This past May, I gave the "theme plenary" speech at the SGIM national meeting. Here is my picture and the text of my remarks about academic general internal medicine.

I believe strongly in work-life balance.

Before I start talking, I think it’s very important that I give you some caveats to prevent too many attacks afterwards: These are my personal opinions. I got to choose what issues I included and excluded.

My goal is to stimulate discussion throughout the meeting and throughout the years. I hope to emphasize the hypothesis that general internists desire complexity. We don’t often have time to address this in our out-patient practice; this leads to a lot of discontent. And if we could go back to focusing on complexity, perhaps we could better define ourselves.

I’d like to acknowledge the following, among many other people, who have helped me a great deal in my discussions: Tom Huddle is a medical historian in our division who has tried to put the history in some context for me, and seems to include my thoughts on a regular basis. I’ve had ongoing, long discussions with Gustavo Heudebert at my institution, and this discussion is really the result of probably five, eight years of us wrangling about what general internal medicine really is. Jim Byrd is a long time colleague and friend at East Carolina, and most of our discussions occur on golf courses. Karen DeSalvo, the Division Chief at Tulane, shared some very interesting things about how she redefined her division at Tulane, which really got me thinking about some of the fine points of this talk. And Jack Peirce -- for those of you who don’t know Jack Peirce very well, try to find him, talk to him. He will make you think.

What I’m going to go over in about fifteen minutes is what academic general internal medicine was prior to the ‘70s when I started medical school, how it emerged during the ‘70s while I was in residency, how we expanded our responsibilities in the ‘80s and ‘90s, and then discuss some challenges for this century.

So prior to the ‘70s. General internists were called academic consultants. As a matter of fact, in the early stages of the 20th century, all internists were general internists. The classic is obviously Osler, so how could you give you this talk without an Oslerian quote?

And he said --and I love this -- "There are, in truth, no specialties in medicine, since to know fully many of the most important diseases, a man must be familiar with their manifestations in many organs." And I apologize for the sexist nature of that remark.

I have to have a quote by Tinsley Harrison, since he founded the Department of Medicine at the University of Alabama at Birmingham, and he’s our local hero. "The true physician has a Shakespearean breadth of interest in the wise and the foolish, the proud and the humble, the stoic hero and the whining. He cares for people."

Now, how did general internal medicine first wane? How did subspecialty medicine grow, and then how did we re-emerge? Well, this is a very short story of a complex set of societal issues, but in the 1950s and ‘60s was the first boom in federal research support. Departments over that period of time slowly reorganized along subspecialty lines. Now, this paralleled what had been going on in the community as there were already board-certified subspecialists in practices. And then ACGME gave all this even more standing.

In many departments, and in the department where I went to medical school was a great example, there was no general internal medicine. So when I was a medical student, it was impossible for me to have a role model.

Some issues that occurred in the ‘70s will be familiar to those of us who went to medical school and residency during that era. A lot of key institutions started general internal medicine, and those prominent institutions stimulated other institutions that it really was very important.

There’s a new RRC requirement for continuity clinic, those of you who are residents. When I was a resident, I did not have to have the continuity clinic. That only occurred in about ’77 or ’78, if I recall exactly right. Once you had the requirement for continuity clinic, someone had to run those clinics. The chairs got a little nervous, because they knew they couldn’t run it, and they didn’t have anybody else who could run it, so they had to hire some general internists.

HRSA came through and developed primary care funding, and so these new divisions grabbed on and said, "This is a way for us to build our divisions." Chairs weren’t so sure about this primary care thing that was going on, but it was money, and chairs never turn down money.

We started to develop academic leaders through, for example, the RWJ clinical scholars program, the Kaiser Fellowship, and a lot of other ways that people developed academic focus. Some funding sources started to emerge, NCHSR -- which begat AHCPR, which begat AHRQ -- started to have some funding, and general internists started submitting to that funding source. RWJ was a funding source, and a variety of other foundations. And, most importantly, SREPCIM founded in 1978, which gave us an academic home.

Once divisions were there, a variety of these things -- and not every division does all these things, and this is not a big issue in all these divisions -- but a variety of things occurred. Many institutions did general medicine consultation and found that a very serious issue, and there are some institutions where that became a major focus of research, a major focus of ideas.

At many institutions, the generalists slowly have grown into being the primary ward attendings. More and more subspecialists are uncomfortable being an attending on a general medicine ward. If you’re a rheumatologist -- and I’m picking on them at random -- and someone has lupus, you’re great. But as soon as they have diabetes also, many rheumatoloigsts start to feel uncomfortable, and if they also have to have coronary artery disease, they actually tremble.

This, in some way, began the hospitalist movement, and trying to distinguish between the hospitalist movement and those general internists who do a lot of in-patient care is a very interesting thing to figure out. But it does lead to understanding that general internal medicine represents both in-patient and out-patient medicine.

We have this new phenomenon of out-patient medicine without in-patient medicine. All of the general internists in the ‘70s that I knew did both in-patient and out-patient medicine. But we had this new emergence of people who just do out-patient medicine and don’t do any in-patient medicine.

And then, especially in the ‘90s, we have the influence of managed care on the growth of many divisions, and I’m going to suggest that this has been a very disruptive force.

