I believe primary care docs are rebelling against the system.  The system has made primary care physicians suffer emotionally and financially.  The system has taken the greatest form of medical care – that consisting of continuity, comprehensiveness, complexity and completeness – and denigrated it. Now I talk about "the system" in an anthropomorphic sense, but "the system" is virtual.  "The system" has no conscious, it is not deliberate, rather it represents ...

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Recently, I had vigorous discussions about retainer medicine.  In both discussions the "opposition" opined that every time an internist (or more recently family physician) leaves the CMS/private insurance grid patient access decreases.  They imply that outpatient generalists have a moral responsibility to continue seeing too many patients and spending inadequate time with each patient. The growth of retainer practices follows simple economic principles.  Patients want to buy physician time; physicians are ...

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I spend much time talking with medical students.  It is part of my job, but more than that I like medical students. What should be the goal of medical schools?  I believe we have an obligation to help our students grow into great physicians.  What philosophical principles should we use? Perhaps the answer to success is Servant Leadership.  As I learn more about this concept, I hope that have become a servant ...

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"Take a good history, do a good exam." I have not contributed to my treasure of quotes with this title.  No one reading the headline well hit their head and mutter, "Wow!"  Yet one can wonder about the lack of careful history taking and basic physical examination skills. This delightful new blog post written by an internal medicine resident says it well: Defensive medicine supersedes quality medicine. You should read the ...

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Recently, I had a discussion with a prominent academic family physician.  I had last seen him 37 years ago when he was getting ready to graduate from medical school and I was a new medical student. We had a wonderful discussion and agreed to disagree about merging primary care.   Long time readers know that I dislike the term for the tasks that outpatient internists do.  Most of the push for merger ...

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A recent comment raised a minor controversy about the strategy of minimizing tests.  I actually do not think that the disagreement is that great, but I feel like exploring the issue. This is the sentence that triggered the comment, courtesy of primary care physician Rob Lamberts:

Order as few tests as possible.  No test should be ordered for informational purposes only; the question, “What will I do with these results?” should always ...

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During my entire career I have seen unwarranted and unseemly squabbling between town and gown. I often hear the gown side insult the town side. While I went straight into academic medicine, I did moonlight in community hospitals. For the past 6 years I have taught part time in a community hospital and part time in an academic VA hospital. I find recent negative comments about academic medicine unfortunate just like ...

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I received a wonderful inquisitive e-mail from a 1st year medical student.  He aspires to an academic internal medicine career and, as a non-traditional student with an MPH, has realistic goals.  He asks:

What scares me is the prospect of going into a relatively low-paying specialty in such a non-lucrative practice environment with such massive educational debt.  Are there any other challenges to going into internal medicine that are unique to ...

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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 ...

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