The silos of ambulatory general internists and hospitalists have emerged in part to be time-efficient, so that the physician’s day is not fragmented by the need to round on inpatients while simultaneously handling a large outpatient load. However, variety is not only the spice of life, but also a source of professional rejuvenation.

As someone whose clinical responsibilities for more than 25 years involved both inpatient and outpatient care (full disclosure: I’m a pulmonary and critical care physician, not a general internist), I always found that the challenge of caring for acutely ill, hospitalized patients nicely complemented the personal gratification from developing long-term relationships with my ambulatory patients. Restricting my patient care responsibilities just to one setting, either inpatient or outpatient, would have clearly limited the richness of my professional life.

In group practices of general internists, a teamwork system of inpatient coverage, where the members of the practice rotate inpatient responsibilities for the entire practice but have no outpatient responsibilities (e.g., for 1-2 weeks at a time), can work quite well. Effectively, the practice has its own rotating hospitalist coming from members of the practice.

Why this Model is Effective

* First, it satisfies the issue of time inefficiency, because it allows each member of the practice at a given time to focus exclusively on one setting – either inpatient or outpatient.

* Second, a teamwork approach within a practice facilitates improved communication and better transitions of patient care between the inpatient and outpatient setting than does shifting responsibility for inpatient care to a physician not associated with the practice.

* Third, this type of teamwork within a practice catalyzes clinical cross-talk and sharing of knowledge, experience, and problem-solving among members of the practice when they care for each other’s patients.

* Fourth, intermittent responsibilities in the inpatient setting allow the ambulatory physician to maintain the knowledge and skills for acute care medicine that will ultimately make him or her a better physician.

* And finally, I think it’s more fun and a lot more satisfying to have intermittent changes in one’s usual work routine.

This model may not be for everyone, but I do think it should be considered before group practices of ambulatory physicians automatically relegate care of their patients to a full-time hospitalist. Some practices use this model, and I have been impressed that they find it attractive and do recognize the benefits that I listed. My recommendation is to try it; I think many internists will like it.

Steven Weinberger is Deputy Executive Vice President and Senior Vice President, Medical Education and Publishing, of the American College of Physicians. His statements do not necessarily reflect official policies of ACP.

Comments are moderated before they are published. Please read the comment policy.

  • Anonymous

    How will busy internists in the outpatient setting be able to cover for their colleague while he is taking care of hospitalized patients? The system you propose is equivalent to having someone in your practice out on vacation at all times. You are correct that in an ideal world, general internists would be able to do both inpatient and outpatient medicine. However, this is not efficient and time is money. Unfortunately, this all boils down to money. In order for this system or a similar system to work, you would need to increase the reimbursements for outpatient medicine so internists could decrease the amount of outpatients they see and allow them to see their patients in the inpatient setting. As a pulmonary/critical care doctor, you make about double the salary of an internist. If you didn’t have your lucrative procedures to bill for and had similar outpatient reimbursments as primary care docs, there is no way you could continue to practice the way you currently do.

  • Happy Hospitalist

    As a hospitalist, we see several groups in my town that practice under this model. Where one member may do all the hospital rounds.

    Except when it’s 2am…
    Or it’s a holiday….
    Or their daughters Saturday morning dance recital…
    Or their anniversary….
    Or they are on Vacation…
    Or the patient is too sick…
    Or the patient’s psychiatric time committment is to great…
    Or their tired of getting paged at 3 am with a blood sugar of 400….

    There are many reasons why groups abandon in patient medicine completely. Even when they try and function in the model you describe. It takes full committment from the partners, many of whom have no desire to go down that path of sacrifice.

    It’s just so much easier to just call the hospitalist.

  • Happy Hospitalist

    Oh I forgot. The ACP has just put the dagger in outpatient internal medicine. In their hard leaning leftist pursuit of universal care, they have equalized NP education with MD education for the medical home model by taking the position that independent medical home models, paid for with federal money, be staffed by independently practicing NPs.

    I thank the Heaven’s every day I decided to be a hospitalist and abandoned outpatient internal medicine from the get go. There is no future in outpatient internal medicine when your own society abandons you.

    So the whole idea of sharing inpatient rounds with your partners is moot. The only outpatient care providers will be nurses with NP degrees. All the internists will be hospitalists or cardiologists.

  • David Block MD, PhD

    Dr Weinberger gives us a gracious, literate, measured vision of medical care based on relationship: professional, personal, public, private. He is the physician who has dreamed dreams, and who, Joseph-like, has solved the dreams of others. His patients are a special category of friend, I do not doubt. He sees them through their fundamental transitions. Each is stronger in resolve to both live the good life and greet the good death. Of course one does general medicine PLUS pulmonary medicine PLUS critical care medicine. With few exceptions, that pretty well covers it all. (Surgeons don’t count in this battle: they wear masks, and they wear scrubs – they don’t wash their own clothes, and they use disposable shoe covers even when sleeping.)

