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.

Monday, January 07, 2008

An Immodest Proposal

I have an idea that's sure to piss off general internists and family docs alike (a sure sign that I'm on to something?): how about if we limit internists to the care of hospital and facility inpatients, and reserve the care of outpatients for the FPs.

Dr. Centor, an academic hospitalist, is obviously excellent at what he does -- in the hospital. He goes out of his way to point out that he doesn't do office care. And much of what he says about internists in offices are, by definition, second hand. If general internal medicine is failing as an outpatient endeavor, the rise of the hospitalist movement seems to be tailor-made as the natural venue for the practice of internal medicine.

I practice exclusively in the office; I don't do hospital or nursing home care. To be sure, there are loudly vocal FPs castigating me as "not a real doctor" for having given those up. Certainly they aren't going to accede to my proposal without a significant fight. But outpatient medicine has its own skill set that includes preventive care, chronic disease management (of multiple concurrent diseases), minor procedures like skin biopsies and lump/bump removal, and acute management of the worried patient with a self-limiting condition, as well as complex diagnostic challenges, among other things. Why not concede that arena to me and my colleagues?

There is a great deal of confusion about the difference between Family Practice and General Internal Medicine. Patients are confused; hell, practitioners are confused. Much of the time, we end up admitting that there really isn't any difference. So why not let Internists concentrate on the "sicker" patients they supposedly excel at caring for -- in the hospital. And let the Family Practitioners specialize in what we do best: keeping people healthy, and out of the hospital.

Let the fur fly...


At Mon Jan 07, 08:47:00 PM, Blogger The Happy Hospitalist said...

there is a whole population of the chronic walking sick.

Do you really have a desire to manage an 85 year old with
hyper TG

Honest question.

Not can you, but do you want to.

At Mon Jan 07, 08:47:00 PM, Blogger Dreaming again said...

My internist ..went on maternity leave last January (2007) and hasn't come back yet. Well, except the 2 hours a week she comes into the office to sign paper work. all while saying "I'm coming, sometime"
But ...she stopped making hospital visits shortly before she took maternity leave.

The doctor I see instead of her, while waiting for her (not really, she's my new doctor) has her title on the door as

I'm trying to figure out how that differentiates from an FP ..but oh well. SHE does not make hospital visits either.

So, then I started to look at maybe another doctor in the practice who might ... found out ...the HOSPITAL has gone to hospitalists care. There are non specialists doing hospital rounds.

It works well ...when they actually contact the PCP for continuity of care. When they don't; it's frustrating to say the least.

At Mon Jan 07, 08:52:00 PM, Anonymous Anonymous said...

dreaming again, this is how you differentiate the specialties.

all doctors go to medical schoolf for 4 years.

family practice does everything, kids, adults, ob. That is their own residency of training 3 additional years

internal medicine does only adults. no ob, no kids. That is their own residency of training 3 additional years

pediatrics does only kids. no ob, no adults. that is their own residency of training 3 additional years.

there is a program available called Med/Peds where in you get a residency program with 2 years of internal medicine and 2 years of pediatrics, a 4 year residency program. That's what is on your docs door.

At Mon Jan 07, 08:58:00 PM, Anonymous Anonymous said...

Actually, your proposal is exactly what goes on in Canada. Internists here don't do any primary care; that is the domain of family practitioners only. People here seem pretty satisfied with the setup. To respond to the Happy Hospitalist's comment, as a FP in Canada you can follow your two year family medicine residency with a third year to improve your skills in a particular patient population such as geriatrics which will help you to manage that complicated 85-yr-old.

At Mon Jan 07, 10:07:00 PM, Anonymous Anonymous said...


Most outpatient internists do a bad job of managing geriatric patients with mulitple comorbidities from a drug selection and dosage point of view alone, even assuming polypharmacy isn't an issue. (Something as simple as Cipro dosing, for example.) Ask an RPh with a BCPS in geriatrics and you could get probably get an informal, hour long CE about common mistakes generalists make on the fly.

