I like DrRich because he is not scared to produce controversy. He has a consistent world view and I often agree with him. This week has made my point inadvertently with these two posts:
The Death of Primary Care is Official
Embracing the Death of Primary Care
When you read his rants, he assumes a minimalist definition of primary care. As I write repeatedly, the definition of primary care remains problematic. DrRich makes my point with his rants.
Here are a few of my missives on primary care:
Dazed and Confused – Levels of primary care?
I should stop using the phrase primary care
In the second rant I quote from an earlier rant:
I personally dislike using the term primary care for internists, because of the misuse of this word. Those who do not understand the value of outpatient internists use the label primary care, and then opine that we could get nurse practitioners to do primary care. Obviously we have a problem of semantics.
Semantics are powerful. The words we use to describe things provides a context that redefines those things. By calling internists primary care physicians, internists proudly view themselves as providing comprehensive, continuous, complex care, while many non-physicians think of sore throats, urinary tract infections and routine hypertension management.
I chose internal medicine for the blend of intelletual stimulation and emotional satisfaction. Internal medicine always provides diagnostic puzzles. I (and most inernists) love the detective work. We all love presenting "cool cases" to our colleagues. But inernal medicine also provides very meaningful doctor patient interactions.
The current problem with outpatient medicine, as I type repeatedly, is one of time. Both the detective work and the emotional piece take appropriate time to develop.
Those words come from last year’s The future of outpatient internal medicine.
The ACP has a difficult political problem. We clearly want comprehensive internists and need many more of that ilk. We have championed and will continue to champion primary care internal medicine with this definition (from the position paper Solutions to the Challenges facing Primary Care Medicine found on this webpage.
"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"
So DrRich reinvents this definition with these words
The choice of nomenclature is yours, of course, but DrRich humbly suggests “Advanced Care Medicine.” What you do is not primary care; it’s far more advanced than that, and nobody could do it without the sort of extensive training you have. Advanced Care Medicine captures that notion. It also opens the possibility of referrals from the new-style PCPs, who occasionally will recognize that at least 20% of their patients (the ones DB writes about as the long tail) will present as clinical puzzles that do not fit very well with any of the standard medical diagnoses with which they are familiar, and another 20% will not respond to the recommended therapy as the guidelines say they must. These patients obviously will need advanced management. Why not refer them to an ACM practitioner?
This faux debate captures the problem of internal medicine. We have always had difficulty defining ourselves. Internists are extremely important, but what we do escapes many politicians, pundits and insurers.
If we do not address the semantics of our profession, then we will have a new profession. Perhaps we will become internists like Great Britain and Canada – oops then we will all be hospitalists. That might work for the physicians, but I believe patients need comprehensive internists, and so does DrRich.
{ 1 comment… read it below or add one }
How about secondary or tertiary care internist who is a peer to the subspecialist and who needs to utilize the services of the subspecialist only when there is the need for a procedure? Or there is the need for treatment after a diagnosis is made and the medical treatment is rare enough or skilled enough to require specialized care. This is off the top of my head and a work in progress.
I think that in many cases of my practice, I need a subspecialist only for the procedure. I just do not like doing procedures.
That would include biopsies of the skin, colonoscopies, endoscopies and bronchoscopies. Things like liver biopsies are a bit more tricky.
In some European countries, such procedures are done with equivalent quality by nurse practitioners. Knowledge and judgment, and experience are hard to come by and take a long term and much study and practice to mature.
There are many ways in which doctors and skilled nurses can work together. In Europe nurses are at least in some cases used to replace the routine activities of specialists. Bronchoscopies, colonoscopies etc. are just inspections. This tendency in Europe reflects a higher appreciation of the cognitive skills of a physician and recognizes procedures for what they are.
Bohdan A. Oryshkevich, MD, MPH