What do general internists do?

I received this comment yesterday:

I find that many of my colleagues are not that interested in learning and do not actively attempt to become better physicians. They have not kept up as they should have. I can say confidently that they would have a difficult time explaining any medical topic in detail to a medical resident. This has been my experience. They are simply not equiped to deal with the nuances of a complicated medical patient without specialist help.

I think DB has had a different experience surrounded by residents in the VA system.

Soon thereafter I received this rebuttal:

I disagree with former internist. In this part of the country, it is the private internists who actually treat the chronic problems; the academic internists are the ones who won’t treat RA, CKD, A-fib or thyroid disease without specialists helping.

Maybe it’s different in other parts of the country; back east pts only saw a specialist once a year if their condition was stable.

Both comments reflect the availability heuristic that I discussed yesterday.  I suspect that the truth is quite different than either comment reflects.

What do I know?  Many internists (and family physicians, and radiologists and surgeons, etc) work hard to maintain their knowledge and skills.  Many internists really do care for the entire patient, and only get consultations when it will really benefit the patient.  Other internists use consultants too sparsely.  They try to care for problems outside their scope of competence.  Finally, some internists order too many consults.  Why do we have these 3 groups?

The first group represents the committed great internists.  They participate in ongoing education, and take pride in the care they give.  They worry less about the money and more about practicing the highest quality medicine.

The second group are always the most dangerous, for they do not know what they do not know, and moreover have egos which decrease the probability that they will ask someone for help.  Occasionally we see residents like this.  They scare me, because I know they will make big mistakes during their career.

The third group represents the sad unintended consequence of our payment system.  These physicians a focused on money, and thus understand that testing and consulting can shorten their visit length without decreasing their payment.  Thus, they can see more patients each day, and make more money.  Would a more intelligent payment system change them?

This third group represents the worst of medicine.  Such behavior is not restricted to generalists.  I see subspecialists who shotgun consultation and order tests like they are free.  These orders and consulters replace thinking with asking others to see their patients, and substitute a careful history and physical exam with an imaging study.

Can we fix this?  I suspect that reforming the payment system would help, but not totally solve this problem. 

Internal medicine is cognitively and emotionally challenging.  Many internists love that challenge.  Others tire of the challenge and look for an easy way out.  Internal medicine does not have an easy way out.