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Thursday, June 23, 2005

Will there be general internists in the future? Should there be and what will they do?

These comments are now over ten years old. I republish it now as most everything I said then seem more on point now.

The current data are clear.There are fewer docs going into general internal medicine.Lower pay, less prestige are two of the reasons offered.

A  "op-ed" like piece in the ACP Observer by the President D. Anderson Hedberg is entitled "Finding the Art within the science of internal medicine". My gut reaction to it is " wouldn't it be nice if it were [still] true.?"The internist he portrays does resemble the internist I thought I was training to be. But I doubt if it is possible to be that type physician today.

Dr. Hedberg quotes a 1998 article by Dr. Robert L. Wortmann, chair of IM at the U. Of Oklahoma in Tulsa. Dr. Wortman said the four distinguishing characteristics of internists are: 1) the ability to be a diagnostician ( internists were once called that) who can practice the deductive scientific process that leads to therapy. 2) the ability to provide care of complex acute and chronic problems. 3) the ability to be a consultant for generalists, specialists and subspecialists and 4) curiosity. One comment he made re "curiosity" does resonate with my IM training. He said that to the internist it is important to consider the "links between disease and pathophysiology as well as between the therapy and its mechanism of action"

These comments definitely had more currency at a time when: 1) there was no competition in primary care save for GPs. and there was a clear distinction between GPs and internists. There were no family doctors-from whom the distinction between them and internists is harder now to draw- and no competitor from nurse practioners. 2) there was the reasonable likelihood of being able to spend enough time with a patient to play out those characteristics and patients did not have to be seen every 10-15 minutes to either meet the clinic or HMO quota or generate enough income to keep the practice going. 3) there was no need to worry and try and determine if the recommended therapy was approvable by the HMO, Insurance company or pharmacy management company.4) there was no hospitalists to compete with you. You were the hospitalist. 5) there was time and opportunity to pursue efforts to satiate your curiosity.

Only about 25 % of internists consider themselves general internists and more and more subspecialists refer back to the general IM doc or the FP problems not clearly linked to their subspeciality.Hospitalists are growing in numbers and the arrow points in the direction of at least some general IM docs pulling back from their roles in the hospitals making them more like FPs than internists.

In short, in today's environment how realistic are the comments of the two physicians quoted above? I think not very. I am afraid their comments were more relevant in an earlier era.It is hard to say what are the distinguishing characteristics of internists in the current practice of medicine.
I believe it is a confluence of factors and forces that are leading to the demise of the general internist. Another major determinative factor is the following:A few decades ago the internist (there was no "general" preceding the designation) was the recognized expert in diseases of the heart, lungs, and kidneys as well as the expert in endocrinology and hematology. Tremendous growth and development of the subspecialist domains of expertise has changed the landscape. Cardiologists are now called in to treat coronary syndromes, pulmonary docs for respiratory failure, etc etc. Oncologists take care of the cancers, kidney doctors the ESRD cases and it is the rheumatologists now giving the disease modifying treatments for rheumatoid arthritis .When emergent or semi-emergent medical issue arise after hours the patient is likely seen in the ER by an ER doc and if hospitalized, then seen by a hospitalist who more likely than not calls in specialists.In short, the areas in which the internist was the expert have largely disappeared and the experts are the IM subspecialists. To a large degree many internists are left with office treatment of the same conditions managed by FPs and nurse practitioners ( hypertension, type 2 diabetes,annual check ups, elevated cholesterol,URIs etc ) How many internists would want their myocardial infarction treated by an internist? I want a cath cardiologist.


Clinical Cases and Images said...

The market demand will shape the future of internists. We'll just have to wait and see, I guess.

Anonymous said...

I agree that economic forces will likely determine the outcome(s), with medicine in the US we can't speak of free market but if you figure out how to follow the money, you will know where to go.And the money does not seem to be going into general internal medicine.

Dr. Luke Van Tessel said...

My favorite med school professors are sixty and seventysomething internists, a dying breed. They know physiology better than physiologists and are masters of the lost art of differential diagnosis. To my jaded generation, we see increasing pay going to people with less knowledge. All the AOA kids get to be orthopods and immediately forget how to manage patients. (They consult medicine.)

You get a lot of money to manage psoriasis. You get HMO hell to manage hypertension or have correct indices of clinical suspicion. And woe to the internist who consults an endocrinologist for his difficult-to-manage diabetes patient; he just lost his 2.6 office visits per year.

Everyone wants the ROAD to happiness: radiology, opthmamology, anesthesia, and derm. Thus, while the best and brightest used to go into general internal medicine or gyn, the former is now a purgatory prior to a cardiology fellowship, and the latter is a bubble-gum sorority. And when the cardiologists blow a vessel on a cath, they have to call in a CT surgeon who gets all the liability.

None of this was in the brochure, but it's still better than law school.

Anonymous said...

I continue to be amazed by how savy you are as a medical student and think back to how clueless and naive I was even as a house officer and fellow.Your comments hit the mark.

Anonymous said...

I have posted a response over at db's Medical Rants. I am not as pessimistic as retired doc.

Oskie said...

I think that eventually the fields of internal medicine and family practice will differentiate into hospital-based and office-based medicine. Many of the academic internal medicine attendings I knew in medical school were not very good role models---bright but socially-awkward or workaholic. Many of the other physician in the "life-style" specialties (derm, gas, rads, PM&R) seemed more well-rounded and interesting. I also think that many medical students today realize that sooner or later everything gets boring in medicine. And when that happens all that you're left with is the lifestyle.