For many years I have advised against internists using the term primary care. Internists have always cared for patients of great complexity with skill and humanity. Until recently all internists did both outpatient and inpatient care. More recently the growth of hospital medicine has convinced many internists to forgo inpatient medicine.
Primary care became a hot term in the 1980s. Unfortunately the term underwent semantic drift and now seems to mean "simple care" to many physicians – both in and out of medical schools. What internists do is not simple care. However, I continue to get comments suggesting that primary care does not need physicians.
Any debate must hinge on a careful definition of terms. This debate suffers from a lack of understanding of the complexity of continuous, comprehensive, complex care that internists provide for their patients.
Dr. Dave wrote this wonderful paragraph:
I am currently a hospitalist but did primary care for 12 years before joining the ranks of hospitalists. Although hospitalized patients are sicker, I found outpatient medicine to be much harder and more challenging. It also didn’t last for a shift – someone has to cover the practice at night and it usually isn’t an NP. Whoever out there thinks that outpatient care can be reduced to plugging people into algorithms is ignorant of the nuances of humanity and our varying responses to diseases and treatment.
However, medical students and residents must face a hidden curriculum both in medical schools and in community hospitals. They face a continuous degradation of outpatient internal medicine (and even more family medicine). Our payment "system" also degrades outpatient medicine.
If we cannot change the culture of medicine, then we will have inadequate outpatient care for our patients. The job needs more prestige than it currently receives. The job needs a better understanding from payers. We need to better understand the limits on the job.
Some critics want to just blame the medical schools for our primary care shortage. While the medical schools are not innocent, they are not the primary guilty party. We have many defendants in the court of hidden curriculum. Some of the defendants write comments on this blog.
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Your comments on terminology resonate with me. Though I’m usually not a fan of linguistic prescription, I think the conversation on these topics would benefit if people were to distinguish between “primary care” in general and its subset “routine care,” using the latter to the extent that there are arguably elements of “routine care” that can be safely performed by NPs/PAs/other non-physicians.
Please, look in the mirror. Both you and Dr. Dave used to practice outpatient internal medicine and are now full time hospitalists. Despite your kind words about outpatient MDs, you are now a role model for future hospitalists. Outpatient internal medicine is not a viable career path for medical students who graduated at the top of the class in high school and college. Resources are not available to do this job in a high quality, professional manner. Let’s let the NPs take it over and move on. Prestige? Did you know I have to fax my clinical notes to CVS pharmacy or they won’t fill test strips for diabetic home glucose monitoring? Just one of the hundreds of insults I deal with each week. You need to stop this theme now and just urge all trainees to become a hospitalist or subspecialist. Even better, take the ROAD to riches. This field is dead, dead, dead for MDs.
Anon – why do you think faxing your clinical notes to a pharmacy is insulting? We have to document to Part B – just like you do, why we fill what we fill & how often.
People, by their very nature are hoarders. They want that extra can of tomato soup, that extra box of test strips, that extra case of water – just in case an earthquake happens. Well – guess what….its all going to be rubble anyway.
But, I can predict almost to the month when the Medicare auditor will show up. If I can’t document usage (which is why your “use as directed” sigs don’t fly), then not only will they not pay for any test strips for that patient – they won’t pay for any test strips I filled that month.
This is what you hire receptionists for – not NPs! Just fax the right page & all is good. Its your attitude thats bad & the idea that you, alone, are not responsible for this patient. If you feel as an outpatient internist, an NP is of value, use that person. I would not go to an internist who did – I want to tell my story once & let you sort it out with your knowledge.
No matter your arena of practice, it is a shared responsibility. I don’t care if you rant and rave your inpt needs Aciphex & can’t take Protonix – it just ‘aint going to happen. We have a contract for Protonix, the literature supports therapeutic substitution & you lose.
If you thought you were going into this field to become an autonomous, omniscient physician – you were sorely mistaken in your expectations! However, many internists do have fulfilling practices. And, no – I wouldn’t see an FP either – my own personal bias.
Thanks Linda, that clears things up. I’m sure med students and residents will be flocking to outpatient IM now. Low pay, tons of meaningless paperwork, lack of prestige and autonomy, diminished long term relationships with patients. What’s not to love?
Well anon, perhaps not tons of students. However, more students in my daughter’s class went to IM than in previous classes. Perhaps they’ll all be hospitalists, who knows.
But, can you really tell me you have prestige & authority as a hospitalist? I work with hospitalists & none of them have much prestige nor authority. Specialists dump on them all the time & folks like me sit on the P&T committees to make the decisions on what drug or device they can or cannot use.
As for patient relationships – hospitalists have NO relationship with patients other than neutral or negative. The patients all want their own physician, not a hospitalist, who is a necessary evil. If you don’t piss them off, its neutral. But, if you do – its negative. I’ve seen both, but I’ve NEVER seen a positive patient relationship with a hospitalist & I’ve been in this game for lots longer than hospitalists have been around!
Sounds to me like you’re bitter with your career path or stuck in a rut & can’t find a way out. Perhaps its that ego thing thats getting in the way?????
Linda, I’d imagine that many of those IM residency graduates will go on to subspecialty fellowships to become cardiologists, nephrologists, endocrinologists, and other -ologists. For the 2009 NRMP residency match, there were 4,853 matches to categorical IM programs. For the 2009 NRMP fellowship match, there were 3,055 matches to medical subspecialty or allergy/immunology fellowships. Obviously this is a crude comparison, but it’s the basis for my skepticism that IM residency numbers alone will do much to either signal or change primary care / outpatient IM numbers.
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