ACP: Increasing the attractiveness of general internal medicine

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

by Steven Weinberger, MD, FACP

acp-logoIn 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.

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