No
Over the weekend I had a wonderful discussion with a prominent academic family physician. I had last seen him 37 years ago when he was getting ready to graduate from medical school and I was a new medical student. We both spoke at the Alabama Academy of Family Practice this weekend.
We had a wonderful discussion and agreed to disagree about merging primary care. Long time readers know that I dislike the term for the tasks that outpatient internists do. Most of the push for merger comes from family medicine.
I sit in an unusual situation – I make rounds at 2 hospitals, one with an internal medicine residency program and the other with a family medicine residency program. I work closely with family physicians and of course I am an internist.
New internists are avoiding primary care assiduously. Internal medicine residency provides abundant options for its graduates. We can understand the forces driving subspecialty choice through simple observation over the years.
As my colleague admitted, in Great Britain internists fill the hospitalist role – they do not do outpatient medicine. Internal medicine's prototypical educator, Sir William Osler, worked primarily in the hospital.
Now I could agree with family medicine providing more primary care options, including allowing emphasis in adult medicine, or pediatrics, or women's health, or sports medicine, or geriatrics … Why should internal medicine change its training? Do we have any evidence that our training is substandard? If an internal medicine graduate wants to do outpatient medicine, he or she will have a learning curve. Having climbed that curve earlier in my career, I believe that any well trained internist who wants to focus on outpatient medicine can succeed in incorporating the knowledge and skills needed for outpatient medicine.
When my obstetrics colleagues hire a new graduate, they have to help them learn how to practice. Surgeons face the same hurdle. Residency training provides us knowledge and skills, but we should not stop learning when residency ends. We all must develop new knowledge and skills the depend on the particular position we are filling.
Family medicine training provides a broad overview of medicine, pediatrics, ob-gyn, sports medicine, psychiatry, etc. Internal medicine training provides depth in adult medicine. While family physician and internal medicine represent overlapping Venn diagrams, they have major and important differences. They need not merge. We should learn from each other, but continue to celebrate our differences.
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DB, thank you for once again raising this issue. This was the subject of one of my criticisms of ACP. Please understand, I know the ACP is an important organization and has done some good things for the profession. But one of their failings is they don’t emphasize the distinction of general IM as its own specialty. As a highly influential organization they are in a unique position to do this. If they do not aggressively promote IM as a distinct specialty the merger will eventually occur. Health care reform’s emphasis on “primary care” will also drive this. If nothing else, the current talk of an impending merger will discourage more and more students from going into IM. After all, who would want to sign up for a specialty that may not exist in 10 or 20 years?
I can think of a few measures from ACP that would be helpful:
Less emphasis in MKSAP and board prep on family practice issues such as office gynecology, office orthopedics and the like.
More emphasis on true internal medicine issues like sepsis, vasculitis, antiphospholipid syndrome, etc.
Emphasis on the general internist as a specialist.
A strong public statement for the preservation general IM as a unique specialty.
Finally, please, please find a better slogan then “Doctors for Adults.”
Maybe, but at this point this seems like rearranging deck chairs on the Titanic.
Merging or staying separate means little while we’re both heading quickly towards economic extinction.
No, they should not fuse. They should work better together.
I have worked as an internist and as a primary care physician
Family practice is the practice of picking needles out of a haystack, of providing access to health care, of doing things in the most simple manner, and of dealing with what comes up, chief complaints that might have nothing to do with internal medicine such as shoulder injuries, lacerations, etc. Also obstetrics and pediatrics. They also deal with preventive care.
Internal medicine is dealing with more complex disease and with problem solving. More in depth reading and critical thinking.
Both are equally difficult. I think that Family Practice may be more monotonous and more stressful. But it may be even more important than internal medicine.
Internists should complement family practitioners and be the secondary line of defense. I also think that internists are more solitary and a bit more arrogant in that they feel that they have a different professional culture. That is we feel we understand the system of health care delivery and medicine better. That may be true since we are more likely to interact both with outpatient and inpatient medicine. Having done both, I think that family practice is more difficult and requires more concentration.
They should work together better.
That is my two cents.
Bohdan A Oryshkevich, MD, MPH
They should merge into a combined 4-year program and focus on supervising midlevel providers.
Glad you internal medicine heroes are here to save the day when I'm unable to handle my complicated patients.
What do you think family practice residents were doing when we weren't rotating on inpatient medicine? Discussing smoking cessation and doing pap smears?
While you were performing your 40th paracentesis, I was managing DIC in a 19-year-old post-partum patient and calculating fluid/electrolyte replacement on someone with a weight of 5 pounds.
Now, 12 years out, I'm still holding your hand when it's time to choose ventilator settings.
You're going to be MY secondary line of defense?
Thanks anyway.
At my two local hospitals IM/FM call is the same call pool. They have separate pediatrics and ob/gyn call pools available. Most of what I do in FM is outpatient, but the inpatient work that I do is comparable to the IM doctors on adult patients. The difference is I can see inpatients and outpatients from birth to a hundred, wherease most IM doctors will not see anyone under 16. I have multiple families where I see three or four generations of patients. Most of the IM doctors seem to have more geriatrics and nursing home patients and shy away from the younger patients. I like the the balance of FM.
I'm a specialist so I am commenting on the outside. I would suggest that if the groups do not formally merge, that they closely collaborate as they have so many overlapping interests. One of the weaknesses of the medical community is that we are splintered and competing against each other. I think that health care reform will exacerbate this. Indeed, 'divide and conquer' was a successful strategy that the administration used.
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