A strong wind would have knocked Geraldine to the ground. At 78 pounds, she was underweight, chronically ill, and in need of acute medical or psychosocial care every time she came to the clinic. A survivor of domestic violence with severe mental illness, she had a history of substance abuse and was infected with both HIV and Hepatitis C. In chronic pain but too high a risk to prescribe opioids, her suicide attempts this past year neared the double digits. But you know what? Unless she was in the hospital, she never missed an appointment in the primary care clinic. A sweet, kind woman with complete biopsychosocial disarray, she had been cured of hepatitis C in the past year; she developed an undetectable viral load; and with medication adherence, she developed a stable mood.
As physicians who practice general internal medicine, we are well-trained to primarily treat or coordinate the care of all Geraldine’s problems. For Geraldine, when this was done successfully, her ER visits slowly decreased; her inpatient admissions decreased; the overall costs of her care decreased. Her life improved. And the value of general medical care personified itself like no other case study.
General internal medicine — either in the inpatient or outpatient setting — has probably never been more exciting than now. It has also never been more needed!
General internal medicine GIM is alive and well, and only getting better. And to that end, the Society of General Internal Medicine (SGIM) is promoting its new #ProudtobeGIM campaign, aimed at encouraging more students to choose a career in GIM. Students need to know that patients like Geraldine are another reason why trainees should choose GIM as a career.
So, let us share with you a top 10 list to choose GIM as a career:
1. The Affordable Care Act. Whether you think it is the best or worst piece of legislation since Medicare, no one can deny its impact on general internal medicine. The people who are insured now get all the screenings we have always recommended without a co-pay. The Medicare prescription donut hole is closing, and access to mental health and substance abuse care is improving. Additionally, care coordination and improved transitions of care are starting to be covered by insurers, which will immortalize them as the standard. In short, all the things generalists have been doing for years because they are the right thing to do have now been recognized and supported across the country.
2. Payment reform. There’s still a difference between generalist and specialist incomes, and outpatient versus inpatient incomes … but an aging population, the ACA, parity legislation and PCMH and population health metrics supported by payers are tightening the gap. This is good news and the results of much GIM advocacy!
3. Team-based care. The days of the “lone doctor” are gone. Students and residents are being trained in how to work on a team of complementary disciplines, from nursing and social work, to pharmacists and chaplains. Residents should now expect to lead or work as part of a team. Physicians have more time to focus their energy on the complex medical care they are trained to provide.
4. Changes in undergraduate medical education. Students are educated as part of team and are learning early on about health disparities — as they should! Using electronic medical records, population health is now achievable at the click of a button (or should be!). Students are seeing how public health principles and socioeconomic determinants of health influence the overall care and health of their patients. They will continue to expect this in residencies and beyond, and mentors and role models should celebrate this change!
5. Changes in graduate medical education. Like undergraduate medical education, there are always changes in GME, but one of the most exciting is the Choosing Wisely campaign. Now, trainees are taught not just what tests to order and why, but perhaps more importantly, what tests not to order and why. This initiative began in the general outpatient primary care setting with a simple “top 5” list of tests not to order. It has grown to over 70 specialties and inspired national competitions among hospitals and medical schools alike. It literally has been the driver of thousands of posters and talks. Generalists have and will continue to lead many changes in GME, and our patients are the better for it. (See SGIM’s contribution to the Choosing Wisely campaign.)
6. Patient-centered medical homes (PCMH). Five years ago, residencies used a PCMH designation as a recruitment tool. Now, if residents are not trained in a PCMH, residencies need to explain why not. All the evidence about achieving the quadruple aim [lower cost, higher quality, better patient satisfaction, better provider satisfaction] should be made very apparent to trainees. Behavioral health co-location and integration is also a large part of this model that has importance in both care coordination and overall health outcomes.
7. Quality improvement and efficiency. From the AMA to the IHI, study after study focuses on both inpatient and outpatient quality and safety. General medicine has improved as a result!
8. Workforce research and changes. Be it JAMA, JGIM, the New York Times, or Wall Street Journal, focus on the primary care pipeline with interventions to strengthen and improve it are numerous. New medical schools are opening; NP residencies and fellowships are popping up across the country; incentives for loan forgiveness in primary care are nearly the norm right now; and flexible schedules are the style du jour.
9. Complexity of patient care. As the primary care pipeline of well-trained internists stays less than robust and other disciplines practice to the full scope of their license, the management of complex medical patients will continue to fall to generalists who are uniquely situated to care for the most multifaceted patients. These are the patients who require the most advanced thinking and care coordination; the unique patients who tend to be “challenging” while at the same time rewarding. As we get the time to care for these most complicated patients, our job satisfaction should improve even more.
10. New delivery models. While face-to-face encounters will likely dominate medical care for the near future, models such as group visits, telemedicine, telephone medicine, email medicine, and even text medicine will become more popular. While much has to be researched about the efficacy of these new delivery models, general internists will be highly involved in their set-up, design, delivery, implementation, and evaluation.
The field of general internal medicine is anything but static, and definitely improving and exciting. It allows a huge degree of flexibility to teach, do research, see patients, participate in health policy and advocacy – often all at the same time! This enthusiasm about all aspects of general internal medicine needs to be made crystal clear to trainees by all levels of GIM faculty. Find out how you can become a part of the #ProudtobeGIM campaign.
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