Musings of a Dinosaur

A Family Doctor in solo private practice; I may be going the way of the dinosaur, but I'm not dead yet.

Friday, February 23, 2007

Primary Care and General Internal Medicine

Dr. Bob and Dr. RW, among others, are in the midst of a discussion about the identity crisis of the General Internist: who they are, what they do, and whether or not they are becoming obsolete.

Let me see if I understand what they're trying to say. Here's DB:
I personally reject the primary care label to describe general internal medicine. Internists are specialists, OK? Internists are not just “doctors for adults” as the ACP defines them. Not even “general” internists.
Ok. They're specialists:
I view general internal medicine as the specialty of complex care of adults. Our patients span inpatient, outpatient and nursing home. While we can do some primary care, we tend to attract patients who have multiple diseases. Our skills are diagnosis and juggling multiple diseases.
So how would you like to get your patients? Not under the fragmented, laughable free-market melee currently mislabeled the "healthcare system," but if things worked the way they should.

Primary care is defined as the first doctor you go to when there's something wrong with you and, theoretically, you don't know what it is. You may think that if you have chest pain you should just go straight to a cardiologist, but because many other things can cause chest pain you're often better off going to a primary first, so that if you do need a specialist, it's more likely to be the right one (cardiology, pulmonary, GI, etc.) Family Practice is the specialty that provides specific training in primary care. Not just triage, either: we can treat about 90% of the problems we see. Referral is not a failure; it's just not always necessary.

People aren't born with multiple complex conditions. Of course there are exceptions, but I think most internists would run screaming from the care of an 18-year-old former micro-preemie with all the sequelae of a NICU graduate -- an adult with multiple, complex diseases -- preferring to leave them for the family docs or the noble pediatricians who got them this far.

I see young healthy people who, rumor has it, grow older and develop diseases. I can diagnose and manage hypertension. I can diagnose and manage diabetes and hyperlipidemia and metabolic syndrome, along with arthritis and GERD, and so on across the board. Describe to me when, who and why I should refer to you? I am more than just a referring gatekeeper. If I have a diagnostic challenge, I am just as capable as you of researching it and, if specialty care is required, determining which specialist's bailiwick is appropriate.

Do you expect me to say something like this: "Well, Mrs. Smith, now that you have multiple complex diseases, I think you should be under the care of a specialist. I'd like you to go see an Internist. They won't provide your primary care [what exactly is that in this context? Immunizations?] but because they enjoy the complexity and diagnostic challenge, I think you will benefit from their style of training and deeper understanding of complex diseases."


Patients don't walk in the door with neat little labels on their foreheads saying "Straightforward Problem," "Multiple co-morbidities," or "Atypical presentation of common problem." Sorting that out is the purview of Primary Care, defined as the doctor who gets "first crack" at a patient. Perhaps that's why your colleagues are trying to enhance the primary care aspects of Internal Medicine.

One of the most important things specialists must do is recognize their scope of care, and realize that outside that scope, other specialists are better qualified to render care than they are, even if they could. A cardiologist who has determined that his patient's chest pain is not cardiac, and strongly suspects it is gastrointestinal in origin, is perfectly capable of ordering an upper GI study, but out of respect for his GI specialty colleagues he defers that decision to them [especially since an upper endoscopy is often a better first test.] As an Internal Medicine Specialist renouncing primary care, what are you conceding that Primaries do that you don't (or, what do we do better than you?)

That said, I agree there are settings where your special expertise in complexity is useful. I speak primarily, of course, of the hospital and the nursing home. Because Americans today are more mobile than ever before, I can also see a role for you taking care of Mama, brought up from Florida who's having problems with her sugars along with her valvular heart disease, borderline renal function, hypertension, CAD, etc. If you want an ambulatory practice, consider limiting it to patients referred by other docs. I wouldn't mind having someone I could send a puzzling patient to once in a while, to help me figure out what's going on, but the respect needs to go both ways.

Once you present yourself as willing to take care of anyone who walks in the door, you are by definition offering Primary Care, whatever you call yourself. If you see yourself as a specialist -- and want to be treated like one -- it's probably best to start by acting like one.


At Sun Feb 25, 02:10:00 PM, Anonymous Anonymous said...

Bravo, you nailed it on the head. I think the hospitalist movement will take over general internal medicine. Perhaps for variety, the hospitalists might want to consider running a low volume, low overhead referral-based outpatient practice one or two half days a week to see a few "complex cases" referred by family physicians and outpatient IM's. The outpatient-only, non-academic IM's are in the same boat as the FP's these days. The "complex cases" are referred to specialists because the current reimbursement system doesn't come close to the cost of paying a single physicians to provide comprehensive care. General pediatrics has been honest about this for a long time. Outpatient practitioners of General IM practice primary care limited to adults. Only those in academic settings still practice in the good old days of managing "complex cases."

At Sun Feb 25, 10:58:00 PM, Blogger Liana said...

Right on!


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