And finally, we have what -- for lack of the better phrase, we’ll call the cyclic appeal of primary care. We were the kings in the early ‘90s. Everybody wanted to be primary care. I remember an ophthalmologist once telling me he was a primary care ophthalmologist.

I was at a party with a radiologist. He told me he did primary care radiology. That doesn’t seem to be quite in vogue this week.

Our divisions changed a lot in the ‘90s. The research units have benefited from greater funding and more fellowship-trained faculty and just look at this meeting, the increase of research productivity.

Many divisions take a leadership role in the educational activities of their departments, and you can trace the history in many divisions where they start out focusing just on the clinic, but slowly but surely, they take on more and more major responsibilities in the department, and that many institutions are an integral part of the entire teaching program. And this is exactly in line with most of our values.

And at many institutions, the clinical enterprise becomes a large concern. And it becomes a concern because the health system views in the early ‘90s that were going to be the front door to the health system. We need to have a bunch of people out there, doing primary care, bringing patients in, so that the hospital can stay rich.

Now, in my mind, managed care is a very questionable influence, and this explosion was a questionable influence, and I take all of this from articles that were in JJIM earlier this year that really inform how I have thought about the doctor-patient relationship, and thought about the time pressures. And I personally am very concerned about where we’ve gone, and the prime pressure of seeing our patients, the impact that that has had on our career satisfaction, with people who do primarily out-patient medicine, the decreased satisfaction of patients. What is it doing to the doctor-patient relationship.

So let me give you my hypothesis of how we got to where we are. None of my advisors bare any responsibility for my hypothesis. I think that general internal medicine embraced the concept of primary care to emphasize continuity and comprehensive care, and that’s what we meant in the ‘70s and ‘80s. But that embracing of primary care did not mean that we wanted to abandon the complexity of secondary care.

In my opinion, the phrase "primary care" has become distorted to often exclude complexity, and that has led to great display by general internists. I believe many of our subspecialty colleagues look at us as primary care, quote, "simple docs," not complex docs, and I know the insurers view us that way.

We don’t want to abandon complexity. That’s why I chose internal medicine. I chose internal medicine because I liked the clinical complexity. I like the patient with five medical problems and 15 medications to figure out. I like the psychosocial complexity of trying to figure out the interaction between the disease and the underlying psychosocial issues. I like the complexity of trying to figure out how to manage patients in the in-patient and get them back to the out-patient and back to the in-patient, and make all that smooth without error.

So these are my questions for this century. Will research funding continue to grow? Will we be able to support the important research that members of this society do?

How will we pay for education? At many institutions, the educational viability of general internal medicine divisions is threatened because no one will pay them to teach.

We have to decide, is general internal medicine primary care, and/or complex care, and how to define it, and how to present ourselves to the rest of the world.

We’re struggling with can you be both an in-patient and out-patient physician, and how do we balance that, not just in academics, but also out in our practicing communities.

We have to focus on how health care is funded, and how that affects generalists. Right now, it makes generalists depressed. Who’s going to pay for complex continuity care? Who’s going to pay for the patient who has diabetes, hypoepidemia, coronary disease, congestive heart failure and hypertension, and they’re trying to do that in fifteen minutes while they’re depressed. It can’t be done well.

We are doing so much more -- we should do so much more for our patients than we did 25 years ago. We know so much better how to do secondary prevention. But it does take time.

Let me focus on one or two other recent trends. There’s a very good article on the New England Journal recently on concierge primary care. When I was at the APC meeting, going through the exhibits, MDVIP had a booth. MDVIP is one of the concierge care companies.

Now, think what you want of concierge care. Try to remember what the underlying forces were that have caused this to emerge and have attracted both patients and physicians to the concept. A lot of it’s about time, a lot of it’s from the physician wanting to be Marcus Welby, really be able to go visit the patient at home, really go visit the patient and accompany them to the specialist. Now, some of us may not be happy morally with the concept, but try to understand why it has emerged, and it’s not just money.

We have physicians refusing new Medicare patients. Why are they refusing new Medicare patients? Because the overhead is greater than you get for seeing the patient, and you can’t make it up in volume.

We have alternate practice structures, and if you have not read the U.S. News and World Report issue, the web site link will be on the SGIM web page. If you’re interested in trying to get that, you can actually read it on line. But it’s very interesting to see how different people are trying to approach practice in 2002.

I’d like to just preview the four talks for this session. The firsT is about hospital medicine, one of the big issues that I mentioned, and trying to understand how hospital services can lead to efficiency.

Then, an ever-ranging topic at this society and at most of our institutions, and that’s how physicians and pharmaceutical companies interact. One of the big research agendas over the last five to six years has been the specialists trying to prove that they can take care of a disease better than generalists. Now, I would suggest that’s the wrong question. The question is, who can take care of the patient better. But this is an article that contrasts specialists with specialoids, and I think you’ll find it very interesting.

And then a randomized control of primary intensive care. If you do a lot more primary care, you can keep people out of the hospital.

I’d like to close with a quote from my favorite CD. It’s from a song called "Reservations." It’s written by Jeff Tweety of Willco. How many people in the audience -- raise your hand if you’re familiar with Willco? We’ve got about 10 percent. That’s pretty good.

Half of them have heard me talk about it in the last two days.

The name of the CD is "Yankee Hotel Fox Trot," and I’m not going to explain why it’s called that. But this is what he said. "I’ve got reservations about so many things, but not about you."