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.

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