How general internal medicine can be saved

A guest column by the American College of Physicians, exclusive to KevinMD.com.

by Steven Weinberger, MD, FACP

In this era of health care reform, much has been written and discussed about the shortage of primary care physicians in the United States, which is projected to get substantially worse over the coming years.

A number of different types of physicians have been lumped together under the term “primary care physicians,” including family practitioners, general internists, osteopathic physicians, and, for the care of children, pediatricians. As an internist in a leadership position with the American College of Physicians, the national society for internal medicine specialists and subspecialists, I will limit my comments about the physician shortage to general internal medicine rather than the broader category of primary care.

Without making eyes roll by invoking “the good old days,” I would note that, when I graduated from medical school in 1973, internal medicine was extremely popular, including general internal medicine. Today, in contrast, based on a study published in 2008 in JAMA, only 2 percent of medical students say they plan to go into general internal medicine. Other data obtained from questionnaires of internal medicine residents during their final year of training show that only about 20 to 25 percent of internal medicine residents now plan to enter general internal medicine, compared with nearly 55 percent in 1998.

What can be done about this problem, whose roots are clearly multifactorial? One important approach is the redesign of practices to become “patient-centered medical homes,” with many components intended to improve the quality and coordination of care that is truly patient-centered. Embedded within the patient-centered medical home model is increased support for team-based care by including payment for care coordination and for many aspects of care that are currently either poorly or not reimbursed.

However, increased payment is only one aspect of what is needed. I believe that a particularly critical component is the redesign of practice responsibilities within a team-based model to make use of the unique skills, experience, and training of the specialist in general internal medicine. I will single out two of these skills.

First is the ability to be a diagnostic sleuth. Solving diagnostic conundra is one of the core skills of the internist, whose training is often focused on using her knowledge of medical science and pathophysiology to address a patient with a new, puzzling, and as yet undiagnosed problem. Second is the ability to apply a broad knowledge of clinical medicine to the longitudinal management of patients with chronic, complex, multiple, and often multisystem diseases.

Whereas the practice of the general internist should be focused largely in those areas that utilize his skills, other essential areas of patient care are often better handled by other non-internist members of the team, utilizing their particular skill sets. Such members of the team include nurses and nurse practitioners, physician assistants, and a variety of other allied health professionals. The specific areas of care best handled by these members of the team include management of routine and readily diagnosed medical problems, wellness and preventive care, many routine aspects of chronic disease management, and patient education. With an appropriately used team-based system, patients may get some aspects of their care through the general internist and other aspects of their care from other members of the team.

Although we often think of general internal medicine as being largely an outpatient specialty, general internists should also have the opportunity to care for patients when hospitalized, if they so desire. In practices that have a number of general internists, this approach is often nicely handled by assigning one of the internists on a rotating basis to handle the care of all hospitalized patients within the practice.

The team-based models in which general internists make best use of their skills and experience are optimal for patient care, at the same time they keep the physician challenged and satisfied that her skills are being appropriately utilized. Without this type of job satisfaction, trying to recruit residents into general internal medicine will continue to be an uphill battle.

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

SmartDoc
This model is not new.
It has already been rejected by (literally) 98% of modern medical students, who have no desire to be disempowered government quasi-slaves, without public sector benefits.
Max
I recall during my rotations I had the highest respect for the general internists and their knowledge. I wanted to be a general internist because of them. During my residency I saw few that emulated those I trained under in med school. They were rushed at the hospital in the wee hours to get round done before their office opened. Meanwhile, the lazy derm slob was waking up around 9, working til 4, and making 3-4 times as much. And no weekends. Sometimes even admiration doesn’t get past the almighty greenback. Amazing how inspring that little thing can be. Makes med students completely engrossed with the wonders of acne and psoriasis. So so fascinating.
DO Student Doc
“A number of different types of physicians have been lumped together under the term “primary care physicians,” including family practitioners, general internists, osteopathic physicians, and, for the care of children, pediatricians.”
Osteopathic Physicians (or DOs) are NOT EXCLUSIVELY primary care physicians. DOs, like Medical Doctors (or MDs) practice in ALL major subspecialties, including many areas of “primary care.” Indeed, in my training, I have been exposed to DOs who are psychiatrists, brain surgeons, ENTs, etc. It is ironic that Dr. Weinberger is noting how few “medical students” plan to go into primary care (the implication, of course, being medical students at MD schools) when “medical students” at DO schools are graduating and entering “primary care” at rates of higher than 50%. Indeed, osteopathic physicians are filling the roles in “primary care” that he is speaking of. Personally, I’m happy for this as I am planning to enter rural primary care as a career.
http://www.drdialogue.com Juliet K. Mavromatis, MD
The Patient-Centered Medical Home model clearly has a lot to offer. I recently wrote a blog at DrDialogue comparing and contrasting it with retainer fee medicine–the other side of the spectrum. They both reject status quo, and call for additional reiumbursement to primary care.
One question, with respect to team care: if I were to stop seeing my healthy patients for routine care and their “run of the mill” problems, how will I:
1. get to know them as people
2. understand when something is really wrong.
The risk of a team based approach versus as practioner-centered approach–no one really gets to know the patient well and understands his or her complexity. It will require great finesse.
http://www.healthleap.com Jesse
I’ve met quite a few doctors who have told me “Only the dummies go into primary care. Anyone that gets A’s in med school goes into a smarter field”
Sad, but thats where the money is.

Taylor
I don’t believe that. Primary Care doctors see patients for such a wide variety of issues, which makes the doctor utilize ALL their knowledge from med school. They also have to look at the patients history as a whole and combine that with many different aspects of medicine.
On another note, it’s not easy to get into med school, get through it, and then residency. So I wouldn’t call someone who didn’t get “A’s” in med school “dummies.”

http://www.healthleap.com Jesse
Taylor, I agree with you, and it’s definitely not my mentality on PCPs. However, there is a sense of macho-ish about this topic from a small segment of the MDs. Sad, considering PCPs have the most communication with the patient and in my view, do the most overall good

Thomas Sinsky M.D.
I would agree with Dr.Mavromatis’s important questions.
I definitely support the medical home model and the concept of team care. However, the division of tasks within the team will determine how successful we are in building the patient-physician relationship.
I believe that the primary care physician should see the patient and integrate the management of prevention, acute symptoms, and chronic illnesses. The relationship is the center of the medical home concept and that can be lost if the patient is shuffled among too many providers. It only takes me a few minutes to see my own patient with a “minor complaint” and yet this is how we build our relationship of trust over time.
The job of the physician includes diagnosis, medical decision making, and relationship building. The other tasks of patient care including: Information gathering, operationalizing medical decision plans, patient education,
order entry, prior authorizations, completion of forms, etc. should be handled by other members of the team.
Our own team consists of one physician and 1.5 nurses.
With this team model we have been able to provide high quality, “lean” efficiency and above average patient, staff and physician satisfaction. I believe it is a model that can attract young physicians to intellectually challenging and emotionally satisfying primary care careers.

ACP: Increasing the attractiveness of general internal medicine

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