Rediscovering generalists as complex-care specialists
By C. Anderson Hedberg, FACP
Earlier this year, Annals of Internal Medicine published a supplement exploring the future of generalism in medicine. That section came on the heels of another supplement the journal published two years ago on the future of primary care.
Why is internal medicine's most prestigious journal devoting so much attention to generalism and primary care? As the two sections and their accompanying editorials point out, this essential but shrinking segment of American medicine is beset by many problems.
In the latest Annals supplement, an editorial notes that revisiting the subject elicits "a collective sense of deja vu." The authors point out that despite many years' worth of discussions and literature on the problems facing generalism, few solutions have emerged.
Physicians who practice general internal medicine are justifiably baffled. They feel their concerns and the value of generalism are not being acknowledged, not only by the public but also by their own medical colleagues. As I travel on behalf of ACP, I consistently hear generalists' frustration—and anger.
In the early days of our specialty, everyone was a generalist. The enormous advances of scientific knowledge and technology over the last century, however, led to the evolution of subspecialization in internal medicine.
Few would argue that the trend toward subspecialization is inherently bad. Subspecialization continues to advance the mastery of the diagnosis, treatment and research of organ-related dysfunction. At some point in their lives, most patients will need the attention of one or more internal medicine subspecialists and their deep knowledge and expertise. Generalists also learn from subspecialists, many of whom teach generalists about developments in their fields during training and in practice.
A growing need
For the overall health of our patients and society, however, we need to make sure that subspecialization does not overwhelm general internal medicine—which remains the principal practice mode of 52% of ACP members. A good example of the critical role generalists play in American medicine can be found in a recent series of New York Times articles that explored the concerns of patients.
One of those articles, "Awash in Information, Patients Face a Lonely, Uncertain Road," tells the stories of patients with serious complex illnesses. The article made it abundantly clear that these patients need a trusted relationship with a well-trained, compassionate generalist to help them coordinate care and navigate an overwhelmingly complex medical system.
As the article pointed out, however, the number of doctors willing to assume that role is rapidly diminishing. Recently published data show that only 27% of third-year internal medicine residents in 2003 chose to become generalists—down from 54% in l998.
The reasons for that drop have been well documented. They include relatively low reimbursement in the face of high student and residency debt; rising practice costs; large patient loads with long and intense work days; inflexible schedules that impede balanced lives; diminished time with patients; administrative burdens; and a dearth of role models.
Yet physicians who work in general internal medicine cite many positives. They take great satisfaction in long-term doctor-patient relationships built on trust. They find that being accessible in times of need and sharing individual patients' worries and joys over many years is deeply rewarding.
Today more than ever, a generalist perspective is necessary to help patients interpret complicated health information, get appropriate referrals, gain access to the full spectrum of screening and preventive services, and navigate an increasingly complex and fragmented health care system.
Generalists are needed to understand the social and cultural context of different patient populations. And they will be increasingly called upon to provide comprehensive, coordinated care to the growing numbers of elderly and chronically ill patients, many with multiple diagnoses and complicated treatment plans.
We know that under certain clinical circumstances, subspecialists can assume some of these roles. But for a large percentage of the population, specialists in general internal medicine are the key. Considering the fact that a large majority of Americans—about 80%, according to recent polls—have a personal physician, it is time to shore up this crucial area of medical care.
Reforms and innovations
How do we begin to rejuvenate generalism in internal medicine? A comprehensive revitalization framework was developed by ACP and other major specialty stakeholders in 2003.
The plan, which was intended to address the concerns of both generalists and subspecialists, highlights four themes: repairing the dysfunctional payment system; redesigning the practice of medicine; defining and articulating the value of internal medicine; and educating and training internists for future internal medicine practice.
ACP and others have proposed new payment models for chronic care management, which now encompasses many time-consuming tasks that are not reimbursed. ACP is also advocating for payment of care provided via phone and e-mail. In addition, the College has called attention to opportunities for enhanced reimbursement that should rise from the pay-for-performance movement, which is on the horizon. (For more about pay for performance, see "The need for payment reform takes on new urgency" in the October ACP Observer.
Specialists in general and subspecialty internal medicine will benefit from these payment-policy innovations. ACP's Practice Management Center is also studying the role that electronic health records and other innovative tools could play to boost practice efficiency—and eventually produce both cost savings and quality improvement.
We should aggressively use all available means to define and articulate the value of general internal medicine to the public, the government, insurers and employers.
We must urge medical schools and residency programs to provide the curriculum, practical training and role models needed to demonstrate the skills and satisfaction of general internal medicine practice. While training in ambulatory medicine is woefully lacking, we also must provide more resources in systems development, communications and professionalism.
And we should aggressively use all available means to define and articulate the value of general internal medicine to the public, the government, insurers and employers.
'Help is on the way'
Currently, ACP's Health and Public Policy Committee is preparing a paper that will examine the current and future roles of generalists and subspecialists in the internal medicine family. The good news is that there is much hope for generalism, as recent studies demonstrate that generalist physicians produce high-quality care that is cost-effective and in demand by the public.
American medical leaders are increasingly aware that at the heart of any successful medical care system is a strong corps of generalist physicians. I am convinced that a well-managed group of general internists can provide excellent patient care and still lead a reasonably balanced life, all while incorporating the new tools and strategies being developed in the emerging medical paradigm.
If you enjoy practicing as a generalist, or you are in training and feel this venerable niche is your calling, follow your heart—and hang on! Help is on the way in the form of better payment, practice tools and an abiding respect for the care you provide.
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