The debate continues – A primary care doctor by any other name …
Bob Doherty is a great guy (except for this Mets thing). He and I have discussed this issue several times. As his article makes clear, he hangs on to the moniker for political reasons. Bob lives in a political world, and he believes that politicians "get" primary care.
I can understand the desire to shed the words "primary care", but I think this would be unwise at a time when politicians and policymakers alike seem to buy into the idea that "primary care" is the keystone of a high performing health care system, as Senate Finance Chair Max Baucus (D-MT) has famously described it. Whether legislators will do enough to live up to primary care’s billing as the "something on which other associated things depend" is still to be determined.
As the ACP solutions paper defines primary care, we should champion it:
"General internists provide long-term, comprehensive care in the office and the hospital, managing both common and complex illnesses of adolescents, adults, and the elderly. Internists receive in-depth training in the diagnosis and treatment of conditions that affect all organ systems. General internists are specially trained to solve puzzling diagnostic problems and can handle severe chronic illnesses and situations where several different illnesses may strike at the same time. They are also trained in the essentials of primary care internal medicine, which incorporates an understanding of disease prevention, wellness, substance abuse, and mental health. Internists’ training is solely directed to care of adult patients; consequently, internists are especially focused on the care of adult and elderly patients with multiple complex chronic diseases."
I live in an educational world of medical students and residents. When they hear primary care, they hear overworked, underappreciated and little or no access to inpatient medicine. We could have a long blog debate on how and why the growth of the hospitalist movement has made the classic general internist an endangered species.
I love general internal medicine. I love attacking a variety of undifferentiated problems. I would be bored focusing mostly on chest pain, COPD or dialysis. Complex patients are fascinating.
If I were graduating from residency today, I would likely become a hospitalist, because outpatient practice alone would not meet my internal conception of the physician that I strive to be. Most students choose internal medicine because of the inpatient experience.
Prior to my 3rd year in med school I had no idea what I would become. My first week on the internal medicine rotation (November 1973) convinced me that I was an internist. I loved and still love ward rounds. Inpatient medicine provides me the opportunity to be a detective and a comforter. This week on rounds we had several challenging diagnostic and therapeutic puzzles. We also diagnosed severe depression and participated in end of life care. We used our entire brains – both right and left.
Having done outpatient medicine for a bit over 20 years, I know that outpatient medicine has the most interesting diagnostic dilemmas, but they occur less frequently. I know the joy of the physician side of a long term physician patient relationship, and I miss it.
For years I have objectied to the dichotomization of general internal medicine. I have blogged about the problems of some hospitalist situations. Most outpatient only general internal medicine situations are even more problematic.
Fortunately, I know some great internists who still do both. They have the best jobs. But their ability to succeed in those jobs is becoming threatened. And few graduates see that job as a desirable one.
So I applaud Bob Doherty for his clear explication. I applaud the political struggle that internal medicine is fighting, but I worry about how we make that job attractive to residents. Perhaps the patient centered medical home is the answer, it just might be.
The term primary care works in the halls of the Capital, but it fails in the minds of students and residents. We will probably continue to debate this for several years. Our debate clearly is shaped by the differing context of our daily lives.
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As the problem with medicine is payment issues, and as long as insurance/government pays for medical care, the problem we have is political; it seems odd to continue this “debate” to shed the name “primary care” to attract residents. Worrying about how we make the job attractive to residents by insisting on “gerneral internist” or “generalist” or calling specialists “partialist” or morphing general medicine into “specialist” does nothing to actually address the problem. “Primary care” fails in the minds of students and residents, in essence because of problems associated with low payment- not enough money means 10min visits and current payment structures means excessive paperwork. General Internal Medicine/Primary Care/”non partialist medicine for adults” fails because it is financially untenable. The failure to give up this “debate” is in essence a insistence on sticking within the context of individual daily lives; not only a failure to actually see the whole, but a strange fascination with “semantic drifts.”
I am afraid that the only thing that will make internal medicine attractive to residents is a fundamentally reformed health care system in which the funding of medical education is different.
It takes weeks for medical students to realize that they have to pay back their loans and that cognition has no value in American medicine. That process undoubtedly may begin in the last year of college when students make the plunge into medicine.
Internal medicine is cognitive. I remember once coming up with the correct diagnosis to a patient while asleep. My mind was obviously thinking. One has to feel that one’s thinking is valued and that learning is valued. It no longer is.
To be a good internist you need to read a lot lifelong, learn clinical quantitative epidemiology to be able to make guesstimates of probability, be able to access information relevant to your patients quickly, and be able to progress quickly or slowly to the proper decisions and diagnoses.
Ruminating about debt or doing procedures to pay back loans destabilizes that cognitive equilibrium. So medical students prefer to do something with straightforward procedures that are well rewarded. The health care system is unfair and irrational and so they look to lifestyle as a compensation. They do not want to confront the status quo. They prefer to work fewer hours.
To revive internal medicine this society will have to restore that cognitive equilibrium.
Loan forgiveness is too little too late.
We can argue all we want about the nuances we want in definitions. The bottom line is that they make no difference.
I have written an op-ed piece on the financing of medical education that I have circulated at the ACP and elsewhere among all the people who are concerned with primary care. Only two people responded. One had little or no sympathy for the attitudes of medical students. The people at the ACP did not respond.
Until the ACP and other similar groups begin to value the human needs of their recruits they will get nowhere. That is to the detriment of American medicine and threatens even the slight prospects we have for true universal health insurance.
Bohdan A. Oryshkevich, MD, MPH