This internist commented today with a reprint of his Annals letter from 2006:
A thoughtful editorial (1) bemoans a decline in the number of practicing internists but admits to a paucity of information in literature and among physician workplace researchers to explain its causes. I have previously made comments (2) relevant to this problem. Thirty years of practice as an internist allow me to make further observations.
Academic medicine is the carpenter that fashioned the coffin of internal medicine. Instead of reengineering internal medicine to accommodate change, it cannibalized the discipline by reducing its worth, creating the hospitalist and ambulatory care internist. These were both nails that helped seal the coffin; the former reduced the influence of the internist in the acute care environment, and the latter blurred distinctions between internists and those without medical degrees who practice in ambulatory care settings.
Medical subspecialties that are nurtured in the ivory towers of academia have further reduced the stature of the internist. Effective lobbying by their affiliated societies and by commercial manufacturers of the medical devices they use assured them disproportionately higher reimbursement than that of their generalist colleagues. Absent an identity, the internist’s only remaining role is thought to be that of provider of ambulatory care to the chronically ill whose medical problems are beyond procedural intervention and lucrative compensation.
A continuing decline in professional stature and income, when coupled with deteriorating working conditions, makes the continued existence of internal medicine untenable. I am pessimistic that current political and professional interests will allow significant change to resuscitate internal medicine. Would it then not be opportune to draft an obituary for internal medicine and commission a requiem to its memory?
I am interested whether Dr. Centor and Dr. Wachter would address my then concerns in the world Internists work in today?
Well I have no influence over Dr. Wachter, but I will reiterate my comments from 2 years ago – Blaming academics for the growth of hospitalists. I agree with many of the problems that the writer cites, but I disagree with the locus of blame.
As a member of the ACP Board of Regents I interact with academicians and practicing internists. We have a wonderful mix of internists – all very committed to our wonderful and honorable profession. I spent much time in discussion with several practicing internists who commit significant time to advancing the profession. We all agree that it really is about the money.
Our payment system is totally broken – you can read many of my previous posts on this topic. So many problems follow from the payment problems.
Because we are paid by the patient, rather than by the appropriate amount of time, we try to see too many patients each day. This decreases our effectiveness and we feel guilty because we cannot spend enough time with each patient. The payment problems discourage many from continuing the proper practice of internal medicine – caring for the patient regardless of site.
We also overpay for procedures. Those physicians who do procedures often see inpatient care as superfluous. They quickly demand (from the hospital) that the hospitalists see those patients – or they will move their business to another hospital.
Hospitalists succeed on a supply demand curve. Too many hospitalists succumb to unreasonable demands on co-management (like the hospitalist in the previous post.)
If we cannot fix the payment system, we will continue to have these problems. Academic medicine really has nothing to do with the problem. In academia we generally react to the real world of practice. We have hospitalists because we have too many patients for our residents to follow.
I am empathetic with the letter and the internist who wrote the letter. I do believe that ACP and SGIM are working to improve the payment system – and I believe that is the answer.
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I see the specialists becoming almost robotic. In my community, the specialists come in for the procedures and to briefly say hi to each patient. Then they send in their PAs or nurse practitioners to round on the patient, do the H&Ps, and follow up visits. The big money is in procedures, and specialists often have 2 ancillary providers to help with the office visits and surgical follow up.
Most of the primary care doctors in my area refuse to take community ER call, which means they only see their own inpatients. Hospitalists provide a service to the self pay, Medicaid, and out of town inpatients that no one wants to see.
Hospitalists do sleep over like residents and can see patients 24 hours a day, meaning discharges can be done any time of the day, making happy hospitals and shortening the average stay by about a day.
Regarding payment, primary care doctors are paid by the number of patients seen. My local hospital considers the FP who can see 7-8 patients an hour an outstanding, read high revenue generating, doctor. The doctors who only see 3-5 patients/ hour are frowned upon as doctors who can’t make it. In primary care, about the only way to increase revenue is to see more patients.
My 60 hour weeks are worth less than the specialist who may only work 30-40 hours directly seeing patients, with the PA/NP doing the rest. My worst HMO contract pays less than $40 for a 99213, including the copay. Avg is around $55 in my area.
One ER visit can be $500-$4,000, and seeing nonurgent conditions in the ER is very expensive. It would save the system money if primary care doctors could see the 70% or more of ER patients who are not emergent in the office. The way to increase access to primary care and to increase primary care physicians is to increase reimbursement to encourage more people to go into primary care.
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