The comments that I made in a recent post regarding the current and future role of the general internist have attracted some attention.Kevin MD mentioned it and several others have made comments. My comments were made based on my observations on private practice and some second hand information about academic IM from my spouse who spent many years as an academic oncologist and informal conversations with many of my colleagues over the past few years. Until today I had not made any effort to read what the academic general internists have written about this issue.Today I did and I came across an excellent article
by Drs. Thomas Huddle, Robert Centor and Gustavo Heudebert which discusses in candid and well expressed detail much of what I had personally observed and about which I had opined.The authors expressed basically the same concerns that I had expressed in my much more informal and less well organized way. In fact, having read that article I believe my views were largely validated. This article should be on my medical student's mythical reading list as it provides an insiders' look at some very important aspects of medicine in the real world.
MEDRANTS also commented on my thoughts in his blog.He suggested that I have overlooked an area in which the expertise of the generalist internist was sorely needed, this being in the management of complex,complicated cases involving patients with multiple medical problems. He is correct; I did not discuss that aspect. Often these patients not only have several illnesses but are taking numerous medications and are interacting with several doctors who may or may not have a sense of the overall picture.I agree that this type practice is really what internists were and are all about. This role is the role of the consultant for the difficult problems and someone who can manage the overall picture of these often perplexing cases. These are problems where the internists can do what he was trained to do and this role of the Oslerian physican with a deep and broad knowledge was what I believe was modeled by the physician educators that I was fortunate enough to have had as role models during my medical training.No one other than the internist is trained for this role in adult medicine.MEDRANTS says general internists are important.They are.My concern is that in the current medical practice environment their future survival in this classical, general internist role is in doubt.
Care of the complicated, multifaceted medical conditions requires time and in the out patient setting time is money.The money as doled out by Medicare and managed care does not properly compensate for the time consuming cognitive activities involved in the management of this type patient.
I believe for the generalist internist to survive there must be a major change in the reimbursement schemes used to compensate outpatients. In the absence of this the internist as office physician will morph into what will not be distinguishable from the family practice doctor or the independent nurse practioners. I believe MEDRANTS' views and mine differ little if at all.
I hope that Dr. Centor, in his role as president of the Society of General Internal Medicine, is able to gather support from the medical establishment (ACP,AMA and maybe even subspeciality societies such as ACCP) to educate the relevant players-including the public- about the importance of the general internist and to lobby for meaningful changes in the reimbursement system so these complex, complicated cases can be managed by those physicians who have been trained to do so and not let the tradition die out.