Nevermind the extra time that population takes and how having an all-senior model as an outpatient doctor probably isn't a good way to make a living.


From a business PoV, I've thought about this question myself in the last couple of weeks. (Since Kevin posted about a company hiring only FPs, actually.) If I were to start a concierge practice, I'd want FPs working for me. Not internists. FPs and are simply more useful. Likewise, if I wanted to make the life sacrifice and go to med school with the idea of flying solo in a cash-only practice, I'd do a Family Practice over an Internal Med residency: it offers more opportunities once you're finished if indeed solo practice is your goal.

I don't think it's a bad thing, really. It's just different from what we have now.

At Mon Jan 07, 11:45:00 PM, Anonymous Anonymous said...

I think your idea will probably come true by natural selection and economic forces. Primary care has been increasingly devalued by society. Any interest by IM residency graduates in outpatient practice will probably disappear in the next five to ten years. Almost all will chose to become hospitalists or go on to subspecialties. FM residency graduates will be mostly FMG's willing to work for low reimbursement rates and women interested in part-time employed outpatient positions. A few entrepreneurial FM or IM/Peds graduates in selected markets may be able to practice in concierge or cash-only situations. There will be increasing shortages of primary care practitioners with NP's and PA's filling some of the void in drugstore and grocery store clinics providing discount acute care. The times they are a changing...

At Tue Jan 08, 01:11:00 AM, Anonymous Anonymous said...

I did rural family medicine in a group of all FPs. I then took a job doing urban urgent care where all the primary care was by internal medicine and peds, and the FPs did most of the urgent care.

The internists did fine with the people with diabetes, heart disease, CHF, and more chronic medical diseases. They did horrible with most ortho things, migraines, psych stuff, dermatology (almost none would take off a lump or I&D an abscess) and many of the men didn't even do paps/pelvics, all of which made up a greater portion of my primary care practice than the first group.

It was frustrating because I knew, for example, that it would do no good to send a patient with migraines back to their internist for management because most of them would just send them to a neurologist. Anytime most of them needed an abscess taken care of or a fracture splinted, we had to do it.

Now, they all did way more hospital rotations in residency, especially critical care ones, so I know they're way better at that than I would be.

So, I agree with you totally--let us do the outpatient and them do the inpatient, where each of our strengths lie.

Plus, though I TOTALLY believed in it when I became an FP, the idea that one can do clinic, hospital, and deliveries and stay sane, I now consider ridiculous. I did it for 5 years and never slept (to do it well required more hours than there were in the day). I respect the people who can do it all well and stay happy, but I think they're few and far between. My old partners have done it for a long time (though not all of them do it all that well), but I can't think of a single one of them who's still happy doing it.


At Tue Jan 08, 03:45:00 AM, Blogger Sara said...

Think of future recruitment - one of the things that draws me to FP is the idea that I can do many things - inpatient, outpatient, emergency, etc. And I do prefer outpatient stuff to interminable rounds and meetings. Let me at the patients! A clinic where anything can walk in the door!

But - what I like about the idea of FP is that I can go as far as I want in any direction - if I want to learn how to cover an invasive ICU shift, I can.

I just don't want the good general doctor, who knows a lot about everything, to turn into a care provider who is a "doctor lite."

If FP becomes an exclusively healthy people field, I am afraid that the practitioners it will attract will be, like someone here said, the noncompetitive students.

It's funny, when I tell some people I am interested in FP, they look at me and make a crack like, "You're too bright for that...if you want to be idealistic, go into hematology." I hope to be part of changing that view of the family doctor, to be someone who could have gone into ophtho, but didn't want to, who makes tough diagnoses like you do, who refers wisely and not constantly.

It's funny, my mom finally sort of caught on, and asked me what's the difference between FP and internal med. The best kind way to explain it for me has been to copy the curriculum off of a residency program in internal med (that shows the pulmonology, endocrinology etc) and one from FP that has the ob/gyn, the pediatrics, the ortho, psych. I figure I succeeded when she finally came home one day and told me that she asked her doctor, who she has gone to for years, whether he was an internist or a family doc!

