How should we define the value of internal medicine?
By Lynne M. Kirk, FACP
In heading up efforts to revitalize our specialty, ACP and several of our sister internal medicine organizations have set an ambitious agenda.
At the top of that list are four goals, which include repairing the dysfunctional payment system; redesigning practice to reduce hassles and improve quality; and educating and training internists for the specialty's future. But the fourth goal may be the most important of them all, the one on which all the others are based: to define and articulate the value of internal medicine.
As internists, we need that definition for ourselves, to help shape the direction of our field. But we also need to define that value for students considering careers in internal medicine, for patients deciding which physician can best meet their needs, and for payers and policy-makers who determine how to pay for medical care.
Defining the value of internal medicine sounds deceptively simple. We know we have received rigorous training and that our ability to care for adult illnesses is broad and deep. We also know we are particularly adept at caring for patients with multiple complex diseases and at diagnosing illnesses that have unusual or complex presentations.
It therefore stands to reason that the scientific literature would provide ample evidence to support what we know to be the value of internal medicine. Unfortunately, that is not the case.
Let's take a look at the available evidence. According to the literature, patients have better outcomes with lower costs over time when they have increased access to primary health care. However, the data do not specifically address whether internists produce better outcomes than other providers.
Evidence also indicates that outcomes for some chronic diseases, such as diabetes, coronary artery disease and HIV/AIDS, improve when patients are treated by specialists or subspecialists in internal medicine.
However, those better outcomes are most strongly correlated to the depth of experience of the individual physician, not to the fact that the physician is an internist. While there is no evidence that internists do a poorer job than others in caring for patients, the fact is that long, rigorous studies to assess care outcomes by internists compared to those of non-internists haven't been done—and would be very difficult and costly to do.
If the evidence isn't there, are there factors in the history of internal medicine that might help us with our definition? Two of my predecessors as College President—C. Anderson Hedberg, MACP, and Charles K. Francis, MACP—have described in their columns how internal medicine was established by physician-educators in Austria and Germany at the end of the 1800s.
The new discipline based clinical care on the knowledge of pathophysiology generated by the scientific method, care that was exemplified by William Osler, MD, in the early 1900s. Over the last century, internists have played a key role in developing medical schools and academic health centers, both here in the U.S. and around the world.
They have also helped create the explosion of biomedical research, resulting in breakthroughs that have significantly improved patients' health and longevity. Thus, at the core of our specialty are the values of scientifically based medicine that generates new knowledge that can be applied to patient care.
Many of the leaders in our field see those core competencies as strengths we need to build on to provide medical care in a new era. Harold C. Sox, MACP, for instance, Editor of Annals of Internal Medicine, wrote in the June 15, 2001, issue of The American Journal of Medicine that "the ultimate internist's skills uniquely fit the needs of patients who have serious, progressive diseases."
Edward H. Wagner, FACP, who along with colleagues at Seattle's Group Health Cooperative helped originate the chronic care model, pointed out in the Dec. 15, 1997, Annals that the defining features needed to meet the needs of the chronically ill are continuity, comprehensiveness and coordination.
And Eric B. Larson, MACP, past Chair of the Board of Regents and noted expert in primary care, now serves as director of the Center for Health Studies in Seattle. According to Dr. Larson, writing in the January 2004 issue of Journal of General Internal Medicine, "[i]nternal medicine's core values and competencies are critical to serving our patients' needs, promoting their wellbeing, and providing compassionate care."
Our core values include scientific rigor and compassionate care.
Perhaps the key to defining our value as internists is to articulate the core values of internal medicine—scientific rigor, comprehensive and compassionate care—as these leaders of our field appear to do.
A succinct message
Several groups have elaborated on those core values, most recently the ACP Foundation in collaboration with the ABIM Foundation and the European Federation of Internal Medicine. In 2002, that collaboration produced the "Physician Charter on Medical Professionalism," which detailed how internal medicine's core values can help physicians navigate a tough and often dysfunctional health care system.
Some key values identified in the charter include:
- providing patient care that is coordinated, comprehensive, compassionate and evidence-based;
- acquiring and sharing knowledge that is intellectually rigorous and characterized by lifelong learning; and
- maintaining professionalism, which is characterized by altruism, accountability, accessibility, commitment to excellence, respect for others and patient advocacy.
Most of these characteristics are not unique to internists, and not every internist's practice will encompass all these components. However, these are the values that most internists I know were trained to uphold—and how they aspire to practice.
Our challenge, then, is this: How do we translate these values into a succinct message that will resonate with students, patients and policy-makers? ACP's tagline, "Doctors for Adults," captures only a portion of the care we provide. But "Doctors for comprehensive, compassionate, evidence-based and expert care for adults with complex diseases," while more descriptive, is a marketing nightmare.
There must be a concise way to explain what we do. In the meantime, our best bet is—as one marketer put it in a very successful tagline—to "Just do it."
That may be difficult in a rapidly changing environment with growing reimbursement and access issues. But by delivering care that incorporates the core competencies of our field, our patients and their families will understand the value we bring to their lives, even without the benefit of a catchy slogan. Ultimately, it's through providing high quality care that we communicate our values to the public—and find our own highest form of professional satisfaction.
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