American College of Physicians: Internal Medicine — Doctors for Adults ®

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Letters

From the March ACP Observer, copyright 2004 by the American College of Physicians.

Revitalization

Bravo and kudos to Mary T. Herald, FACP, for convening a summit on internal medicine. ("Internal medicine takes a hard look at itself during summit on revitalization" in the December 2003 ACP Observer.) I'm delighted to see the College, as usual, taking a leadership role on critical issues that must be addressed to enable us to continue to provide excellent care to patients.

The discussion of practice hassles disturbed me, however. We are all drowning in paperwork, and mere "tweaking" of the system will not resolve this. Instead of asking health plans to simplify paperwork, we should try to eliminate it.

Most health plans report that they approve well over 95% of physicians' requests. We need to make health care more efficient and stop the useless paper exercises that result in "rationing by hassles."

Richard S. Frankenstein, FACP
Garden Grove, Calif.

'Big doctoring'

In his recent interview, Fitzhugh Mullan, MD, got it right! ("Making the case for 'big doctoring' in primary care" in the December 2003 ACP Observer.) Finally, someone has captured the essence of what Oslerian internal medicine is—and should be—about.

I believe Dr. Mullan has also solved the problem of what we should call ourselves. The public may never comprehend the term internist, but they would easily understand what type of medicine a "generalist" provides. Our job is truly to serve as the patient's quarterback, executing the basic "plays" that are run 95% of the time in medicine, and then calling in an effective and reliable specialist for what we cannot do.

We cannot escape the essential arduousness of our specialty. It is hard work, but we can make medical students see that we are truly the single most indispensable part of the health care team.

Joseph G. Weigel, FACP
Somerset, Ky.

Performance measures

The efforts of ACP and other agencies to work on performance measures are to be commended. ("ACP's response to the performance measure movement" in the January/February 2004 ACP Observer.)

Performance measures will be difficult, however, because of several factors in the physician-patient equation. On the physician side, the success of performance measures will depend on doctors' ability to stay current with clinical improvements in diagnosis, treatment and follow-up.

Not all physicians, however, possess such up-to-date knowledge. Take type 2 diabetes mellitus, for instance. In my experience, a fair number of physicians don't give—in addition to the prescribed oral hypoglycemic medication—small doses of very short-acting, regular insulin before meals to help control patients' blood sugar surges.

As for patients, compliance is a major obstacle. Many patients simply object to daily insulin injections. All these factors make it very difficult to accept the results of performance measures as true values.

Munir E Nassar, FACP
Pittsford, NY

With respect to Dr. Herald's response to performance measures, internists should be nervous. I'm in my 24th year of practice and feeling a profound sense of deja vu when it comes to measuring physician performance.

First, who is pushing these measures on us? Private insurance companies, managed care plans and Medicare are the principle players, and they never do anything that will not improve their bottom line. The performance measures movement is about money, and if past is prologue, the money in question is ours—and these organizations want to hold onto it.

Collecting the mountains of data needed to operate a program like this will take time—our time. And then there are issues of data quality. These programs are still "experiments" conducted on us for their benefit.

Have any of us ever been favorably impressed with the reams of reports sent to us that purport to measure all aspects of our practices? Typically, these are aggregate data that lack specifics about patient management and are truly useless.

Schisms are already developing between physicians who see patients with complex illnesses and those who see patients for quickly resolved, simple episodic care. These measures will only make that problem worse, as no plan that I've worked with has come close to determining an accurate case mix.

My recommendation: ACP should prepare its own independent, broad-based measures, rather than collaborate with or be co-opted by insurers. Physicians will then be in a position to reject measures that are inaccurate and penalize us financially.

Michael E. Miller, ACP Member
Waban, Mass.

Reimbursement

Although Dr. Wheby's message in his President's Column is well-meaning, he is off the mark in his understanding of the plight of College members who practice general internal medicine. ("ACP's long, continuing fight for better reimbursement" in the January/February ACP Observer.)

Physicians' perspectives of the problems confronting internal medicine differ depending on where we are positioned. His view from "the ivory tower" is different from those of us working in the trenches.

While the College's effort to prevent a reduction in reimbursements must be commended, the practicing internist has been relegated to caring for the terminally ill and old. Because this care is poorly compensated and enervating, the number of hospitalists has grown as hospitals have struggled with fixed reimbursements and burgeoning specialty care.

Community internists have reluctantly abandoned the care of the hospitalized patient, finding it offers little financial reward. Hospital medical staffs, which are now specialty-heavy, give the internist only a minor role in their governance.

In my community of 200,000, only three internists who entered private practice in the last decade have stayed. The others have all joined a large group practice affiliated with a single health plan, taking a small pay cut in exchange for fixed hours and few administrative hassles.

If you exclude this group practice, orthopedic surgeons in this community outnumber internists two to one, while cardiologists outnumber us three to one. Unless this trend is stopped, we will soon have more magnetic resonance imaging scanners than internists.

Academic medical centers must take some responsibility for this sorry state. While their leaders until recently paid lip service to the growth of internal medicine, prestige and finances drove them to favor the specialties over internists.

The College has a unique opportunity to reinvigorate the discipline of internal medicine. ACP's leaders can do this by advocating for appropriate reimbursements for the activities that are a part of this discipline, and by restructuring training programs to cater more to the approaching graying populations that will be served best and most cost-effectively by internists.

Ashok V. Daftary, FACP
Stockton, Calif.

Dr. Wheby responds:

Thank you for your thoughtful response to my column. I understand your frustration. We are all experiencing similar problems, whether we work in a community practice or here in "the ivory tower," as you call it.

Your comment about advocating for appropriate reimbursements describes exactly what the College is trying to do with its revitalization initiative. We are working with the internal medicine organizations that are responsible for training programs. We are also planning models that will provide different and more equitable ways to reimburse internists for the time-consuming care they provide.

I hope you will keep up your interest in pushing College leaders to hear different points of view.

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