And lastly, my grandfather recently died, was ill for a while before, but no complex medical problems, and he had a good outpatient internist, who we did like a lot.

But... a lot of things about his care were very badly managed - such as his depression toward the end, and some of the rehabilitative stuff like worrying about keeping him walking. Many times I thought to myself, I wish he had a family doc who knew him well, who listened a little bit more about his wishes, who knew how to use more than one antidepressant after someone had a bad reaction to one, who would take it a little more seriously when we
said something was wrong.

It wasn't that the medical care wasn't good - it was that the approach would have been different.
After a long time, I realized that this doctor didn't even ever ask my grandfather what his profession had been, something that had been tremendously important to him throughout his life.

Here's another funny point to mention: almost every internist I ask, unless they are in a specialty like endo, says they wouldn't do it over again. Maybe not even be a doctor. But so far, in all the rotations and socially, the family doctors say it's hard, but that they would go into it all over again.

Once again, Dinosaur, looks like you've brought up a good point. I'll keep coming back to see new comments!

At Tue Jan 08, 09:28:00 AM, Anonymous Anonymous said...

i hope you keep that attitude!
good luck!

At Tue Jan 08, 01:26:00 PM, Anonymous Anonymous said...

I think the ? to be answered here is :
do you want to manage the patient or manage the problem or both. My two cents is, if you chose,"both", you have by default agreed to a compromised personal life.

At Tue Jan 08, 04:07:00 PM, Blogger DDx:dx said...

Watch out for the trumpet fanfare and drum roll, because I want to proclaim an anthem.
I believe the original principles of Family Medicine, if maintained and valued by the medical profession would have helped us avoid alot of the problems we currently have in US healthcare. Well-trained, skilled generalists have a healthy skepticism toward each new procedure or drug and tend to follow the healthy"Middle Path".
Please, excuse me for waving the banner.
I trained in FM along side IM's. We had a basically different outlook, although quantum different than the specialists. IM's needed to prove it wasn't Zebra's hoofbeats when FM's could simply smell the horseshit. Not that they couldn't develop a MUCH longer differential dx list....But honestly, common things occur commonly and I believe FM's have a generalists statistical mindset that allows them a less inteventionalists approach. I think American might be healthier today if about ten years ago alot more doctors would have "Just stood there instead of doing SOMETHING"..(stents, bone marrow transplants for metastatic disease, Vioxx, the list is long).
Still, for Family Medicine to be effective we need to demonstrate an ability to continually improve our services, provide consistent services( Uh, yeah, I deliver babies, but, no I don't do well with psych stuff.)and have SOME VALUE to our profession, and the public....
Da data DAHHH.

At Tue Jan 08, 04:54:00 PM, Blogger Dreaming again said...

ddx ... it was a family physician that kept pushing me to find a diagnosis for myasthenia gravis. He did not know what I had (a neuro had told him it was difinitively NOT MG ...long story)

He knew the difference between a horse's hoofbeat and a zebra. He knew I was a zebra. (to the point, he called me that once!!! *grin*)

When I finally WAS diagnosed correctly, I'm not sure who was more relieved, my family or him.

He's now training docs ...and makes sure they know the difference.

At Tue Jan 08, 11:36:00 PM, Blogger janemariemd said...

I guess no one posting here knows any good general internists trying to keep their patients out of the hospital--it's not just FPs who work at this Dino! I believe many FPs have very large panels, with such a broad range of patients and problems, as well as well-visits--how could any FP imagine s/he could manage everything that walks in the door? I have patients who found me, having left family docs, to get more comprehensive care for their dementia and other chronic medical problems from someone who isn't trying to see 35 patients a day and do office procedures because they pay and will keep the practice afloat.

