A tune by the late, great Lou Reed, “The Last Great American Whale,” on his iconic New York album has a line in it that I will of necessity paraphrase and that goes something like the following: “Stick a fork in it, turn it over, it's done.”
I have internist colleagues who feel the same about the future of general internal medicine, and in particular so-called “ambulatory” internal medicine. At the risk of making too many cultural references, I, as in Samuel Clemens's quip, think that reports of the death of general internal medicine are greatly exaggerated.
It was not that many years ago (OK, more like 40, but within the memory of many of us) that general internists were highly valued clinicians (doctors' doctors); were paid on par with other physicians; often had a subspecialty area of interest; and enjoyed a professionally and personally satisfying lifestyle. Since then, we have suffered the death of a thousand cuts with the persistent whittling away of compensation, stature, and well-being. Proceduralists' compensation has diverged greatly from that of cognitive specialists. Administrative burdens have increased logarithmically with the predictable rise in moral injury, aka burnout. This has been a self-reinforcing downward spiral, which has driven students and residents away from general medicine in droves. This can and must be reversed.
I think the future of the general medicine specialist is in fact bright, but it will require a significant effort on an individual, professional, and societal level. Here is the path forward from the perspective of a proud general internist who remains committed to the highest ideals of our profession.
First, the payers for medical care, both public and private, need to narrow the disparity in remuneration for cognitive versus procedural work. We know that more primary care is associated with lower costs, higher patient satisfaction, and lower mortality. There is some exceptionally good news in this regard. ACP has been working tirelessly, largely through your Medical Practice and Quality Committee, to advocate that CMS increase payments to generalists. It looks very much as if years of work have finally come to fruition, with a very significant increase in the valuation of evaluation and management codes that internists use most frequently included in the final rule for the 2020 Medicare Physician Fee Schedule.
In a zero-sum game, this recognition by CMS is no small thing. Multiple other efforts have led to other potential changes that will allow general internists to be paid for all the work that they do between visits, with additional codes for chronic care and principal care. These changes will benefit all general internists in all practice settings and arrangements.
Second, we need to vastly decrease the administrative burden that has been suffocating all physicians, but especially primary care physicians. The electronic medical record, for all its promise, has largely been a disaster for front-line physicians who now spend twice as much time satisfying coding requirements than actually speaking with and examining their patients. Here again ACP has had great success, not least in having CMS emulate our Patients Before Paperwork initiative with its Patients Over Paperwork program.
Coupled with other initiatives within the College, there exists the very real possibility that documentation burden may be greatly reduced while at the same time restoring the story to patient and physician narratives. Think about having the luxury of giving undivided attention to your patient in the exam room, then providing a short cogent narrative of your clinical interaction and diagnostic thought process. No bullets, no artifactual “macros,” and no coders second-guessing you!
Third, we need to embrace team-based care. There is a shortage of primary care physicians now, and projections only show things getting worse at the same time the demand for services and the imperative to improve quality will increase. Internists will need to assemble and lead teams of clinicians and caregivers of all stripes, where everyone works at the top of their license with the collective goal of patient-centered care across the spectrum of primary, secondary, and even tertiary care. Artificial intelligence and other technology, while not without some potential for unintended consequences, could be a great boon to internists as a tool to aid them in the care of their patients. ACP is again at the table to ensure that benefit for clinicians and patients is the primary objective.
Last, we need to start exercising our “superpowers,” as suggested by Nirav Shah, MD, MACP, in his commentary published in Annals of Internal Medicine. There is a demographic imperative for general internists in an aging society with a tsunami of baby boomers and their accumulation of chronic diseases. Economic forces are shifting care from hospitals to the outpatient arena. No one, and I do mean no one, other than internists acting as comprehensivists can adequately manage the care of these patients with multiple comorbidities often presenting with subtle signs and symptoms. Subspecialists will still be necessary for technical procedures and consultations for particularly difficult situations, but only the generalist will be able to offer the holistic care that will be required.
General internists further need to claw back many of the pieces of patient care that have been whittled away over the years. We should “own” diabetes, hypertension, chronic kidney disease, congestive heart failure, hepatitis C, HIV, palliative/hospice care, dementia, and so on. No internist can know everything, but on top of a knowledge of the general breadth of medicine, the vagaries of screening guidelines, and the complexities of immunizations, I would challenge every internist to develop an expertise in a niche of medicine that she is especially passionate about.
By paying internists commensurate with their value, by unshackling internists from data entry, by allowing internists to devote their attention to the more complex of our patients, and by developing and honing our superpowers, we can ultimately get back to the future, and reassume the mantle of the “doctor's doctor.” I'm all in. Are you?