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Monday, April 11, 2016

The alleged demise of the internist-is it just the money?

A blog  entry, now several years old,by one of my favorite medical bloggers, DB aka Dr. Robert Centor, offered an important insight into some of the current problems with the specialty of internal medicine which include few medical graduates opting for general internal medicine and the low level of general satisfaction of many internists.It is clearly not your grandfather's internist anymore.

 Dr. Centor was commenting specifically on the suggestion by one of his colleagues that the training of internists needed to be revamped with more emphasis on outpatient issue and less on inpatient matter.He seemed to believe and I agree that that was not the answer. Rather DB's key message,in regard to the decreasing popularity of general internal medicine as a choice of medical students, I believe was the following:

"...I believe the problem is money – and that has impacted everything else."

As long as the internists "reimbursement" was what was known as "reasonable, customary and prevailing" the classical internist type practice thrived and "those were the days my friend and we thought they would never end" but they did. The beginning of the end of that type practice can be traced to the imposition of price controls on physician fees by Medicare. Soon after the other third party payers clamped down as well in part with the largely now defunct mechanisms subsumed under the rubric "managed care" whose effects still linger although the programs were rejected by the patients.

With managed care the collegial and self reinforcing relationships that grew up in the pre-managed care era disappeared. Now longer could the internist refer to the physician of his choice it was typically necessary to refer only to someone on the patent's plan.No longer could the family practice physician or the surgeon or ObGyn send a patient to the internist she knew she could trust to take good care of the patient.

With the new payment system ( ever decreasing fees from governmental and non-governmental payers) and the breakdown of the old informal, ad hoc but very useful referral systems, satisfaction for the internists began to fall.Importantly,with decreased fees per patient encounter the incentive was to increase patient encounters and spend less time with each patient.

Further, internists 's practices gradually became a game not of his choosing. Guidelines proliferated and the internist's attention turned more the care of the worried well and a check list practice evolved making sure your patient flossed,wore seat belts and had her colonoscopy and five fruits and veggies a day. Much of it became trivialized to the point where it really began to actually make sense for an assistant (PA nurse practitioner) to do much of what somehow had become expected. And then there is the "existential angst" brought about by the conflict of the old with new medical professionalism.See here for my earlier rant on that and for DrRich's very similar views in his comment to the post.

With decreasing fees per patient encounter it became harder and harder for the traditional internist to care for patients in and out of the hospital and see patients after hours in an emergency room and make the ends of his practice meet with enough left over to make it all seem worthwhile. The notion of a hospital-only practice with regular hours offer many discouraged and burning out internists an out and for younger internist to spend their time taking care of sick patients, i.e. the complex problems that traditionally internists dealt with.  

Of course, there is more to the origin of the hospitalist than the angst of the internist and the dwindling pay schedules but I still marvel a bit at the readiness of the internist to change roles to become a physician whose stock and trade was episodic care with little if any chance for the type of long term care through the course of a chronic illness that was once typical of an internist's practice .

So even though the internist turned hospitalist gained more time off, probably better income, and less business type hassles and a chance to deal with the type of serious , complex, medical problems that internists train to manage, but it was only part (although a major part) of what an internist used to be. And of course, the internist who remained with a truncated medical practice had to forgo much of what his training was all about.  More and more, I am convinced that the type practice that an internist had was largely dependent on the economic environment of the times and when that environment changed so did the internist and to the degree the new professionalism is the currency so has the medical ethics.

addendum: typo corrected 4/12/16

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