    Our hospitalists say, “Here is the new reality. By recognizing how we are used, we only need grimace at how we are abused. By accepting cynicism, we at least make sense of our own despair. It may be a gallows laugh, but it’s laughter nonetheless.” They are poignant; genuine and authentic.

    So we have two visions, at least. Weinberger talks about the efficiency of Care. Our commentators talk about the efficiency of Consumption. Weinberger assumes the one-on-one of two individuals, known to each other, who together negotiate the terms of personhood. Medicine is “spiritus”; no wonder he became a physician of breath. Our hospitalists, no less deeply moved, point out that we exist in a managerial hierarchy, that we provide a fungible commodity in the eyes of that hierarchy, and that we will respond on the basis of how we are rewarded.

    Is there a resolution? Will Dr Weinberger mind his CPTs and Managerial Cues from the land of the MBA? Will our hospitalists develop the profound mythology of their own clinical care so that they, too, can define their relationships, and have a sense of their own continuity beyond jumping from one lily pad admission to another, and draw a complete narrative after their own 25 years?

    Yes, it sounds like so much gratuitous bullshit – a typical neurological consultation. (My own full disclosure: we are what we are). But, folks (I almost said, “brothers and sisters”), these are the horns of our dilemma. Maybe I’m lucky enough to be retired, dumb enough to have paid less attention to my own practice management issues than I should have.

    But one thing we know: just like Yeats said, somewhere out there stirs the dark form of the immanent physician, no longer the student that we ourselves were when all seemed so clear, slowly making its way to birth. We had better make sure this is OUR child.

    There are 25, 062 readers of this forum. God help us if there are not an equal number of voices demanding a place at this table to decide our future.

  • stargirl65

    Your vision sounds great but in my town most of the internists/family physicians are in solo practice. Doing both means being on call ALL THE TIME. Working in the office all day and then admitting at night. Going to the ER at then end of an 8 hour work day. Getting up at night to admit and see your patients, then going to work the next day. No breaks ever. I can no longer be done with sanity. Even the residents get limits on their hours. I wouldn’t if I was to do both inpatient and outpatient.

  • Erik

    If you do hospital medicine 2 weeks out of the year, you’re not very good at it.

    If you are out of the office one out of every 6 weeks, your patients don’t see you, they see whoever is availible.

    The “dream model” sounds very nice until you actually apply it – patients still don’t see their own doctor in the hospital and they don’t see him as an outpatient either.

    It’s time to accept that the hospital and the office are two different disciplines with 2 different goals.

  • Mitchell Cohen

    Dr. Weinberger’s comments once again show why doctor’s that actually practice medicine feel abadoned by those that ‘represent” us. I do currently take care of my own hospital patients-they are not cared for by a hospitalist. I am currently working 80+ hours a week, seeing 20 patients a day, caring for my own hospital patients and making the exact same income that I did 15 years ago. My expenses to run my practice go up 10% a year(everyone else gets paid).

    Until someone actually pays us for the work that we do, and releases us from the control of Medicare and 3rd party payers that only find new and inventive ways to add more time and costs to the practice of medicine while simultaneously decreasing reimbursement things will only get worse. What doctor who has a choice would actually want this lifestyle when there are so many easier and more lucrative ways to earn a living in medicine?

    Window dressing such as noted above do little to alleviate current conditions. I would like to see a real debate of how internists take back our specialty. Maybe we should start by thowing out our “leaders” out that helped us to get into this mess in the first place.

  • Paul Bunge

    tried it. loved it. couldn’t get paid for it.

    medicine is a constantly changing field. but the training and credentials of a general internist have not changed or kept up. We could improve this by expanding our scope. No sense bemoaning that the NP’s get paid as much as we do when we don’t do anything more than they do. Let the general internists take over the basic bronchocsopies, the screening scopes, the diagnostic caths, the echo interpretations, and then we can talk.

  • Steven Weinberger

    I appreciate the thoughtful comments and the opportunity to participate in the dialogue generated by the column.

    To be clear, the model I am describing will not “fix” the entire problem with the attractiveness of primary care, and I certainly didn’t intend to suggest that it would. As I stated at the beginning of the column, I wasn’t going to discuss how all the various components of health care reform need to address the problem. Rather, I wanted to present one practice model that has been used successfully in a number of practices, in a way that does make efficient use of the aggregate time of physicians in the practice.

    The model I was describing will clearly not work in a solo practice; the practice needs to have at least several physicians so that a team-based system is feasible. In addition, how it is designed may depend upon the number of physicians in the practice and the number of patients within the practice who are typically hospitalized. If the practice has a large number of hospitalized patients, then the physician designated to cover the hospitalized patients at a given time would be doing only inpatient medicine at that time. If there are relatively few hospitalized patients, then the designated physician would still likely be seeing some outpatients during that time.

    There is no question that appropriate reimbursement for primary care services is absolutely critical for the future of outpatient internal medicine. However, at the same time, I believe that the profession cannot ignore those non-monetary issues relating to practice design and structure that may improve both physician satisfaction and quality of care.

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