Sunday, December 24, 2006

Is being a hospitalist the only way to still be a old time internist?

Dr. Laurence Wellikson seems to believe that the only way -at least a way-to recapture the core of what internist used to do (care for the patient with the complex problem(s))is to become a hospitalist.

Here is a point-counterpoint presentation by Dr. Willikson,CEO of the Society of Hospital Medicine,and Dr. Robert Centor,President of the Society of General Internal Medicine on the topic of "What is an Internist?"

Willikson seems right on target when he speaks about "internists [having] devolved into gatekepers and primary care physicians" ...[and] competing with Family Practitioners and Nurse Practitioners to be the traffic cop for resource use and burgeoning specialization."

He then inserts some of the current- in- vogue- jargon of the business consultants and speaks about the importance of preparing a "value proposition" and then makes what I consider to be a "boil the oceans" type suggestion namely to "reset the reimbursement system".

Given the current power relationship between third party payers and physicians it hard to conceive of what doctors could do to change the system. Hospitalists are either employees of the hospitals in which they practice or are contractors. The only tool either group has to bring about change is the strike, an action that physicians have rarely participated in. Changing the current medical care-reimbursement system is going to take more than hospitalists or internists writing a value statement, which I understand to be a statement made by a business explaining what they do and why the targeted customer should by it. (It occurs to me what if other specialists were exhorted to author a value statement.Perhaps neurosurgeons would propose "We take out brain tumors better than anybody."

Hospitalists do seem to spend most of their work day doing what many of us wanted to do when we decided to become internists and I hate to think the only avenue for the Oslerian type internist to travel is that of the hospitalist but that may be the reality though we have not quite arrived at that point yet. I hate to think that because an important part of what I used to do was not only caring for the complicated case in the hospital but also as an outpatient. This was a common occurence with COPD patients with exacerbations requiring hospital and often ICU type care. Internists should be the ones caring for patients with complex medical problems in and out of a hospital setting. There are still internists who care for the complex cases as in and out patients but clearly it is getting harder to do that. Dr. Wellikson seems to think internists should care for complex cases outside the hospital as well but leaves me wondering how he thinks that will happen.

2 comments:

Anonymous said...

Doctors are bizarre in their self-absorption. The question is NOT whether reimbursements schemes should be re-jiggered so that internists can do what they want to do. Only doctors are so arrogant as to assert that markets must be moved so that they can do what they want to do.

Is there a need for internists? Do they provide for better outcomes? Either show that 1. patients prefer them or 2. have some nice, rigorous randomized studies demonstrative effectivness.

Otherwise, please shut up.

Michael Rack, MD said...

The days when most docs went into private practice after a 1-year internship, and internists specialized in seeing complex patients, are long gone. Today internists are just 1 of the 3 types of primary care docs- peds for children, internists for adults, and family docs for children and adults.
Many med students go into internal med for one of 2 reasons these days: 1) they intend do a subspecialty fellowship after residency or 2) they want to be primary care docs but don't want to deal with kids or the surgical part of a family practice residency.