Outpatient internal medicine needs a consultant track

I have spent most of the past 2 weeks on the road – first at ACP and this week at SGIM. I have talked with many internists, but several conversations have contributed to writing this post. Each of several leaders contributed to these ideas, but I will keep them anonymous so the innocent are protected.

Here are the main assumptions:

1. Internists by training excel in the care of complexity
2. Pursuing the label of primary care back in the 1980s was a major mistake
3. Hospital medicine exists for the benefit of true primary care physicians, because they do not have enough patients hospitalized to make the trip to the hospital worthwhile

I have no objections to those internists who want to continue the primary care strategy. However, we should follow the British Empire model and fully develop the consultant model. What do I mean by the consultant model?

I believe that we should support the development of a specific type of outpatient internist, one who handles complex patients as their main task. They could do just outpatient consultation and work closely with a hospitalist group, or they could be duelists. They would receive many referrals from hospitalists, and some from primary care physicians.

These consultants could give advice to primary care physicians on balancing the care of complex patients, or they could assume total care. Now we would have to develop a more rational payment system to support these consultants.

Many retainer practices serve this function. I have two friends in Birmingham who have a small retainer practice that fits this definition. They have markedly restricted their practice and have predominantly complex sick patients. They work with the hospitalist group, and they come to the hospital to insure excellent transitions and continuity.

Consultant internists would be experts in all the major chronic diseases – e.g., CHF, COPD, cirrhosis, diabetes, CKD – and their interactions.

If we could design this job properly (and some have done this), we would have improved outpatient care and decreased inpatient care. Obviously our current RBRVS system will not support this model, but I would favor some major demonstration projects to define the appropriate panel size and cost.

Those who enter internal medicine generally accept and enjoy complexity. I believe that we could define the consultant job in such a way as to make it a highly desirable job. It might help primary care physicians who find such patients time sinks.

So, in summary, I believe we should consider dividing outpatient internal medicine into two tracks – consultant and primary care. Now I am ready for both supporting and attacking comments.

Robert Centor is an internal medicine physician who blogs at DB’s Medical Rants.

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  • http://drpullen.com Edward

    This coming from a family physician. I think you have a great idea. Years ago I had a great working relationship with a couple of local internists, so that I could use them as consultants, or ask them to assume care of really complex adult patients. Now any internist I ask for this help feels I am “dumping” my responsibility onto them. As a primary care physician, trying to coordinate and provide care to really sick and complex patients, I need to use too many limited subspecialists in a few cases. An internist who desired this type of patient would be a great asset. With the current payment system this is not going to work. This internist would ideally be able to have an RN or ARNP work with them to manage their cases, and get paid for that work. This would work best by allowing them a “retainer” plus fee for service, or just a high retainer payment. Then they could focus on a limited number of patients. Agree that pilot projects would be the way to make this work. The key would be to get incentives in place to assure these consultant internists really take care of these tough patients, and not just be a “medical home” where referrals to the same subspecialists other primary physicians rely on are overutilized. As always the devil is in the details, but a great idea to work from. It could come about quickly, as many internists who are deciding to drop their patient’s inpatient care for outpatient practices have the skill sets in place.

  • anon

    I”ll go a step further and say that some semblance of this is being forced upon Primary Care physicians already and, to survive, the field will need to adopt something like you described. However, instead of Internists splitting into Primary Care and Consultants, I’d argue that the split will be Physicians and mid-level practitioners, with physicians serving as the “consultants” to the mid-levels, and taking care of the complex patients themselves.

    The argument that having the traditional primary care physician see every patient and manage it because it prevents referrals to specialists is a great, and logical, argument except… it isn’t happening. In practice, primary care (as it stands now) is a heavy duty triage system because many (before you get offended, *not all* PCPs) hear a murmur and simply refer it out to the Cardiologists, etc. Mid-levels can do that, and do it much more cheaply.

    The system you described is probably evolving already. It’s just a matter of how well physicians can adapt.

  • stargirl65

    I am basically doing what you are describing. I am not seeing how this is new. The only new thing would be to get paid for this.

  • http://glasshospital.com GlassHospital

    I would go with the spelling “dualist” rather than “duelist.” That is, unless the PCP/”consultant”-internists wish to have a duel with the hospitalist-internists.

    Or maybe a smackdown with the AMA’s RUC. Now there’s something I bet any kind of internist could get behind (except those high falutin’ specialist-internists….).

  • http://medrants.com db

    The reason we do not have a supply of consultants is payment. We must develop a payment system for outpatient medicine that rivals inpatient medicine. We must limit the hassle factor and maximize time spent with patients.

  • jsmith

    We have this setup in our clinic. We have an internist who sees the more complicated pts while the FPs see more volume. She gets a half hour to 45 minutes per pt and we get 15 minutes. We’re all on salary. It seems to work out fairly well, as well as anything does in outpt medicine these days.
    Clinically, this setup makes a lot of sense for the country and individual docs and pts. But as the HC system is currently structured, it is probably a non-starter. An outpt consultant model with IM or FM doing the consulting and NP or PA doing the volume would work only if we could get enough warm medical bodies who want the job, but this is not likely because of the income disparities and irksomeness of the job compared with med students’ other options. As I recall, Dr.Centor used to do outpt and inpt IM but is now a hospitalist. Just as he left outpt IM (and I’m certainly not blaming him), so I think a lot of young docs/med students also take a look at outpt IM and are completely appalled. Major restructuring would need to be done to make it attractive, and that’s not likely to happen in the near term. So my best guess is that because of both money and work irksomeness it will not happen in a big way. Sad for America’s health and budget.
    To have a functioning market you need supply and demand. The demand for these docs is there but not the supply.

  • KP Internist

    The complexity of the conditions that a primary care doctor feels comfortable handling should be determined by that individual provider. Send them to the specialist for management of the specific issue that you don’t have expertise in. Or, hit the books and learn more about how to manage that issue. I just don’t see that subdividing Internal Medicine into more tracts would serve patients any better and will result in more uncoordinated care.

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