Seriously, there are good doctors practicing in every specialty, and a few of us are doing both the office and the hospital. I like the hospital stuff because it is interesting and these are MY patients who are sick there. But, I like seeing people in my office, who are doing well, or even better than the last time I saw them, sometimes thanks to my efforts. 100% hospital would be depressing, one complicated Medicare patient after another, one urosepsis NH patient after another, and pressure all the time to get patients out.

At Wed Jan 09, 08:55:00 AM, Blogger Dr. Matthew Mintz said...

Though I agree with one of the responders that market forces and (hopefully) changes in health care delivery and financing will utlimately determine what will happen, I think there are several issues raised by the Dinosaur's post.
1. Should generalists (FP's and IM's) do inpatiennt, outpatient or both. As an IM who now does only outpatient medicine, I would argue that the advantages to keeping the two separated, outweigh the disadvantages (continuity). As medical knowledge continues to expand, it becomes increasingly more difficult to practice up to date, evidence based practice. The treatment of common medical conditions in the acute inpatient and chronic outpatient setting is so vastly different, and continues to change rapidly; I think it extremely challenging for any generalist to keep up with both. That being said, practice setting is extremely important. In a more rural settings there are simply not enough generalists to do both inpatient and outpatient medicine separately. We might consider (and some programs have already done so) varying traning in both IM and FP to allow residents to choose to focus on outpatient, inpatient or both.
2. Are IM's well suited for outpatient medicine. I would say enthusiastically "yes." Much of what we see in the outpatient setting is chronic diseases, which general internists are very good at taking care of. Not only are there not enough specialists to go around, but specialists can often loose site of the big picture (like my patient who was started on long term steroids by a rheumatologist who forgot about bone density screening an bisphophonate use for prevention).
3. The 3rd issue is the role of IM's and FP's. I think this is a much more challening issue. FP training gives them a broader range of skills, IM training focus more on acute and chronic disease in adults; but both can do excellents jobs in the outpatient primary care setting. I think our country has enough chronically ill patients as well as patients who need routine preventive care that there is plenty of room for docs in both specialties.

At Wed Jan 09, 10:10:00 AM, Blogger Tom said...

Well, for one thing you'd need a whole heck of a lot more family practice people than you have right now.

That, of course, would require either compulsion (see: USSR) or economic incentive (see: Free Market). If the former is chosen, I'll grab my 12 gauge. If the latter is chosen, then there will be room for both FPs and internists since the 'good' ones (from the paying patient's prespective) will be selected for.

Any other proposal is either somebody's dream (likely with an axe to grind) or some form of the 'former' (Communism).

At Wed Jan 09, 09:29:00 PM, Blogger Dr. Smak said...

Great topic, lots of good comments. The days when a physician could master the ICU, the hospital, and the outpatient setting are long gone. There's just too much subject matter to keep current on.

Be wary of those who suggest that outpatient medicine should be left to physician extenders - it is easily as complex as inpatient, and as our population ages more and more patients will need a solid primary care physician.

Like Dino, I do solely outpatient medicine, and I think I'm a better doctor for it. But I disagree that all FPs should make that choice. I feel like my inpatient training was good, and that I would make a good hospitalist as well. And I'm sure there are internists out there that "specialize" in outpatient care.

I'm a big supporter of the hospitalist movement, tho of course it has it's drawbacks. I'd like to see communication between my practice and our hospitalist improve. Maybe that should be part of the training as well, for both FP and IM programs.

At Sat Jan 12, 08:30:00 PM, Blogger janemariemd said...

I believe most general internists in outpatient practice are no longer seeing their inpatients. I believe my partner and I are the internal medicine "dinosaurs"--in that we still do both.

I pretty much agree that hospitalists are here to stay, and they have their strengths and weaknesses. But I don't think the communication and coordination of care will improve as long as their is a COLOSSAL disincentive to provide it like we currently have. We aren't paid for it, and sad to say, activities that are paid for (direct patient encounters) will often take precedent. This is wy I find retainer medicine so attractive.


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