General internal medicine – the domain

April 28, 2004

Task Force Redefines the Domain of General Internal Medicine

The Society of General Internal Medicine (SGIM) asked a task force to redefine the domain of general internal medicine. The recommendations of the Task Force on the Domain of General Internal Medicine (DGIM) are published in the April 20 issue of the Annals of Internal Medicine, along with editorials providing additional opinions.
“The [SGIM] believes that the chaos and dysfunction that characterize today’s medical care and the challenges facing general internal medicine should spur innovation,” write Eric B. Larson, MD, MPH, from the Group Health Cooperative, Center for Health Studies in Seattle, Washington, and colleagues from the SGIM Task Force on the DGIM. “Remaining true to its core values and competencies, general internal medicine should stay both broad and deep, ranging from uncomplicated primary care to continuous care of patients with multiple, complex, chronic diseases.”
Specific recommendations are that postgraduate and continuing education should develop mastery, enabling general internists wherever they may practice to lead teams and be responsible for team care, to embrace changes in information systems, and to provide most of the care required by their patients.
Fee-for-service and other physician reimbursements should be changed to recognize the value of services performed outside the traditional face-to-face visit, and to offer incentives to improve quality and efficiency and to provide comprehensive, ongoing care. Options could include giving physicians a patient management fee plus reimbursement for specific services, or a salary with incentives for productivity, quality, and improved outcomes.
Residency training in general internal medicine should provide both broad and deep medical knowledge, including mastery of informatics, management, and team leadership. The final one to two years of residency training should be flexible and based on practice goals, leading to a certificate of added qualification in generalist fields.
Research initiatives should include practice and operations management, focused on more effective shared decision-making, transparent medical records, and closer personal connection between physicians and patients.
“The task force believes that these changes will benefit patients and the public and reenergize general internal medicine,” the authors write. “Our field must adapt to a new world of consumerism, rising public expectations, widespread information dissemination, and contradictory pressures to hold down costs at a time when the demand for services is increasing because more people survive to old age with chronic disease.”

I had the opportunity to read and comment on this report during its construction. Like any such report I can find areas which I dislike. On balance though, SGIM has taken an important initiative to address the important question of how to reinvigorate general internal medicine.

A careful reading will reveal many issues that we discuss in this blog. I always try to take such reports in context of the old Southern saying: “If it ain’t broke, don’t fix it!”

Well, generalist care is broken, and thus requires remedies. I certainly hope that this report focuses the debate. We need a healthy discussion to develop more functional solutions to generalism.