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.

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.

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.

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.

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.

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.

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.