What makes a high quality internist?

This rant must focus on internists because that is my profession. Each specialty will have a different description of high quality.

I have spent considerable time considering the skills that I value in internists. This is my initial attempt at defining them, please write if I leave something important out.

I give the highest rating to understanding the story. What the heck does db mean? I have a responsibility to understand what is bothering the patient and to figure out what diagnosis (or diagnoses) are causing the symptoms. One cannot overestimate the importance of making correct diagnoses.

Next I must understand the context of disease for the patient. What is the patient’s socioeconomic situation? What psychosocial situations do they confront? I must develop a management plan which fits their context.

Third, I must consider proven appropriate prevention. Certainly secondary prevention has a strong evidence base. Some primary prevention does make a difference. If I can convince the patient to decrease their lifestyle risk factors (smoking, high risk sexual activity, not wearing seat belts) then I likely have helped the patient.

Fourth, I must consider each new medication in the context of the entire medication list. We should try to minimize polypharmacy. We must be aware of potential side effects and interactions.

Perhaps at the end of my list I would include adherence to performance indicators. I consider this the accounting part of medical care. We check off the list so that someone else thinks we are providing high quality care. But these checklists are not sufficient. To be a high quality internist, I value most diagnostic acumen and personalizing management strategies.

I probably object most strenuously to P4P because it ignores the values that I treasure. It indirectly denigrates the values that I attribute to a great internist. It therefore lacks face validity for my profession.